Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Mosby's 2014 Nursing Drug Reference (206 page)
Do not confuse:
HYDROmorphone
/meperidine/morphine
Dilaudid
/Demerol
Inhibits ascending pain pathways in CNS, increases pain threshold, alters pain perception
Moderate to severe pain, nonproductive cough
Hypersensitivity
Black Box Warning:
Respiratory depression, opioid-naive patients
Precautions:
Pregnancy (C), breastfeeding, children <18 yr, addictive personality, increased intracranial pressure, MI (acute), severe heart disease, renal/hepatic disease, bowel impaction, abrupt discontinuation, COPD
Black Box Warning:
Substance abuse, accidental exposure, potential for overdose/poisoning
Calculator
• Adult:
PO
(oral solution) 2.5-10 mg q3-6hr or (tabs) 2-4 mg q4-6hr;
EXT REL
(Exalgo): convert to
EXT REL
by giving total daily dose of immediate release/day, in 1 daily dose, if needed titrate
EXT REL
q3-4days until adequate pain relief; use 25-50% increase for each titration step, if more than 2 doses of rescue medication needed in 24 hr consider titration;
IM/SUBCUT/IV
1-2 mg q4-6hr prn, may be increased (opioid-naive patients may require lower dose);
RECT
3 mg q6-8hr prn
• Geriatric:
PO
1-2 mg q4-6hr
• Child
>
50 kg (unlabeled):
PO
2-4 mg q3-4hr in opioid-naive patients, titrate
• Infant
>
6 mo/child
<
50 kg (unlabeled):
PO
0.04-0.08 mg/kg q3-4hr in opioid-naive patients, titrate
• Adult:
Child-Pugh B, or C
(oral liquid, immediate rel tab, supp) give reduced dose based on response, impairment (parental) give 25% to 50% of dose (moderate impairment)
Available forms:
Inj 1, 2, 4, 10 mg/ml; tabs 2, 4, 8 mg; supp 3 mg; oral sol 5 mg/5 ml; ext rel tab 8, 12, 16 mg
•
Give with food or milk for GI irritation
•
Ext rel (Exalgo):
discontinue all other ext rel opioids, give q24hr; do not crush, break, chew
•
When pain is beginning to return; determine interval by response
Black Box Warning:
Do not use ext rel products in opioid-naive patients
•
Converting from oral opioids:
conversion ratios are approximate; initiate ext rel tabs at 50% of calculated total daily equivalent dose of ext rel, give q24hr; max increase q3-4days, consider titration increases of 25-50% with each step
•
Converting from transdermal patch (fentanyl):
initiate ext rel tabs 18
hr after removal of patch; for each 25 mcg/hr dose of transdermal fentaNYL dose is 12 mg q24hr, start dose at 50% of calculated HYDROmorphone ext rel dose q24hr; titrate no more often than q3-4days, consider dose increases of 25-50% with each step; if more than 2 rescue doses are required in 24 hr, consider titration
•
Use short 30G needle, make sure not to inject ID
•
Rotate inj sites
•
Direct,
diluted with 5 ml sterile water or NS; give through
Y
-connector or 3-way stopcock; give ≤2 mg over 3-5 min
•
IV INF:
Dilute each 0.1-1 mg/ml NS (0.1-1 mg/ml), deliver by opioid syringe infusor; may be diluted in D
5
W, D
5
/NaCl, 0.45% NaCl, NS for larger amounts, delivery through inf pump
Additive compatibilities:
Bupivacaine, cloNIDine, fluorouracil, heparin, midazolam, ondansetron, potassium chloride, promethazine, verapamil, ziconotide
Solution compatibilities:
D
5
W, D
5
/0.45% NaCl, D
5
/0.9% NaCl, D
5
/LR, D
5
/Ringer’s sol, 0.45% NaCl, 0.9% NaCl, Ringer’s and lactated Ringer’s sol
Syringe compatibilities:
Atropine, bupivacaine, cefTAZidime, chlorproMAZINE, cimetidine, dimenhyDRINATE, diphenhydrAMINE, fentaNYL, glycopyrrolate, hydrOXYzine, LORazepam, midazolam, pentazocine, promethazine, ranitidine, scopolamine, tetracaine, thiethylperazine, trimethobenzamide
Y-site compatibilities:
Acyclovir, allopurinol, amifostine, amikacin, amsacrine, aztreonam, cefamandole, ceFAZolin, cefepime, cefmetazole, cefoperazone, cefotaxime, cefOXitin, cefTAZidime, ceftizoxime, cefuroxime, cephalothin, cephapirin, chloramphenicol, cisatracurium, CISplatin, cladribine, clindamycin, cyclophosphamide, cytarabine, diltiazem, DOBUTamine, DOPamine, DOXOrubicin, DOXOrubicin liposome, doxycycline, EPINEPHrine, erythromycin lactobionate, famotidine, fentaNYL, filgrastim, fludarabine, foscarnet, furosemide, gentamicin, granisetron, heparin, kanamycin, labetalol, LORazepam, magnesium sulfate, melphalan, methotrexate, metroNIDAZOLE, mezlocillin, midazolam, milrinone, morphine, moxalactam, nafcillin, niCARdipine, nitroglycerin, norepinephrine, ondansetron, oxacillin, PACLitaxel, penicillin G potassium, piperacillin, piperacillin/tazobactam, propofol, ranitidine, remifentanil, teniposide, thiotepa, ticarcillin, tobramycin, trimethoprim-sulfamethoxazole, vancomycin, vecuronium, vinorelbine
CNS:
Drowsiness, dizziness, confusion, headache, sedation, euphoria
, mood changes,
seizures
CV:
Palpitations, bradycardia, change in B/P, hypotension, tachycardia, peripheral vasodilation
EENT:
Tinnitus, blurred vision, miosis, diplopia
GI:
Nausea, vomiting, anorexia, constipation, cramps
, dry mouth, paralytic ileus
GU:
Increased urinary output, dysuria, urinary retention
INTEG:
Rash
, urticaria, bruising, flushing, diaphoresis, pruritus
RESP:
Respiratory depression,
dyspnea
IM:
Onset 15-30 min, peak 1/2-1 hr, duration 4-5 hr, metabolized by liver, excreted by kidneys, crosses placenta, excreted in breast milk, half-life 2-3 hr
Increase:
effects—other CNS depressants (alcohol, opiates, sedative/hypnotics, antipsychotics, skeletal muscle relaxants)
Increase:
severe CNS, respiratory depression—MAOIs
Decrease:
HYDROmorphone effects—opiate antagonists
Increase:
action—chamomile, hops, kava, lavender, St. John’s wort, valerian
Increase:
amylase
Black Box Warning:
Respiratory dysfunction:
respiratory depression, character, rate, rhythm; notify prescriber if respirations <10/min
•
I&O ratio; check for decreasing output; may indicate urinary retention
•
CNS changes: dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction
•
Bowel function, constipation
•
Allergic reactions: rash, urticaria
•
Need for pain medication, physical dependence
•
Pain:
control, sedation by scoring on 0-10 scale, ATC dosing is best for pain control
•
Storage in light-resistant area at room temp
•
Assistance with ambulation
•
Safety measures: side rails, nightlight, call bell within easy reach
•
Therapeutic response: decrease in pain
•
To report any symptoms of CNS changes, allergic reactions
•
That physical dependency may result when used for extended periods; that withdrawal symptoms may occur: nausea, vomiting, cramps, fever, faintness, anorexia
•
To avoid driving, other hazardous activities because drowsiness occurs
Naloxone (Narcan) 0.2-0.8 mg IV (nontolerant patients), O
2
, IV fluids, vasopressors
Canada only Side effects:
italics
= common;
bold
= life-threatening Nurse Alert
(hye-drox-ee-klor′oh-kwin)
Apo-Hydroxyquine
, Plaquenil
Func. class.:
Antimalarial, antirheumatic (DMARDs)
Chem. class.:
4-Aminoquinoline derivative
Impairs complement-dependent antigen–antibody reactions
Malaria caused by susceptible strains of
Plasmodium vivax, P. malariae, P. ovale, P. falciparum
(some strains); SLE, rheumatoid arthritis
Unlabeled uses:
SLE in children
Hypersensitivity to this product or chloroquine; retinal field changes
Black Box Warning:
Children (long term), ocular disease
Precautions:
Pregnancy (C), breastfeeding, blood dyscrasias, severe GI disease, neurologic disease, alcoholism, hepatic disease, G6PD deficiency, psoriasis, eczema
Calculator
• Adult:
PO Suppression or prevention:
400 mg/wk, begin 1-2 wk before travel, continue 4 wk after returning;
treatment:
800 mg, then 400 mg after 6-8 hr, then 400 mg/day on 2nd and 3rd day, total dose 2 g
• Child:
PO Suppression or prevention:
6.4 mg/kg (5 mg/kg base) weekly, begin 1-2 wk before travel, continue 4 wk after returning;
treatment:
10 mg/kg, 6.4 mg/kg (5 mg/kg base) at 6, 18, 24 hr after 1st dose
• Adult:
PO
400 mg (310 mg base) daily-bid; length depends on patient response;
maintenance
200-400 mg/day
• Child (unlabeled):
PO
5 mg/kg/day, max 400 mg/day; long-term therapy is contraindicated
• Adult:
PO
400-600 mg/day for 4-12 wk then 200-300 mg/day after good response
Available forms:
Tabs 200 mg
•
Tabs may be crushed and mixed with food, fluids
•
With food or milk; at same time each day to maintain product level
•
For malaria, prophylaxis should be started 2 wk before exposure, continued for 4-6 wk after leaving exposure area
CNS:
Headache, stimulation, fatigue, irritability,
seizures,
bad dreams, dizziness, confusion, psychosis, decreased reflexes
CV:
Hypotension, heart block,
asystole with syncope
EENT:
Blurred vision, corneal changes, retinal changes, difficulty focusing
, tinnitus, vertigo, deafness, photophobia, corneal edema
GI:
Nausea, vomiting, anorexia
, diarrhea, cramps
HEMA:
Thrombocytopenia, agranulocytosis, leukopenia, aplastic anemia
INTEG:
Pruritus, pigmentation changes, skin eruptions, lichen-planus–like eruptions, eczema,
exfoliative dermatitis,
alopecia,
Stevens-Johnson syndrome,
photosensitivity
Peak 3 hr; terminal half-life 32-50 days; metabolized in liver; excreted in urine, feces, breast milk; crosses placenta, protein binding 45%
Increase:
digoxin, methotrexate levels
Increase:
antibody titer—rabies vaccine
Decrease:
hydroxychloroquine action—magnesium or aluminum compounds
Decrease:
effect of—live virus vaccines, botulinum toxoids
•
SLE, malaria symptoms:
before treatment and daily
•
Rheumatoid arthritis:
pain, swelling, ROM, temp of joints
•
Ophthalmic exam at baseline and q6mo if long-term treatment or product dosage >150 mg/day
•
Hepatic studies q wk: AST, ALT, bilirubin if patient receiving long-term treatment
•
Blood dyscrasias:
blood studies: CBC, platelets; WBC, RBC, platelets may be decreased; if severe, product should be discontinued; assess for malaise, fever, bruising, bleeding (rare)
•
For decreased reflexes: knee, ankle
•
ECG
during therapy: watch for depression of T waves, widening of QRS complex
•
Allergic reactions:
pruritus, rash, urticaria
•
For ototoxicity
(tinnitus, vertigo, change in hearing); audiometric testing should be done before, after treatment
For toxicity:
blurring vision, difficulty focusing, headache, dizziness, knee, ankle reflexes; product should be discontinued immediately
•
Storage in tight, light-resistant container at room temp; keep inj in cool environment
•
Therapeutic response: decreased symptoms of malaria, SLE, rheumatoid arthritis
•
To use sunglasses in bright sunlight to decrease photophobia; to wear protective clothing (photosensitivity)
•
That urine may turn rust or brown; that skin may become blue-black
•
To report hearing, visual problems, fever, fatigue, bruising, bleeding, which may indicate blood dyscrasias
Induce vomiting; gastric lavage; administer barbiturate (ultrashort acting), vasopressor, ammonium chloride; tracheostomy may be necessary