Ephedrine Nursing Considerations, Patient Teachings, and More

Kenneth Oja, PhD, RN

This article will cover key information about ephedrine and what nurses need to know when caring for the client taking ephedrine.

Ephedrine Key Information

Ephedrine is an alpha and beta-adrenergic agonist, decongestant, bronchodilator, and vasopressor. It is available as "ephedrine sulfate" or "ephedrine hydrochloride.” Still, nurses may also encounter clients who are taking a brand name medication containing ephedrine such as Akovaz, Bronkaid, Corphedra, Emerphed, Primatene, or Rezipres.

CONTENT

What is it?
Pharmacology
Indications
Administration and Dosage
Contraindications
Nursing Considerations
Ephedrine FAQs

Ephedrine raises blood pressure by stimulating heart rate and cardiac output, which increases the body's peripheral vascular resistance⁽¹⁾. It also causes bronchodilation, making it easier for clients to breathe by relaxing smooth muscles in the lungs and opening up airways (bronchi) that have become narrowed or inflamed by certain conditions such as asthma or allergies⁽¹⁾.

Other therapeutic functions include reducing swelling in the nasal passages and chest and decreasing mucus production.

Nurses should be aware that clients may be taking ephedrine in one of its multiple forms, which include nasal sprays and solutions, tablets, capsules, and intravenous or intramuscular solutions.

Pharmacology

Mechanisms of Action

As a sympathomimetic amine, the primary mechanism of action of ephedrine depends on its secondary effect on the adrenergic receptor system.

The agonist activity at the alpha and beta-adrenergic receptors is weak, so the primary mechanism is to displace norepinephrine from storage vesicles in presynaptic neurons. This displaced norepinephrine is delivered into the neuronal synapse triggering the postsynaptic alpha and beta-adrenergic receptors.

This stimulation of the alpha and beta-adrenergic receptors causes the therapeutic effects of increasing the body's peripheral vascular resistance, which raises blood pressure, and bronchodilation, which is the relaxing of the smooth muscles in the lungs and opening up of the airways that makes it easier for clients to breathe⁽¹⁾.

Pharmacokinetics

Ephedrine is quickly absorbed in the body after being taken by mouth. The half-life is about 6 hours, with peak plasma concentrations occurring in about 1 hour⁽²⁾. A small amount of ephedrine is metabolized in the liver and it is mostly excreted in the urine⁽²⁾.

Ephedrine Indications

One of the most common indications for ephedrine is to treat symptomatic hypotension in clients undergoing surgical procedures.

The administration of spinal or epidural anesthesia before and during surgery can significantly lower blood pressure requiring ephedrine to return the blood pressure to normal levels⁽¹⁾.

Other Common Indications

Allergy Relief: Exposure to allergens can cause airways in the lungs to become narrowed or inflamed. As a bronchodilator, ephedrine opens up the airways and improves breathing.
Nasal Congestion⁽³⁾: Ephedrine causes vasoconstriction in the upper respiratory tract, which shrinks swollen mucous membranes and can open up clogged nasal passages. This decreased swelling promotes the drainage of mucous and improves breathing.

Less Common Indications and Off-label Use

Asthma: While ephedrine can be used to treat asthma, its use for this condition is rare due to the possible cardiovascular side effects and availability of other medications such as albuterol⁽¹⁾.
Myasthenia Gravis: As a central nervous system (CNS) stimulant, it can be used as an additive therapy to improve symptoms and weakness in clients with myasthenia gravis.
Urinary Incontinence: A study from 1975 found ephedrine to be effective in treating urinary incontinence due to its ability to stimulate urethral closure, but this isn't a common treatment by current standards.
Dysmenorrhea: Clients experiencing menstrual pain or cramping can benefit from ephedrine due to its ability to increase uterine blood flow.
Mydriatic Agent: Local application to the eye dilates the pupils. Medications that produce mydriasis can be used during eye exams for a more in-depth examination of the retina.
Type I Diabetic Neuropathy: Clients with this condition may experience peripheral edema and ephedrine may reduce the swelling with its ability to produce a diuretic effect.
Narcolepsy and Depressive States: Two additional conditions that can benefit from ephedrine as a CNS stimulant, though used off-label.
Adams-Stokes Syndrome: Ephedrine has also been used off-label to treat this condition due to the similar-acting properties of epinephrine.
Weight Loss: This is another off-label use for ephedrine, but its use for this purpose was banned by the Food and Drug Administration (FDA) for the association with heart attacks, strokes, seizures, and sudden deaths.

Administration and Dosage

Some of the most common uses are included below with potential dosage and considerations.

Indication: Hypotension secondary to spinal anesthesia

Route: IV

Dose: For adults, initial dose: 5-10 mg bolus. Administer additional boluses as needed, not to exceed a total cumulative dosage of 50 mg. Titrate dosage according to blood pressure goal.

Considerations: Premixed formulations (Emerphed and Rezipres) should NOT be diluted before use. Do not use unless the liquid is completely clear. Start at the lower dosing range in geriatric clients and those with decreased renal, hepatic, or cardiac function.

Indication: Bronchodilation, Nasal Decongestant

Route: PO

Dose:

For adults, initial dose: 5-10 mg bolus. Administer additional boluses as needed, not to exceed a total cumulative dosage of 50 mg. Titrate dosage according to blood pressure goal.
For children greater than 2 years, 3 mg/kg/d in 4-6 divided doses. 6-12 years: 6.25-12.5 mg every 4 hours. Maximum dose should not exceed 75 mg in 24 hours)

Considerations: Instruct clients to take the last dose around bedtime, if they can, to minimize insomnia.

Indication: Nasal Decongestant

Route: IN

Dose: For adults, 2-4 drops in each nostril every 4 hours.

Considerations: Instruct clients to clear their nose before administration. Clients should not use the medication for more than 3 or 4 days.

*Dosage Note: Administration and dosage may vary by brand. Nurses must know the specific brand being used and always follow the administration and dosage guidelines outlined by the drug manufacturer.

Important: Ephedrine is on the Institute for Safe Medication Practice's list of confused drug names. It is critical that nurses DO NOT confuse ePHEDrine with EPINEPHrine.

Contraindications for Ephedrine

While the use of ephedrine is generally considered safe, nurses must conduct a thorough health history of clients who are taking ephedrine to identify certain conditions where its use might be contraindicated or require extra precautions⁽⁴⁾:

History of high blood pressure, heart disease, or stroke: Ephedrine can cause increased heart rate and blood pressure, which is dangerous for clients with existing cardiovascular conditions.
Mental health diagnoses: A potential side effect of ephedrine is anxiety, thus it should be avoided by clients who have a history of anxiety or depression.
Undergoing therapy with monoamine oxidase (MAO) inhibitors: The cardiac and pressor effects of ephedrine could be prolonged or exacerbated by MAO inhibitors.
Pregnant or breastfeeding women: Ephedrine should be avoided during pregnancy and nursing as the effects on the newborn and breast milk production are unknown.
Children under the age of 12: Only use with extreme caution as the safety and efficacy of ephedrine in the pediatric population have not been established by the Food and Drug Administration (FDA).
Closed-angle glaucoma: Ephedrine could exacerbate this condition.
Hyperthyroidism: There is an increased risk of adverse effects when used by clients with this condition.
Diabetes: Using ephedrine in diabetic clients may interfere with blood sugar control as it may cause hyperglycemia (increased blood sugar).
Enlarged prostate: Alpha-adrenergic agents such as ephedrine inhibit the ability to urinate. Clients with an enlarged prostate already experience decreased urination so ephedrine can exacerbate this issue and cause acute urinary retention.
Renal impairment: These clients eliminate medications from the body at a slower rate, so the effects of ephedrine could be prolonged. This increases the risk of adverse reactions.

Drug Interactions and Side Effects

Nurses also need to be aware of what medications their clients are taking. Ephedrine could interact with other medications including those used to treat blood pressure, heart conditions, or depression, and certain health or dietary supplements like St John's Wort.

Other side effects may include⁽⁴⁾:

Headache
Nervousness
Anxiety
Agitation
Restlessness
Insomnia
Dizziness / vertigo
Palpitations
Tachycardia
Hypertension
Dyspnea
Nausea
Vomiting
Anorexia
Weight loss
Difficult or painful urination
Urinary retention
Sweating

The intensity of adverse effects may vary for different clients, so it's important to monitor the client closely. While some of these side effects may not need emergent nursing intervention, consider additional treatments within the nursing scope of practice if the side effects bother the client or do not go away.

Reach out to the client's healthcare provider if medical attention or treatments are required. Most likely, many of these possible side effects will subside during treatment as the client's body adjusts to the medication.

Nurses who suspect other adverse reactions that aren't on this list should consult with the client's primary healthcare provider to determine appropriate steps in the plan of care.

Ephedrine Nursing Considerations

Key assessments for nurses in care of the patient taking ephedrine include monitoring for the therapeutic effects of the medication and potential side effects.

Possible Nursing Diagnoses

Problem-focused Nursing Diagnoses

Ineffective Airway Clearance
Acute Pain
Anxiety

Risk Nursing Diagnoses

Risk for Decreased Cardiac Output
Risk for Ineffective Tissue Perfusion
Risk for Impaired Gas Exchange
Risk for Impaired Urinary Elimination
Risk for Injury

Nursing Assessment

Conduct a thorough health history of the client. Be especially aware of conditions which could be exacerbated by taking ephedrine such as a history of high blood pressure or heart disease.
Review the client's medication list (if available) and identify anything that could potentially interact with ephedrine including tricyclic antidepressants, beta-blockers, or diuretics.
Review all lab and test results and any other procedures the client may have undergone.
Conduct an assessment of the client's environment to identify possible threats to safety and the presence of items that could cause a fall or other physical injury.
Assess the client's learning preferences and health literacy in order to provide the appropriate education about taking ephedrine.

Perform a head-to-toe physical assessment:

Neurological. Note level of consciousness by assessing if the patient is alert and oriented to person, place, time, and situation. Assess for any signs and symptoms of anxiety, nervousness, agitation, or restlessness. Assess for headache pain.
Cardiovascular. Assess for chest pain. Listen to heart sounds. Check peripheral pulses and capillary refill. Assess for peripheral edema noting pitting or non-pitting.
Respiratory. Assess airway for patency. Assess for coughing. Listen to lungs for abnormal, decreased, or absent breath sounds. Check oxygen saturation with pulse oximetry. Note the quality, rate, pattern, and depth of respirations. Assess for nasal flaring, dyspnea on exertion, or use of accessory muscles for breathing.
Gastrointestinal. Listen for presence/absence of bowel sounds. Monitor food and fluid intake and note if any loss of appetite. Check weight and note trends. Assess for abdominal distention and constipation. Assess for nausea or vomiting. Note color of tongue and oral mucous membranes.
Genitourinary. Monitor quality, frequency, and amount of urine output and note changes and trends. Compare urine output with fluid intake. Assess for bladder distention. Note frequency and urgency of urination. Assess for any difficulty with urinating, any pain or burning with urination, or blood in the urine. Assess for incontinence.
Skin. Note color, texture, temperature, and moisture. Assess for pressure injuries and cellulitis.

Nursing Interventions with Rationale

Place on a cardiac monitor. Clients receiving ephedrine are at increased risk for arrhythmias. The nurse must ensure the client's heart rate and rhythm are normal.
Monitor blood pressure. Ephedrine raises blood pressure. The nurse must ensure the client's blood pressure is within normal range.
Treat chest pain immediately. Clients receiving ephedrine are at increased risk for chest pain. If chest pain is present, the nurse should have the client lie down, give oxygen, print a telemetry strip, medicate for pain, and notify the physician. These actions will increase oxygen delivery to the heart and improve the client's prognosis.
Position the client upright if tolerated. Clients taking ephedrine may have a history of breathing problems. An upright position promotes increased lung expansion and better air exchange.
Provide oxygen therapy if needed. If clients are experiencing shortness of breath, the nurse may administer supplemental oxygen as prescribed. The nurse must also monitor the client's oxygen saturation with pulse oximetry to determine effectiveness.
Teach proper coughing and deep breathing. This helps promote removal of secretions and improved oxygenation in clients with allergic conditions and congestion.
Encourage or assist the client with walking. This also helps to promote removal of secretions, improves lung expansion, and encourages deep breathing.
Provide reassurance. Clients taking ephedrine are at risk for anxiety, which can also increase shortness of breath.

Patient Education

Provide the client with materials about ephedrine based on learning preferences.
Explain the purpose of taking ephedrine to the client.
Instruct the client to only take ephedrine as directed.
Review possible side effects of ephedrine and instruct clients to notify a healthcare provider right away if they start to experience any side effects.
Discuss the potential for abuse as ephedrine is a commonly abused drug.

Ephedrine Toxicity

If a client takes too much ephedrine, it will most often cause a rapid increase in blood pressure or seizures⁽¹⁾. These are emergent situations requiring close monitoring of the client's blood pressure and possible administration of antihypertensive medications if the blood pressure does not start to come down. Seizures may require the administration of benzodiazepines. Mechanical ventilation might be indicated if the client's breathing becomes shallow or they develop cyanosis.

Ephedrine NCLEX Questions

These are some example questions about ephedrine that you may see on the NCLEX exam:

1. Before administering ephedrine, Nurse Tony assesses the patient's history. Because of ephedrine's central nervous system (CNS) effects, it is not recommended for:

Patients with an acute asthma attack
Patients with narcolepsy
Patients under age 6
Elderly patients

2. A client is admitted to the emergency department with an acute asthma attack. The physician prescribes ephedrine sulfate, 25 mg subcutaneously (S.C.). How soon should the ephedrine take effect?

Rapidly
In 3 minutes
In 1 hour
In 2 hours

3. A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client?

"Use your nasal decongestant spray regularly to help clear your passages.”
"Ask your doctor for antibiotics. Antibiotics will help decrease the secretion.”
"It is important to increase your activity. A daily brisk walk will help promote drainage.”
"Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks.”

Ephedrine FAQs

How does ephedrine increase blood pressure? Ephedrine increases blood pressure by stimulating heart rate and cardiac output, which increases the body's peripheral vascular resistance.

Why is ephedrine banned? The Food and Drug Administration (FDA) banned the use of ephedrine for weight loss and increased alertness in 2004. Their decision was based on a review of studies that associated the use of ephedrine with heart attacks, strokes, seizures, and sudden deaths.

STAFF NOTE: Original Community Post

This article was created in response to a community post. The comments and responses have been left intact as they may be helpful. Here's the original post:

Quote

I need to do a drug card on Ephedrine, and I cannot find it in my Davis Drug Guide, does anybody know another name for this drug so I can find the information I need? I am doing OB drug cards and this is on the Labor and Delivery Drug sheets, My client did not use it, but we still have to do them anyway, any help would be much appreciated. Thanks in advance!

Answer: Some of the brand name medications containing ephedrine include Akovaz, Bronkaid, Corphedra, Emerphed, Primatene, and Rezipres. You may be able to find more information using one of these names.

References

1. https://www.ncbi.nlm.nih.gov/books/NBK547661/

2. https://www.sciencedirect.com/topics/medicine-and-dentistry/ephedrine
3. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/509768
4. https://www.pdr.net/drug-summary/Akovaz-ephedrine-sulfate-23927