Question

What nursing assessment should be performed regarding each medication? What planning and

implementation should the patient and family do regarding each medication? How do the patient

and family evaluate each medication’s effectiveness?

Furosemide

Hydrocodone

Isosorbide

Potassium chloride

Answer 1

Furosemide

Trade Name(s)Lasix
Ther. Class.
diuretics

Pharm. Class.
loop diuretics

Indications
Edema due to heart failure, hepatic impairment, 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, potassium, and calcium.
Effectiveness persists in impaired renal function.
Therapeutic Effect(s):

Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions).
Decreased BP.
Pharmacokinetics
Absorption: 60–67% absorbed after oral administration (↓ in acute HF and in renal failure); also absorbed from IM sites.

Distribution: Crosses placenta, enters breast milk.

Protein Binding: 91–99%.

Metabolism and Excretion: Minimally metabolized by liver, some nonhepatic metabolism, some renal excretion as unchanged drug.

Half-life: 30–60 min (↑ in renal impairment).

TIME/ACTION PROFILE (diuretic effect)

ROUTE   ONSET   PEAK   DURATION
PO   30–60 min   1–2 hr   6–8 hr
IM   10–30 min   unknown   4–8 hr
IV   5 min   30 min   2 hr
Contraindication/Precautions
Contraindicated in:

Hypersensitivity;
Cross-sensitivity with thiazides and sulfonamides may occur;
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;
Diabetes mellitus;
Hypoproteinemia (↑ risk of ototoxicity);
Severe renal impairment (↑ risk of ototoxicity);
OB: Lactation: Safety not established;
Pedi: ↑ risk for renal calculi and patent ductus arteriosis in premature neonates;
Geri: May have ↑ risk of side effects, especially hypotension and electrolyte imbalance, at usual doses.
Adverse Reactions/Side Effects
CNS: blurred vision, dizziness, headache, vertigo

CV: hypotension

Derm: ERYTHEMA MULTIFORME, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, photosensitivity, pruritis, rash, urticaria

EENT: hearing loss, tinnitus

Endo: hypercholesterolemia, hyperglycemia, hypertriglyceridemia, hyperuricemia

F and E: dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis

GI: anorexia, constipation, diarrhea, dry mouth, dyspepsia, ↑ liver enzymes, nausea, pancreatitis, vomiting

GU: ↑ BUN, excessive urination, nephrocalcinosis

Hemat: APLASTIC ANEMIA, AGRANULOCYTOSIS, hemolytic anemia, leukopenia, thrombocytopenia

MS: muscle cramps

Neuro: paresthesia

Misc: fever

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

↑ risk of hypotension with antihypertensives, nitrates, or acute ingestion of alcohol .
↑ risk of hypokalemia with other diuretics, amphotericin B, stimulant laxatives, and corticosteroids .
Hypokalemia may ↑ risk of digoxin toxicity and ↑ risk of arrhythmia in patients taking drugs that prolong the QT interval.
↓ lithium excretion, may cause lithium toxicity.
↑ risk of ototoxicity with aminoglycosides or cisplatin .
↑ risk of nephrotoxicity with cisplatin .
NSAIDS ↓ effects of furosemide.
May ↑ risk of methotrexate toxicity.
↓ effects when given at same time as sucralfate, cholestyramine, or colestipol .
↑ risk of salicylate toxicity (with use of high-dose salicylate therapy).
Concurrent use with cyclosporine may ↑ risk of gouty arthritis.
Route/Dosage
Edema

PO (Adults) 20–80 mg/day as a single dose initially, may repeat in 6–8 hr; may ↑ dose by 20–40 mg every 6–8 hr until desired response. Maintenance doses may be given once or twice daily (doses up to 2.5 g/day have been used in patients with HF or renal disease). Hypertension– 40 mg twice daily initially (when added to regimen, ↓ dose of other antihypertensives by 50%); adjust further dosing based on response; Hypercalcemia– 120 mg/day in 1–3 doses.

PO (Children >1 mo) 2 mg/kg as a single dose; may be ↑ by 1–2 mg/kg every 6–8 hr (maximum dose = 6 mg/kg).

PO Neonates 1–4 mg/kg/dose 1–2 times/day.

IM IV (Adults) 20–40 mg, may repeat in 1–2 hr and ↑ by 20 mg every 1–2 hr until response is obtained, maintenance dose may be given every 6–12 hr; Continuous infusion– Bolus 0.1 mg/kg followed by 0.1 mg/kg/hr, double every 2 hr to a maximum of 0.4 mg/kg/hr.

IM IV Children 1–2 mg/kg/dose every 6–12 hr; Continuous infusion– 0.05 mg/kg/hr, titrate to clinical effect.

IM IV Neonates 1–2 mg/kg/dose every 12–24 h.

NURSING IMPLICATIONS

Assessment
Assess fluid status. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify health care professional if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs.
Monitor BP and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension.
Geri: Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies.
Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digoxin are at increased risk of digoxin toxicity because of the potassium-depleting effect of the diuretic. Potassium supplements or potassium-sparing diuretics may be used concurrently to prevent hypokalemia.
Assess patient for tinnitus and hearing loss. Audiometry is recommended for patients receiving prolonged high-dose IV therapy. Hearing loss is most common after rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs.
Assess for allergy to sulfonamides.
Assess patient for skin rash frequently during therapy. Discontinue furosemide at first sign of rash; may be life-threatening. Stevens-Johnson syndrome, toxic epidermal necrolysis, or erythema multiforme may develop. Treat symptomatically; may recur once treatment is stopped.
Lab Test Considerations:

Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy. Commonly ↓ serum potassium. May cause ↓ serum sodium, calcium, and magnesium concentrations. May also cause ↑ BUN, serum glucose, creatinine, and uric acid levels.

Potential Diagnoses
Excess fluid volume (Indications)
Deficient fluid volume (Side Effects)
Implementation
Do not confuse Lasix (furosemide) with Luvox (fluvoxamine).
If administering twice daily, give last dose no later than 5 pm to minimize disruption of sleep cycle.
IV route is preferred over IM route for parenteral administration.
PO May be taken with food or milk to minimize gastric irritation. Tablets may be crushed if patient has difficulty swallowing.
Do not administer discolored solution or tablets.
IV Administration
IV Push: Diluent: Administer undiluted (larger doses may be diluted and administered as intermittent infusion [see below]).Concentration: 10 mg/mL.
Rate: Administer at a rate of 20 mg/min. Pedi: Administer at a maximum rate of 0.5–1 mg/kg/min (for doses <120 mg) with infusion not exceeding 10 min.
Intermittent Infusion: Diluent: Dilute larger doses in 50 mL of D5W, D10W, D20W, D5/0.9% NaCl, D5/LR, 0.9% NaCl, 3% NaCl, or LR. Infusion stable for 24 hr at room temperature. Do not refrigerate. Protect from light.Concentration: 1 mg/mL.
Rate: Administer at a rate not to exceed 4 mg/min (for doses >120 mg) in adults to prevent ototoxicity. Pedi: not to exceed 1 mg/kg/min with infusion not exceeding 10 min. Use an infusion pump to ensure accurate dose.

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 (see food sources for specific nutrients).
Advise patient to contact health care professional if weight gain more than 3 lbs in 1 day.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any OTC medications concurrently with this therapy.
Instruct patient to notify health care professional of medication regimen before treatment or surgery.
Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
Advise patient to contact health care professional immediately if rash, muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs.
Advise diabetic patients to monitor blood glucose closely; may cause increased blood glucose levels.
Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected, or if breastfeeding. Monitor fetal growth during pregnancy; increased risk for higher birth weights.
Emphasize the importance of routine follow-up examinations.
Geri: Caution older patients or their caregivers about increased risk for falls. Suggest strategies for fall prevention.
Advise patients on antihypertensive regimen to continue taking medication even if feeling better. Furosemide controls but does not cure hypertension.
Reinforce the need to continue additional therapies for hypertension (weight loss, exercise, restricted sodium intake, stress reduction, regular exercise, moderation of alcohol consumption, cessation of smoking).
Evaluation/Desired Outcomes
Decrease in edema.
Decrease in abdominal girth and weight.
Increase in urinary output.
Decrease in BP.
IV Administration.

Hydrocodone

Indications :

Extended-release product: Management of pain that is severe enough to warrant daily, around-the-clock , long-term opioid treatment where alternative treatment options are inadequate. Combination products: Management of moderate to severe pain. Antitussive (usually in combination products with decongestants)

Action :

Bind to opiate receptors in the CNS. Alter the perception of and response to painful stimuli while producing generalized CNS depression: Suppress the cough reflex via a direct central action.

Therapeutic Effects: Decrease in severity of moderate pain. Suppression of the cough reflex.

Pharmacokinetics Absorption:Well absorbed following oral administration. Distribution: Unknown.

Metabolism and Excretion: Mostly metabolized by the liver; eliminated in the urine (50– 60% as metabolites, 15% as unchanged drug)

Trade Name(s)Hysingla ER
Zohydro ER
HYDROcodone/Acetaminophen

NURSING IMPLICATIONS

Assessment

● Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is 10/min, assess level of sedation. Physical stimulationmay be sufficient to prevent significant hypoventilation. Dose may need to be decreased by 25– 50%. Initial drowsiness will diminish with continued use.

● Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk, and laxatives to minimize constipating effects. Stimulant laxatives should be administered routinely if opioid use exceeds 2– 3 days, unless contraindicated.

● Pain: Assess type, location, and intensity of pain prior to and 1 hr (peak) following administration. When titrating opioid doses, increases of 25– 50% should be administered until there is either a 50% reduction in the patient’s pain rating on a numerical or visual analogue scale or the patient reports satisfactory pain relief. A repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal.

● An equianalgesic chart (see Appendix B) should be used when changing routes or when changing from one opioid to another.

● Prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent patient from receiving adequate analgesia. Most patients who receive opioids for pain do not develop psychological dependence. If progressively higher doses are required, consider conversion to a stronger opioid.

● Cough: Assess cough and lung sounds during antitussive use.

● Lab Test Considerations: May causeqplasma amylase and lipase concentrations.

● Toxicity and Overdose: If an opioid antagonist is required to reverse respiratory depression or coma, naloxone is the antidote. Dilute the 0.4-mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by direct IV push every 2 min. For children and patients weighing 40 kg, dilute 0.1 mg of naloxone in 10 mL of 0.9% NaCl for a concentration of 10 mcg/mL and administer 0.5 mcg/kg every 2 min. Titrate dose to avoid withdrawal, seizures, and severe pain.

Potential Nursing Diagnoses:

Acute pain (Indications)

Disturbed sensory perception (visual, auditory) (Side Effects)

Risk for injury (Side Effects)

Implementation

● High Alert: Accidental overdose of opioid analgesics has resulted in fatalities. Before administering, clarify all ambiguous orders; have second practitioner independently check original order and dose calculations.

● Do not confuse hydrocodone with oxycodone. Do not confuse Reprexain with Zyprexa.

● Explain therapeutic value of medication prior to administration to enhance the analgesic effect.

● Regularly administered doses may be more effective than prn administration. Analgesic is more effective if given before pain becomes severe.

● Combination with nonopioid analgesics may have additive analgesic effects and permit lower doses. Maximum doses of nonopioid agents limit the titration of hydrocodone doses.

● Medication should be discontinued gradually after long-term use to prevent withdrawal symptoms. ● PO:May be administered with food or milk to minimize GI irritation.

● Swallow extended-release capsules whole; do not open, crush, dissolve, or chew.

Patient/Family Teaching

● Advise patient to take medication as directed and not to take more than the recommended amount. Severe and permanent liver damage may result from prolongeduse or high doses of acetaminophen. Renal damage may occur with prolonged use of acetaminophen or ibuprofen. Doses of nonopioid agents should not exceed the maximum recommended daily dose. Do not stop taking without discussing with health care professional; my cause withdrawal symptoms if discontinued abruptly after prolonged use.

● Instruct patient on how and when to ask for and take pain medication.

● Advise patient that hydrocodone is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the individual for whom it was prescribed.

● May cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving or other activities requiring alertness until response to the medication is known.

● Advise patient to notify health care professional if pain control is not adequate or if side effects occur.

● Advise patient to change positions slowly to minimize orthostatic hypotension.

● Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication. ● Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications.

● Emphasize the importance of aggressive prevention of constipation with the use of hydrocodone.

● Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.

● Advise patient that good oral hygiene, frequent mouth rinses, and sugarless gum or candy may decrease dry mouth.

● Advise patient to notify health care professional if pregnancy is planned or suspected, or if breast feeding.

Evaluation/Desired Outcomes

● Decrease in severity of pain without a significant alteration in level of consciousness or respiratory status.

● Suppression of nonproductive cough.

Isosorbide

Indications: Acute treatment of anginal attacks (SL only). Prophylactic management of angina pectoris.Unlabeled Use: Treatment of chronic heart failure (unlabeled).

Action: Produce vasodilation (venous greater than arterial). Decrease left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload). Net effect is reduced myocardial oxygen consumption. Increase coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions.

Therapeutic Effects: Relief and prevention of anginal attacks.

Pharmacokinetics Absorption: Isosorbide dinitrate undergoes extensive first-pass metabolism by the liver, resulting in 25% bioavailability; isosorbide mononitrate has 100% bioavailability (does not undergo first-pass metabolism).

Metabolism and Excretion: Isosorbide dinitrate is metabolized by the liver to 2 active metabolites (5–mononitrate and 2–mononitrate). Isosorbide mononitrate is primarily meteabolized by the liver to inactive metabolites; primarily excreted in urine as metabolites.

Half-life: Isosorbide dinitrate—1 hr; isosorbide mononitrate—5 hr

NURSING IMPLICATIONS

Assessment

● Assess location, duration, intensity, and precipitating factors of anginal pain.

● Monitor BP and pulse routinely during period of dosage adjustment.

● Lab Test Considerations: Excessive doses mayqmethemoglobin concentrations. Potential Nursing Diagnoses Ineffective tissue perfusion (Indications) Activity intolerance (Indications) Implementation Isosorbide Dinitrate

● Do not confuse Isordil (isosorbide dinitrate) with Plendil (felodipine).

● PO:Swallow extended-release capsules whole; do not break, crush, or chew .

● SL: tablets should be held under tongue until dissolved.

● Avoid eating, drinking, or smoking until tablet is dissolved. Replace tablet if inadvertently swallowed. Isosorbide Mononitrate

● PO: Extended-release tablets should be swallowed whole. Do not break, crush, or chew.

Patient/Family Teaching

● Instruct patient to take medication as directed, even if feeling better. Take missed doses as soon as remembered; doses of isosorbide dinitrate should be taken at least 2 hr apart (6 hr with extended-release preparations); daily doses of isosorbide mononitrate should be taken 7 hr apart. Do not double doses. Do not discontinue abruptly.

● Caution patient to make position changes slowly to minimize orthostatic hypotension.

● May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.

● Instruct patient to take last dose of day (when taking 2– 4 doses/day) no later than 7 pm to prevent the development of tolerance.

● Advise patient to avoid concurrent use of alcohol with this medication.Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, or herbal products.

● Inform patient that headache is a common side effect that should decrease with continuing therapy. Aspirin or acetaminophen may be ordered to treat headache. Notify health care professional if headache is persistent or severe. Do not alter dose to avoid headache.

● Advise patient to notify health care professional if dry mouth or blurred vision occurs. Evaluation/Desired Outcomes

● Decrease in frequency and severity of anginal attacks.

● Increase in activity tolerance.

Potassium chloride (oral)

Indications: Treatment/prevention of potassium depletion.

Action: Maintain acid-base balance, isotonicity, and electrophysiologic balance of the cell. Activator in many enzymatic reactions; essential to transmission of nerve impulses; contraction of cardiac, skeletal, and smooth muscle; gastric secretion; renal function; tissue synthesis; and carbohydrate metabolism. Therapeutic Effects: Replacement. Prevention of deficiency.

Pharmacokinetics Absorption:Well absorbed following oral administration.

Distribution: Enters extracellular fluid; then actively transported into cells.

Metabolism and Excretion: Excreted by the kidneys.

NURSINGIMPLICATIONS

Assessment

● Assess for signs and symptoms of hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias, polyuria, polydipsia) and hyperkalemia (see Toxicity and Overdose).

● Lab Test Considerations: Monitor serum potassium before and periodically during therapy. Monitor renal function, serum bicarbonate, and pH. Determine serum magnesium level if patient has refractory hypokalemia; hypomagnesemia should be corrected to facilitate effectiveness of potassium replacement. Monitor serum chloride because hypochloremia may occur if replacing potassium without concurrent chloride.

● Toxicity and Overdose: Symptoms of toxicity are those of hyperkalemia (slow, irregular heartbeat; fatigue; muscle weakness; paresthesia; confusion; dyspnea; peaked T waves; depressed ST segments; prolonged QT segments; widened QRS complexes; loss of P waves; and cardiac arrhythmias).

● Treatment includes discontinuation of potassium, administration of sodium bicarbonate to correct acidosis, dextrose and insulin to facilitate passage of potassium into cells, calcium salts to reverse ECG effects (in patients who are not receiving digoxin), sodium polystyrene used as an exchange resin, and/or dialysis for patient with impaired renal function.

Potential Nursing Diagnoses Imbalanced nutrition: less than body requirements (Indications)

Implementation

● For most purposes, potassium chloride should be used, except for renal tubular acidoses (hyperchloremic acidosis), in which other salts are more appropriate (potassium bicarbonate, potassium citrate, or potassium gluconate).

● If hypokalemia is secondary to diuretic therapy, consideration should be given to decreasing the dose of diuretic, unless there is a history of significant arrhythmias or concurrent digitalis glycoside therapy.

● PO: Administer with or after meals to decrease GI irritation.

● Use of tablets and capsules should be reserved for patients who cannot tolerate liquid preparations.

● Dissolve effervescent tablets in 3– 8 oz of cold water. Ensure that effervescent tablet is fully dissolved. Powders and solutions should be diluted in 3– 8 oz of cold water or juice (do not use tomato juice if patient is on sodium restriction). Instruct patient to drink slowly over 5– 10 min.

● Tablets and capsules should be taken with a meal and full glass of water. Do not chew or crush enteric-coated or extended-release tablets or capsules. Micro-K ExtenCaps capsules can be opened and sprinkled on soft food (pudding, applesauce) and swallowed immediately with a glass of cool water or juice. Patient/Family Teaching

● Explain to patient purpose of the medication and the need to take as directed, especially when concurrent digoxin or diuretics are taken. A missed dose should be taken as soon as remembered within 2 hr; if not, return to regular dose schedule. Do not double dose.

● Emphasize correct method of administration. GI irritation or ulcerationmay result from chewing enteric-coated tablets or insufficient dilution of liquid or powder forms.

● Instruct patient to avoid salt substitutes or low-salt milk or food unless approved by health care professional. Patient should be advised to read all labels to prevent excess potassium intake.

● Advise patient regarding sources of dietary potassium. Encourage compliance with recommended diet.

● Instruct patient to report dark, tarry, or bloody stools; weakness; unusual fatigue; or tingling of extremities. Notify health care professional if nausea, vomiting, diarrhea, or stomach discomfort persists. Dosage may require adjustment.

● Emphasize the importance of regular follow-up exams to monitor serum levels and progress.

Evaluation/Desired Outcomes :

● Prevention and correction of serum potassium depletion.

● Cessation of arrhythmias caused by digoxin toxicity.