Mosby's 2014 Nursing Drug Reference (285 page)

BOOK: Mosby's 2014 Nursing Drug Reference
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Canada only   Side effects:
italics
= common;
bold
= life-threatening   
Nurse Alert

natamycin ophthalmic

 

nebivolol (Rx)

(ne-biv′oh-lol)

Bystolic

Func. class.:
Antihypertensive

Chem. class.:
β
1
-blocker

ACTION:

Competitively blocks stimulation of β-adrenergic receptors within vascular smooth muscle; decreases rate of SA node discharge, increases recovery time, slows conduction of AV node, thereby resulting in decreased heart rate (negative chronotropic effect), which decreases O
2
consumption in myocardium due to β
1
-receptor antagonism; decreases renin-aldosterone-angiotensin system at high doses, inhibits β
2
-receptors in bronchial system at high doses

USES:

Hypertension alone or in combination

Unlabeled uses:
Heart failure

CONTRAINDICATIONS:

Cardiogenic shock, heart failure, severe hepatic disease, severe bradycardia, sick sinus syndrome, AV heart block; hypersensitivity to product, β-blockers

Precautions:
Pregnancy (C), breastfeeding, children, major surgery, peripheral vascular disease, diabetes mellitus, thyrotoxicosis disease, COPD, asthma, well-compensated heart failure, renal/hepatic disease, abrupt discontinuation, acute bronchospasm

DOSAGE AND ROUTES
Calculator
Hypertension

• Adult:
PO
5 mg/day, may be increased to desired response q2wk; max 40 mg/day

• Geriatric:
PO
max 40 mg/day

Renal/hepatic dose

• Adult:
PO
CCr <30 ml/min, 2.5 mg/day; may increase cautiously; (Child-Pugh class B) 2.5 mg daily, use dose escalation cautiously

Heart failure (unlabeled)

• Adult:
PO
1.25 mg titrated to max 10 mg/day

Available forms:
Tabs 2.5, 5, 10, 20 mg

Administer:
PO route

• 
Without regard to meals; tab may be crushed or swallowed whole; give with food to prevent GI upset

SIDE EFFECTS

CNS:
Insomnia, fatigue, dizziness, mental changes
, drowsiness, headache

CV:
Bradycardia, MI,
AV heart block, edema

GI:
Nausea, diarrhea
, vomiting, abdominal pain

GU:
Impotence

HEMA:
Thrombocytopenia

INTEG:
Rash, pruritus, vasculitis, urticaria, psoriasis,
angioedema

MISC:
Renal failure, pulmonary edema,
hyperuricemia, hypercholesterolemia

RESP:
Bronchospasm,
dyspnea

PHARMACOKINETICS

Peak 1.5-4 hr; half-life 12 hr; metabolized in liver by CYP2D6; 38% excreted in urine, 44% in feces

INTERACTIONS

 
Do not give with other β-blockers, mefloquine

Increase:
nebivolol action—CYP2D6 inhibitors (amiodarone, buPROPion, chloroquine, chlorpheniramine, chlorproMAZINE, cinacalcet, diphenhydrAMINE, DULoxetine, FLUoxetine, haloperidol, imatinib, PARoxetine, promethazine,
propoxyphene, quiNIDine, quiNINE, ritonavir, terbinafine, thioridazine), cimetidine, calcium channel blockers (nondihydropyridine)

Decrease:
nebivolol action—CYP2D6 inducers (rifampin), sildenafil

Drug/Herb

• 
May increase nebivolol effect—hawthorn

• 
May decrease nebivolol effect—ephedra

Drug/Lab Test

Increase:
serum lipoprotein levels, BUN, potassium, triglycerides, uric acid, LDH, AST, ALT, alk phos

Decrease:
platelets

NURSING CONSIDERATIONS
Assess:

• 
Hypertension:
B/P during beginning treatment, periodically thereafter; apical/radial pulse before administration; notify prescriber of any significant changes (pulse <50 bpm);
signs of CHF
(dyspnea, crackles, weight gain, jugular venous distention)

• 
Baselines of renal, hepatic function tests before therapy begins and periodically,
do not use in Child-Pugh class >B

• 
Edema in feet, legs daily: monitor I&O

Perform/provide:

• 
Storage protected from light, moisture; place in cool environment

Evaluate:

• 
Therapeutic response: decreased B/P after 1-2 wk; decreased dysrhythmias

Teach patient/family:

 
Not to discontinue product abruptly because severe cardiac reactions may occur, to taper over 2 wk; not to double dose; if dose is missed, to take as soon as remembered up to 4 hr before next dose

• 
That product may mask signs of hypoglycemia or alter blood glucose levels

• 
Not to use OTC products containing α-adrenergic stimulants (nasal decongestants, OTC cold preparations) unless directed by prescriber

• 
To report low pulse, dizziness, confusion, depression, fever

• 
To take pulse, B/P at home; advise patient when to notify prescriber

• 
To comply with weight control, dietary adjustments, modified exercise program

• 
To carry emergency ID to identify product, allergies

• 
To avoid hazardous activities if dizziness, drowsiness present

• 
To report symptoms of CHF:
difficulty breathing, especially on exertion or when lying down, night cough, swelling of extremities

• 
To continue with required lifestyle changes (exercise, diet, weight loss, stress reduction)

TREATMENT OF OVERDOSE:

Lavage, IV atropine for bradycardia, IV theophylline for bronchospasm, digoxin, O
2
, diuretic for cardiac failure, IV glucose for hypoglycemia, IV diazepam (or phenytoin) for seizures, IV fluids, IV pressors

Canada only   Side effects:
italics
= common;
bold
= life-threatening   
Nurse Alert

nelfinavir (Rx)

(nell-fin′a-ver)

Viracept

Func. class.:
Antiretroviral

Chem. class.:
Protease inhibitor

ACTION:

Inhibits human immunodeficiency virus (HIV-1) protease, which prevents maturation of the infectious virus

Uses:
HIV-1 in combination with other antiretrovirals

CONTRAINDICATIONS:

Hypersensitivity to protease inhibitors

Precautions:
Pregnancy (B), breastfeeding, renal/hepatic disease, hemophilia, PKU, pancreatitis, diabetes, infection, immune reconstitution syndrome

DOSAGE AND ROUTES
Calculator
HIV infection

• Adult and child >13 yr:
PO
750 mg tid or 1250 mg bid

• Child 2-13 yr:
PO
25-35 mg/kg tid, max 2500 mg/day

Prevention of HIV infection after exposure (unlabeled)

• Adult:
PO
1250 mg bid with 2 other antiretroviral agents × 4 wk

Available forms:
Tabs 250, 625 mg; powder, oral 50 mg/g/scoop

Administer:
PO route

• 
Do not mix with juice or acidic fluids

• 
Oral powder:
mixed with fluids if desired; stable mixed for 6 hr, may use in child unable to take tabs, do not mix with water in original bottle

• 
Tabs
may be crushed and dispersed in water or mixed with food; consume immediately

SIDE EFFECTS

CNS:
Headache, asthenia, poor concentration,
seizures, suicidal ideation

CV:
Bleeding

ENDO:
Hyperglycemia, hyperlipidemia

GI:
Diarrhea
, anorexia, dyspepsia,
nausea, flatulence
,
hepatitis, pancreatitis

HEMA:
Anemia, leukopenia, thrombocytopenia,
Hgb abnormalities

INTEG:
Rash
, dermatitis,
anaphylaxis

MS:
Pain, arthralgia, myalgia, myopathy

OTHER:
Hypoglycemia,
redistribution/accumulation of body fat,
immune reconstitution syndrome

PHARMACOKINETICS

Half-life 3½-5 hr, excreted in feces (87%), peak 2-4 hr, 98% protein binding; metabolized by CYP3A4 enzyme system; potent inhibitor of CYP3A4

INTERACTIONS
Drug/Herb

 
Increase:
serious dysrhythmias: amiodarone, ergots, lovastatin, midazolam, pimozide, quiNIDine, simvastatin, triazolam, salmeterol

Increase:
effect of—atorvastatin, azithromycin, rifabutin, indinavir, saquinavir, cycloSPORINE, tacrolimus, sirolimus, sildenafil, alfentanil, alosetron, buprenorphine, busPIRone, bortezomib, calcium channel blockers, cilostazol, disopyramide, dofetilide, DOCEtaxel, donepezil, ethosuximide, fentaNYL, galantamine, gefitinib, levomethadyl, systemic lidocaine, PACLitaxel, sibutramine, SUFentanil, vinca alkaloids, ziprasidone, zonisamide, traZODone, tricyclic antidepressants, sildenafil

Increase:
nelfinavir levels—ketoconazole, indinavir, ritonavir; delavirdine, other HIV protease inhibitors

Decrease:
nelfinavir levels—rifamycins, nevirapine, PHENobarbital, phenytoin, carBAMazepine

Decrease:
effect of—didanosine, methadone, oral contraceptives, phenytoin

Drug/Herb

 
Decrease:
antiretroviral effect—St. John’s wort; do not use concurrently

Drug/Food

Increase:
absorption with food

Drug/Lab Test

Increase:
AST, ALT, alk phos, total bilirubin, CPK, LDH, lipids, uric acid

Decrease:
WBC, platelets

NURSING CONSIDERATIONS
Assess:

• 
Resistance testing at initiation, with failure of treatment

• 
Signs of infection, anemia

• 
Hepatic studies: ALT, AST

• 
Bowel pattern before, during treatment; if severe abdominal pain with bleeding occurs, product should be discontinued; monitor hydration

 
Immune reconstitution syndrome:
occurs with combination therapy, including MAC, CMV, PCP TB requiring treatment

 
Anaphylaxis, hypersensitivity reaction:
wheezing, flushing; swelling of lips, tongue, throat, skin eruptions, rash, urticaria, itching

• 
HIV:
serum lipid profile, plasma HIV RNA, blood glucose, viral load, CD4 cell counts at baseline and throughout treatment

Teach patient/family:

• 
To avoid taking with other medications unless directed by prescriber

• 
Diarrhea
is most common side effect, may use loperamide to control

• 
That product does not cure but does manage symptoms; that product does not prevent transmission of HIV to others

• 
To use a nonhormonal form of birth control while taking this product if using contraceptives

• 
If dose is missed, to take as soon as remembered up to 1 hr before next dose; not to double dose

• 
To take with food

• 
To report symptoms of hyperglycemia, bleeding, abdominal pain; yellowing of skin, eyes

• 
Phenylketonuria:
powder contains phenylalanine

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