VERAPAMIL HYDROCHLORIDE 

(ver-ap'a-mill)
Calan, Calan SR, Covera-HS, Isoptin, Isoptin SR, Verelan, Verelan PM
Classifications: CARDIOVASCULAR AGENT; CALCIUM CHANNEL
BLOCKER; ANTIARRHYTHMIC, MISCELLANEOUS
Pregnancy Category: C

Availability
40 mg, 80 mg, 120 mg tablets; 120 mg, 180 mg, 240 mg sustained-release tablets; 100 mg, 120 mg, 180
mg, 200 mg, 240 mg, 300 mg sustained-release capsules; 5 mg/2 mL injection

Actions
Inhibits calcium ion influx through slow channels into cells of myocardial and arterial smooth muscle.
Dilates coronary arteries and arterioles and inhibits coronary artery spasm. Decreases and slows SA and
AV node conduction without affecting normal arterial action potential or intraventricular conduction.
Associated vasodilation of arterioles decreases total peripheral vascular resistance and reduces arterial BP
at rest. May slightly decrease heart rate.

Therapeutic Effects
Dilates coronary arteries and inhibits coronary artery spasm, which increases myocardial oxygen delivery
and produces an antianginal effect. Also decreases nodal conduction, which results in an antiarrhythmic
effect.

Uses
Supraventricular tachyarrhythmias; Prinzmetal's (variant) angina, chronic stable angina; unstable,
crescendo or preinfarctive angina and essential hypertension.

Unlabeled Uses
Paroxysmal supraventricular tachycardia, atrial fibrillation; prophylaxis of migraine headache; and as
alternate therapy in manic depression.

Contraindications
Severe hypotension (systolic <90 mm Hg), cardiogenic shock, cardiomegaly, digitalis toxicity, second- or
third-degree AV block; Wolff-Parkinson-White syndrome including atrial flutter and fibrillation; accessory
AV pathway, left ventricular dysfunction, severe CHF, sinus node disease, sick sinus syndrome (except in
patients with functioning ventricular pacemaker). Safe use during pregnancy (category C), lactation, or in
children (oral) is not established.

Cautious Use
Duchenne's muscular dystrophy; hepatic and renal impairment; MI followed by coronary occlusion, aortic
stenosis.

Route & Dosage

Angina
Adult: PO 80 mg q6–8h, may increase up to 320–480 mg/d in divided doses (Note: Covera-
HS must be given once daily h.s.)

Hypertension
Adult: PO 40–80 mg t.i.d. or 90–240 mg sustained-release 1–2 times/d up to 480 mg/d
(Note: Covera-HS must be given once daily h.s.)

Supraventricular Tachycardia, Atrial Fibrillation

Adult: PO 240–480 mg/d in divided doses IV 5–10 mg IV direct, may repeat in 15–30 min if
needed
Child: IV <1 y, 0.1–0.2 mg/kg; 1–15 y, 0.1–0.3 mg/kg (2–5 mg)

Administration
Oral

 Give with food to reduce gastric irritation.

 Capsules can be opened and contents sprinkled on food. Do NOT dissolve or chew capsule
contents.
 Give Covera-HS once a day in the evening.
 Do not withdraw abruptly; may increase and extend duration of pain in the angina patient.

Intravenous

PREPARE: IV Direct: Given undiluted or diluted in 5 mL of sterile water for injection.

Inspect parenteral drug preparation before administration. Make sure solution is clear and
colorless.  

ADMINISTER: Direct: Give a single dose over 2–3 min.  

INCOMPATIBILITIES Solution/additive: Albumin, aminophylline, amphotericin
B, hydralazine, cotrimoxazole. Y-site: Albumin, amphotericin B cholesteryl
complex, ampicillin, mezlocillin, nafcillin, oxacillin, propofol, sodium bicarbonate.

 Store at 15°–30° C (59°–86° F) and protect from light.

Adverse Effects ( 1%)

CNS: Dizziness, vertigo, headache, fatigue, sleep disturbances, depression,
syncope. CV: Hypotension, congestive heart failure, bradycardia, severe tachycardia, peripheral
edema, AV block. GI: Nausea, abdominal discomfort, constipation, elevated liver enzymes. Body as a
Whole: Flushing, pulmonary edema, muscle fatigue, diaphoresis. Skin: Pruritus.

Diagnostic Test Interference

Verapamil may cause elevations of serum AST, ALT, alkaline phosphatase.
Interactions
Drug: BETA BLOCKERS increase risk of CHF, bradycardia, or heart block; significantly increased levels
of digoxin and carbamazepine and toxicity; potentiates hypotensive effects of HYPOTENSIVE AGENTS;
levels of lithium and cyclosporine may be increased, increasing their toxicity; calcium salts (IV) may
antagonize verapamil effects. Food: Grapefruit juice may increase verapamil
levels. Herbal: Hawthorne may have additive hypotensive effects.

Pharmacokinetics
Absorption: 90% absorbed, but only 25–30% reaches systemic circulation (first pass
metabolism). Peak: 1–2 h PO; 4–8 h sustained release; 5 min IV. Distribution: Widely distributed,
including CNS; crosses placenta; present in breast milk. Metabolism: Metabolized in
liver. Elimination: 70% excreted in urine; 16% in feces. Half-Life: 2–8 h.

Nursing Implications
Assessment & Drug Effects

 Monitor therapeutic effectiveness. Drug should decrease angina frequency, nitroglycerin

consumption, and episodes of ST segment deviation.
 Establish baseline data and periodically monitor: BP and pulse.
 Lab tests: Baseline and periodic liver and kidney functions.
 Instruct patient to remain in recumbent position for at least 1 h after dose is given to diminish
subjective effects of transient asymptomatic hypotension that may accompany infusion.
 Monitor for AV block or excessive bradycardia when infusion is given concurrently with digitalis.
 Monitor I&O ratio during IV and early oral maintenance therapy. Renal impairment prolongs
duration of action, increasing potential for toxicity and incidence of adverse effects. Advise
patient to report gradual weight gain and evidence of edema.
 Monitor ECG continuously during IV administration. Essential because drug action may be
prolonged and incidence of adverse reactions is highest during IV administration in older adults,
patients with impaired kidney function, and patients of small stature.
 Check BP shortly before administration of next dose to evaluate degree of control during early
treatment for hypertension.

Patient & Family Education

 Monitor radial pulse before each dose, notify physician of an irregular pulse or one slower than
established guideline.
 Adhere to established guidelines for exercise program.
 Do not drive or engage in potentially hazardous activities until response to drug is known.
 Decrease intake of caffeine-containing beverage (i.e., coffee, tea, chocolate).
 Change positions slowly from lying down to standing to prevent falls because of drug-related
vertigo until tolerance to reduced BP is established.
 Notify physician of easy bruising, petechiae, unexplained bleeding.
 Do not use OTC drugs, especially aspirin, unless they are specifically prescribed by physician.
 Do not breast feed while taking this drug without consulting physician.

MAGNESIUM SULFATE
(mag-nes'i-um)
Epsom Salt
Classifications: GASTROINTESTINAL AGENT; SALINE CATHARTIC; REPLACEMENT
AGENT; ANTICONVULSANT
Prototype: Magnesium Hydroxide
Pregnancy Category: A

Availability
0.8 mEq/mL, 1 mEq/mL, 4 mEq/mL injection

Actions
Orally: Acts as a laxative by osmotic retention of fluid, which distends colon, increases water content of
feces, and causes mechanical stimulation of bowel activity. Parenterally: Acts as a CNS depressant and
also as a depressant of smooth, skeletal, and cardiac muscle function. Anticonvulsant properties thought to
be produced by CNS depression, principally by decreasing the amount of acetylcholine liberated from
motor nerve terminals, thus producing peripheral neuromuscular blockade.

Therapeutic Effects
Effective parenterally as a CNS depressant, smooth muscle relaxant and anticonvulsant in labor and
delivery, and cardiac disorders. It is a laxative when taken orally.

Uses
Orally to relieve acute constipation and to evacuate bowel in preparation for x-ray of intestines.
Parenterally to control seizures in toxemia of pregnancy, epilepsy, and acute nephritis and for prophylaxis
and treatment of hypomagnesemia. Topically to reduce edema, inflammation, and itching.

Unlabeled Uses
To inhibit premature labor (tocolytic action) and as adjunct in hyperalimentation.

Contraindications
Myocardial damage; heart block; cardiac arrest except for certain arrhythmias; IV administration during
the 2 h preceding delivery; PO use in patients with abdominal pain, nausea, vomiting, fecal impaction, or
intestinal irritation, obstruction, or perforation.

Cautious Use
Impaired kidney function; digitalized patients; concomitant use of other CNS depressants; neuromuscular
blocking agents, or cardiac glycosides; pregnancy (category A), lactation, children.

Route & Dosage

Laxative
Adult: PO 10–15 g once/d

Preeclampsia, Eclampsia
Adult: IM/IV 4 g in 250 mL D5W infused slowly, followed by 4–5 g IM in alternate buttocks
q4h

Hypomagnesemia Seizures
Adult: IM/IV Mild, 1 g q6h for 4 doses; Severe, 250 mg/kg infused over 4 h
Child: IV 20–100 mg/kg q4–6h prn

Total Parenteral Nutrition

Adult: IV 0.5–3 g/d

Administration
Oral

 Give in the morning or mid-afternoon in a glass of water for laxative action. Disguise bitter, salty
taste by chilling or flavoring with lemon or orange juice.

Intramuscular

 Give deep using the 50% concentration for adults and the 20% concentration for children.

Intravenous

 Note: Verify correct IV concentration and rate of infusion for administration to

infants, children with physician.

PREPARE: Direct/IV Infusion: Give solutions with concentrations of  20% undiluted.  

ADMINISTER: Direct: Give at a rate of 150 mg over at least 1 min. Note: 20% solution

contains 200 mg/mL, 10% solution contains 100 mg/mL.  IV Infusion: Give required dose
over 4 h. Do not exceed the direct rate.  

INCOMPATIBILITIES Solution/additive: 10% fat emulsion; amphotericin B, calcium

gluceptate, clindamycin, cyclosporine, dobutamine, polymyxin B
sulfate, procaine, sodium bicarbonate. Y-site: Amiodarone, amphotericin B,
cholesteryl, cefepime.

Adverse Effects ( 1%)

Body as a Whole: Flushing, sweating, extreme thirst, sedation, confusion, depressed reflexes or no
reflexes, muscle weakness, flaccid paralysis, hypothermia. CV: Hypotension, depressed cardiac
function, complete heart block, circulatory collapse. Respiratory: Respiratory
paralysis. Metabolic: Hypermagnesemia, hypocalcemia, dehydration, electrolyte imbalance including
hypocalcemia with repeated laxative use.

Interactions
Drug: NEUROMUSCULAR BLOCKING AGENTS add to respiratory depression and apnea.
Pharmacokinetics
Onset: 1–2 h PO; 1 h IM. Duration: 30 min IV; 3–4 h PO. Distribution: Crosses placenta; distributed
into breast milk. Elimination: Eliminated in kidneys.

Nursing Implications
Assessment & Drug Effects

 Observe constantly when given IV. Check BP and pulse q10–15 min or more often if indicated.
 Lab tests: Monitor plasma magnesium levels in patients receiving drug parenterally (normal: 1.8–
3.0 mEq/L). Plasma levels in excess of 4 mEq/L are reflected in depressed deep tendon reflexes
and other symptoms of magnesium intoxication (see ADVERSE EFFECTS). Cardiac arrest occurs at
levels in excess of 25 mEq/L. Monitor calcium and phosphorus levels also.
 Early indicators of magnesium toxicity (hypermagnesemia) include cathartic effect, profound
thirst, feeling of warmth, sedation, confusion, depressed deep tendon reflexes, and muscle
weakness.
 Monitor respiratory rate closely. Report immediately if rate falls below 12.
 Test patellar reflex before each repeated parenteral dose. Depression or absence of reflexes is a
useful index of early magnesium intoxication.
 Check urinary output, especially in patients with impaired kidney function. Therapy is generally
not continued if urinary output is less than 100 mL during the 4 h preceding each dose.
 Observe newborns of mothers who received parenteral magnesium sulfate within a few hours of
delivery for signs of toxicity, including respiratory and neuromuscular depression.
 Observe patients receiving drug for hypomagnesemia for improvement in these signs of
deficiency: Irritability, choreiform movements, tremors, tetany, twitching, muscle cramps,
tachycardia, hypertension, psychotic behavior.
 Have calcium gluconate readily available in case of magnesium sulfate toxicity.

Patient & Family Education

 Drink sufficient water during the day when drug is administered orally to prevent net loss of body
water.
 Recommended daily allowances of magnesium are obtained in a normal diet. Rich sources are
whole-grain cereals, legumes, nuts, meats, seafood, milk, most green leafy vegetables, and
bananas.
 Do not breast feed while taking this drug without consulting physician

INDOMETHACIN
(in-doe-meth'a-sin)
Indameth, Indocid  , Indocin, Indocin SR
Classifications: CENTRAL NERVOUS SYSTEM AGENT; ANALGESIC, ANTIPYRETIC; NSAID
Prototype: Ibuprofen
Pregnancy Category: B (D in third trimester)

Availability
25 mg, 50 mg capsules; 75 mg sustained release capsules; 25 mg/5 mL oral suspension; 50 mg
suppositories; 1 mg injection

Actions
Potent nonsteroidal compound with antiinflammatory, analgesic, and antipyretic effects similar to those of
aspirin. Appears to reduce motility of polymorphonuclear leukocytes, development of cellular exudates,
and vascular permeability in injured tissue resulting in its antiinflammatory effects.

Therapeutic Effects
Antipyretic and antiinflammatory actions may be related to its ability to inhibit prostaglandin biosynthesis.
It is a potent analgesic.

Uses
Palliative treatment in active stages of moderate to severe rheumatoid arthritis, ankylosing rheumatoid
spondylitis, acute gouty arthritis, and osteoarthritis of hip in patients intolerant to or unresponsive to
adequate trials with salicylates and other therapy. Also used IV to close patent ductus arteriosus in the
premature infant.

Unlabeled Uses
To relieve biliary pain and dysmenorrhea, Paget's disease, athletic injuries, juvenile arthritis, idiopathic
pericarditis.

Contraindications
Allergy to indomethacin, aspirin, or other NSAID; nasal polyps associated with angioedema, history of GI
lesions; pregnancy (category B; D in third trimester), lactation, children ( 14 y).

Cautious Use
History of psychiatric illness, epilepsy, parkinsonism; impaired renal or hepatic function; uncontrolled
infections; coagulation defects, CHF; older adults, persons in hazardous occupations.

Route & Dosage

Rheumatoid Arthritis
Adult: PO 25–50 mg b.i.d or t.i.d. (max: 200 mg/d) or 75 mg sustained release 1–2 times/d

Pediatric Arthritis
Child: PO 1–2 mg/kg/d in 2–4 divided doses (max: 4 mg/kg/d) or 150–200 mg/d

Acute Gouty Arthritis

Adult: PO/PR 50 mg t.i.d. until pain is tolerable, then rapidly taper

Bursitis
Adult: PO 25–50 mg t.i.d. or q.i.d. (max: 200 mg/d) or 75 mg sustained release 1–2 times/d

Close Patent Ductus Arteriosus

Premature neonate: IV <48 h, 0.2 mg/kg followed by 2 doses of 0.1 mg/kg q12–24h; 2–7 d,
0.2 mg/kg followed by 2 doses of 0.2 mg/kg q12–24h; <7 d, 0.2 mg/kg followed by 2 doses
of 0.25 mg/kg q12–24h
Administration
Oral

 Give immediately after meals, or with food, milk, or antacid (if prescribed) to minimize GI side
effects.

Rectal

 Indomethacin rectal suppository use is contraindicated with history of proctitis or recent bleeding.

Intravenous

PREPARE: Direct: Dilute 1 mg with 1 mL of NS or sterile water for injection without

preservatives. Resulting concentration (1 mg/mL) may be further diluted with an additional
1 mL for each 1 mg to yield 0.5 mg/mL.  

ADMINISTER: Direct: Give by direct IV with a single dose given over 5–10 s.  

 Avoid extravasation or leakage; drug can be irritating to tissue.

 Discard any unused drug, since it contains no preservative.

 Store oral and rectal forms in tight, light-resistant containers unless otherwise directed. Do not
freeze.

Adverse Effects ( 1%)

Body as a Whole: Hypersensitivity (rash, purpura, pruritus, urticaria, angioedema, angiitis, rapid fall in
blood pressure, dyspnea, asthma syndrome in aspirin-sensitive patients), edema, weight gain, flushing,
sweating. CNS: Headache, dizziness, vertigo, light-headedness, syncope, fatigue, muscle weakness,
ataxia, insomnia, nightmares, drowsiness, confusion, coma, convulsions, peripheral neuropathy, psychic
disturbances (hallucinations, depersonalization, depression), aggravation of epilepsy,
parkinsonism. CV: Elevated BP, palpitation, chest pains, tachycardia, bradycardia, CHF. Special
Senses: Blurred vision, lacrimation, eye pain, visual field changes, corneal deposits, retinal disturbances
including macula, tinnitus, hearing disturbances, epistaxis. GI: Nausea, vomiting, diarrhea, anorexia,
bloating, abdominal distention, ulcerative stomatitis, proctitis, rectal bleeding, GI ulceration, hemorrhage,
perforation, toxic hepatitis. Hematologic: Hemolytic anemia, aplastic anemia (sometimes
fatal), agranulocytosis, leukopenia, thrombocytopenic purpura, inhibited platelet
aggregation. Urogenital: Renal function impairment, hematuria, urinary frequency; vaginal bleeding,
breast changes. Skin: Hair loss, exfoliative dermatitis, erythema nodosum, tissue irritation with
extravasation. Metabolic: Hyponatremia, hypokalemia, hyperkalemia, hypoglycemia or hyperglycemia,
glycosuria (rare).

Diagnostic Test Interference

Increased AST, ALT, bilirubin, BUN; positive direct Coombs' test.

Interactions
Drug: ORAL ANTICOAGULANTS, heparin, alcohol may prolong bleeding time; may
increase lithium toxicity; effects of ORAL
ANTICOAGULANTS, phenytoin, SALICYLATES, SULFONAMIDES, SULFONYLUREAS increased
because of protein-binding displacement; increased toxicity including GI bleeding
with SALICYLATES, NSAIDs; may blunt effects
of ANTIHYPERTENSIVES and DIURETICS. Herbal: Feverfew, garlic, ginger, ginkgo may increase
bleeding potential.

Pharmacokinetics
Absorption: Completely absorbed from GI tract. Onset: 1–2 h. Peak: 3 h. Duration: 4–6
h. Metabolism: Metabolized in liver. Elimination: Excreted primarily in urine. Half-Life: 2.5–124 h.

Nursing Implications
Assessment & Drug Effects

 Monitor for therapeutic effectiveness: In acute gouty attack, relief of joint tenderness and pain is
usually apparent in 24–36 h; swelling generally disappears in 3–5 d. In rheumatoid arthritis:
Reduced fever, increased strength, reduced stiffness, and relief of pain, swelling, and tenderness.
 Question patient carefully regarding aspirin sensitivity before initiation of therapy.
 Observe patients carefully; instruct to report adverse reactions promptly to prevent serious and
sometimes irreversible or fatal effects.
 Lab tests: Monitor renal function, hepatic function, CBC with differential, BP and HR, visual and
hearing acuity periodically.
 Monitor weight and observe dependent areas for signs of edema in patients with underlying
cardiovascular disease.
 Monitor I&O closely and keep physician informed during IV administration for patent ductus
arteriosus. Significant impairment of renal function is possible; urine output may decrease by 50%
or more. Also monitor BUN, serum creatinine, glomerular filtration rate, creatinine clearance, and
serum electrolytes.

Patient & Family Education

 Notify physician of S&S of GI bleeding, visual disturbance, tinnitus, weight gain, or edema.
 Do not take aspirin or other NSAIDs; they increase possibility of ulcers.
 Note: Frontal headache is the most frequent CNS adverse effect; if it persists, dosage reduction or
drug withdrawal may be indicated. Take drug at bedtime with milk to reduce the incidence of
morning headache.
 Do not drive or engage in other potentially hazardous activities until response to drug is known.
 Do not breast feed while taking this drug.

TERBUTALINE SULFATE
(ter-byoo'te-leen)
Brethaire, Brethine, Bricanyl
Classifications: AUTONOMIC NERVOUS SYSTEM AGENT; BETA-ADRENERGIC
AGONIST; BRONCHODILATOR
Prototype: Albuterol
Pregnancy Category: B

Availability
2.5 mg, 5 mg tablets; 0.2 mg aerosol; 1 mg/mL injection

Actions
Synthetic adrenergic stimulant with selective beta2- and negligible beta1-agonist (cardiac) activity. Exerts
preferential effect on beta2 receptors in bronchial smooth muscles, inhibits histamine release from mast
cells, and increases ciliary motility.

Therapeutic Effects
Relieves bronchospasm in chronic obstructive pulmonary disease (COPD) and significantly increases vital
capacity. Promotes relaxation of vascular smooth muscle, contraction of GI and urinary sphincters,
increase in renin, pancreatic beta-cell secretion, and serum HDL-cholesterol concentration. Increases
uterine relaxation (thereby preventing or abolishing high intrauterine pressure).

Uses
Orally or subcutaneously as a bronchodilator in bronchial asthma and for reversible airway obstruction
associated with bronchitis and emphysema.

Unlabeled Uses
To delay delivery in preterm labor.

Contraindications
Known hypersensitivity to sympathomimetic amines; severe hypertension and coronary artery disease;
tachycardia with digitalis intoxication; within 14 d of MAO inhibitor therapy; angle-closure glaucoma.
Used only after evaluation of risk-benefit ratio in pregnancy (category B) and lactation.

Cautious Use
Angina, stroke, hypertension; diabetes mellitus; thyrotoxicosis; history of seizure disorders; cardiac
arrhythmias; older adults; kidney and liver dysfunction.

Route & Dosage

Bronchodilator
Adult: PO 2.5–5 mg t.i.d. at 6 h intervals (max: 15 mg/d) SC 0.25 mg q15–30min up to 0.5
mg in 4 h Inhaled 2 inhalations separated by 60 sec q4–6h
Adolescent: PO 12–15 y, 2.5 mg t.i.d. at 6 h intervals (max: 7.5 mg/d) SC 0.25 mg q15–
30min up to 0.5 mg in 4 h Inhaled 2 inhalations separated by 60 sec q4–6h
Child: PO <12 y, 0.05 mg/kg q8h, gradually increase up to 0.15 mg/kg q8h (max: 5
mg/d) SC 0.005–0.01 mg/kg (max: 0.4 mg) q15–20min times 2 doses

Premature Labor
Adult: PO 2.5 mg q4–6h

Administration
Oral

 Give with fluid of patient's choice; tablets may be crushed.

 Be certain about recommended doses: PO preparation, 2.5 mg; SC, 0.25 mg. A decimal point error
can be fatal.
 Give with food if GI symptoms occur.

Subcutaneous

 Give SC injection into lateral deltoid area.

 Store all forms at 15°–30° C (59°–86° F); protect from light. Do not freeze.

Adverse Effects ( 1%)

CNS: Nervousness, tremor, headache, light-headedness, drowsiness, fatigue,
seizures. CV: Tachycardia, hypotension or hypertension, palpitation, maternal and fetal
tachycardia. GI: Nausea, vomiting. Body as a Whole: Sweating, muscle cramps.

Diagnostic Test Interference

Terbutaline may increase blood glucose and free fatty acids.

Interactions
Drug: Epinephrine, other SYMPATHOMIMETIC BRONCHODILATORS may add to effects; MAO
INHIBITORS, TRICYCLIC ANTIDEPRESSANTS potentiate action on vascular system; effects of
both BETA-ADRENERGIC BLOCKERS and terbutaline antagonized.

Pharmacokinetics
Absorption: 33–50% absorbed from GI tract. Onset: 30 min PO; <15 min SC; 5–30 min
inhaled. Peak: 2–3 h PO; 30–60 min SC; 1–2 h inhaled. Duration: 4–8 h PO; 1.5–4 h SC; 3–4 h
inhaled. Distribution: Distributed into breast milk. Metabolism: Metabolized in
liver. Elimination: Excreted primarily in urine, 3% in feces. Half-Life: 3–4 h.

Nursing Implications
Assessment & Drug Effects

 Assess vital signs: Baseline pulse and BP and before each dose. If significantly altered from
baseline level, consult physician. Cardiovascular adverse effects are more apt to occur when drug
is given by SC route or it is used by a patient with cardiac arrhythmia.
 Most adverse effects are transient, however, rapid heart rate may persist for a relatively long time.
 Be aware that onset and degree of effect and incidence and severity of adverse effects of SC
formulation resemble those of epinephrine.
 Aerosolized drug produces minimal cardiac stimulation or tremors.
 Be aware that muscle tremor is a fairly common adverse effect that appears to subside with
continued use.
 Monitor for symptoms of hypoglycemia in neonates born of a mother who used terbutaline during
pregnancy.
  Monitor patient being treated for premature labor for CV S&S for 12 h after drug is discontinued.
Report tachycardia promptly.
 Monitor I&O ratio. Fluid restriction may be necessary. Consult physician.

Patient & Family Education

 Adhere to established dosage regimen (i.e., do not change dose intervals or omit, increase, or
decrease the dose).
 Inhalator therapy: Review instructions for use of inhalator (included in the package).
 Learn how to take your own pulse and the limits of change that indicate need to notify the
physician.
 Consult physician if breathing difficulty is not relieved or if it becomes worse within 30 min after
an oral dose.
 Keep appointments with physician for evaluation of continued drug effectiveness and clinical
condition. Terbutaline appears to have a short clinical period for sustained effectiveness.
 Consult physician if symptomatic relief wanes; tolerance can develop with chronic use. Usually, a
substitute agent will be prescribed.
 Do not self-dose this drug, particularly during long-term therapy. In the face of waning response,
increasing the dose will not improve the clinical condition and may cause overdosage. Understand
that decreasing relief with continued treatment indicates need for another bronchodilator, not an
increase in dose.
 Do not puncture container, use or store it near heat or open flame, or expose to temperatures above
49° C (120° F), which may cause bursting. Contents of the aerosol (inhalator) are under pressure.
 Do not use any other aerosol bronchodilator while being treated with aerosol terbutaline. Do not
self-medicate with an OTC aerosol.
 Do not use OTC drugs without physician approval. Many cold and allergy remedies, for example,
contain a sympathomimetic agent that when combined with terbutaline may cause harmful adverse
effects.
 Do not breast feed while taking/using this drug.

RITODRINE HYDROCHLORIDE
(ri'toe-dreen)
Yutopar
Classifications: AUTONOMIC NERVOUS SYSTEM AGENT; BETA-ADRENERGIC AGONIST
Prototype: Isoproterenol
Pregnancy Category: C

Availability
10 mg/mL, 15 mg/mL, 0.3 mg/mL injection

Actions
Preferentially stimulates beta2-receptors in uterine smooth muscle, reducing intensity and frequency of
uterine contractions and lengthening gestation period. (Actions may be eliminated by beta-adrenergic
antagonists.) Transitory cardiovascular effects include increased cardiac output, increased maternal and
fetal heart rates, and widening of maternal pulse pressure (beta1 stimulation).

Therapeutic Effects
Beta2- adrenergic agonist clinically effective in preventing or delaying preterm labor (tocolytic effect).
Uterine contractions will decrease in frequency and intensity during treatment.
Uses
To manage premature labor in selected patients.

Contraindications
Mild to moderate preeclampsia or eclampsia, intrauterine infection, cervix dilated 4 cm or more (in a single
pregnancy); pregnancy (category C); hypertension; diabetes mellitus; prior to 20th wk or after 36th wk of
pregnancy or if continuation of pregnancy would be hazardous to mother and fetus (e.g., antepartum
hemorrhage, eclampsia, intrauterine fetal death, maternal cardiac disease, pulmonary hypertension,
maternal hyperthyroidism, severe diabetes mellitus). Also hypovolemia, cardiac arrhythmias associated
with tachycardia or digitalis intoxication, uncontrolled hypertension; thyrotoxicosis; bronchial asthma
being treated with betamimetics or steroids; lactation.

Cautious Use
Concomitant use of potassium-depleting diuretics, cardiac disease.

Route & Dosage

Premature Labor
Adult: PO Start 30 min before terminating infusion, 10 mg q2h for first 24 h, then 10–20 mg
q4–6h (max: 120 mg/d) IV 50–100 mcg/min, may increase by 50 mcg/min q10min until
uterine relaxation is achieved, may continue for up to 12 h after contractions have ceased

Administration
Note: IV solution should be clear. Discard if cloudy or a precipitate is present.

Intravenous

PREPARE: IV Infusion: Add 150 mg ritodrine to 500 mL D5W or NS solution to yield 0.3

mg/mL (300 mcg/mL).  

ADMINISTER: IV Infusion: Begin at 50 mcg/min and increase by 50 mcg q10 min until

desired response. Monitor IV infusion flow rate to prevent circulation overload. Use a
microdrip and infusion pump.  

 Place patient in left lateral recumbent position throughout the infusion period to
reduce risk of hypotension.

 Store drug below 30° C (86° F). Do not freeze.

Adverse Effects ( 1%)

Body as a Whole: erythema, nervousness, restlessness, anxiety, malaise, anaphylactic
shock , sweating, chills, drowsiness, weakness, myotonic and muscular dystrophies. CNS: Tremor,
headache. CV: Altered maternal and fetal heart rates and maternal BP (dose
related), palpitations, arrhythmias, chest pain, pulmonary edema. Endocrine: Temporary
hyperglycemia. GI: Nausea, vomiting, epigastric distress, ileus, bloating, constipation,
diarrhea. Urogenital: Glycosuria. Respiratory: Dyspnea, hyperventilation. Skin: Rash.

Diagnostic Test Interference

Ritodrine (IV route) may produce an increase in serum levels of glucose, insulin, and free fatty acids, and
a decrease in serum potassium. It temporarily elevates results of glucose tolerance test.

Interactions
Drug: CORTICOSTEROIDS may precipitate pulmonary edema; BETA AGONISTS add to cardiovascular
adverse effects; effects of both ritodrine and BETA BLOCKERS antagonized.

Pharmacokinetics
Absorption: 30% absorbed from GI tract. Peak: 30–60 min. Distribution: Crosses
placenta. Metabolism: Metabolized in liver. Elimination: Excreted in urine. Half-Life: 1.7–2.6 h.

Nursing Implications
Assessment & Drug Effects

 Monitor continuously for pronounced dose-related adverse effects to maternal and fetal heart rates
and maternal BP while infusion is running.
 Be alert to S&S of pulmonary edema (see Appendix F).

Patient & Family Education

 Report immediately any of the following: palpitations, chest pain, dizziness, respiratory distress,
weakness, tremors, sweating or chills.
 Do not breast feed while taking this drug.

ALBUTEROL 
(al-byoo'ter-ole)
Accuneb, Novosalmol  , Proventil, Proventil HFA, Proventil
Repetabs, Salbutamol, Ventolin, Ventolin HFA, Volmax
Classifications: AUTONOMIC NERVOUS SYSTEM AGENT; BETA-ADRENERGIC AGONIST
(SYMPATHOMIMETIC); BRONCHODILATOR (RESPIRATORY SMOOTH MUSCLE RELAXANT)
Pregnancy Category: C

Availability
2 mg, 4 mg tablets; 4 mg, 8 mg, extended-release tablets; 2 mg/5 mL syrup; 200 mcg capsules for
inhalation; 0.083%, 0.5% solution for inhalation

Actions
Synthetic sympathomimetic amine and moderately selective beta2-adrenergic agonist with comparatively
long action. Acts more prominently on beta2 receptors (particularly smooth muscles of bronchi, uterus, and
vascular supply to skeletal muscles) than on beta1 (heart) receptors. Inhibits histamine release by mast
cells. Produces bronchodilation, regardless of administration route, by relaxing smooth muscles of
bronchial tree.

Therapeutic Effects
Bronchodilation decreases airway resistance, facilitates mucus drainage, and increases vital capacity.

Uses
To relieve bronchospasm associated with acute or chronic asthma, bronchitis, or other reversible
obstructive airway diseases. Also used to prevent exercise-induced bronchospasm.

Unlabeled Uses
Adjunct in treatment of refractory heart failure and to stimulate intracellular transport of potassium in
hyperkalemic familial periodic paralysis.

Contraindications
Pregnancy (category C), lactation. Use of oral syrup in children <2 y.

Cautious Use
Cardiovascular disease, hypertension, hyperthyroidism, diabetes mellitus, hypersensitivity to
sympathomimetic amines or to fluorocarbon propellant used in inhalation aerosols.

Route & Dosage

Bronchospasm
Adult: PO 2–4 mg 3–4 times/d, 4–8 mg sustained release 2 times/d Inhaled 1–2 inhalations
q4–6h
Child: PO 2–6 y, 0.1–0.2 mg/kg t.i.d. (max: 4 mg/dose); 6–12 y, 2 mg 3–4
times/d Inhaled 6–12 y, 1–2 inhalations q4–6h

Administration
Oral

 Do not crush extended release tablets. Scored tablets may be broken in half.
 Note: An initial dose of 2 mg t.i.d. or q.i.d. is recommended for older adult patients.
 Store tablets and syrup between 2°–25° C (36°–77° F) in tight, light-resistant container.

Inhalation

 Administer albuterol 20–30 min before concomitant beclomethasone (Vanceril) inhalation

treatments to allow deeper penetration of beclomethasone into lungs, unless otherwise directed by
physician.
  Store canisters between 15°–30° C (59°–86° F) away from heat and direct sunlight.

Adverse Effects ( 1%)

Body as a Whole: Hypersensitivity reaction. CNS: Tremor, anxiety, nervousness, restlessness,
convulsions, weakness, headache, hallucinations. CV: Palpitation, hypertension, hypotension, bradycardia,
reflex tachycardia. Special Senses: Blurred vision, dilated pupils. GI: Nausea,
vomiting. Other: Muscle cramps, hoarseness.

Diagnostic Test Interference

Transient small increases in plasma glucose may occur.

Interactions
Drug: With epinephrine, other SYMPATHOMIMETIC BRONCHODILATORS, possible additive
effects; MAO INHIBITORS, TRICYCLIC ANTIDEPRESSANTS potentiate action on vascular
system; BETA-ADRENERGIC BLOCKERS antagonize the effects of both drugs.

Pharmacokinetics
Onset: Inhaled: 5–15 min; PO 30 min. Peak: Inhaled: 0.5–2 h; PO 2.5 h. Duration: Inhaled: 3–6 h; PO
4–6 h (8–12 h with sustained release). Metabolism: Metabolized in liver; may cross the
placenta. Elimination: 76% of dose eliminated in urine in 3 d. Half-Life: 2.75 h.

Nursing Implications
Assessment & Drug Effects

 Monitor therapeutic effectiveness which is indicated by significant subjective improvement in

pulmonary function within 60–90 min after drug administration.
 Monitor for: S&S of fine tremor in fingers, which may interfere with precision handwork; CNS
stimulation, particularly in children 2–6 y, (hyperactivity, excitement, nervousness, insomnia),
tachycardia, GI symptoms. Report promptly to physician.
 Lab tests: Periodic ABGs, pulmonary functions, and pulse oximetry.
 Consult physician about giving last albuterol dose several hours before bedtime, if drug-induced
insomnia is a problem.

Patient & Family Education

 Review directions for correct use of medication and inhaler (see ADMINISTRATION).

 Avoid contact of inhalation drug with eyes.
 Do not increase number or frequency of inhalations without advice of physician.
 Notify physician if albuterol fails to provide relief because this can signify worsening of
pulmonary function and a reevaluation of condition/therapy may be indicated.
 Note: Albuterol can cause dizziness or vertigo; take necessary precautions.
 Do not use OTC drugs without physician approval. Many medications (e.g., cold remedies)
contain drugs that may intensify albuterol action.
 Do not breast feed while taking this drug without consulting physician.

HYDRALAZINE HYDROCHLORIDE 
(hye-dral'a-zeen)
Alazine, Apresoline
Classifications: CARDIOVASCULAR AGENT; NONNITRATE
VASODILATOR; ANTIHYPERTENSIVE
Pregnancy Category: C

Availability
10 mg, 25 mg, 50 mg, 100 mg tablets; 20 mg/mL vial

Actions
Reduces BP mainly by direct effect on vascular smooth muscles of arterial-resistance vessels, resulting in
vasodilation. Has little effect on venous-capacitance vessels. Hypotensive effect may be limited by
sympathetic reflexes, which increase heart rate, stroke volume, and cardiac output.

Therapeutic Effects
Diastolic response is often greater than systolic response. Vasodilation reduces peripheral resistance and
substantially improves cardiac output, and renal and cerebral blood flow. Postural hypotensive effect is
reportedly less than that produced by ganglionic blocking agents.

Uses
Most commonly in stepped-care approach to treat moderate to severe hypertension. Also in early
malignant hypertension and resistant hypertension that persists after sympathectomy.

Unlabeled Uses
Conjunctively with cardiac glycosides and other vasodilators in short-term treatment of acute CHF;
unexplained pulmonary hypertension.

Contraindications
Coronary artery disease, mitral valvular rheumatic heart disease, MI, tachycardia, SLE. Safe use during
pregnancy (category C) or lactation is established.

Cautious Use
Cerebrovascular accident, advanced renal impairment, use with MAO INHIBITORS.

Route & Dosage

Hypertension
Adult: PO 10–50 mg q.i.d. IM 10–50 mg q4–6h IV 10–20 mg q4–6h
Geriatric: PO Start with 10 mg 2–3 times/d
Child: PO 3–7.5 mg/kg/d in 4 divided doses IV/IM 1.7–3.5 mg/kg/d in 4 divided doses
Administration
Oral

 Give with food; bioavailability is increased by taking it with food.

 Discontinue gradually to avoid sudden rise in BP and acute heart failure.
 Inform patients of the dangers of abrupt withdrawal.

Intramuscular

 Give deep into a large muscle.

Intravenous

PREPARE: Direct: Give undiluted. Use immediately after being drawn into syringe. Do not
add to IV solutions.  

ADMINISTER: Direct: Give each 10 mg or fraction thereof over 1 min.  

INCOMPATIBILITIES Solution/additive: Aminophylline, ampicillin, chlorothiazide, edet
ate calcium
disodium, hydrocortisone, mephentermine, methohexital, nitroglycerin, phenobarbital, 
verapamil.

 Store at 15°–30° C (59°–86° F) in tight, light-resistant containers unless otherwise directed. Avoid
freezing.

Adverse Effects ( 1%)

Body as a Whole: Hypersensitivity (rash, urticaria, pruritus, fever, chills, arthralgia, eosinophilia,
cholangitis, hepatitis, obstructive jaundice). CNS: Headache, dizziness,
tremors. CV: Palpitation, angina, tachycardia, flushing, paradoxical pressor response. Overdose:
arrhythmia, shock. Special Senses: Lacrimation, conjunctivitis. GI: Anorexia, nausea, vomiting,
diarrhea, constipation, abdominal pain, paralytic ileus. Urogenital: Difficulty in urination,
glomerulonephritis. Hematologic: Decreased hematocrit and hemoglobin,
anemia, agranulocytosis (rare). Other: Nasal congestion, muscle cramps, SLE-like syndrome, fixed drug
eruption, edema.

Diagnostic Test Interference

Positive direct Coombs' tests in patients with hydralazine-induced SLE. Hydralazine interferes with
urinary 17-OHCS determinations (modified Glenn-Nelson technique).

Interactions
Drug: BETA BLOCKERS and other ANTIHYPERTENSIVE AGENTS compound hypotensive effects.

Pharmacokinetics
Absorption: Readily absorbed from GI tract. Onset: 20–30 min. Peak: 2 h. Duration: 2–6
h. Distribution: Crosses placenta; distributed into breast milk. Metabolism: Metabolized in intestinal
wall and liver. Elimination: 90% rapidly excreted in urine; 10% excreted in feces. Half-Life: 2–8 h.

Nursing Implications
Assessment & Drug Effects

 Lab tests: Determine antinuclear antibody titer before initiation of therapy and periodically during
prolonged therapy.
 Make baseline and periodic determinations of BUN, creatinine clearance, uric acid, serum
potassium, blood glucose, and ECG.
 Monitor for S&S of SLE, especially with prolonged therapy.
 Monitor BP and HR closely. Check every 5 min until it is stabilized at desired level, then every 15
min thereafter throughout hypertensive crisis.
 Monitor I&O when drug is given parenterally and in those with renal dysfunction.

Patient & Family Education

 Monitor weight, check for edema, and report weight gain to physician.
 Note: Some patients experience headache and palpitations within 2–4 h after first PO dose;
symptoms usually subside spontaneously.
 Make position changes slowly and avoid standing still, hot baths/showers, strenuous exercise, and
excessive alcohol intake.
 Do not drive or engage in other potentially hazardous activities until response to drug is known.
 Do not breast feed while taking this drug without consulting physician.

NITROPRUSSIDE SODIUM
(nye-troe-pruss'ide)
Nipride, Nitropress
Classifications: CARDIOVASCULAR AGENT; ANTIHYPERTENSIVE; NONNITRATE
VASODILATOR
Prototype: Hydralazine
Pregnancy Category: C

Availability
50 mg injection

Actions
Potent, rapid-acting hypotensive agent with effects similar to those of nitrates.

Therapeutic Effects
Acts directly on vascular smooth muscle to produce peripheral vasodilation, with consequent marked
lowering of arterial BP, associated with slight increase in heart rate, mild decrease in cardiac output, and
moderate lowering of peripheral vascular resistance.

Uses
Short-term, rapid reduction of BP in hypertensive crises and for producing controlled hypotension during
anesthesia to reduce bleeding.

Unlabeled Uses
Refractory CHF or acute MI.

Contraindications
Compensatory hypertension, as in atriovenous shunt or coarctation of aorta, and for control of hypotension
in patients with inadequate cerebral circulation. Safety during pregnancy (category C) or lactation is not
established.

Cautious Use
Hepatic insufficiency, hypothyroidism, severe renal impairment, hyponatremia, older adult patients with
low vitamin B12 plasma levels or with Leber's optic atrophy.

Route & Dosage

Hypertensive Crisis
Adult/Child: IV 0.5–10 mcg/kg/min (average 3 mcg/kg/min)

Administration

Intravenous

 Note: Solutions must be freshly prepared with D5W and used no later than 4 h after
reconstitution.

PREPARE: Continuous: Dissolve each 50 mg in 2–3 mL of D5W. Further dilute in 250 mL

D5W to yield 200 mcg/mL or 500 mL D5W to yield 100 mcg/mL. Following reconstitution,
solutions usually have faint brownish tint; if solution is highly colored, do not use it.
Promptly wrap container with aluminum foil or other opaque material to protect drug from
light.  

ADMINISTER: Continuous: Administer by infusion pump or similar device that will allow

precise measurement of flow rate required to lower BP. Give at the rate required to lower
BP but do not exceed the maximum dose of 10 mcg/kg/min.  

INCOMPATIBILITIES Solution/additive: Amiodarone, dobutamine, propafenone. Y-site: 
Cisatracurium, haloperidol.

 Store reconstituted solutions protected from light; stable for 24 h.

Adverse Effects ( 1%)

Body as a Whole: Diaphoresis, apprehension, restlessness, muscle twitching, retrosternal
discomfort. Thiocyanate toxicity (profound hypotension, tinnitus, blurred vision, fatigue, metabolic
acidosis, pink skin color, absence of reflexes, faint heart sounds, loss of consciousness). CV: Profound
hypotension, palpitation, increase or transient lowering of pulse rate, bradycardia, tachycardia, ECG
changes. GI: Nausea, retching, abdominal pain. Metabolic: Increase in serum creatinine, fall or rise in
total plasma cobalamins. CNS: Headache, dizziness. Special Senses: Nasal
stuffiness. Other: Irritation at infusion site.

Interactions
No clinically significant interactions established.

Pharmacokinetics
Onset: Within 2 min. Duration: 1–10 min after infusion is terminated. Metabolism: Rapidly
converted to cyanogen in erythrocytes and tissue, which is metabolized to thiocyanate in
liver. Elimination: Excreted in urine primarily as thiocyanate. Half-Life: (thiocyanate): 2.7–7 d.

Nursing Implications
Assessment & Drug Effects

 Monitor constantly to titrate IV infusion rate to BP response.

 Relieve adverse effects by slowing IV rate or by stopping drug; minimize them by keeping patient
supine.
 Notify physician immediately if BP begins to rise after drug infusion rate is decreased or infusion
is discontinued.
 Monitor I&O.
 Lab tests: Monitor blood thiocyanate level in patients receiving prolonged treatment or in patients
with severe kidney dysfunction (levels usually are not allowed to exceed 10 mg/dL). Determine
plasma cyanogen level following 1 or 2 d of therapy in patients with impaired liver function.