Download LPN IV Push Medications

LPN IV Push Medications
Part 2
April 2010
Additional IV Push Medications
 Ativan
 Decadron
 Digoxin
 Phenergan
 Robinul
 Solumedrol
 Valium
Ativan (Lorazepam)
 Class: Benzodiazepine, Anxiolytic
 Action: Thought to depress CNS at
limbic system and disrupt
neurotransmission in reticular
activating system
 Availability: Injection- 2 mg/ml, 4
mg/ml; Tablets- 0.5 mg, 1 mg, 2 mg
Ativan, cont.
 Indications & dosage
Anxiety- 2-3 mg PO daily in two or three divided
doses. Maximum dosage is 10 mg daily.
Insomnia- 2-4 mg PO at bedtime
Pre-Op- 0.05 mg/kg not to exceed 4 mg deep IM 2
hours prior to surgery OR 0.044 mg/kg not to exceed
2 mg IV 15-20 min. prior to surgery
Status epilepticus- 4 mg IV given slowly- no faster
than 2 mg per min., Can repeat if seizures recur after
10-15 min. Don’t exceed 8 mg in 12 hours.
Ativan, cont.
 Dosage adjustment required in elderly or
debilitated patients
 Off label uses: acute alcohol withdrawal
syndrome
 Contraindications: hypersensitivity to
drug, other benzodiazepines, polyethylene
or propylene glycol, or benzyl alcohol,
acute angle glaucoma, coma, CNS
depression, hepatic or renal failure
Ativan, cont.
 Precautions: Use cautiously in renal or
hepatic impairment, history of suicide
attempt, drug abuse, depressive disorder,
or psychosis, elderly patients, pregnant or
breastfeeding patients
 Administration: Dilute IV doses with
equal volume of diluent such as NS or D5W.
Give each 2 mg dose IV slow push over 2-5
minutes. Don’t exceed rate of 2 mg/min.
Ativan, cont.
 Adverse Reactions: amnesia,
agitation, ataxia, depression,
disorientation, dizziness, drowsiness,
headache, incoordination, asthenia,
hypotension with too rapid
administration IV, bradycardia,
tachycardia, apnea, cardiac arrest,
blurred vision, diplopia, nystagmus,
nausea, abdominal discomfort
Ativan, cont.
 Interactions:
Drug to drug: additive effects with other
benzodiazepines
Contraceptives: increased ativan clearance
Drug to Herbs: increased CNS depression
with chamomile, hops, kava, skullcap,
valerian
Drug-behaviors: increased CNS depression
with alcohol, increased metabolism and
decreased efficacy of ativan with smoking
Ativan, cont.
 Patient monitoring:
During IV administration, monitor
EKG/cardiovascular and respiratory
status
Monitor V.S. closely
Evaluate for amnesia
Watch closely for CNS depression,
signs & symptoms of overdose
Monitor LFTs & CBC
Decadron (Dexamethasone)
 Class: Glucocorticoid, anti-inflammatory
 Action: reduces inflammation by
suppressing polymorphonuclear leukocyte
migration, reversing increased capillary
permeability, and stabilizing leukocyte
lysosomal membranes. Also suppresses
immune response (by lymphatic activity),
stimulate bone marrow, and promotes
protein, fat, and carbohydrate metabolism
Decadron, cont.
 Availability:
Elixir: 0.5mg/5 ml
Oral solution: 0.5 mg/5 ml, 1 mg/ml
IV: 4 mg/ml, 10 mg/ml, 20 mg/ml, 24
mg/ml
Tablets: 0.25 mg, 0.5 mg, 0.75 mg, 1 mg,
1.5 mg, 2 mg, 4 mg, 6 mg
Decadron, cont.
 Indications & Dosages:
Allergic and inflammatory conditions0.75- 9 mg/day PO as a single dose or in divided
doses, in severe cases much higher doses may
be required
Cerebral edemainitially 10 mg IV followed by 4 mg IM every 6
hours, then reduce dosage gradually over 5-7
days
Cushing’s syndrome1 mg PO at 11 pm or 0.5 mg PO every 6 hours
for 48 hours (with urine collection testing as
ordered)
Decadron, cont.
 Off-label uses:
-acute altitude sickness
-bacterial meningitis
-bronchopulmonary dysplasia in
preterm infants
-hirsutism
-suppression test for detection, diagnosis,
or management of depression
Decadron, cont.
 Contraindications:
Hypersensitivity to drug, benzyl
alcohol, bisulfites, EDTA, creatinine,
polysorbate 80, or methylparaben
Systemic fungal infections
Decadron, cont.
 Precautions:
Use cautiously in:
renal insufficiency, cirrhosis, diabetes,
diverticulitis, GI disease, cardiovascular
disease, hypoprothrombinemia,
hypothyroidism, myasthenia gravis,
glaucoma, osteoporosis, infections,
underlying immunosuppression, psychotic
tendencies, pregnant or breastfeeding
patients, children
Decadron, cont.
 Administration:
Give PO dose with food or milk
When giving IM, inject deep into
gluteal muscle, rotate sites as needed
For IV use may give undiluted as
single dose over 1 minute
Decadron, cont.
 Adverse reactions:
headache, malaise, vertigo, psychiatric disturbances,
increased ICP, seizures, hypotension,
thrombophlebitis, myocardial rupture after recent MI,
thromboembolism, cataracts, nausea, vomiting,
abdominal distetion, dry mouth, anorexia, peptic
ulcer, bowel perforation, pancreatitis, ulcerative
esophagitis, hyperglycemia, cushingoid appearance,
fluid retention, adrenal suppression, hypokalemic
alkalosis, muscle wasting, muscle pain, osteoporosis,
tendon rupture, long bone fractures, diaphoresis,
angioedema, erythema, rash, pruritis, acne,
decreased wound healing, bruising, fragile skin,
weight gain or loss, increased susceptability to
infections
Decadron, cont.

Interactions:
Drug to drug: barbiturates, phenytoin, rifampin- decreased
decadron effects
Digoxin- increases risk of dig toxicity
Ephedrine- increased decadron clearance
Contraceptives- block decadron absorption
Fluoroquinolones- increased risk of tendon rupture
Ketoconazole, itraconazole- increased decadron level
and effects
Live-virus vaccines- decreased antibody response to
vaccine
Loop & thiazide diuretics- additive hypokalemia
NSAIDs- increased risk of GI effects
Somatrem, somatropin- decreased response to these
drugs
Decadron, cont.
 Drug-Diagnostic tests- calcium &
potassium- levels decreased, cholesterol &
glucose- levels increased
 Drug-Herbs- echinacea- increased immunestimulating effect, ginseng= potentiation of
immune-modulating response
 Drug-behaviors – alcohol use- increased
gastric irritation & GI ulcers
Digoxin (lanoxin)
 Class: cardiac glycoside, inotrope,
antiarrhythmic
 Action: increases force and velocity
of myocardial contraction and
prolongs refractory period of AV node
by increasing calcium entry into
myocardial cells. Slows conduction
through SA and AV nodes and
produces antiarrhythmic effects
Digoxin, cont.
 Availability:
Capsules: 0.05 mg, 0.1 mg, 0.2 mg
Tablets: 0.125 mg. 0.25 mg, 0.5 mg
Elixir (pediatric): 0.05 mg/ml
IV: 0.05 mg/ml, 0.1 mg/ml, 0.25 mg/ml
Digoxin, cont.
 Indications and dosage:
Heart failure, tachyarrhythmias, atrial fib/flutter,
PSAT
LPNs will only be giving this
drug for maintenance dosing.
LPNs will NOT be pushing this
drug for initial digitializing of
the patient.
Digoxin, cont.
 Dosage adjustment: renal impairment,
hyperthyroidism, elderly patients
 Off-label uses: SVT, intrauterine tachycardias
 Contraindications: hypersensitivity to drug,
uncontrolled ventricular tachycardias, AV block,
idiopathic hypertrophic subaortic stenosis, constrictive
pericarditis
 Precautions: renal or hepatic impairment, electrolyte
imbalances, myocardial infarction, thyroid disorders,
obesity, elderly patients, pregnant or breastfeeding
patients
Digoxin, cont.
 Administration:
Measure apical pulse for one full
minute before administering. If rate
is below 60 bpm, withhold dose and
notify provider.
Drug has narrow therapeutic index,
monitor patient carefully for toxicity
Digoxin, cont.
 Adverse reactions: fatigue,
headache, asthenia, bradycardia, EKG
changes, arrhythmias, blurred or
yellow vision, nausea, vomiting,
diarrhea, gynecomastia,
thrombocytopenia, decreased
appetite.
Digoxin, cont.

Interactions:
Drug-drug: many drugs result in changes in digoxin blood
level possibly leading to toxicity, check nursing drug
resources for a complete list; partial list includes
amiodarone, cyclosporine, diclofenac, diltiazem,
propafenone, quinidine, quinine, verapamil, amphotericin B,
corticosteroids, mezlocillin, pipercillin, thiazide and loop
diuretics, ticarfillin, antacids, cholestyramine, colestipol,
kaolin/pectin, beta blockers, laxatives, spironalactone,
thyroid hormones
Drug-herb: cocoa seed, coffee seed, cola seed, guarana
seed, horsetail, licorice, aloe, yerba mate, may lead to
toxicity
Digoxin, cont.
 Therapeutic range for digoxin blood
levels is 0.5 to 2.0 ng/ml
Phenergan
 Promethazine
 Nonselective phenothiazine
 Antihistamine, antiemetic, sediativehypnotic
 Black box warning: don’t use
suppositories in patients under the
age of 2 due to potential for fatal
respiratory depression
Phenergan, cont.
 Action- blocks effects but not release of
histamine and exerts strong alphaadrenergic effects. Inhibits chemoreceptor
triggers in the medulla and alters the
dopamine effects by indirectly reducing
stimulation in CNS
 Availability:
Injection: 25 mg/ml, 50 mg/ml
Suppositories: 12.5 mg, 25 mg, 50 mg
Syrup: 6.25/5ml
Tablets: 12.5 mg, 25 mg, 50 mg
Phenergan, cont.
 Indications: Type 1 hypersensitivity
reaction, nausea, motion sickness, sedation
 Dosages: Adults- 25-50 mg PO, PR, IM or
IV q4-6 hours prn
 At City, IV doses are limited to 12.5 mg
IV push diluted in 10 ml NS
administered through the port farthest
from the patient over several minutes.
Phenergan should not be administered
through a saline lock. IV fluids must
be infusing.
Phenergan, cont.
 Contraindications: hypersensitivity,
previous idiosyncratic reaction to
phenothiazines, asthma, COPD, obstructive
sleep apnea, coma
 Precautions: cardiovascular or hepatic
disease, seizures, bone marrow depression,
narrow angle glaucoma, prostatic
hypertrophy, stenosing peptic ulcer,
pyloroduodenal or bladder neck
obstruction, CNS depression, pregnant or
breastfeeding patients, children under age
2
Phenergan, cont.
 Administration: Administer no faster than 25
mg/min or in concentrations greater than 25 mg/ml,
inject deep IM into large muscle, don’t give
subcutaneously
 Adverse reactions: confusion, disorientation,
fatigue, drowsiness, sedation, dizziness,
extrapyramidal reactions, insomnia, nervousness,
neuroleptic malignant syndrome, hypertension,
hypotension, brady & tachycardia, blurred vision,
tinnitus, constipation, dry mouth, blood dyscrasias,
respiratory depression, rash
Phenergan, cont.
 Interactions:
Drug-drug: additive anticholinergic effects with
anticholinergics; CNS depressants: additive CNS
depression; Epinephrine: reversal of epi’s vasopressor
effects; MAO inhibitors: increased extrapyramidal
effects
Drug-diagnostic tests: increased glucose levels, false
positive or negative pregnancy tests, false negative
skin allergan tests
Drug-herbs:evening primrose- increased risk seizures,
kava- increased risk adverse drug reactions
Drug-behavior: additive CNS depression with alcohol,
increased risk photosensitivity with sun exposure
Robinul (glycopyrrolate)
 Class: anticholinergic, antispasmodic,
antimuscarinic, parasympatholytic
 Action: inhibits action of acetylcholine on
muscarinic receptors that mediate effects of
parasympathetic postganglionic impulses.
This inhibition relaxes cardiac smooth
muscle, inhibits vagal reflexes, and
decreases tracheal and bronchial secretions
Robinul, cont.
 Availability:
IV: 0.2 mg/ml
Tablets: 1 mg, 2 mg
Robinul, cont.
 Indications and dosage: adjunct in
peptic ulcer disorders, to diminish
secretions and block cardiac vagal
reflexes before or during surgery, to
diminish or block cholinergic effects
caused by anticholinesterase
 1 mg PO tid to max 8 mg/day OR
0.1-0.2 mg IM or IV tid to qid
Robinul, cont.
 Off label uses: sweating
 Contraindications: hypersensitivity to drug,
arrhythmias, COPD, GI disease, infection, atony, or
ileus, myasthenia gravis, glaucoma, obstructive
uropathy, severe prostatic hypertrophy
 Precautions: cardiovascular disease, heart failure,
hypertension, renal or hepatic disease, Down
syndrome, hyperthyroidism, hiatal hernia, ulcerative
colitis, mild to moderate BPH, autonomic heuropathy,
spasticity, suspected brain damage, pregnant or
breastfeeding patients
Robinul, cont.
 Administration: give oral dose 3060 minutes before meals
 IV administration: either undiluted
or diluted with D5W or saline, give
each 0.2 mg over 1-2 min.
 Keep resuscitation equipment on
hand to treat curare-like effects of
overdose
Robinul, cont.
 Adverse reactions: weakness, nervousness,
insomnia, drowsiness, dizziness, headache, confusion,
excitement, palpitations, tachycardia, blurred vision,
photophobia, mydriasis, increased intraocular
pressure, cycloplegia, nausea, vomiting, constipation,
abdominal distention, epigastric distress, heartburn,
gastroesophageal reflux, dry mouth, paralytic ileus,
urinary hesitancy or retention, lactation suppression,
erectile dysfunction, urticaria, decreased sweating or
anhidrosis, loss of taste, fever, allergic reaction,
irritation at IM injection site, anaphylaxis, malignant
hyperthermia
Robinul, cont.
 Interactions: increased
anticholinergic effects with
amantidine, antihistamines,
antiparkinsonians, disopyramide,
glutethimide, meperidine,
phenothiazines, procainamide,
quinidine, tircyclic antidepressants
Solumedrol
(methylprednisolone sodium succinate)
 Class: glucocorticoid, antiasthmatic, antiinflammatory (steroidal),
immunosuppressant
 Action: reduces inflammation and prevents
edema by stabilizing membranes and
reducing permeability of leukocytic cells.
Suppresses immune system by interfering
with antigen-antibody interactions of
macrophages and T cells
Solumedrol, cont.
 Availability:
Solution for IV/IM: 40 mg, 125 mg,
500 mg, 1 g, 2 g
Suspension for injection: 20 mg/ml,
40 mg/ml, 80 mg/ml
Tablets: 2 mg, 4 mg, 8 mg, 16 mg,
24 mg, 32 mg
Solumedrol, cont.
 Indications:
diseases and disorders of endocrine
system, collagen, skin, eye, GI,
respiratory, or hematologic system,
neoplastic diseases, allergies,
multiple sclerosis, tuberculous
meningitis, trichinosis, rheumatic
disorders, osteoarthritis, bursitis,
localized inflammatory lesions
Solumedrol, cont.
 Dosages:
4-160 mg PO daily in four divided
doses depending on disease or
disorder
High dose therapy: 30 mg/kg IV over
at least 30 min., may be repeated in
4-6 ours for 48 hours.
Solumedrol, cont.
 Off label uses: lupus nephritis,
pneumocystis jiroveci pneumonia in
AIDS patients
 Contraindications: hypersensitivity
to drug or its component, systemic
fungal infections
Solumedrol, cont.
 Precautions: cardiovascular, hepatic,
renal, or GI disease. Active untreated
infections, thromboembolic tendency,
idiopathic thrombocytopenia purpura,
osteoporosis, myasthenia gravis,
hypothyroidism, glaucoma, ocular herpes
simplex, vaccinia or varicella, seizure
disorders, metastatic cancer, pregnant or
breastfeeding patients, children
Solumedrol, cont.
 Give prophylactic antacids in patients
receiving high doses to prevent peptic
ulcers
 Methylprednisilone acetate is not for IV
use- IM, intra-articular, intralesional or soft
tissue injection
 Methylprednisilone sodium succinate is for
IV or IM use
 For IV use, inject 500 mg dose over 2 to 3
min or more
Solumedrol, cont.

Adverse reactions: headache, restlessness, nervousness,
depression, euphoria, personality changes, psychoses, vertigo,
paresthesias, insomnia, adhesive arachnoiditis, conus medullarus
syndrome, increased intracranial pressure, seizures, meningitis,
hypotension, hypertension, arrhythmias, heart failure, shock, fat
embolism, thrombophlebitis, thromboembolism, cataracts,
glaucoma, increased intraoccular pressure, nasal irritation, nasal
septum perforation, sneezing, epistaxis, nasopharyngeal or
oropharyngeal fungal infection, dysphonia, hoarseness, throat
irritation, nausea, vomiting, abdominal distention, rectal bleeding,
dry mouth, anorexia, esophageal candidiasis, esophageal ulcer,
peptic ulcer, pancreatitis, amenorrhea, irregular menses, cough,
wheezing, bronchospasm, decreased growth, hyperglycemia, fluid
retention, cushingoid state, hypothalamic-pituitary-adrenal
suppresion, adrenal suppression, acute adrenal insufficiency,
muscle wasting, tendon rupture, weakness, rash, pruritis,
decreased wound healing, fragile skin, skin atrophy, bad taste,
weight gain, etc.
Solumedrol, cont.
 Interactions:
Drug to drug: amphotericin B,
mezlocillin, piperacillin, thiazide and
loop diuretics, ticarcillin- additive
hypokalemai, fluoroquinolonesincreased risk of tendon rupture,
isoniazid, phenobarbital, phenytoin,
rifampin- decreased
Valium
 Diazepam
 Action: produces anxiolytic effect and CNS
depression by stimulating gamma-amniobutyric acid
receptors, relaxes skeletal muscles of the spine by
inhibiting afferent pathways, controls seizures by
enhancing presynaptic inhibition
 Availability:
Injection: 5 mg/ml
Oral solution: 1 mg/ml, 5 mg/5 ml
Rectal gel: 2.5 mg, 10 mg, 15 mg, 20 mg
Tablets: 2 mg, 5 mg, 10 mg
Valium, cont.
 Indications: anxiety disorders, before
interventional procedures, status
epilepticus and severe recurrent seizures,
muscle spasm, acute alcohol withdrawal
 Off label uses: panic attacks, adjunct to
general anesthesia
 Contraindications: hypersensitivity, other
benzodiazepines, alcohol, or tartrazine,
coma or CNS depression, narrow angle
glaucoma
Valium, cont.
 Dosages: Adults 2-10 mg PO two to four times a day,
2-10 mg IV q3-4 hours, 5-15 mg IV pre-cardioversion
or endoscopy
 Precautions: hepatic dysfunction, severe renal
impairment, elderly patients, pregnant or
breastfeeding patients, children
 For IV administration: administer slowly into large
vein, rate of 1 minute per 5 mg in adults or at least 3
minutes for each 0.25 mg/kg in children
 IV route preferred over IM route
 Don’t mix wit other meds or solutions in syringe
 Enforce bed rest for 3 hours post-administration
 Give deep IM and slowly into large muscle mass
Valium, cont.
 Adverse reactions: dizziness, drowsiness, lethargy,
depression, light-headedness, disorientation, anger,
manic or hypomanic episodes, restlessness,
paresthesia, headache, slurred speech, dysarthria,
stupor, tremor, dystonia, vivid dreams, extrapyrimidal
reactions, mild paradoxical excitation, brady or
tachycardia, hyper or hypotension, palpitations,
cardiovascular collapse, blurred vision, diplopia,
nystagmus, nasal congestion, nausea, vomiting,
diarrhea, constipation, gastric disorders, difficulty
swallowing, increased salivation, urinary retention or
incontinence, menstrual irregularities, gynecomastia,
libido changes, blood dyscrasias, hepatic dysfunction,
muscle rigidity, dermatitis, rash, pruritus, diaphoresis,
weight gain or loss, decreased appetite, edema,
hiccups, fever, dependence
Valium, cont.
 Interactions:
Drug-drug: additive effects with
antidepressants, antihistamines,
barbiturates, opioids; decreased levels with
numerous drugs- check ddrug references,
increased dig levels, decreased levodopa
levels
Drug-diagnostic tests: increased levels of
liver enzymes, decreased platelet counts
Drug-behavior: increased CNS depression
with alcohol
Valium, cont.
 Patient monitoring: vital signs and
neuro status, supervise ambulation
especially in elderly, monitor cbc,
renal, and liver enzymes
 Avoid sudden drug withdrawal, taper
gradually to termination of therapy
Questions
 How fast are each of the following
meds pushed?
1. solumedrol
2. decadron
3. robinal
4. digoxin
5. valium
6. phenergan
Answer
 SLOW IV PUSH
Questions
 Which medication may only be push
for maintenance purposes only?
Meaning if this is the initial
administration of this drug to
establish a therapeutic value, the LPN
may not push it.
Answer
 Digoxin
Questions
 Which drug must be diluted in 10 ml
normal saline, pushed through the
port farthest from the patient over
several minutes?
Answer
 Phenergan
Questions
 Which drug has an off label use for
panic attacks but is commonly used
pre-procedurally for endoscopy and
cardioversion?
Answer
 Valium
Questions
 Which two things must be verified
before bar coding the patient in
preparation for drug administration
every time?
Answer
 Patient’s correct name and date of
birth, no nicknames
Questions
 What are the five rights to drug
administration that the prudent nurse
checks EVERY time a medication is
administered?
Answer





Right
Right
Right
Right
Right
patient
drug
dose
route
time
Medication Checklist
Please obtain a copy of the Medication
#2 Checklist from your Nurse
Manager.
You must complete IV administration of
three different medications. One of
those three medications must be
phenergan and you must be directly
observed administering phenergan on
3 separate occasions.