Nursing Path

CARING is the essence of NURSING. -Jean Watson

Nursing Path

Knowing is not enough, we must APPLY. Willing is not enough, we must DO. -Bruce Lee

Nursing Path

Treat the patient as a whole, not just the hole in the patient.

Nursing Path

Success is not final. Failure is not fatal. It is the courage to continue that counts. -Winston Churchill

Nursing Path

A problem is a chance for you to do your best. -Duke Ellington

Metro Manila Developmental Screening Test (MMDST)

  • Simple and clinically useful tool
  • To determine early serious developmental delays
  • Dr. William K. Frankenburg
  • Modified and standardized by Dr. Phoebe D. Williams DDST to MMDST
  • Developed for health professionals (MDs, RNs, etc) • It is not an intelligence test
  • It is a screening instrument to determine if child’s development is within normal
  • Children 6 ½ years and below
  • Measures developmental delays
  • Evaluates 4 aspects of development
Aspects of development
In the care of pediatric clients, growth and development are not in isolation.  Nurses being competent in the aspects of growth and development particularly principles, theories and milestones are in best position to counsel clients on these aspects.  Having background knowledge on growth and development, nurses are equipped with assessment skills to determine developmental delays through the aid of screening tests.
The Metro Manila Developmental Screening Test (MMDST) is a screening test to note for normalcy of the child’s development and to determine any delays as well in children 6 ½ years old and below.  Modified and standardized by Dr. Phoebe Williams from the original Denver Developmental Screening Test (DDST) by Dr. William K. Frankenburg, MMDST evaluates 4 sectors of development:
  • Personal-Social – tasks which indicate the child’s ability to get along with people and to take care of himself
  • Fine-Motor Adaptive – tasks which indicate the child’s ability to see and use his hands to pick up objects and to draw
  • Language – tasks which indicate the child’s ability to hear, follow directions and to speak
  • Gross-Motor – tasks which indicate the child’s ability to sit, walk and jump
MMDST KIT.  Preparation for test administration involves the nurse ensuring the completeness of the test materials contained in the MMDST Kit.  These materials should be followed as specified:
  • MMDST manual
  • test Form
  • bright red yarn pom-pom
  • rattle with narrow handle
  • eight  1-inch colored wooden blocks (red, yellow, blue green)
  • small clear glass/bottle with 5/8 inch opening
  • small bell with 2 ½ inch-diameter mouth
  • rubber ball 12 ½ inches in circumference
  • cheese curls
  • pencil
EXPLAINING THE PROCEDURE. Once the materials are ready, the nurse explains the procedure to the parent or caregiver of the child.  It has to be emphasized that this is not a diagnostic test but rather a screening test only.    When conducting the test, the parents or caregivers of the child under study should be informed that it is not an IQ test as it may be misinterpreted by them.  The nurse should also establish rapport with the parent and the child to ensure cooperation.

AGE & THE AGE LINE. To proceed in the administration of the test, the nurse is to compute for the exact age of the child, meaning the age of the child during the test date itself.  The age is the most crucial component of the test because it determines the test items that will be applicable/ administered to the child.  The exact age is computing by subtracting the child’s birth date with the test date.  After computing, draw the age line in the test form.

TEST ITEMS. There are 105 test items in MMDST but not all are administered.  The examiner prioritizes items that the age line passes through.  It is however imperative to explain to the parent or caregiver that the child is not expected to perform all the tasks correctly.  If the sequence were to be followed, the examiner should start with personal-social then progressing to the other sectors.  Items that are footnoted with “R” can be passed by report.

SCORING.  The test items are scored as either Passed (P), Failed (F), Refused (R), or Nor Opportunity (NO).  Failure of an item that is completely to the left of the child’s age is considered a developmental delay. Whereas, failure of an item that is completely to the right of the child’s age line is acceptable and not a delay.

  • Manner in which each test is administered must be exactly the same as stated in the manual, words or direction may not be changed
  • If the child is premature, subtract the number of weeks of prematurity.  But if the child is more than 2 years of age during the test, subtracting may not be necessary
  • If the child is shy or uncooperative, the caregiver may be asked to administer the test provided that the examiner instructs the caregiver to administer it exactly as directed in the manual
  • If the child is very shy or uncooperative, the test may be deferred


Drug Name
Generic Name : cefprozil
Brand Name: Cefzil
Classification: Antibiotic, Cephalosporin (second generation)
Pregnancy Category B
Dosage & Route
  • Skin and soft tissue infections, Susceptible infections including upper and lower respiratory infections
  • Adult: 500 mg/day as a single dose or in 2 divided doses, increased to 500 mg bid if necessary.
  • Child: 20 mg/kg/day once or twice daily, up to a max dose of 500 mg once daily, if necessary, bid for otitis media.
Therapeutic actions
  • Cefprozil inhibits cell wall synthesis and has activity against a broad range of gram-positive and gram-negative bacteria.
    • Absorption: Well absorbed from the GI tract. Bioavailability: 90-95%.
    • Distribution: 35-45% bound to plasma proteins. Widely distributed in the body tissues.
    • Excretion: Plasma half-life: 1-1.4 hr; prolonged in renal impairment. About 60% excreted unchanged in the urine.
  • Pharyngitis or tonsillitis caused by Streptococcus pyogenes
  • Secondary bacterial infection of acute bronchitis and exacerbation of chronic bronchitis caused by Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
  • Dermatologic infections caused by Staphylococcus aureus, S. pyogenes
  • Otitis media caused by S. pneumoniae, H. influenzae, M. catarrhalis
  • Acute sinusitis caused by S. pneumoniae, S. aureus, H. influenzae, M. catarrhalis
Adverse effects
  • Nausea; vomiting; diarrhea; hypersensitivity reactions; nephrotoxicity; convulsions; CNS toxicity; hepatic dysfunction; hematologic disorders; pain at Injection site (IM); thrombophlebitis (IV infusion); superinfection with prolonged use.
  • Potentially Fatal: Pseudomembranous colitis.
  • Hypersensitivity
Nursing considerations
  • History: Penicillin or cephalosporin allergy, pregnancy or lactation, renal failure
  •  Physical: Renal function tests, respiratory status, skin status, culture and sensitivity tests of infected area
  • Culture infection before drug therapy.
  • Give drug with food to decrease GI discomfort.
  • Refrigerate suspension after reconstitution, and discard after 14 days.
  • Discontinue if hypersensitivity reaction occurs.
  • Give the patient yogurt or buttermilk in case of diarrhea.
  • Arrange for oral vancomycin for serious colitis that fails to respond to discontinuation.
Teaching points
  • Take this drug with food.
  • Complete the full course of this drug, even if you feel better.
  • This drug is prescribed for this particular infection; do not use it to self-treat any other infection.
  • You may experience these side effects: Stomach upset, loss of appetite, nausea (take drug with food); diarrhea; headache, dizziness.
  • Report severe diarrhea with blood, pus, or mucus; rash or hives; difficulty breathing; unusual tiredness, fatigue; unusual bleeding or bruising.


Cefdinir (Omnicef) is a cephalosporin (third gen) works as bactericidal and inhibits synthesis of bacterial cell wall, causing cell death.
Generic Names & Brand Names
(sef’ din er)
Pregnancy Category B
Drug classes
Cephalosporin (third generation)
Therapeutic actions
Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death.
  • Community-acquired pneumonia caused by Haemophilus influenzae, H. parainfluenzae, Streptococcus pneumoniae, Mor­ax­ella catar­rhalis
  • Acute exacerbations of chronic bronchitis caused by H. influenzae, H. parainfluenzae, S. pneumoniae, M. catarrhalis
  • Acute maxillary sinusitis caused by H. influenzae, S. pneumoniae, M. catarrhalis
  • Pharyngitis and tonsillitis caused by S. pyogenes
  • Uncomplicated skin and skin structure infections caused by Staphylococcus aureus, S. pyogenes
  • Acute bacterial otitis media caused by H. influenzae, S. pneumoniae, M. catarrhalis
  • Pharyngitis and tonsillitis caused by S. pyogenes
  • Uncomplicated skin and skin-structure infections caused by Staphylococcus aureus, S. pyogenes
Contraindications and cautions
  • Contraindicated with allergy to cephalosporins or penicillins.
  • Use cautiously with renal failure, lactation, pregnancy.
Available forms
Capsules—300 mg; oral suspension—125 mg/5 mL
  • Community-acquired infection, uncomplicated skin, or skin-structure infections: 300 mg PO q 12 hr for 10 days.
  • Acute exacerbation of chronic bronchitis, acute maxillary sinusitis, pharyngitis, or tonsillitis: 300 mg q 12 hr PO for 10 days or 600 mg q 24 hr PO for 10 days.
  • Otitis media, acute maxillary sinusitis, pharyngitis, tonsillitis: 7 mg/kg q 12 hr PO or 14 mg/kg q 24 hr PO for 10 days up to maximum dose of 600 mg/day.
  • Skin and skin-structure infections: 7 mg/kg PO q 12 hr for 10 days.
For creatinine clearance < 30 mL/min, 300 mg PO daily. For patients on dialysis, 300 mg PO every other day; start with 300 mg PO at the end of dialysis and then every other day.
Oral60 min8–10 hr
Metabolism: T1/2: 100 min
Distribution: Crosses the placenta, enters breast milk
Excretion: Renal, unchanged
Adverse effects
  • CNS: Headache, dizziness, lethargy, paresthesias
  • GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudo­membranous colitis, liver toxicity
  • GU: Nephrotoxicity
  • HematologicBone marrow depression
  • Hypersensitivity: Ranging from rash to fever to anaphylaxis; serum sickness reaction
  • Other: Superinfections
  • Increased nephrotoxicity with aminoglycosides
  • Increased bleeding effects if taken with oral anticoagulants
  • Interferes with absorption of cefdinir if taken with antacids containing magnesium or aluminum or with iron supplements; separate by at least 2 hr
Drug-lab test
  • Possibility of false results on tests of urine glucose using Benedict’s solution, Fehling’s solution, Clinitest tablets; urinary 17-ketosteroids; direct Coombs’ test
Nursing considerations
  • History: Penicillin or cephalosporin allergy; pregnancy or lactation, renal failure
  • Physical: Kidney function, respiratory status, skin status; culture and sensitivity tests of infected area
  • Arrange for culture and sensitivity tests of infected area before beginning drug therapy and during therapy if infection does not resolve.
  • Reconstitute oral suspension by adding 39 mL water to the 60 mL bottle, 65 mL water to the 120 mL bottle; shake well before each use. Store at room temperature. Discard after 10 days.
  • Give drug with meals; arrange for small, frequent meals if GI complications occur. Separate antacids or iron supplements by 2 hr from the cefdinir dose.
  • Arrange for treatment of superinfections if they occur.
Teaching points
  • Take this drug with meals or food. Store suspension at room temperature, shake well before each use; discard any drug after 10 days.
  • Complete the full course of this drug, even if you feel better before the course of treatment is over.
  • This drug is prescribed for this particular infection; do not self-treat any other infection with this drug.
  • You may experience these side effects: Stomach upset, loss of appetite, nausea (taking the drug with food may help); diarrhea (stay near bathroom facilities); headache, dizziness.
  • Report severe diarrhea with blood, pus, or mucus; rash or hives; difficulty breathing; unusual tiredness, fatigue; unusual bleeding or bruising.

Medication Calculation

D = Desired Dose
Q = Quantity of Solution
H = Strength on Hand
X = Unknown quantity of Drug
  • Physician orders 500 mg of ibuprofen (desired Dose) for a patient and you have 250 mg (Quantity on Hand) tablets (Quantity of solution) on hand.
  • Solution: D ÷ H x Q = X 500mg ÷ 250 mg x 1 tablet = 2 tablets Answer: 2 tablets.
  • Physician orders 1500 mg of liquid ibuprofen for a patient. Quantity of Ibuprofen is 500 mg in 1 cc, how much will you administer?
  • Solution: 1500 mg ÷ 500 mg x 1cc = 3 cc Answer: 3 cc
Dosage and Conversions
  • MD orders 300 mg of Ibuprophen to be taken by a 6 kg infant every 4 hours. Label shows 75 – 150 mg/kg per day. Is the physician’s order within normal range?
  • Solution: 6 x 75 = 450 mg (minimum dosage per day); 150 X6 = 900 (maximum dosage per day) 24 ÷ 4 = 6 dosages : 300 x 6 = 1800
  • Answer: Dosage is not within range
IV Calculations
[amount of fluid to be infused] x [drop factor] ÷ minutes to infuse = gtts/min
  • Dr. A. orders your patient to receive 125 ml of D5W an hour for the next 8 hours. The nursing unit uses tubing with a drop factor of 10. What is the drip rate per minute?
  • Solution: Convert 1 hour to 60 minutes: 1250 x 10 gtts ÷ 60 minutes = 20.83 or 21 gtts/min
  • Answer: 21 gtts/min
  • Dr. B. orders a liter of D5W to run this 8-hour shift. The drop factor is 15. What is the drip rate per minute?
  • Solution: 1 liter = 1000 cc of solution, next convert 8 hours to minutes (8 X 60 minutes) = 480 minutes 1000 cc x 15 gtts ÷ 480 minutes = 31.25 or 31 gtts/min
  • Answer: 31 gtts/min
  • Your patient weighs 200 lb and the order is to infuse 250 mg dobutamine in 500 ml NS at 10 mcg/kg/min. How many milligrams of dobutamine will infuse per hour?
  • Solution: 200÷2.2= 90.90kg: 60 minutes = 1 hour: 10 mcg x 90.90kg x 60 min=5454.54 mcg/hour ÷ 1000 = 54.54mg/hr or 54.5mg/hr
  • Answer:54.5mg/hr
The “7 Rights” of Medication Administration
  1. Right Patient
  2. Right Drug
  3. Right Dose
  4. Right Route
  5. Right Time
  6. Right Documentation
  7. Right to Refuse
Conversion Table
  • 1 kilogram (kg) = 1000 grams (g)
  • 1 gram (g) = 1000 milligrams (mg)
    • Convert Grams to Milligrams by Multiplying grams by 1,000
    • Convert Milligrams to grams by dividing milligrams by 1,000
  • 1 milligram (mg) = 1000 micrograms (mcg)
  • Grains (gr.) 15 = 1 Gram (g) or 1000 milligrams (mg)
    • To convert g. to gr multiply by 15
    • To convert gr to g divide by 15.
  • 1 Grain (gr.) = 60 Milligrams (mg)
    • To convert gr. to mg multiply gr. by 60
    • To convert mg to gr. divide mg. by 60
  • 1ml = 1 cc
  • 1 ounce = 30 ml
  • 1 tablespoon (T or tbsp) = 15 ml
  • 1 teaspoon (t or tsp) = 5 ml
  • 2.2 lb = 1 kg
  • To convert pounds to kg divide pounds by 2.2
  • To convert kg to pounds multiply by 2.2


Drug Name
Generic Name : carvedilol
Brand Name: Coreg
Classification: Alpha- and beta-adrenergic blocker, Antihypertensive
Pregnancy Category C
Dosage & Route
  • hypertension
    • Adult: Initially, 12.5 mg once daily increased to 25 mg once daily after 2 days. Alternatively, initial dose of 6.25 mg bid increased to 12.5 mg bid after 1-2 wk, increased further if necessary to 50 mg once daily or in divided doses.
    • Elderly: 12.5 mg once daily.
  • Angina pectoris
    • Adult: Initially, 12.5 mg bid increased to 25 mg bid after 2 days.
  • heart failure
    • Adult: Initially, 3.125 mg bid, doubled to 6.25 mg bid after 2 wk if tolerated, then gradually increased to the max dose the patient can tolerate at intervals of not <2 wk. Max dose: >85 kg: 50 mg bid; <85 kg: 25 mg bid.
  • Left ventricular dysfunction post myocardial infarction
    • Adult: Initially: 6.25 mg bid, if tolerated, after 3-10 days, increase to 12.5 mg bid and then to a target dose of 25 mg bid.
Therapeutic actions
  • Carvedilol causes vasodilation by blocking the activity of α-blockers, mainly at alpha-1 receptors. It exerts antihypertensive effect partly by reducing total peripheral resistance and vasodilation. It is used in patients with renal impairment, NIDDM or IDDM.
    • Absorption: Absorbed well from the GI tract (oral); peak plasma concentrations after 1-2 hr.
    • Distribution: Enters breast milk. Protein-binding: >98%.
    • Metabolism: Hepatic: Considerable first-pass effect.
    • Excretion: Via bile (as metabolites); 6-10 hr (elimination half-life).
  • Hypertension, alone or with other oral drugs, especially diuretics
  • Treatment of mild to severe CHF of ischemic or cardiomyopathic origin with digitalis, diuretics, ACE inhibitors
  • Left ventricular dysfunction (LVD) after MI
  • Unlabeled uses: Angina (25–50 mg bid)
Adverse effects
  • Bradycardia, AV block, angina pectoris, hypervolemia, leucopenia, hypotension, peripheral edema, allergy, malaise, fluid overload, melena, periodontitis, hyperuricemia, hyponatremia, increased alkaline phosphatase, glycosuria, prothrombin time, SGPT and SGOT levels, purpura, somnolence, impotence, albuminuria, hypokinesia, nervousness, sleep disorder, skin reaction, tinnitus, dry mouth, anemia, sweating, fatigue, arthralgia, aggravation, dizziness. Diarrhea, nausea, vomiting, insomnia, hypercholesterolemia, weight gain, abnormal vision, rhinitis, pharyngitis and hypertriglyceridemia.
  • Hypersensitivity; severe chronic heart failure, bronchial asthma or related bronchospastic conditions; severe hepatic impairment. Patients with NYHA class IV cardiac failure, 2nd or 3rd ° AV block, sick sinus syndrome (unless a permanent pacemaker is in place), cardiogenic shock or severe bradycardia. Lactation.
Nursing considerations
  • History: CHF, bronchial asthma, heart block, cardiogenic shock, hypersensitivity to carvedilol, pregnancy, lactation, hepatic impairment, peripheral vascular disease, thyrotoxicosis, diabetes, anesthesia or major surgery
  • Physical: Baseline weight, skin condition, neurologic status, P, BP, ECG, respiratory status, LFTs, renal and thyroid function tests, blood and urine glucose
  • WARNING: Do not discontinue drug abruptly after chronic therapy (hypersensitivity to catecholamines may have developed, causing exacerbation of angina, MI, and ventricular arrhythmias); taper drug gradually over 2 wk with monitoring.
  • Consult with physician about withdrawing drug if patient is to undergo surgery (withdrawal is controversial).
  • Give with food to decrease orthostatic hypotension and adverse effects.
  • Monitor for orthostatic hypotension and provide safety precautions.
  • Monitor diabetic patient closely; drug may mask hypoglycemia or worsen hyperglycemia.
  • WARNING: Monitor patient for any sign of hepatic impairment (pruritus, dark urine or stools, anorexia, jaundice, pain); arrange for LFTs and discontinue drug if tests indicate liver injury. Do not restart carvedilol.
Teaching points
  • Take drug with meals.
  • Do not stop taking drug unless instructed to do so by a health care provider.
  • Avoid use of over-the-counter medications.
  • Advise the diabetic patient to promptly report changes in glucose.
  • You may experience these side effects: Depression, dizziness, light-headedness (avoid driving or performing dangerous activities; getting up and changing positions slowly may help ease dizziness).
  • Report difficulty breathing, swelling of extremities, changes in color of stool or urine, very slow heart rate, continued dizziness.

carisoprodol (isomeprobamate)

Drug Name
Generic Name : carisoprodol (isomeprobamate)
Brand Name: Soma
Classification: Centrally acting skeletal muscle relaxant
Pregnancy Category NR
Dosage & Route
  • Adjunct in the short-term symptomatic treatment of painful muscle spasm associated with musculoskeletal conditions
  • Adult: 350 mg 3-4 times daily for up to 2-3 wk.
  • Elderly: Half of the usual dose.
Therapeutic actions
  • Carisoprodol blocks interneuronal synaptic activity in the descending reticular formation and spinal cord resulting in skeletal muscle relaxation.
    • Duration: 4-6 hrs.
    • Absorption: Absorbed from the GIT (oral); peak plasma concentrations after 30 min.
    • Distribution: Enters breast milk (significant amounts).
    • Metabolism: Hepatic; yields meprobamate.
    • Excretion: Via urine (as metabolites).
  • Relief of discomfort associated with acute, painful musculoskeletal conditions as an adjunct to rest, physical therapy, and other measures
Adverse effects
  • Dizziness, drowsiness, nausea, epigastric distress, tachycardia, orthostatic hypotension, Hypersensitivity reactions, rash.
  • Potentially Fatal: Idiosyncratic reaction (rare).
  • Acute intermittent porphyria, hypersensitivity. Lactation.
Nursing considerations
  • History: Allergic or idiosyncratic reactions to carisoprodol, meprobamate; acute intermittent porphyria, suspected porphyria; lactation
  • Physical: T; skin color, lesions; orientation, affect; P, BP, orthostatic BP; bowel sounds, liver evaluation; LFTs, renal function tests, CBC
  • WARNING: Monitor patient for potentially serious idiosyncratic reactions—most likely with first few doses.
  • Reduce dose with hepatic impairment.
  • Provide safety measures if CNS effects occur.
  • Drug may be habit forming. Monitor patient.
Teaching points
  • Take this drug exactly as prescribed; do not take a higher dosage; take with food if GI upset occurs.
  • Avoid alcohol, sleep-inducing, or over-the-counter drugs; these could cause dangerous effects; if you feel you need one of these preparations, consult your health care provider.
  • You may experience these side effects: Drowsiness, dizziness, vertigo (avoid driving or activities that require alertness); dizziness when you get up or climb stairs (avoid sudden changes in position, use caution climbing stairs); nausea (take drug with food; eat frequent small meals); insomnia, headache, depression (transient effects).
  • Report rash, severe nausea, dizziness, insomnia, fever, difficulty breathing.

carbamazepine (Tegretol)

Carbamazepine or Tegretol is an antiepileptic drug indicated for patients with refractory seizure disorders. Carbamazepine is also used in treating pain in trigeminal neuralgia.
Generic Names & Brand Names
(kar ba maz e peen)
Apo-Carbamazepine (CAN), Carbatrol, Epitol, Novo-Carbamaz (CAN), Tegretol, Tegretol-XR
Pregnancy Category D
Drug class
Therapeutic actions
Mechanism of action not understood; antiepileptic activity may be related to its ability to inhibit polysynaptic responses and block post-tetanic potentiation. Drug is chemically related to the TCAs.
  • Refractory seizure disorders: Partial seizures with complex symptoms (psychomotor, temporal lobe epilepsy), generalized tonic-clonic (grand mal) seizures, mixed seizure patterns or other partial or generalized seizures. Reserve for patients unresponsive to other agents with seizures difficult to control or who are experiencing marked side effects, such as excessive sedation
  • Trigeminal neuralgia (tic douloureux): Treatment of pain associated with true trigeminal neuralgia; also beneficial in glossopharyngeal neuralgia
  • Unlabeled uses: Neurogenic diabetes insipidus (200 mg bid–tid); certain psychiatric disorders, including bipolar disorders, schizoaffective illness, resistant schizophrenia, and dyscontrol syndrome associated with limbic system dysfunction; alcohol withdrawal (800–1,000 mg/day); restless leg syndrome (100–300 mg/day hs); non-neuritic pain syndrome (600–1,400 mg/day); hereditary or nonheriditary chorea in children (15–25 mg/kg/day).
Contraindications and cautions
  • Contraindicated with hypersensitivity to carbamazepine or TCAs, history of bone marrow depression, concomitant use of MAOIs, lactation, pregnancy.
  • Use cautiously with history of adverse hematologic reaction to any drug (increased risk of severe hematologic toxicity); glaucoma or increased IOP; history of cardiac, hepatic, or renal damage; psychiatric patients (may activate latent psychosis).
Available forms
Tablets—200 mg; chewable tablets—100 mg; ER tablets—100, 200, 400 mg; ER capsules—200, 300 mg; suspension—100 mg/5 mL, 200 mg/10 mL
Individualize dosage; a low initial dosage with gradual increase is advised.
  • Epilepsy: Initial dose, 200 mg PO bid on the first day; increase gradually by up to 200 mg/day in divided doses q 6–8 hr, until best response is achieved. Suspension:100 mg PO qid. Do not exceed 1,200 mg/day in patients > 15 yr; doses up to 1,600 mg/day have been used in adults (rare). For maintenance, adjust to minimum effective level, usually 800–1,200 mg/day.
  • Trigeminal neuralgia: Initial dose, 100 mg PO bid on the first day; may increase by up to 200 mg/day, using 100-mg increments q 12 hr as needed. Do not exceed 1,200 mg/day. For maintenance, control of pain can usually be maintained with 400–800 mg/day (range 200–1,200 mg/day). Attempt to reduce the dose to the minimum effective level or to discontinue the drug at least once every 3 mo.
  • Combination therapy: When added to existing antiepileptic therapy, do so gradually while other antiepileptics are maintained or discontinued.
  • < 6 yr: Optimal daily dose < 35 mg/kg/day.
  • 6–12 yr: Initial dose, 100 mg PO bid on the first day. Increase gradually by adding 100 mg/day at 6- to 8-hr intervals until best response is achieved. Do not exceed 1,000 mg/day. Dosage also may be calculated on the basis of 20–30 mg/kg/day in divided doses tid–qid.
  • > 12 yr: Use adult dosage. Do not exceed 1,000 mg/day in patients 12–15 yr; 1,200 mg/day in patients > 15 yr.
  • Use caution; drug may cause confusion, agitation.
OralSlow4–5 hr
ER OralSlow3–12 hr
Metabolism: Hepatic; T1/2: 25–65 hr, then 12–17 hr
Distribution: Crosses placenta; enters breast milk
Excretion: Urine and feces
Adverse effects
  • CNS: Dizziness, drowsiness, unsteadiness, disturbance of coordination, confusion, headache, fatigue, visual hallucinations, depression with agitation, behavioral changes in children, talkativeness, speech disturbances, abnormal involuntary movements, paralysis and other symptoms of cerebral arterial insufficiency, peripheral neuritis and paresthesias, tinnitus, hyperacusis, blurred vision, transient diplopia andoculomotor disturbances, nystagmus, scattered punctate cortical lens opacities, conjunctivitis, ophthalmoplegia, fever, chills; SIADH
  • CV: CHF, aggravation of hypertension, hypotension, syncope and collapse, edema, primary thrombophlebitis, recurrence of thrombophlebitis, aggravation of CAD, arrhythmias and AV block; CV complications
  • Dermatologic: Pruritic and erythematous rashes, urticaria, Stevens-Johnson syndrome, photosensitivity reactions, alterations in pigmentation, exfoliative dermatitis, alopecia, diaphoresis, erythema multiforme andnodosum, purpura, aggravation of lupus erythematosus
  • GI: Nausea, vomiting, gastric distress, abdominal pain, diarrhea, constipation, anorexia, dryness of mouth or pharynx, glossitis, stomatitis; abnormal liver function tests, cholestatic and hepatocellular jaundice,hepatitis, massive hepatic cellular necrosis with total loss of intact liver tissue
  • GU: Urinary frequency, acute urinary retention, oliguria with hypertension, renal failure, azotemia, impotence, proteinuria, glycosuria, elevated BUN, microscopic deposits in urine
  • Hematologic: Hematologic disorders (severe bone marrow depression)
  • Respiratory: Pulmonary hypersensitivity characterized by fever, dyspnea, pneumonitis or pneumonia
  • Increased serum levels and manifestations of toxicity with erythromycin, troleandomycin, cimetidine, danazol, isoniazid, propoxyphene, verapamil; dosage of carbamazepine may need to be reduced (reductions of about 50% recommended with erythromycin)
  • Increased CNS toxicity with lithium
  • Increased risk of hepatotoxicity with isoniazid (MAOI); because of the chemical similarity of carbamazepine to the TCAs and because of the serious adverse interaction of TCAs and MAOIs, discontinue MAOIsfor minimum of 14 days before carbamazepine administration
  • Decreased absorption with charcoal
  • Decreased serum levels and decreased effects of carbamazepine with barbiturates
  • Increased metabolism but no loss of seizure control with phenytoin, primidone
  • Increased metabolism of phenytoin, valproic acid
  • Decreased anticoagulant effect of warfarin, oral anticoagulants; dosage of warfarin may need to be increased during concomitant therapy but decreased if carbamazepine is withdrawn
  • Decreased effects of nondepolarizing muscle relaxants, haloperidol
  • Decreased antimicrobial effects of doxycycline
Nursing considerations
  • History: Hypersensitivity to carbamazepine or TCAs; history of bone marrow depression; concomitant use of MAOIs; history of adverse hematologic reaction to any drug; glaucoma or increased IOP; history of cardiac, hepatic, or renal damage; psychiatric history; lactation; pregnancy
  • Physical: Weight; T; skin color, lesions; palpation of lymph glands; orientation, affect, reflexes; ophthalmologic examination (including tonometry, funduscopy, slit lamp examination); P, BP, perfusion; auscultation; peripheral vascular examination; R, adventitious sounds; bowel sounds, normal output; oral mucous membranes; normal urinary output, voiding pattern; CBC including platelet, reticulocyte counts and serum iron; hepatic function tests, urinalysis, BUN, thyroid function tests, EEG
  • Use only for classifications listed. Do not use as a general analgesic. Use only for epileptic seizures that are refractory to other safer agents.
  • Give drug with food to prevent GI upset.
  • Do not mix suspension with other medications or elements—precipitation may occur.
  • WARNING: Reduce dosage, discontinue, or substitute other antiepileptic medication gradually. Abrupt discontinuation of all antiepileptic medication may precipitate status epilepticus.
  • Suspension will produce higher peak levels than tablets—start with a lower dose given more frequently.
  • Ensure that patient swallows ER tablets whole—do not cut, crush, or chew.
  • Arrange for frequent liver function tests; discontinue drug immediately if hepatic dysfunction occurs.
  • WARNING: Arrange for patient to have CBC, including platelet, reticulocyte counts, and serum iron determination, before initiating therapy; repeat weekly for the first 3 mo of therapy and monthly thereafter for at least 2–3 yr. Discontinue drug if there is evidence of marrow suppression, as follows:
Erythrocytes < 4 million/mm3
Hematocrit< 32%
Hemoglobin< 11 gm/dL
Leukocytes< 4,000/mm3
Platelets< 100,000/mm3
Reticulocytes< 0.3% (20,000/mm2)
Serum iron150 g/100 mL
  • Arrange for frequent eye examinations, urinalysis, and BUN determinations.
  • Arrange for frequent monitoring of serum levels of carbamazepine and other antiepileptics given concomitantly, especially during the first few weeks of therapy. Adjust dosage on basis of data and clinical response.
  • Counsel women who wish to become pregnant; advise the use of barrier contraceptives.
  • Evaluate for therapeutic serum levels (usually 4–12 mcg/mL).
Teaching points
  • Take drug with food as prescribed. Swallow ER tablets whole, do not cut, crush, or chew them.
  • Do not discontinue this drug abruptly or change dosage, except on the advice of your physician.
  • Avoid alcohol, sleep-inducing, or OTC drugs; these could cause dangerous effects.
  • Arrange for frequent checkups, including blood tests, to monitor your response to this drug. Keep all appointments for checkups.
  • Use contraceptives at all times; if you wish to become pregnant, you should consult your physician.
  • Wear a medical alert tag at all times so that any emergency medical personnel will know that you have epilepsy and are taking antiepileptic medication.
  • You may experience these side effects: Drowsiness, dizziness, blurred vision (avoid driving or performing other tasks requiring alertness or visual acuity); GI upset (take the drug with food or milk; eat frequent small meals).
  • Report bruising, unusual bleeding, abdominal pain, yellowing of the skin or eyes, pale feces, darkened urine, impotence, CNS disturbances, edema, fever, chills, sore throat, mouth ulcers, rash, pregnancy.

Medication Administration

Principles of Medication Administration
I. “Six Rights” of drug administration
1. The Right Medication – when administering medications, the nurse compares the label of the medication container with medication form.
The nurse does this 3 times:
  1. Before removing the container from the drawer or shelf
  2. As the amount of medication ordered is removed from the container
  3. Before returning the container to the storage
2. Right Dose –when performing medication calculation or conversions, the nurse should have another qualified nurse check the calculated  dose
3. Right Client – an important step in administering medication safely is being sure the medication is given to the right client.
  1. To identify the client correctly:
  2. The nurse checks the medication administration form against the client’s identification bracelet and asks the client to state his or      her name to ensure the client’s identification bracelet has the correct information.
4. Right Route – if a prescriber’s order neither does nor designates a route of administration, the nurse consult the prescriber. Likewise, if the specified route is not recommended, the nurse should alert the prescriber immediately.
5. Right Time
  1. The nurse must know why a medication is ordered for certain times of the day and whether the time schedule can be altered
  2. Each institution has are commended time schedule for medications ordered at frequent interval
  3. Medication that must act at certain times are given priority (e.g insulin should be given at a precise interval before a meal)
6. Right Documentation –Documentation is an important part of safe medication administration
  1. The documentation for the medication should clearly reflect the client’s name, the name of the ordered medication, the time, dose, route and frequency
  2. Sign medication sheet immediately after administration of the drug
Client’s Right Related to Medication Administration
A client has the following rights:
  1. To be informed of the medication’s name, purpose, action, and potential undesired effects.
  2. To refuse a medication regardless of the consequences
  3. To have a qualified nurses or physicians assess medication history, including allergies
  4. To be properly advised of the experimental nature of medication therapy and to give written consent for its use
  5. To received labeled medications safely without discomfort in accordance with the six rights of medication administration
  6. To receive appropriate supportive therapy in relation to medication therapy
  7. To not receive unnecessary medications
II. Practice Asepsis
  • Wash hand before and after preparing the medication to reduce transfer of microorganisms.
III. Nurse who administers the medications is responsible for their own action
  • Question any order that you considered incorrect (may be unclear or appropriate)
IV. Be knowledgeable about the medication that you administer
  • A fundamental rule of safe drug administration is: “Never administer an unfamiliar medication”
V. Keep the Narcotics in locked place
VI. Use only medications that are in clearly labeled containers. Relabeling of drugs is the responsibility of the pharmacist.
VII. Return liquid that is cloudy in color to the pharmacy.
VIII. Before administering medication, identify the client correctly
IX. Do not leave the medication at the bedside. Stay with the client until he actually takes the medications.
X. The nurse who prepares the drug administers it. Only the nurse prepares the drug knows what the drug is. Do not accept endorsement of medication.
XI. If the client vomits after taking the medication, report this to the nurse in charge or physician.
XII. Preoperative medications are usually discontinued during the postoperative period unless ordered to be continued.
XIII. When a medication is omitted for any reason, record the fact together with the reason.
XIV. When the medication error is made, report it immediately to the nurse in charge or physician
  • To implement necessary measures immediately. This may prevent any adverse effects of the drug.
Oral Administration
  1. The easiest and most desirable way to administer medication
  2. Most convenient
  3. Safe, does nor break skin barrier
  4. Usually less expensive
  1. Inappropriate if client cannot swallow and if GIT has reduced motility
  2. Inappropriate for client with nausea and vomiting
  3. Drug may have unpleasant taste
  4. Drug may discolor the teeth
  5. Drug may irritate the gastric mucosa
  6. Drug may be aspirated by seriously ill patient.
Drug Forms for Oral Administration
  1. Solid– tablet, capsule, pill, powder
  2. Liquid– syrup, suspension, emulsion, elixir, milk, or other alkaline substances.
  3. Syrup– sugar-based liquid medication
  4. Suspension– water-based liquid medication. Shake bottle before use of medication to properly mix it.
  5. Emulsion– oil-based liquid medication
  6. Elixir– alcohol-based liquid medication. After administration of elixir, allow 30 minutes to elapse before giving water. This allows maximum absorption of the medication.
“Never crush Enteric-Coated or Sustained Release Tablet”
  • Crushing enteric-c-coated tablets – allows the irrigating medication to come in contact with the oral or gastric mucosa, resulting in mucositis or gastric irritation.
  • Crushing sustained-released medication – allows all the medication to be absorbed at the same time, resulting in a higher than expected initial level of medication and a shorter than expected duration of action
Sublingual Administration
  • A drug that is placed under the tongue, where it dissolves.
  • When the medication is in capsule and ordered sublingually, the fluid must be aspirated from the capsule and placed under the tongue.
  • A medication given by the sublingual route should not be swallowed, or desire effects will not be achieved
  1. Same as oral
  2. Drug is rapidly absorbed in the bloodstream
  1. If swallowed, drug may be inactivated by gastric juices.
  2. Drug must remain under the tongue until dissolved and absorbed
Buccal Administration
  • A medication is held in the mouth against the mucous membranes of the cheek until the drug dissolves.
  • The medication should not be chewed, swallowed, or placed under the tongue (e.g sustained release nitroglycerine, opiates, antiemetic, tranquilizer, sedatives)
  • Client should be taught to alternate the cheeks with each subsequent dose to avoid mucosal irritation
  1. Same as oral
  2. Drug can be administered for local effect
  3. Ensures greater potency because drug directly enters the blood and bypass the liver
  • If swallowed, drug may be inactivated by gastric juice
Topical Administration
  • Application of medication to a circumscribed area of the body.
1. Dermatologic – includes lotions, liniment and ointments, powder.
  1. Before application, clean the skin thoroughly by washing the area gently with soap and water, soaking an involved site, or locally debriding tissue.
  2. Use surgical asepsis when open wound is present
  3. Remove previous application before the next application
  4. Use gloves when applying the medication over a large surface. (e.g. large area of burns)
  5. Apply only thin layer of medication to prevent systemic absorption.
2. Ophthalmic – includes instillation and irrigation
  1. Instillation – to provide an eye medication that the client requires.
  2. Irrigation – To clear the eye of noxious or other foreign materials.
  3. Position the client either sitting or lying.
  4. Use sterile technique
  5. Clean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from the inner to the outer canthus
  6. Instill eye drops into lower conjunctival sac.
  7. Instill a maximum of 2 drops at a time. Wait for 5 minutes if additional drops need to be administered. This is for proper absorption of the     medication.
  8. Avoid dropping a solution onto the cornea directly, because it causes discomfort.
  9. Instruct the client to close the eyes gently. Shutting the eyes tightly causes spillage of the medication.
  10. For liquid eye medication, press firmly on the nasolacrimal duct (inner cantus) for at least 30 seconds to prevent systemic absorption of    the medication.
3. Otic Instillation – to remove cerumen or pus or to remove foreign body
  1. Straighten the ear canal:
  2. Perform hand hygiene. Apply gloves if drainage is present.
  3. Have the client assume a side-lying position (if not contraindicated) with ear to be treated facing up.
  4. Warm the solution at room temperature or body temperature, failure to do so may cause vertigo, dizziness, nausea and pain.
    • 0-3 years old: pull the pinna downward and backward
    • Older than 3 years old: pull the pinna upward and backward
  5. Instill eardrops on the side of the auditory canal to allow the drops to flow in and continue to adjust to body temperature
  6. Press gently bur firmly a few times on the tragus of the ear to assist the flow of medication into the ear canal.
  7. Ask the client to remain in side lying position for about 5 minutes
  8. At times the MD will order insertion of cotton puff into outermost part of the canal. Do not press cotton into the canal. Remove cotton after 15 minutes.
4. Nasal – Nasal instillations usually are instilled for their astringent effects (to shrink swollen mucous membrane), to loosen secretions and facilitate drainage or to treat infections of the nasal cavity or sinuses. Decongestants, steroids, calcitonin.
  1. Have the client blow the nose prior to nasal instillation
  2. Assume a back lying position, or sit up and lean head back.
  3. Elevate the nares slightly by pressing the thumb against the client’s tip of the nose. While the client inhales, squeeze the bottle.
  4. Keep head tilted backward for 5 minutes after instillation of nasal drops.
  5. When the medication is used on a daily basis, alternate nares to prevent irritations
5. Inhalation – use of nebulizer, metered-dose inhaler
  1. Semi or high-fowler’s position or standing position. To enhance full chest expansion allowing deeper inhalation of the medication
  2. Shake the canister several times. To mix the medication and ensure uniform dosage delivery
  3. Position the mouthpiece 1 to 2 inches from the client’s open mouth. As the client starts inhaling, press the canister down to release one dose of the medication. This allows delivery of the medication more accurately into the bronchial tree rather than being trapped in the oropharynx then swallowed
  4. Instruct the client to hold breath for 10 seconds to enhance complete absorption of the medication.
  5. If bronchodilator, administer a maximum of 2 puffs, for at least 30 second interval. Administer bronchodilator before other inhaled medication. This opens airway and promotes greater absorption of the medication.
  6. Wait at least 1 minute before administration of the second dose or inhalation of a different medication by MDI
  7. Instruct client to rinse mouth, if steroid had been administered. This is to prevent fungal infection.
6. Vaginal – drug forms: tablet liquid (douches), jelly, foam and suppository.
  1. Close room or curtain to provide privacy.
  2. Assist client to lie in dorsal recumbent position to provide easy access and good exposure of vaginal canal, also allows suppository     to dissolve without escaping through orifice.
  3. Use applicator or sterile gloves for vaginal administration of medications.
  • Vaginal Irrigation – is the washing of the vagina by a liquid at low pressure. It is also called douche.
    1.  Empty the bladder before the procedure
    2. Position the client on her back with the hips higher than the shoulder (use bedpan)
    3. Irrigating container should be 30 cm (12 inches) above
    4. Ask the client to remain in bed for 5-10 minute following administration of vaginal suppository, cream, foam, jelly or irrigation
Rectal Administration
  • Can be use when the drug has objectionable taste or odor.
  1. Need to be refrigerated so as not to soften.
  2. Apply disposable gloves.
  3. Have the client lie on left side and ask to take slow deep breaths through mouth and relax anal sphincter.
  4. Retract buttocks gently through the anus, past internal sphincter and against rectal wall, 10 cm (4 inches) in adults, 5 cm (2 in) in children and infants. May need to apply gentle pressure to hold buttocks together momentarily.
  5. Discard gloves to proper receptacle and perform hand washing.
  6. Client must remain on side for 20 minute after insertion to promote adequate absorption of the medication.
Parenteral Administration
  • Administration of medication by needle.Parenteral Adminitration (1)
Intradermal – under the epidermis.
  1. The site are the inner lower arm, upper chest and back, and beneath the scapula.
  2. Indicated for allergy and tuberculin testing and for vaccinations.
  3. Use the needle gauge 25, 26, 27: needle length 3/8”, 5/8” or ½”
  4. Needle at 10–15 degree angle; bevel up.
  5. Inject a small amount of drug slowly over 3 to 5 seconds to form a wheal or bleb.
  6. Do not massage the site of injection. To prevent irritation of the site, and to prevent absorption of the drug into the subcutaneous.
Subcutaneous– Vaccines, heparin, preoperative medication, insulin, narcotics.
  • outer aspect of the upper arms
  • anterior aspect of the thighs
  • Abdomen
  • Scapular areas of the upper back
  • Ventrogluteal
  • Dorsogluteal
  1. Only small doses of medication should be injected via SC route.
  2. Rotate site of injection to minimize tissue damage.
  3. Needle length and gauge are the same as for ID injections
  • Use 5/8 needle for adults when the injection is to administer at 45 degree angle; ½ is use at a 90 degree angle.
  1. For thin patients: 45 degree angle of needle
  2. For obese patient: 90 degree angle of needle
  3. For heparin injection: do not aspirate.
  4. Do not massage the injection site to prevent hematoma formation
  5. For insulin injection: Do not massage to prevent rapid absorption which may result to hypoglycemic reaction.
  6. Always inject insulin at 90 degrees angle to administer the medication in the pocket between the subcutaneous and muscle layer. Adjust the length of the needle depending on the size of the client.
  7. For other medications, aspirate before injection of medication to check if the blood vessel had been hit. If blood appears on pulling back of the plunger of the syringe, remove the needle and discard the medication and equipment.
  • Needle length is 1”, 1 ½”, 2” to reach the muscle layer
  • Clean the injection site with alcoholized cotton ball to reduce microorganisms in the area.
  • Inject the medication slowly to allow the tissue to accommodate volume.
1. Ventrogluteal site
  1. The area contains no large nerves, or blood vessels and less fat. It is farther from the rectal area, so it less contaminated.
  2. Position the client in prone or side-lying.
  3. When in prone position, curl the toes inward.
  4. When side-lying position, flex the knee and hip. These ensure relaxation of gluteus muscles and minimize discomfort during injection.
  5. To locate the site, place the heel of the hand over the greater trochanter, point the index finger toward the anterior superior iliac spine, and then abduct the middle (third) finger. The triangle formed by the index finger, the third finger and the crest of the ilium is the site.
2. Dorsogluteal site
  1. Position the client similar to the ventrogluteal site
  2. The site should not be use in infant under 3 years because the gluteal muscles are not well developed yet.
  3. To locate the site, the nurse draw an imaginary line from the greater
  4. trochanter to the posterior superior iliac spine. The injection site id lateral and superior to this line.
  5. Another method of locating this site is to imaginary divide the buttock into four quadrants. The upper most quadrant is the site of injection. Palpate the crest of the ilium to ensure that the site is high enough.
  6. Avoid hitting the sciatic nerve, major blood vessel or bone by locating the site properly.
3. Vastus Lateralis
  1. Recommended site of injection for infant
  2. Located at the middle third of the anterior lateral aspect of the thigh.
  3. Assume back-lying or sitting position.
4. Rectus femoris site –located at the middle third, anterior aspect of thigh.
5. Deltoid site
  1. Not used often for IM injection because it is relatively small muscle and is very close to the radial nerve and radial artery.
  2. To locate the site, palpate the lower edge of the acromion process and the midpoint on the lateral aspect of the arm that is in line with the axilla. This is approximately 5 cm (2 in) or 2 to 3 fingerbreadths below the acromion process.
* IM injection – Z tract injection
  1. Used for parenteral iron preparation. To seal the drug deep into the muscles and prevent permanent staining of the skin.
  2. Retract the skin laterally, inject the medication slowly. Hold retraction of skin until the needle is withdrawn
  3. Do not massage the site of injection to prevent leakage into the subcutaneous.
  • The nurse administers medication intravenously by the following method:
    1. As mixture within large volumes of IV fluids.
    2. By injection of a bolus, or small volume, or medication through an existing intravenous infusion line or intermittent venous access (heparin or saline lock)
    3. By “piggyback” infusion of solution containing the prescribed medication and a small volume of IV fluid through an existing IV line.
  • Most rapid route of absorption of medications.
  • Predictable, therapeutic blood levels of medication can be obtained.
  • The route can be used for clients with compromised gastrointestinal function or peripheral circulation.
  • Large dose of medications can be administered by this route.
  • The nurse must closely observe the client for symptoms of adverse reactions.
  • The nurse should double-check the six rights of safe medication.
  • If the medication has an antidote, it must be available during administration.
  • When administering potent medications, the nurse assesses vital signs before, during and after infusion.
Nursing Interventions in IV Infusion
  1. Verify the doctor’s order
  2. Know the type, amount, and indication of IV therapy.
  3. Practice strict asepsis.
  4. Inform the client and explain the purpose of IV therapy to alleviate client’s anxiety.
  5. Prime IV tubing to expel air. This will prevent air embolism.
  6. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton ball to prevent infection.
  7. Shave the area of needle insertion if hairy.
  8. Change the IV tubing every 72 hours. To prevent contamination.
  9. Change IV needle insertion site every 72 hours to prevent thrombophlebitis.
  10. Regulate IV every 15-20 minutes. To ensure administration of proper volume of IV fluid as ordered.
  11. Observe for potential complications.
Types of IV Fluids
  1. Isotonic solution – has the same concentration as the body fluid
    • D5 W
    • Na Cl 0.9%
    • Plain Ringer’s lactate
    • Plain Normosol M
  2. Hypotonic – has lower concentration than the body fluids.
    • NaCl 0.3%
  3. Hypertonic – has higher concentration than the body fluids.
    • D10W
    • D50W
    • D5LR
    • D5NM
Complication of IV Infusion
1. Infiltration – the needle is out of nein, and fluids accumulate in the subcutaneous tissues.
  • Pain, swelling, skin is cold at needle site; pallor of the site, flow rate has decreases or stops.
Nursing Intervention:
  • Change the site of needle
  • Apply warm compress. This will absorb edema fluids and reduce swelling.
2. Circulatory Overload – Results from administration of excessive volume of IV fluids.
  • Headache
  • Flushed skin
  • Rapid pulse
  • Increase BP
  • Weight gain
  • Syncope and faintness
  • Pulmonary edema
  • Increase volume pressure
  • SOB (shortness of breath)
  • Coughing
  • Tachypnea
  • Shock
Nursing Interventions:
  • Slow infusion to KVO
  • Place patient in high fowler’s position. To enhance breathing
  • Administer diuretic, bronchodilator as ordered
3. Drug Overload – the patient receives an excessive amount of fluid containing drugs.
  • Dizziness
  • Shock
  • Fainting
Nursing Intervention:
  • Slow infusion to KVO.
  • Take vital signs
  • Notify physician
4. Superficial Thrombophlebitis – it is due to o0veruse of a vein, irritating solution or drugs, clot formation, large bore catheters.
  • Pain along the course of vein
  • Vein may feel hard and cordlike
  • Edema and redness at needle insertion site.
  • Arm feels warmer than the other arm
Nursing Intervention:
  • Change IV site every 72 hours
  • Use large veins for irritating fluids.
  • Stabilize venipuncture at area of flexion.
  • Apply cold compress immediately to relieve pain and inflammation; later with warm compress to stimulate circulation and promotion absorption.
  • “Do not irrigate the IV because this could push clot into the systemic circulation’
5. Air Embolism – Air manages to get into the circulatory system; 5 ml of air or more causes air embolism.
  • Chest, shoulder, or back pain
  • Hypotension
  • Dyspnea
  • Cyanosis
  • Tachycardia
  • Increase venous pressure
  • Loss of consciousness
Nursing Intervention
  • Do not allow IV bottle to “run dry”
  • “Prime” IV tubing before starting infusion.
  • Turn patient to left side in the trendelenburg position. To allow air to rise in the right side of the heart. This prevent pulmonary embolism.
6. Nerve Damage – may result from tying the arm too tightly to the splint.
  • Numbness of fingers and hands
Nursing Interventions
  • Massage the are and move shoulder through its ROM
  • Instruct the patient to open and close hand several times each hour.
  • Physical therapy may be required
Note: apply splint with the fingers free to move.
7. Speed Shock – may result from administration of IV push medication rapidly.
  • To avoid speed shock, and possible cardiac arrest, give most IV push medication over 3 to 5 minutes.
General Principles of Parenteral Administration
  1. Check doctor’s order.
  2. Check the expiration for medication – drug potency may increase or decrease if outdated.
  3. Observe verbal and non-verbal responses toward receiving injection. Injection can be painful; client may have anxiety, which can increase the pain.
  4. Practice asepsis to prevent infection. Apply disposable gloves.
  5. Use appropriate needle size to minimize tissue injury.
  6. Plot the site of injection properly to prevent hitting nerves, blood vessels, and bones.
  7. Use separate needles for aspiration and injection of medications to prevent tissue irritation.
  8. Introduce air into the vial before aspiration. To create a positive pressure with in the vial and allow easy withdrawal of the medication.
  9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain.
  10. Introduce the needle in quick thrust to lessen discomfort.
  11. Either spread or pinch muscle when introducing the medication. Depending on the size of the client.
  12. Minimized discomfort by applying cold compress over the injection site before introduction of medicati0n to numb nerve endings.
  13. Aspirate before the introduction of medication. To check if blood vessel had been hit.
  14. Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort of pulling tissues as needle is withdrawn.
  15. Massage the site of injection to haste absorption.
  16. Apply pressure at the site for few minutes. To prevent bleeding.
  17. Evaluate effectiveness of the procedure and make relevant documentation.

Maslow’s Hierarchy of Basic Human Needs

    Maslow’s Hierarchy of Basic Human Needs
  • Each individual has unique characteristics, but certain needs are common to all people.
  • A need is something that is desirable, useful or necessary. Human needs are physiologic and psychological conditions that an individual must meet to achieve a state of health or well-being.
  1. Oxygen
  2. Fluids
  3. Nutrition
  4. Body temperature
  5. Elimination
  6. Rest and sleep
  7. Sex
Safety and Security
  1. Physical safety
  2. Psychological safety
  3. The need for shelter and freedom from harm and danger
Love and belonging
  1. The need to love and be loved
  2. The need to care and to be cared for.
  3. The need for affection: to associate or to belong
  4. The need to establish fruitful and meaningful relationships with people, institution, or organization
Self-Esteem Needs
  1. Self-worth
  2. Self-identity
  3. Self-respect
  4. Body image
Self-Actualization Needs
  1. The need to learn, create and understand or comprehend
  2. The need for harmonious relationships
  3. The need for beauty or aesthetics
  4. The need for spiritual fulfillment
Characteristics of Basic Human Needs
  1. Needs are universal.
  2. Needs may be met in different ways
  3. Needs may be stimulated by external and internal factor
  4. Priorities may be deferred
  5. Needs are interrelated
Maslow’s Characteristics of a Self-Actualized Person
  1. Is realistic, sees life clearly and is objective about his or her observations
  2. Judges people correctly
  3. Has superior perception, is more decisive
  4. Has a clear notion of right or wrong
  5. Is usually accurate in predicting future events
  6. Understands art, music, politics and philosophy
  7. Possesses humility, listens to others carefully
  8. Is dedicated to some work, task, duty or vocation
  9. Is highly creative, flexible, spontaneous, courageous, and willing to make mistakes
  10. Is open to new ideas
  11. Is self-confident and has self-respect
  12. Has low degree of self-conflict; personality is integrated
  13. Respect self, does not need fame, and possesses a feeling of self-control
  14. Is highly independent, desires privacy
  15. Can appear remote or detached
  16. Is friendly, loving and governed more by inner directives than by society
  17. Can make decisions contrary to popular opinion
  18. Is problem centered rather than self-centered
  19. Accepts the world for what it is

Making an Unoccupied Bed

Objectives of Making an Unoccupied Bed
  1. To meet the patient’s need by providing a safe comfortable bed.
  2. For neatness and tidiness.
Principles of Bedmaking: (Techniques vary but principles are the same).
  1. Have everything ready on hand before starting.
  2. Remember that the bed is made for use, for durability and comfort and that it should have a finished appearance.
  3. Place all linen on perfectly straight line on the bed, otherwise , it would be impossible to make bed tight and free from wrinkles.
  4. All comes should look neat, smooth and firm.
  5. Throughout the procedure, the nurse should study her movements so as to avoid waste of time and energy
  6. When finished inspect the bed and see if it measures to the highest standard of health and comfort of the patient economy of time, effort and materials and smooth finished appearance
Note: Do not use torn linen and in private rooms avoid stained linen.
Equipments Needed:
  • 2 large sheets
  • Rubber sheet
  • Draw sheet
  • Pillow case
  • Bath towel & wash cloth
  • Pillow & mosquito net p.r.n
  • Additional for private rooms
  • Woolen blanket top sheet
  • Extra pillow with pillow case
  • Hand towel
  • Bedspread or coverlet
  1. Gather all equipment and place at the bedside table and arrange them in the order of their use.
  2. Get bottom sheet and spread it lengthwise on mattress with the center fold at center of bed, with right side up and with narrow them even with foot of mattress. Tuck the head part and miter the corner nearest to you by bring the side of the sheet at night angle to the side of the mattress. Then tuck from the head part making a boxlike appearance going down to the foot part.
  3. Place the rubber sheet 15 to 18 inches from the edge of the mattress. Put the draw sheet over the rubber sheet giving an allowance of one inch longer than the rubber sheet at the head part and luck both together.
  4. Place the top sheet with the wrong side up wider harm at the head part in line with the upper edge of the mattress and with the centerfold along the middle of the bed. Tuck the foot part and miter the corner. Leave the side free.
  5. Go to the other side of the bed.
  6. Full the bottom sheets firmly, tuck at head part miter the corner and tuck the sides working towards the foot.
  7. Adjust the rubber sheet and draw sheet, pull them firmly and tuck them in separately.
  8. Tuck top sheet at food part and miter the corner. Leave side free. Fold back top part about 14 inches.
  9. Put the pillowcase and lay pillow flat on bed with the open and of case away from the main door.
  10. In the private room fold down the top sheet 18 inches away from the head part of the bed. Place a bedspread on top.
  11. Hang the bath towel, hand towel and washcloth on rack
  12. Straighten bed, bedside table and replace chair

Making an Occupied Bed

  1. To change the linen with the least possible disturbance to the patient.
  2. To draw or fix the sheets under the patients very firmly so that it would not wrinkle.
  3. To remove crumbs from the bed.
  4. To make patient feel comfortable.
  • Necessary linen.
  • Tray for stripping and airing.
  • Laundry bag or hamper
  1. Do the medical handwashing.
  2. Gather equipments at bed side and arrange according to use. Explain procedure to patient and screen.
  3. Loosen the linens starting at the foot part, then to the sides and around. Remove pillows unless contraindicated.
  4. Place clean top sheet over dirty top sheet wider hem, wrong side out at the head part of bed. Spread, then remove the dirty linen without exposing the patient.
  5. Turn patient towards one side of the bed.
  6. Work on the unoccupied side of the bed. Roll dirty linens toward the patient (except rubber sheet).
  7. Place bottom sheet following the principles, tuck head part miter corner tuck. Roll used rubber sheet towards you. Replace with a new one.
  8. Place draw sheep over rubber sheet. Tuck together.
  9. Turn patient towards made bed.
  10. Work on the other side. Remove dirty linens.
  11. Spread clean linens, tuck head part of the bottom sheet, miter at side, tuck all together. Do the same with rubber sheet and draw sheet.
  12. Turn patient to the center of the bed.
  13. Arrange top sheet, fold head part up to the patient’s chest.
  14. Make a toe pleat.
  15. Tuck foot part, miter corner.
  16. Time limit, check features of a good bed and proper body mechanics.
  1. Provision for privacy as situation requires.
  2. Carefully turning the patient. So as to prevent over exertion and feeling or insecurity.
  3. Provision of opportunity for patient to Participate.
  4. Placement of top bedding so that shoulder may be covered and the necessary adjustments made over toes.
  5. Careful observation of skin areas of the patient.

Anxiety and Dizziness

Dizziness is actually a non-specific term used to describe certain symptoms, such as feeling lightheaded, faint, weak, nauseous, or unsteady. Most people see their doctors immediately when they experience any dizziness, and that is mainly because the symptoms can be very uncomfortable at times. While the condition can make you feel concerned, it is usually not due to anything very serious. In fact, anxiety and dizziness are related with each other.

Can Anxiety Cause Dizziness?

Yes, it is possible to feel dizzy when you have anxiety or are experiencing anxiety attacks. Anxiety can make you feel dizzy from the following aspects:
  • Hyperventilation: It makes you feel dizzy because it disturbs your oxygen-carbon dioxide balance. During an anxiety attack, it is natural to feel hyperventilated as the result of breathing too quickly. You may also develop this condition if you have poor breathing patterns, which will then lead to insufficient supply of oxygen to your body.
  • Panic: Dizziness may well be a symptom associated with panic attacks. When you panic, it is natural to feel the rush of adrenaline, which is responsible for making you feel dizzy and lightheaded.
  • Vision Problems: You may notice lightheadedness and dizziness when you have certain vision problems. That happens because your brain has difficulties in interpreting your vision due to the problems you have.
  • Dehydration: Not drinking enough water leads to dehydration, and dehydration can cause dizziness. Your dehydration symptoms become severe when you are also anxious or are experiencing panic attacks.
Anxiety and dizziness may be present at the same time, but you are less likely to feel dizzy for too long in this situation. If you feel dizzy more often and for extended time, it could be due to other underlying conditions such as multiple sclerosis or even low blood pressure. If you experienced lightheadedness for the first time in your life which was severe as well, you should see your doctor immediately to identify the underlying cause.

How to Overcome Dizziness Related with Anxiety

1. Deep Breathing

Deep breathing helps improve the supply of oxygen to your brain and relaxes your nervous system. This helps reduce dizziness quickly.
  • Lie down on the floor with a hand on your abdomen and the thumb of your other hand placed against one nostril.
  • Close your mouth and breathe in through your open nostril. Fill in your belly and feel your hand on the abdomen moving up.
  • Hold your breath for a few seconds by closing your other nostril as well.
  • Exhale slowly after 3 seconds. Do 10 reps.
  • Be sure to sit quietly for 5 minutes after performing the exercise and breathe normally.

2. Drink Water

Not getting enough fluids can make you become dehydrated, which will lead to dizziness. You may experience the same when you engage in strenuous workouts and do not drink enough water to rehydrate your body. Diarrhea or vomiting can also cause excessive fluid loss.
  • Be sure to drink a glass of water when you feel dizzy. This helps rehydrate your body and prevent dizziness.
  • Try including herbal tea in your diet. You can also drink fruit juices, soups, and broths.

3. Eat Something

Anxiety and dizziness are related, and being hungry for extended hours can lower your blood sugar levels and can also make you feel dizzy. This is especially common in people who have diabetes. To resolve the issue, you should eat something when you feel dizzy and ensure you do not remain hungry for extended hours to prevent dizziness. You can opt for the following:
  • Have a snack high in sugar or carbs like a banana or a chocolate bar.
  • Enjoy any fruit with high water content to prevent dehydration.
  • Have a bowl of yogurt with any fruit.
  • Eat a handful of roasted nuts like almonds, cashews, or walnuts.

4. Change Your Position

When you feel lightheaded, you should change your position. Sit if you are standing and lie down if you are sitting. You should not try to walk when you are feeling dizzy because there is an increased risk of an injury. Here is what you should do:
  • Put your head in a lower position in case you are sitting down and are feeling lightheaded.
  • Be sure to remain lying down or seated for a couple of minutes or until the dizziness has passed completely.

5. Focus on a Spot

You should find a particular spot and focus on it to get dizziness under control. The technique helps dancers maintain a better control over their bodies while dancing. You can try the same.
  • Just focus on a spot like a speck of dirt on the floor or a crack on the wall to lessen the sensation of spinning around.

6. Try the Epley Maneuver

The maneuver involves titling your neck and head in a specific way to treat symptoms of dizziness or vertigo. Here is how to do it:
  • Sit down and tile your head towards one side. Maintain a 45 degrees angle.
  • Lie back while keeping your head at the same angle and maintain this position for a couple of minutes.
  • Now, turn your head again but towards the other side. You should keep your head tilted at a 90-degree angle. Slowly roll your body towards the same direction until you are looking at the floor.
  • Maintain the position for another minute or so and then return to a seated position.

7. Overcome Anxiety

Dealing with stress and anxiety is never easy, and that is why you may have a hard time to solve the problem of anxiety and dizziness. Nevertheless, you can take certain steps to avoid becoming overwhelmed in your daily life. For instance:
  • Try something that reduces stress. It could be a change of job, a different working schedule, reduced hours, or spending more time working from home.
  • Try natural stress-relieving methods, such as yoga, meditation, deep breathing, and tai chi. 


Generic Name : captopril
Brand Name: Apo-Capto (CAN), Capoten, Gen-Captopril (CAN), Novo-Captopril (CAN), Nu-Capto (CAN)
Classification: ACE inhibitor,  Antihypertensive
Pregnancy Category C (first trimester)
Pregnancy Category D (second and third trimesters) 
Dosage & Route
  • PO HTN Initial: 12.5 mg twice daily. Maintenance: 25-50 mg twice daily. Max: 50 mg 3 times/day. Heart failure Initial: 6.25-12.5 mg 2-3 times/day. Max: 50 mg 3 times/day. Post MI Start 3 days after MI. Initial: 6.25 mg/day, may increase after several wk to 150 mg/day in divided doses if needed and tolerated. Diabetic nephropathy 25 mg 3 times/day.
Therapeutic actions
  • Captopril competitively inhibits the conversion of angiotensin I (ATI) to angiotensin II (ATII), thus resulting in reduced ATII levels and aldosterone secretion. It also increases plasma renin activity and bradykinin levels. Reduction of ATII leads to decreased sodium and water retention. By these mechanisms, captopril produces a hypotensive effect and a beneficial effect in congestive heart failure.
    • Absorption: 60-75% absorbed from the GI tract (oral); peak plasma concentrations after 1 hr. Absorption may be reduced in the presence of food.
    • Distribution: Protein-binding: 30%; crosses the placenta and enters breast milk at about 1% of maternal blood concentrations.
    • Excretion: Via urine (40-50% as unchanged, the rest as disulfide and other metabolites); 2-3 hr (elimination half-life), may be increased in renal impairment. Removed by hemodialysis.
  • Treatment of hypertension alone or in combination with thiazide-type diuretics
  • Treatment of CHF in patients unresponsive to conventional therapy; used with diuretics and digitalis
  • Treatment of diabetic nephropathy
  • Treatment of left ventricular dysfunction after MI
  • Unlabeled uses: Management of hypertensive crises; treatment of rheumatoid arthritis; diagnosis of anatomic renal artery stenosis, hypertension related to scleroderma renal crisis; diagnosis of primary aldosteronism, idiopathic edema; Bartter’s syndrome; Raynaud’s syndrome
Adverse effects
  • Hypotension, tachycardia, chest pain, palpitations, pruritus, hyperkalemia. Proteinuria; angioedema, skin rashes; taste disturbance, nonproductive cough, headache.
  • Potentially Fatal: Neutropenia, usually occurs within 3 mth of starting therapy especially in patients with renal dysfunction or collagen diseases. Hyperkalaemia. Anaphylactic reactions.
  • Known hypersensitivity to the drug. Bilateral renal artery stenosis, hereditary angioedema; renal impairment; pregnancy.
Nursing considerations
  • History: Allergy to captopril, history of angioedema, impaired renal function, CHF, salt or volume depletion, pregnancy, lactation
  • Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, LFTs, renal function tests, CBC and differential
  • Administer 1 hr before meals.
  • WARNING: Ensure that patient is not pregnant before beginning treatment. Encourage use of contraceptives; if pregnancy is detected, stop drug.
  • WARNING: Alert surgeon and mark patient’s chart with notice that captopril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion.
  • Monitor patient closely for fall in BP secondary to reduction in fluid volume (due to excessive perspiration, and dehydration, vomiting, or diarrhea); excessive hypotension may occur.
  • Reduce dosage in patients with impaired renal function.
Teaching points
  • Take drug 1 hour before meals; do not take with food. Do not stop without consulting your health care provider.
  • Be careful of drop in blood pressure (occurs most often with diarrhea, sweating, vomiting, or dehydration); if light-headedness or dizziness occurs, consult your health care provider.
  • Severe fetal damage can occur if captopril is taken during pregnancy. Use of contraceptives is advised; if pregnancy should occur, stop drug and notify health care provider.
  • Avoid over-the-counter medications, especially cough, cold, allergy medications that may contain ingredients that will interact with ACE inhibitors. Consult your health care provider.
  • You may experience these side effects: Cough, GI upset, loss of appetite, change in taste perception (limited effects, will pass); mouth sores (frequent mouth care may help); rash; fast heart rate; dizziness, light-headedness (usually passes after the first few days; change position slowly, and limit your activities to those that do not require alertness and precision).
  • Report mouth sores; sore throat, fever, chills; swelling of the hands or feet; irregular heartbeat, chest pains; swelling of the face, eyes, lips or tongue; difficulty breathing.


Calcitonin (Cibacalcin) is an hormonal agent indicated for patients with Paget’s disease.
Generic Names & Brand Names
(kal si toe’ nin)
calcitonin, human
calcitonin, salmon
Calcimar, Caltine (CAN), Miacalcin, Miacalcin Nasal Spray, Osteocalcin

Pregnancy Category C (human) 
Pregnancy Category B (salmon)
Drug classes
  • Hormonal agent
  • Calcium regulator
Therapeutic actions
The calcitonins are polypeptide hormones secreted by the thyroid; human calcitonin is a synthetic product classified as an orphan drug; salmon calcitonin appears to be a chemically identical polypeptide but with greater potency per milligram and longer duration; inhibits bone resorption; lowers elevated serum calcium in children and patients with Paget’s disease; increases the excretion of filtered phosphate, calcium, and sodium by the kidney.
  • Human and salmon calcitonin: Paget’s disease
  • Salmon calcitonin: Postmenopausal osteoporosis in conjunction with adequate calcium and vitamin D intake to prevent loss of bone mass
  • Salmon calcitonin: Hypercalcemia, emergency treatment
Contraindications and cautions
  • Contraindicated with allergy to salmon calcitonin or fish products, lactation.
  • Use cautiously with renal insufficiency, osteoporosis, pernicious anemia.
Available forms
Injection (human)—1 mg/mL; injection (salmon)—200 IU/mL; nasal spray (salmon)—200 IU/actuation
Calcitonin, human
  • Paget’s disease: Starting dose of 0.5 mg/day subcutaneously; some patients may respond to 0.5 mg two to three times per week or 0.25 mg/day. Severe cases may require up to 1 mg/day for 6 mo. Discontinue therapy when symptoms are relieved.
Calcitonin, salmon
  • Skin testing: 0.1 mL of a 10 IU/mL solution injected subcutaneously.
  • Paget’s disease: Initial dose 100 IU/day IM or subcutaneously. For maintenance dose, 50 IU/day or every other day. Actual dose should be determined by patient response.
  • Postmenopausal osteoporosis: 100 IU/day IM or subcutaneously, with supplemental calcium (calcium carbonate, 1.5 g/day) and vitamin D (400 units/day) or 200 IU intranasally daily.
  • Hypercalcemia: Initial dose, 4 IU/kg q 12 hr IM or subcutaneously. If response is not satisfactory after 1–2 days, increase to 8 IU/kg q 12 hr; if response remains unsatisfactory after 2 more days, increase to 8 IU/kg q 6 hr.
Safety and efficacy not established.
IM, SC15 min16–25 min8–24 hr
NasalRapid31–39 min8–24 hr
Metabolism: Renal; T1/2: 43 min (salmon), 1 hr (human)
Distribution: May enter breast milk
Excretion: Urine