NS4P1 Medications

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  1. Filgrastim (Neupogen)
    -Class: colony-stimulating factors; Granulocyte colony stimulating Factor

    • -Indications: To prevent Febrile Neutropenia and associated infectionin patients who have received bone marrow–depressing antineoplastics for the treatment of nonmyeloid malignancies.
    • 2.Reduction of neutrophil recovery time in pts undergoing induction and consolidation chemotherapy for acute myelogenous leukemia.
    • 3. Management of severe/chronic neutropenia (associated also with HIV)4. Mobilization of hematopoietic progenitor cells into peripheral blood for collection by leukapheresis.

    -Actions A glycoprotein, filgrastim binds to and stimulates immature neutrophils to divide and differentiate. Also activates mature neutrophils.

    • -Side Effects
    • GI: SPLENIC RUPTURE, splenomegalyEENT: hemoptysisHemat: excessive leukocytosis, sickle cell crises, thrombocytopeniaResp: ACUTE RESPIRATORY DISTRESS SYNDROME, pulmonary infiltratesLocal: ALLERGIC REACTIONS, pain, redness at subcut siteMS: medullary bone pain

    • -Assessment
    • Monitor heart rate, BP, and respiratory status before and periodically during therapy.Assess bone pain throughout therapy.Monitor for signs and symptoms of allergic reactions (rash쎩 urticaria쎩 facial edema, wheezing쎩 dyspnea, (hypotension쎩 tachycardia). Usually occur within 30 min of administration. Treatment includes antihistamines쎩 steroids쎩 bronchodilators쎩 and/or epinephrine

    • -Labs
    • After bone marrow transplant, the daily dose is titrated by the neutrophil response. When the ANC is >1000/mm3 for 3 consecutive days, the dose should be reduced by 5 mcg/kg/day. If the ANC remains >1000/mm3 for 3 or more consecutive days, filgrastim is discontinued. If the ANC decreases to <1000/mm3, filgrastim should be resumed at 5 mcg/kg/day. monitor CBC with differential and platelet count twice weekly during initial 4 wk of therapy and during 2 wk after any dose adjustment.May cause ↓ platelet count and transient ↑ in uric acid, LDH, and alkaline phosphatase concentrations.

    • -Administration Info
    • Administer no earlier than 24 hr after cytotoxic chemotherapy, at least 24 hr after bone marrow infusion, and not during the 24 hr before administration of chemotherapy.
    • Refrigerate; do not freeze. Do not shake. May warm to room temperature for up to 6 hr before injection. Discard if left at room temperature for >6 hr. Vial is for 1-time use only.

    • SC: If dose requires >1 mL of solution, may be divided into 2 injection sites.May also be administered as a continuous subcut infusion over 24 hr after bone marrow transplantation.
    • IV Administration
    • Continuous Infusion: Diluent: Dilute in D5W. Refrigerate; do not freeze. Do not shake. May warm to room temperature for up to 6 hr before injection. Vial is for 1-time use only. Concentration: Dilute to a final concentration of at least 15 mcg/mL. If the final concentration is <15 mcg/mL, human albumin in a concentration of 2 mg/mL must be added to D5W before filgrastim to prevent adsorption of the components of the drug delivery system.

    • Rate: After chemotherapy dose is administered via infusion over 15–60 min.
    • After chemotherapy dose may also be administered as a continuous infusion.
    • After bone marrow transplant, dose should be administered as an infusion over 4 or 24 hr.

    • -Family Teaching
    • Advise female patient to notify health care professional if pregnancy is planned or suspected or if breast feeding. Encourage patients that become pregnant during therapy to enroll in Amgen's Pregnancy Surveillance Program

    Home Care Issues: Instruct patient on correct technique and proper disposal for home administration. Caution patient not to reuse needle, vial, or syringe. Provide patient with a puncture-proof container for needle and syringe disposal.
  2. Epoetin Alfa (Epogen or Erythropoietin or Procrit)
    -Class: Antianemic. Hormones: erythropoiesis stimulating agents (ESA)

    -Indications: To Increase hematocrit in anemia; For anemia associated with CKD, Zidovudine(AZT) therapy in HIV pts, chemotherapy in nonmyeloid malignancies. Also to reduice the need for allogeneic red blood cell transfusions in patients undergoing elective, noncardiac, nonvascular surgery.

    -Actions: Stimulates erythropoiesis (production of red blood cells) and Maintains and may elevate RBCs, decreasing the need for transfusions.

    • -Side Effects
    • CNS: SEIZURES, headacheCV: HF, MI, STROKE, THROMBOEMBOLIC EVENTS (ESPECIALLY WITH HEMOGLOBIN >11 G/DL), hypertensionDerm: transient rashesEndo: restored fertility, resumption of mensesMisc: ↑ mortality and ↑ tumor growth (with hemoglobin ≥12 g/dL)

    Watch for hypertension, headache and nausea

    • -Assessment
    • Monitor BP before and during therapy
    • Monitor for symptoms of anema (Fatigue, dyspnea, pallor)
    • Monitor dialysis shunts for thrill and bruit
    • Monitor hematocrit

    • **CONTRAINDICATIONS:
    • 1. Hemoglobin > 11 mg/dl
    • 2. Hypersensitivity to albumin

    • **Precautions: poorly controlled hypertenison
    • patients with cancers of myeloid origin

    • -Labs
    • CBC diff, platelets and BP!
    • May cause ↑ in WBCs and platelets. May ↓ bleeding times.Monitor serum ferritin, transferrin, and iron levels to assess need for concurrent iron therapy. Transferrin saturation should be at least 20% and ferritin should be at least 100 ng/mL. If ↑ in hemoglobin continues and exceeds 11 g/dL, dose should be withheld until hemoglobin begins to ↓

    • -Administration Info
    • IV Admin: Transfusions are still required for severe symptomatic anemia. Supplemental iron should be initiated with epoetin and continued throughout therapy.
    • Institute seizure precautions in patients who experience greater than a 4-point increase in hematocrit in a 2-wk period or exhibit any change in neurologic status. Risk of seizures is greatest during the first 90 days of therapy.
    • SC: This route is often used for patients not requiring dialysis.
    • May be admixed in syringe immediately before administration with 0.9% NaCl with benzyl alcohol 0.9% in a 1:1 ratio to prevent injection site discomfort.
    • Direct IV: Diluent: Administer undiluted or dilute with an equal amount of 0.9% NaCl. Concentration: 1000–40,000 units/mL.
    • Rate: May be administered as direct injection or bolus over 1–3 minutes into IV tubing or via venous line at end of dialysis session.
    • NOTE: Contraindicated in: uncontrolled hypertensions, pts with erythropoetin levels > 200 mUnits/mL

    • -Family Teaching
    • Explain rationale for concurrent iron therapy (increased red blood cell production requires iron).
    • Anemia of Chronic Renal Failure: Stress importance of compliance with dietary restrictions, medications, and dialysis. Foods high in iron and low in potassium include liver, pork, veal, beef, mustard and turnip greens, peas, eggs, broccoli, kale, blackberries, strawberries, apple juice, watermelon, oatmeal, and enriched bread. Epoetin will result in increased sense of well-being, but it does not cure underlying disease.

    • NOTES
    • 1. Don't shake solution: may denature glycoprotein
    • 2. Montiro hct, hemoglboin and serum iron levels as well as fluid and electrolyte balance
    • 3. MONITOR FOR SEIZURES: rapid increase in hematocrit level increase risk of HYPERENSIVE ENCEPALOPATHY
  3. Erythromycin
    -Class: Antiinfective. Macrolide.

    -Indications For infections (Infections caused by susceptible organisms including:Upper and lower respiratory tract infections,Otitis media (with sulfonamides),Skin and skin structure infections,Pertussis,Diphtheria,Erythrasma,Intestinal amebiasis,Pelvic inflammatory disease,Nongonococcal urethritis,Syphilis,Legionnaires' disease,Rheumatic fever.)-Actions: Suppresses protein synthesis at the level of the 50S bacterial ribosome.

    • -Side Effects
    • CNS: seizures (rare)EENT: ototoxicityCV: TORSADE DE POINTES, VENTRICULAR ARRHYTHMIAS, QT interval prolongationGI: PSEUDOMEMBRANOUS COLITIS, nausea, vomiting, abdominal pain, cramping, diarrhea, hepatitis, infantile hypertrophic pyloric stenosis, pancreatitis (rare)GU: interstitial nephritisDerm: rashLocal: phlebitis at IV siteMisc: allergic reactions, superinfection

    • -Assessment
    • Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy.Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results.Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis.

    • -Labs
    • Monitor liver function tests periodically on patients receiving high-dose, long-term therapy.
    • May cause ↑ serum bilirubin, AST, ALT, and alkaline phosphatase concentrations.May cause false ↑ of urinary catecholamines.

    • -Administration Info
    • PO: around the clockIV: Add 10 mL of sterile water for injection without preservatives to 250- or 500-mg vials and 20 mL to 1-g vial. Solution is stable for 7 days after reconstitution if refrigerated.

    • Intermittent Infusion: Diluent: Dilute in 0.9% NaCl or D5W. Concentration: 1–5 mg/mL.
    • Rate: Administer slowly over 20–60 min to avoid phlebitis. Assess for pain along vein; slow rate if pain occurs; apply ice and notify health care professional if unable to relieve pain.
    • Continuous Infusion: May also be administered as an infusion over 4 hr. Diluent: 0.9% NaCl, D5W, or LR. Concentration: 1 g/L.

    • -Family Teaching
    • Instruct patient to take medication around the clock and to finish the drug completely as directed, even if feeling better. Take missed doses as soon as remembered, with remaining doses evenly spaced throughout day. Advise patient that sharing of this medication may be dangerous.May cause nausea, vomiting, diarrhea, or stomach cramps; notify health care professional if these effects persist or if severe abdominal pain, yellow discoloration of the skin or eyes, darkened urine, pale stools, or unusual tiredness develops. May cause infantile hypertrophic pyloric stenosis in infants; notify health care professional if vomiting and irritability occur.Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional. May occur up to several weeks after discontinuation of medication.Advise patient to report signs of superinfection (black, furry overgrowth on the tongue; vaginal itching or discharge; loose or foul-smelling stools).Instruct patient to notify health care professional if symptoms do not improve.
  4. Macrolides
    Binds with Ribosomal receptor sites in susceptible organisms to inhibit bacterial protein synthesis. 

    3 drugs: Erythromycin, kAzithromycin, Clarithormycin

    TREATS: Upper respiratory, ear, skin infections, symphills (for penicillin sensitive pts); cholera and chancroid

    Contraindictations: Liver dysfunction. Avoid erythromycin with  per exisciting prlonged QT

    • SE: Diarrhea, n/v, abdominal pain, 
    • -High levels of erythromycin can prlong QT inerval, therby psoing a risk of potentially fatal cardiac dysrhthmias. 

    • NURSING IMPLICATIONS: 
    • 1. Take med 1 hour before or 2 hours AFER food or antacids
    • 2. Aluminum and mg antacids reduce rate of absoption 
    • 3. Observe for s/s of suprainfection
    • 4.IV MUST BE INFUSED OVER 60 MINS
    • 5. For ERYTHROMYCIN: Monitor Warfarin levels and watch for prlonged QT inteval
  5. Pantoprazole
    -Class: antiulcer agents; Pharm. Class. proton pump inhibitors

    -Indications: Erosive esophagitis associated with GERD.Decrease relapse rates of daytime and nighttime heartburn symptoms on patients with GERD.Pathologic gastric hypersecretory conditions.Unlabeled Use(s):Adjunctive treatment of duodenal ulcers associated with Helicobacter pylori.

    -Actions: Binds to an enzyme in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen.

    • -Side Effects
    • CNS: headacheGI: PSEUDOMEMBRANOUS COLITIS, abdominal pain, diarrhea, eructation, flatulenceEndo: hyperglycemiaF and E: hypomagnesemia (especially if treatment duration ≥3 mo)MS: bone fracture

    -Assessment: Assess patient routinely for epigastric or abdominal pain and for frank or occult blood in stool, emesis, or gastric aspirate.

    -Labs: May cause abnormal liver function tests, including ↑ AST, ALT, alkaline phosphatase, and bilirubin.May cause hypomagnesemia. Monitor serum magnesium prior to and periodically during therapy.

    • -Administration Info
    • IV Administration
    • IV: Reconstitute each vial with 10 mL of 0.9% NaCl. Reconstituted solution is stable for 6 hr at room temperature.
    • Direct IV: Diluent: Administer undiluted. Concentration: 4 mg/mL.
    • Rate: Administer over at least 2 min.Intermittent Infusion: Diluent: Dilute further with D5W, 0.9% NaCl, or LR. Concentration: 0.4–0.8 mg/mL. Diluted solution is stable for 24 hr at room temperature.Rate: Administer over 15 min at a rate of <3 mg/min.

    • -Family Teaching
    • Instruct patient to take medication as directed for the full course of therapy, even if feeling better.
    • Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation.Advise patient to report onset of black, tarry stools; diarrhea; or abdominal pain to health care professional promptly.
  6. Cephalasporins
    DO NOT USE IN PTS WITH A HISTORY OF SEVERE REACTION TO PENICILLIN!

    Each generation has increasing bactericidal activity to break down gram neg bacteria as well as to reach the cerbrospinal fluid. They interfere with BACTERIAL CELL WALL SYNTHESIS and are considered broad-specturm. The Cell weakens, swells, bursts and dies as a result of increased osmotic pressure inside he cell. Increased Cephalosporin resistance is caused by production of beta lactmases. 

    SE: Suprainfection (ceftriaxone, cefoperazone and cefotetan may cause dbleeding tendencies).

    • Nursing implications:
    • 1. Notify of diarrhea: can promote C. Diff infection
    • 2.Evaluate IM and IV sites for reaction: abscess and thrombophlebitis (avoid by rotating injection sites and injecting in a dilute solution)
    • 3. DONT reconstitute ceftriaxone with any calcium diluents (Ringer's solution)
    • 4. Oral suspensions should be refrigerated. 
    • 5. Teach pt to report s/s of allergies (rash, itching, hives)

    Labs: Renal and hepatic studies

    • Watch for rash, anorexia, hypersensitivity and GI pain.
    • Cephalosporins penetrate well into most body fluids and the ECF of most tissues, especially when inflammation (which enhances diffusion) is present.

    • However, the only cephalosporins that reach CSF levels high enough to treat meningitis are
    • Ceftriaxone
    • Cefotaxime
    • Ceftazidime
    • Cefepime

    All cephalosporins penetrate poorly into ICF and the vitreous humor.

    Most cephalosporins are excreted primarily in urine, so their doses must be adjusted in patients with renal insufficiency. Cefoperazone and ceftriaxone, which have significant biliary excretion, do not require such dose adjustment.

    => First-generation cephalosporins: These drugs have excellent activity against Gram-positive cocciOral 1st-generation cephalosporins are commonly used for uncomplicated skin and soft-tissue infections, which are usually due to staphylococci and streptococci.

    => Second-generation cephalosporins are active against Gram-positive cocci & Certain gram-negative bacilli

    => Third-generation cephalosporins: These drugs are active against Haemophilus influenzae and some Enterobacteriaceae (eg, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis) that do not produce ampC β-lactamase or extended-spectrum β-lactamase (ESBL). Ceftazidime is also active against Pseudomonas aeruginosa

    Contraindications: Cephalosporins are contraindicated in patients who are allergic to them or who have had an anaphylactic reaction to penicillins.
  7. Propofol (Diprivan)
    -Class: General Anesthetics

    • -Indications
    • Induction of general anesthesia in children >3 yr and adults.
    • Maintenance of balanced anesthesia when used with other agents in children >2 mo and adults.
    • Initiation and maintenance of monitored anesthesia care (MAC).
    • Sedation of intubated, mechanically ventilated patients in intensive care units (ICUs).

    • -Actions
    • Short-acting hypnotic. Mechanism of action is unknown.Produces amnesia.Has no analgesic properties.

    • -Side Effects
    • CNS: dizziness, headacheResp: APNEA, coughCV: bradycardia, hypotension, hypertensionGI: abdominal cramping, hiccups, nausea, vomitingDerm: flushingLocal: burning, pain, stinging, coldness, numbness, tingling at IV siteMS: involuntary muscle movements, perioperative myocloniaGU: discoloration of urine (green)Misc: PROPOFOL INFUSION SYNDROME, fever

    • -Assessment
    • Assess respiratory status, pulse, and BP continuously throughout propofol therapy. Frequently causes apnea lasting ≥60 sec. Maintain patent airway and adequate ventilation. Propofol should be used only by individuals experienced in endotracheal intubation, and equipment for this procedure should be readily available.Assess level of sedation and level of consciousness throughout and following administration.
    • When using for ICU sedation, wake-up and assessment of CNS function should be done daily during maintenance to determine minimum dose required for sedation
    • Monitor for propofol infusion syndrome (severe metabolic acidosis, hyperkalemia, lipemia, rhabdomyolysis, hepatomegaly, cardiac and renal failure). Most frequent with prolonged, high-dose infusions (>5 mg/kg/hr for >48 hr) but has also been reported following large-dose, short-term infusions during surgical anesthesia

    -Labs: None

    - Toxicity Overdose:If overdose occurs, monitor pulse, respiration, and BP continuously. Maintain patent airway and assist ventilation as needed. If hypotension occurs, treatment includes IV fluids, repositioning, and vasopressors

    • -Administration Info
    • Direct IV: Diluent: Usually administered undiluted. If dilution is necessary, use only D5W. Shake well before use. Solution is opaque, making detection of contaminants difficult. Do not use if separation of the emulsion is evident. Contains no preservatives; maintain sterile technique and administer immediately after preparation.
    • Concentration: Undiluted: 10 mg/mL. If dilution is necessary, dilute to concentration ≥2 mg/mL.Discard unused portions and IV lines at the end of anesthetic procedure or within 6 hr. For ICU sedation, discard after 12 hr if administered directly from vial or after 6 hr if transferred to a syringe or other container. Do not administer via filter <5–micron pore size.Aseptic technique is essential. Solution is capable of rapid growth of bacterial contaminants. Infections and subsequent deaths have been reported.
    • Rate: Administer over 3–5 min. Titrate to desired level of sedation. Frequently causes pain, burning, and stinging at injection site; use larger veins of the forearm, antecubital fossa, or a dedicated IV catheter.
    • Lidocaine 10–20 mg IV may be administered prior to injection to minimize pain. Pedi: Induction doses may be administered over 20–30 seconds.

    • -Family Teaching
    • Inform patient that this medication will decrease mental recall of the procedure.May cause drowsiness or dizziness. Advise patient to request assistance prior to ambulation and transfer and to avoid driving or other activities requiring alertness for 24 hr following administration.Advise patient to avoid alcohol or other CNS depressants without the advice of a health care professional for 24 hr following administration.
  8. Enoxaparin Sodium
    -Class
    -Indications
    -Actions
    -Side Effects
    -Assessment
    -Labs
    -Overdose?
    -Administration Info
    -Family Teaching
    Lovenox

    -Class: Anticoagulant/Antithrombotic (Low molecular weight heparins

    --Indications: Prevention of Venous Thromboemobolism, DVT, or PE in med surge patients, prevents ischemic complications (with aspirin) for unstable angina

    -Action: Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin.

    -Side effects: BLEEDING, Annemia, Thrombocytopenia, dizziness, hedache, n/v, increased liver enzymes, HYPERkalemia

    -Assessment: s/s bleeding, hemmorrhage

    -LABS: CBC, Platelets, H&H (If this decreases, assess for hemmorhage), aPTT, Therapeutic range of Antifactor Xa: 0.5-1 unit/mL, may cause increase in AST and ALT levels, May cause HYPERkalemia

    -OVERDOSE: Protamine Sulfate 1 mg for each mg of enoxaparin slowly administered IV

    => Administration: SubCutaneous tissue, . Alternate injection sites daily between the left and right anterolateral and left and right posterolateral abdominal wall. Inject entire length of needle at a 45° or 90° angle into a skin fold held between thumb and forefinger; hold skin fold throughout injection. Do not aspirate or massage. Rotate sites frequently. Do not administer IM because of danger of hematoma formation. Solution should be clear, colorless to pale yellow; do not inject solution containing particulate matter.

    => Family teaching: Don't take aspirin, Naproxen or ibuprofen without consulting a doctor. Report any signs of bleeding/bruising

    • NOTE: Double check that pt isn't already receiving Heparin.
    • Injections should always be 2 inches from umbilicus or any incisional area.
    • Labs: platelets, complete CBC.
  9. Heparin
    -Class: Anticoagulant/ Antithrombotic

    -For: prophylaxis & treatment of Venous Clots, PE's, A Fib Clots or Flush (10-100 units for patency)

    • => Action: Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin.
    • In low doses, prevents the conversion of prothrombin to thrombin by its effects on factor Xa.
    • Higher doses neutralize thrombin, preventing the conversion of fibrinogen to fibrin.

    • => Purpose: Prevent clot formation
    • Prevention of Deep Vein Thrombosis, Pulmonary Embolism, and emboli in atrial fib. Used to treat dissseminated intravascular coagulation.  Preffered fffor pregnancy. Prevents coagulation in heart-lung machines and dialyzers in patients after open heart surgery and dialysis

    => Side Effects: BLEEDING, Heparing Induced Thrombocytopenia (HIT)

    • => Assess for bleeding/Hemorrhage
    • **Precautions: Bleeding tendencies (hemophillia, dissecting aneurysim, peptic ulcer
    • Thrombocytopenia (uncontrollablebleeding, threatened abortion
    • Postop patients: especially eye, brain, and spinal cord surgeries, lumbar puncture and regional anesthisia.

    • **Side EFFECTS: 
    • -Heparin Inducedd Thrombocytopenia
    • -May supress renal function and result in spontaenous bleeding. 

    • => LABS:
    • -Monitor activated partial thromboplastin time (aPTT): 1.5-2.5 x control
    • -Hematocrit.
    • -Monitor Platelets Q2-3 days(may cause thrombocytopenia)
    • -Monitor AST and ALT; can cause hyperkalemia.

    • => PT Teaching:
    • 1. Avoid taking Aspirin, NSAIDS
    • 2. Garlic, Ginger, Chammmmomile tea..increases bleeding with Heparin.
    • 3. Caution patient to avoid IM injections and activities leading to injury and to use a soft toothbrush and electric razor during heparin therapy BLEEDING PRECAUTIONS!

    • NOTE: NOT GIVEN ORAL or IM!
    • Protamin sulfate is the antidote
    • Avoid aspirin or any med that decreases platelet aggregation (plavix)
    • ONLY GIVEN IV or SUBCUT. Apply firm pressure for 1-2 mins but DON"T massage!
  10. ceftraixone
    • -Aka Rocephin
    • -NOT TO BE CONFUSED WITH CEFAZOLIN

    -Class: Antiinfective/ 3rd class Cephalosporin

    -Action: Binds to the bacterial cell wall membrane, causing cell death.

    • -Adverse Side Effects: Seizures in High Doses, Anaphylaxis, Bone Marrow Supression, Super Infections, Rash
    • -Note: cross-allergy with penicillin (if a patient tells you s/he is allergic to penicillin, then s/he might also be allergic to cephalosporins)

    => LABS: Increase AST, ALT, alkaline phosphatase, bilirubin, LDH, BUN, and creatinine.

    => Pt teaching: Avoid alcohol, may give false positive for proteinuria and glycosuria
  11. Methylprednisolone
    -Trade: SoluMedrol

    -Class: Steroid (anti-inflammatory); immunosuppressants, Corticosteroids!

    -Action: Therapeutic Effect(s): Suppression of inflammation and modification of the normal immune response.

    => Side Effect: CNS Depression, HTN, PEPTIC ULCERS, Slows down wound healing, Increased Blood Sugar, Adrenal Supression, fluid retention, HYPOkalemia, Weight Loss, Muscle wasting, Osteoporosis, increases susceptibility to infection

    • => LABS:
    • Serum Electrolytes (Potassium-hypokalemia cause) and glucose (causes hyperglycemia)
    • WBCs may decrease
    • Tends to increase sodium and cholesterol/Lipid values
    • note: supresses allergy skin tests (tb--immunosupresses.)

    • => PT teaching:
    • Glucocorticoids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately

    .Long-term Therapy: Encourage patient to eat a diet high in protein, calcium, and potassium, and low in sodium and carbohydrates (see food sources for specific nutrients). Alcohol should be avoided during therapy.
  12. Digoxin:
    -Class: Antiarrythmic & Digitalis Glycoside

    -For: Heart Failure, A fib, A flutter, Tachycardia

    • => Action:
    • Increases the force of myocardial contraction.
    • Prolongs refractory period of the AV node.
    • Decreases conduction through the SA and AV nodes.
    • Therapeutic Effect(s): Increased cardiac output (positive inotropic effect) and slowing of the heart rate (negative chronotropic effect).
    • *Use Cautiously in:
    • Hypokalemia (↑ risk of digoxin toxicity);
    • Hypercalcemia (↑ risk of toxicity, especially with mild hypokalemia);
    • Hypomagnesemia (↑ risk of digoxin toxicity);
    • Diuretic use (may cause electrolyte abnormalities including hypokalemia and hypomagnesemia)

    => Side Effects: Weakness, n/v, bradycardia, Arrythmias,Hypokalemia (signs?), Thromboocytopenia and electrolyte imbalances

    • => DIG TOXICITY:*Digoxin will slow down the heart rate but increase contractility* The major point to remember about digoxin is that the therapeutic window is very narrow from 0.5-2.0ng/mL. Over 2.0ng/mL you will see signs of digoxin toxicity:
    • -Digoxin toxicity signs:yellow spots or halos
    • nausea
    • anorexia
    • vomiting
    • abdominal pain

    • => LABS:
    • Focus on Potassium, Magnesium and Calcium (Hypokalemia, hypomagnesemia, HYPERcalcemia--> susceptible to dig tox)

    • => Nursing Considerations
    • -Stop if Apical pulse < 60 BPM. (listen for one minute)
    • -Administer 1 hour before or 2 hours after meal (concurrent ingestion of high fiber meals may decrease absorption)

    => Teach pts: Signs of Hypokalemia. TO monitor apical Pulse.

    • DIGOXIN TOXICITIY: 
    • -Optimal level: 0.5-0.8 ng/mL
    • TOXIC:>2.0 ng/mL
    • Hypokalemia is the MOST common predisposig factor to toxicity

    • S/S: anorexia, n/v. 
    • CNS signs: fatigue, visual disturbances
    • Dysrhythmias: dig can mim most dysrhtymias. if cardiac rate or thythm changes,  notify doctor
  13. Furosemide:
    -Lasix (Loop Diuretic)

    -For Hypertension OR Edema due to HF, Hepatic impairment, or renal disease

    • => Action:
    • Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule.
    • Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium.
    • Effectiveness persists in impaired renal function.

    • => Side Effects:
    • -Hyperglycemia, Hypocalcemia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis, hypotension, increased BUN, aplastic anemia, leukopenia, thromocytopenia, parasthesias, PHOTOSENSITIVITY!

    • => Assess:
    • -Fluid status, BP, tinnitus and hearing loss, allergy for sulfonamides

    => LABS: elecrolytes, causes decreased sodium, calcium, mg BUT increases BUN , creatinine, glucose and uric acids

    => Pt teaching: change positions slowly, sunsscreen

    • =>Nursing Consideration: cross sensitivity with thiazides and sulfonamides may occur
    • Teach to take early in the day to decrease nocturia and report any hearing loss/ or s/ss of gout.
  14. Octreotide:
    -Class: Antidiarrheals, hormones

    -For: treating severe diarrhea or acromegaly (abnormal growth of the hands, feet, and face, caused by overproduction of growth hormone by the pituitary gland.)

    • => Action:
    • Suppresses secretion of serotonin and gastroenterohepatic peptides.
    • Increases absorption of fluid and electrolytes from the GI tract and increases transit time.
    • Decreases levels of serotonin metabolites.
    • Also suppresses growth hormone, insulin, and glucagon.


    • Therapeutic Effect(s):Control of severe flushing and diarrhea associated with GI endocrine tumors
    • NOTE: octreotide (Sandostatin):Hemostasis and conttrol of bleeding in esophageal and gastric vacrices, constriction of splanchnic arterial bed.

    => Side Effects: Diziness, drowsiness, visual disturbances, hypotension, bradycardia, hyper or hypoglycemia

    => Assess: frequency of stools, pulse, BP, fluids, electrolytes, turgor for dehydrations, s/s of hypoglycemia

    => LABS: Liver enzymes, decreased serum thyroxine (T4), 5-HIAA, serotonin

    => Pt teaching: drowsiness, diziness
  15. Isophane
    aka NPH Insulin, SubQ administration (Presence of protamine delays peak effect and prolongs action.)

    • -Trade names: HumuLIN
    • -Class: Antidiabetics, hormones, pancreatics

    -Indication: Control of hyperglycemia in patients with diabetes mellitus.

    -Action: Lowers blood glucose by: stimulating glucose uptake in skeletal muscle and fat,inhibiting hepatic glucose production.

    • =>Onset: 2-4 hours
    • => PEAK: 4-10
    • => DURATION: 10-16 hours

    • => Side Effects: Hypoglycemia, Lipodystrophy, pruritus, erythema, Anaphylaxis
    • -note: corticosteroids increase more demand for insulin

    • => Assessment:
    • -Hypoglycemic signs: anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait)

    -HYPERglycemia: confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; unusual thirst

    • => ADMINISTRATION:
    • 1. ONLY Insulin syringes can be used
    • 2. Rotate vial between palms, Don't shake (causes Inaccuarate doseages)
    • 3. When mixing: cloudy, clear, clear, cloudy (to avoid contamination of regular/clear insulin)
    • 4. Administer within 30-60 mins of a meal!

    => LABS:-A1C-Accuchecks

    => Patient Teaching: Explain this is to control diabetes, but dosen't control it. Nutrition guidelines. Advice to carry a source of sugar/candy and disease identification band.
  16. **Lispro
    -aka HumaLOG (RAPID acting)

    -Class: hormone, antidiabetic, pancreatics -For DM 1 & DM 2;

    - Action: Lowers blood glucose by:stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production.

    • =>Onset: within 15 minutes
    • => PEAK: 1-2
    • => DURATION:3-4 hours

    • => Side Effects: Hypoglycemia, Lipodystrophy, pruritus, erythema, Anaphylaxis
    • -note: corticosteroids increase more demand for insulin

    => LABS:-A1C-Accuchecks

    • => Assessment:
    • -Hypoglycemic signs: anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait)
    • -HYPERglycemia: confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; unusual thirst

    • => Admin:
    • -can be administered with intermediate or long acting (Due to the short duration of action, insulin lispro must be used with a longer acting insulin, insulin infusion pump or in combination with oral sulfonurea agents.)
    • - Administer insulin lispro within 15 min before a meal. Rotate injection sites. Do not administer IV.

    => Patient Teaching: Explain this is to control diabetes, but dosen't control it. Nutrition guidelines. Advice to carry a source of sugar/candy and disease identification band.
  17. Aspart
    -aka NovoLOG (also rapid acting)

    -Class: Antidiabetics, hormones, pancreatics

    -Indication: Control of hyperglycemia in patients with diabetes mellitus.

    -Action: Lowers blood glucose by :stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production.

    • =>Onset: within 15 minutes
    • => PEAK: 1-2
    • => DURATION:3-4 hours

    • => Side Effects: Hypoglycemia, Lipodystrophy, pruritus, erythema, Anaphylaxis
    • -note: corticosteroids increase more demand for insulin

    => LABS:-A1C-Accuchecks

    • => Assessment:
    • -Hypoglycemic signs: anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait)
    • -HYPERglycemia: confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; unusual thirst

    • => Admin:
    • -can be administered with intermediate or long acting (Due to the short duration of action, insulin lispro must be used with a longer acting insulin, insulin infusion pump or in combination with oral sulfonurea agents.)
    • - Administer insulin aspart subcut in the abdominal wall, thigh, or upper arm within 5–10 min before a meal. Rotate injection sites.
    • => Patient Teaching: Explain this is to control diabetes, but dosen't control it. Nutrition guidelines. Advice to carry a source of sugar/candy and disease identification band.
  18. **Regular Insulin
    -Trade: Humulin R, NovoLIN R

    • -Class: Ther. Class.antidiabetics hormone
    • Pharm. Class.pancreatics

    • -Indications: Control of hyperglycemia in patients with diabetes mellitus.
    • Action: Lowers blood glucose by:stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production.

    • =>Onset: 10-30 mins
    • => PEAK: 15-30 mins
    • => DURATION: 30-60 mins

    • => Side Effects: Hypoglycemia, Lipodystrophy, pruritus, erythema, Anaphylaxis
    • -note: corticosteroids increase more demand for insulin

    => Administer: 15-30 minutes before a meal.

    => LABS:-A1C-Accuchecks

    • => Assessment:
    • -Hypoglycemic signs: anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait)
    • -HYPERglycemia: confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; unusual thirst
  19. **Glargine
    -aka Lantus (LONG acting)

    • -Class: pancreatics, hormones
    • -For Type 1 & Type 2 DM
    • -Provides slower prolonged absorption and a relatively constant concentrations over 24 hr.

    • =>Onset: 3-4 hours
    • => PEAK: NONE
    • => DURATION: 24 hours

     LABS:-A1C-Accuchecks

    • => Assessment:-
    • Hypoglycemic signs: anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait)
    • HYPERglycemia: confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; unusual thirst

    • => ADMIN:
    • -DO NOT MIX WITH ANY OTHER INSULIN
    • - Administer subcut once daily at any time during the day, but at the same time each day. Do not administer IV or use with insulin pumps.
  20. Demerol (Meperidine)
    -Opioid Analgesic/Agonist

    -For moderate to severe pain

    -Action: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli, while producing generalized CNS depression.

    • => Side Effects: Hypotension, Bradycardia, RESP DEPRESSION, blurred vission, confusion, sedation, floating, Seizures.
    • -Worsened with alchol, antihistamines, sedatives/hypnotics.

    • => Assess: Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Dose may need to be decreased by 25–50%. Initial drowsiness will diminish with continued use.
    • -Bowel functions (constipation can be avoided with increased fluids/lax)
    • -Monitor patients on chronic or high-dose therapy for CNS stimulation (restlessness, irritability, seizures) due to accumulation of normeperidine metabolite. Risk of toxicity increases with doses >600 m g/24 hr, chronic administration (>2 days), and renal impairment.

    => LAB: May increase plasma amylase and lipase

    • => ADMIN stuff:
    • -Narcan/Naloxene is antidote (Dilute the 0.4-mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by direct IV push every 2 min.)

    => TEACH: causes drowsiness or dizziness, assistance when ambulating, move slowly to avoid orthastatic hyptonsion, Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.
  21. Morphine Sulfate
    -Opioid Analgesic

    - Action: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression ( agonist activity at the receptor site can result in alalgesisa, eulphoria, depression, hallucinations,, miosis, and sedation) 

    -Indications: For severe pain, pulmonary edema, and MI pain

    => Contraindications: Avoid bisulfites, alchohols, tartrazine, significant respiratory depression, severe bronchial asthma

    • => Side Effects: RESPIRATORY DEPRESSION, hypotension, bradycardia, sedation, confusion, constipation, urinary retions, physical dependence and tolerance
    • -↑ CNS depression with alcohol, sedative/hypnotics, clomipramine, barbiturates, tricyclic antidepressants, and antihistamines .

    => Assessment: Pain (type, location, intensity), LOC, BP, pulse.

    => LABS: Increases plasma amylase and lipase levels

    => ADMIN: PO with food and milk to minimize GI irritation

    • ------------
    • OTHER NOTES: 
    • -The opium poppy is one of nature's way of controlling pain


    SE: Decreased BP, resp depression, urinary retention, constipation, ortho hyptotension

    ROUTES: PO, IM, SC< PR or transdermal

    USES: releives pain AND decreases anxiety--therefore decreases myocardial oxygen demans with pain from a myocardial infraction

    Know: DONT administer if <10 RR/min

    CONTRAINDICATIONS:  hypersensitivity, intracranial pressure and suspectedd head injuries, heaptic and renal dysunftion
  22. Levofloxacin
    -Trade: Levaquin

    -Class: Antinfective/Fluoroquinolones

    -Action: Interferes with DNA Replication of gram negative bacteria

    • => Adverse Side Effects: 
    • diarrhea (b/c the normal flora in the gut is also destroyed)
    • decreased WBC and Hct
    • increased liver enzymes (AST, ALT)
    • elevated alkaline phosphatase (also from the liver)
    • Hepatotoxicity, Pseudotumor Cerebri (Elevateed ICP!)

    • => Nursing Considerations: culture and sensitivity before therapy starts
    • do not take with food (slows absorption); can take 1 hour before meals or 2 hours after meals
    • do not take with iron preps or antacids (slows absorption)
    • can take with Probenecid (a gout medication) - enhances benefits of fluoroquinolones

    • ==================
    • Fluoroquinolones (Class)
    • - Fights UTIs, URIs, GIs and soft tissue infections
    • -CIPRO NEEDS TO BE INFUSED OVER 60 MINS. Monitor PT times for patients with vanco.
    • -Watch for photosensitivity, no milk products, iron, zinc, mg and aluminum antacids 6 hours BEFORE and 2 hours AFTER ingestions
    • -Be careful in kids: can cause tendinitis or tendon rupture and in adult sover 60. Watch for C Diff.

    Action: Bactericidal; inhbiits DNA enzyme that interferes with replication; is considered broad spectrum against most ram negative and some gram positive bacteria, not not against anaerobic infections

    Contraindications: Hypersensitivity, h/o myastenia gravis, Avoid in children and pregnant
  23. Clindamycin Cleocin (clindamycin)
    => Class: anti-infectives

    => Purpose:-Inhibits protein synthesis in susceptible bacteria at the level of the 50S ribosome.Active against most gram-positive aerobic cocci, including:Staphylococci,Streptococcus pneumoniae,other streptococci, but not enterococci.

    • => Admin Precautions
    • -Safe: PO Most infections– 150–450 mg q 6 hr.-

    SE:CNS: dizziness, headache, vertigoCV: arrhythmias, hypotensionGI: PSEUDOMEMBRANOUS COLITIS, diarrhea, bitter taste (IV only), nausea, vomitingDerm: rashLocal: local irritation (topical products), phlebitis at IV site

    • IV Administration
    • pH: 5.5–7.0.Intermittent Infusion: Diluent: Vials must be diluted before use. Dilute a dose of 300 mg or 600 mg in 50 mL and a dose of 900 mg or 1200 mg in 100 mL. Compatible diluents include D5W, 0.9% NaCl, D5/0.9% NaCl, D5/0.45% NaCl, or LR. Admixed solution stable for 16 days at room temperature. Premixed infusion is already diluted and ready to use. Concentration: Not to exceed 18 mg/mL.
    • Rate: Not to exceed 30 mg/min. Hypotension and cardiopulmonary arrest have been reported following rapid IV administration.
    • -Therapeutic Effect(s):Bactericidal or bacteriostatic, depending on susceptibility and concentration. (For Skin infections, Acne,Osteomyelitis, Septicemia)
    • -Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy; Obtain specimens for culture and sensitivity prior to initiating therapy. First dose may be given before receiving results.-Monitor bowel elimination. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to HCP promptly as a sign of pseudomembranous colitis.-Assess patient for hypersensitivity (skin rash, urticaria).

    => Lab Levels:Monitor CBC; may cause transient ↓ in leukocytes, eosinophils, and platelets. May cause ↑ alkaline phosphatase, bilirubin, CPK, AST, and ALT concentrations.

    => Antidote? No.
  24. Ondansetron (Zofran)
    -Class: antiemetic. Pharm. Class.five ht3 antagonists

    -Indications Prevention of nausea and vomiting associated with highly or moderately emetogenic chemotherapy.PO: Prevention of nausea and vomiting associated with radiation therapy.Prevention and treatment of postoperative nausea and vomiting.

    • -Action
    • Blocks the effects of serotonin at 5-HT3–receptor sites (selective antagonist) located in vagal nerve terminals and the chemoreceptor trigger zone in the CNS.
    • Therapeutic Effect(s): Decreased incidence and severity of nausea and vomiting following chemotherapy or surgery.

    • Adverse Reactions/Side Effects
    • CNS: headache, dizziness, drowsiness, fatigue, weaknessCV: TORSADE DE POINTES, QT interval prolongationGI: constipation, diarrhea, abdominal pain, dry mouth, ↑ liver enzymesNeuro: extrapyramidal reactionsAssessmentAssess patient for nausea, vomiting, abdominal distention, and bowel sounds prior to and following administration.Assess patient for extrapyramidal effects (involuntary movements, facial grimacing, rigidity, shuffling walk, trembling of hands) periodically during therapy.Monitor ECG in patients with hypokalemia, hypomagnesemia, HF, bradyarrhythmias, or patients taking concomitant medications that prolong the QT interval.

    Lab Test Considerations:May cause transient ↑ in serum bilirubin, AST, and ALT levels.

    • => Implementation
    • First dose is administered prior to emetogenic event.
    • PO: For orally disintegrating tablets, do not attempt to push through foil backing; with dry hands, peel back backing and remove tablet. Immediately place tablet on tongue; tablet will dissolve in seconds, then swallow with saliva. Administration of liquid is not necessary.
    • IV Administration
    • Direct IV: Administer undiluted (2 mg/mL) immediately before induction of anesthesia or postoperatively if nausea and vomiting occur shortly after surgery.Rate: Administer over at least 30 sec and preferably over 2–5 min.
    • Intermittent Infusion: Diluent: Dilute doses for prevention of nausea and vomiting associated with chemotherapy in 50 mL of D5W, 0.9% NaCl, D5/0.9% NaCl, D5/0.45% NaCl. Solution is clear and colorless. Stable for 7 days at room temperature following dilution.
    • Concentration: 1 mg/mL.
    • Rate: Administer each dose over 15 min.

    • -Patient/Family Teaching
    • Instruct patient to take ondansetron as directed.Advise patient to notify health care professional immediately if symptoms of irregular heart beat or involuntary movement of eyes, face, or limbs occur.
  25. Potassium (Intermittent Infusion)
    • Potassium is never given by intravenous (IV) push or by the intramuscular or subcutaneous route.
    • A dilution of no more than 1 mEq/10 mL of solution is recommended (MUST ALWAYS BE DILUTED!)
    • After adding potassium to an IV solution, rotate and invert the bag to ensure that the potassium is distributed evenly throughout the IV solution.
    • Ensure that the IV bag containing potassium is properly labeled.
    • The maximum recommended infusion rate is 5 to 10mEq/hr, never to exceed 20 mEq/hr under any circumstances.
    • A client receiving more than 10 mEq/hr should be placed on a cardiac monitor and monitored for cardiac changes, and the infusion should be controlled by an infusion device.
    • Potassium infusion can cause phlebitis; therefore thenurse should assess the IV site frequently for signs of phlebitis or infiltration. If either occurs, the infusionshould be stopped immediately.
    • The nurse should assess renal function before administering potassium, and monitor intake and output during administration.

    • NURSING CONSIDERATIONS: 
    • 1. Monitor serum potassum
    • 2. Watch for signs of renal insufficienciy: increased creatinine and incread BUN-- stop potassium and notify doctor if renal failure symtoms


    • **Contraindications:
    • 1. HYPERkalemia
    • 2. REnal Impairment
    • 3. Untreated Addison disease

    SIDE EFFECTS: Gastro discomfort (N/V/D)
  26. Activated Partial Thromboplastin TIme (aPTT)
    -Evaluates how well the coagulation sequence (intrinsinc clotting system is function my measuring the amount of time ti takes in seconds for recalcified citrated plasma to clot after partial thromboplastin is added to it.

    -This test screens for deficiencies and inhitors of all factors, except factors 7 and 13.

    -Usually used to montiro the effectiveness of heparin therapy and screen for cagulation disorders

    => Value: 20-36 seconds; when receiving hep therapy, aPTT should be between 1.5-2.5


    • => Nursing consideration:
    • 1. Draw blood one hour BEFORE next heparine therapy dose
    • 2. Provide direct pressure to the venipuncture site for 3-5 minutes.
    • 3. If aPTT value is prlonged (longer than 90 seconds), initiate bleeding precautions.
  27. . Prothrombin Time (PT) and International Normalized Ration (INR)
    • -Prothrombin: a vitamin K Dependent glycoprotein produced by the live that is necessary for fibrin clot formation.
    • -PT measures the amount of time it takes in second for clot formation

    -Usedd to monitor response to warfarin/Coumadin

    -Screens for dysfunction of the exttrinsinc clotting system resulting from liver disease, vitamin K deficiency or Disseminated intravascular coagulation

    -A PT valvue within 2 seconds is NORMAL

    => INR is used for oral anticoagulation-Standardizes the PT ratio and is calcuated in the lab setting by raising the observed PT ratio to the power of the international sensitiviey index...

    • => Values:
    • -PT for male: 9.6-11 and Female: 9.5-11.3
    • -INR: 2-3 for standard warfarin therapy, 3-4.5 for high dose warfarin therapy

    • => Nursing consideration :
    • 1. IF pt is prescribed, baseline specimen should be drawn before anticoagulation therapy is started.
    • 2. Concurrent warfarin therapy WITH heparin therapy can lengthen the PT for up to 5 hours after dosing
    • 3. Diets high in green leafy veggies can increase the absoption of vitamin K, which shoftens the pT

Card Set Information

Author:
Radhika316
ID:
313778
Filename:
NS4P1 Medications
Updated:
2016-01-11 05:39:25
Tags:
NS4P1 NS4 Meds Medications Jamee Math
Folders:

Description:
filgrastim epoetin alfa Digoxin Heparin enoxaparin Insulin lispro NPH glargine Potassium (Intermittent Infusion) Erythromycin Morphine meperidine promethazine pantoprazole furosemide methylprednisolone cephalosporins clindamycin levofloxacin ondansetron octreotide propofol
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