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If the patient is taking indinavir and didanosine purchase imuran 50 mg amex muscle relaxant and pain reliever, the drugs should be given at least 1 h apart on an empty stomach cheap imuran 50 mg with visa yawning spasms. The oral solution of ritonavir may be mixed with chocolate milk to improve the taste. Delavirdine tablets may be mixed in water by adding four tablets to at least 3 oz of water, waiting a few minutes, and then stirring. Have the client drink the mixture promptly, rinse the glass, and swallow the rinse to be sure the entire dose is taken. To give nelfinavir to infants and young children, the oral Acidic foods or juices (eg, orange juice, apple juice, apple sauce) powder can be mixed with a small amount of water, milk, or for- should not be used because they produce a bitter taste. Give intravenous (IV) acyclovir, cidofovir, foscarnet, and To decrease tissue irritation and increased toxicity from high ganciclovir over 1 h. With cidofovir therapy, give probenecid 2 g 3 h before cid- To slow renal excretion of cidofovir and decrease nephrotoxic effects ofovir, 1 g 2 h before cidofovir, and 1 g 8 h after completion of the cidofovir infusion f. With acyclovir for genital herpes, observe for fewer recur- rences when given for prophylaxis; observe for healing of le- sions and decreased pain and itching when given for treatment. With amantadine, observe for absence of symptoms when given for prophylaxis of influenza A and decreased fever, cough, muscle aches, and malaise when given for treatment. With cidofovir, ganciclovir or foscarnet for cytomegalovirus retinitis, observe for improved vision. With antiretroviral drugs, observe for improved clinical status (fewer signs and symptoms) and improved laboratory markers (eg, decreased viral load, increased CD4+ cell count) 3. General effects—anorexia, nausea, vomiting, diarrhea, These effects occur with most systemic antiviral drugs and may fever, headache range from mild to severe. With IV acyclovir—phlebitis at injection site, skin rash, Encephalopathy is rare but potentially serious; other effects com- urticaria, increased blood urea nitrogen or serum creatinine, monly occur. With topical acyclovir—burning or stinging and pruritus These effects are usually transient. With amantadine and rimantadine—central nervous system CNS symptoms are reportedly more likely with zalcitabine aman- (CNS) effects with anxiety, ataxia, dizziness, hyperexcitability, tadine than with rimantadine and may be similar to those caused insomnia, mental confusion, hallucinations, slurred speech by atropine and CNS stimulants. Adverse reactions are more likely to occur in older adults and those with renal impairment. With didanosine, zalcitabine, and zidovudine—peripheral Peripheral neuropathy is more likely with and the drug should be neuropathy (numbness, burning, pain in hands and feet), pan- discontinued if symptoms occur. Pancreatitis may be more likely creatitis (abdominal pain, severe nausea and vomiting, elevated with didanosine, especially in those with previous episodes, alco- serum amylase) hol consumption, elevated serum triglycerides, or advanced HIV infection. Didanosine should be stopped promptly if symptoms of pancreatitis occur. With ganciclovir and foscarnet—bone marrow depression Renal impairment may be more likely to occur with foscarnet. With indinavir, ritonavir, and saquinavir—circumoral and The most frequent adverse effects are the general ones listed peripheral paresthesias, debilitation, fatigue above. With lamivudine and stavudine—peripheral neuropathy, flu-like syndrome (fever, malaise, muscle and joint aches or pain), dizziness, insomnia, depression i. With ophthalmic antiviral drugs—pain, itching, edema, or These symptoms result from tissue irritation or hypersensitivity inflammation of the eyelids reactions. With ribavirin—increased respiratory distress Pulmonary function may deteriorate. With zidovudine—bone marrow depression (BMD; anemia, Anemia may occur within 2–4 wk of starting the drug; granulocy- leukopenia, granulocytopenia, thrombocytopenia); anemia and topenia is more likely after 6–8 wk. A complete blood count should neutropenia in newborn infants be performed every 2 wk. Colony-stimulating factors have been used to aid recovery of bone marrow function. The hematologic effects on newborn infants may occur when the mothers received zidovudine during pregnancy.

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When abbreviations are used purchase imuran 50 mg with mastercard muscle relaxant vecuronium, by prescribers or others discount imuran 50mg on line spasms lower stomach, in- Registered and licensed practical nurses are legally empow- terpret them accurately or question the writers about ered, under state nurse practice acts, to give medications or- intended meanings. Current nursing practice re- nurse practitioners may prescribe medications. However, when they are needed, accuracy is for safe and accurate administration. For medications with a narrow safety margin may be held liable for not giving a drug or for giving a wrong or potentially serious adverse effects, ask a pharmacist drug or a wrong dose. In addition, the nurse is expected to or a colleague to do the calculation also and compare the have sufficient drug knowledge to recognize and question results. The fact that a physician wrote an check measurements of insulin and heparin, unusual erroneous order does not excuse the nurse from legal liability doses (ie, large or small), and any drugs to be given if he or she carries out that order. The nurse also is legally responsible for actions delegated • Use the correct procedures and techniques for all routes to people who are inadequately prepared for or legally barred of administration. For example, use appropriate anatomic from administering medications (such as nursing assistants). The basic techniques and guidelines de- cations to ordered drugs; new signs or symptoms that scribed in this chapter are aimed at safe and accurate prepa- may indicate adverse effects of administered drugs; ration and administration; most errors result when these heart, liver, or kidney disorders that may interfere with practices are not followed. Legal responsibilities in other aspects of drug therapy are • Verify the identity of all clients before administering less tangible and clear-cut. One reason is their great diversity, in age from birth to MEDICATION ERRORS 18 years and weight from 2–3 kilograms (kg) to 100 kg or more. Another is that most drugs have not been tested Increasing attention is being paid to the number and conse- in children. A third reason is that many drugs are mar- quences of medication errors. In one study of 1116 hospi- keted in dosage forms and concentrations suitable for tals, medication errors (a total of 430,586) were reported in adults. This often requires dilution, calculation, prepara- approximately 5% of admitted patients. Each dose of a drug must be recorded require additional treatment, or death). Specific drugs often associated with errors include in- ized, locked cabinets for which each nurse on a unit has a sulin, heparin, and warfarin. These automated systems maintain an inventory getting each dose of a medication to the intended client. Each step or person has a potential for contributing to a Controlled drugs, such as opioid analgesics, are usually medication error (Box 3–1). All health care providers in- kept as a stock supply in a locked drawer or automated cabi- volved in drug therapy must be extremely vigilant in all net and replaced as needed. Each nurse must comply with legal regulations and agency policies for dispensing and recording controlled drugs. The unit- MEDICATION ORDERS dose system, in which most drugs are dispensed in single- dose containers for individual clients, is widely used. The main pur- for information about prescription and nonprescription drugs pose of including potential sources of errors here is to increase the when needed. Drugs may have similar names that can lead to erroneous pre- Health Care Providers scribing, dispensing, or administration. As a result, the FDA-proposed labeling function, and disease process when selecting a drug or dosage; fail changes to make the differences more noticeable. The FDA is to consider other medications the client is taking, including pre- also looking at proposed trade names of new drugs prior to mar- scription and over-the-counter drugs; lack sufficient knowledge keting, to see if they are likely to be confused with older drugs, about the drug; fail to monitor for, or instruct others to monitor for, and increasing surveillance of medication errors attributed to effects of administered drugs; and fail to discontinue drugs appro- drug name confusion. This can dispense incorrect medications, mislabel containers, or fail to ask lead to errors if container labels are not read carefully, especially outpatients about other drugs being taken. Nurses may have in- if the products are shelved or stored next to each other. Clients/Consumers People may take drugs from several prescribers; fail to inform one Circumstances physician about drugs prescribed by another; get prescriptions Prescribers, pharmacists, and nurses may have a heavy workload, filled at more than one pharmacy; fail to get prescriptions filled or with resultant rushing of prescribing, dispensing, or administering refilled; underuse or overuse an appropriately prescribed drug; medications. They may also experience distractions by interrup- take drugs left over from a previous illness or prescribed for some- tions, noise, and other events in the work environment that make one else; fail to follow instructions for drug administration or stor- it difficult to pay needed attention to the medication-related task. Occasionally, verbal or telephone orders are accept- DRUG PREPARATIONS AND able.

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Lithium should be stopped 1 to mainly attributed to genetic or ethnic variations in drug- 2 days before surgery and resumed when full oral intake of metabolizing enzymes in the liver order imuran 50mg with visa spasms right side. Lithium may prolong the effects are genetically heterogeneous and individual members may of anesthetics and neuromuscular blocking drugs cheap imuran 50mg free shipping muscle relaxants. African Americans tend to have higher plasma levels for Use in Children a given dose, respond more rapidly, experience a higher incidence of adverse effects, and metabolize TCAs Depression commonly occurs in children and adolescents and more slowly than whites. To decrease adverse effects, antidepressant drugs are widely prescribed. However, drug initial doses may need to be lower than those given to therapy is largely empiric and of unproven effectiveness. In addition, in children (eg, two SSRIs, fluvoxamine and sertraline, are baseline and periodic ECGs are recommended to detect approved for treatment of obsessive-compulsive disorder, adverse drug effects on the heart. Studies have not been and some TCAs are approved for treatment of enuresis), none done with newer antidepressants. Moreover, the long- Americans report more adverse reactions than whites term effects of antidepressant drugs on the developing brain and may need smaller doses. Asians tend to metabolize antidepressant drugs slowly lines for the use of antidepressants in children and adoles- and therefore have higher plasma drug levels for a given cents. For most children and adolescents, it is probably best to TCAs and a limited number of Asian subgroups. Thus, reserve drug therapy for those who do not respond to it cannot be assumed that all antidepressant drugs and nonpharmacologic treatment and those whose depres- all people of Asian heritage respond the same. To avoid sion is persistent or severe enough to impair function in drug toxicity, initial doses should be approximately half usual activities of daily living. For adolescents, it may be important to discuss sexual be titrated according to clinical response and serum effects because the SSRIs and venlafaxine cause a drug levels. This recommendation is supported by a sur- high incidence of sexual dysfunction (eg, anorgasmia, vey from several Asian countries that reported the use of much smaller doses of TCAs than in the United States. In addition, in Asians as in African Americans, How Can You Avoid This Medication Error? Studies have not been Jane, a 17-year-old, was admitted to your psychiatric unit after a sui- done with newer antidepressants. When you approach her with her morning medications are no apparent differences between effects in Asians (including an antidepressant), she is lying on her bed in a fetal po- and whites. She instructs you to just leave her medications on the table so she can take them 3. Few studies have been done, with some re- 176 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM decreased libido, erectile dysfunction). Nefazodone and mirtazapine, and nefazodone are unlikely to cause venlafaxine may also be used in older adults, with smaller ini- sexual dysfunction. SSRIs are not approved in children (<18 years of age), TCAs may cause or aggravate conditions that are common and their safety and effectiveness have not been estab- in older adults (eg, cardiac conduction abnormalities, urinary lished. However, for children, as for other groups, retention, narrow-angle glaucoma). In addition, impaired these drugs are considered first-line antidepressants compensatory mechanisms make older adults more likely to and safer than TCAs and MAOIs. Common adverse ef- experience anticholinergic effects, confusion, hypotension, fects include sedation and activation; it is often diffi- and sedation. If a TCA is chosen for an older adult, nor- cult to distinguish therapeutic effects (improvement of triptyline or desipramine is preferred. In addition, any TCA mood, increased energy and motivation) from the ad- should be given in small doses initially and gradually in- verse effects of behavioral activation (agitation, hypo- creased over several weeks, if necessary, to achieve thera- mania, restlessness). TCAs are not recommended for use in children younger because the drugs are metabolized and excreted more slowly than 12 years of age except for short-term treatment of than in younger adults. Initial dosage should be decreased by enuresis in children older than 6 years of age. However, 30% to 50% to avoid serious adverse reactions; increments they are used to treat depression, mainly amitriptyline, should be small. Vital signs, serum drug levels, and ECGs desipramine, imipramine, and nortriptyline.

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