S

Medication Review – Session Notes (Part 1)

Hydromorphone (Dilaudid)

  • Class / Trade name
    • Class C opioid agonist; analgesic for moderate–severe pain
    • Trade & generic: Dilaudid = Hydromorphone
  • Potency relationships
    • ≈ 7\times stronger than morphine
    • Fentanyl ≈ 10\times stronger than morphine (contextual comparison)
  • Key adverse effects
    • Respiratory depression, nausea, sedation, constipation
  • Nursing actions
    • If RR ≤ 10 breaths min⁻¹ → stop infusion, assess, apply O₂, call provider before giving naloxone
    • Keep O₂ and naloxone available
  • Ethical / practical points
    • Autonomously stopping the infusion is correct; giving an antidote requires provider order on NCLEX, even if practice varies in real life

Insulin Detemir (Levemir)

  • Long-acting basal insulin; replaces missing pancreatic hormone in Type 1 & 2 DM
  • PK profile
    • Onset 1{-}2\text{ h}
    • Peak 6{-}8\text{ h}
    • Duration ≤ 24\text{ h}
  • Not used to cover meals (no post-prandial control)
  • Education → take at the same time daily; monitor for hypoglycemia

Tramadol

  • Synthetic opioid (Schedule IV); centrally acting, PO only
  • Uses – moderate–severe pain; low abuse potential
  • Major cautions
    • ↓ Seizure threshold → avoid in epilepsy, head trauma, alcohol withdrawal, heavy lavender oil ingestion (also lowers threshold)
    • Do not combine with alcohol or other CNS depressants
  • ADRs: sedation, dizziness, dry mouth, constipation

Methylergonovine (Methergine)

  • Ergot alkaloid; post-partum hemorrhage / uterine atony
  • Dose usually IM; causes sustained uterine contraction
  • ADRs – nausea, hypertension, headache
  • Risk factors for PPH (link‐in)
    • Macrosomia → overstretched uterus → atony
    • Lacerations, retained placenta (inspect: smooth vs tree side)
  • Contraindication: uncontrolled HTN

Methotrexate

  • DMARD & antineoplastic; folate antagonist
  • Indications – RA, psoriasis, Crohn’s, ectopic pregnancy, several cancers
  • Mechanism – immunosuppression → ↓ inflammation in autoimmune disease
  • ADRs – N/V/D, stomatitis, hepatotoxic ↑ LFTs, renal failure, pulmonary fibrosis, fatigue
  • Labs/monitor: CBC, LFTs, creatinine, CXR baseline

Gabapentin

  • Anticonvulsant; partial seizures & neuropathic pain (off-label)
  • Absorbed rapidly (onset 2{-}3\text{ h}) → effective q8h → tid dosing maximises analgesia
  • ADRs – somnolence, dizziness, fatigue

Nitroglycerin

  • Organic nitrate; SL, IV, transdermal
  • Absolute contraindication with tadalafil / sildenafil / vardenafil (PDE-5 inhibitors) → profound hypotension
  • ADRs – headache, flushing, reflex tachycardia
  • Safety – orthostatic precautions, sit/lie when taking tablet

Oxytocin (Pitocin)

  • Uterine stimulant: induce/augment labour, treat PPH
  • ADRs – uterine tachysystole (> 5 Cx/10 min, > 2 min each, or < 1 min apart), rupture, ↑ BP, fetal hypoxia/late decels
  • Management of tachysystole → stop oxytocin, give tocolytic (terbutaline, nifedipine), O₂, reposition, notify HCP
  • Magnesium sulfate used primarily for pre-eclampsia but is also a tocolytic

Meloxicam

  • 1st-generation NSAID; osteo- & rheumatoid arthritis
  • Long-term ADR – GI bleed/ulcer
  • Ulcer prophylaxis
    • Give with food/milk
    • Add PPI (omeprazole) or H₂ blocker (ranitidine)

Risperidone

  • Atypical antipsychotic; schizophrenia, bipolar mania, autism-related irritability
  • ADRs – weight gain, dyslipidemia, diabetes, orthostatic hypotension, sedation, EPS risk ↑ with long-acting injectable
  • Monitoring
    • Fasting lipids & glucose (cholesterol < 200\ \text{mg·dL}^{-1})
    • Weight, A1c; assess for EPS (AIMS scale)

Methylprednisolone (Solu-Medrol)

  • Glucocorticoid (IV/IM)
  • Chronic use → Cushing’s syndrome (buffalo hump, moon face, truncal obesity, weakness, hyperglycemia, hypernatremia, hypokalemia)
  • Immunosuppressive: ↑ infection risk; teach to report fever > 38\ ^\circ\text{C}

Budesonide + Formoterol (Symbicort)

  • Inhaled steroid + LABA; maintenance therapy asthma/COPD (NOT rescue)
  • ADRs – oral candidiasis, GI upset, infections
  • Education
    • Rinse mouth after use
    • Do not stop abruptly → adrenal insufficiency

Allopurinol

  • Xanthine oxidase inhibitor (uricostatic); chronic gout, tumor lysis hyperuricemia
  • Not for acute attack (use colchicine, short-course NSAID)
  • Diet: ↓ purines (aged cheese, organ meats, smoked meats)
  • Give with food if nausea
  • ADR: rash → Stevens–Johnson risk; stop drug & notify provider

Vancomycin

  • Glycopeptide; MRSA, C. difficile (PO for C-diff)
  • ADRs – nephrotoxicity, Red-Man syndrome (histamine mediated pruritic flushing w/o airway compromise)
  • Monitoring
    • Trough 15 min pre-dose; Peak 30 min post-infusion
    • Renal labs: BUN 10{-}20\ \text{mg·dL}^{-1}, Creatinine 0.6{-}1.2\ \text{mg·dL}^{-1}
    • Hold dose until trough drawn

Piperacillin + Tazobactam (Zosyn)

  • Extended-spectrum penicillin + β-lactamase inhibitor
  • Loading dose 4.5\text{ g} (adult)
  • Cross-reactivity: penicillin allergy
  • Often paired with vancomycin for broad coverage

Clopidogrel (Plavix)

  • Platelet aggregation inhibitor (P2Y₁₂ ADP antagonist)
  • Prevents MI, ischemic CVA, post-stent thrombus
  • ADR – bleeding, GI upset, rash
  • D/C 5 days pre-elective surgery
  • Assess for occult bleeding (H/H, melena vs iron-dark stool)

Lithium

  • Mood stabiliser for bipolar mania/depression
  • Therapeutic level 0.4{-}1.4\ \text{mEq·L}^{-1}
  • Toxicity
    • Early: >!2.0 → N/V/D, tremor, ataxia, slurred speech
    • Severe: >!2.5 → seizures, coma, death
  • Prevention
    • Consistent Na⁺ intake; avoid hyponatremia/dehydration
    • Avoid NSAIDs & caffeine (↑ levels)
  • Pregnancy category D

Haloperidol (Haldol)

  • High-potency typical antipsychotic; schizophrenia, psychosis, Tourette’s
  • ADRs
    • EPS: dystonia, akathisia, tardive dyskinesia (lip smacking, tongue rolling)
    • Neuroleptic malignant syndrome: rigidity, sudden hyperthermia, autonomic instability, ↑ CK
    • Neutropenia

Zolpidem (Ambien)

  • Sedative–hypnotic for short-term insomnia
  • Rapid onset → take immediately before bed
  • ADRs – dizziness, daytime drowsiness, sleep-walking/driving, agitation, depression
  • Avoid alcohol, CNS depressants, operating machinery

Esomeprazole (Nexium)

  • Proton-pump inhibitor; GERD, PUD
  • Give \approx1\text{ h} before meals
  • Long-term (> 1 yr) risks
    • ↓ Ca²⁺ & Mg²⁺ absorption → osteoporosis (hip fracture ↑ 44\%)
    • ↓ B₁₂ → macrocytic pernicious anemia
    • Rebound hypersecretion when abruptly stopped

Amiodarone

  • Class III anti-dysrhythmic; FDA-approved for recurrent VF/unstable VT; common off-label for AF
  • ADRs – pulmonary fibrosis, bradycardia/heart failure, liver & thyroid dysfunction, photosensitivity
  • Very long half-life (weeks)
  • Nursing
    • Baseline & periodic CXR/PFTs, LFTs, TSH
    • Report dyspnea, cough, weight gain, syncope
    • Avoid grapefruit juice (↑ levels)

Aripiprazole (Abilify)

  • Atypical antipsychotic; schizophrenia, bipolar, MDD adjunct, autism irritability
  • Low metabolic & EPS burden but
    • Risk of akathisia, insomnia, headache
    • Black-box: suicidal thoughts in young adults → monitor mood

Epoetin Alfa (Erythropoietin)

  • Recombinant hormone; anemia of CKD, chemo, zidovudine, pre-op
  • Hold if
    • Hgb > 11\ \text{g·dL}^{-1}
    • ↑ Hgb > 1\ \text{g·dL}^{-1} in ≤ 2 wk
  • ADRs – HTN, thrombotic stroke, AV-fistula clot, tumor progression
  • Monitor H/H, ferritin, transferrin saturation, K⁺, BP
  • Physiologic note: endogenous EPO released by kidneys at low O₂; high altitude ↑ RBC mass

Risedronate (Actonel)

  • Bisphosphonate; prevents/treats osteoporosis, glucocorticoid-induced bone loss
  • Administration
    • AM, full glass H₂O, swallow whole
    • Remain upright ≥ 30\text{ min}, NPO other than water during that period
  • ADRs – esophagitis, musculoskeletal pain, jaw osteonecrosis
  • Ensure adequate Ca²⁺ + Vit D; evaluate lifestyle risks (sedentary, steroids, menopause)

Pregabalin (Lyrica)

  • Anticonvulsant; neuropathic pain, fibromyalgia, partial seizures, alcohol detox (off-label)
  • ADRs – dizziness, somnolence, peripheral edema, weight gain, blurred vision, ataxia
  • Pain assessment in non-verbal pts → FACES scale, body posture, restlessness, vital signs

Insulin Aspart (NovoLog)

  • Rapid-acting bolus insulin
  • PK
    • Onset 10{-}20\text{ min}
    • Peak 40{-}50\text{ min}
    • Duration 3{-}5\text{ h}
  • Give 5–10 min before meals; monitor for hypoglycemia at peak

Diltiazem (Cardizem)

  • Non-DHP calcium-channel blocker; HTN, angina, AF/A-flutter, SVT rate control
  • ADRs – bradycardia, heart block, heart failure, peripheral edema
  • HF monitoring: dyspnea, orthopnea, > 2 lb weight gain day⁻¹, crackles, edema

General Cross-links & Exam Tips

  • Peak/trough ABX (vanco, gentamicin) & lab values: BUN 10{-}20, Cr 0.6{-}1.2
  • Glucocorticoids (prednisone, methyl-pred) + long-acting inhaled steroids (budesonide) → adrenal suppression & osteoporosis; taper slowly
  • Caffeine acts as a mild diuretic/CNS stimulant → avoid with lithium & severe anxiety
  • Grapefruit interactions: statins, amiodarone, nifedipine, buspirone
  • Purine-rich foods mnemonic "SMASH PA" (Seafood, Meat-organs, Alcohol, Sardines, Herring, Poultry, Anchovies)