LPN IV Push Medications

1
LPN IV Push Medications

• Part 2
• April 2010

2
Additional IV Push Medications

• Ativan
• Decadron
• Digoxin
• Phenergan

• Robinul
• Solumedrol
• Valium

3
Ativan (Lorazepam)

• Class Benzodiazepine, Anxiolytic
• Action Thought to depress CNS at limbic system
  and disrupt neurotransmission in reticular
  activating system
• Availability Injection- 2 mg/ml, 4 mg/ml
  Tablets- 0.5 mg, 1 mg, 2 mg

4
Ativan, cont.

• Indications dosage
• Anxiety- 2-3 mg PO daily in two or three
  divided doses. Maximum dosage is 10 mg daily.
• Insomnia- 2-4 mg PO at bedtime
• Pre-Op- 0.05 mg/kg not to exceed 4 mg deep IM 2
  hours prior to surgery OR 0.044 mg/kg not to
  exceed 2 mg IV 15-20 min. prior to surgery
• Status epilepticus- 4 mg IV given slowly- no
  faster than 2 mg per min., Can repeat if seizures
  recur after 10-15 min. Dont exceed 8 mg in 12
  hours.

5
Ativan, cont.

• Dosage adjustment required in elderly or
  debilitated patients
• Off label uses acute alcohol withdrawal syndrome
• Contraindications hypersensitivity to drug,
  other benzodiazepines, polyethylene or propylene
  glycol, or benzyl alcohol, acute angle glaucoma,
  coma, CNS depression, hepatic or renal failure

6
Ativan, cont.

• Precautions Use cautiously in renal or hepatic
  impairment, history of suicide attempt, drug
  abuse, depressive disorder, or psychosis, elderly
  patients, pregnant or breastfeeding patients
• Administration Dilute IV doses with equal volume
  of diluent such as NS or D5W. Give each 2 mg
  dose IV slow push over 2-5 minutes. Dont exceed
  rate of 2 mg/min.

7
Ativan, cont.

• Adverse Reactions amnesia, agitation, ataxia,
  depression, disorientation, dizziness,
  drowsiness, headache, incoordination, asthenia,
  hypotension with too rapid administration IV,
  bradycardia, tachycardia, apnea, cardiac arrest,
  blurred vision, diplopia, nystagmus, nausea,
  abdominal discomfort

8
Ativan, cont.

• Interactions
• Drug to drug additive effects with other
  benzodiazepines
• Contraceptives increased ativan clearance
• Drug to Herbs increased CNS depression with
  chamomile, hops, kava, skullcap, valerian
• Drug-behaviors increased CNS depression with
  alcohol, increased metabolism and decreased
  efficacy of ativan with smoking

9
Ativan, cont.

• Patient monitoring
• During IV administration, monitor
  EKG/cardiovascular and respiratory status
• Monitor V.S. closely
• Evaluate for amnesia
• Watch closely for CNS depression, signs
  symptoms of overdose
• Monitor LFTs CBC

10
Decadron (Dexamethasone)

• Class Glucocorticoid, anti-inflammatory
• Action reduces inflammation by suppressing
  polymorphonuclear leukocyte migration, reversing
  increased capillary permeability, and stabilizing
  leukocyte lysosomal membranes. Also suppresses
  immune response (by lymphatic activity),
  stimulate bone marrow, and promotes protein, fat,
  and carbohydrate metabolism

11
Decadron, cont.

• Availability
• Elixir 0.5mg/5 ml
• Oral solution 0.5 mg/5 ml, 1 mg/ml
• IV 4 mg/ml, 10 mg/ml, 20 mg/ml, 24 mg/ml
• Tablets 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg,
  2 mg, 4 mg, 6 mg

12
Decadron, cont.

• Indications Dosages
• Allergic and inflammatory conditions-
• 0.75- 9 mg/day PO as a single dose or in divided
  doses, in severe cases much higher doses may be
  required
• Cerebral edema-
• initially 10 mg IV followed by 4 mg IM every 6
  hours, then reduce dosage gradually over 5-7 days
• Cushings syndrome-
• 1 mg PO at 11 pm or 0.5 mg PO every 6 hours for
  48 hours (with urine collection testing as
  ordered)

13
Decadron, cont.

• Off-label uses
• -acute altitude sickness
• -bacterial meningitis
• -bronchopulmonary dysplasia in
• preterm infants
• -hirsutism
• -suppression test for detection, diagnosis,
• or management of depression

14
Decadron, cont.

• Contraindications
• Hypersensitivity to drug, benzyl alcohol,
  bisulfites, EDTA, creatinine, polysorbate 80, or
  methylparaben
• Systemic fungal infections

15
Decadron, cont.

• Precautions
• Use cautiously in
• renal insufficiency, cirrhosis, diabetes,
  diverticulitis, GI disease, cardiovascular
  disease, hypoprothrombinemia, hypothyroidism,
  myasthenia gravis, glaucoma, osteoporosis,
  infections, underlying immunosuppression,
  psychotic tendencies, pregnant or breastfeeding
  patients, children

16
Decadron, cont.

• Administration
• Give PO dose with food or milk
• When giving IM, inject deep into gluteal muscle,
  rotate sites as needed
• For IV use may give undiluted as single dose
  over 1 minute

17
Decadron, cont.

• Adverse reactions
• headache, malaise, vertigo, psychiatric
  disturbances, increased ICP, seizures,
  hypotension, thrombophlebitis, myocardial rupture
  after recent MI, thromboembolism, cataracts,
  nausea, vomiting, abdominal distetion, dry mouth,
  anorexia, peptic ulcer, bowel perforation,
  pancreatitis, ulcerative esophagitis,
  hyperglycemia, cushingoid appearance, fluid
  retention, adrenal suppression, hypokalemic
  alkalosis, muscle wasting, muscle pain,
  osteoporosis, tendon rupture, long bone
  fractures, diaphoresis, angioedema, erythema,
  rash, pruritis, acne, decreased wound healing,
  bruising, fragile skin, weight gain or loss,
  increased susceptability to infections

18
Decadron, cont.

• Interactions
• Drug to drug barbiturates, phenytoin, rifampin-
  decreased
• decadron effects
• Digoxin- increases risk of dig toxicity
• Ephedrine- increased decadron clearance
• Contraceptives- block decadron absorption
• Fluoroquinolones- increased risk of tendon
  rupture
• Ketoconazole, itraconazole- increased decadron
  level
• and effects
• Live-virus vaccines- decreased antibody
  response to
• vaccine
• Loop thiazide diuretics- additive hypokalemia
• NSAIDs- increased risk of GI effects
• Somatrem, somatropin- decreased response to
  these
• drugs

19
Decadron, cont.

• Drug-Diagnostic tests- calcium potassium-
  levels decreased, cholesterol glucose- levels
  increased
• Drug-Herbs- echinacea- increased
  immune-stimulating effect, ginseng potentiation
  of immune-modulating response
• Drug-behaviors alcohol use- increased gastric
  irritation GI ulcers

20
Digoxin (lanoxin)

• Class cardiac glycoside, inotrope,
  antiarrhythmic
• Action increases force and velocity of
  myocardial contraction and prolongs refractory
  period of AV node by increasing calcium entry
  into myocardial cells. Slows conduction through
  SA and AV nodes and produces antiarrhythmic
  effects

21
Digoxin, cont.

• Availability
• Capsules 0.05 mg, 0.1 mg, 0.2 mg
• Tablets 0.125 mg. 0.25 mg, 0.5 mg
• Elixir (pediatric) 0.05 mg/ml
• IV 0.05 mg/ml, 0.1 mg/ml, 0.25 mg/ml

22
Digoxin, cont.

• Indications and dosage
• Heart failure, tachyarrhythmias, atrial
  fib/flutter, PSAT
• LPNs will only be giving this drug for
  maintenance dosing. LPNs will NOT be pushing
  this drug for initial digitializing of the
  patient.

23
Digoxin, cont.

• Dosage adjustment renal impairment,
  hyperthyroidism, elderly patients
• Off-label uses SVT, intrauterine tachycardias
• Contraindications hypersensitivity to drug,
  uncontrolled ventricular tachycardias, AV block,
  idiopathic hypertrophic subaortic stenosis,
  constrictive pericarditis
• Precautions renal or hepatic impairment,
  electrolyte imbalances, myocardial infarction,
  thyroid disorders, obesity, elderly patients,
  pregnant or breastfeeding patients

24
Digoxin, cont.

• Administration
• Measure apical pulse for one full minute before
  administering. If rate is below 60 bpm, withhold
  dose and notify provider.
• Drug has narrow therapeutic index, monitor
  patient carefully for toxicity

25
Digoxin, cont.

• Adverse reactions fatigue, headache, asthenia,
  bradycardia, EKG changes, arrhythmias, blurred or
  yellow vision, nausea, vomiting, diarrhea,
  gynecomastia, thrombocytopenia, decreased
  appetite.

26
Digoxin, cont.

• Interactions
• Drug-drug many drugs result in changes in
  digoxin blood level possibly leading to toxicity,
  check nursing drug resources for a complete list
  partial list includes amiodarone, cyclosporine,
  diclofenac, diltiazem, propafenone, quinidine,
  quinine, verapamil, amphotericin B,
  corticosteroids, mezlocillin, pipercillin,
  thiazide and loop diuretics, ticarfillin,
  antacids, cholestyramine, colestipol,
  kaolin/pectin, beta blockers, laxatives,
  spironalactone, thyroid hormones
• Drug-herb cocoa seed, coffee seed, cola seed,
  guarana seed, horsetail, licorice, aloe, yerba
  mate, may lead to toxicity

27
Digoxin, cont.

• Therapeutic range for digoxin blood levels is 0.5
  to 2.0 ng/ml

28
Phenergan

• Promethazine
• Nonselective phenothiazine
• Antihistamine, antiemetic, sediative-hypnotic
• Black box warning dont use suppositories in
  patients under the age of 2 due to potential for
  fatal respiratory depression

29
Phenergan, cont.

• Action- blocks effects but not release of
  histamine and exerts strong alpha-adrenergic
  effects. Inhibits chemoreceptor triggers in the
  medulla and alters the dopamine effects by
  indirectly reducing stimulation in CNS
• Availability
• Injection 25 mg/ml, 50 mg/ml
• Suppositories 12.5 mg, 25 mg, 50 mg
• Syrup 6.25/5ml
• Tablets 12.5 mg, 25 mg, 50 mg

30
Phenergan, cont.

• Indications Type 1 hypersensitivity reaction,
  nausea, motion sickness, sedation
• Dosages Adults- 25-50 mg PO, PR, IM or IV q4-6
  hours prn
• At City, IV doses are limited to 12.5 mg IV push
  diluted in 10 ml NS administered through the port
  farthest from the patient over several minutes.
  Phenergan should not be administered through a
  saline lock. IV fluids must be infusing.

31
Phenergan, cont.

• Contraindications hypersensitivity, previous
  idiosyncratic reaction to phenothiazines, asthma,
  COPD, obstructive sleep apnea, coma
• Precautions cardiovascular or hepatic disease,
  seizures, bone marrow depression, narrow angle
  glaucoma, prostatic hypertrophy, stenosing peptic
  ulcer, pyloroduodenal or bladder neck
  obstruction, CNS depression, pregnant or
  breastfeeding patients, children under age 2

32
Phenergan, cont.

• Administration Administer no faster than 25
  mg/min or in concentrations greater than 25
  mg/ml, inject deep IM into large muscle, dont
  give subcutaneously
• Adverse reactions confusion, disorientation,
  fatigue, drowsiness, sedation, dizziness,
  extrapyramidal reactions, insomnia, nervousness,
  neuroleptic malignant syndrome, hypertension,
  hypotension, brady tachycardia, blurred vision,
  tinnitus, constipation, dry mouth, blood
  dyscrasias, respiratory depression, rash

33
Phenergan, cont.

• Interactions
• Drug-drug additive anticholinergic effects with
  anticholinergics CNS depressants additive CNS
  depression Epinephrine reversal of epis
  vasopressor effects MAO inhibitors increased
  extrapyramidal effects
• Drug-diagnostic tests increased glucose levels,
  false positive or negative pregnancy tests, false
  negative skin allergan tests
• Drug-herbsevening primrose- increased risk
  seizures, kava- increased risk adverse drug
  reactions
• Drug-behavior additive CNS depression with
  alcohol, increased risk photosensitivity with sun
  exposure

34
Robinul (glycopyrrolate)

• Class anticholinergic, antispasmodic,
  antimuscarinic, parasympatholytic
• Action inhibits action of acetylcholine on
  muscarinic receptors that mediate effects of
  parasympathetic postganglionic impulses. This
  inhibition relaxes cardiac smooth muscle,
  inhibits vagal reflexes, and decreases tracheal
  and bronchial secretions

35
Robinul, cont.

• Availability
• IV 0.2 mg/ml
• Tablets 1 mg, 2 mg

36
Robinul, cont.

• Indications and dosage adjunct in peptic ulcer
  disorders, to diminish secretions and block
  cardiac vagal reflexes before or during surgery,
  to diminish or block cholinergic effects caused
  by anticholinesterase
• 1 mg PO tid to max 8 mg/day OR 0.1-0.2 mg IM or
  IV tid to qid

37
Robinul, cont.

• Off label uses sweating
• Contraindications hypersensitivity to drug,
  arrhythmias, COPD, GI disease, infection, atony,
  or ileus, myasthenia gravis, glaucoma,
  obstructive uropathy, severe prostatic
  hypertrophy
• Precautions cardiovascular disease, heart
  failure, hypertension, renal or hepatic disease,
  Down syndrome, hyperthyroidism, hiatal hernia,
  ulcerative colitis, mild to moderate BPH,
  autonomic heuropathy, spasticity, suspected brain
  damage, pregnant or breastfeeding patients

38
Robinul, cont.

• Administration give oral dose 30-60 minutes
  before meals
• IV administration either undiluted or diluted
  with D5W or saline, give each 0.2 mg over 1-2
  min.
• Keep resuscitation equipment on hand to treat
  curare-like effects of overdose

39
Robinul, cont.

• Adverse reactions weakness, nervousness,
  insomnia, drowsiness, dizziness, headache,
  confusion, excitement, palpitations, tachycardia,
  blurred vision, photophobia, mydriasis, increased
  intraocular pressure, cycloplegia, nausea,
  vomiting, constipation, abdominal distention,
  epigastric distress, heartburn, gastroesophageal
  reflux, dry mouth, paralytic ileus, urinary
  hesitancy or retention, lactation suppression,
  erectile dysfunction, urticaria, decreased
  sweating or anhidrosis, loss of taste, fever,
  allergic reaction, irritation at IM injection
  site, anaphylaxis, malignant hyperthermia

40
Robinul, cont.

• Interactions increased anticholinergic effects
  with amantidine, antihistamines,
  antiparkinsonians, disopyramide, glutethimide,
  meperidine, phenothiazines, procainamide,
  quinidine, tircyclic antidepressants

41
Solumedrol (methylprednisolone sodium succinate)

• Class glucocorticoid, antiasthmatic,
  anti-inflammatory (steroidal), immunosuppressant
• Action reduces inflammation and prevents edema
  by stabilizing membranes and reducing
  permeability of leukocytic cells. Suppresses
  immune system by interfering with
  antigen-antibody interactions of macrophages and
  T cells

42
Solumedrol, cont.

• Availability
• Solution for IV/IM 40 mg, 125 mg, 500 mg, 1 g,
  2 g
• Suspension for injection 20 mg/ml, 40 mg/ml, 80
  mg/ml
• Tablets 2 mg, 4 mg, 8 mg, 16 mg, 24 mg, 32 mg

43
Solumedrol, cont.

• Indications
• diseases and disorders of endocrine system,
  collagen, skin, eye, GI, respiratory, or
  hematologic system, neoplastic diseases,
  allergies, multiple sclerosis, tuberculous
  meningitis, trichinosis, rheumatic disorders,
  osteoarthritis, bursitis, localized inflammatory
  lesions

44
Solumedrol, cont.

• Dosages
• 4-160 mg PO daily in four divided doses
  depending on disease or disorder
• High dose therapy 30 mg/kg IV over at least 30
  min., may be repeated in 4-6 ours for 48 hours.

45
Solumedrol, cont.

• Off label uses lupus nephritis, pneumocystis
  jiroveci pneumonia in AIDS patients
• Contraindications hypersensitivity to drug or
  its component, systemic fungal infections

46
Solumedrol, cont.

• Precautions cardiovascular, hepatic, renal, or
  GI disease. Active untreated infections,
  thromboembolic tendency, idiopathic
  thrombocytopenia purpura, osteoporosis,
  myasthenia gravis, hypothyroidism, glaucoma,
  ocular herpes simplex, vaccinia or varicella,
  seizure disorders, metastatic cancer, pregnant or
  breastfeeding patients, children

47
Solumedrol, cont.

• Give prophylactic antacids in patients receiving
  high doses to prevent peptic ulcers
• Methylprednisilone acetate is not for IV use- IM,
  intra-articular, intralesional or soft tissue
  injection
• Methylprednisilone sodium succinate is for IV or
  IM use
• For IV use, inject 500 mg dose over 2 to 3 min
  or more

48
Solumedrol, cont.

• Adverse reactions headache, restlessness,
  nervousness, depression, euphoria, personality
  changes, psychoses, vertigo, paresthesias,
  insomnia, adhesive arachnoiditis, conus
  medullarus syndrome, increased intracranial
  pressure, seizures, meningitis, hypotension,
  hypertension, arrhythmias, heart failure, shock,
  fat embolism, thrombophlebitis, thromboembolism,
  cataracts, glaucoma, increased intraoccular
  pressure, nasal irritation, nasal septum
  perforation, sneezing, epistaxis, nasopharyngeal
  or oropharyngeal fungal infection, dysphonia,
  hoarseness, throat irritation, nausea, vomiting,
  abdominal distention, rectal bleeding, dry mouth,
  anorexia, esophageal candidiasis, esophageal
  ulcer, peptic ulcer, pancreatitis, amenorrhea,
  irregular menses, cough, wheezing, bronchospasm,
  decreased growth, hyperglycemia, fluid retention,
  cushingoid state, hypothalamic-pituitary-adrenal
  suppresion, adrenal suppression, acute adrenal
  insufficiency, muscle wasting, tendon rupture,
  weakness, rash, pruritis, decreased wound
  healing, fragile skin, skin atrophy, bad taste,
  weight gain, etc.

49
Solumedrol, cont.

• Interactions
• Drug to drug amphotericin B, mezlocillin,
  piperacillin, thiazide and loop diuretics,
  ticarcillin- additive hypokalemai,
  fluoroquinolones- increased risk of tendon
  rupture, isoniazid, phenobarbital, phenytoin,
  rifampin- decreased

50
Valium

• Diazepam
• Action produces anxiolytic effect and CNS
  depression by stimulating gamma-amniobutyric acid
  receptors, relaxes skeletal muscles of the spine
  by inhibiting afferent pathways, controls
  seizures by enhancing presynaptic inhibition
• Availability
• Injection 5 mg/ml
• Oral solution 1 mg/ml, 5 mg/5 ml
• Rectal gel 2.5 mg, 10 mg, 15 mg, 20 mg
• Tablets 2 mg, 5 mg, 10 mg

51
Valium, cont.

• Indications anxiety disorders, before
  interventional procedures, status epilepticus and
  severe recurrent seizures, muscle spasm, acute
  alcohol withdrawal
• Off label uses panic attacks, adjunct to general
  anesthesia
• Contraindications hypersensitivity, other
  benzodiazepines, alcohol, or tartrazine, coma or
  CNS depression, narrow angle glaucoma

52
Valium, cont.

• Dosages Adults 2-10 mg PO two to four times a
  day, 2-10 mg IV q3-4 hours, 5-15 mg IV
  pre-cardioversion or endoscopy
• Precautions hepatic dysfunction, severe renal
  impairment, elderly patients, pregnant or
  breastfeeding patients, children
• For IV administration administer slowly into
  large vein, rate of 1 minute per 5 mg in adults
  or at least 3 minutes for each 0.25 mg/kg in
  children
• IV route preferred over IM route
• Dont mix wit other meds or solutions in syringe
• Enforce bed rest for 3 hours post-administration
• Give deep IM and slowly into large muscle mass

53
Valium, cont.

• Adverse reactions dizziness, drowsiness,
  lethargy, depression, light-headedness,
  disorientation, anger, manic or hypomanic
  episodes, restlessness, paresthesia, headache,
  slurred speech, dysarthria, stupor, tremor,
  dystonia, vivid dreams, extrapyrimidal reactions,
  mild paradoxical excitation, brady or
  tachycardia, hyper or hypotension, palpitations,
  cardiovascular collapse, blurred vision,
  diplopia, nystagmus, nasal congestion, nausea,
  vomiting, diarrhea, constipation, gastric
  disorders, difficulty swallowing, increased
  salivation, urinary retention or incontinence,
  menstrual irregularities, gynecomastia, libido
  changes, blood dyscrasias, hepatic dysfunction,
  muscle rigidity, dermatitis, rash, pruritus,
  diaphoresis, weight gain or loss, decreased
  appetite, edema, hiccups, fever, dependence

54
Valium, cont.

• Interactions
• Drug-drug additive effects with
  antidepressants, antihistamines, barbiturates,
  opioids decreased levels with numerous drugs-
  check ddrug references, increased dig levels,
  decreased levodopa levels
• Drug-diagnostic tests increased levels of liver
  enzymes, decreased platelet counts
• Drug-behavior increased CNS depression with
  alcohol

55
Valium, cont.

• Patient monitoring vital signs and neuro status,
  supervise ambulation especially in elderly,
  monitor cbc, renal, and liver enzymes
• Avoid sudden drug withdrawal, taper gradually to
  termination of therapy

56
Questions

• How fast are each of the following meds pushed?
• 1. solumedrol
• 2. decadron
• 3. robinal
• 4. digoxin
• 5. valium
• 6. phenergan

57
Answer

• SLOW IV PUSH

58
Questions

• Which medication may only be push for maintenance
  purposes only? Meaning if this is the initial
  administration of this drug to establish a
  therapeutic value, the LPN may not push it.

59
Answer

• Digoxin

60
Questions

• Which drug must be diluted in 10 ml normal
  saline, pushed through the port farthest from the
  patient over several minutes?

61
Answer

• Phenergan

62
Questions

• Which drug has an off label use for panic attacks
  but is commonly used pre-procedurally for
  endoscopy and cardioversion?

63
Answer

• Valium

64
Questions

• Which two things must be verified before bar
  coding the patient in preparation for drug
  administration every time?

65
Answer

• Patients correct name and date of birth, no
  nicknames

66
Questions

• What are the five rights to drug administration
  that the prudent nurse checks EVERY time a
  medication is administered?

67
Answer

• Right patient
• Right drug
• Right dose
• Right route
• Right time

68
Medication Checklist

• Please obtain a copy of the Medication 2
  Checklist from your Nurse Manager.
• You must complete IV administration of three
  different medications. One of those three
  medications must be phenergan and you must be
  directly observed administering phenergan on 3
  separate occasions.