What are the different suture types?

Surgical Sutures are normally classified into two types, absorbable and non-absorbable. They can also be
classified based on their construction, either mono-filament or multi-filament, coating provided, absorption
profile and also whether they are made from natural or synthetic materials. Sutures can also be classified
according to their usage e.g. cardiovascular sutures, ophthalmic sutures, general sutures, orthopaedic sutures
etc.

View Suture Materials Chart for properties of different suture materials.

Absorbable and Non-absorbable sutures

Sutures can be divided into two types – those which are absorbable and will break down harmlessly in the
body over time without intervention, and those which are non-absorbable and must be manually removed if
they are not left indefinitely. The type of suture used varies on the operation, with the major criteria being the
demands of the location and environment and depends on the discretion and professional experience of the
Surgeons.

Sutures to be placed internally would require re-opening if they were to be removed. Sutures which lie on the
exterior of the body can be removed within minutes, and without re-opening the wound. As a result,
absorbable sutures are often used internally; non-absorbable externally.

Sutures to be placed in a stressful environment, for example the heart (constant pressure and movement) or the
bladder (adverse chemical presence) may require specialized or stronger materials to perform their role;
usually such sutures are either specially treated, or made of special materials, and are often non-absorbable to
reduce the risk of degradation.

Absorbable sutures include :- Polyglycolic Acid sutures, Polyglactin 910 , Catgut, Poliglecaprone 25 and
Polydioxanone sutures.
Non-Absorbable sutures include :- Polypropylene sutures, Nylon (poylamide), Polyester, PVDF, silk and
stainless steel sutures.

Monofilament and Multifilament Sutures

Sutures can also be divided into two types on the basis of material structure i.e. monofilament sutures and
multifilament or braided sutures. Braided sutures provide better knot security whereas monofilament sutures
provide better passage through tissues. In general, Monofilament sutures elicit lower tissue reaction compared
to braided sutures. Multifilament sutures are braided and often coated with various materials like silicon, wax,
PTFE, polycaprolactone, calcium stearate etc.

Monofilament sutures include :- Polypropylene sutures, Catgut, Nylon, PVDF, Stainless steel,
Poliglecaprone and Polydioxanone sutures.
Multifilament or braided sutures include :- PGA sutures, Polyglactin 910, silk and polyester sutures.
 Classification of sutures based on suture size
Surgical Sutures and ligatures are available in a number of sizes. Sutures are classified into different sizes
based on the diameter of the thread. United States Pharmacopeia's classification of sutures into various sizes is
widely accepted across the world.

The following U.S.P. and metric suture sizes chart shows the diameter range for collagen and synthetic
sutures.

Synthetic and Natural Sutures

Surgical sutures can also be divided into two types on the basis of raw material origin i.e. natural and synthetic
sutures.

Natural sutures include silk and catgut sutures whereas all other sutures are synthetic in nature.

Coated and Un-Coated Sutures

Some types of sutures are available with specialized coatings on the surface to enhance properties like
knotting, easy passage through tissue and reduce tissue reaction. Normally, coating is applied to braided
sutures rather than monofilament sutures. It is easier to coat braided sutures compared to monofilaments.
Coating materials like chromium salt, silicon, wax, PTFE, polycaprolactone, calcium stearate. Polymeric
coating materials are known to be more bio-compatible than conventional coating materials like chromium
salts, beeswax, pafaffin, gelatin etc. There are new functional coatings like antibacterial or antimicrobial
coating given to both monofilament and multifilament sutures, stem cell coating for improving healing
properties.

Coated sutures include :- PGA sutures, Catgut Chromic, Polyglactin 910, silk and polyester sutures, braided
or twisted nylon, Poliglecaprone and Polydioxanone sutures.

Un-coated sutures include :- Monofilament Polypropylene sutures, monofilament Nylon, PVDF, Stainless
steel.

Sutures Classification based on usage

Sutures are also classified into various types based on the usage or application. Sutures are normally classifed
into general sutures, cardiovascular sutures, valve sutures, orthopaedic sutures, dental sutures, gynaec,
veterinary sutures, cosmetic surgery sutures, ophthalmic sutures etc. A variety of suture materials may be used
for a particular application based on the requirements. However, the suture sizes, length, needle profiles, etc.,
will be with a small change for a particular application.
Signs and symptoms[edit]
Generally it is preferable to describe specific signs in lieu of declaring fetal distress that include:

 Decreased movement felt by the mother

 Meconium in the amniotic fluid ("meconium stained fluid")
 Non-reassuring patterns seen on cardiotocography:
 increased or decreased fetal heart rate (tachycardia and bradycardia), especially during and
after a contraction
 decreased variability in the fetal heart rate
 late decelerations
 Biochemical signs, assessed by collecting a small sample of baby's blood from a scalp prick
through the open cervix in labor
  fetal metabolic acidosis
 elevated fetal blood lactate levels (from fetal scalp blood testing) indicating the baby has
a lactic acidosis
Some of these signs are more reliable predictors of fetal compromise than others. For example,
cardiotocography can give high false positive rates, even when interpreted by highly experienced
medical personnel. Metabolic acidosis is a more reliable predictor, but is not always available.

Causes[edit]
There are many causes of "fetal distress" including:

 Breathing problems
 Abnormal position and presentation of the fetus
 Multiple births
 Shoulder dystocia
 Umbilical cord prolapse
 Nuchal cord
 Placental abruption
 Premature closure of the fetal ductus arteriosus
 Uterine rupture
 Intrahepatic cholestasis of pregnancy, a liver disorder during pregnancy

Treatment[edit]
Instead of referring to "fetal distress", current recommendations hold to look for more specific signs
and symptoms, assess them, and take the appropriate steps to remedy the situation[2] through the
implementation of intrauterine resuscitation.[3] Traditionally the diagnosis of "fetal distress" led
the obstetrician to recommend rapid delivery by instrumental delivery or by caesarean section if
vaginal delivery is not advised.
What is the umbilical cord?

The umbilical cord is a flexible, tube-like structure that, during pregnancy, connects the
fetus to the mother. The umbilical cord is the baby's lifeline to the mother. It transports
nutrients to the baby and also carries away the baby's waste products. It is made up of
three blood vessels – two arteries and one vein.

What is umbilical cord prolapse?

Umbilical cord prolapse is a complication that occurs prior to or during delivery of the
baby. In a prolapse, the umbilical cord drops (prolapses) through the open cervix into
the vagina ahead of the baby. The cord can then become trapped against the baby's
body during delivery. Umbilical cord prolapse occurs in approximately one in every 300
births.
What are the consequences of umbilical cord prolapse?

An umbilical cord prolapse presents a great danger to the fetus. During the delivery, the
fetus can put stress on the cord. This can result in a loss of oxygen to the fetus, and
may even result in a stillbirth.

What causes an umbilical cord prolapse?

The most common cause of an umbilical cord prolapse is a premature rupture of the
membranes that contain the amniotic fluid. Other causes include:

 Premature delivery of the baby

 Delivering more than one baby per pregnancy (twins, triplets, etc.)
 Excessive amniotic fluid
 Breech delivery (the baby comes through the birth canal feet first)
 An umbilical cord that is longer than usual

How is an umbilical cord prolapse diagnosed?

The doctor can diagnose a prolapsed umbilical cord in several ways. During delivery,
the doctor will use a fetal heart monitor to measure the baby's heart rate. If the umbilical
cord has prolapsed, the baby may have bradycardia (a heart rate of less than 120 beats
per minute). The doctor can also conduct a pelvic examination and may see the
prolapsed cord, or palpate (feel) the cord with his or her fingers.

How is an umbilical cord prolapse managed?

Because of the risk of lack of oxygen to the fetus, an umbilical cord prolapse must be
dealt with immediately. If the doctor finds a prolapsed cord, he or she can move the
fetus away from the cord in order to reduce the risk of oxygen loss.

In some cases, the baby will have to be delivered immediately by cesarean section. If
the problem with the prolapsed cord can be solved immediately, there may be no
permanent injury. However, the longer the delay, the greater the chance of problems
(such as brain damage or death) for the baby.

failure to progress in labor

When labor fails to progress, your cervix is not dilating and your baby is not
descending. Find out causes like cephalopelvic disproportion, inefficient contractions,
and posterior presentation.
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If your cervix is not dilating, or your baby is not descending, as quickly as
expected during the first stage, your doctor will try to assess why this is and if
something can be done. Usually, your doctor will assess the three P's: the
passenger (the size of the baby and his position in the uterus); the powers (the
efficiency of your contractions); and the passage (the size and shape of your
pelvis). These three elements work together and each one is important for
your labor to progress smoothly.
There are several reasons why a labor may not progress. These include if the
baby's head is too large for the mother's pelvis, known as cephalopelvic
disproportion (CPD); if contractions are inefficient; and if the baby is in a
posterior position with his back facing the mother's back.

Cephalopelvic disproportion
Sometimes CPD may be suspected before labor, in late pregnancy. This may
be the case if the doctor thinks that you have a narrow pelvis or a prominent
sacral bone, both of which may make birth slower or more difficult. However,
an assessment of the pelvis alone is not an accurate way to predict if you'll be
able to have a successful vaginal birth and, even if the pelvis is not an optimal
shape, the doctor may be happy for you to continue trying for a vaginal birth.
This is because it's not the shape of your pelvis alone that is important, but the
interaction between your baby (the passenger) and your pelvis.
If CPD is suspected, but the baby's head has engaged, a vaginal birth can still
be attempted. The labor will be monitored with a labor graph and if there are
signs that the baby is in distress, an emergency cesarean may be performed. If
the head hasn't engaged toward the end of labor, a planned cesarean may be
offered.
If your doctor suspects CPD in labor, she will reassess the baby's size to
check if she originally underestimated his or her weight. Even though the
combination of a large estimated weight and a slow labor can suggest that
there may be delivery problems, often labor proceeds normally.

Inefficient contractions
If your labor isn't progressing because your cervix is dilating slowly or has
stopped dilating, your doctor will assess the frequency of your contractions,
which should be every 2 to 3 minutes. She'll also assess how strong the
contractions are by palpating your abdomen: the firmer it feels during
contractions, the more likely they are to be effective. If contractions are more
widely spaced than they should be and their strength indicates they're unlikely
to be effective, she may use one or two techniques to speed up labor, known
as augmenting labor. First, she may artificially rupture the membranes if they
haven't already ruptured, a process known as ARM (see Breaking the water).
This can shorten the duration of labor by around one to two hours.
If ARM has no effect, you may be given the drug oxytocin to increase the
strength and frequency of contractions (see Breaking the water). Initially, a
small dose is given and then increased over time until you're having three or
four moderately strong contractions every 10 minutes. If this is done, you'll
have continuous electronic fetal monitoring (see Oxytocin, Syntocinon,
Pitocin) to check that the baby is not distressed by the sudden onset of
stronger contractions.
If your labor is still not progressing several hours after the drugs have been
started, then a cesarean may be recommended.

Posterior presentation
The best position for your baby in labor is an occipito-anterior position with
the back of the head (occiput) facing your front. If the back of the head faces
your back (occipito-posterior) this can make it hard for the baby to turn and
move down the birth canal and can prolong labor. The doctor may suggest that
you change positions to encourage the baby to turn. If the baby fails to rotate,
forceps or vacuum may be needed to aid the delivery (see Forceps).

Generic Name: Methergine

Brand name:Methylergonovine Maleate
Pharmacologic:ergot alkaloids
Availability Tablets:200 mcg (0.2 mg).Injection: 200 mcg (0.2 mg)/ml in 1-ml
ampules.

Action
Methylergonovine maleate(methergine) is an ergot alkaloid that stimulate smooth
muscle tissue.Because the smooth muscle of the uterus is especially sensitive to this
drug ,it is used postpartally to stimulate the uterus to contract in order to decrease
blood loss by clamping off uterine blood vessels and to promote the involution
process .In addition the drug has vasoconstrictive effect on all blood vessels,especially
the larger arteries.
Route,Dosage,Frequency
Methergine has a rapid onset of action and may be given orally or intramuscularly.
Usually IM dose: 0.2 mg following expulsion of the placenta.The dose may be
repeated every 2-4 hours if necessary.
Usual oral dose: 0.2 mg every 4 hours (six doses)

Maternal Contraindications
Pregnancy,hepatic or renal disease, cardiac disease, hypertension or preeclampsia
contraindicate this drugs use.Methylergonovine maleate must be used with caution
during lactation.

Maternal Side Effects

Hypertension,nausea,vomiting,headache,brandycardia,dizziness,tinnitus,abdominal
cramps,palpitations,dyspnea,chest pain and allergic reactions may be noted.

Nursing Implications

 Monitor fundal height and consistency and the amount and character of the
lochia.
 Assess the blood pressure before and routinely throughout drug administration.
 Observe for adverse effects or symptoms of ergot toxicity(ergotism) such as
nausea and vomiting,headache,muscle pain,cold or numb fingers and toes,chest
pain and general weakness.

Patient /Family Teaching

 Instruct patient to take medication as directed; do not skip or double up on

missed doses. If a dose is missed, omit it and return to regular dose schedule.
 Advise patient that medication may cause menstrual-like cramps
 Caution patient to avoid smoking, because nicotine constricts blood vessels.
 Instruct patient to notify health care professional if infection develops, as this
may cause increased sensitivity to the medication.

An a

BUPIVACAINE HYDROCHLORIDE
(byoo-piv'a-kane)
Marcaine, Sensorcaine
Classifications: CENTRAL NERVOUS SYSTEM AGENT; LOCAL ANESTHETIC (AMIDE-TYPE)
Prototype: Procaine
Pregnancy Category: C

Availability

0.25%, 0.5%, 0.75% injection

Actions

Anesthetic of the amide type. Decreases sodium flux into nerve cell, inhibiting initial
depolarization, and prevents propagation and conduction of the nerve impulse. Progression of
anesthesia, related to diameter, myelination, and conduction velocity of affected fibers is
manifested clinically as sequential loss of nerve function. May stimulate or depress the CNS or
do both.

Therapeutic Effects

Primary depressant effect is in medulla and higher centers affecting patient's reaction to pain,
temperature, and touch, as well as proprioception and skeletal muscle tone.

Uses

Infiltration anesthesia; peripheral, sympathetic nerve, and epidural (including caudal) block
anesthesia; 0.75% bupivacaine solution in dextrose is used for spinal anesthesia.

Contraindications

Known sensitivity to bupivacaine, local anesthetics, other amide-type anesthetics. Parabens, or

metabisulfites; acidosis; heart block; severe hemorrhage; hypotension and shock; hypertension,
cerebrospinal diseases; obstetrical paracervical anesthesia or spinal anesthesia in septicemia;
topical or IV regional anesthesia; intercurrent use with chloroprocaine; history of malignant
hyperthermia. Safety during pregnancy (category C) other than during labor, lactation, or
children <12 y is not established.

Cautious Use

Older adults or debilitated patients; hepatic or renal disease; known drug allergies and
sensitivities; dysrhythmias; children >12 y; obstetrical delivery.
Route & Dosage
Infiltration Anesthesia
Adult: IM Local infiltration, sympathetic block 0.25% solution; Lumbar epidural 0.25%, 0.5%, 0.75%
solutions; Caudal block, peripheral nerve block 0.25%, 0.5% solutions; Retrobulbar block 0.75%
solution
Child: IM 1–3.7 mg/kg

Administration
Intramuscular

 Inject slowly with frequent aspirations to avoid intravascular injection.

Intrathecal

 Do not use preparations containing preservatives for epidural or spinal anesthesia.

 Do not use multiple-dose vial for lumbar or caudal epidural block.
 Store ampuls at 15°–30° C (59°–86° F); protect from freezing. Solutions with epinephrine should
be protected from light.

INCOMPATIBILITIES Solution/additive: Sodium bicarbonate

Adverse Effects ( 1%)

Body as a Whole: Hypersensitivity [cutaneous lesions, urticaria, sneezing, diaphoresis, syncope,
hyperthermia, angioneurotic edema (including laryngeal edema), anaphylaxis, anaphylactoid
reaction]. CNS:Nervousness, unusual anxiety, excitement, dizziness, drowsiness, tremors, convulsions,
unconsciousness, respiratory arrest. Special Senses: Pupillary constriction; blurred or double vision;
tinnitus. GI:Nausea, vomiting. Other: Inflammation or sepsis at injection site, chills, pupillary
constriction. Associated with Epidural Anesthesia, Body as a Whole: Total spinal block, persistent
analgesia, paresthesia.Urogenital: Urinary retention, fecal incontinence, loss of perineal sensation and
sexual function. Other: Slowing of labor, increased incidence of forceps delivery, cranial nerve palsies
(with inadvertent intrathecal injection).

Interactions
Drug: CNS DEPRESSANTS augment CNS depression; with isoproterenol, ergonovine there is persistent
hypertension and a risk of CVA if bupivacaine used with epinephrine. MAO INHIBITORS, TRICYCLIC
ANTIDEPRESSANTS, PHENOTHIAZINES cause severe or prolonged hypotension or hypertension if
bupivacaine used with epinephrine.

Pharmacokinetics
Onset: 4–17 min for epidural, caudal, peripheral, or sympathetic block; within 1 min for spinal
block. Duration: 3–5 h for epidural, caudal, peripheral, or sympathetic block; 1.25–2.5 h for spinal
block. Distribution: Crosses placenta. Metabolism: Metabolized in liver. Elimination: 6% excreted
unchanged in urine. Half-Life: 1.5–5.5 h in adults, 8.1 h in neonates.

Nursing Implications

Assessment & Drug Effects

 Monitor for signs of inadvertent intravascular injection, which can produce a transient
"epinephrine response" (increased heart rate or systolic BP or both, circumoral pallor,
palpitations, nervousness) within 45 seconds in the unsedated patient and an increase by 20
bpm or more in heart rate for at least 15 seconds in sedated patient.
 Vasoconstrictor-containing solution should be administered cautiously, if at all, to areas with
end arteries (e.g., digits, penis) or to areas that have a compromised blood supply; ischemia and
gangrene can result. Inspect areas for evidence of reduced perfusion because of vasospasm:
pale, cold, sensitive skin.
 Note: Systemic reactions (toxicity) are more apt to occur in children or older adults and may
develop rapidly or be delayed for as long as 30 min after administration.
 Monitor for toxicity: CNS stimulation (unusual anxiety, excitement, restlessness) usually occurs
first, followed by CNS depression (drowsiness, unconsciousness, respiratory arrest). However,
because stimulation is apt to be transient or absent, drowsiness may be the first sign in some
patients (especially children and older adults).
 Monitor BP and fetal heart rate continuously during labor because maternal hypotension may
accompany regional anesthesia. Place mother on left side with legs elevated.
 Monitor cardiac and respiratory status continuously in patients receiving retrobulbar and dental
blocks.

Patient & Family Education

 After spinal anesthesia, sensation to lower extremities may not return for 2.5–3.5 h.

Rho(D) IMMUNE GLOBULIN

(row)
BayRho-D Full Dose, RhoGAM, Rhophylac, WinRho SDF
Rho(D) IMMUNE GLOBULIN MICRO-DOSE
BayRho-D Mini Dose, MICRhoGAM
Classifications: BIOLOGIC RESPONSE MODIFIER; IMMUNOGLOBULIN
Prototype: Immune Globulin
Pregnancy Category: C

Availability

BayRho-D 15–18% solution in single dose vial

RhoGAM, MICRhoGAM 5% solution in prefilled syringes

Rhophylac 300 mcg prefilled syringe WinRho SDF 120 mcg, 300 mcg, 1000 mcg vials

Actions

Sterile nonpyrogenic gamma globulin solution containing immunoglobulins (IgG) of at least

90% IgG, which provides passive immunity by suppressing active antibody response and
formation of anti-Rho(D) (isoimmunization) in Rh-negative [Rho(D)-negative] individuals
previously exposed to Rh-positive [Rho(D)-positive, Du-positive] blood.

Therapeutic Effects

Effective for exposure in Rh-negative women when Rh-positive fetal RBCs enter maternal
circulation during third stage of labor, fetal-maternal hemorrhage (as early as second trimester),
amniocentesis, or other trauma during pregnancy, termination of pregnancy, and following
transfusion with Rh-positive RBC, whole blood, or components (platelets, WBC) prepared from
Rh-positive blood.

Uses

To prevent isoimmunization in Rh-negative individuals exposed to Rh-positive RBC (see above).

Rho(D) immune globulin micro-dose is for use only after spontaneous or induced abortion or
termination of ectopic pregnancy up to and including 12 wk of gestation.

Contraindications

Rho(D)-positive patient; person previously immunized against Rho(D) factor, hypersensitivity for
thimerosal (in commercial preparations), severe immune globulin hypersensitivity, bleeding
disorders; pregnancy (category C), neonates, pediatric clients.
Cautious Use

Idiopathic thrombocytopenia purpura (ITP), IgA deficiency.

Route & Dosage

Note: Only WinRho SDF can be given IV. BayRho-E and RhoGAM are available in regular and
mini-dose vials

Antepartum Prophylaxis
Adult: IM/IV 1 vial or 300 mcg at approximately 28 wk; followed by 1 vial of mini-dose or 120 mcg within
72 h of delivery if infant is Rh-positive

Postpartum Prophylaxis
Adult: IM/IV 1 vial or 300 mcg within 72 h of delivery if infant is Rh-positive

Following Amniocentesis, Miscarriage, Abortion, Ectopic Pregnancy

Adult: IM 1 vial of the microdose, preferably within 3 h but at least within 72 h

Transfusion Accident
Adult: IM/IV 1 vial or 300 mcg for each volume of RBCs infused divided by 15, given within at least 72 h
of accident

Administration

Note: Each vial of Rho(D) immune globulin contains enough anti-Rho(D) to suppress the
immunizing potential of 15 mL Rh-positive packed RBC. Each vial of micro-dose contains
enough anti-Rho(D) to suppress the immune response to 2.5 mL of Rh-positive packed RBC.

Intramuscular

 Make sure that lot numbers of drug used for the cross-match and the drug to be administered
are the same.
 Administer Rho(D) immune globulin via IM to the mother only; not to the infant.
 Use the deltoid muscle. Give in divided doses at different sites, all at once or at intervals, as long
as the entire dose is given within 72 h after delivery or termination of pregnancy.
 Reconstitute with 1.25 mL of NS (using the same method to dissolve as for IV). Give immediately
after reconstitution.
 Keep epinephrine immediately available; systemic allergic reactions sometimes occur.
Intravenous

Note: 5 IU equals 1 mcg.

PREPARE: Direct: Reconstitute each vial with 2.5 ml NS (provided by manufacturer). Direct
stream of diluent to side of vial, swirl to dissolve, do not shake. Concentration of reconstituted
vials: 600 IU yields 240 IU/mL and 1500 IU vial yields 600 IU/mL.

ADMINISTER: Direct: Give a single dose over 3–5 min.

 Refrigerate commercially prepared solutions, although may remain stable up to 30 d at room

temperature according to manufacturers. Discard solutions that have been frozen. Store powder
at 2°–8° C (36°–46° F) unless otherwise directed; avoid freezing.

Adverse Effects ( 1%)

Body as a Whole: Injection site irritation, slight fever, myalgia, lethargy.

Interactions
Drug: May interfere with immune response to LIVE VIRUS VACCINE; should delay use of LIVE VIRUS
VACCINES for 3 mo after administration of Rho(D) immune globulin.

Pharmacokinetics
Peak: 2 h IV, 5–10 d IM. Half-Life: 25 d.

Nursing Implications

Assessment & Drug Effects

 Obtain history of systemic allergic reactions to human immune globulin preparations prior to
drug administration.
 Send sample of newborn's cord blood to laboratory for cross-match and typing immediately
after delivery and before administration of Rho(D) immune globulin. Confirm that mother is
Rho(D) and Du-negative. Infant must be Rh-positive.

Patient & Family Education

 Be aware that administration of Rho(D) immune globulin (antibody) prevents hemolytic disease
of the newborn in a subsequent pregnancy.
Generic Name:Vitamin K(Pytonadione)
Brand name:Aqua-Mephyton
Classification:fat-soluble vitamins,Antifibrinolytic Agents

Action
Phytonadione is used in prophylaxis and treatment of hemorrhagic disease of the
newborn. It promotes liver formation of the clotting factors II, VII, IX and X. At birth,
the newborn does not have bacteria in the colon that necessary for synthesizing fat-
soluble vitamin K.Therefore,the newborn may have deceased levels of prothrombin
during the first 5 to 8 days of life reflected by a prolongation of prothrombin time.

Route,Dosage,Frequency

Intramuscular injection is given in the vastus lateralis thigh muscle.A one time
only prophylactic dose of 0.5 to 1 mg is given intramuscularly in the birthing
area within 1 hour of birth.

If mother receive anticoagulant during pregnancy, an additional dose may be ordered

by the physician and is given 6-8 hours after the first injection,IM/subcutaneous
concentration: 1 mg/0.5 ml(neonatal stren gth)can use 10 mg/ml concentration to
minimize volume injected.

Neonatal Side Effects

Pain and edema may occur at injection site. Allergic reaction such as rash and
urticaria,may also occur.

Nursing Implications

 Document the giving of the medication to newborn to prevent an accidental

doubling of the dose.
 Observe for bleeding (usually occurs on second or third day). Bleeding may
be seen as generalized ecchymoses or bleeding from umbilical cord,
circumcision site, nose or gastrointestinal tract.
 Observe for jaundice and kernicterus,especially in preterm infants.
 Observe for signs of local inflammation.
 Apply pressure to the injection site to prevent further bleeding
  Protect drug from light.
 Give vitamin K before circumcision procedure
Generic Name: Calcium Gluconate
Brand Name: Kalcinate
Classifications: fluid and electrolytic and water balance agent; replacement solution
Pregnancy Category: B

Availability
500 mg, 650 mg, 975 mg, 1 gm tablets; 10% injection

Actions
Calcium is an essential element for regulating the excitation threshold of nerves and
muscles, for blood clotting mechanisms, cardiac function (rhythm, tonicity,
contractility), maintenance of renal function, for body skeleton and teeth. Also plays a
role in regulating storage and release of neurotransmitters and hormones; regulating
amino acid uptake and absorption of vitamin B12, gastrin secretion, and in maintaining
structural and functional integrity of cell membranes and capillaries. Calcium gluconate
acts like digitalis on the heart, increasing cardiac muscle tone and force of systolic
contractions (positive inotropic effect).

Therapeutic effects
Rapidly and effectively restores serum calcium levels in acute hypocalcemia of various
origins and effective cardiac stabilizer under conditions of hyperkalemia or
resuscitation.

Uses
Negative calcium balance (as in neonatal tetany, hypoparathyroidism, vitamin D
deficiency, alkalosis). Also to overcome cardiac toxicity of hyperkalemia, for
cardiopulmonary resuscitation, to prevent hypocalcemia during transfusion of citrated
blood. Also as antidote for magnesium sulfate, for acute symptoms of lead colic, to
decrease capillary permeability in sensitivity reactions, and to relieve muscle cramps
from insect bites or stings. Oral calcium may be used to maintain normal calcium
balance during pregnancy, lactation, and childhood growth and to prevent primary
osteoporosis. Also in osteoporosis, osteomalacia, chronic hypoparathyroidism, rickets,
and as adjunct in treatment of myasthenia gravis and Eaton-Lambert syndrome.
Contraindicatons
Ventricular fibrillation, metastatic bone disease, injection into myocardium;
administration by SC or IM routes; renal calculi, hypercalcemia, predisposition to
hypercalcemia (hyperparathyroidism, certain malignancies); pregnancy (category B).

Cautious use
Digitalized patients, renal or cardiac insufficiency, sarcoidosis, history of lithiasis,
immobilized patients; lactation.

Route & Dosage

Supplement for Osteoporosis

adult: PO 1–2 g b.i.d. to q.i.d.
IV 7 mEq q 1–3d
child: PO 45–65 mg/kg/d in divided doses.
IV 1–7 mEq q 1–3d
neonate: PO 50–130 mg/kg/d (max 1 g).
IV mEq q 1–3d

Hypocalcemic Tetany
adult: IV 4.5–16 mEq prn
child: IV 0.5–0.7 mEq/kg t.i.d. or q.i.d.
neonate: IV 2.4 mEq/kg/d in divided doses

CPR
adult: IV 2.3–3.7 mEq x 1

Hyperkalemia with Cardiac Toxicity

adult: IV 2.25–14 mEq q 1–2 min

Exchange Transfusions with Citrated Blood

adult: IV 1.35 mEq for each 100 mL of blood
neonate: IV 0.45 mEq for each 100 mL of blood

Administration
Oral

 Ensure that chewable tablets are chewed or crushed before being swallowed
with a liquid.
 Give with meals to enhance absorption.
Intravenous

PREPARE direct: May be given undiluted intermittent: /continuous: May be diluted

in 1000 mL of NS.

ADMINISTER direct: Give direct IV at a rate of 0.5 mL or a fraction thereof over 1

min. Do not exceed 2 mL/min. intermittent: /continuous: Give slowly, not to exceed
200 mg/min, through a small-bore needle into a large vein to avoid possibility of
extravasation and resultant necrosis. With children, scalp veins should be avoided.
Avoid rapid infusion. High concentrations of calcium suddenly reaching the heart can
cause fatal cardiac arrest.

Incompatibilities Solution / Additive: Amphotericin B, cefamandole, dobutamine,

methylprednisolone, metoclopramide. Y-site: Amphotericin B cholesteryl complex,
fluconazole,

Indomethacin.

 Injection should be stopped if patient complains of any discomfort. · Patient

should be advised to remain in bed for 15–30 min or more following injection,
depending on response.
Adverse Effects

BodyWhole: Tingling sensation. With rapid IV, sensations of heat waves (peripheral
vasodilation), fainting.
GI: PO preparation: Constipation, increased gastric acid secretion.
CV: (With rapid infusion) hypotension, bradycardia, cardiac arrhythmias, cardiac arrest,
Skin: Pain and burning at IV site, severe venous thrombosis, necrosis and sloughing
(with extravasation).
 Nursing Implications

Assessment & Drug Effects

 Assess for cutaneous burning sensations and peripheral vasodilation, with

moderate fall in BP, during direct IV injection.
 Monitor ECG during IV administration to detect evidence of hypercalcemia:
decreased QT interval associated with inverted T wave.
 Observe IV site closely. Extravasation may result in tissue irritation and
necrosis.
 Monitor for hypocalcemia and hypercalcemia.
 Lab tests: Determine levels of calcium and phosphorus (tend to vary
inversely) and magnesium frequently, during sustained therapy. Deficiencies
in other ions, particularly magnesium, frequently coexist with calcium ion
depletion.
Patient & Family Education

 Report S&S of hypercalcemia promptly to your care provider.

 Milk and milk products are the best sources of calcium (and phosphorus).
Other good sources include dark green vegetables, soy beans, tofu, and
canned fish with bones.
 Calcium absorption can be inhibited by zinc-rich foods: nuts, seeds, sprouts,
legumes, soy products (tofu).
 Check with physician before self-medicating with a calcium supplement.
 Do not breast feed while taking this drug without consulting physician.

promethazine hydrochloride
 FACEBOOK
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Drug Name
Generic Name : promethazine hydrochloride
Brand Name: Phenadoz, Phenergan
Classification: Phenothiazine, Dopaminergic blocking agent, Antihistamine,
Antiemetic, Anti-motion sickness drug, Sedative or hypnotic

Pregnancy Category C
Dosage & Route
Available forms : Tablets—12.5, 25, 50 mg; syrup—6.25, 25 mg/5 mL;
suppositories—12.5, 25, 50 mg; injection—25, 50 mg/mL
ADULTS
 Allergy: Average dose is 25 mg PO or by rectal suppository, preferably at
bedtime. If needed, 12.5 mg PO before meals and hs; 25 mg IM or IV for serious
reactions. May repeat within 2 hr if needed at bedtime.
 Motion sickness: 25 mg PO bid. Initial dose should be scheduled 30–60 min
before travel; repeat in 8–12 hr if needed. Thereafter, give 25 mg on arising and
before evening meal.
 Nausea and vomiting: 25 mg PO; repeat doses of 12.5–25 mg as needed, q 4–6 hr.
Give rectally or parenterally if oral dosage is not tolerated. 12.5–25 mg IM or IV,
not to be repeated more frequently than q 4–6 hr.
 Sedation: 25–50 mg PO, IM, or IV.
 Preoperative use: 50 mg PO the night before, or 50 mg with an equal dose of
meperidine and the required amount of belladonna alkaloid.
 Postoperative sedation and adjunctive use with analgesics: 25–50 mg PO, IM, or
IV.
 Labor: 50 mg IM or IV in early stages. When labor is established, 25–75 mg with
a reduced dose of opioid. May repeat once or twice at 4-hr intervals. Maximum
dose within 24 hr is 100 mg.
PEDIATRIC PATIENTS > 2 YR
 Allergy: 25 mg PO at bedtime or 6.25–12.5 mg tid.
 Motion sickness: 12.5–25 mg PO or rectally bid.
 Nausea and vomiting: 1 mg/kg IM q 4–6 hr as needed.
 Sedation: 12.5–25 mg PO or 12.5–25 mg PO or PR at bedtime q 4–6 hr.
 Preoperative use: 1 mg/kg PO in combination with an equal dose of meperidine
and the required amount of an atropine-like drug.
 Postoperative sedation and adjunctive use with analgesics: 1 mg/kg PO, IM, IV,
or rectally.
Therapeutic actions
 Promethazine, a phenothiazine derivative, blocks postsynaptic dopaminergic
receptors in the brain and has a strong α-adrenergic blocking effect. It
competitively binds to H1-receptors.
Indications
 Symptomatic relief of perennial and seasonal allergic rhinitis, vasomotor rhinitis,
allergic conjunctivitis; mild, uncomplicated urticaria and angioedema;
amelioration of allergic reactions to blood or plasma; dermatographism,
adjunctive therapy (with epinephrine and other measures) in anaphylactic
reactions
 Treatment and prevention of motion sickness; prevention and control of nausea
and vomiting associated with anesthesia and surgery
 Preoperative, postoperative, or obstetric sedation
 Adjunct to analgesics to control postoperative pain
 Adjunctive IV therapy with reduced amounts of meperidine or other opioid
analgesics in special surgical situations, such as repeated bronchoscopy,
ophthalmic surgery, or in poor-risk patients
Adverse effects
 CNS depression, paradoxical excitation in childn, dryness of mouth, blurring of
vision, retention of urine, constipation, glaucoma, tachycardia, headache,
hypotension, tinnitus.
Contraindications
 Hypersensitivity, coma, porphyria, cardiac disease, hypokalaemia, intra-arterial or
SC inj, neonates and young children, pregnancy, lactation.
Nursing considerations
Assessment
 History: Hypersensitivity to antihistamines or phenothiazines, severe CNS
depression, bone marrow depression, vomiting of unknown cause, concomitant
therapy with MAOIs, lactation, lower respiratory tract disorders, glaucoma,
prostatic hypertrophy, CV disease or hypertension, breast cancer, thyrotoxicosis,
pregnancy, history of sleep apnea or a family history of SIDS, child with Reye’s
syndrome
 Physical: Weight, T; reflexes, orientation, IOP; P, BP, orthostatic BP; R,
adventitious sounds; bowel sounds and normal output, liver evaluation; urinary
output, prostate size; CBC; urinalysis; LFTs, renal and thyroid function tests
Interventions
 BLACK BOX WARNING: Do not give tablets OR rectal suppositories to
children < 2 yr.
 Give IM injections deep into muscle.
 Do not administer subcutaneously; tissue necrosis may occur.
 WARNING: Do not administer intra-arterially; arteriospasm and gangrene of the
limb may result.
 WARNING: Reduce dosage of barbiturates given concurrently with promethazine
by at least half; arrange for dosage reduction of opioid analgesics given
concomitantly by one-fourth to one-half.
Teaching points
 Take drug exactly as prescribed.
 Avoid using alcohol.
 Avoid driving or engaging in other dangerous activities if dizziness, drowsiness,
or vision changes occur.
 Avoid prolonged exposure to sun, or use a sunscreen or covering garments.
 Maintain fluid intake, and use precautions against heat stroke in hot weather.
 Report sore throat, fever, unusual bleeding or bruising, rash, weakness, tremors,
impaired vision, dark urine, pale stools, yellowing of the skin or eyes.

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