Morphine Sulfate

Trade Names

Actions/Pharmacodynamics

Indications

Contraindications

Adverse Effects

Nursing Considerations

Trade Names:  Astramorph PF, Avinza, Depo-Dur, Duramorph, Epimorph, Infumorph, , Kadian, MS Contin; MSIR, Oramorph SR, RMS, Roxanol, Statex

Actions:  natural opioid agonist - binds with the same receptors as endogenous opioid peptides.  analgesia, euphoria, respiratory depression and physical dependence; sedation, miosis, dysphoric, hallucinogenic, and cardiac stimulant effects.  Controls severe pain; also used as an adjunct to anesthesia

Indications:  

Contraindications: 

Adverse Effects: 

Nursing Considerations:  obtain baseline respiratory rate, depth and rhythm and size of pupils - respirations of 12/min and below and miosis are signs of toxicity; withhold drug and report to physician; observe pt. closely to be certain pain relief is achieved; watch for elevated pulse or respiratory rate, restlessness, anorexia or drawn facial expression that may indicate need for analgesia; differentiate restlessness as sign of pain and need for med, restlessness associated with hypoxia, and restlessness caused by morphine induced CNS stimulation (more common in women and older adults); monitor for respiratory depression for at least 24 h; assess vital signs at regular intervals; encourage changes in position, deep breathing, and coughing (unless contraindicated) at regularly scheduled intervals; be alert for nausea and orthostatic hypotension in ambulatory patients or when a supine patient assumes the head up position or in patients not experiencing severe pain; monitor I&O ratio and pattern.  EDUCATION:  avoid alcohol and other CNS depressants, avoid OTC meds, do not smoke, do not ambulate without assistance; use caution or avoid tasks requiring alertness

SCHEDULE II

Naloxone Hydrochloride

Trade Name(s)

Actions/Pharmacodynamics

Indications

Contraindications

Adverse Effects

Nursing Considerations

Trade Name:  Narcan

Actions/Pharmacodynamics:  NARCOTIC ANTAGONIST.  produces no significant analgesia, respiratory depression, psychotomimetic effects, or miosis when administered in the absence of narcotics and possesses more potent narcotic antagonist action. Reverses the effects of opiates, including respiratory depression, sedation and hypotension.

Indications:  Narcotic overdosage; complete or partial reversal of narcotic depression. Drug of choice when nature of depressant drug is not known and for diagnosis of suspected opioid overdosage.  Challenge for opioid dependence.  UNLABELED USES:  Shock and to reverse alcohol induced or clonidine-induced coma or respiratory depression.

Contraindications:  hypersensitivity to naloxone, naltrexone, nalmefene; respiratory depression due to nonopioid drugs; substance abuse; pregnancy (category C).

Adverse Effects:  BODY AS A WHOLE:  reversal of analgesia; tremors; hyperventilation; slight drowsiness; sweating.  CV:  increased BP, tachycardia.  GI:  nausea, vomiting.  Hematologic:  elevated partial thromboplastin time

Nursing Considerations:  Observe pt. closely - duration of action of some narcotics may exceed that of naloxone - repeat dose might be necesssary; may precipitate opiate withdrawal if administered to a pt. who is opiate dependent (narcotic abstinence symptoms induced by naloxone start to diminish in 20-40 minutes and disappear w/in 90 mins; monitor vitals; monitor surgical and obstetric patients closely for bleeding (can affect coagulation). Observe for reversal of analgesia (nausea, vomiting, sweating, tachycardia)

Hydromorphone Hydrochloride

Trade Name(s)

Actions/Pharmacodynamics

Indications

Contraindications

Adverse Effects

Nursing Considerations

Trade Names:  Dilaudid, Dilaudid-HP

Actions/Pharmacodynamics:  Semisynthetic derivative structurally similar to morphine but with 8-10x more potent analgesic effect.  More rapid onset and shorter duration of action than morphine, and is reported to have less hynotic effect.  An effective narcotic analgesic that controls mild to moderate pain.  Has antitussive properties.

Indications:  Relief of moderate to severe pain and control of persistent non-productive cough.

Contraindications:  Intolerance to opiate antagonists; opiate-naive patients; acute bronchial asthma, COPD, upper airway obstruction, decreased respiratory reserve, severe respiratory depression, pregnancy (Category C); lactation

Adverse Effects:  GI:  Nausea, vomiting, constipation.  CNS:  euphoria, dizziness, sedation, drowsiness(common).  CV:  Hypotension, bradycardia or tachycardia.  RESPIRATORY:  respiratory depression (life threatening).  SPECIAL SENSES:  Blurred vision. 

Nursing implications:  Note baseline respiratory rate, rhythm, depth and size of pupils before administration (respirations of 12/min or less and mitosis are signs of toxicity) - withhold drug and promptly notify physician); monitor vital signs and regular intervals (respiratory depression may occur); assess effectiveness of pain relief after 30 min; carefully monitor drug effects in older adults, debilitated patients and those with impaired renal and hepatic function; assess effectiveness of cough (drug depresses cough and sigh reflexes - may induce atelectasis); nausea and orthostatic hypotension most often occur in ambulatory pts or when supine pt. assumes head-up position; monitor I&O ratio and pattern, assess lower abd. for bladder distention, report oliguria or urinary retention; monitor bowel pattern - drug induced constipation may require treatment.  EDUCATION:  inform pt. to request med at onset of pain, not to wait until pain is severe; use caution when performing activities requiring alertness - drug can cause drowsiness, dizziness, blurred vision; avoid alcohol and other CNS depressants while on this drug

Baclofen

Trade Name(s)

Actions/Pharmacodynamics

Indications

Contraindications

Adverse Effects

Nursing Considerations

Trade Name(s): Kemstro, Lioresal

Actions/Pharmacodynamics: 

• skeletal muscle relaxant
• Depresses afferent reflex activity
• stimulates GABA receptors, decreasing excitatory input into alpha-motor neurons
• Reduces skeletal muscle spasm caused by upper motor neuron lesions

Indications:

• symptomatic relief of painful spasms in multiple sclerosis and in the management of spinal cord injury or disease
• UNLABELED USES:  treatment of trigeminal neuralgia and tardive dystonia associated with antipsychotic meds, chronic pain

Contraindications:

• Pregnancy (category C)
• coagulopathy
• bacteremia
• intramuscular or intrathecal administration
• subcutaneous administration

Adverse Effects:

• CNS:  transient drowsiness, vertigo, dizziness, weakness, fatigue, headache, confusion, insomnia; ataxia, loss of seizure control in epileptic patients; abrupt discontinuation of intrathecal administration can cause high fever, altered mental status, exaggerated rebound spasticity, muscle rigidity
• CV:  hypotension
• SPECIAL SENSES:  tinnitus, nasal congestion, blurred vision, mydriasis, nystagmus, diplopia, stabismus, miosis
• GI:  nausea, constipation, vomiting, jaundice
• Urogenital:  urinary frequency

Nursing Considerations

• supervise ambulation (loss of spasticity can affect ability to stand/walk)
• lab tests:  baseline and periodic BP, weight, blood sugar, hepatic function tests, urine
• monitor for adverse neuropsychiatric or genitourinary symptoms that resemble underlying disease...report to physician
• observe for side effects -mental confusion, depression, hallucinations
• monitor pts with epilepsy
• EDUCATION:  CNS depressant effects will be additive to other CNS depressants, including alcohol; monitor blood glucose if diabetic; do not drive or engage in other hazardous activity until response to drug is known; report adverse reactions (dose may be decreased); do not self-dose with OTC drugs w/o physician approval; do not stop taking drug unless directed by physician - withdrawal needs to be accomplished gradually over 2+ wks.  Abrupt withdrawal following prolonged admin. may cause anxiety, agitated behavior, hallucinations, tachycardia, spasticity, seizures

Orlistat

Trade Name(s)

Actions/Pharmacodynamics

Indications

Contraindications

Adverse Effects

Nursing Considerations

Trade Names

• Alli
• Xenical

Actions/Pharmacodynamics

• inhibitor of GI lipase
• reduces intestinal absorption of dietary fat by forming inactive enzymes w/ pancreatic and gastric lipase in the GI tract
• indicated by weight loss/decreased BMI.  Reduces intestinal absorption of dietary fat because at least 95% of orlistat is eliminated in the feces; reduces caloric intake in obese individuals

Indications

• weight loss and weight maintenance in obese patients
• reduce risk for weight regain after prior weight loss

Contraindications

• hypersensitivity to orlistat
• malabsorption syndrome
• cholestasis
• gallbladder disease
• hypothyroidism
• organic causes of obesity
• anorexia nervosa
• bulemia nervosa
• lactation
• safety not established in pts <16

Adverse Effects

• Fatigue
• headache, dizziness, anxiety
• hypertension
• stroke
• GI:  oily spotting, flatus with discharge, fecal urgency, fatty/oily stool, oily evacuation, increased defacation, fecal incontinence, abdominal pain/discomfort, nausea, infectious diarrhea, rectal pain/discomfort, vomiting
• tooth disorder, gingival disorder
• rash
• menstrual irregularity

Nursing Considerations:

• Monitor weight and BMI
• closely monitor diabetics for hypoglycemia
• monitor BP frequently
• EDUCATION:  take daily multivitamin containing fat-soluble vitamins at least 2h before/after orlistat; remember common GI adverse effects typically resolve after 4 wk therapy; avoid high fat meals to minimize adverse GI effects - distribute calories over 3 main meals/day; monitor weight several times/week; diabetics:  monitor blood glucose carefully following weight loss

Tiotropium Bromide

Trade Name(s)

Actions/Pharmacodynamics

Indications

Contraindications

Adverse Effects

Nursing Considerations

Trade Name:  Spiriva

Actions/Pharmacodynamics: 

• inhibits muscarinic receptors of smooth muscle in bronchial airways, resulting in bronchodilation (can last up to 24h)

Indications:

• maintenance treatment of bronchospasm associated with COPD

Contraindications:

• hypersensitivity to tiotropium, atropine, ipratropium
• acute bronchospasm
• pregnancy (category C)
• children <18

Adverse Effects:

• chest pain
• edema
• infection
• monoliasis
• flu-like syndrome
• cough
• allergic reaction
• dysphonia
• paraesthesia
• depression
• abdominal pain
• constipation
• dry mouth
• dyspepsia
• vomiting
• reflux
• stomatitis
• hypercholesteremia
• hyperglycemia
• myalgia
• skeletal pain
• epistaxis
• pharyngitis
• rhinitis
• laryngitis
• sinusitis
• upper respiratory tract infection
• rash
• cataract
• UTI

Nursing Considerations:

• withhold drug and notify physician if s/s of angioedema occurs
• monitor for anticholinergic effects (tachycardia, urinary retention)
• EDUCATION:  do not allow powdered meds to contact eyes - may cause blurred vision and dilated pupils; intended as once daily maintenance treatment (not useful for acute episodes of bronchospasm); withhold drug and notify physician if swelling around face, neck, mouth occurs; report:  constipation, increased HR, blurred vision, urinary difficulty

Heparin

Trade Name

Actions/Pharmacodynamics

Indications

Contraindications

Adverse Effects

Nursing Considerations

Trade Name:  Heparin

Actions/Pharmacodynamics: 

• directly affects cascade of blood coagulation by enhancing inhibitory actions of antithrombin III on factors essential to normal blood clotting, thereby blocking conversion of prothrombin to thrombin and fibrinogen to fibrin
• inhibits formation of new clots (does not lyse already existing thrombi, but may prevent their extension and propagation)

Indications:

• prevention and treatment of venous thrombosis and pulmonary embolism
• treatment of atrial fibrillation with embolization
• diagnosis and treatment of DIC
• prevention of clotting in blood samples and heparin lock sets and during dialysis procedures
• unlabeled:  adjunct therapy of coronary occlusion with acute MI, prevention of left ventricular thrombi and CVA post-MI, prevention of cerebral thrombosis in evolving CVA

Contraindications:

• history of hypersensitivity to heparin (white clot syndrome)
• active bleeding
• bleeding tendencies (hemophilia, purpura, throbocytopenia)
• jaundice
• ascorbic acid deficiency
• inaccessible ulcerative lesions
• visceral carcinoma
• open wounds
• extensiive denudation of skin
• advanced kidney, liver, or biliary disease
• active TB
• bacterial endocarditis
• tube drainage of stomach or small intestines
• threatened abortion
• suspected intracranial hemorrhage
• severe hypertension
• recent surgery of eye, brain or spinal cord
• spinal tap
• shock
• pregnancy (category C) - especially last trimester

Adverse effects:  Loss of hair; bruising, thrombocytopenia, elevated AST, ALT levels, hyperkalemia, chills, fever, urticaria, asthma, osteoporosis, suppression of renal function (long-term, high dose therapy), white clot syndrome

Nursing considerations:

• baseline blood coagulation tests - Hct, Hgb, RBC, platelet counts prior to initiation and at regular intervals throughout therapy
• monitor APTT (activated partial thromboplastin time) levels closely (adjust dose to keep b/w 1.5-2.5x normal level)
• blood coagulation tests 30 m before scheduled doses
• monitor vital signs - report fever, drop in BP, rapid pulse, S/S of hemorrhage
• observe needle sites for hematoma, inflammation
• EDUCATION:  protect from injury; notify physician of pink, red, dark brown or cloudy urine; red or brown vomit; red or black stools; bleeding gums; ecchymoses, hematoma; epitaxis, bloody sputum, chest pain, abd. or lumbar pain or swelling; increase in menstrual flow; pelvic pain, dizziness, headache, faintness
• heparin does not usually affect bleeding time - engage in normal activities as long as there is not a low platelet count
• smoking and alcohol may alter response to heparin and are not advised
• do not take aspirin or other OTC meds w/o physician approval

Nursing

Aliskiren

Trade Name

Actions/Pharmacodynamics

Indications

Contraindications

Adverse Effects

Nursing Considerations

Trade Name:  Tekturna

Action/Pharmacodynamics:

• renin inhibitor that reduces renin activity and inhibits conversion of angiotensinogen to angiotensin I and production of angiotensin II.
• lowers blood pressure by decreasing vasoconstriction and aldosterone production, thus reducing sodium reabsorption and fluid retention

Indications: treatment of hypertension, either as monotherapy or in combo with other antihypertensive agents

Contraindications:  hypersensitivity ot aliskiren, hyperkalemia, hypercalcemia, dehydration, pregnancy (category C 1st trimester; category D 2nd and 3rd trimester), lactation, children < 18

Adverse effects:  headache, dizziness, diarrhea, hyperkalemia, angioedema, rash

Nursing Considerations: 

• monitor for hypotension after initiation of therapy and after dose increase
• monitor for angioedema (withhold drug and notify physician
• periodic serum potassium lab test
• EDUCATION:  full therapeutic effect is usually obtained by wk 2; immediately report:  swelling of face, lips, tongue; difficulty breathing or swallowing; swelling of hands/feet; high fat meals interfere w/ absorption of drug