Mosby's 2014 Nursing Drug Reference (152 page)

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Canada only Side effects:
italics
= common;
bold
= life-threatening
Nurse Alert

ePHEDrine nasal agent

See
Appendix B

epinastine (ophthalmic)

(ep-ih-nas′teen)

Elestat

Func. class.:
Antihistamine (ophthalmic)

Chem. class.:
Histamine 1 receptor antagonist/mast cell stabilizer

ACTION:

A topically active, direct H
₁- receptor antagonist and mast cell stabilizer; by reducing these inflammatory mediators, it relieves the ocular pruritus associated with allergic conjunctivitis

USES:

Prevention of ocular pruritus associated with signs and symptoms of allergic conjunctivitis

CONTRAINDICATIONS:

Hypersensitivity

Precautions:
Pregnancy (C), breastfeeding, children, contact lenses

DOSAGE AND ROUTES
Calculator

• Adult/child ≥3 yr:
OPHTH
Instill 1 drop in each eye bid

Available forms:
Ophthalmic sol 0.5%

Ophthalmic route

•
For topical ophthalmic use only

•
Wash hands before and after use. Tilt the head back slightly and pull the lower eyelid down with the index finger. Squeeze the prescribed number of drops into the conjunctival sac and gently close eyes for 1–2 min; do not blink

•
Do not touch the tip of the dropper to the eye, fingertips, or other surface

•
The preservative benzalkonium chloride may be absorbed by soft contact lenses. Wait ≥10 min after instilling the ophthalmic solution before inserting contact lenses; contact lenses should not be worn if eye is red

•
Do not share ophthalmic drops with others

•
Keep bottle tightly closed when not in use

•
Treatment should be continued throughout the period of exposure (i.e., until the pollen season is over or until exposure to the offending allergen is terminated), even when symptoms are absent

SIDE EFFECTS

EENT:
Ocular irritation, folliculosis, hyperemia, ocular pruritus

MISC:
Infection (including cold symptoms and upper respiratory infections), headache, rhinitis, sinusitis, increased cough, pharyngitis

PHARMACOKINETICS

Onset 3-5 min, peak 2 hr, duration 8 hr

NURSING CONSIDERATIONS

Assess:

•
Eyes: for itching, redness, use of soft or hard contact lenses

Evaluate:

•
Therapeutic response: absence of redness, itching in the eyes

Teach patient/family:

Ophthalmic route

•
Product is for topical ophthalmic use only

•
Do not touch the tip of the dropper to the eye, fingertips, or other surface

•
Wait ≥10 min after instilling the oph
thalmic solution before inserting contact lenses; contact lenses should not be worn if eye is red

•
Keep bottle tightly closed when not in use

•
Do not share ophthalmic drops with others

•
Remove contact lenses before use because the preservative benzalkonium chloride may be absorbed by soft contact lenses; product should not be used to treat contact lens–related irritation

Canada only Side effects:
italics
= common;
bold
= life-threatening
Nurse Alert

HIGH ALERT
EPINEPHrine (Rx)

(ep-i-nef′rin)

Adrenaclick, Primatene Mist, Twinject, Walgreens Bronchial Mist

EPINEPHrine HCL

Adrenalin, EpiPen, EpiPen Jr.

Func. class.:
Bronchodilator nonselective adrenergic agonist, vasopressor

Chem. class.:
Catecholamine

Do not confuse:
EPINEPHrine
/ePHEDrine

ACTION:

β
₁- and β
₂-agonist causing increased levels of cAMP, thereby producing bronchodilation, cardiac, and CNS stimulation; high doses cause vasoconstriction via α-receptors; low doses can cause vasodilation via β
₂-vascular receptors

USES:

Acute asthmatic attacks, hemostasis, bronchospasm, anaphylaxis, allergic reactions, cardiac arrest, adjunct in anesthesia, shock

Unlabeled uses:
Bradycardia, chloroquine overdose

CONTRAINDICATIONS:

Hypersensitivity to sympathomimetics, sulfites, closed-angle glaucoma, nonanaphylactic shock during general anesthesia

Precautions:
Pregnancy (C), breastfeeding, cardiac disorders, hyperthyroidism, diabetes mellitus, prostatic hypertrophy, hypertension, organic brain syndrome, local anesthesia of certain areas, labor, cardiac dilation, coronary insufficiency, cerebral arteriosclerosis, organic heart disease

DOSAGE AND ROUTES
Calculator

Anaphylaxis/severe asthma exacerbation

• Adult:
IM/SUBCUT
0.3-0.5 mg, may repeat q10-15min (anaphylaxis) or q20min-4 hr (asthma)

Severe allergic reactions type I

• Adult/child ≥30 kg:
IM
0.3 mg (EpiPen/EpiPen 2-Pak, 1:1000)

• Child <30 kg:
IM
0.15 mg (EpiPen Jr/EpiPen Jr 2-Pak 1:2000)

• Adult/child ≥66 lb:
IM/SUBCUT
0.3 mg (0.3 ml) initially (Twinject 1.1 ml 1:1000, 1 mg/ml, containing 2 doses of 0.3 mg)

• Adult/child 33-66 lb:
IM/SUBCUT
0.15 mg (0.15 ml) initially, may give another 0.15 mg after 10 min (Twinject 1.1 ml 1:1000 [1 mg/ml] containing 2 doses of 0.15 mg)

Status asthmaticus

• Adult/adolescent:
SUBCUT 0.3-0.5 mg (0.3-0.5 ml of the 1:1000 injection) q20min × 3 doses

• Infant/child:
SUBCUT 0.01 mg/kg-0.5 mg q20min × 3 doses

Available forms:
Nasal spray (sol) 1 mg/ml; sol for inj 1 mg/ml, 1:10,000, 1:1000; inh vapor (sol) 0.22 mg/actuation; pressurized inh (sol) 0.22 mg/actuation; sol for inj 0.15 mg/0.15 ml autoinjector, 0.3 mg/0.3 ml autoinjector, 0.15 mg/0.3 ml

Administer:

•
Increased dose of insulin for diabetic patients if glucose is elevated

•
Check for correct concentration, route, dosage before administering

•
Give subcut, IM, intraosseously, IV; suspensions are for subcut use only; do not give IV

•
Visually inspect parenteral products for particulate matter and discoloration before use; do not use sols that are pinkish to brownish or that contain a precipitate

•
Avoid extravasation during parenteral administration; if extravasation occurs, infiltrate the affected area with phentolamine diluted in NS

Inhalation route

•
Place in nebulizer (10 gtt of a 1% base sol)

•
Dilute racepinephrine 2.25% sol

IM route

•
EPINEPHrine injection should preferably be into the deltoid or anterior thigh (vastus lateralis). Do not administer into the gluteal muscle

•
Twinject is light sensitive and should be stored in the carrying case provided. Do not refrigerate. Protect from freezing. Replace if solution is discolored or contains a precipitate

SUBCUT route

•
Inject, taking care not to inject intradermally. Massage injection site well after use to enhance absorption and to decrease local vasoconstriction. Injection can cause tissue irritation

Intraosseous INF route (unlabeled)

•
During CPR, the same EPINEPHrine dosage may be given via the intraosseous route when IV access is not available

Intracardiac route

•
Intracardiac route should be reserved for extreme emergencies. Intracardiac injection should only be performed by properly trained medical personnel

Endotracheal route

•
Per the ACLS or PALS guidelines, the EPINEPHrine parenteral product is administered via endotracheal (ET) route. ET administration should only be used if access to IV or intraosseous routes is not possible

• Adult:
Dilute dose in 5–10 ml of NS or sterile distilled water. Administer via ET tube. Endotracheal absorption of EPINEPHrine may be improved by diluting with water instead of NS

• Child:
After dose administration, flush the ET tube with a minimum of 5 ml NS

Direct IV INJ route

•
Inject EPINEPHrine directly into a vein over 5–10 min for adults or 1–3 min for children. May be given IV push in cardiac arrest

•
In neonates, may administer via the umbilical vein

•
During adult cardiopulmonary resuscitation (CPR):
Resuscitation drugs may be given IV by bolus injection into a peripheral vein, followed by an injection of 20 ml IV fluid; elevate the extremity for 10–20 sec to facilitate drug delivery to the central circulation

Continuous IV INF route

•
Dilute 1 mg EPINEPHrine in 250 or 500 ml of a compatible IV inf sol to provide a concentration of 4 or 2 mcg/ml, respectively; give into a large vein, if possible. More-concentrated sols (16–32 mcg/ml) may be used in fluid-restricted patients when administered through a central line

Y-site compatibilities:
Alfentanil, amikacin, amiodarone, amphotericin B liposome, anidulafungin, ascorbic acid, atracurium, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride/gluconate, CARBOplatin, caspofungin, ceFAZolin, cefoperazone, cefotaxime, cefoTEtan, cefOXitin, cefTAZidime, ceftizoxime, cefTRIAXone, cefuroxime, chloramphenicol, chlorproMAZINE, cimetidine, cisatracurium, CISplatin, clindamycin, cyanocobalamin, cyclophosphamide, cycloSPORINE, cytarabine, DACTINomycin, DAPTOmycin, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydrAMINE, DOBUTamine, DOCEtaxel, DOPamine, DOXOrubicin, doxycycline, enalaprilat, epirubicin, epoetin alfa, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentaNYL, fluconazole, fludarabine, folic acid, furosemide, gemcitabine, gentamicin, glycopyrrolate, granisetron, heparin,
hydrocortisone, HYDROmorphone, ifosfamide, imipenem-cilastatin, isoproterenol, ketorolac, labetalol, levofloxacin, lidocaine, linezolid, LORazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, metaraminol, methicillin, methotrexate, methoxamine, methyldopa, methylPREDNISolone, metoclopramide, metoprolol, metroNIDAZOLE, midazolam, milrinone, minocycline, mitoXANtrone, morphine, multiple vitamins, nafcillin, nalbuphine, naloxone, niCARdipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, PACLitaxel, palonosetron, pancuronium, pantoprazole, PEMEtrexed, penicillin G potassium, pentamidine, pentazocine, phentolamine, phenylephrine, phytonadione, piperacillin/tazobactam, potassium chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, protamine, pyridoxime, quinupristin/dalfopristin, ranitidine, remifentanil, ritodrine, rocuronium, sodium acetate, streptomycin, succinylcholine, SUFentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, trimethaphan, urokinase, vancomycin, vasopressin, vecuronium, verapamil, vinCRIStine, vinorelbine, vitamin B complex with C, voriconazole, warfarin, zoledronic acid

SIDE EFFECTS

CNS:
Tremors, anxiety
, insomnia, headache,
dizziness
, confusion, hallucinations,
cerebral hemorrhage
, weakness, drowsiness

CV:
Palpitations, tachycardia
, hypertension,
dysrhythmias, increased T wave

GI:
Anorexia, nausea, vomiting

MISC:
Sweating, dry eyes

RESP:
Dyspnea

PHARMACOKINETICS

Crosses placenta, metabolized in liver

IM:
Onset variable, duration 1-4 hr

SUBCUT:
Onset 5-15 min, duration 20 min-4 hr

INH:
Onset 1-5 min, duration 1-3 hr

INTERACTIONS

•
Do not use with MAOIs or tricyclics; hypertensive crisis may occur

•
Toxicity: other sympathomimetics

Decrease:
hypertensive effects—β-adrenergic blockers

Drug/Herb

•
Increased stimulation: coffee, tea, guarana, yerba maté

NURSING CONSIDERATIONS

Assess:

•
Asthma:
auscultate lungs, pulse, B/P, respirations, sputum (color, character); monitor pulmonary function studies before and during treatment

•
ECG
during administration continuously; if B/P increases, decrease dose; B/P, pulse q5min after parenteral route; CVP, ISVR, PCWP during inf if possible; inadvertent high arterial B/P can result in angina, aortic rupture, cerebral hemorrhage

•
Inj site: tissue sloughing; administer phentolamine with NS

•
Sulfite sensitivity;
may be life-threatening

•
Cardiac status, I&O; blood glucose in diabetes

•
Allergic reactions, bronchospasms:
withhold dose, notify prescriber

Perform/provide:

•
Storage of reconstituted sol refrigerated ≤24 hr

•
Do not use discolored sol

Evaluate:

•
Therapeutic response: increased B/P with stabilization or ease of breathing

Teach patient/family:

•
About the reason for product administration; how to administer

•
To rinse mouth after use to prevent dryness after inhalation