Medical Management

Medical ManagementDrug StudyCELECOXIB

GENERIC NAME: CelecoxibBRAND NAME: Celebrex; Coxib

CLASSIFICATION: Non-Steroidal Anti-Inflammatory Drugs/ analgesic

MECHANISM OF ACTION: Inhibition of the COX-2 enzyme,resulting in lower concentrations of prostaglandins which is activated in response to disease and inflammation that causes pain and discomfort; Does not affect the COX-1 enzyme, which protects the lining of the GI tract and has blood clotting and renal functions.

INDICATION: Management of acute pain and treat inflammation

ORDERED DOSE: 200 mg 1 cap 8hoursSUGGESTED DOSE: 200mg twice a day.

SIDE EFFECTS: diarrhea, gas or bloating, sore throat, cold symptomsADVERSE EFFECTS:

CNS: Headache, dizziness, somnolence, insomnia,fatigue, tiredness, dizziness, tinnitus,ophthamologiceffectsDermatologic: Rash,pruritus, sweating, dry mucous membranes,stomatitisGI: Nausea, abdominal pain,dyspepsia,flatulence, GI bleedHematologic: Neutropenia,eosinophilia,leukopenia,pancytopenia, thrombocytopenia,agranulocytosis,granulocytopenia,aplasticanemia, decreased hemoglobin orhematocrit, bone marrow depression, menorrhagiaOther: Peripheral edema,anaphylactoidreactions to anaphylactic shock

CONTRAINDICATIONS: Contraindicated with allergies to sulfonamides, celecoxib, NSAIDs, or aspirin; significant renal impairment; pregnancy (third trimester); lactation. Use cautiously with impaired hearing, hepatic, and CV conditions.INTERACTIONS:Drug-drug: warfarin= Increased risk of bleedingAspirin= increase your risk of side effects if taken together.Drug-food: take with full stomach= decrease the chance of stomach upsetNURSING RESPONSIBILITIES:Observe the 10 rights in giving the drug.

Monitor vital signs before and after giving the drug.Advice patient to take with food or milk to minimize GI upset.Tell patient to avoid alcohol while on the course of medication.Warn patient about the possible side effects and tell it is normal.Ask patient to repost any adverse effects such as dyspnea, tachycardia and severe headache. Tell patient to increase oral fluid intake in cases of diarrhea.

Lactated Ringers Solution with 5%Dextros (D5LR) GENERIC NAME: Lactated Ringers Solution with 5%Dextros (D5LR)

BRAND NAME: Euro-med 5% Dextrose in Lactated Ringers Solution, Vis IVCLASSIFICATION: Nonpyrogenic, parenteral fluid, electrolyte and nutrient replenisher

MECHANISM OF ACTION: Hypertonic solutions are those that have an effective osmolarity greater than the body fluids. These solutions draw fluid out of the intracellular and interstitial compartments into the vascular compartment, expanding vascular volume. It raises intravascular osmotic pressure and provides fluid, electrolytes and calories for energy

INDICATION:Replacement therapy particularly in extracellular fluid deficit accompanied by acidosisTreatment ofshockPersons needing extra calories who cannot tolerate fluid overloadORDERED DOSE: 1L @ 120cc/ hrSUGGESTED DOSE: 1L @ 100- 120cc/ hrSIDE EFFECTS: Increased serum osmolality, Hypernatremia, Hypokalemia, Altered thermoregulation, pulmonaryedema, cardiovascular overload

ADVERSE EFFECTS:Reactions which may occur because of the solution or the technique of administration includes: Febrile response; infection at the site of injection; venous thrombosis or phlebitis extending from the site of injection, extravasation: hypervolemia.Integumentary: Allergic reaction or anaphylactoid symptoms such as localized or generalized urticarial and pruritus;periorbital, facial ,and/or laryngeal edema;Respiratory: Coughing, sneezing and/or difficulty with breathing

CONTRAINDICATIONS:Pregnancy Category: CHypersensitivity to any of the components.Contains potassium, do not use with renal failure patients/HyperkalemiaLiver Dysfunction

INTERACTIONS:Should not be used with phenytoin (Dilantin) or amrinone (Inocor)Increase risk of sodium and fluid retention; corticosteroidsRenal clearance of acidic drugs such as solicyeates and barbituratesIncrease risk of hyperkalemia; increase renal clearance of lithium; decrease renal clearance of alkaline drug

NURSING RESPONSIBILITIES:Do not administer unless solution is clear and container is undamaged.Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin.Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis.Solution containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus.Check vital signs frequently; Report adverse reactions.Monitor fluid intake and outputIn very low birth weight infants or children, excessive or rapid administration of dextrose injection may result in increased serum osmolality and possible intracerebralhemorrhage.Properly label the IV FluidObserve aseptic technique when changing IV fluid.Dont give concentrated solutions IM or subcutaneously.

OMEPRON

GENERIC NAME:omeprazole

BRAND NAME:Omepron

CLASSIFICATION: Anti-secretory drug, Proton pump inhibitorMECHANISM OF ACTION: Gastric acid-pump inhibitor; suppresses gastric acid secretion by specific inhibitor of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal at the secretory surface of the gastric parietal cell; blocks the final step of acid production.

INDICATION: As an alternative for patients who cannot tolerate oral therapy in the following conditions: benign gastric ulcer, duodenal ulcer, gastroesopahgeal reflux disease.Acid aspiration prophylaxis

ORDERED DOSE:40 mg IVTT @ 7:30 am SUGGESTED DOSE: 40 mg IVTT once daily up to 5 daysSIDE EFFECTS:Headache, dizziness, vertigo, rash, dry skin, epistaxis, diarrheaADVERSE EFFECTS:Dermatologic: skinrashes, urticaria, pruritusGastrointestinal: constipation, diarrhea, flatulence, nausea, vomiting, acid regurgitation, abdominal painOthers: headache, photosensitivity, dizziness, lightheadedness, arthritic.

INTERACTIONS: Absorption of ketconazole, itraconazole, ampicillin esters, iron salts, and other drugs whose bioavailability is dependent on gastric pH may be reduced during omeprazole therapy as with other acid secretion inhibitors due to decreased intra-gastric activity.Omeprazole can delay elimination of diazepam, phenytoin, warfarin.

Plasma concentrations of omeprazole and clarithromycin are increased during concomitant oral administration.Caution with foods, devices, and cosmetics act prohibits dispensing without prescription.

NURSING RESPONSIBILITIES:Assess hypersensitivity to omeprazoleAdminister before mealsAdminister with antacids if neededReport for severe headacheMonitor urinalysis for hematuria and proteinuriaAssess GI system: bowel sounds every 8hours

KETOROLAC

GENERIC NAME:Ketorolac

BRAND NAME: Ketomed, ToradolCLASSIFICATION: Nonsteroidal anti-inflammatory agents, non-opioid analgesics, Anti- pyreticMECHANISM OF ACTION: Interferes with prostaglandin biosynthesis by inhibiting cyclooxygenase pathway of arachidonic acid metabolism; also act as potent inhibitor of platelet aggregation.INDICATION: Moderately severe acute painORDERED DOSE: 07/24/15 15mg IVTT; 40x2doses

SUGGESTED DOSE: 30mg IVTT every 6 hours

SIDE EFFECTS: Upset stomach, mild nausea or vomiting, diarrhea, constipation, mild heartburn, stomach pain, bloating, dizziness, headache, drowsiness, sweating, ringing in your ears.ADVERSE EFFECTS: CNS: drowsiness, headache, dizzinessCV: hypertensionEENT: tinnitusGI: nausea, vomiting, diarrhea, constipation, flatulence, dyspepsia, epigastric pain, stomatitisHematologic: thrombocytopeniaSkin: rash, pruritus, diaphoresisOther: excessive thirst, edema, injection site pain

CONTRAINDICATIONS: Contraindicated in patients with hypersensitivity to drug, its components, aspirin, or other NSAIDs, peptic ulcer disease, GI bleeding or perforation, advance renal impairment, risk of renal failure, increased risk of bleeding, suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis. Prophylactic use before major surgery, intraoperative use when hemostasis is critical. Labor and delivery, breastfeeding

INTERACTIONS: ACE inhibitors (such as captopril, lisinopril), angiotensin II receptor blockers (such as valsartan, losartan), corticosteroids (such as prednisone), methotrexate, probenecid, other medications that may affect the kidneys (including cidofovir), "water pills" (diuretics such as furosemide).

NURSING RESPONSIBILITIES:Monitor BP upon administration. < 90/80 never administer. Refer to doctor.Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria.Assess pain (note type, location, and intensity) prior to and 1-2hr following administration.Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy.Monitor for adverse reactions, especially prolonged bleeding time and CNS reactionsMonitor fluid intake and output.ZEGENGENERIC NAME: Cefuroxime

BRAND NAME: Zegen

CLASSIFICATION: AntibacterialMECHANISM OF ACTION: Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death.INDICATION: Treatment of bone and joint infections, bronchitis, gonorrhea, meningitis, otitis media, peritonitis, pharyngitis, sinusitis, skin infections, surgical infections and UTIORDERED DOSE:7/23/15 (-) 1.5g IVTT7/24/15 750mg IVTT (-) ANST500mg 1tab BID

SUGGESTED DOSE: 500mg 1tab BID

SIDE EFFECTS: Hypersensitivity to penicillins. Possible superinfection in prolonged use. Nephrotoxicity and ototoxicity.ADVERSE EFFECTS: Thrombophlebitis, pruritus, urticarial, diarrhea, nausea, pseudomembranous colitis. Decrease in hematocrit, transient increase in liver enzyme, elevation in serum creatinine and BUN. Possible seizure and angioedema.CONTRAINDICATON: Contraindicated with allergy to cephalosporins or penicillins. Use cautiously with renal failure, lactation, pregnancy

INTERACTION: Diuretics, probenecid

NURSING RESPONSIBILITIES: Give oral tablets with food to decrease GI upset and enhance absorption.Take full course of therapy even if you are feeling better.This drug is specific for this infection and should not be used to self treat other problems.They may experience stomach upset or diarrhea.Discontinue if hypersensitivity occurs

NUBAINGENERIC NAME: Nalbuphine Hydrochloride

BRAND NAME: Nubain

CLASSIFICATION: Opioid agonist antagonist analgesic

MECHANISM OF ACTION: Nalbuphine acts as an agonist at specific opioid receptors in the CNS to produce analgesia, sedation but also acts to cause hallucinations and is an antagonist at mu receptors.INDICATION: Relief of moderate to severe pain. Preoperative analgesia, supplement to surgical anesthesia, and for obstetric analgesia during labor and delivery.ORDERED DOSE: 7/24/15 5mg slow IVTT, PRN for pain every 4 hours

SUGGESTED DOSE: 10 mg/ml IVTT every 4 hours x 6doses, PRN

SIDE EFFECTS: feeling nervous or restless, depression, strange dreams, stomach pain, upset stomach, bitter taste in your mouth, skin itching or burning, mild rash, blurred vision, slurred speech, flushing (warmth, redness, or tingly feeling).ADVERSE EFFECTS: CNS: Sedation, Clamminess, sweating headache, nervousness, restlessness, depression, crying, confusion, faintness, hostility, unusual dreams, hallucinations, euphoria, dysphoria, unreality, dizziness, vertigo, floating feeling, feeling of heaviness, numbness, tingling, flushing, warmth, blurred vision.CV: Hypotension, Hypertension, bradycardia, tachycardia DERMATOLOGIC: Itching, burning, urticarialGI: Nausea, vomiting, cramps, dyspepsia, bitter taste, dry mouthGU: Urinary urgency RESPIRATORY: Respiratory depression, dyspnea, asthma

CONTRAINDICATION: Hypersensitivity to nalbuphine, sulfites; lactation.Use cautiously with emotionally unstable clients or those with a history of narcotic abuse; pregnancy prior to labor, labor or delivery, bronchial asthma, COPD, respiratory depression, anoxia, increased intracranial pressure, acute MI when nausea and vomiting are present, biliary tract surgery.

INTERACTION: Narcotic analgesic, general anesthesia, phenothiazines, sedatives, hyponotics, alcohol.

NURSING RESPONSIBILITIES:Monitor respiratory rate before and after giving nubain because it causes respiratory depressionMonitor I and O to determine if there is excessive fluid lossMonitor blood pressure before and after administering the medication to prevent any complication.MIDAZOLAM

GENERIC NAME: Midazolam

BRAND NAME: VersedCLASSIFICATION: Anxiolytics/Hypnotic and sedatives/AnticonvulsantsMECHANISM OF ACTION: Midazolam is a short-acting benzodiazepine. It exerts sedative and hypnotic, muscle relaxant, anxiolytic and anticonvulsant actions. While the probable anxiolytic action might be as a result of the drug's ability to increase glycine inhibitory neurotransmitter level, the hypnotic/anaesthetic action may be due to the occupation of the benzodiazepine and GABA receptors leading to membrane hyperpolarization and neuronal inhibition, and further interfering with the re-uptake of GABA at the synapses.

INDICATION: Preoperative sedative; conscious sedation prior to diagnostic, therapeutic or endoscopic procedures; induction of general anesthesia; supplement to nitrous oxide and oxygen for short surgical procedures; infusion for sedation of intubated and mechanically ventilated patients as a component of anesthesia or during treatment in critical care setting.ORDERED DOSE: 7/23/15 2mg IVTT on call to ORSUGGESTED DOSE: Preoperative SedativeAdultsIM 0.07 to 0.08 mg/kg approximately 1 h before surgery.Conscious SedationAdultsIV 1 to 2.5 mg as 1 mg/mL dilution over 2 min. Increase by small increments to total dose of no more than 5 mg in at least 2 min intervals; use less if patient is premedicated with other CNS depressants.

SIDE EFFECTS: Headache, Nausea, Drowsiness, Vomiting, Hiccups, Coughing, Pain, redness, or hardening of your skin at the injection site if the drug is given intravenously.

ADVERSE EFFECTS: Cardiovascular - Bigeminy; hypotension; PVCs; tachycardia; cardiac arrest; vasovagal episode; bradycardia; nodal rhythm.CNS - Headache; oversedation; retrograde amnesia; euphoria or dysphoria; confusion; argumentativeness; anxiety; emergence delirium and dreaming; nightmares; tonic/clonic movements; tremor; athetoid movements; ataxia; dizziness; slurred speech; paresthesia; weakness; loss of balance; drowsiness; nervousness; agitation; restlessness; prolonged emergence from anesthesia; insomnia; dysphonia.Dermatologic - Hives; hive-like elevation at injection site; swelling or feeling of burning; warmth or coldness at injection site; rash; pruritus.EENT - Vision disturbances; nystagmus; pinpoint pupils; cyclic eyelid movements; blocked ears; blurred vision; diplopia; difficulty focusing; loss of balance.GI - Nausea; vomiting; acid taste; excessive salivation; retching.Respiratory - Respiratory depression or arrest; decreased tidal volume, decreased respiratory rate; apnea, coughing; laryngospasm; bronchospasm; dyspnea; hyperventilation; wheezing; shallow respirations; airway obstruction; tachypnea.Others - Pain, tenderness and induration at injection site; yawning; chills; lethargy; weakness; toothache; faint feeling; hematoma; desaturation, apnea, hypotension, paradoxical reactions, hiccough, seizure-like activity, nystagmus (children).

CONTRAINDICATION: Acute narrow-angle glaucoma; coma or patients in shock, acute alcohol intoxication, intrathecal and epidural administration. Acute pulmonary insufficiency or marked neuromuscular respiratory weakness including unstable myasthenia gravis, severe respiratory depression.

INTERACTION: Anesthetics, inhalation - Inhalation anesthetics may need to be reduced if midazolam is used as an induction agent. IV administration decreases minimum alveolar concentration of halothane required for general anesthesia.Azole antifungal agents - Serum concentration of certain benzodiazepines may be increased and prolonged, producing enhanced CNS depression and prolonged effects.Barbiturates, alcohol, other CNS depressants - May prolong effect and increase risk of underventilation or apnea.Cimetidine - May increase midazolam levels.Oral Contraceptives - Coadministration may result in prolongation of benzodiazepine t .Droperidol, narcotics, secobarbital - May accentuate hypnotic effect of midazolam.Ethanol - Increased CNS effects with acute ethanol ingestion.

Fluvoxamine - Reduced clearance, prolonged t and increased serum concentrations of certain benzodiazepines may occur. Sedation or ataxia may be increased.Indinavir - Possibly severe sedation and respiratory depression.Propofol - Pharmacologic effects of propofol may be increased.Rifamycins - Pharmacokinetic parameters of benzodiazepines may be altered.Ritonavir - Possibly severe sedation and respiratory depression.Theophyllines - Sedative effects of benzodiazepines may be antagonized.Thiopental - Moderate reduction in induction dosage requirements has been noted following use of IM midazolam for premedication.Valproic acid - Pharmacokinetic parameters of benzodiazepines may be increased. Liver metabolism may be decreased.Verapamil - Effects of certain benzodiazepines may be increased, producing increased CNS depression and prolonged effects.

NURSING RESPONSIBILITIES:Do not use small veins for IV injection.Administer IM injections deep into muscle.Monitor IV injection site for extravasation.Arrange to reduce dosage of midazolam if patient is also being given oploid analgesics; reduce dosage by at least 50%and monitor patient closely.Monitor level of consciousness before, during, and for at least2-6 hours after administration of midazolam.Carefully monitor Pulse, Blood Pressure, and respirations during administration.

FLEET ENEMAGENERIC NAME: Sodium phosphate

BRAND NAME: Fleet Enema Extra, Fleet Pedia-Lax EnemaCLASSIFICATION: LaxativeMECHANISM OF ACTION: As a laxative, exerts osmotic effect in the small intestine by drawing water into the lumen of the gut, producing distention and promoting peristalsis and evacuation of the bowel.INDICATION: Relief of occasional constipation. Part of bowel cleansing regimen in preparing the colon for surgery, x-ray, or endoscopic examination.

ORDERED DOSE: 7/23/15 Fleet enema early AM

SUGGESTED DOSE: ConstipationFleet Enema/Fleet Enema Extra:1 bottle/24 hrsBowel CleansingColon Preparation for Surgery, X-Ray, or Endoscopic Examination:Fleet Enema/Fleet Enema Extra:1 bottle/24 hrs

SIDE EFFECT: More common: Abdominal or stomach pain, bloating, nausea, vomiting

ADVERSE EFFECT: Hypersensitivity, pruritus, dehydration, hyperphosphatemia, hypocalcemia, hypokalemia, hypernatremia, metabolic acidosis, N/V, abdominal pain/distention, diarrhea, GI pain, chills, blistering.

CONTRAINDICATION: Hypersensitivity to sodium phosphate salts or any component of the formulation; congenital megacolon, toxic megacolon, bowel obstruction, bowel perforation, imperforate anus (enema), congestive heart failure, ascitesIntravenous phosphate preparation: Should not be used in diseases with high phosphate levels, low calcium levels or hypernatremia.Oral: Should not be used in patients with kidney disease, unstable angina pectoris, gastric retention, ileus, acute obstruction or pseudo-obstruction, severe chronic constipation, acute colitis, or hypomotility syndrome (ie, hypothyroidism, scleroderma). Should not be used in patients on a sodium-restricted diet.INTERACTION: Antacids: Do not give with magnesium- and aluminum-containing antacids which can bind with phosphate.Bisphosphonates: Increased risk of hypoglycemia with concurrent use.Sucralfate: Do not give with sucralfate which can bind with phosphate.Oral preparations: May affect absorption of other medications due to rapid intestinal peristalsis and watery diarrhea caused by agentIntravenous preparation: Use caution with thiazide diuretics, may lead to renal damage

NURSING RESPONSIBILITIES:Provide privacy. To prevent feeling of embarrassment.Introduce solution slowly. To prevent sudden stimulation of peristalsis and the client can better tolerate introduction of solution.If abdominal cramps occur during introduction of solution, temporarily stop the flow of solution by clamping the tube until peristalsis relaxes.Assess for N/V, abdominal pain, hypersensitivity to product.Advise to inform physician if experiencing abdominal pain, N/V, sudden change in bowel habits. Encourage to drink large amounts of clear liquids to prevent dehydrationDo perianal care.

PLAIN LACTATED RINGER SOLUTIONGENERIC NAME: Plain Lactated RingerBRAND NAME: Baxter, BruanCLASSIFICATION: Non Pyrogenic Fluids and Electrolytes Isotonic SolutionMECHANISM OF ACTION: produces a metabolic alkalinizing effect. Lactate ions are metabolized ultimately to carbon dioxide and water, which requires the consumption of hydrogen cations.INDICATION: Lactated Ringers Injection, USP is indicated as a source of water and electrolytes or as an alkalinizing agent.

ORDERED DOSE: 7/24/15 PLR 1L OR

SUGGESTED DOSE: As directed by a physician. Dosage is dependent upon the age, weight and clinical condition of the patient as well as laboratory determinations.

SIDE EFFECT: Allergic reactions or anaphylactoid symptoms such as localized or generalized urticaria and pruritis; periorbital, facial, and/or laryngeal edema; coughing, sneezing, and/or difficulty with breathing.ADVERSE EFFECT: Febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from the site of infection, extravasation, and hypervolemia.CONTRAINDICATION: Patients with a known hypersensitivity to sodium lactate.In patients older than 28 days (including adults), ceftriaxone must not be administered simultaneously with intravenous calcium-containing solutions, including Lactated Ringers Injection, USP, through the same infusion lineINTERACTION: Corticosteroids - patients treated with drugs that may increase the risk of sodium and fluid retention.Renal clearance of acidic drugs such as salicylates and barbiturates may be increased.Renal clearance of alkaline drugs, such as sympathomimetics and dextroamphetamine sulfate, may be decreased.Renal clearance of lithium may also be increased.Because of its potassium content, this should be administered with caution in patients treated with agents or products that can cause hyperkalemia or increase risk of hyperkalemia, such as potassium sparing diuretics, ACE inhibitors, angiotensin II receptor antagonists, or the immunosuppressants tacrolimus and cyclosporine.thiazide diuretics or vitamin D - can increase the risk of hypercalcemia.

NURSING RESPONSIBILITIES:Do not administer unless solution is clear and container is undamaged. Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin.In very low birth weight infants, excessive or rapid administration of dextrose injection may result in increased serum osmolality and possible intracerebral hemorrhage.Check vital signs frequently; Report adverse reactions.Monitor fluid intake and output