indomethacin (Apo-Indomethacin†, Arthrexin‡, Indocid‡†, Indocid SR†, Indocin, Indocin SR, Novo-Methacin†)
Pharmacologic Class: NSAID
Therapeutic Class: nonopioid analgesic; antipyretic; anti-inflammatory
Indications & dosages
Moderate to severe rheumatoid arthritis or osteoarthritis, ankylosing spondylitis; Acute gouty arthritis; Acute painful shoulders (bursitis or tendinitis)
Adverse reactions
P.O. and P.R.
CNS: headache, dizziness, depression, drowsiness, confusion, somnolence, fatigue, peripheral neuropathy, psychic disturbances, syncope, vertigo.
CV: hypertension, edema.
EENT: hearing loss, tinnitus.
GI: nausea, anorexia, diarrhea, abdominal pain, peptic ulceration, GI bleeding, constipation, dyspepsia, pancreatitis.
GU: hematuria.
Hematologic: iron-deficiency anemia.
Metabolic: hyperkalemia.
Skin: pruritus, urticaria, Stevens-Johnson syndrome.
Other: hypersensitivity reactions.
GU: hematuria, proteinuria, interstitial nephritis.
Interactions
Drug-drug
Aminoglycosides, cyclosporine, methotrexate: May enhance toxicity of these drugs. Avoid using together.
Anticoagulants: May cause bleeding. Monitor patient closely.
Antihypertensives: May decrease antihypertensive effect. Monitor patient closely.
Antihypertensives, furosemide, thiazide diuretics: May impair response to both drugs. Avoid using together, if possible.
Aspirin: May decrease level of indomethacin. Avoid using together.
Aspirin, corticosteroids: May increase risk of GI toxicity. Avoid using together.
Bisphosphonates: May increase risk of gastric ulceration. Monitor patient for symptoms of gastric irritation or GI bleeding.
Diflunisal, probenecid: May decrease indomethacin excretion. Watch for increased indomethacin adverse reactions.
Digoxin: May prolong half-life of digoxin. Use together cautiously.
Dipyridamole: May enhance fluid retention. Avoid using together.
Lithium: May increase lithium level. Monitor patient for toxicity.
Penicillamine: May increase bioavailability of penicillamine. Monitor patient closely.
Phenytoin: May increase phenytoin level. Monitor patient closely.
Triamterene: May cause nephrotoxicity. Avoid using together.
Drug-herb
Dong quai, feverfew, garlic, ginger, horse chestnut, red clover: May cause bleeding. Discourage use together.
Senna: May inhibit diarrheal effects. Discourage use together.
White willow: Herb and drug contain similar components. Discourage use together.
Drug-lifestyle
Alcohol use: May cause GI toxicity. Discourage use together.
Effects on lab test results
May increase potassium level. May decrease hemoglobin level and hematocrit.
May increase liver function test values.
May cause positive direct Coombs test results.
Contraindications & cautions
Contraindicated in patients hypersensitive to drug and in those with a history of aspirin- or NSAID-induced asthma, rhinitis, or urticaria.
Contraindicated in pregnant or breast-feeding women and in neonates with untreated infection, active bleeding, coagulation defects or thrombocytopenia, congenital heart disease needing patency of the ductus arteriosus, necrotizing enterocolitis, or significant renal impairment. Suppositories are contraindicated in patients with history of proctitis or recent rectal bleeding.
Contraindicated in pregnant women.
Use cautiously in elderly patients, those with history of GI disease, and those with epilepsy, parkinsonism, hepatic or renal disease, CV disease, infection, and mental illness or depression.
Nursing considerations
Because of the high risk of adverse effects from long-term use, drug shouldn't be used routinely as an analgesic or antipyretic.
Sustained-release capsules shouldn't be used for acute gouty arthritis.
Give oral dose with food, milk, or antacid to decrease GI upset.
If ductus arteriosus reopens, a second course of one to three doses may be given. If ineffective, surgery may be needed.
Watch for bleeding in patients receiving anticoagulants, patients with coagulation defects, and neonates.
Because NSAIDs impair synthesis of renal prostaglandins, they can decrease renal blood flow and lead to reversible renal impairment, especially in patients with renal failure, heart failure, or liver dysfunction; in elderly patients; and in those taking diuretics. Monitor these patients closely.
Drug causes sodium retention; watch for weight gain (especially in elderly patients) and increased blood pressure in patients with hypertension.
Monitor patient for rash and respiratory distress, which may indicate a hypersensitivity reaction.
Because of their antipyretic and anti-inflammatory actions, NSAIDs may mask signs and symptoms of infection.
Serious GI toxicity (including peptic ulcers and bleeding) can occur in patient taking NSAIDs, despite lack of symptoms.
NSAIDs may cause increased risk of thrombotic events, MI, and stroke. Risk may be increased with duration of use and in patients with history of cardiovascular disease or risk factors of cardiovascular disease.
Monitor patient on long-term oral therapy for toxicity by conducting regular eye examinations, hearing tests, CBCs, and kidney function tests.
Patient teaching
Tell patient to take oral drug with food, milk, or antacid to prevent GI upset.
Alert patient that using oral form with aspirin, alcohol, other NSAIDs, or corticosteroids may increase risk of adverse GI reactions.
Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine, or stool; coffee-ground vomit; and black, tarry stool. Tell him to notify prescriber immediately if any of these occurs.
Tell patient to immediately report signs or symptoms of cardiac events, such as chest pain, shortness of breath, weakness, and slurred speech.
Warn patient to avoid hazardous activities that require mental alertness until CNS effects are known.
Tell patient to notify prescriber immediately if visual or hearing changes occur
Tuesday, January 19, 2010
NCLEX-RN Topic 12: alendronate sodium (Fosamax, Fosamax Plus D)
alendronate sodium (Fosamax, Fosamax Plus D)
Therapeutic Class: bone resorption inhibitor
Indications & dosages
Osteoporosis in postmenopausal women; to increase bone mass in men with osteoporosis
To prevent osteoporosis in postmenopausal women
Adverse reactions
CNS: headache.
GI: abdominal pain, nausea, dyspepsia, constipation, diarrhea, flatulence, acid regurgitation, esophageal ulcer, vomiting, dysphagia, abdominal distention, gastritis, taste perversion.
Musculoskeletal: musculoskeletal pain.
Interactions
Drug-drug
Antacids, calcium supplements, many oral drugs: May interfere with absorption of alendronate. Instruct patient to wait at least 30 minutes after taking alendronate before taking other drug orally.
Aspirin, NSAIDs: May increase risk of upper GI adverse reactions with drug doses greater than 10 mg daily. Monitor patient closely.
Ranitidine (I.V. form): May increase availability of alendronate. Reduce dosage, as needed.
Drug-food
Any food: May decrease absorption of drug. Advise patient to take with full glass of water at least 30 minutes before food, beverages, or ingestion of other drugs.
Effects on lab test results
May decrease calcium and phosphate levels.
Contraindications & cautions
Contraindicated in patients hypersensitive to drug and in those with hypocalcemia, severe renal insufficiency, or abnormalities of the esophagus that delay esophageal emptying.
Use cautiously in patients with active upper GI problems (dysphagia, symptomatic esophageal diseases, gastritis, duodenitis, ulcers) or mild to moderate renal insufficiency.
Nursing considerations
Correct hypocalcemia and other disturbances of mineral metabolism (such as vitamin D deficiency) before therapy begins.
When used to treat osteoporosis, disease may be confirmed by findings of low bone mass on diagnostic studies or by history of osteoporotic fracture.
The recommended daily intake of vitamin D is 400 to 800 international units. Fosamax Plus D provides 400 international units daily when taken once weekly. Patients at risk for vitamin D deficiency, such as those who are chronically ill, nursing home bound, who have a GI malabsorption syndrome, or who are older than age 70, may require additional supplementation.
In Paget disease, drug is indicated for patients with alkaline phosphatase level at least two times upper limit of normal, for those who are symptomatic, and for those at risk for future complications from the disease.
Alert: Give drug with 6 to 8 ounces of water at least 30 minutes before patient's first food or drink of the day to facilitate delivery to the stomach. Don't allow patient to lie down for 30 minutes after taking drug.
Monitor patient's calcium and phosphate levels throughout therapy.
Look alike-sound alike: Don't confuse Fosamax with Flomax.
Patient teaching
Stress importance of taking tablet only with 6 to 8 ounces of water at least 30 minutes before ingesting anything else, including food, beverages, and other drugs. Tell patient that waiting longer than 30 minutes improves absorption.
Warn patient not to lie down for at least 30 minutes after taking drug to facilitate delivery to stomach and to reduce risk of esophageal irritation.
Advise patient to report adverse effects immediately, especially chest pain or difficulty swallowing.
Advise patient to take supplemental calcium and vitamin D if dietary intake is inadequate.
Tell patient about benefits of weight-bearing exercises in increasing bone mass. If applicable, explain importance of reducing or eliminating cigarette smoking and alcohol use
Therapeutic Class: bone resorption inhibitor
Indications & dosages
Osteoporosis in postmenopausal women; to increase bone mass in men with osteoporosis
To prevent osteoporosis in postmenopausal women
Adverse reactions
CNS: headache.
GI: abdominal pain, nausea, dyspepsia, constipation, diarrhea, flatulence, acid regurgitation, esophageal ulcer, vomiting, dysphagia, abdominal distention, gastritis, taste perversion.
Musculoskeletal: musculoskeletal pain.
Interactions
Drug-drug
Antacids, calcium supplements, many oral drugs: May interfere with absorption of alendronate. Instruct patient to wait at least 30 minutes after taking alendronate before taking other drug orally.
Aspirin, NSAIDs: May increase risk of upper GI adverse reactions with drug doses greater than 10 mg daily. Monitor patient closely.
Ranitidine (I.V. form): May increase availability of alendronate. Reduce dosage, as needed.
Drug-food
Any food: May decrease absorption of drug. Advise patient to take with full glass of water at least 30 minutes before food, beverages, or ingestion of other drugs.
Effects on lab test results
May decrease calcium and phosphate levels.
Contraindications & cautions
Contraindicated in patients hypersensitive to drug and in those with hypocalcemia, severe renal insufficiency, or abnormalities of the esophagus that delay esophageal emptying.
Use cautiously in patients with active upper GI problems (dysphagia, symptomatic esophageal diseases, gastritis, duodenitis, ulcers) or mild to moderate renal insufficiency.
Nursing considerations
Correct hypocalcemia and other disturbances of mineral metabolism (such as vitamin D deficiency) before therapy begins.
When used to treat osteoporosis, disease may be confirmed by findings of low bone mass on diagnostic studies or by history of osteoporotic fracture.
The recommended daily intake of vitamin D is 400 to 800 international units. Fosamax Plus D provides 400 international units daily when taken once weekly. Patients at risk for vitamin D deficiency, such as those who are chronically ill, nursing home bound, who have a GI malabsorption syndrome, or who are older than age 70, may require additional supplementation.
In Paget disease, drug is indicated for patients with alkaline phosphatase level at least two times upper limit of normal, for those who are symptomatic, and for those at risk for future complications from the disease.
Alert: Give drug with 6 to 8 ounces of water at least 30 minutes before patient's first food or drink of the day to facilitate delivery to the stomach. Don't allow patient to lie down for 30 minutes after taking drug.
Monitor patient's calcium and phosphate levels throughout therapy.
Look alike-sound alike: Don't confuse Fosamax with Flomax.
Patient teaching
Stress importance of taking tablet only with 6 to 8 ounces of water at least 30 minutes before ingesting anything else, including food, beverages, and other drugs. Tell patient that waiting longer than 30 minutes improves absorption.
Warn patient not to lie down for at least 30 minutes after taking drug to facilitate delivery to stomach and to reduce risk of esophageal irritation.
Advise patient to report adverse effects immediately, especially chest pain or difficulty swallowing.
Advise patient to take supplemental calcium and vitamin D if dietary intake is inadequate.
Tell patient about benefits of weight-bearing exercises in increasing bone mass. If applicable, explain importance of reducing or eliminating cigarette smoking and alcohol use
NCLEX-RN Topic 11: Performing Tracheostomy Care
IMPLEMENTATION
➧Wash hands.
Prevents transmission of microorganisms.
➧ Perform tracheotomy suction.
Removes secretion to prevent occlusion of outer cannula by secretions.
➧ Allow patient to reoxygenate by breathing 100% oxygen, and pour the hydrogen peroxide and normal saline into sterile bowls. Place tracheotomy O2 collar over tracheotomy to ensure oxygen saturation.
Allows efficient and organized completion of tracheotomy care.
➧ Don sterile gloves; remove soiled dressing with forceps and discard in trash receptacle.
Prevents transmission of microorganisms.
➧ Keeping dominant hand sterile, remove oxygen source and inner cannula with nondominant hand; place cannula in hydrogen peroxide basin.
Hydrogen peroxide loosens the secretions.
➧ Place tracheotomy oxygen collar over outer cannula.
Maintains oxygenation of patient.
➧ Clean inner cannula using small brush.
Brush provides mechanical force to remove thick secretions.
➧ Rinse inner cannula with normal saline using nondominant nonsterile hand to pour saline.
Cleanses secretions and hydrogen peroxide from inner cannula.
➧ Replace inner cannula and secure locking mechanism. Reapply oxygen source.
Secures inner cannula and re-establishes oxygen supply. (Note: some tracheotomy devices do not have an inner cannula.)
➧ Cleanse outer cannula with a sterile cotton swab moistened with hydrogen peroxide.
Aseptically removes secretions from stoma site.
➧ Rinse stoma with cotton swab soaked in normal saline and dried with sterile 4X4s.
Rinses hydrogen peroxide from surface and dries surface, prohibiting a moist medium for microorganisms.
➧ Do not release all tracheotomy ties at the same time.
To prevent dislodgement of tracheotomy.
➧ Cut length adequate enough to wrap around the patient’s neck twice and cut ends on diagonal. Insert end of tie through eye of faceplate and pull through ipsilateral eye. Slide tie around neck to other eyelet and insert through second eyelet. Bring one tie around back of neck until ends meet. Tie ends securely allowing one finger breath between neck and tie.
Cutting ends on diagonal aids in insertion of tie through eyelet. One finger breath between neck and ties prevents ties from being too tight.
➧ Insert fresh tracheotomy dressing under clean ties and faceplate.
Absorbs drainage.
➧ Position patient comfortably and assess respiratory status.
Promotes comfort. Reassessment of airway patency and respiratory status ensures good patient outcomes and provides clues to whether further interventions are needed.
➧Wash hands.
Prevents transmission of microorganisms
➧Wash hands.
Prevents transmission of microorganisms.
➧ Perform tracheotomy suction.
Removes secretion to prevent occlusion of outer cannula by secretions.
➧ Allow patient to reoxygenate by breathing 100% oxygen, and pour the hydrogen peroxide and normal saline into sterile bowls. Place tracheotomy O2 collar over tracheotomy to ensure oxygen saturation.
Allows efficient and organized completion of tracheotomy care.
➧ Don sterile gloves; remove soiled dressing with forceps and discard in trash receptacle.
Prevents transmission of microorganisms.
➧ Keeping dominant hand sterile, remove oxygen source and inner cannula with nondominant hand; place cannula in hydrogen peroxide basin.
Hydrogen peroxide loosens the secretions.
➧ Place tracheotomy oxygen collar over outer cannula.
Maintains oxygenation of patient.
➧ Clean inner cannula using small brush.
Brush provides mechanical force to remove thick secretions.
➧ Rinse inner cannula with normal saline using nondominant nonsterile hand to pour saline.
Cleanses secretions and hydrogen peroxide from inner cannula.
➧ Replace inner cannula and secure locking mechanism. Reapply oxygen source.
Secures inner cannula and re-establishes oxygen supply. (Note: some tracheotomy devices do not have an inner cannula.)
➧ Cleanse outer cannula with a sterile cotton swab moistened with hydrogen peroxide.
Aseptically removes secretions from stoma site.
➧ Rinse stoma with cotton swab soaked in normal saline and dried with sterile 4X4s.
Rinses hydrogen peroxide from surface and dries surface, prohibiting a moist medium for microorganisms.
➧ Do not release all tracheotomy ties at the same time.
To prevent dislodgement of tracheotomy.
➧ Cut length adequate enough to wrap around the patient’s neck twice and cut ends on diagonal. Insert end of tie through eye of faceplate and pull through ipsilateral eye. Slide tie around neck to other eyelet and insert through second eyelet. Bring one tie around back of neck until ends meet. Tie ends securely allowing one finger breath between neck and tie.
Cutting ends on diagonal aids in insertion of tie through eyelet. One finger breath between neck and ties prevents ties from being too tight.
➧ Insert fresh tracheotomy dressing under clean ties and faceplate.
Absorbs drainage.
➧ Position patient comfortably and assess respiratory status.
Promotes comfort. Reassessment of airway patency and respiratory status ensures good patient outcomes and provides clues to whether further interventions are needed.
➧Wash hands.
Prevents transmission of microorganisms
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