from the greek meaning without sitting.

is a syndrome characterized by unpleasant sensations of “inner” restlessness that manifests itself with an inability to sit still or remain motionless.


  • as a side effect of medications:
  • neuroleptic antipsychotics eg phenothiazines
  • antispasmodics
  • antidepressants.
  • to a lesser extent, be caused by Parkinson’s disease and Parkinsonian-like syndromes.

The Transdermal Nitroglycerin Patch




  • Long term prophylactic management of angina pectoralis
  • Control of hypotension of the surgical patient
  • Management of chronic CHF


  • acts directly on the smooth muscle of the blood vessels in a similar manner to that of the natural endothelium derived relaxing factor, nitric oxide.
  • increases coronary blood flow by dilating coronary arteries
  • decreases left ventricular end-diastolic volume and left ventricular end-diastolic volume

Transdermal patch time profile:

  • onset = 40-60min
  • duration = 8-24hrs

Route and Dose

  • 0.1-0.6mg/hr
  • up to 0.8 mg/hr
  • Patch worn 12-14hrs/day
  • prevention of nitrate tolerance by maintaining the presence of therapeutic serum levels for only 12-14 hrs/day
  • If nitrates are administered around the clock, tolerance to their effects develops


The University of British Columbia. 1995. Medical Management of Ischemic Heart Disease: The Optimal Use of Nitrates. Therapeutics Initiative. Retrieved January 18, 2010 from http://www.ti.ubc.ca/node/94

The Subcutaneous Butterfly


The subcutaneous tissue lies between the skin (epidermis and dermis) and the underlying muscle; it is made up of loose connective tissue and varying amounts of fat.  It also contains cutaneous nerves, small lymph vessels and blood vessels.

 Subcutaneous treatment can be given when treatment is not suitable to be given orally. Subcutaneous treatment can be given in preference to intramuscular medication.

Subcutaneous treatment can be given in preference to intravenous treatment.

medication may be given several times a day into the same site.

The most frequently used sites include

  • Abdomen and chest wall (avoiding the umbilical area)
  • Thighs: upper and lateral aspects
  • Buttocks
  • Upper arms: upper and outer aspects

Subcutaneous injections

  • 1-2mls can be injected as a bolus into a site.

Subcutaneous infusions

  • The abdomen is frequently chosen for infusion of larger volumes.  However, many individuals do not like the thought of having needles in their abdomen.
  • Erythema and swelling at the site of infusion





  • anticoagulant
  • reduces risk of thrombus formation


Heparin Hemorrhage Risk Indicators

  • bleeding gums
  • hemotemesis
  • hematuria
  • melena



  • aPTT = activated partial thromboplastin time or PTT = partial thromboplastin time
  • allows therapeutic heparin range to be monitored


Preexisting conditions that contraindicate heparin use:

  • threatened abortion
  • cerebral of aortic aneurysm
  • cerebrovascular hemorrhage
  • severe hypertension
  • blood dyscrasia
  • recent opthalmic surgery
  • recent neurosurgery


Preexisting conditions indicative of increased hemorrhage risk

  1. recent childbirth
  2. severe diabetes
  3. severe retanopathy
  4. hepatopathy
  5. severe trauma
  6. vasculitis
  7. active ulcer or GI lesion
  8. GU or Respiratory tract lesion


Over the counter medications which increase hemorrhage risk

  1. aspirin
  2. nonsteroidal antiinflammatories
  3. cephalosporins
  4. antithyroid agents
  5. probenecid
  6. thrombolytics
  7. garlic
  8. ginger
  9. ginkgo
  10. horse chestnut
  11. feverfew


Intramuscular (IM) Injections


IM injection sites

  1. faster absorption that sub Q due to greater vascularity of muscle

  2. weight and amount of adipose tissue can influence needle site selection

  3. obese clients may require a 7.5cm long needle

  4. thin clients may require a 1.3-2.5cm needle

  5. 90 degree angle for IM

  6. healthy average sized pt can tolerate a 3mL dose into a large muscle

  7. Children and seniors can tolerate 2mL

  8. Small children and large infants 1mL


Site selection factors:

  1. free or infection or necrosis

  2. free of local bruising or abrasions

  3. location of underlying bones, nerves and major blood vessels


Common Muscle Groups for IM injection Sites


  1. Gluteus medius

  1. Vastus Lateralis

 3. Dorsogluteal

 4. Deltoid



Perry, A, G, Potter, P, A, Ross-Kerr, J, C and Wood, M, J. 2006. Canadian fundamentals of nursing. 3rded. Toronto: Elselvier

Subcutaneous Injections and Body Sites


Preparing a subcutaneous injection:




Wash your hands thoroughly with soap and water. Dry on a clean towel.Remove the plastic cap from the drug vial. Wipe the top of the rubber stopper with an alcohol swap. let dry for 10 seconds.



 After removing the bubbles, check the dose of medication in the syringe to be sure that you have drawn up the correct dose. Draw up more medication as needed then repeat the above steps to remove air bubbles.  

 Carefully recap the needle to prevent needle stick injuries during transit to the administration location.

 Use a chart for injection sites, and mark each site once it is used.


This is important because repeated injections in the same area can cause scarring and hardening of fatty tissue that will interfere with absorption of medication.

  Expose the injection site. Clean the skin in a circular motion with an alcohol swab, beginning at the center and moving outwards, and let the area dry for about 10 seconds. Remove the needle cap. Hold the syringe barrel as if you were holding a pencil.With your other hand, pinch a fold of skin where the injection will be made.


Hold the syringe at a 45o to 90o angle (half-slanted to straight up from the surface), about 2 inches from the skin surface.




 Insert the needle with a quick jab, as if throwing a dart. The needle should go all of the way into the skin.

Pull back on the plunger a little.

If you see blood in the syringe, do not inject the solution.

Remove the syringe right away and discard this syringe.

Prepare a new syringe and try again at a new site.

If there is NO blood in the syringe, slowly push the plunger to inject the drug solution.

Remove the needle.

Put a clean alcohol swab over the injection site, hold for 5 seconds.

If there is bleeding cover with an adhesive bandage.

SC1.jpg image by derixc




 Choosing an injection site:

Rotate injection sites, so that the same site is only used once every 6 to 7 weeks.

 Use an injection site where there is a layer of fat between the skin and muscle, such as the thighs, upper arms or abdomen.

 Remove the needle cap, and push the needle through the rubber stopper into the vial. 

Turn the vial upside down and make sure that the needle tip is in the solution. 

 Pull back the syringe plunger slowly, to draw out your dose.  

Remove the needle from the vial and gently tap the syringe barrel (needle end up) to clear air bubbles. Collect air bubbles at the top of the syringe barrel and slowly push the plunger to eject air. 


Perry, A, G, Potter, P, A, Ross-Kerr, J, C and Wood, M, J. 2006. Canadian fundamentals of nursing. 3rded. Toronto: Elselvier

Hypertension Etiology and Management




  • systolic 130-139

  • diastolic readings of 85-89

 NB: normal BP = 120/80



  • systolic greater than 140 mmHg

  • diastolic 90 mm Hg




  • thickening of the arterial walls

  • loss of elasticity in the arterial walls

  • Increase in peripheral vascular resistance within the thick and inelastic vessels

  • Heart pumps against greater resistance

  • result: blood flow to vital organs (heart, brain and kidneys) decreases


Anti-Hypertension Medications



Mechanism of Action


Furosenmide (Lasix)

Spironolactone (Aldactone)




Lowers blood pressure by reducing reabsorption of sodium and water.by the kidneys and thereby lowering the volume of circulating blood

Beta-Adrenergic Blockers

Atenolol (Tenormin)

Nadolo (Corgard)

Timolol Maleate (Blocadren)

Propranolol (Inderal)

Combine with beta-andrenergic receptors in the heart, arteries and arterioles to block response to sympathetic nerve impulses

reduce heart rate and thereby reduce cardiac output


Hydralasine hydrochloride (Apresoline)

Minoxidil (Loniten)

Act on arteriolar smooth muscle to cause relaxation and reduce peripheral vascular resistance

Calcium channel blockers

Diltiazem (Cardizem, Dilacor XR)Verpamil hydrochloride (Calan SR)

Nifeddipine (Procardia)

Nicardipine (Cardine)

Reduce peripheral vascular resistance by systemic vasodilation

Angiotensin-converting enzyme (ACE) inhibitors

Captopril (Capoten)

Enalapril (Vasotec)

Lisinopril (Prinivil, Zestril)

Benazepril (Lotensin)

Lower blood pressure by blocking the conversion of angiotensin I to angiotensin II, preventing vasoconstriction, reduce aldosterone production and fluid retension, lowering circulating fluid volume


Step approach to Antihypertensive therapy


  1. Initially begin with less than the maximum dose of a thiazide type diuretic, then gradually increase the dose as required until maximum dosage is reached

 2. If blood pressure is not controlled with diuretics alone a sympathetic inhibitor should be added. The dose is increased as required until maximum dosage is reached or side effects appear at the higher level of this medication.

 3. If a third drug is needed to manage the hypertension, hydralazine type peripheral vasodilators are used in combination with the sympathetic inhibitor and diuretic.

 4. If the first three steps are ineffective and reasons other than drug failure have been ruled out, guanethidine, minoxidil or captopril may be added in increasing doses as needed or substituted for one of the drugs.

Perry, A, G, Potter, P, A, Ross-Kerr, J, C and Wood, M, J. 2006. Canadian fundamentals of nursing. 3rded. Toronto: Elselvier