Medical Management

Drug Study

CELECOXIB

GENERIC NAME: Celecoxib

BRAND 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 8hours

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

SUGGESTED DOSE: 200mg twice a day.

ADVERSE EFFECTS:

CNS: Headache, dizziness, somnolence, insomnia,fatigue, tiredness,

dizziness, tinnitus,ophthamologiceffects
Dermatologic:
Rash,pruritus,
sweating,
dry
mucous
membranes,stomatitis
GI: Nausea, abdominal pain,dyspepsia,flatulence, GI bleed
Hematologic:
Neutropenia,eosinophilia,leukopenia,pancytopenia,
thrombocytopenia,agranulocytosis,granulocytopenia,aplasticanem
ia, decreased hemoglobin orhematocrit, bone marrow depression,
menorrhagia
Other: 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 bleeding
Aspirin= increase your risk of side effects if taken together.
Drug-food: take with full stomach= decrease the chance of stomach upset

NURSING 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

IV

CLASSIFICATION: 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
acidosis
Treatment of shock
Persons needing extra calories who cannot tolerate fluid overload

ORDERED DOSE: 1L @ 120cc/ hr

SUGGESTED DOSE: 1L @ 100- 120cc/ hr

SIDE 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: C
Hypersensitivity to any of the components.
Contains potassium, do not use with renal failure patients/Hyperkalemia
Liver Dysfunction

INTERACTIONS:
Should not be used with phenytoin (Dilantin) or amrinone (Inocor)
Increase risk of sodium and fluid retention; corticosteroids
Renal clearance of acidic drugs such as solicyeates and barbiturates
Increase 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 output
In 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 Fluid
Observe aseptic technique when changing IV fluid.
Dont give concentrated solutions IM or subcutaneously.

OMEPRON

GENERIC NAME:omeprazole

BRAND NAME:

CLASSIFICATION:

MECHANISM 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.

Omepron
Anti-secretory drug, Proton pump inhibitor

 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:

SUGGESTED DOSE: 40 mg IVTT once daily up to 5 days

SIDE EFFECTS: Headache, dizziness, vertigo, rash, dry skin, epistaxis,

diarrhea

40 mg IVTT @ 7:30 am

ADVERSE EFFECTS:
Dermatologic: skinrashes, urticaria, pruritus
Gastrointestinal: constipation, diarrhea, flatulence, nausea, vomiting, acid
regurgitation, abdominal pain
Others: 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 omeprazole
Administer before meals
Administer with antacids if needed
Report for severe headache
Monitor urinalysis for hematuria and proteinuria
Assess GI system: bowel sounds every 8hours

KETOROLAC

GENERIC NAME:Ketorolac

BRAND NAME: Ketomed, Toradol

CLASSIFICATION: Nonsteroidal
analgesics, Anti- pyretic

MECHANISM 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 pain

ORDERED DOSE: 07/24/15 15mg IVTT; 40x2doses

anti-inflammatory

agents,

non-opioid

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, dizziness
CV: hypertension
EENT: tinnitus
GI: nausea, vomiting, diarrhea, constipation, flatulence, dyspepsia,
epigastric pain, stomatitis
Hematologic: thrombocytopenia
Skin: rash, pruritus, diaphoresis
Other: 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
reactions
Monitor fluid intake and output.

ZEGEN
GENERIC NAME: Cefuroxime
BRAND NAME: Zegen
CLASSIFICATION: Antibacterial
MECHANISM 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
UTI
ORDERED DOSE: 7/23/15 (-) 1.5g IVTT
7/24/15 750mg IVTT (-) ANST
500mg 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

NUBAIN

GENERIC 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, urticarial
GI: Nausea, vomiting, cramps, dyspepsia, bitter taste, dry mouth
GU: 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 depression
Monitor I and O to determine if there is excessive fluid loss
Monitor blood pressure before and after administering the medication to
prevent any complication.

MIDAZOLAM

GENERIC NAME: Midazolam

BRAND NAME: Versed

CLASSIFICATION: Anxiolytics/Hypnotic and sedatives/Anticonvulsants

MECHANISM 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 reuptake 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 OR

SUGGESTED DOSE:
Preoperative Sedative
Adults
IM 0.07 to 0.08 mg/kg approximately 1 h before surgery.

Conscious Sedation
Adults
IV 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 ENEMA

GENERIC NAME: Sodium phosphate

BRAND NAME: Fleet Enema Extra, Fleet Pedia-Lax Enema

CLASSIFICATION: Laxative

MECHANISM 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:
Constipation
Fleet Enema/Fleet Enema Extra: 1 bottle/24 hrs
Bowel Cleansing
Colon 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, ascites
Intravenous 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 agent
Intravenous 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 dehydration
Do perianal care.

PLAIN LACTATED RINGER SOLUTION

GENERIC NAME: Plain Lactated Ringer

BRAND NAME: Baxter, Bruan

CLASSIFICATION: Non Pyrogenic Fluids and Electrolytes Isotonic

Solution

MECHANISM 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 line

 INTERACTION:
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