DRUG THERAPEUTIC RECORD

Brand Name Drug Classification INDICATIONS ADVERSE EFFECTS NURSING RESPONSIBILITIES

Pharmacotherapeutic:
Corticosteroid Management of Before
Hydrovex
Clinical: Glucocorticoids adrenocortical Long-term therapy:  Identify patient using two
insufficiency, anti- Hypocalcemia, patient-specific identifiers
Pregnancy Category / inflammatory, hypokalemia, muscle  Obtain baseline weight,
Generic Name immunosuppressive. wasting (esp. arms, legs) B/P, serum glucose,
Pregnancy / Lactation
spontaneous fractures, cholesterol, electrolytes.
Hydrocortisone amenorrhea, cataracts,  Review for allergies.
glaucoma, peptic ulcer  Be alert to infection
Route of (reduced immune
Administration & Dose Pregnancy category C response): sore throat,
fever.
Contraindication /
Precaution / Side Effects During
100 mg Interactions  Monitor electrolytes, B/P,
IVTT CONTRAINDICATIONS: weights, serum glucose.
Mechanism of Action
Fungal, tuberculosis,  Watch for hypocalcemia,
viral skin lesions; serious hypokalemia, nausea,
Frequency Inhibits accumulation of
infections.  Insomnia vomiting.
inflammatory cells at
inflammation sites,  Heartburn
CAUTIONS: Thyroid  Anxiety After
phagocytosis, lysosomal
dysfunction, cirrhosis,  Monitor pt for fever, sore
enzyme release,  Abdominal
hypertension, throat, muscle aches,
synthesis and/ or distention
osteoporosis, untreated sudden weight gain,
release of mediators of  Diaphoresis
systemic infections, swelling, visual
inflammation.  Mood swings
q6h renal/hepatic disturbances, behavioral
impairment.  Increased changes.
appetite  Avoid taking any
INTERACTIONS: May  Delayed wound medications without
decrease effects of healing consulting physician.
diuretics, insulin, oral
hypoglycemic,
potassium supplement.
 DRUG THERAPEUTIC RECORD

NURSING
Brand Name Drug Classification INDICATIONS ADVERSE EFFECTS
RESPONSIBILITIES
Before
PHARMACOTHERAPEUTIC:  Identify patient using two
Low molecular- weight patient-specific
Dexane heparin identifiers
 Assess baseline data.
CLINICAL: Anticoagulant  Obtain baseline CBC
May lead to bleeding  Assess potential risk of
Pregnancy Category / Prevention of post-op deep complications ranging bleeding.
Generic Name
Pregnancy / Lactation vein thrombosis (DVT). from local ecchymoses
to major hemorrhage. During
Enoxaparin  Monitor CBC, platelet
count, stool for occult
Route of blood.
Administration & Pregnancy category B  Monitor for any sign of
Dose bleeding (bleeding at
surgical site, hematuria,
SQ Contraindication / blood in stool, bruising).
Side Effects After
0.4ml Precaution / Interactions
Mechanism of Action  Injection site  Observe patient for
CONTRAINDICATIONS: hematoma unusual bleeding or
Active major bleeding,  Nausea bruising.
Frequency Potentiates action of  Avoid taking any OTC
concurrent heparin  Peripheral
antithrombin III, inactivates medications without
OD therapy, hypersensitivity to edema
coagulation factor Xa. consulting physician.
heparin, pork products,
thrombocytopenia
associated with positive in
vitro test for antiplatelet
antibodies.

CAUTIONS:
Conditions with increased
risk of hemorrhage.
 INTERACTIONS:

DRUG THERAPEUTIC RECORD

 Brand Name Drug Classification INDICATIONS ADVERSE EFFECTS NURSING RESPONSIBILITIES
Before:
Pharmacotherapeutic:  Identify patient using two
Centrally acting synthetic patient-specific identifiers
Algesia opioid analgesic. Seizures reported in  Assess baseline data
patients receiving  Assess onset, type,
Clinical: Analgesic tramadol within location, duration of pain.
Management of
recommended dosage  Review past medical
moderate to moderately
Pregnancy Category / range. May have history, esp. epilepsy,
Generic Name severe pain.
Pregnancy / Lactation prolonged duration of  Seizures for any adverse
action, cumulative effect effects.
Tramadol + in patients with  Assess renal function,
Paracetamol hepatic/renal LFT.
impairment,
Route of During:
Pregnancy category C  Monitor pulse, B/P,
Administration & Dose
renal/hepatic function.
Contraindication /  Assess for clinical
PO Precaution / Side Effects improvement, record
120mg Interactions onset of
Mechanism of Action CONTRAINDICATIONS: Frequent (25%–15%):  relief of pain
Acute alcohol Dizziness, vertigo,  Assist with ambulation if
intoxication, concurrent Nausea, constipation, dizziness, vertigo occurs.
Frequency Binds to mu-opioid  Monitor daily pattern of
use of centrally acting headache, drowsiness.
OD receptors, inhibits reuptake bowel activity, stool
analgesics, hypnotics,
of norepinephrine, consistency.
opioids, psychotropic Occasional (10%–5%):
serotonin, inhibiting  Palpate bladder for
drugs, hypersensitivity to Vomiting,
ascending and descending urinary retention.
opioids. pruritus, CNS stimulation
pain pathways.
(e.g., nervousness,
Anxiety, agitation, After:
tremor, euphoria, mood  Avoid patient of drug
swings, hallucinations), dependence
asthenia, diaphoresis,  Report severe
dyspepsia, dry mouth, constipation, difficulty
diarrhea. breathing, excessive
sedation, seizures,
Rare (less than 5%): muscle weakness,
 Malaise, vasodilation, tremors, chest pain, and
anorexia, flatulence, palpitations.
rash, blurred vision,  Notify patient for possible
urinary retention/ side-effects such as
frequency, menopausal drowsiness, dizziness,

DRUG THERAPEUTIC RECORD

 Brand Name Drug Classification INDICATIONS ADVERSE EFFECTS NURSING RESPONSIBILITIES
Pharmacotherapeutic: Common: tremor, Before:
Sympathomimeti(β2- headache, tachycardia;  Identify patient using two
Ventolin HFA adrenergic agonists Uncommon: palpitations patient-specific identifiers
Clinical: Bronchodilator , muscle cramps, mouth  Assess vital signs for
and throat irritation; baseline data
Pregnancy Category / Rare: hypokalemia,  Assess clients history for
Generic Name Indicated for the routine peripheral vasodilatation; any contraindication
Pregnancy / Lactation
management of chronic Very rare: cardiac  Assess the characteristics
Salbutamol bronchospasm arrhythmias including of respirations
(unresponsive to atrial fibrillation,
Route of conventional therapy) supraventricular During:
Administration & Dose and treatment of acute tachycardia and extra  Use the medication only
severe asthma (status systoles, hyperactivity, through a nebulizer
asthmaticus). paradoxical  Administer accurately
Pregnancy category: B bronchospasm, lactic because adverse
Lactation: Unknown if acidosis, hypersensitivity reactions and tolerance
distributed in breast milk reactions including might occur.
angioedema, urticarial,  Raise side rails up
Inhalation route bronchospasm, because client might be
1neb hypotension and restless and drowsy
collapse. because of this drug.
Contraindication /  Keep room well-lit in case
Precaution / Side Effects of vertigo.
Interactions
Mechanism of Action CONTRAINDICATIONS: After:
Salbutamol (Ventolin) is  Observe lips and
contraindicated in fingernails for cyanosis
Frequency Anti-asthma,
patients with a history of  Observe for hand tremor
Bronchodilator
Q6h hypersensitivity to any of  Evaluate for clinical
its components. improvement (quieter,
slow respirations, relaxed
CAUTIONS: must only facial expressions,
be used by inhalation, to cessation of retractions)
be breathed in through  Assess vital signs after
the mouth, and must not administration
be injected or
 swallowed. Also, should
be used with caution in
patients known to have
received large doses of
other sympathomimetic
drugs.

INTERACTIONS:
Salbutamol (Ventolin)
and non-selective beta-

DRUG THERAPEUTIC RECORD

Brand Name Drug Classification INDICATIONS ADVERSE EFFECTS NURSING RESPONSIBILITIES

 Pharmacotherapeutic:
Clinical:

Pregnancy Category /
Generic Name
Pregnancy / Lactation

Route of
Administration & Dose Pregnancy category Before
Contraindication /
During
Precaution / Side Effects
Interactions
After
Mechanism of Action CONTRAINDICATIONS:

CAUTIONS:
Frequency INTERACTIONS:

Cues/Needs Nursing Scientific Basis Objectives Nursing Interventions Rationale Evaluation

Diagnosis
Electrolyte After series of Independent:
imbalance nursing  Assess fluid  Many
related to interventions, intake & output factors
insufficient fluid the patient will  Maintain fluid  To
volume as be able to; balance prevent
evidenced by  Display dehydrati
hypokalemia; laborator on and
3.3 potassium y results  Monitor ECG shift to
within electrolyt
normal  Provide es
range for balanced  Abnormal
an nutrition potassium
individua through levels,
l blenderized both low
feeding & high,
Dependent: an
 Administer associate
medications d with
Collaberative: changes
 Consult with in ECG
dietitian/nutriti
onist for
feeding.