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

Loss and Grief

  • Absence of an object, person, body part, emotion, idea or function that was valued
  1. Actual loss is identified and verified by others
  2. Perceived Loss cannot be verified by others
  3. Maturational Loss occurs in normal development
  4. Situational Loss occurs without expectations
  5. Ultimate Loss (Death) results in a lost for a dying person as well as for those left behind, can be viewed as a time of growth for all who experienced it
Grieving Process (Theories of Grief, Dying and Mourning)
 1. 3 Phases of Grief
  • Protest- lack of acceptance, concerning the loss, characterized by anger, ambivalence and crying
  • Despair- denial and acceptance occurs simultaneously causing disorganized behavior, characterized by crying and sadness
  • Detachment- loss is realized; characterized by hopelessness, accurately defining the relationship with the lost individual and energy to move forward in life.
2. Kubler-5 Stages of Grieving
  • Denial – characterized by shock and disbelief, serves as a buffer to mobilize defense mechanism
  • Anger– resistance of the loss occurs, anger is typically directed toward others
  • Bargaining – deals are sought with God or other higher power in an effort to postpone the loss
  • Depression– loss is realized; may talk openly or withdraw.
  • Acceptance– recognition of the loss occurs disinterest may occur; future thinking may occur.
3. Worden’s 4 Tasks of Mourning
  • Accept the reality of the loss, the loss is accepted
  • Experience the pain of grief, healthy behaviors are accomplished to assist in the grieving process.
  • Adjust to the environment without the deceased, task are accomplished to reorient the environment, i.e. removing the clothes of the deceased from the closet.
  • Emotionally relocate the deceased and move forward with life, correctly align the past, the present & look towardsthe future
Anticipatory Grief
  • Expression of the symptoms of grief prior to the actual loss, grief period following the lost may be shortened and the intensity lessened because of the previous of grief; for example, a child told that a family move is expected may grieve about losing friends prior to actually living
Complications of Bereavement
  1. Chronic Grief – symptoms of grief occur beyond the expected time frame and the severity of symptoms is greater; depression may result.
  2. Delayed Grief – when symptoms of grief are not expressed and are suppressed, a delayed reaction of grief occurs, the nurse should discuss the normal process of grieving with the client and give permission to express these symptoms
Symptoms of Normal Grief
  1. Feelings include sadness, exhaustion, numbness, helplessness, loneliness, and disorganization, preoccupation with the lost object or person, anxiety, depression.
  2. Thought patterns include fear, guilt, denial, ambivalence, anger
  3. Physical sensations include nausea, vomiting, anorexia, weight loss or gain, constipation or diarrhea, Diminished hearing or sight, chest pain, shortness of breath, tachycardia
  4. Behaviors include crying, difficulty carrying out activities of daily living and insomnia
Nursing Health Promotion (to facilitate mourning)
  1. Help client accept that the loss is real by providing sensitive, factual information concerning the loss
  2. Encourage the expression of feelings to support people; this build relationships and enhances the grief process
  3. Support efforts to live without the diseased person or in the face of disability; this promotes a client’s sense of control as well as a healthy vision of the future
  4. Encourage establishment with new relationships to facilitate healing.
  5. Allow time to grief, the work of grief may take longer for some; observe for a healthy progression of symptoms.
  6. Interpret “normal” behavior by teaching thoughts, feelings, and behaviors that can be expected in the grief process
  7. Provide continuing support in the form of the presence for therapeutic communication and resource information.
  8. Be alert for signs of ineffective coping such as inability to carry out activities of daily living, signs of depression, or lack of expression of grief.

Lifting and Moving Patient from Bed

  1. Stand facing patient at the side of the bed.
  2. Assume a broad stance, one leg forward of the other with knees and hips flexed, bring arms to the level of the bed.
  3. Place one arm under shoulders and neck pf patient and another arm under small of patient’s back.
  4. Shift body weight from front to back foot, rock backward to a crouch position, bringing patients towards his side. Nurse’s hips come downwards as he rocks backwards. Patient should be pulled.
  1. Stand at the side of the bed towards which patient is to be turned. Place patient’s far arm across his chest and far leg over near leg, near arm is lateral to and away from his body.
  2. Stand opposite to the patient’s waist and face side of the bed with one foot a step in front of the other.
  3. Place one hand on patient’s far shoulder and one hand on his far hip.
  4. Shift weight from forwarded leg to rear leg, patient is turned towards the nurse hips come downward.
  5. Patient is stopped by nurse’s elbows, which come to rest on mattress at the edge of the bed.
  1. Stand at side of the side of the bed and face patient head.
  2. Assume a wide stance with foot next to bed behind the other foot.
  3. Pass arm over the patient’s near shoulders and rest hand between patient’s shoulder blades.
  4. Rock backward, shift weight from forwarded foot to rear foot, hips coming straight down.
  1. Stand at one side of the bed facing the head of the patient. Foot next to bed is to rear and the other foot forward. Provide wide base of support.
  2. Bend knees to bring arm next to bed down to a level with a surface of the bed.
  3. With elbow on the patient‘s bed grasps the nurse’s arm in the same manner.
  4. Rock forward, shift weight from forwarded foot to rear foot to bring hips downward. Elbow remains on bed, which serves as fulcrum.
  1. Stand at the side of the bed and face the far corner of the foot of the bed.
  2. Flex knees so that arms are leveled with the bed. Put arm under patient, one arm under patient’s head and shoulders, one hand under small of his back.
  3. Rock forward. Shift weight from forwarded foot to rear foot, hips coming downward. Patient will slide diagonally across the bed towards the head and side of the bed.
  4. Repeat from tuck and legs of patient.
  5. Go to the other side of the bed and repeat number 1 – 3. Continue this process until patient is satisfactorily positioned.
  1. Patient flexes knees, bringing heels up to his buttocks.
  2. Stand at the side of the bed, turn slightly towards patient’s head. One foot is stepped in front of the other foot closer to bed. Feet are directed towards the head of the bed.
  3. Place one arm under patient’s shoulders, one arm under thighs. Flex knees to bring arms to the level of the surface of the bed.
  4. Patient places chin on his chest and pushes with his feet. Nurse shifts weight from rear foot to forwarded foot. Patient grasps the head of the bed with his hands to pull on his own weight.
  1. Patient flexes knees and brings heels towards the buttocks.
  2. Nurse faces the side of the bed and stands opposite to the patient’s buttocks. Assume a board stance.
  3. Flex knees to bring arms to the level of the bed, place one hand under sacral area of the patient. The elbow is resting firmly on the 3 bed.
  4. As the patient raises his hips, the nurse comes to a crouching position by bending his knees while his arms act as a lever to help support the patient’s buttocks. Nurse’s hips come straight down. While supporting patient in this position, free hand can place bedpan under the patient’s sacral area.
  1. Patient is turned to the side towards the edge of the bed.
  2. The nurse ensures that the patient does not fall out of the bed by raising the head of the bed.
  3. Face the far bottom corner of the bed, support the shoulders of the patient with one arm and the other arm helps patient extend lower legs over the side of the bed top the rear of the other foot.
  4. Bring patient to a natural sitting position on the bed; support the patient’s shoulders and legs over the side of the bed. Pivot body to lower legs of the patient. Patient’s legs are swung downward. Nurse’s weight is shifted form front to rear leg.
  1. The patient assumes a suiting position on the edge of the bed, put on shoes/slipper and gown.
  2. Place the chair at the side of the bed with back towards foot of the bed.
  3. Stand facing patient with foot closer to the chair and a step in front of the other to give the nurse a wide base of support.
  4. Place patient’s hands on the nurses shoulders and the nurse grasps patient’s waist.
  5. Patient steps on the floor and the nurse flexes her knees, forwarded knee is against the patient knee. This provides patient’s knees bending involuntarily.
  6. Turn with the patient while maintaining a wide base of support. Bend knees as the patient sits on chair.

bupropion hydrochloride

Drug Name
Generic Name : bupropion hydrochloride
Brand Name: Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban
Classification: Antidepressant, Smoking deterrent
Pregnancy Category B 
Dosage & Route
  • Smoking cessation
    • Adult: Modified-release preparation: Initially, 150 mg once daily for 6 days then increased to 150 mg bid. Period of treatment: 7-12 wk. To discontinue treatment if abstinence is not achieved by 7th wk. Max: 300 mg/day.
    • Elderly: 150 mg/day.
  • Depression
    • Adult: Initially, 100 mg bid increased to 100 mg tid after 3 days if necessary. Increased further to 150 mg tid if no improvement has been observed after several wk of therapy. Max: 150 mg tid. As a modified-release preparation: 150 mg once daily in the morning, increased to 150 mg bid after 3 days if necessary, may further increase to 200 mg bid after several wk if needed. Max: 450 mg as a single dose.
Therapeutic actions
  • Bupropion HCl is a relatively weak inhibitor of the neuronal uptake of norepinephrine, serotinin and dopamine. The mechanism by which it aids in smoking cessation is presumed to be mediated by its noradrenergic and/or dopaminergic actions.
    • Absorption: Well absorbed from the GI tract but undergoes extensive first pass effect.
    • Distribution: ≥80% bound to plasma proteins. Crosses the placenta and distributed into breast milk.
    • Excretion: Terminal half-life of immediate-release preparation: about 14 hr. Mainly excreted in the urine as metabolites.
  • Treatment of depression
  • Aid to smoking cessation treatment (Zyban)
  • Unlabeled uses: Treatment of neuropathic pain, ADHD
Adverse effects
  • Facial edema; nausea, dry mouth, constipation, diarrhea, anorexia; mouth ulcer; thirst; myalgia, arthralgia; insomnia, dream, abnormality, anxiety, disturbed concentration, dizziness, nervousness, tremor, dysphoria; rhinitis, increased cough, pharyngitis, sinusitis; dyspnea, epistaxis, agitation, insomnia, tremor, headache, weight loss, vomiting, skin rash.
  • Potentially Fatal: Stevens-Johnson syndrome.
  • Epilepsy; eating disorders (e.g. bulimia or anorexia nervosa); hypersensitivity.
Nursing considerations
  • History: Hypersensitivity to bupropion, history of seizure disorder, bulimia or anorexia, head trauma, CNS tumor, treatment with MAOI, renal or hepatic disease, heart disease, lactation
  • Physical: Skin, weight; orientation, affect, vision, coordination; P, rhythm, auscultation; R, adventitious sounds; bowel sounds, condition of mouth
  • Give drug three times a day for depression; do not administer more than 150 mg in any one dose. Administer sustained-release forms twice a day with at least 8 hr between doses.
  • Increase dosage slowly to reduce the risk of seizures.
  • Administer 100-mg tablets four times a day for depression, with at least 4 hr between doses, if patient is receiving > 300 mg/day; use combinations of 75-mg tablets to avoid giving > 150 mg in any single dose.
  • Arrange for patient evaluation after 6 wk.
  • Discontinue MAOI therapy for at least 14 days before beginning bupropion.
  • Monitor hepatic and renal function tests in patients with a history of hepatic or renal impairment.
  • Have patient quit smoking within first 2 wk of treatment for smoking cessation; may be used with transdermal nicotine.
  • BLACK BOX WARNING: Monitor response and behavior; suicide is a risk in depressed patients, children, and adolescents.
Teaching points
  • Take this drug in equally divided doses three to four times a day as prescribed for depression. Take sustained-release forms twice a day, at least 8 hours apart. Do not combine doses or make up missed doses. Take once a day, or divided into two doses at least 8 hours apart for smoking cessation.
  • Avoid or limit the use of alcohol while on this drug. Seizures can occur if these are combined.
  • May be used with transdermal nicotine; most effective for smoking cessation if combined with behavioral support program.
  • You may experience these side effects: Dizziness, lack of coordination, tremor (avoid driving or performing tasks that require alertness); dry mouth (use frequent mouth care; suck sugarless lozenges); headache, insomnia (consult with care provider if these become a problem; do not self-medicate); nausea, vomiting, weight loss (eat frequent small meals).
  • Report dark urine, light-colored stools; rapid or irregular heartbeat; hallucinations; severe headache or insomnia; fever, chills, sore throat.


Drug Name
Generic Name : bumetanide
Brand Name: Bumex, Burinex (CAN)
Classification:  Loop (high-ceiling) diuretic
Pregnancy Category C
Dosage & Route
  • edema
    • Adult: 1 mg once daily. Give 2nd dose 6-8 hr later if necessary.
    • Elderly: 0.5 mg daily.
  • Refractory edema
    • Adult: Initially, 5 mg daily increased by 5 mg every 12-24 hr as required. High doses may be divided in 2-3 doses. Max: 10 mg/day.
  • hypertension
    • Adult: 0.5-1 mg daily. Max: 5 mg/day.
  • pulmonary edema
  • Adult: 1-2 mg IV repeated 20 min later if necessary, or 2-5 mg in 500 ml of a suitable infusion fluid given over 30-60 min.
  • Emergency cases of edema
  • Adult: 0.5-1 mg via slow IV/IM inj, subsequently adjust dose according to response.
Therapeutic actions
  • Bumetanide induces diuresis by inhibiting reabsorption of water and electrolytes (sodium and chloride) in the ascending loop of Henle and proximal renal tubule.
    • Absorption: Almost completely and rapidly absorbed from the GIT.
    • Distribution: 95% bound to plasma proteins.
    • Excretion: Elimination half-life: about 1-2 hr. About 80% excreted in the urine; 50% as unchanged drug.
  • Edema associated with CHF, cirrhosis, renal disease
  • IV: Acute pulmonary edema
  • Unlabeled use: Treatment of adult nocturia (not effective in men with BPH)
Adverse effects
  • Muscle cramps, dizziness, hypotension, headache, nausea, impaired hearing, pruritus, ECG changes, musculoskeletal pain, rash, chest discomfort, renal failure, premature ejaculation, thrombocytopenia, hypokalaemia, hypomagnesaemia, hyponatraemia, hyperuricaemia, hyperglycaemia, hypocalcaemia.
  • Potentially Fatal: Encephalopathy (in patients with preexisting liver disease).
  • Hypersensitivity, progressive renal failure and anuria, hepatic coma, severe electrolyte depletion.
Nursing considerations
  • History: Allergy to bumetanide, electrolyte depletion, anuria, severe renal failure, hepatic coma, SLE, gout, diabetes mellitus, lactation
  • Physical: Skin color, lesions; edema; orientation, reflexes, hearing; pulses, baseline ECG, BP, orthostatic BP, perfusion; R, pattern, adventitious sounds; liver evaluation, bowel sounds; urinary output patterns; CBC, serum electrolytes (including calcium), blood glucose, LFTs, renal function tests, uric acid, urinalysis
  • Give with food or milk to prevent GI upset.
  • Mark calendars or use reminders if intermittent therapy is best for treating edema.
  • Give single dose early in day so increased urination will not disturb sleep.
  • Avoid IV use if oral use is possible.
  • BLACK BOX WARNING: Arrange to monitor serum electrolytes, hydration, liver function during long-term therapy, water and electrolyte depletion can occur.
  • Provide diet rich in potassium or supplemental potassium.
Teaching points
  • Record alternate day or intermittent therapy on a calendar or dated envelopes.
  • Take the drug early in day so increased urination will not disturb sleep; take with food or meals to prevent GI upset.
  • Weigh yourself on a regular basis, at the same time and in the same clothing; record the weight on your calendar.
  • You may experience these side effects: Increased volume and frequency of urination; dizziness, feeling faint on arising, drowsiness (avoid rapid position changes; hazardous activities, such as driving; and alcohol consumption); sensitivity to sunlight (use sunglasses, sunscreen, wear protective clothing); increased thirst (suck sugarless lozenges; use frequent mouth care); loss of body potassium (a potassium-rich diet, or supplement will be needed).
  • Report weight change of more than 3 pounds in 1 day; swelling in ankles or fingers; unusual bleeding or bruising; nausea, dizziness, trembling, numbness, fatigue; muscle weakness or cramps.


Drug Name
Generic Name : budesonide
Brand Name:
  • Inhalation: Entocort (CAN), Pulmicort Respules, Pulmicort Turbuhaler, Rhinocort Aqua, Rhinocort Turbuhaler (CAN)
  • Oral: Entocort EC
Classification:   Corticosteroid
Pregnancy Category B, C (oral) 
Dosage & Route
  • PO Inflammatory bowel disease Active: 9 mg/day, up to 8 wk. Maintenance: 6 mg once daily, up to 3 month. Inhalation Asthma As metered dose inhaler: 400 mcg/day in 2 divided doses, up to 1.6 mg/day in severe cases. Maintenance: 200-400 mcg/day. As dry powd inhaler: 200-800 mcg/day. As nebulised soln: Inhale 1-2 mg twice daily. Maintenance: 0.5-1 mg twice daily. Nasal Prophylaxis and treatment of rhinitis Initial: 200 mcg into each nostril daily, may reduce to 100 mcg into each nostril daily until symptoms are controlled. Nasal polyps 100 mcg twice daily into each nostril for up to 3 month.
Therapeutic actions
  • Budesonide controls the rate of protein synthesis, depresses the migration of polymorphonuclear leukocytes, fibroblasts, reverses capillary permeability and lysosomal stabilisation at the cellular level to prevent or control inflammation.
  • Management of symptoms of seasonal or perennial allergic rhinitis in adults and children; nonallergic perennial rhinitis in adults
  • Turbuhaler: Maintenance treatment of asthma as prophylactic therapy in adults and children > 6 yr and for patients requiring corticosteroids for asthma
  • Inhalation suspension: Maintenance treatment and prophylaxis therapy of asthma in children 12 mo–8 yr
  • Oral: Treatment and maintenance of clinical remission for up to 3 mo of mild to moderate active Crohn’s disease involving the ileum or ascending colon
Adverse effects
  • Loss of skin collagen and SC atrophy; local hypopigmentation of deeply pigmented skin; dryness, irritation, epistaxis, rarely ulceration or perforation of the nasal septum; smell and taste disturbances; hoarseness and candidiasis of the mouth or throat.
  • Hypersensitivity. Acute infections uncontrolled by antimicrobial chemotherapy.
Nursing considerations
  • History: Untreated local nasal infections, nasal trauma, septal ulcers, recent nasal surgery, lactation
  • Physical: BP, P, auscultation; R, adventitious sounds; examination of nares

  • BLACK BOX WARNING: Taper systemic steroids carefully during transfer to inhalational steroids; deaths from adrenal insufficiency have occurred.
  • Arrange for use of decongestant nose drops to facilitate penetration if edema, excessive secretions are present.
  • Prime unit before use for Pulmicort Turbuhaler; have patient rinse mouth after each use.
  • Use aerosol within 6 mo of opening. Shake well before each use.
  • Store Respules upright and protected from light; gently shake before use; open envelopes should be discarded after 2 wk.
Nasal inhalation

  • Prime pump eight times before first use. If not used for 2 consecutive days, reprime with 1 spray or until fine mist appears. If not used for more than 14 days, rinse applicator and reprime with 2 sprays or until fine mist appears.

  • Make sure patient does not cut, crush, or chew capsules; they must be swallowed whole.
  • Administer the drug once each day, in the morning; do not administer with grapefruit juice.
  • Encourage patient to complete full 8 wk of drug therapy.
  • WARNING: Monitor patient for signs of hypercorticism—acne, bruising, moon face, swollen ankles, hirsutism, skin striae, buffalo hump—which could indicate need to decrease dosage.
Teaching points

  • Do not use more often than prescribed; do not stop without consulting your health care provider.
  • It may take several days to achieve good effects; do not stop if effects are not immediate.
  • Use decongestant nose drops first if nasal passages are blocked.
  • Prime unit before use for Pulmicort Turbuhaler; rinse mouth after each use.
  • Store Respules upright, protect from light; discard open envelopes after 2 weeks; gently shake before use.
  • You may experience these side effects: Local irritation (use your device correctly), dry mouth (suck sugarless lozenges).
  • Report sore mouth, sore throat, worsening of symptoms, severe sneezing, exposure to chickenpox or measles, eye infections.

  • Take the drug once a day in the morning. Do not cut, crush, or chew the capsules, they must be swallowed whole.
  • If you miss a day, take the capsules as soon as you remember them. Take the next day’s capsules at the regular time. Do not take more than three capsules in a day.
  • Take the full course of the drug therapy (8 weeks in most cases).
  • Do not take this drug with grapefruit juice; avoid grapefruit juice entirely while using this drug.
  • Store Respules upright, protected from light; discard open envelopes after 2 weeks. Shake before use.
  • You may experience these side effects: Dizziness, headache (avoid driving or operating dangerous machinery if these effects occur); nausea, flatulence (small, frequent meals may help; try to maintain your fluid and food intake).
  • Report chest pain, ankle swelling, respiratory infections, increased bruising.

brompheniramine maleate (parabromdylamine maleate)

Drug Name
Generic Name :  brompheniramine maleate (parabromdylamine maleate)
Brand Name: BroveX, BroveX CT, Bidhist, Lodrane XR, LoHist 12 Hour, VaZol
Classification:  Antihistamine (alkylamine type)
Pregnancy Category C
Dosage & Route
  • Allergic conditions (urticaria, rhinitis, conjunctivitis)
  • Adult: 4-8 mg 3-4 times daily. Individualise dosage according to patient’s response and tolerance.
  • Child: ≤3 yr: 0.4-1 mg/kg/ day, given as 4 divided doses. 3-6 yr: 1-2 mg and 6-12 yr: 2-4 mg, doses to be given 3-4 times daily.
  • Allergic conditions (urticaria, rhinitis, conjunctivitis)
  • Adult: 10 mg every 8-12 hr. Dose can be given via SC, IM or slow IV inj. Max: 40 mg/24 hr.
Therapeutic actions
  • Brompheniramine is an antihistamine with antimuscarinic and moderate sedative actions.
  • Symptomatic relief of symptoms associated with perennial and seasonal allergic rhinitis—runny nose, sneezing, itching nose and throat, watery eyes
Adverse effects
  • CNS depression including slight drowsiness to deep sleep, lassitude, dizziness, incoordination. Headache, psychomotor impairment and antimuscarinic effects. Rarely, rashes and hypersensitivity reactions; blood disorders, convulsions, sweating, myalgia, paraesthesias, extrapyramidal effects, tremor, confusion, sleep and GI disturbances, tinnitus, hypotension, hair loss.
  • Premature infants or neonates.
Nursing considerations
  • History: Allergy to any antihistamines, tartrazine, narrow-angle glaucoma, stenosing peptic ulcer, symptomatic prostatic hypertrophy, asthmatic attack, bladder neck obstruction, pyloroduodenal obstruction, third trimester of pregnancy, lactation
  • Physical: Skin color, lesions, texture; orientation, reflexes, affect; vision examination; P, BP; R, adventitious sounds; bowel sounds; prostate palpation; CBC with differential
  • Give orally with food if GI upset occurs.
Teaching points
  • Take as prescribed; avoid excessive dosage; take with food if GI upset occurs.
  • Avoid alcohol while on this drug; serious sedation could occur.
  • Oral liquid and oral suspensions differ in strength; do not use interchangeably.
  • You may experience these side effects: Dizziness, sedation, drowsiness (use caution if driving or performing tasks that require alertness); epigastric distress, diarrhea or constipation (take with meals); dry mouth (frequent mouth care, sucking sugarless lozenges may help); thickening of bronchial secretions, dryness of nasal mucosa (try a humidifier).
  • Report difficulty breathing, hallucinations, tremors, loss of coordination, unusual bleeding or bruising, visual disturbances, irregular heartbeat.

Leavell and Clark’s Three Levels of Prevention

Primary Prevention
  • Seeks to prevent a disease or condition at a prepathologic state; to stop something from ever happening.
Health Promotion
  • health education
  • marriage counseling
  • genetic screening
  • good standard of nutrition adjusted to developmental phase of life
Specific Protection
  • use of specific immunization
  • attention to personal hygiene
  • use of environmental sanitation
  • protection against occupational hazards
  • protection from accidents
  • use of specific nutrients
  • protections from carcinogens
  • avoidance to allergens
Secondary Prevention
  • Also known as “Health Maintenance”. Seeks to identify specific illnesses or conditions at an early stage with prompt intervention to prevent or limit disability; to prevent catastrophic effects that could occur if proper attention and treatment are not provided
Early Diagnosis and Prompt Treatment
  • case finding measures
  • individual and mass screening survey
  • prevent spread of communicable disease
  • prevent complication and sequelae
  • shorten period of disability
Disability Limitations
  • Adequate treatment to arrest disease process and prevent further complication and sequelae.
  • Provision of facilities to limit disability and prevent death.
Tertiary Prevention
  • Occurs after a disease or disability has occurred and the recovery process has begun; Intent is to halt the disease or injury process and assist the person in obtaining an optimal health status. To establish a high-level wellness. “To maximize use of remaining capacities’
Restoration and Rehabilitation
  • Work therapy in hospital
  • Use of shelter colony

bisoprolol fumarate

Drug Name
Generic Name : bisoprolol fumarate
Brand Name: Zebeta
Classification: Beta1-selective adrenergic blocker, Antihypertensive
Pregnancy Category C
Dosage & Route
  • PO Angina pectoris; HTN 2.5-10 mg/day. Max: 20 mg/day. Heart failure Initial: 1.25 mg once daily, may increase gradually. Max: 10 mg/day.
Therapeutic actions
  • Bisoprolol selectively and competitively blocks β-1 receptors but has little or no effect on β-2 receptors except at high doses.
  • Management of hypertension, used alone or with other antihypertensives
Adverse effects
  • Giddiness, headache, fatigue, bradycardia. Nausea, vomiting, diarrhea or constipation, stomach discomfort, mild ocular stinging, photophobia, keratitis, decreased sexual ability. GI disturbances, dyspnoea, cold extremities, insomnia, hallucination, drowsiness and mood alterations.
  • Potentially Fatal: AV block, bradycardia. Rare but may occur in patients with preexisting cardiac disease. Includes severe bronchospasm, hypoglycaemia, hypotension, orthostatic hypotension, bradyarrhythmias. ‘Rebound phenomenon’ leading to unstable angina or MI on sudden withdrawal.
  • Low cardiac output and uncompensated cardiac failure; sinus bradycardia, 1st ° heart block, cardiogenic shock, bronchospasm; severe hemorrhage.
  • Pregnancy.
Nursing considerations
CLINICAL ALERT! Name confusion has occurred between Zebeta (bisoprolol) and DiaBeta (glyburide); use caution.
  • History: Sinus bradycardia, cardiac arrhythmias, cardiogenic shock, CHF, renal failure, diabetes or thyrotoxicosis, pregnancy, lactation
  • Physical: Baseline weight, skin condition, neurologic status, P, BP, ECG, R, LFTs, renal function tests, blood and urine glucose
  • WARNING: Do not discontinue drug abruptly after long-term 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).
Teaching points
  • Do not stop taking this drug unless instructed to do so by a health care provider.
  • Avoid over-the-counter medications.
  • Avoid driving or dangerous activities if dizziness, weakness occur.
  • You may experience these side effects: Dizziness, light-headedness, loss of appetite, nightmares, depression, sexual impotence.
  • Report difficulty breathing, night cough, swelling of extremities, slow pulse, confusion, depression, rash, fever, sore throat.


Drug Name
Generic Name: betamethasone, betamethasone dipropionate, betamethasone sodium phosphate, betamethasone sodium phosphate and acetate , betamethasone valerate
Brand Name:
  • Topical dermatologic ointment, cream, lotion, aerosol: Diprolene, Diprolene AF, Diprosone, Maxivate, Taro-Sone (CAN), Teladar
  • Systemic, including IV and local injection: Betnesol (CAN), Celestone Phosphate
  • Systemic, IM, and local intra-articular, intralesional, intradermal injection: Celestone Soluspan
  • Topical dermatologic ointment, cream, lotion: Betaderm (CAN), Beta-Val, Luxiq, Prevex B (CAN), Psorion Cream, Valisone
Classification: Corticosteroid (long acting), Glucocorticoid, Hormone

Pregnancy Category C

Dosage & Route
  • PO Allergic and inflammatory disorders; congenital adrenal hyperplasia 0.5-5 mg/day. IM Allergic and inflammatory disorders As betamethasone Na phosphate and betamethasone acetate: Initial: 0.25-9 mg/day in 1-2 divided doses. Ophth Allergic and inflammatory conditions of the eye As 0.1% soln: As Na phosphate: Instill 1-2 hrly until symptoms are controlled. As 0.1% oint: As Na phosphate: Apply 2-4 times/day or at night w/ the eye drops. Topical Skin disorders As dipropionate (0.05%) or valerate (0.025 or 0.1%): Apply as directed.
Therapeutic actions
  • Betamethasone is a corticosteroid with mainly glucocorticoid activity. It prevents and controls inflammation by controlling the rate of protein synthesis, depressing the migration of polymorphonuclear leukocytes and fibroblasts, and reversing capillary permeability and lysosomal stabilisation.
Systemic administration
  • Hypercalcemia associated with cancer
  • Short-term management of inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (eg, SLE), dermatologic diseases (eg, pemphigus), status asthmaticus, and autoimmune disorders
  • Hematologic disorders: Thrombocytopenia purpura, erythroblastopenia
  • Ulcerative colitis, acute exacerbations of MS, and palliation in some leukemias and lymphomas
  • Trichinosis with neurologic or myocardial involvement
Intra-articular or soft-tissue administration
  • Arthritis, psoriatic plaques, and so forth
Dermatologic preparations
  • Relief of inflammatory and pruritic manifestations of steroid-responsive dermatoses
Adverse effects
  • Sodium and fluid retention, potassium and calcium depletion. Muscle wasting, weakness, osteoporosis. GI disturbances and bleeding. Increased appetite and delayed wound healing; hirsutism, bruising, striae, acne; raised intracranial pressure, headache, depression, psychosis, menstrual irregularities. Hyperglycaemia, DM. Suppression of pituitary-adrenocortical axis. Growth retardation in children (prolonged therapy). Increased susceptibility for infections. Topical use: Dermal atrophy, local irritation, folliculitis, hypertrichosis. Inhalation: Hoarseness, candidiasis of mouth and throat. Topical application to the eye: Corneal ulcers, raised IOP and reduced visual acuity. Intradermal injection: Local hypopigmentation of deeply pigmented skin. Intra-articular injection: Joint damage, fibrosis, esp in load bearing joints.
  • Potentially Fatal: Abrupt withdrawal leading to acute adrenal insufficiency manifesting as malaise, weakness, mental changes, muscle and joint pains, dystonia, hypoglycaemia, hypotension, dehydration and death. Rapid IV inj may cause CV collapse.
  • Hypersensitivity; systemic fungal or acute infections.
Nursing considerations
  • History (systemic administration): Infections, fungal infections, amebiasis, vaccinia and varicella, and antibiotic-resistant infections; kidney or liver disease; hypothyroidism; ulcerative colitis with impending perforation; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF; hypertension; thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation
  • Physical: Baseline weight, T, reflexes and grip strength, affect and orientation, P, BP, peripheral perfusion, prominence of superficial veins, R and adventitious sounds, serum electrolytes, blood glucose
Systemic use

  • Give daily dose before 9 AM to mimic normal peak corticosteroid blood levels.
  • Increase dosage when patient is subject to stress.
  • Taper doses when discontinuing high-dose or long-term therapy.
  • Do not give live virus vaccines with immunosuppressive doses of corticosteroids.
Topical dermatologic preparations

  • Examine area for infections and skin integrity before application.
  • Administer cautiously to pregnant patients; topical corticosteroids have caused teratogenic effects and can be absorbed from systemic site.
  • WARNING: Use caution when occlusive dressings or tight diapers cover affected area; these can increase systemic absorption of the drug.
  • Avoid prolonged use near eyes, in genital and rectal areas, and in skin creases.
Teaching points
Systemic use

  • Do not stop taking the oral drug without consulting your health care provider.
  • Take single dose or alternate-day doses before 9 AM.
  • Avoid exposure to infections; ability to fight infections is reduced.
  • Wear a medical alert tag so emergency care providers will know that you are on this medication.
  • You may experience these side effects: Increase in appetite, weight gain (counting calories may help); heartburn, indigestion (eat frequent small meals; take antacids); poor wound healing (consult with your care provider); muscle weakness, fatigue (frequent rest periods will help).
  • Report unusual weight gain, swelling of the extremities, muscle weakness, black or tarry stools, fever, prolonged sore throat, colds or other infections, worsening of original disorder.
Intrabursal, intra-articular therapy

  • Do not overuse joint after therapy, even if pain is gone.
Topical dermatologic preparations

  • Apply sparingly; do not cover with tight dressings.
  • Avoid contact with the eyes.
  • Report irritation or infection at the site of application


Drug Name
Generic Name: benzonatate
Brand Name: Benzonatate Softgels, Tessalon, Tessalon Perles
Classification: Antitussive (nonopioid)
Pregnancy Category C

Dosage & Route

  • 100–200 mg PO tid; up to 600 mg/day may be used.
Therapeutic actions
  • Related to the local anesthetic tetracaine; anesthetizes the stretch receptors in the respiratory passages, lungs, and pleura, hampering their activity and reducing the cough reflex at its source.
  • Symptomatic relief of nonproductive cough
  • Unlabeled use: May be used to reduce cough reflex during procedures (ie, endoscopy)
Adverse effects
  • CNS: Sedation, headache, mild dizziness, hallucinations, nasal congestion, sensation of burning in the eyes
  • Dermatologic: Pruritus, skin eruptions
  • GI: Constipation, nausea, GI upset
  • Other: Vague “chilly” feeling, numbness in the chest
  • Contraindicated with allergy to benzonatate or related compounds (tetracaine); lactation.
  • Use cautiously with pregnancy.
Nursing considerations
  • History: Allergy to benzonatate or related compounds (tetracaine); lactation, pregnancy
  • Physical: Nasal mucous membranes; skin color, lesions; orientation, affect; adventitious sounds
  • WARNING: Administer orally; caution patient not to chew or break capsules but to swallow them whole; choking could occur if drug released in the mouth.
Teaching points
  • Swallow the capsules whole; do not chew or break capsules because numbness of the throat and mouth could occur, and swallowing could become difficult.
  • You may experience these side effects: Rash, itching (skin care may help); constipation, nausea, GI upset; sedation, dizziness (avoid driving or tasks that require alertness).
  • Report restlessness, tremor, difficulty breathing, constipation, rash, bizarre behavior.

Laboratory and Diagnostic Examination

Urine Specimen
1. Clean-Catch mid-stream urine specimen for routine urinalysis, culture and sensitivity test
  1. Best time to collect is in the morning, first voided urine
  2. Provide sterile container
  3. Do perineal care before collection of the urine
  4. Discard the first flow of urine
  5. Label the specimen properly
  6. Send the specimen immediately to the laboratory
  7. Document the time of specimen collection and transport to the lab.
  8. Document the appearance, odor, and usual characteristics of the specimen.
2. 24-hour urine specimen
  1. Discard the first voided urine.
  2. Collect all specimens thereafter until the following day
  3. Soak the specimen in a container with ice
  4. Add preservative as ordered according to hospital policy
3. Second-Voided urine – required to assess glucose level and for the presence of albumen in the urine.
  1. Discard the first urine
  2. Give the patient a glass of water to drink
  3. After few minutes, ask the patient to void
4. Catheterized urine specimen
  1. Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the bladder and adequate specimen can be collected.
  2. Clamping the drainage tube and emptying the urine into a container are contraindicated after a genitourinary surgery.
Stool Specimen
1. Fecalysis – to assess gross appearance of stool and presence of ova or parasite
  1. Secure a sterile specimen container
  2. Ask the pt. to defecate into a clean, dry bed pan or a portable commode.
  3. Instruct client not to contaminate the specimen with urine or toilet paper (urine inhibits bacterial growth and paper towel contain bismuth which interfere with the test result.
2. Stool culture and sensitivity test
  • To assess specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotics.
3. Fecal Occult blood test
  • Are valuable test for detecting occult blood (hidden) which may be present in colo-rectal cancer, detecting melena stool
  1. Hematest– (an Orthotolidin reagent tablet)
  2. Hemoccult slide– (filter paper impregnated with guaiac)
    • *Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours.
  3. Colocare – a newer test, requires no smear
  1. Advise client to avoid ingestion of red meat for 3 days
  2. Patient is advice on a high residue diet
  3. Avoid dark food and bismuth compound
  4. If client is on iron therapy, inform the MD
  5. Make sure the stool in not contaminated with urine, soap solution or toilet paper
  6. Test sample from several portion of the stool.
  1. Never collect a venous sample from the arm or a leg that is already being use d for I.V therapy or blood administration because it mat affect the result.
  2. Never collect venous sample from an infectious site because it may introduce pathogens into the vascular system
  3. Never collect blood from an edematous area, AV shunt, site of previous hematoma, or vascular injury.
  4. Don’t wipe off the povidine-iodine with alcohol because alcohol cancels the effect of povidine iodine.
  5. If the patient has a clotting disorder or is receiving anticoagulant coagulant therapy, maintain pressure on the site for at least 5 min after withdrawing the needle.
Arterial puncture for ABG test
  1. Before arterial puncture, perform Allen’s test first.
  2. If the patient is receiving oxygen, make sure that the patient’s therapy has been underway for at least 15 min before collecting arterial sample
  3. Be sure to indicate on the laboratory request slip the amount and type of oxygen therapy the patient is having.
  4. If the patient has just received a nebulizer treatment, wait about 20 minutes before collecting the sample.
Blood specimen
  1. No fasting for the following tests:
    • CBC, Hgb, Hct, clotting studies, enzyme studies, serum electrolytes
  2. Fasting is required:
    • FBS, BUN, Creatinine, serum lipid (cholesterol, triglyceride)
Sputum Specimen
1. Gross appearance of the sputum
  1. Collect early in the morning
  2. Use sterile container
  3. Rinse the mount with plain water before collection of the specimen
  4. Instruct the patient to hack-up sputum
2. Sputum culture and sensitivity test
  1. Use sterile container
  2. Collect specimen before the first dose of antibiotic
3. Acid-Fast Bacilli
  1. To assess presence of active pulmonary tuberculosis
  2. Collect sputum in three consecutive mornings
4. Cytologic sputum exam
  1. To assess for presence of abnormal or cancer cells.

IV Fluid/Solution Quick Reference Guide

  • Intravenous Solutions are used in fluid replacement therapy by changing the composition of the serum by adding fluids and electrolytes.
Listed below is a table which may serve as your quick reference guide on the different intravenous solutions.
Normal Saline (NS)
0.9% NaCl in WaterCrystalloid Solution
(308 mOsm)
Increases circulating plasma volume when red cells are adequate
  • Replaces losses without altering fluid concentrations.
  • Helpful for Na+ replacement
1/2 Normal Saline (1/2 NS)
0.45% NaCl in WaterCrystalloid Solution
(154 mOsm)
Raises total fluid volume
  • Useful for daily maintenance of body fluid, but is of less value for replacement of NaCldeficit.
  • Helpful for establishing renal function.
  • Fluid replacement for clients who don’t need extra glucose (diabetics)
Lactated Ringer’s (LR)
Normal saline with electrolytes and buffer
(275 mOsm)
Replaces fluid and buffers pH
  • Normal saline with K+, Ca++, and lactate (buffer)
  • Often seen with surgery
Dextrose 5% in water Crystalloid solution
Isotonic (in the bag)
*Physiologically hypotonic
(260 mOsm)
Raises  total fluid volume.Helpful in rehydrating and excretory purposes.
  • Provides 170-200 calories/1,000cc for energy.
  • Physiologically hypotonic -the dextrose is metabolized quickly so that only water remains – a hypotonic fluid
Dextrose 5% in 0.9% saline
(560 mOsm)
Replaces fluid sodium, chloride, and calories.
  • Watch for fluid volume overload
D5 1/2 NS
Dextrose 5% in 0.45% saline
(406 mOsm)
Useful for daily maintenance of body fluids and nutrition, and for rehydration.
  • Most common postoperative fluid
Dextrose 5% in Lactated Ringer’s
(575 mOsm)
Same as LR plus provides about 180 calories per 1000cc’s.
  • Watch for fluid volume overload
(295 mOsm)
Replaces fluid and buffers pH
  • pH 7.4
  • Contains sodium, chloride, calcium,       potassium and magnesium
  • Common fluid for OR and PACU

benazepril hydrochloride

Drug Name
Generic Name:  benazepril hydrochloride

Brand Name: Lotensin
Classification: Antihypertensive, ACE inhibitor
Pregnancy Category C (first trimester)
Pregnancy Category D (second and third trimesters)

Dosage & Route
  • Adult: Initially, 10 mg once daily. Maintenance: 20-40 mg daily as a single or in 2 divided doses. Max dose: 80 mg/day.
  • Child: ≥6 yr: 0.2 mg/kg/day. Max dose: 40 mg/day.
  • Renal impairment: Avoid usage in children with CrCl <30 ml/min.
 CrCl (ml/min)
 Dosage Recommendation
 <30 Initial dose: 5 mg daily.     Max maintenance dose: 40  mg daily.
Heart failure
  • Adult: Initially, 2.5 mg once daily adjusted according to patient’s response. Max: 20 mg daily.
Therapeutic actions
  • Benazepril and its metabolite benazeprilat inhibit ACE that catalyzes the conversion of angiotensin I to angiotensin II, thus leading to reduced aldosterone secretion by the adrenal cortex and decreased vasopressor activity.
  • Treatment of hypertension alone or in combination with thiazide-type diuretics
Adverse effects
  • Headache, dizziness, fatigue; cough; somnolence, nausea; hypotension, transient elevations in BUN and serum creatinine; palpitations; constipation, gastritis; melena, rash, pruritus; musculoskeletal pain; paraesthesia, anxiety; UTI; hyperkalaemia; leucopenia and flushing.
  • Potentially Fatal: Angioedema (rare).
  • Hypersensitivity. History of bilateral renal artery stenosis, angioedema; pregnancy.
Nursing considerations
  • History: Allergy to benazepril or other ACE inhibitors, impaired renal function, CHF, salt or volume depletion, lactation, pregnancy
  • Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, LFTs, renal function tests, CBC and differential
  • WARNING: Alert surgeon: Note use of benazepril on patient’s chart; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion.
  • Monitor patient for possible drop in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea) because excessive hypotension may occur.
  • BLACK BOX WARNING: Ensure that patient is not pregnant; fetal abnormalities and death have occurred if used during second or third trimester. Encourage use of contraceptive measures.
  • Reduce dosage in patients with impaired renal function.
Teaching points
  • Do not stop taking the medication without consulting your health care provider.
  • Be careful in any conditions that may lead to a drop in blood pressure (such as diarrhea, sweating, vomiting, dehydration); if light-headedness or dizziness occurs, consult your health care provider.
  • You should not become pregnant while on this drug. Serious fetal abnormalities could occur; use of contraceptives is advised.
  • You may experience these side effects: GI upset, loss of appetite (transient effects; if persistent consult health care provider); light-headedness (transient; change position slowly, and limit activities to those that do not require alertness and precision); dry cough (irritating but not harmful; consult health care provider).
  • Report mouth sores; sore throat, fever, chills; swelling of the hands, feet; irregular heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty breathing, persistent cough.

beclomethasone dipropionate

Drug Name
Generic Name: beclomethasone dipropionate

Brand Name:  Apo-Beclomethasone (CAN), Beconase AQ, Propaderm (CAN), QVAR
Classification: Corticosteroid, Glucocorticoid, Hormone
Pregnancy Category C

Dosage & Route
  • Skin disorders
  • Adult: Apply a 0.025% cream/ointment onto affected area.

  • Prophylaxis and treatment of allergic and non allergic rhinitis
  • Adult: 100 mcg bid or 50 mcg 3-4 times daily in each nostril. Max: 400 mcg daily.

  • Prophylaxis of asthma
  • Adult: Initially, 600-800 mcg daily. Maintenance: 400 mcg daily in 2-4 divided doses.
  • Child: As dipropionate: 50 or 100 mcg bid-qid or 100 or 200 mcg bid.

  • Severe asthma
  • Adult: 250 mcg four times daily or 500 mcg bid. May be increased to 500 mcg 3-4 times daily if necessary. Max: 2 mg daily.
Therapeutic actions
  • Beclometasone controls the rate of protein synthesis, depresses the migration of polymorphonuclear leukocytes, fibroblasts, reverses capillary permeability and lysosomal stabilisation at the cellular level to prevent or control inflammation.
  • Respiratory inhalant use: Control of bronchial asthma that requires corticosteroids along with other therapy
  • Intranasal use: Relief of symptoms of seasonal or perennial rhinitis that respond poorly to other treatments; prevention of recurrence of nasal polyps following surgical removal
Adverse effects
  • Loss of skin collagen and SC atrophy; local hypopigmentation of deeply pigmented skin; dryness, irritation, epistaxis, rarely ulceration or perforation of the nasal septum; smell and taste disturbances; hoarseness and candidiasis of the mouth or throat.
  • Hypersensitivity. Acute infections uncontrolled by antimicrobial chemotherapy.
Nursing considerations
  • History: Acute asthmatic attack, status asthmaticus; systemic fungal infections; allergy to any ingredient; lactation; untreated local infections, nasal septal ulcers, recurrent epistaxis, nasal surgery or trauma
  • Physical: Weight, T; P, BP, auscultation; R, adventitious sounds; chest radiograph before respiratory inhalant therapy; examination of nares before intranasal therapy
  • BLACK BOX WARNING: Taper systemic steroids carefully during transfer to inhalational steroids; deaths resulting from adrenal insufficiency have occurred during and after transfer from systemic to aerosol steroids.
  • Use decongestant nose drops to facilitate penetration of intranasal steroids if edema or excessive secretions are present.
Teaching points
  • This respiratory inhalant has been prescribed to prevent asthmatic attacks, not for use during an attack.
  • Allow at least 1 minute between puffs (respiratory inhalant); if you also are using an inhalational bronchodilator (isoproterenol, albuterol, metaproterenol, epinephrine), use it several minutes before using the steroid aerosol.
  • Rinse your mouth after using the respiratory inhalant aerosol.
  • Use a decongestant before the intranasal steroid, and clear your nose of all secretions if nasal passages are blocked; intranasal steroids may take several days to produce full benefit.
  • Use this product exactly as prescribed; do not take more than prescribed, and do not stop taking the drug without consulting your health care provider. The drug must not be stopped abruptly but must be slowly tapered.
  • You may experience these side effects: Local irritation (use the device correctly), headache (consult your health care provider for treatment).
  • Report sore throat or sore mouth.


Drug Name
Generic Name: baclofen
Brand Name:  Apo-Baclofen (CAN), Gen-Baclofen (CAN), Lioresal, Lioresal Intrathecal
Classification: Centrally acting skeletal muscle relaxant
Pregnancy Category C

Dosage & Route
  • PO 5 mg 3 times/day for 3 days, increased to 10 mg 3 times/day for 3 days. May further increase if needed. Max: 100 mg/day. Intrathecal Test dose: 25 or 50 mcg. Increase dose by 25 mcg not more often than 24 hrly until 100 mcg/dose to determine appropriate dose. Responders w/ response lasting >8-12 hr, the test dose that was used to produce the response can be given as a 24-hr infusion; if the response lasted ≤8-12 hr, then a dose equivalent to twice the test dose is given. Adjust daily dosage as required. Maintenance: 12 mcg-2 mg/day for spasticity of spinal origin; 22 mcg-1.4 mg/day for spasticity of cerebral origin.
Therapeutic actions
  • Baclofen is an antispastic. It inhibits both monosynaptic and polysynaptic reflexes at spinal level.
  • Alleviation of signs and symptoms of spasticity resulting from MS, particularly for the relief of flexor spasms and concomitant pain, clonus, muscular rigidity (for patients with reversible spasticity to aid in restoring residual function); treatment of central spasticity (via SynchroMed pump)
  • Spinal cord injuries and other spinal cord diseases—may be of some value
  • Unlabeled uses: Trigeminal neuralgia (tic douloureux); may be beneficial in reducing spasticity in cerebral palsy in children (intrathecal use)
Adverse effects
  • Sedation, drowsiness, ataxia, dizziness, headache, confusion, hallucinations, skin reactions, GI symptoms, enuresis.
  • Potentially Fatal: Respiratory or CV depression, seizures.
  • Hypersensitivity. Active peptic ulcer disease.
Nursing considerations
  • History: Hypersensitivity to baclofen, skeletal muscle spasm resulting from rheumatic disorders, stroke, cerebral palsy, Parkinson’s disease, seizure disorders, lactation, pregnancy
  • Physical: Weight; T; skin color, lesions; orientation, affect, reflexes, bilateral grip strength, visual examination; P, BP; bowel sounds, normal GI output, liver evaluation; normal urinary output; LFTs, renal function tests, blood and urine glucose
  • Patients given implantable device for intrathecal delivery need to learn about the programmable delivery system, frequent checks; how to adjust dose and programming.
  • Give with caution to patients whose spasticity contributes to upright posture or balance in locomotion or whenever spasticity is used to increase function.
  • BLACK BOX WARNING: Taper dosage gradually to prevent hallucinations, possible psychosis, or other serious effects; abrupt discontinuation can cause serious reactions.
Teaching points
  • Take this drug exactly as prescribed. Do not stop taking this drug without consulting your health care provider; abrupt discontinuation may cause hallucinations or other serious effects.
  • Avoid alcohol, sleep-inducing, or over-the-counter drugs because these could cause dangerous effects.
  • Do not take this drug during pregnancy. If you decide to become pregnant or find that you are pregnant, consult your health care provider.
  • You may experience these side effects: Drowsiness, dizziness, confusion (avoid driving or engaging in activities that require alertness); nausea (eat frequent small meals); insomnia, headache, painful or frequent urination (effects reversible; will go away when the drug is discontinued).
  • Report frequent or painful urination, constipation, nausea, headache, insomnia, or confusion that persists or is severe.


Drug Name
Generic Name: azithromycin

Brand Name:  Zithromax, Zmax
Classification: Macrolide
Pregnancy Category B

Dosage & Route
  • PO Resp tract infections; Skin and soft tissue infections 500 mg once daily for 3 days. Uncomplicated genital chlamydial infections 1 g as a single dose. Uncomplicated gonorrhoea 2 g as a single dose. Prophylaxis of disseminated MAC infections 1.2 g once wkly. Treatment or secondary prophylaxis: W/ other antimycobacterials: 500 mg once daily. Typhoid 500 mg once daily for 7 days. Granuloma inguinale Initial: 1 g, then 500 mg/day until all lesions has healed completely.
Therapeutic actions
  • Azithromycin blocks transpeptidation by binding to 50s ribosomal subunit of susceptible organisms and disrupting RNA-dependent protein synthesis at the chain elongation step.
  • Treatment of lower respiratory infections: Acute bacterial exacerbations of COPD due to Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae; community-acquired pneumonia due to S. pneumoniae, H. influenzae
  • Treatment of lower respiratory infections: Streptococcal pharyngitis and tonsillitis due to Streptococcus pyogenes in those who cannot take penicillins
  • Treatment of uncomplicated skin infections due to Staphylococcus aureus, S. pyogenes, Streptococcus agalactiae
  • Treatment of nongonococcal urethritis and cervicitis due to Chlamydia trachomatis; treatment of PID
  • Treatment of acute sinusitis
  • Treatment of otitis media caused by H. influenzae, M. catarrhalis, S. pneumoniae in children > 6 mo
  • Treatment of pharyngitis and tonsillitis in children > 2 yr who cannot use first-line therapy
  • Prevention and treatment of disseminated Mycobacterium avium complex (MAC) in patients with advanced AIDS
  • Treatment of patients with mild to moderate acute bacterial sinusitis caused by H. influenzae, Moracellis catarrhalis, S. pneumoniae (Zmax)
  • Treatment of mild to moderate community acquired pneumonia caused by Chlamydophila pneumoniae, H. influenzae, Mycoplasma pneumoniae, S. pneumoniae (Zmax)
  • Unlabeled uses: Uncomplicated gonococcal infections caused by N. gonorrhoeae; gonococcal pharyngitis caused by N. gonorrhoeae; chlamydial infections caused by C. trachomatis; prophylaxis after sexual attack
Adverse effects
  • Mild to moderate nausea, vomiting, abdominal pain, dyspepsia, flatulence, diarrhoea, cramping; angioedema, cholestatic jaundice; dizziness, headache, vertigo, somnolence; transient elevations of liver enzyme values.
  • Contraindicated with hypersensitivity to azithromycin, erythromycin, or any macrolide antibiotic.
  • Use cautiously with gonorrhea or syphilis, pseudomembranous colitis, hepatic or renal impairment, lactation.
Nursing considerations
  • History: Hypersensitivity to azithromycin, erythromycin, or any macrolide antibiotic; gonorrhea or syphilis, pseudomembranous colitis, hepatic or renal impairment, lactation
  • Physical: Site of infection; skin color, lesions; orientation, GI output, bowel sounds, liver evaluation; culture and sensitivity tests of infection, urinalysis, LFTs, renal function tests
  • Culture site of infection before therapy.
  • Administer on an empty stomach 1 hr before or 2–3 hr after meals. Food affects the absorption of this drug.
  • Prepare Zmax by adding 60 mL water to bottle, shake well.
  • Counsel patients being treated for STDs about appropriate precautions and additional therapy.
Teaching points
  • Take the full course prescribed. Do not take with antacids. Tablets and oral suspension can be taken with or without food.
  • Prepare Zmax by adding 60 milliliters (1/4 cup) water to bottle, shake well, drink all at once.
  • You may experience these side effects: Stomach cramping, discomfort, diarrhea; fatigue, headache (medication may help); additional infections in the mouth or vagina (consult with health care provider for treatment).
  • Report severe or watery diarrhea, severe nausea or vomiting, rash or itching, mouth sores, vaginal sores.


Drug Name
Generic Name: azathioprine
Brand Name: Azasan, Imuran
Classification: Immunosuppressant
Pregnancy Category D

Dosage & Route
  • PO Rheumatoid arthritis Initial: 1 mg/kg/day for 6-8 wk. May adjust dose gradually to 2.5 mg/kg/day if needed. Prevention of rejection in organ and tissue transplantation 1-5 mg/kg/day. Auto-immune diseases 1-3 mg/kg/day.
Therapeutic actions
  • Azathioprine is an immunosuppressant, which inhibits DNA, RNA and protein synthesis and antagonises purine synthesis. It also inhibits mitosis and interferes with cellular metabolism of susceptible organisms. Azathioprine inj should be discontinued as soon as oral therapy can be introduced
  • Renal homotransplantation: Adjunct for prevention of rejection
  • Rheumatoid arthritis: Use only with adults meeting criteria for classic rheumatoid arthritis and not responding to conventional management
  • Unlabeled use: Treatment of chronic ulcerative colitis, myasthenia gravis, Behçet’s syndrome, Crohn’s disease
Adverse effects
  • Fever, chills; bone marrow depression characterised by leucopenia, thrombocytopenia or anaemia; anorexia, nausea, diarrhoea; arthralgias; secondary infections; hepatotoxicity, rash, alopoecia.
  • Potentially Fatal: Myelosuppression, mutagenicity and carcinogenicity; veno-occlussive liver disease.
  • Hypersensitivity; previous treatment with alkylating agents; pregnancy, lactation.
Nursing considerations
  • History: Allergy to azathioprine; rheumatoid arthritis patients previously treated with alkylating agents; pregnancy or male partners of women trying to become pregnant; lactation
  • Physical: T; skin color, lesions; liver evaluation, bowel sounds; LFTs, renal function tests, CBC
  • Give drug IV if oral administration is not possible; switch to oral route as soon as possible.
  • Administer in divided daily doses or with food if GI upset occurs.
  • BLACK BOX WARNING: Monitor blood counts regularly; severe hematologic effects may require the discontinuation of therapy; increases risk of neoplasia.
Teaching points
  • Take drug in divided doses with food if GI upset occurs.
  • Avoid infections; avoid crowds or people who have infections. Notify your physician at once if you are injured.
  • Notify your health care provider if you think you are pregnant or wish to become pregnant, or if you are a man whose sexual partner wishes to become pregnant.
  • You may experience these side effects: Nausea, vomiting (take drug in divided doses or with food), diarrhea, rash.
  • Report unusual bleeding or bruising, fever, sore throat, mouth sores, signs of infection, abdominal pain, severe diarrhea, darkened urine or pale stools, severe nausea and vomiting.

Intramuscular (IM) Administration

Here are the steps needed to accomplish administering IM injections. Feel free to read through the steps .
  1. You will be needing all these supplies. Prepare the medication to be given, syringe, alcohol prep pad, gauze, band-aid and needle. The needles are usually 21g or 22g, and 1 1/2″ long.
  2. Wash your hands.
  3. Prepare/Mix the medication accordingly and put it into the syringe.
  4. Attach the new needle into the syringe.
  5. Medication can be given into the:
    • Ventrogluteal – Patient may lie on back or side with hip and knee flexed.
    • Vastus lateralis – Patient may lie on the back or may assume a sitting position.
    • Deltoid – Patient may sit or lie with arm relaxed.
    • Dorsogluteal – Patient may lie prone with toes pointing inward or on side with upper leg flexed and placed in front of lower leg.
  6. The site should be free of bumps and scars.
  7. Clean the site with an alcohol pad. Allow the alcohol to dry. Do not use a blower or fan to quicken the drying process.
  8. Spread the skin with your fingers and inject the needle straight down in a dart-like motion all the way.
  9. Pull back on the plunger a little. If you see blood enter the syringe, pull the needle out a little and inject the medication. If you do not see blood, simply inject.
  10. Pull the needle out and dispose of properly in a sharps container. Do not put medical or sharp waste in the regular garbage.
  11. Use the gauze to dab up any blood, if necessary, and cover with a bandage.
  12. Wash your hands.

atropine sulfate

Drug Name
Generic Name: atropine sulfate
Brand Name:
  • Parenteral and oral preparations: AtroPen, Minims (CAN), Sal-Tropine
  • Ophthalmic solution: Atropine Sulfate S.O.P., Isopto Atropine Ophthalmic
Classification: Anticholinergic, Antimuscarinic, Parasympatholytic, Antiparkinsonian, Antidote, Diagnostic agent (ophthalmic preparations), Belladonna alkaloid

Pregnancy Category C

Dosage & Route

Systemic administration
0.4–0.6 mg PO, IM, IV, or subcutaneously.
  • Hypotonic radiography: 1 mg IM.
  • Surgery: 0.5 mg (0.4–0.6 mg) IM (or subcutaneously or IV) prior to induction of anesthesia; during surgery, give IV; reduce dose to < 0.4 mg with cyclopropane anesthesia.
  • Bradyarrhythmias: 0.4–1 mg (up to 2 mg) IV every 1–2 hr as needed.
  • Antidote: For poisoning due to cholinesterase inhibitor insecticides, give large doses of at least 2–3 mg parenterally, and repeat until signs of atropine intoxication appear; for rapid type of mushroom poisoning, give in doses sufficient to control parasympathetic signs before coma and CV collapse intervene. Auto-injector provides rapid administration.
Ophthalmic solution

  • For refraction: Instill 1–2 drops into eye 1 hr before refracting.
  • For uveitis: Instill 1–2 drops into eye qid.

Systemic administration

    Refer to the following table:

 Weight Dose (mg)
 7–16 lb (3.2–7.3 kg) 0.1
 16–24 lb (7.3–10.9 kg) 0.15
 24–40 lb (10.9–18.1 kg) 0.2
 40–65 lb (18.1–29.5 kg) 0.3
 65–90 lb (29.5–40.8 kg) 0.4
 > 90 lb (> 40.8 kg) 0.4–0.6
  • Surgery: 0.1 mg (newborn) to 0.6 mg (12 yr) injected subcutaneously 30 min before surgery.
  • Antidote:
    • > 90 lb: 2 mg auto-injector.
    • 40–90 lb: 1-mg auto-injector.
    • 15–40 lb: 0.5 mg auto-injector.
    • < 15 lb: 0.25 mg auto-injector.

  • More likely to cause serious adverse reactions, especially CNS reactions, in elderly patients; use with
Therapeutic actions
  • Competitively blocks the effects of acetylcholine at muscarinic cholinergic receptors that mediate the effects of parasympathetic postganglionic impulses, depressing salivary and bronchial secretions, dilating the bronchi, inhibiting vagal influences on the heart, relaxing the GI and GU tracts, inhibiting gastric acid secretion (high doses), relaxing the pupil of the eye (mydriatic effect), and preventing accommodation for near vision (cycloplegic effect); also blocks the effects of acetylcholine in the CNS.
Systemic administration
  • Antisialagogue for preanesthetic medication to prevent or reduce respiratory tract secretions
  • Treatment of parkinsonism; relieves tremor and rigidity
  • Restoration of cardiac rate and arterial pressure during anesthesia when vagal stimulation produced by intra-abdominal traction causes a decrease in pulse rate, lessening the degree of AV block when increased vagal tone is a factor (eg, some cases due to digitalis)
  • Relief of bradycardia and syncope due to hyperactive carotid sinus reflex
  • Relief of pylorospasm, hypertonicity of the small intestine, and hypermotility of the colon
  • Relaxation of the spasm of biliary and ureteral colic and bronchospasm
  • Relaxation of the tone of the detrusor muscle of the urinary bladder in the treatment of urinary tract disorders
  • Control of crying and laughing episodes in patients with brain lesions
  • Treatment of closed head injuries that cause acetylcholine release into CSF, EEG abnormalities, stupor, neurologic signs
  • Relaxation of uterine hypertonicity
  • Management of peptic ulcer
  • Control of rhinorrhea of acute rhinitis or hay fever
  • Antidote (with external cardiac massage) for CV collapse from overdose of parasympathomimetic (cholinergic) drugs (choline esters, pilocarpine), or cholinesterase inhibitors (eg, physostigmine, isoflurophate, organophosphorus insecticides)
  • Antidote for poisoning by certain species of mushroom (eg, Amanita muscaria)
Ophthalmic preparations
  • Diagnostically to produce mydriasis and cycloplegia-pupillary dilation in acute inflammatory conditions of the iris and uveal tract
Adverse effects
Systemic administration
  • CNS: Blurred vision, mydriasis, cycloplegia, photophobia, increased IOP, headache, flushing, nervousness, weakness, dizziness, insomnia, mental confusion or excitement (after even small doses in the elderly), nasal congestion
  • CV: Palpitations, bradycardia (low doses), tachycardia (higher doses)
  • GI: Dry mouth, altered taste perception, nausea, vomiting, dysphagia, heartburn, constipation, bloated feeling, paralytic ileus, gastroesophageal reflux
  • GU: Urinary hesitancy and retention; impotence
  • Other: Decreased sweating and predisposition to heat prostration, suppression of lactation
Ophthalmic preparations
  • Local: Transient stinging
  • Systemic: Systemic adverse effects, depending on amount absorbed
  • Contraindicated with hypersensitivity to anticholinergic drugs.
Systemic administration
  • Contraindicated with glaucoma; adhesions between iris and lens; stenosing peptic ulcer; pyloroduodenal obstruction; paralytic ileus; intestinal atony; severe ulcerative colitis; toxic megacolon; symptomatic prostatic hypertrophy; bladder neck obstruction; bronchial asthma; COPD; cardiac arrhythmias; tachycardia; myocardial ischemia; impaired metabolic, hepatic, or renal function; myasthenia gravis.
  • Use cautiously with Down syndrome, brain damage, spasticity, hypertension, hyperthyroidism, lactation.
Ophthalmic solution
  • Contraindicated with glaucoma or tendency to glaucoma.
Nursing considerations
  • History: Hypersensitivity to anticholinergics; glaucoma; adhesions between iris and lens; stenosing peptic ulcer; pyloroduodenal obstruction; paralytic ileus; intestinal atony; severe ulcerative colitis; toxic megacolon; symptomatic prostatic hypertrophy; bladder neck obstruction; bronchial asthma; COPD; cardiac arrhythmias; myocardial ischemia; impaired metabolic, liver, or renal function; myasthenia gravis; Down syndrome; brain damage; spasticity; hypertension; hyperthyroidism; lactation
  • Physical: Skin color, lesions, texture; T; orientation, reflexes, bilateral grip strength; affect; ophthalmic examination; P, BP; R, adventitious sounds; bowel sounds, normal GI output; normal urinary output, prostate palpation; LFTs, renal function tests, ECG
  • Ensure adequate hydration; provide environmental control (temperature) to prevent hyperpyrexia.
  • Have patient void before taking medication if urinary retention is a problem.
Teaching points
When used preoperatively or in other acute situations, incorporate teaching about the drug with teaching about the procedure; the ophthalmic solution is mainly used acutely and will not be self-administered by the patient; the following apply to oral medication for outpatients:
  • Take as prescribed, 30 minutes before meals; avoid excessive dosage.
  • Avoid hot environments; you will be heat intolerant, and dangerous reactions may occur.
  • You may experience these side effects: Dizziness, confusion (use caution driving or performing hazardous tasks); constipation (ensure adequate fluid intake, proper diet); dry mouth (sugarless lozenges, frequent mouth care may help; may be transient); blurred vision, sensitivity to light (reversible; avoid tasks that require acute vision; wear sunglasses in bright light); impotence (reversible); difficulty in urination (empty the bladder prior to taking drug).
  • Report rash; flushing; eye pain; difficulty breathing; tremors, loss of coordination; irregular heartbeat, palpitations; headache; abdominal distention; hallucinations; severe or persistent dry mouth; difficulty swallowing; difficulty in urination; constipation; sensitivity to light.