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CORTICOSTEROID, ANTI-INFLAMMATORY

Hydrocortisone Use: As a topical corticosteroid, the drug is used for the relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.

Contraindicated in:

• Topical steroids contraindicated in presence of varicella, vaccinia, on surfaces with compromised circulation, and in
• children <2 y.

Cautious use in:

• Children;
• diabetes mellitus;
• stromal herpes simplex;
• glaucoma, tuberculosis of eye;
• osteoporosis;
• untreated fungal,
• bacterial, or viral infections

Adverse Effects:

• Skin: Skin thinning and atrophy, acne, impaired wound healing; petechiae, ecchymosis, easy bruisings; suppression of skin test reaction; hypopigmentation or hyperpigmentation, hirsutism, acneiform eruptions, subcutaneous fat atrophy; allergic dermatitis, urticaria, angioneurotic edema, increased sweating.

Clinical Implications: Administer retention enema preferably after a bowel movement. The enema should be retained at least 1 h or all night if possible. If an occlusive dressing is to be used, apply medication sparingly, rub until it disappears, and then reapply, leaving a thin coat over lesion. Completely cover area with transparent plastic or other occlusive device or vehicle. Avoid covering a weeping or exudative lesion. Usually, occlusive dressings are not applied to face, scalp, scrotum, axilla, and groin. Inspect skin carefully between applications for ecchymotic, petechial, and purpuric signs, maceration, secondary infection, skin atrophy, striae or milaria; if present, stop medication and notify physician. Warn patient not to self-dose with OTC topical preparations of a corticosteroid more than 7 d. They should not be used for children <2 y. If symptoms do not abate, consult physician. Usually, topical preparations are applied after a shower or bath when skin is damp or wet. Cleansing and application of prescribed preparation should be done with extreme gentleness because of fragility, easy bruisability, and poor-healing skin. Hazard of systemic toxicity is higher in small children because of the greater ratio of skin surface area to body weight. Apply sparingly. Urge patient on long-term therapy with topical corticosterone to check expiration date.

CORTICOSTEROID, ANTI-INFLAMMATORY

Hydrocortisone Use: Oral inhalation to treat steroid-dependent asthma, nasal inhalation for the management of the symptoms of seasonal or perennial rhinitis

Contraindicated in:

• Nonasthmatic bronchitis,
• primary treatment of status asthmaticus,
• acute attack of asthma.

Cautious use in:

• Patients receiving systemic corticosteroids;
• use with extreme caution if at all in respiratory tuberculosis,
• untreated fungal,
• bacterial, or viral infections, and ocular herpes simplex;
• nasal inhalation therapy for nasal septal ulcers,
• nasal trauma, or surgery.

Adverse Effects:

• Oral inhalation: Candidal infection of oropharynx and occasionally larynx, hoarseness, dry mouth, sore throat, sore mouth.

• Nasal (inhaler): Transient nasal irritation, burning, sneezing, epistaxis, bloody mucous, nasopharyngeal itching, dryness, crusting, and ulceration; headache, nausea, vomiting.

• Other: With excessive doses, symptoms of hypercorticism.

Clinical Implications: Note that oral inhalation and nasal inhalation products are not to be used interchangeably.

• Oral inhaler: Emphasize the following: (1) Shake inhaler well before using. (2) After exhaling fully, place mouthpiece well into mouth with lips closed firmly around it. (3) Inhale slowly through mouth while activating the inhaler. (4) Hold breath 5–10 sec, if possible, then exhale slowly. (5) Wait 1 min between puffs. Clean inhaler daily. Separate parts as directed in package insert, rinse them with warm water, and dry them thoroughly. Rinsing mouth and gargling with warm water after each oral inhalation removes residual medication from oropharyngeal area. Mouth care may also delay or prevent onset of oral dryness, hoarseness, and candidiasis.
• Nasal inhaler: Directions for use of nasal inhaler provided by manufacturer should be carefully reviewed with patient. Emphasize the following points: (1) Gently blow nose to clear nostrils. (2) Shake inhaler well before using. (3) If 2 sprays in each nostril are prescribed, direct one spray toward upper, and the other toward lower part of nostril. (4) Wash cap and plastic nosepiece daily with warm water; dry thoroughly. Inhaled steroids do not provide immediate symptomatic relief and are not prescribed for this purpose.

BETA-ADRENERGIC BLOCKERS

Propranolol HCl Use: Intraocular hypertension and chronic open-angle glaucoma.

Adverse Effects/Clinical Implications: May cause mild ocular stinging and discomfort; tearing; may also have the adverse effects of systemic beta blockers. May mask symptoms of acute hypoglycemia in diabetic patients (tachycardia, tremor, but not sweating). May precipitate thyroid storm in patients with hyperthyroidism. Patients with impaired cardiac function and the elderly should report to physician signs and symptoms of CHF (see Appendix G). Monitor BP for hypotension and heart rate for bradycardia.

MIOTICS

Pilocarpine HCl Use: Open-angle and angle-closure glaucomasto reduce IOP and to protect the lens during surgery and laser iridotomyto counteract effects of mydriatics and cycloplegics following surgery or ophthalmoscopic examination

Adverse Effects/Clinical Implications: Ocular: Ciliary spasm with browache, twitching of eyelids, eye pain with change in eye focus, miosis, diminished vision in poorly illuminated areas, blurred vision, reduced visual acuity, sensitivity, contact allergy, lacrimation, follicular conjunctivitis, conjunctival irritation, cataract, retinal detachment. CNS: Headache, drowsiness, depression, syncope. GI: Abnormal taste, dry mouth. Clinical Implications: Wait 15 min after instillation before inserting soft contact lenses to avoid staining the lenses. Use with MAO inhibitors may have increased risk of hypertensive emergency. May increase the effects of beta blockers and other antihypertensives on blood pressure and heart rate. TCAs may reduce the effects of brimonidine. Brinzolamide is a carbonic anhydrase inhibitor (prototype: acetazolamide) and is a sulfonamide. It should not be used by patients with sulfa allergies. Demecarium bromide is capable of producing cumulative systemic effects. It is essential to adhere precisely to prescribed drug concentration, dosage schedule, and technique of administration. Reconstituted solutions of echothiophate remain stable for 1 mo at room temperature. Expiration date should appear on label. The length of time solutions remain stable under refrigeration varies with manufacturer. Echothiophate therapy is generally discontinued 2–6 wk before surgery. If necessary, alternate miotic therapy is substituted. Medication should be given in the evening. Give at least 5 min apart from other topical ophthalmic drugs. The patient with brown or hazel eyes may require a stronger ophthalmic solution or more frequent instillation of physostigmine for desired effects than the patient with blue eyes.

PROSTAGLANDINS

Latanoprost Use: Open-angle glaucoma and intraocular hypertension.

Adverse Effects: Ocular: Conjunctival hyperemia, g rowth of eyelashes, ocular pruritus, ocular dryness, visual disturbance, ocular burning, foreign body sensation, eye pain, pigmentation of the periocular skin, blepharitis, cataract, superficial punctate keratitis, eyelid erythema, ocular irritation, eyelash darkening, eye discharge, tearing, photophobia, allergic conjunctivitis, increases in iris pigmentation (brown pigment), conjunctival edema. Body as a Whole: Headaches, abnormal liver function tests, asthenia, and hirsutism. Clinical Implications: Should instill in the evening. Wait 15 min after instillation before inserting soft contact lenses to avoid staining the lenses. Give at least 5 min apart from other topical ophthalmic drugs.

MYDRIATIC

Homatropine HBr Use: Mydriatic for ocular examination and as cycloplegic to measure errors of refraction. Also inflammatory conditions of uveal tract, ciliary spasm, as a cycloplegic and mydriatic in preoperative and postoperative conditions, and as an optical aid in select patients with axial lens opacities.

Contraindicated in: Primary (narrow-angle) glaucoma or predisposition to glaucoma; children <6 y. Cautious use in: Increased IOP, infants, children, pregnancy (category C), the elderly or debilitated; hypertension; hyperthyroidism; diabetes; cardiac disease. Adverse Effects: Increased IOP, blurred vision, photophobia. Prolonged use: Local irritation, congestion, edema, eczema, follicular conjunctivitis. Excessive dosage/systemic absorption: Symptoms of atropine poisoning (flushing, dry skin, mouth, nose; decreased sweating; fever, rash, rapid/irregular pulse; abdominal and bladder distension; hallucinations, confusion). CNS: Psychotic reaction, behavior disturbances, ataxia, incoherent speech, restlessness, hallucinations, somnolence, disorientation, failure to recognize people, grand mal seizures. Clinical Implications: Carefully monitor cyclopentolate patients with seizure disorders, since systemic absorption may precipitate a seizure. Photophobia associated with mydriasis may require patient to wear dark glasses. Since drug causes blurred vision, supervision of activity may be indicated.

VASOCONSTRICTOR; DECONGESTANT

Naphazoline HCl Use: Ocular vasoconstrictor

Contraindicated in: Narrow–angle glaucoma; concomitant use with MAO INHIBITORS or TRICYCLIC ANTIDEPRESSANTS Cautious use in: Hypertension, cardiac irregularities, advanced arteriosclerosis; diabetes; hyperthyroidism; elderly patients. Adverse Effects: Pupillary dilation, increased intraocular pressure, rebound redness of the eye, headache, hypertension, nausea, weakness, sweating. Overdosage: Drowsiness, hypothermia, bradycardia, shocklike hypotension, coma.

CORTICOSTEROID, ANTI-INFLAMMATORY

Hydrocortisone Use: Inflammation Unlabelled Uses: Anterior uveitis

Contraindicated in: Ocular fungal diseases, herpes simplex keratitis, ocular infections, ocular mycobacterial infections, viral disease of cornea or conjunctiva such as vaccina, varicella. Adverse Effects: Ocular: Blurred vision, photophobia, conjunctival edema, corneal edema, erosion, eye discharge, dryness, irritation, pain; prolonged use: glaucoma, ocular hypertension, damage to optic nerve, defects in visual acuity and visual fields, posterior subcapsular cataract formation, secondary ocular infections. Other: Headache, taste perversion. Clinical Implications: Shake all products well before use.

OCULAR ANTIHISTAMINES

Use: Relief of signs and symptoms of allergic conjunctivitis

Adverse Effects: Ocular: Allergic reactions, burning, stinging, discharge, dry eyes, eye pain, eyelid disorder, itching keratitis, lacrimation disorder, mydriasis, photophobia, rash. CNS: Drowsiness, fatigue, headache. Other: Dry mouth, cold syndrome, pharyngitis, rhinitis, sinusitis, taste perversion. Clinical Implications: Wait 10 min after instilling emedastine before inserting soft contact lenses; do not use levocabastine, olopatadine with soft contact lenses.

The FDA requires that all prescription drugs absorbed systemically or known to be potentially harmful to the fetus be classified according to one of five pregnancy categories (A, B, C, D, X).

Category A

Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester (and there is no evidence of risk in later trimesters), and the possibility of fetal harm appears remote.

Category B

Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of a risk in later trimesters).

Category C

Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal effects or other) and there are no controlled studies in women, or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.

Category D

There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective). There will be an appropriate statement in the "warnings" section of the labeling.

Category X

Studies in animals or human beings have demonstrated fetal abnormalities or there is evidence of fetal risk based on human experience, or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant. There will be an appropriate statement in the "contraindications" section of the labeling.

acute dystonia

extrapyramidal symptom manifested by abnormal posturing, grimacing, spastic torticollis (neck torsion), and oculogyric (eyeball movement) crisis.

adverse effec

unintended, unpredictable, and nontherapeutic response to drug action. Adverse effects occur at doses used therapeutically or for prophylaxis or diagnosis. They generally result from drug toxicity, idiosyncrasies, or hypersensitivity reactions caused by the drug itself or by ingredients added during manufacture, e.g., preservatives, dyes, or vehicles.

afterload

resistance that ventricles must work against to eject blood into the aorta during systole.

agranulocytosis

sudden drop in leukocyte count; often followed by a severe infection manifested by high fever, chills, prostration, and ulcerations of mucous membrane such as in the mouth, rectum, or vagina.

akathisia

extrapyramidal symptom manifested by a compelling need to move or pace, without specific pattern, and an inability to be still.

analeptic

restorative medication that enhances excitation of the CNS without affecting inhibitory impulses.

anaphylactoid reaction

excessive allergic response manifested by wheezing, chills, generalized pruritic urticaria, diaphoresis, sense of uneasiness, agitation, flushing, palpitations, coughing, difficulty breathing, and cardiovascular collapse.

anticholinergic actions

inhibition of parasympathetic response manifested by dry mouth, decreased peristalsis, constipation, blurred vision, and urinary retention.

bioavailability

fraction of active drug that reaches its action sites after administration by any route. Following an IV dose, bioavailability is 100%; however, such factors as first-pass effect, enterohepatic cycling, and biotransformation reduce bioavailability of an orally administered drug.

blood dyscrasia

pathological condition manifested by fever, sore mouth or throat, unexplained fatigue, easy bruising or bleeding.

cardiotoxicity

impairment of cardiac function manifested by one or more of the following: hypotension, arrhythmias, precordial pain, dyspnea, electrocardiogram (ECG) abnormalities, cardiac dilation, congestive failure.

cholinergic response

stimulation of the parasympathetic response manifested by lacrimation, diaphoresis, salivation, abdominal cramps, diarrhea, nausea, and vomiting.

circulatory overload

excessive vascular volume manifested by increased central venous pressure (CVP), elevated blood pressure, tachycardia, distended neck veins, peripheral edema, dyspnea, cough, and pulmonary rales.

CNS stimulation

excitement of the CNS manifested by hyperactivity, excitement, nervousness, insomnia, and tachycardia.

CNS toxicity

impairment of CNS function manifested by ataxia, tremor, incoordination, paresthesias, numbness, impairment of pain or touch sensation, drowsiness, confusion, headache, anxiety, tremors, and behavior changes.

congestive heart failure (CHF)

impaired pumping ability of the heart manifested by paroxysmal nocturnal dyspnea, cough, fatigue or dyspnea on exertion, tachycardia, peripheral or pulmonary edema, and weight gain.

Cushing's syndrome

fatty swellings in the interscapular area (buffalo hump) and in the facial area (moon face), distension of the abdomen, ecchymoses following even minor trauma, impotence, amenorrhea, high blood pressure, general weakness, loss of muscle mass, osteoporosis, and psychosis.

dehydration

decreased intracellular or extracellular fluid manifested by elevated temperature, dry skin and mucous membranes, decrease tissue turgor, sunken eyes, furrowed tongue, low blood pressure, diminished or irregular pulse, muscle or abdominal cramps, thick secretions, hard feces and impaction, scant urinary output, urine specific gravity above 1.030, an elevated hemoglobin.

disulfiram-type reaction

Antabuse-type reaction manifested by facial flushing, pounding headache, sweating, slurred speech, abdominal cramps, nausea, vomiting, tachycardia, fever, palpitations, drop in blood pressure, dyspnea, and sense of chest constriction. Symptoms may last up to 24 hours.

enzyme induction

stimulation of microsomal enzymes by a drug resulting in its accelerated metabolism and decreased activity. If reactive intermediates are formed, drug-mediated toxicity may be exacerbated.

first-pass effect

reduced bioavailability of an orally administered drug due to metabolism in GI epithelial cells and liver or to biliary excretion. Effect may be avoided by use of sublingual tablets or rectal suppositories.

fixed drug eruption

drug-induced circumscribed skin lesion that persists or recurs in the same site. Residual pigmentation may remain following drug withdrawal.

half-life (t-)

time required for concentration of a drug in the body to decrease by 50%. Half-life also represents the time necessary to reach steady state or to decline from steady state after a change (i.e., starting or stopping) in the dosing regimen. Half-life may be affected by a disease state and age of the drug user.

heat stroke

a life-threatening condition manifested by absence of sweating; red, dry, hot skin; dilated pupils; dyspnea; full bounding pulse; temperature above 40C (105F); and mental confusion.

hepatic toxicity

impairment of liver function manifested by jaundice, dark urine, pruritus, lightcolored stools, eosinophilia, itchy skin or rash, and persistently high elevations of alanine amino-transferase (ALT) and aspartate aminotransferase (AST).

hyperammonemia

elevated level of ammonia or ammonium in the blood manifested by lethargy, decreased appetite, vomiting, asterixis (flapping tremor), weak pulse, irritability, decreased responsiveness, and seizures.

hypercalcemia

elevated serum calcium manifested by deep bone and flank pain, renal calculi, anorexia, nausea, vomiting, thirst, constipation, muscle hypotonicity, pathologic fracture, bradycardia, lethargy, and psychosis.

hyperglycemia

elevated blood glucose manifested by flushed, dry skin, low blood pressure and elevated pulse, tachypnea, Kussmaul's respirations, polyuria, polydipsia; polyphagia, lethargy, and drowsiness.

hyperkalemia

excessive potassium in blood, which may produce lifethreatening cardiac arrhythmias, including bradycardia and heart block, unusual fatigue, weakness or heaviness of limbs, general muscle weakness, muscle cramps, paresthesias, flaccid paralysis of extremities, shortness of breath, nervousness, confusion, diarrhea, and GI distress.

hypermagnesemia

excessive magnesium in blood, which may produce cathartic effect, profound thirst, flushing, sedation, confusion, depressed deep tendon reflexes (DTRs), muscle weakness, hypotension, and depressed respirations.

hypernatremia

excessive sodium in blood, which may produce confusion, neuromuscular excitability, muscle weakness, seizures, thirst, dry and flushed skin, dry mucous membranes, pyrexia, agitation, and oliguria or anuria.

hypersensitivity reactions

excessive and abnormal sensitivity to given agent manifested by urticaria, pruritus, wheezing, edema, redness, and anaphylaxis.

hyperthyroidism

excessive secretion by the thyroid glands, which increases basal metabolic rate, resulting in warm, flushed, moist skin; tachycardia, exophthalmos; infrequent lid blinking; lid edema; weight loss despite increased appetite; frequent urination; menstrual irregularity; breathlessness; hypoventilation; congestive heart failure; excessive sweating.

hyperuricemia

excessive uric acid in blood, resulting in pain in flank; stomach, or joints, and changes in intake and output ratio and pattern.

hypocalcemia

abnormally low calcium level in blood, which may result in depression; psychosis; hyperreflexia; diarrhea; cardiac arrhythmias; hypotension; muscle spasms; paresthesias of feet, fingers, tongue; positive Chvostek's sign. Severe deficiency (tetany) may result in carpopedal spasms, spasms of face muscle, laryngospasm, and generalized convulsions.

hypoglycemia

abnormally low glucose level in the blood, which may result in acute fatigue, restlessness, malaise, marked irritability and weakness, cold sweats, excessive hunger, headache, dizziness, confusion, slurred speech, loss of consciousness, and death.

hypokalemia

abnormally low level of potassium in blood, which may result in malaise, fatigue, paresthesias, depressed reflexes, muscle weakness and cramps, rapid, irregular pulse, arrhythmias, hypotension, vomiting, paralytic ileus, mental confusion, depression, delayed thought process, abdominal distension, polyuria, shallow breathing, and shortness of breath.

hypomagnesemia

abnormally low level of magnesium in blood, resulting in nausea, vomiting, cardiac arrhythmias, and neuromuscular symptoms (tetany, positive Chvostek's and Trousseau's signs, seizures, tremors, ataxia, vertigo, nystagmus, muscular fasciculations).

hypophosphatemia

abnormally low level of phosphates in blood, resulting in muscle weakness, anorexia, malaise, absent deep tendon reflexes, bone pain, paresthesias, tremors, negative calcium balance, osteomalacia, osteoporosis.

hypothyroidism

condition caused by thyroid hormone deficiency that lowers basal metabolic rate and may result in periorbital edema, lethargy, puffy hands and feet, cool, pale skin, vertigo, nocturnal cramps, decreased GI motility, constipation, hypotension, slow pulse, depressed muscular activity, and enlarged thyroid gland.

hypoxia

insufficient oxygenation in the blood manifested by dyspnea, tachypnea, headache, restlessness, cyanosis, tachycardia, dysrhythmias, confusion, decreased level of consciousness, and euphoria or delirium.

international normalizing ratio

measurement that normalizes for the differences obtained from various laboratory readings in the value for thromboplastin blood level.

leukopenia

abnormal decrease in number of white blood cells, usually below 5000 per cubic millimeter, resulting in fever, chills, sore mouth or throat, and unexplained fatigue.

liver toxicity

manifested by anorexia, nausea, fatigue, lethargy, itching, jaundice, abdominal pain, dark-colored urine, and flu-like symptoms.

metabolic acidosis

decrease in pH value of the extracellular fluid caused by either an increase in hydrogen ions or a decrease in bicarbonate ions. It may result in one or more of the following: lethargy, headache, weakness, abdominal pain, nausea, vomiting, dyspnea, hyperpnea progressing to Kussmaul breathing, dehydration, thirst, weakness, flushed face, full bounding pulse, progressive drowsiness, mental confusion, combativeness.

metabolic alkalosis

increase in pH value of the extracellular fluid caused by either a loss of acid from the body (e.g., through vomiting) or an increased level of bicarbonate ions (e.g., through ingestion of sodium bicarbonate). It may result in muscle weakness, irritability, confusion, muscle twitching, slow and shallow respirations, and convulsive seizures.

microsomal enzymes

drugmetabolizing enzymes located in the endoplasmic reticulum of the liver and other tissues chiefly responsible for oxidative drug metabolism, e.g., cytochrome P450.

myopathy

any disease or abnormal condition of striated muscles manifested by muscle weakness, myalgia, diaphoresis, fever, and reddish-brown urine (myoglobinuria) or oliguria.

nephrotoxicity

impairment of the nephrons of the kidney manifested by one or more of the following: oliguria, urinary frequency, hematuria, cloudy urine, rising BUN and serum creatinine, fever, graft tenderness or enlargement.

neuroleptic malignant syndrome (NMS)

potentially fatal complication associated with antipsychotic drugs manifested by hyperpyrexia, altered mental status, muscle rigidity, irregular pulse, fluctuating BP, diaphoresis, and tachycardia.

orphan drug

(as defined by the Orphan Drug Act, an amendment of the Federal Food, Drug, and Cosmetic Act which took effect in January 1983): drug or biological product used in the treatment, diagnosis, or prevention of a rare disease. A rare disease or condition is one that affects fewer than 200,000 persons in the United States, or affects more than 200,000 persons but for which there is no reasonable expectation that drug research and development costs can be recovered from sales within the United States.

ototoxicity

impairment of the ear manifested by one or more of the following: headache, dizziness or vertigo, nausea and vomiting with motion, ataxia, nystagmus.

prodrug

inactive drug form that becomespharmacologically active through biotransformation.

protein binding

reversible interaction between protein and drug resulting in a drug-protein complex (bound drug) which is in equilibrium with free (active) drug in plasma and tissues. Since only free drug can diffuse to action sites, factors that influence drug-binding (e.g., displacement of bound drug by another drug, or decreased albumin concentration) may potentiate pharmacological effect.

pseudomembranous enterocolitis

life-threatening superinfection characterized by severe diarrhea and fever.

pseudoparkinsonism

extrapyramidal symptom manifested by slowing of volitional movement (akinesia), mask facies, rigidity and tremor at rest (especially of upper extremities); and pill rolling motion.

pulmonary edema

excessive fluid in the lung tissue manifestied by one or more of the following: shortness of breath, cyanosis, persistent productive cough (frothy sputum may be blood tinged), expiratory rales, restlessness, anxiety, increased heart rate, sense of chest pressure.

renal insufficiency

reduced capacity of the kidney to perform its functions as manifested by one or more of the following: dysuria, oliguria, hematuria, swelling of lower legs and feet.

serotonin syndrome

manifested by restlessness, myoclonus, mental status changes, hyperreflexia, diaphoresis, shivering, and tremor.

Somogyi effect

rebound phenomenon clinically manifested by fasting hyperglycemia and worsening of diabetic control due to unnecessarily large p.m. insulin doses. Hormonal response to unrecognized hypoglycemia (i.e., release of epinephrine, glucagon, growth hormone, cortisol) causes insensitivity to insulin. Increasing the amount of insulin required to treat the hyperglycemia intensifies the hypoglycemia.

superinfection

new infection by an organism different from the initial infection being treated by antimicrobial therapy manifested by one or more of the following: black, hairy tongue; glossitis, stomatitis; anal itching; loose, foul-smelling stools; vaginal itching or discharge; sudden fever; cough.

tachyphylaxis

rapid decrease in response to a drug after administration of a few doses. Initial drug response cannot be restored by an increase in dose.

tardive dyskinesia

extrapyramidal symptom manifested by involuntary rhythmic, bizarre movements of face, jaw, mouth, tongue, and sometimes extremities.

vasovagal symptoms

transient vascular and neurogenic reaction marked by pallor, nausea, vomiting, bradycardia, and rapid fall in arterial blood pressure.

water intoxication (dilutional hyponatremia)

less than normal concentration of sodium in the blood resulting from excess extracellular and intracellular fluid and producing one or more of the following: lethargy, confusion, headache, decreased skin turgor, tremors, convulsions, coma, anorexia, nausea, vomiting, diarrhea, sternal fingerprinting, weight gain, edema, full bounding pulse, jugular vein distension, rales, signs and symptoms of pulmonary edema.

-Observe skin for any untoward effects such as bluish, purple appearance or a feeling of numbness.

-Contraindicated to rheumatoid arthritis, Raynaud's Phenomenon, and Buerger's disease.

-Ask for allergy to iodine or seafood.

-Avoid performing postural drainage immediately before or for up to 1 1/2 hours after meals.

-After the procedure, instruct patient to cough to expel secretions.

-Provide oral hygiene.