NUR 120 (UNIT 4) Medications for Cardiac Disorders 1.1 - 9.1
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Created by:
palentan Plus on February 20, 2012
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Description:
Mrs Gulledge
Nur 120
CCTC Spring 2012
Classes:
Med Surg I Wabash V. 2012, Text Chapters
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103 terms
Terms | Definitions |
|---|---|
 Thiazide Diuretics actions: | - Keeps chloride and the sodium in the tubule to be excreted in the urine (wastes Na and Cl), thus preventing the reabsorption of both in the vascular system - Blocks reabsorption of bicarbonate (urine will be more base) |
| Thiazide Diuretics Drug-Drug | - cholestyramine or colestipol - digoxin toxicity increases - Decreases effectiveness antidiabetic agents (may need to adjust the dose) - Increases quinine (malaria tx) toxicity & lithium (antipsychotic) toxicity |
| Thiazide Diuretics Contras | - Allergy to thiazides or sulfonamides - Fluid and electrolyte imbalances, and renal and liver disease - Bipolar disorders |
| Thiazide Diuretics cautions | - Gout - Systemic lupus erythematosus - Diabetes - Hyperparathyroidism - Pregnancy (B, C) and lactation |
| Hydrochlorothiazide: Indications | - Adjunctive therapy for edema associated with CHF, cirrhosis, corticosteroid or estrogen therapy, and renal dysfunction; treatment of hypertension as monotherapy or in combination with other antihypertensives |
| Hydrochlorothiazide: Actions | - Inhibits reabsorption of sodium and chloride in distal renal tubules, increasing the excretion of sodium, chloride, and water by the kidneys |
| Hydrochlorothiazide: AE/SE | - Dizziness, vertigo, orthostatic hypotension, nausea, anorexia, vomiting, dry mouth, diarrhea, polyuria, nocturia, muscle cramps or spasms (build up of Ca leads to muscle spasms), headaches, decreased calcium excretion, hypokalemia, increased blood glucose levels, urine slightly alkalinized (HCO3 loss), dysrhythmias (urine more alkaline -- increase risk of infection) |
| Theo is for REAL but don't give it to a BEAR | Theo = Thiazide Renal (physical) dysfunction Edema Adjunct to hypertension Liver Disease Bi-polar Electrolyte imbalance Allergy to sulfonimides/Thiazide Renal (chemical) Disease/Liver Disease |
| Heparin | - Normally found in mast cells - Enhances inhibitory action of antithrombin III, interferes w/ conversion of prothrombin to thrombin (prolongs coagulation time) - Inactivated by stomach acids - can not be given orally - Administer IV or SC - avoid IM, do NOT massage or aspirate - SC site - Antidote: 1% Protamine sulfate - Labs - APTT or PTT - Side effect - bleeding (hemorrhage) - Pregnancy category B |
| Heparin: Indications | - Prevention and treatment of venous thrombosis and pulmonary emboli; treatment of atrial fibrillation with embolization; diagnosis and treatment of DIC; prevention of clotting in blood samples and heparin lock sets |
| Heparin: Actions | - Inhibits thrombus and clot production by blocking the conversion of prothrombin to thrombin and fibrinogen to fibrin |
| Heparin: AE/SE | - Loss of hair, bruising, chills, fever, osteoporosis, suppression of renal function (with longterm use) |
| Heparin Patient/Family Teaching | - Avoid activities that may result in injury - NO contact sports - Immediately report bleeding problems - Menstruation may be increased - Avoid smoking and alcohol - Do not take other drugs or supplements - Learn subcutaneous injection techniques - Inform dentist prior to procedures - Use soft toothbrush - Use electric razor |
| Heparin Nursing Considerations: | - Baseline blood tests - whole blood clotting time 2.5 to 3 times control - Monitor aPTT (activated partial thromboplastin time) 1.5 to 3 times control value - Collect blood for testing 30 minutes prior to dose - Monitor for signs of bleeding - Apply firm pressure x 10 minutes for needle sticks & discontinuing IV site - Reduce risk of trauma - Antidote: protamine sulfate - administer slowly - Not to exceed 50mg IV in 10 minutes |
| Heparin (memory) |  |
| Low-Molecular Weight Heparins Actions | - Inhibit thrombus and clot formation by blocking factors Xa and IIa - Block angiogenesis, the process that allows cancer cells to develop new blood vessels - Do not greatly affect thrombin, clotting, or prothrombin times; therefore cause fewer systemic adverse effects - Indicated for prevention of clots and emboli formation after certain surgeries or prolonged bed rest - Administer for 7 to 14 days postoperative |
| Low molecular weight heparin: enoxaparin (Lovenex), dalteparin (Fragmin), tinzaparin (Innohep) | - Inhibits coagulation factor X - Administered SC in anterolateral or posterolateral abdominal wall (love handles) - Never aspirate or massage site - Dose based on weight, not labs - Adverse effect: bleeding, same as heparin - Antidote: Protamine sulfate |
| Warfarin (Coumadin) general info | - Oral route - 99% protein bound - Does NOT dissolve clots - prevents clots - Adverse effects: bleeding, hypotension, wheezing, rash, hair loss, swelling of face, lips, tongue, prolonged & painful erections - Teratogenic - pregnancy category D - Takes several days to reach maximum effect - Genetic marker for metabolism |
| warfarin (Coumadin) Nursing Considerations | - Monitor Prothrombin Time (PT) 1.5 to 2.5 times control value and International Normalized Ratio (INR) of 2 - 3 - Monitor urine, stool, liver function, and blood - Monitor risk groups for nonadherence - Antidote: Vitamin K - Schedule regular periodic blood tests |
| warfarin (Coumadin) Patient/Family Teaching | - Minimize risk of injury - Use same brand and take at same time - Avoid high-fat diet, moderate vitamin K foods - Avoid excessive alcohol - Extra precautions to avoid pregnancy - Notify all physicians, dentists, podiatrists if taking - Wear MedicAlert bracelet - Report: red or black stools, red or orange urine, nosebleeds, - severe headaches, stomach pains, bruising, excessive bleeding, unusually heavy menstrual periods |
| Warfarin Sodium (Coumadin) (memory) |  |
| Anticoagulants: heparin, LMWH | - SQ or IV - Prevents the formation of clots - Prolongs clotting time - Antidote: protamine sulfate - Labs: PTT and WBCT |
| Anticoagulants: warfarin (Coumadin) | - PO - Prevents the formation of clots - Prolongs clotting time - Antidote: Vitamin K - Labs: PT and INR - Teratogenic |
| Bleeding Precautions (memory) |  |
| Aspirin: Indications | Reduction of risk of recurrent TIAs or strokes in males with a history of TIA due to fibrin or platelet emboli; reduction of death or nonfatal MI in patients with a history of infarction or unstable angina; MI prophylaxis; also used for its anti-inflammatory, analgesic, and antipyretic effects |
| Aspirin: Actions | Inhibits platelet aggregation by inhibiting platelet synthesis of thromboxane A2 |
| Aspirin: AE/SE | Acute aspirin toxicity with hyperpnea, possibly leading to fever, coma, and cardiovascular collapse; nausea, dyspepsia, heartburn, epigastric discomfort, GI bleeding, occult blood loss, dizziness, tinnitus, difficulty hearing, anaphylactoid reaction |
| Antiplatelet Drugs Nursing Considerations | - Monitor lab tests - complete blood count (CBC), clotting times - Observe for bleeding - bruising, use pressure dressings & ice - Watch for hypersensitivity (allergy) - Minimize bleeding risk - Use soft toothbrush, electric razor, no contact sports - Elevate head of bed and keep limb straight when femoral artery access is used |
| Antiplatelet Drugs Patient/Family Teaching | - Immediately report unusual bleeding - Do not use other medications or other OTC medications or herbal supplements - Teach to use electric razor, soft toothbrush - No contact sports - Wear MedicAlert bracelet |
| Nitroglycerin: Indications | Treatment of acute angina, prophylaxis of angina, intravenous treatment of angina unresponsive to beta-blockers or organic nitrates, perioperative hypertension, congestive heart failure (CHF) associated with acute MI; to produce controlled hypotension during surgery |
| Nitroglycerin: Actions | Relaxes vascular smooth muscle with a resultant decrease in venous return and decrease in arterial blood pressure, reducing the left ventricular workload and decreasing myocardial oxygen consumption |
| Nitroglycerin: AE/SE | Hypotension, headache, dizziness, tachycardia, rash, flushing, nausea, vomiting, sweating, chest pain |
| Nitrates Nursing Considerations | - Administer 1 tab SL every 5 min x 15 min - No relief call health care provider - Store dark vial - Tablet should burn or "fizzle" - Instruct not to swallow tablets - Instruct not to chew/crush sustained-release - Wear gloves for transdermal patch (can cause headache die to vasodilation) - Spray translingual spray under tongue, not inhaled - Wean off over 4-6 weeks |
| Nitrates Patient/Family Teaching | - Take at earliest sign of anginal pain - Slow position changes - Call 911 if pain unrelieved by 3 tablets - 5 minutes apart - over 15 minutes - Take 5 -10 minutes prior to exercise - Remove patches at bedtime, apply in AM - Report blurred vision, dry mouth, chest pain, fainting - Avoid alcohol, coffee, cigarettes - Wear medic-alert bracelet - Store in dark container, replace every 3 months (lose potency really quickly) - Dress appropriately in cold weather - wear mask (cold gives chest pains - teach to stay in when very cold) |
| Nitroglycerin (memory) |  |
| Antihypertensive Drugs (memory) |  |
| ACE Inhibitor (memory) |  |
| ACE Inhibitor method of action | Decrease in blood flow (kidneys) signals --> release of renin --> angiotension --> enzyme --> angiotensen II --> increase in peripheral resistance --> increase in BP ACE Inhibitors block the enzyme and stops the process which leads to a reduction in BP |
| Angiotensin-Converting Enzyme Inhibitors (ACE) Actions | Blocks ACE from converting angiotensin I to angiotensin II, leading to a decrease in blood pressure, a decrease in aldosterone production, and a small increase in serum potassium levels along with sodium and fluid loss |
| Angiotensin-Converting Enzyme Inhibitors (ACE) Contras | - Allergies - Impaired renal function - Pregnancy (birth defects) and lactation |
| Angiotensin-Converting Enzyme Inhibitors (ACE) Caution | HF (don't want to slow down the heart too much) |
| ACE Inhibitors Nursing Considerations | - Assess blood pressure prior to administration - Hold for BP 90-100/60 (Have to have BP before giving drug) - Administer on an empty stomach 1 hour before or 2 hours after meals - Watch for "first dose phenomenon" - Prevent dehydration - Decrease dose for renal failure - Dry, hacking cough is a common adverse effect |
| Angiotensin II Receptor Blockers: Indications | Alone or as part of combination therapy for the treatment of hypertension; treatment of diabetic nephropathy with an elevated serum creatinine and proteinuria in patients with type 2 diabetes and hypertension |
| Angiotensin II Receptor Blockers: Actions | Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal glands; blocks the vasoconstriction and release of aldosterone associated with the renin-angiotensin system |
| Angiotensin II Receptor Blockers: AE/SE | Dizziness, headache, diarrhea, abdominal pain, symptoms of upper respiratory tract infection, cough, back pain, fever, muscle weakness, hypotension (Liver and kidneys must be in good working order) |
| Angiotensin II Receptor Blockers Nursing Considerations | - Can take with food (irritating to GI tract) - Prevent dehydration - Do not use if pregnant or breastfeeding - Use barrier contraceptives - Discontinue immediately if pregnant - Watch for syncope, cough, alopecia (hair loss) |
| Beta Blockers Mnemonic | B = Bronchospasms - do NOT give to patients with bronchoconstrictive diseases E = Elicits decrease in cardiac output & contractility T = Treat hypertension A = AV conduction decreases - treats arrhythmias Do NOT discontinue abruptly - causes rebound angina, confusion in elderly, psychosis |
| Beta Blockers Indications | Treatment of cardiac arrhythmias, especially supraventricular tachycardia; treatment of ventricular tachycardia induced by digitalis or catecholamines |
| Beta Blockers Action | Competitively blocks beta-adrenergic receptors in the heart and kidney; has a membrane-stabilizing effect and decreases the influence of the sympathetic nervous system |
| Beta Blockers AE/SE | Bradycardia, CHF, cardiac arrhythmias, heart blocks, cerebrovascular accident (CVA), pulmonary edema, gastric pain, flatulence, nausea, vomiting, diarrhea, impotence, decreased exercise tolerance, antinuclear antibody (ANA) development |
| Beta Blockers Nursing Considerations | - Monitor BP, Pulse, and Respiratory status (you will want to know if the lings are filling up c fluid) - Obtain medical history - * asthma, COPD - smoking - drugs cause loss of bronchodilation - diabetics - monitor blood glucose frequently (due to the tendency of B blockers to increase blood glucose levels) - Wean off drug over 2 weeks - Teach to change positions slowly - Explain change in sexual function - Review laboratory tests: - kidney, liver, electrolytes |
| Calcium Channel Blockers Indications | Treatment of essential hypertension |
| Calcium Channel Blockers Actions | Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells, depressing the impulse and leading to slowed conduction, decreased myocardial contractility, and dilation of arterioles, which lowers blood pressure and decreases myocardial oxygen consumption |
| Calcium Channel Blockers Contras | Allergy, heart block or sick sinus syndrome (don't want to decrease it if it is already too slow), renal or hepatic dysfunction, pregnancy, and lactation |
| Calcium Channel Blockers AE/SE | Dizziness, light-headedness, headache, peripheral edema, bradycardia, atrioventricular block, flushing, nausea |
| Calcium Channel Blockers Nursing Considerations | - Monitor BP, Pulse, cardiac status (are there any arrhythmias? listen to the apical and feel the radial pulse at the same time) - Grapefruit juice increases drug to toxic level (interferes c P-450 enzyme system which is the livers system to detoxify drugs) - Take 1 hour before or 2 hours after meals - Prevent dehydration - Wean off drug - Do not use in pregnancy or breastfeeding - African Americans respond better to CCBs |
| B1 and B2 Blocker Actions (memory) |  |
| Beta Blocker Actions (memory) |  |
| Beta Blocker AE/SE (memory) |  |
| Cardiac Glycosides overview | - Slows heart rate (- chronotropic) - Increases force of myocardial contraction (+ inotropic) - Decreases conduction velocity through the AV node (- dromotropic) - Increases cardiac output and renal perfusion - Increases urine output and decreased blood volume |
| Cardiac Glycosides Indication Digoxin: | Treatment of CHF, atrial fibrillation |
| Cardiac Glycosides Digoxin: Actions | Increases intracellular calcium and allows more calcium to enter the myocardial cell during depolarization; this causes a positive inotropic effect (increased force of contraction), increased renal perfusion with a diuretic effect and decrease in renin release, a negative chronotropic effect (slower heart rate), and slowed conduction through the atrioventricular (AV) node |
| Cardiac Glycosides Digoxin: AE/SE | Headache, weakness, drowsiness, visual disturbances, arrhythmias, GI upset digoxin (Lanoxin, Lanoxicaps) |
| Cardiac Glycosides Patient/Family Teaching | - Take radial pulse daily report <60 or >110 (at >110 drug levels are either getting too toxic or not working) - Immediately report adverse effects - Check weight daily, report gain 2 lb in 2 days - Administer before or after meals - not with food - Diet - eat high K+ foods (wastes K+) - Take as prescribed - Do not take any OTC medications, esp. antacids (antacids interfere with absorption) - Do not switch brands - Do not breastfeed |
| Cardiac Glycosides Nursing Considerations | - Take apical pulse for 1 minute before administration. - Withhold medication if apical pulse below parameters (Adult = 60, Child = 70, Infant = 90, newborn = 100) - Administer loading or "digitalizing" dose - Narrow therapeutic index (0.5 - 2.0 ng/ml - toxic > 2.0 ng/ml)(must follow c labs to monitor) - Monitor lab values - K+ - Monitor I & O, daily weight - No IM injection, administer IV slowly over 5 minutes - Antidote: Digoxin Immune Fab, Digibind, Digifab |
| Cardiac Glycosides: Lizzy Dizzy (memory) |  |
| Loop Diuretics: furosemide (Lasix) | Most commonly used; less powerful than new drugs; larger margin of safety for home use |
| Loop Diuretics Furosemide: Indicaitons | Treatment of edema associated with CHF, acute pulmonary edema, hypertension |
| Loop Diuretics Furosemide: Actions | Inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle, leading to a sodium-rich diuresis increase risk of hyponatremia |
| Loop Diuretics Furosemide: AE/SE | Dizziness, vertigo, paresthesias, blurred vision, orthostatic hypotension, thrombophlebitis, photosensitivity, rash, urticaria, nausea, anorexia, vomiting, constipation, glycosuria, urinary bladder spasm, leukopenia, anemia, thrombocytopenia, muscle cramps, and spasms, hypokalemia, hypocalcemia, tachycardia, metabolic alkalosis, ototoxicity (8th cranial nerve damage -> tinnitus --> deafness) |
| Nursing Considerations - Potassium Wasting Diuretics | - Measure BP, P before taking & regularly - Monitor: daily weight (report 3 lb increase)(same scale, same time, same clothing), - I & O, skin turgor, lung sounds, heart sounds - Rise slowly - Administer early in day, bathroom access - Provide K+ diet - Take with meals, milk to decrease GI upset - Monitor electrolytes - K+, Ca +, glucose - Adequate fluid intake - fluid rebound - page 816 - Avoid extravasation if given IV |
| Potassium Rich Foods: | Avocados, Bananas, Broccoli, Cantaloupe, Dried fruits Grapefruit, Lima beans, Nuts, Navy beans , Oranges, Peaches, Potatoes, Prunes, Rhubarb, Sanka coffee, Sunflower seeds, Spinach, Tomatoes, Watermelon |
| normal potassium levels: | 3.5 - 5 mg/dL |
| What is the most effective way for the nurse to evaluate effectiveness of diuretics? | pt's weight |
| Xanthines (Aminophylline is IV form Theophylline in oral form): Actions | - Direct effect on the smooth muscles of the resp tract, both in the bronchi and in the blood vessels. Used for apnea and bradycardia in premature infants - Used for Cheyne-Stokes respirations |
| Xanthines (Aminophylline is IV form Theophylline in oral form): Indications | symptomatic relief of bronchial asthma & reversible bronchospasm asstd c bronchitis & emphysema |
| Xanthines (Aminophylline is IV form Theophylline in oral form): Caution/Contras | GI problems, coronary disease, respir dysfunction, renal or hepatic disease, alcoholism, or hyprthyroidism sml thera margin: 10 - 20 mcg/mL |
| Xanthines (Aminophylline is IV form Theophylline in oral form): Drug-Drug | - Many drugs interact with xanthines - Nicotine increases the metabolism of Xanthines |
| Xanthines (Aminophylline is IV form Theophylline in oral form): AE/SE | Irritability, restlessness, dizziness, palpitations, life-threatening arrhythmias, loss of appetite, proteinuria, respiratory arrest, fever, flushing, GI upset, seizures, brain damage, death |
| Xanthines (Aminophylline is IV form Theophylline in oral form): PT/NC | - Advise NO smoking - Administer oral drug with 8 oz water or food or milk (GI upset) - Decrease caffeine use - Excessive charcoal-broiled foods decrease effectiveness - Provide rest periods and quiet environment - Treat headaches - Periodic blood tests to monitor serum theophylline levels - Avoid OTC medications |
| Narcotic Agonist Morphine: Indication | Relief of moderate to severe acute or chronic pain; preoperative medication; component of Brompton's cocktail for severe chronic pain; intraspinal to reduce intractable pain |
| Narcotic Agonist Morphine: Actions | Acts as an agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, and sedation |
| Narcotic Agonist Morphine: AE/SE | Light-headedness, dizziness, sedation, nausea, vomiting, dry mouth, constipation, ureteral spasm, respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest |
| Morphone (memory) |  |
| Statins: HMG-CoA Reductase Inhibitors: Actions | Inhibits HMG-CoA reductase enzyme (controls production of cholesterol), decreases serum cholesterol levels, LDLs, and triglycerides, increases HDL levels *help decrease intermittent claudication pain* |
| Statins: HMG-CoA Reductase Inhibitors: Contraindications | Allergy to drug or fungi Active liver disease or history of alcoholic liver disease Pregnancy (Category X) or lactation |
| Statins: HMG-CoA Reductase Inhibitors: Caution | Impaired endocrine function |
| Statins: HMG-CoA Reductase Inhibitors: AE/SE | GI symptoms: flatulence, abdominal pain, cramps, nausea, vomiting, and constipation CNS: headache, dizziness, blurred vision, insomnia, fatigue, cataracts Liver failure Rhabdomyolysis (injury to glomerulus causing renal failure) the breakdown of muscle fibers that leads to the release of muscle fiber contents (myoglobin) into the bloodstream. |
| Statins: HMG-CoA Reductase Inhibitors: Drug-Drug | erythromycin, cyclosporine, gemfibrozil, niacin, antifungal drugs cause increased risk of rhabdomyolysis digoxin or warfarin = increases toxicity Increases estrogen levels w/ oral contraceptives Grapefruit juice = increased serum levels & toxicity of inhibitor |
| Statins: HMG-coA Reductase Inhibitors Nursing Considerations | Obtain baseline lipid values Monitor LDL and serum cholesterol levels Assess lipid lab tests within 2 - 4 weeks of initiation of therapy or change in dose Exercise program for 3 - 6 months prior to taking Obtain baseline weight Assess for signs of rhabdomyolysis (breakdown of muscle fibers resulting in the release of muscle fiber contents (myoglobin) into the bloodstream - can lead to kidney damage) Observe for digoxin and warfarin toxicity Withhold if serious medical condition Discontinue if liver function tests 3 times normal - AST & ALT |
| Statins: HMG-CoA Reductase Inhibitors Patient/Family Teaching | Take in evening (bedtime) with food Maintain cholesterol-lowering diet Avoid grapefruit/grapefruit juice Avoid drug interactions Counsel about pregnancy and lactation Use barrier method of contraception Restrict/eliminate alcohol intake Periodic eye exams |
| Vasodilators: Indications | Hypertensive crisis, maintenance of controlled hypotension during anesthesia, acute CHF |
| Vasodilators: Actions | Acts directly on vascular smooth muscle to cause vasodilation and drop of blood pressure; does not inhibit cardiovascular reflexes and tachycardia; renin release will occur |
| Vasodilators: AE/SE | Apprehension, headache, retrosternal pressure, palpitations, cyanide toxicity, diaphoresis, nausea, vomiting, abdominal pain, irritation at the injection site |
| Vasodilators Nursing Considerations | - Light sensitive - Monitor for cyanide toxicity - see page 687 Suppresses iodine uptake - hypothyroidism Monitor BP closely during administration Prevent dehydration |
| clopidogrel (Plavix) Patient/Family Teaching | Immediately report unusual bleeding or bruising Know it may take longer to stop bleeding Do not stop taking drug Do not use NSAIDs including ASA, other OTC medications, or herbal supplements Inform dentist and other care providers prior to procedures Evaluate unexplained fever/infection |
| clopidogrel (Plavix) is a | Platelet Aggregation Inhibitor - stops platelets from sticking together |
| clopidogrel (Plavix) (memory) |  |
| pentoxifylline (Trental) is a | blood viscosity reducing agent |
| pentoxifylline (Trental) | used to improve blood flow in patients with circulation problems to reduce aching, cramping, and tiredness in the hands and feet. It works by decreasing the thickness (viscosity) of blood. This change allows your blood to flow more easily, especially in the small blood vessels of the hands and feet. *Management of symptomatic peripheral vascular disease (intermittent claudication)* |
| pentoxifylline (Trental) AE/SE | CNS: agitation, dizziness, drowsiness, headache, insomnia, nervousness. EENT: blurred vision. Resp: dyspnea. CV: angina, arrhythmias, edema, flushing, hypotension. GI: abdominal discomfort, belching, bloating, diarrhea, dyspepsia, flatus, nausea, vomiting. Neuro: tremor. |
| pentoxifylline (Trental) Nursing Considerations | - Assess patient for intermittent claudication prior to and periodically throughout therapy - Monitor blood pressure periodically in patients on concurrent antihypertensive therapy |
| pentoxifylline (Trental) Patient Teaching | - Consult health care professional before discontinuing medication, because several weeks of therapy may be required before effects are seen - May cause dizziness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to medication is known - Advise patient to avoid smoking, because nicotine constricts blood vessels - Instruct patient to notify health care professional if nausea, vomiting, GI upset, drowsiness, dizziness, or headache persists |
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