Calcium Gluconate Description : electrolyte Indication : dietary supplement or treatment when calcium level is deficient (e.g.

e.g. tetany, hypoparathyroidism, postmenopausal, osteoporosis, rickets, osteomalacia) prevention of hypocalcemia during exchange transfusions for weak or ineffective myocardial contraction when epinephrine fails in cardiac resuscitation adjunctive therapy for: insect bites or stings sensitivity reactions (to reduce capillary permeability) depression due to overdose of magnesium sulfate acute symptoms of lead colic

Dosage and Administration: Adults : IV infusion preferred. 1 g contains 90 mg (4.5 mEq) calcium. 0.5 to 2 g as required; daily dose 1 to 15 g. Pediatrics: 500mg/kg/day IV given in divided doses. Side Effects : nausea, vomiting, constipation, pain, drowsiness, headache, muscle weakness, slowed heart rate, tingling sensation, sense of oppression or heat waves, peripheral vasodilation, local burning, decreased BP, bradycardia, cardiac arrhythmias, syncope, cardiac arrest, local irritation, severe necrosis, sloughing and abscess formation, hypercalcemia (anorexia, nausea, vomiting, constipation, abdominal pain, dry mouth, thrist, polyuria), rebound hyperacidity, milk-alkali syndrome (hypercalcemia, alkalosis, renal damage ) Special precautions: sensitivity to calcium, renal calculi, hypercalcemia, ventricular fibrillation during cardiac resuscitation, with risk of digitalis toxicity, use cautiously with renal impairement, pregnancy, lactation Nursing Considerations: Note allergy to calcium, renal calculi, hypercalcemia, digitalis toxicity, renal impairment Baseline assessment of: vital signs (P, BP), ECG, signs of hypocalcemia (mouth twitching, tingling, numbness, facial spasm, laryngospasm, carpopedal spasm, muscle cramps, bleeding tendencies, weak cardiac contractions), signs of digitalis toxicity (nausea, vomiting, anorexia, bradycardia, cardiac dsyrhythmia, visual disturbances) Review drugs taken by patient (thiazide diuretics can increase calcium levels)

Laboratory: serum electrolytes, urinalysis Assessment of intravenous site and patency of intravenous line Warm solution to body temperature, use small needle inserted to a large vein, infuse slowly (0.5 to 2mL/min), stop infusion if patient complains of discomfort, resume when symptoms disappear Avoid mixing calcium salt with carbonates, phosphates, sulfates, tartrates, amphotericin, cefazolin, clindamycin, dobutamin, prednisone (to prevent precipitation) Use 5% dextrose in water and not saline solution (because saline produces calcium loss) Have patient remain recumbent for a short time after infusion Instruct patient and patients guardian to report pain, uncomfortable sensation or symptoms related to calcium excess or cardiac dysrhythmia experienced by patient Monitor: o serial serum calcium levels, o metabolic alkalosis, o IV patency and site o cardiac response closely o ECG for onset of dysrhythmias or change in calcium levels (hypocalcemia: prolonged ST segment & QT interval; hypercalcemia: shortened ST segment & QT interval) Suggest to: o consume milk, and protein-rich foods (to enhance calcium absorption) o eating fruits and fiber (for improving bowel elimination)

Digoxin (Lanoxin) Description: cardiac glycoside Indications: treat congestive heart failure, atrial tachycardia, flutter or fibrillation Dosage and Administration: Adults: Loading dose, 0.75 to 1.25 mg PO or 0.125 to 0.25 mg IV. Maintenance dose, 0.125 to 0.25 mg/day PO. Pediatrics: Maintenance dose, 20% to 30% of loading dose in divided daily doses. Usually 0.125 to 0.5 mg/day PO; 20 % to 30% for premature infants. Side Effects: anorexia, nausea, vomiting, blurred vision (yellow-green halos), diplopia, photophobia, drowsiness, fatigue, confusion, altered mental status, headache, weakness, bradycardia, arrhythmias, atrioventricular block, GI upset

Special Precautions: sensitivity to digitalis, ventricular tachycardia, ventricular fibrillation, heart block, sick sinus syndrome, IHSS, acute MI, renal insufficiency, electrolyte abnormalities (decreased magnesium & potassium, increased calcium) Nursing Considerations: Note allergy to digitalis, presence of contraindication Baseline assessment of: weight, orientation, affect, reflexes, vision, vital signs (P, BP, R), ECG, cardiac and lung auscultation, peripheral pulses, peripheral perfusion, edema, abdominal percussion, bowel sounds, urinary output Laboratory: renal function test (BUN & creatinine), liver function test (ALT & AST), electrolyte imbalances Review drugs taken by patient (avoid mixing digoxin with dobutamine) Assessment of intravenous site and patency of intravenous line Monitor apical pulse for 1 minute before administering. Check dosage and preparation carefully (do not use if solution contains precipitates) Inject slowly over 5 minutes or longer. Monitor therapeutic drug levels: 0.5 to 2ng/mL. Have emergency equipment ready: potassium salts, lidocaine, phenytoin, atropine, and cardiac monitor (in case of toxicity) Take patients pulse at the same time each day. Weigh patient every other day with same clothing at the same time. Instruct patient and patients guardian to report loss of appetite, nausea, vomiting, visual disturbances, unusual tiredness or weakness, swelling of ankles, legs or fingers, difficulty of breathing. Monitor ECG for dysrhythmias, vital signs, renal and liver function & IV patency and site.

Hydrocortisone Description: adrenal cortical steroid Indications: Replacement therapy in adrenal cortical insufficiency To treat allergic or inflammatory states: o severe or incapacitating allergic conditions (e.g. anaphylaxis, status asthmaticus) o short term inflammatory and allergic disorders (e.g. asthma, COPD, rheumatoid arthritis, SLE, pemphigus, autoimmune disorders) o ocular and vascular inflammation o to relieve minor skin irritation, rashes due to seborrheic dermatitis, psoriasis, and hemorrhoids

shock: trauma, surgery (e.g. organ transplant to prevent organ rejection)

Dosage and Administration: Adults: Individualized dosage, based on severity and response. Give daily before 9a.m. to minimize adrenal suppression. If long-term therapy is needed, alternate-day therapy should be considered. After long-term therapy, withdraw drug slowly to avoid adrenal insufficiency. For maintenance therapy, reduce initial dose in small increments, at intervals until lowest clinically satisfactory dose is reached. Pediatrics: Individualized dosage based on severity and response rather than on formulae that correct adult doses for age or weight. Carefully observe growth and development in infants and children on prolonged therapy. Side Effects: nausea, diarrhea, abdominal distention, increased appetite, sweating, headache, depression, flush, mood changes, vertigo, headache, paresthesia, insomnia, seizures, psychosis, hypotension, shock, hypertension, heart failure secondary to fluid retention, thromboembolism, thrombophlebitis, fat embolism, cardiac arrhythmias secondary to electrolyte disturbance, thin, fragile skin, petechiar, ecchymoses, purpura, striae, subcutaneous fat atrophy, cataracts, glaucoma (long-term therapy), increased intra-ocular pressure, amernorrhea, irregular menses, growth retardation, decreased carbohydrate tolerance, diabetes mellitus, cushingoid state (longterm therapy), hypothalamus-pituitary-adrenal axis suppression (therapy longer than 5 days), cushings syndrome, hyperglycemia, peptic or gastroesophageal ulcer, pancreatitis, weight gain (long term therapy)sodium and fluid retention, hypokalemia, hypocalcemia, increased blood sugar, increased serum cholestrerol, decreased serum T3 and T4 levels, anaphylactoid or hypersensitivity reactions, muscle weakness, steroid myopathy, loss of muscle mass, osteoporosis, spontaneous fractures (long term therapy), immunosuppression, aggravation or masking of infections, impaired wound healing Special Precautions: sensitivity to any component of drug; fungal infections, herpes simplex skin infections, amebiasis, hepatitis B, vaccinia, varicella, and antibiotic-resistant infections, immunosuppression, recent intestinal surgery; use cautiously with kidney disease, liver disease, cirrhosis, hypothyroidism, ulcerative colitis with impending perforation, diverticulitis, recent Gi surgery, active or latent peptic ulcer, inflammatory bowel disease with exacerbations or impending perforation, hypertension, heart failure, thromboembolic tendencies, throbophlebitis, osteoporosis, cibvulsive disorders, metastatic carcinoma, diabetes mellitus, tuberculosis, lactation Nursing Considerations: Have baseline assessment of weight, vital signs (T, BP, P, R), reflexes, affect, bilateral grip strength, ophthalmologic examination, auscultation of lung sounds, peripheral perfusion, discoloration, pain, prominence of superficial vessels, liver palpation,

Laboratory: Chest X-ray, upper GI X-ray, complete blood count, serum electrolyte, 2-hr postprandial blood glucose, urinalysis, thyroid function test, serum cholesterol Review drugs taken by patient. Assessment of intravenous site and patency of intravenous line Give daily before 9a.m. (to mimic normal peak diurnal corticosteroid levels and minimize HPA suppression) Space multiple doses evenly throughout the day. When discontinuing, taper dosage slowly (to prevent adrenal insufficiency). Monitor vital signs, blood glucose, intake and output, weight, wound healing. Instruct patient and patients guardian to report muscle and joint pains, fatigue, anorexia, nausea, vomiting, diarrhea, unusual weight loss or gain (swelling of lower extremities, puffy face), dizziness, muscle weakness, black or tarry stools, epigastric burning, fever, colds, worsening of symptoms.

Nalbuphine Hydrochloride Description: opioid agonist-antagonist analgesic Indications: for control or relief of moderate to severe pain preoperative anesthesia or as adjunct to anesthesia prevention and treatment of intrathecal morphine-induced pruritus after cesarean section

Dosage and Administration: Adults: Usual dose is 10 mg for a 70-kg (154 lb) person IM, IV, or subcutaneously every 3 to 6 hours as needed. Individualized dosage. In non-tolerant patients, the recommended single maximum dose is 20 mg, with a maximum total daily dose of 160 mg. Patients dependent on opioids may experience withdrawal symptoms with administration of nalbuphine; control by small increments of morphine by slow IV administration until relief occurs. If the previous opioid was morphine, meperidine, codeine, or another opioid with similar duration of activity, administer one-fourth the anticipated nalbuphine dose initially, and observe for signs of withdrawal. If no untoward symptoms occur, progressively increase doses until analgesia is obtained. Pediatrics: Not recommended to children younger than 18 years old Side Effects: dizziness, confusion, hallucinations, blurred vision, headache, flushing, sedation, nervousness, restlessness, euphoria, depression, crying, dysphoria, unusual dreams, dry mouth, bitter taste, nausea, vomiting, abdominal cramps, clammy skin, urinary urgency, sedations, clamminess, sweating, headache, dizziness, vertigo, hostility, floating feeling, feeling of

heaviness, tingling, flushing, warmth, hypotension, hypertension, bradycardia, tachycardia, pruritus, burning, urticaria, cramps, dyspepsia, dry mouth, respiratory depression, dyspnea, asthma Special Precautions: sensitivity to nalbuphine, sulphites, use cautiously with emotionally unstable patients or with history of narcotic abuse, bronchial asthma, COPD, respiratory depression, anoxia, increased intracranial pressure, acute MI, biliary tract surgery, renal or hepatic dysfunction, labor or delivery, lactation Nursing Considerations: History: allergy to nalbuphine, sulfites, emotional instability, bronchial asthma, respiratory depression, anoxia, increased intracranial pressure, MI, biliary tract surgery Physical (baseline): orientation, reflexes, bilateral grip strength, affect, pupil size, vision, vital signs (P, BP, R), auscultation of heart and lung sounds, check bowel sounds and date of last bowel movement (to identify constipation) normal urine output and pain (type, duration, location) Review drugs taken by patient (avoid mixing with nafcillin, ketorolac, barbiturates) Laboratory: liver function test (AST, ALT), renal function test (BUN, creatinine) Assessment of intravenous site and patency of intravenous line Taper dosage when discontinuing after prolonged use (to avoid withdrawal symptoms) Keep opiod antagonist and facilities for assited or controlled respiration (in case of respiratory depression) Reassure patients guardian about addiction liability Monitor vital signs or changes in respiration Instruct patient to report nausea, vomiting, palpitations, shortness of breath, difficulty of breathing, dizziness, headache, constipation, dysuria, rash, blurred vision, hallucinations, tachycardia, respiratory depression Suggest to lie quietly and have frequent small meals

Ranitidine Hydrochloride Description: Histamine2 Antagonist Indications: treatment of gastric and duodenal ulcers, gastro-esophageal reflux disease, heartburn, erosive esophagitis, acid indigestion, sour stomach prevent acid reflux, stress ulcers, aspiration pneumonitis pathologic hypersecretory conditions (e.g. Zollinger-Ellison syndrome)

Dosage and Administration:

Adults: 75 to 150 mg bid PO or 50 mg IM or IV every 6 to 8 hours. Individualized dose with patients response. Do not exceed 6 g/day. Pediatrics: safety and efficacy not established Side Effects: headache, nausea, dizziness, vertigo, diarrhea, constipation, depression, rash, blurred vision, malaise, somnolence, insomnia, tachycardia, bradycardia, premature ventricular contraction, blood dyscrasia, rash, alopecia, vomiting, abdominal pain, hepatitis, increased alanine amino transaminase levels, gynecomastia, impotence, decreased libido, leucopenia, granulocytopenia, thrombocytopenia, pancytopenia, pain at injection site, local burning or itching at IV site, arthralgia Special Precautions: sensitivity to ranitidine, severe renal disease, severe liver disease Nursing Considerations: Have baseline assessment of skin lesions, orientation, affect, vital signs (P), ECG, liver evaluation, abdominal examination, urine output Laboratory: complete blood count, renal function test (BUN & creatinine), liver function test (ALT & AST), electrolyte imbalances Review drugs taken by patient (avoid mixing ranitidine with amphotericin B) Assessment of intravenous site and patency of intravenous line Instruct patient and patients guardian to report pain, coughing or vomiting of blood, constipation or diarrhea, severe headache, sore throat, unusual bruising or bleeding, tarry stools, confusion, hallucinations, dizziness, muscle or joint pain Monitor ECG for dysrhytmias, renal and liver function & IV patency and site