Epinephrine CLASSIFICATIONS: Therapeutic: antiasthmatics, bronchodilators, vasopressors Pharmacologic: adrenergics INDICATIONS: Subcut: IV: Inhaln: Management of reversible airway

y disease due to asthma or COPD Subcut: IV: Management of severe allergic reactions IV, Intracardiac, Intratracheal, Intraosseous (part of advanced cardiac life support [ACLS] and pediatric advanced life support [PALS] guidelines): Management of cardiac arrest (unlabeled) Inhaln: Management of upper airway obstruction and croup (racemic epinephrine) Local/Spinal: Adjunct in the localization/prolongation of anesthesia ACTION Results in the accumulation of cyclic adenosine monophosphate (cAMP) at beta-adrenergic receptors Affects both beta1(cardiac)-adrenergic receptors and beta2(pulmonary)-adrenergic receptor sites Produces bronchodilation

Also has alpha-adrenergic agonist properties, which result in vasoconstriction Inhibits the release of mediators of immediate hypersensitivity reactions from mast cells Therapeutic Effects: Bronchodilation Maintenance of heart rate and blood pressure Localization/prolongation of local/spinal anesthetic CONTRAINDICATIONS: Contraindicated in: Hypersensitivity to adrenergic amines Cardiac arrhythmias Some products may contain bisulfites or fluorocarbons (in some inhalers) and should be avoided in patients with known hypersensitivity or intolerance Use Cautiously in: Cardiac disease (angina, tachycardia, MI) Hypertension Hyperthyroidism Diabetes Cerebral arteriosclerosis Glaucoma (except for ophthalmic use) Elderly patients (more susceptible to adverse reactions; may require dosage reduction) Pregnancy (near term)and lactation

ADVERSE REACTIONS/SIDE EFFECTS: CNS: nervousness, restlessness, tremor, headache, insomnia, Resp: paradoxical bronchospasm (excessive use of inhalers), CV: angina, arrhythmias, hypertension, tachycardia, GI: nausea, vomiting, Endo: hyperglycemia, PATIENT/FAMILY TEACHING: Instruct patient to take medication exactly as directed. If on a scheduled dosing regimen, take a missed dose as soon as possible; space remaining doses at regular intervals. Do not double doses. Caution patient not to exceed recommended dose; may cause adverse effects, paradoxical bronchospasm, or loss of effectiveness of medication: o Instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or chest pain o Advise patient to consult health care professional before taking any OTC medications or alcoholic beverages concurrently with this therapy. Caution patient also to avoid smoking and other respiratory irritants

Inhaln: Review correct administration technique (aerosolization, IPPB, metered-dose inhaler) with patient. See Appendix B for administration with metered-dose inhaler. Wait 1-5 min before administering next dose. Mouthpiece should be washed after each use: o Do not spray inhaler near eyes o Instruct patient to save inhaler; refill canisters may be available o Advise patients to use bronchodilator first if using other inhalation medications, and allow 5 min to elapse before administering other inhalant medications, unless otherwise directed o Advise patient to rinse mouth with water after each inhalation dose to minimize dry mouth o Advise patient to maintain adequate fluid intake (2000-3000 ml/day) to help liquefy tenacious secretions o Advice patient to consult health care professional if respiratory symptoms are not relieved or worsen after treatment if chest pain, headache, severe dizziness, palpitations, nervousness, or weakness occurs.

Atropine CLASSIFICATION: Therapeutic: antiarrhythmics Pharmacologic: anticholinergics , antimuscarinics INDICATIONS: IM: Given preoperatively to decrease oral and respiratory secretions IV: Treatment of sinus bradycardia and heart block PO: Adjunctive therapy in the management of peptic ulcer and irritable bowel syndrome IV: Reversal of adverse muscarinic effects of anticholinesterase agents (neostigmine, physostigmine, or pyridostigmine) IM: IV: Treatment of anticholinesterase (organophosphate pesticide) poisoning Inhaln: Treatment of exercise-induced bronchospasm ACTION: Inhibits the action of acetylcholine at postganglionic sites located in: Smooth muscle Secretory glands CNS (antimuscarinic activity) Low doses decrease: Sweating

Salivation Respiratory secretions Intermediate doses result in: Mydriasis (pupillary dilation) Cycloplegia (loss of visual accommodation) Increased heart rate GI and GU tract motility are decreased at larger doses Therapeutic Effects: Increased heart rate Decreased GI and respiratory secretions Reversal of muscarinic effects May have a spasmolytic action on the biliary and genitourinary tracts CONTRAINDICATIONS/PRECAUTIONS Contraindicated in: Hypersensitivity Narrow-angle glaucoma Acute hemorrhage Tachycardia secondary to cardiac insufficiency or thyrotoxicosis Obstructive disease of the GI tract Use Cautiously in: Elderly and the very young (increased susceptibility to adverse reactions) Intra-abdominal infections

 Prostatic hypertrophy Chronic renal, hepatic, pulmonary, or cardiac disease Pregnancy and lactation (safety not established; IV administration may produce fetal tachycardia) Children with spastic paralysis or brain damage Infants with Down's syndrome have increased sensitivity to cardiac effects and mydriasis ADVERSE REACTIONS/SIDE EFFECTS: CNS: drowsiness, confusion, hyperpyrexia, EENT: blurred vision, cycloplegia, photophobia, dry eyes, mydriasis, CV: tachycardia, palpitations, arrhythmias, GI: dry mouth, constipation, impaired GI motility, GU: urinary hesitancy, retention, impotency, Resp: tachypnea, pulmonary edema, Misc: flushing, decreased sweating, PATIENT/FAMILY TEACHING Instruct patient to take as directed. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses May cause drowsiness. Caution patients to avoid driving or other activities requiring alertness until response to medication is known

Instruct patient that oral rinses, sugarless gum or candy, and frequent oral hygiene may help relieve dry mouth Caution patients that atropine impairs heat regulation. Strenuous activity in a hot environment may cause heat stroke. Pedi: Instruct parents or caregivers that medication may cause fever and to notify health care professional before administering to a febrile child Instruct patient to consult health care professional before taking any OTC medications or herbal products concurrently with atropine Geri: Inform male patients with benign prostatic hypertrophy that atropine may cause urinary hesitancy and retention. Changes in urinary stream should be reported to health care professional

Furosemide CLASSIFICATIONS: Therapeutic: diuretics Pharmacologic: loop diuretics INDICATIONS: Edema due to: CHF Hepatic or renal disease Hypertension 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, hydrogen, and calcium May have renal and peripheral vasodilatory effects Effectiveness persists in impaired renal function Therapeutic Effects: Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions) Decreased blood pressure CONTRAINDICATIONS: Contraindicated in: Hypersensitivity

Cross-sensitivity with thiazides and sulfonamides may occur Pre-existing electrolyte imbalance, hepatic coma, or anuria Some liquid products may contain alcohol, avoid in patients with alcohol intolerance Use Cautiously in: Severe liver disease (may precipitate hepatic coma; concurrent use with potassium-sparing diuretics may be necessary) Electrolyte depletion Geri: Geriatric patients may have increased risk of side effects, especially hypotension and electrolyte imbalance, at usual doses ADVERSE REACTIONS/SIDE EFFECT: CNS: dizziness, encephalopathy, headache, insomnia, nervousness, EENT: hearing loss, tinnitus, CV: hypotension, GI: constipation, diarrhea, dry mouth, dyspepsia, nausea, vomiting, GU: excessive urination, Derm: photosensitivity, rashes, Endo: hyperglycemia,

F and E: dehydration, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis, Hemat: blood dyscrasias, Metab: hyperglycemia, hyperuricemia, MS: arthralgia, muscle cramps, myalgia, Misc: increased BUN, PATIENT/FAMILY TEACHING Instruct patient to take furosemide as directed. Take missed doses as soon as possible; do not double doses Caution patient to change positions slowly to minimize orthostatic hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic hypotension Instruct patient to consult health care professional regarding a diet high in potassium Advise patient to consult health care professional before taking OTC medication or herbal products concurrently with this therapy Instruct patient to notify health care professional of medication regimen before treatment or surgery Geri: Caution older patients or their caregivers about increased risk for falls. Suggest strategies for fall prevention

Advise patient to contact health care professional immediately if muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs Advise patient taking furosemide tablets not to change brands when refilling prescription; bioavailability among brands is variable Advise diabetic patients to monitor blood glucose closely; may cause increased blood glucose levels Hypertension: Advise patients on antihypertensive regimen to continue taking medication even if feeling better. Furosemide controls but does not cure hypertension

Nalbuphine Nubain CLASSIFICATIONS: Therapeutic: opioid analgesics Pharmacologic: opioid agonists/analgesics INDICATIONS Moderate to severe pain Also provides: Analgesia during labor Sedation before surgery Supplement to balanced anesthesia ACTION Binds to opiate receptors in the CNS Alters the perception of and response to painful stimuli while producing generalized CNS depression In addition, has partial antagonist properties, which may result in opioid withdrawal in physically dependent patients Therapeutic Effects: Decreased pain CONTRAINDICATIONS/PRECAUTIONS: Contraindicated in: Hypersensitivity to nalbuphine or bisulfites

Patients who are physically dependent on opioids and have not been detoxified (may precipitate withdrawal) Use Cautiously in: Head trauma Increased intracranial pressure Severe renal, hepatic, or pulmonary disease Hypothyroidism Adrenal insufficiency Alcoholism Undiagnosed abdominal pain Prostatic hypertrophy Patients who have recently received opioid agonists ADVERSE REACTIONS/SIDE EFFECTS: CNS: dizziness, headache, sedation, confusion, dysphoria, euphoria, floating feeling, hallucinations, unusual dreams, EENT: blurred vision, diplopia, miosis (high doses), Resp: respiratory depression, CV: hypertension, orthostatic hypotension, palpitations, GI: dry mouth, nausea, vomiting, constipation, ileus, GU: urinary urgency, Derm: clammy feeling, sweating, Misc: physical dependence, psychological dependence, tolerance,

PATIENT/FAMILY TEACHING Instruct patient on how and when to ask for pain medication May cause drowsiness or dizziness. Advise patient to call for assistance when ambulating and to avoid driving or other activities requiring alertness until response to the medication is known Caution patient to change positions slowly to minimize orthostatic hypotension Advise patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may decrease dry mouth Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis Advise patient to avoid concurrent use of alcohol or other CNS depressants with this medication

Diphenhydramine CLASSIFICATIONS: Therapeutic: allergy, cold, and cough remedies, antihistamines , antitussives INDICATIONS Relief of allergic symptoms caused by histamine release including: Anaphylaxis Seasonal and perennial allergic rhinitis Allergic dermatoses Parkinson's disease and dystonic reactions from medications Mild nighttime sedation Prevention of motion sickness Antitussive (syrup only) ACTION Antagonizes the effects of histamine at H1-receptor sites; does not bind to or inactivate histamine Significant CNS depressant and anticholinergic properties Therapeutic Effects: Decreased symptoms of histamine excess (sneezing, rhinorrhea, nasal and ocular pruritus, ocular tearing and redness, urticaria) Relief of acute dystonic reactions

Prevention of motion sickness Suppression of cough

CONTRAINDICATIONS: Contraindicated in: Hypersensitivity Acute attacks of asthma Lactation Known alcohol intolerance Use Cautiously in: Geri: Appears on Beers list. Geriatric patients are more susceptible to adverse drug reactions and anticholinergic effects (delirium, acute confusion, dizziness, dry mouth, blurred vision, urinary retention, constipation, tachycardia); dosage reduction or non-anticholinergic antihistamine recommended Severe liver disease Narrow-angle glaucoma Seizure disorders Prostatic hypertrophy Peptic ulcer May cause paradoxical excitation in young children Hyperthyroidism Pregnancy (safety not established)

ADVERSE REACTIONS/SIDE EFFECTS: CNS: drowsiness, dizziness, headache, paradoxical excitation (increased in children), EENT: blurred vision, tinnitus, CV: hypotension, palpitations, GI: anorexia, dry mouth, constipation, nausea, GU: dysuria, frequency, urinary retention, Derm: photosensitivity, Resp: chest tightness,, thickened bronchial secretions, , wheezing, Local: pain at IM site, PATIENT/FAMILY TEACHING Instruct patient to take medication as directed; do not exceed recommended amount. Caution patient not to use oral OTC diphenhydramine products with any other product containing diphenhydramine, including products used topically Geri: Instruct older adults to avoid OTC products that contain diphenhydramine due to increased sensitivity to anticholinergic effects and potential for adverse reactions related to these effects May cause drowsiness. Advise patient to avoid driving or other activities requiring alertness until response to drug is known. Pedi: Can cause excitation in children. Caution parents or caregivers about proper

dose calculation; overdosage, especially in infants and children, can cause hallucinations, seizures or death Inform patient that this drug may cause dry mouth. Frequent oral rinses, good oral hygiene, and sugarless gum or candy may minimize this effect. Notify dentist if dry mouth persists for more than 2 wk Advise patient to use sunscreen and protective clothing to prevent photosensitivity reactions Caution patient to avoid use of alcohol and other CNS depressants concurrently with this medication Advise patients taking diphenhydramine in OTC preparations to notify health care professional if symptoms worsen or persist for more than 7 days

Nicardipine CLASSIFICATIONS: Therapeutic: antianginals, antihypertensives Pharmacologic: calcium channel blockers INDICATIONS Management of: Hypertension Angina pectoris Vasospastic (Prinzmetal's) angina ACTION Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction Therapeutic Effects: o Systemic vasodilation resulting in decreased blood pressure o Coronary vasodilation resulting in decreased frequency and severity of attacks of angina CONTRAINDICATIONS: Contraindicated in: Hypersensitivity

Sick sinus syndrome 2nd- or 3rd-degree AV block (unless an artificial pacemaker is in place) BP <90 mmHg Advanced aortic stenosis Use Cautiously in: Severe hepatic impairment (dosage reduction recommended) Geriatric patients (dosage reduction/slower IV infusion rates recommended for most agents; increased risk of hypotension) Severe renal impairment (dosage reduction may be necessary) History of serious ventricular arrhythmias or CHF ADVERSE REACTIONS/SIDE EFFECTS: CNS: abnormal dreams, anxiety, confusion, dizziness, drowsiness, headache, jitteriness, nervousness, psychiatric disturbances, weakness, EENT: blurred vision, disturbed equilibrium, epistaxis, tinnitus, Resp: cough, dyspnea, shortness of breath, CV: ARRHYTHMIAS, CHF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, syncope, tachycardia, GI: abnormal results in liver function studies, anorexia, constipation, diarrhea, dry mouth, dysgeusia, dyspepsia, nausea, vomiting,

GU: dysuria, nocturia, polyuria, sexual dysfunction, urinary frequency, Derm: dermatitis, erythema multiforme, flushing, increased sweating, photosensitivity, pruritus/urticaria, rash, Endo: gynecomastia, hyperglycemia, Hemat: anemia, leukopenia, thrombocytopenia, Metab: weight gain, MS: joint stiffness, muscle cramps, Neuro: paresthesia, tremor, Misc: STEVENS-JOHNSON SYNDROME, gingival hyperplasia, PATIENT/FAMILY TEACHING Advise patient to take medication exactly as directed, even if feeling well. If a dose is missed, take as soon as possible unless almost time for next dose; do not double doses. May need to be discontinued gradually Instruct patient on technique for monitoring pulse. Instruct patient to contact health care professional if heart rate is <50 bpm Caution patient to change positions slowly to minimize orthostatic hypotension May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to the medication is known

Instruct patient to avoid concurrent use of alcohol or OTC medications, especially cold preparations, without consulting health care professional Advise patient to notify health care professional if irregular heartbeat, dyspnea, swelling of hands and feet, pronounced dizziness, nausea, constipation, or hypotension occurs or if headache is severe or persistent Caution patient to wear protective clothing and to use sunscreen to prevent photosensitivity reactions Angina: Instruct patient on concurrent nitrate or betablocker therapy to continue taking both medications as directed and to use SL nitroglycerin as needed for anginal attacks o Advise patient to contact health care professional if chest pain does not improve, worsens after therapy, or occurs with diaphoresis; if shortness of breath; or if persistent headache occurs Hypertension: Encourage patient to comply with other interventions for hypertension (weight reduction, low-sodium diet, smoking cessation, moderation of alcohol consumption, regular exercise, and stress management). Medication controls but does not cure hypertension o Instruct patient and family in proper technique for monitoring blood pressure. Advise patient to take blood pressure weekly and to report significant changes to health care professional

Diazepam CLASSIFICATIONS: Therapeutic: antianxiety agents, anticonvulsants, sedative/hypnotics, skeletal muscle relaxants (centrally acting) Pharmacologic: benzodiazepines INDICATIONS Adjunct in the management of: Anxiety Preoperative sedation Conscious sedation Provides light anesthesia and anterograde amnesia Treatment of status epilepticus/uncontrolled seizures Skeletal muscle relaxant Management of the symptoms of alcohol withdrawal ACTION Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter Produces skeletal muscle relaxation by inhibiting spinal polysynaptic afferent pathways Has anticonvulsant properties due to enhanced presynaptic inhibition Therapeutic Effects: Relief of anxiety

Sedation Amnesia Skeletal muscle relaxation Decreased seizure activity

CONTRAINDICATIONS/PRECAUTIONS Contraindicated in: Hypersensitivity Cross-sensitivity with other benzodiazepines may occur Comatose patients Pre-existing CNS depression Uncontrolled severe pain Narrow-angle glaucoma Pregnancy or lactation Use Cautiously in: Hepatic dysfunction Severe renal impairment History of suicide attempt or drug dependence Geri: Long--acting benzodiazepines cause prolonged sedation in the elderly. Appears on Beers list and is associated with increased risk of falls ( dose required or consider shortacting benzodiazepine.) Debilitated patients (dosage reduction required) Patients with low albumin

 Pedi: Metabolites can accumulate in neonates. Injection contains benzyl alcohol which can cause potentially fatal gasping syndrome in neonates ADVERSE REACTIONS/SIDE EFFECTS: CNS: dizziness, drowsiness, lethargy, depression, hangover, headache, paradoxical excitation, EENT: blurred vision, Resp: respiratory depression, CV: hypotension (IV only), GI: constipation, diarrhea (may be caused by propylene glycol content in oral solution), nausea, vomiting, Derm: rashes, Local: pain (IM), phlebitis (IV), venous thrombosis, Misc: physical dependence, psychological dependence, tolerance, PATIENT/FAMILY TEACHING Instruct patient to take medication exactly as directed and not to take more than prescribed or increase dose if less effective after a few weeks without checking with health care professional. Abrupt withdrawal of diazepam may cause insomnia, unusual irritability or nervousness, and seizures. Advise patient that sharing of this medication may be dangerous

Medication may cause drowsiness, clumsiness, or unsteadiness. Advise patient to avoid driving or other activities requiring alertness until response to medication is known. Geri: Advise geriatric patients of increased risk for CNS effects and potential for falls Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication Advise patient to notify health care professional if pregnancy is suspected or planned Emphasize the importance of follow-up examinations to determine effectiveness of the medication Seizures: Patients on anticonvulsant therapy should carry identification describing disease process and medication regimen at all times Carefully review package insert for Diastat rectal gel with patient/caregiver prior to administration