Clayton's Basic Pharmacology for Nurses [19 ed.] 0323796303, 9780323796309, 9780323812580, 9780323829731

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Basic Pharmacology for Nurses

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EDITION

Basic Pharmacology for Nurses Michelle J. Willihnganz, MS, RN, CNE RCTC Nursing Instructor Rochester Community and Technical College Rochester, Minnesota

Samuel L. Gurevitz, PharmD

Associate Professor College of Pharmacy and Health Sciences Butler University Indianapolis, Indiana

Bruce D. Clayton, BS Pharm, PharmD, RPh Professor Emeritus of Pharmacy Practice College of Pharmacy and Health Sciences Butler University Indianapolis, Indiana

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ELSEVIER 3251 Riverport Lane St. Louis, Missouri 63043 BASIC PHARMACOLOGY FOR NURSES, NINETEENTH EDITION

ISBN: 978-0-323-79630-9

Copyright © 2022 by Elsevier, Inc. All rights reserved. Previous editions copyrighted 2020, 2017, 2013, 2010, 2007, 2004, 2001, 1997, 1993, 1989, 1985, 1981, 1977, 1973, 1969, 1965, 1961, and 1957. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices Knowledge and best practice in this eld are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verication of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Control Number: 2021939099

Content Strategist: Brandi Graham Director, Content Development: Laurie Gower Senior Content Development Specialist: Rebecca Leenhouts Publishing Services Manager: Deepthi Unni Project Manager: Janish Ashwin Paul Design Direction: Renee Duenow Printed in India Last digit is the print number:

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To Kevin, the love of my life, and to my wonderful daughters Katie and Jennifer, who always stand beside me. —MJW

To my wonderful wife Eileen and to our daughter Maire. —SLG

To Francine, for her unfailing support and encouragement, and to Sarah, Nathaniel, Evelyn, and Grace and Beth, Clayton, and Arden, the lights of our lives! —BDC

Reviewers and Ancillary Contributors

REVIEWERS Alice M. Hupp, BS, RN Lead Instructor Vocational Nursing North Central Texas College Gainesville, Texas Ashley R. Williams, MSN, RN, CEN Assistant Professor of Nursing Capito Department of Nursing University of Charleston Charleston, West Virginia Cabell Huntington Hospital Huntington, West Virginia Heather Clark, DNP, RN Director Penn State Practical Nursing Program Penn State Lehigh Valley Center Valley, Pennsylvania Darla K. Shar, MSN, RN Associate Director Practical Nursing Education Hannah E. Mullins School of Practical Nursing Salem, Ohio Joanna Cain, BSN, BA, RN President & Founder Global Academic Consultants Boulder, Colorado Lorraine Kelley, RN Faculty Department of Nursing and Emergency Medical Services Pensacola State College Pensacola, Florida

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Molly M. Showalter, MSN Ed., RN Interim Vocational Nursing Program Director Department of Health Professions Texas Southmost College Brownsville, Texas Odelia Garcia, MS, MSN, BSN, RN Vocational Nursing Program Instructor Nursing Texas State Technical College Harlingen, Texas Grace Frankel BSc. Pharm, PharmD, BCPS Clinical Pharmacist Bethesda Regional Health Centre/Southern Health Steinbach, Manitoba, Canada James J Mizner Jr, MBA, BS, RPh Panacea Solutions Consulting-Principal Reston, VA

ANCILLARY CONTRIBUTOR Laura Bevlock Kanavy, MSN, BSN, RN Director, Practical Nursing Program Career Technology Center of Lackawanna County Scranton, Pennsylvania Test Bank, NCLEX Review Questions

LPN/LVN Advisory Board

Nancy Bohnarczyk, MA Adjunct Instructor College of Mount St. Vincent New York, New York

Tawnya S. Lawson, MS, RN Dean, Practical Nursing Program Hondros College Westerville, Ohio

Sharyn P. Boyle, MSN, RN-BC Instructor, Associate Degree Nursing Passaic County Technical Institute Wayne, New Jersey

Kristin Madigan, MS, RN Nursing Faculty Pine Technical and Community College Pine City, Minnesota

Nicola Contreras, BN, RN Faculty Galen College San Antonio, Texas

Hana Malik, DNP, FNP-BC Academic Director Illinois College of Nursing Lombard, Illinois

Dolores Cotton, MSN, RN Practical Nursing Coordinator Meridian Technology Center Stillwater, Oklahoma

Mary Lee Pollard, PhD, RN, CNE Dean, School of Nursing Excelsior College Albany, New York

Patricia Donovan, MSN, RN Director of Practical Nursing and Curriculum Chair Porter and Chester Institute Rocky Hill, Connecticut

Barbara Ratliff, MSN, RN Program Director, Practical Nursing Cincinnati State Cincinnati, Ohio

Nancy Haughton, MSN, RN Practical Nursing Program Faculty Chester County Intermediate Unit Downingtown, Pennsylvania

Mary Ruiz-Nuve, MSN, RN Director of Practical Nursing Program St. Louis College of Health Careers St. Louis, Missouri

Dawn Johnson, DNP, RN, Ed Practical Nurse Program Director Great Lakes Institute of Technology Erie, Pennsylvania

Renee Sheehan, MSN/Ed, RN Director of Nursing, Vocational Nursing Nursing Assistant Programs Summit College Colton, California

Mary E. Johnson, MSN, RN Director of Nursing Dorsey Schools Roseville, Michigan Bonnie Kehm, PhD, RN Faculty Program Director Excelsior College Albany, New York

Faye Silverman, MSN/ED, RN, WOCN, PHN Nursing Education Consultant Online Nursing Instructor Lancaster, California Fleur de Liza S. Tobias-Cuyco, BSc, CPhT Dean, Director of Student Affairs, and Instructor Preferred College of Nursing Los Angeles, California

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Preface

The 19th edition of Basic Pharmacology for Nurses, in the tradition of the book’s standards rst established in 1957, advocates the administration of medication with safety and precision while focusing on medication safety through medication monitoring and patient education. In the practice setting, the nurse not only must demonstrate knowledge of the underlying disease process but also must be able to perform an accurate assessment. The nurse must also plan and implement care in a manner that involves the patient as an active participant in decisions affecting care. Therefore a primary concern throughout this book is the integration of patient teaching about drug therapy to enable the patient to reach therapeutic goals and attain an optimum level of health. The nurse must also validate patient understanding to ensure that the individual has the ability to provide safe self-care and monitoring of the prescribed treatment plan. User friendly in content, structure, and layout, the text is concise and easy to read. With its emphasis on the seven Rights of Drug Administration (right drug, right time, right indication, right dosage, right patient, right route, and right documentation), Basic Pharmacology for Nurses provides students with the information needed to provide safe, effective nursing care for patients receiving drug therapy.

ORGANIZATION AND SPECIAL FEATURES

CONTENT THREADS Basic Pharmacology for Nurses, 19th edition, shares some features and design elements with other Elsevier books that you may be using. The purpose of these Content Threads is to make it easier for students and instructors to use the variety of books required by a fast-paced and demanding curriculum. The shared features in Basic Pharmacology for Nurses, 19th edition, include the following: • Cover and internal design similarities; the colorful, student-friendly design encourages reading and learning of this core content • Numbered lists of Objectives that begin each chapter • Key Terms with pronunciations at the beginning of each chapter; the Key Terms are in color when they are dened in the chapter • Bulleted lists of Key Points at the end of each chapter Next Generation (NG) NCLEX style questions are at the end of each chapter. These questions use singleepisode and unfolding cases. They include the six viii

NCSBN Clinical Judgment Measurement Model cognitive processes and skills; answers are provided on the Evolve student website. In addition to content and design threads, these textbooks benet from the advice and input of the Elsevier Advisory Board.

CONTENTS Unit I explores pharmacology foundations, principles, life span considerations, the nursing process with pharmacology, and patient education. Unit II contains the unique Illustrated Atlas of Medication Administration that provides extensive step-by-step instructions and illustrations that show primary routes of administration and proper administration techniques for all forms of medications. Units III through X provide an overview of each drug class, followed by narrative discussions of the most common individual drugs. The units and chapters are organized by body system.

CHAPTER ORGANIZATION • Each drug chapter in Units III through X begins with an overview of a clinical problem and its management. • The general nursing implications section includes clearly identied headings for Assessment, Implementation, and Patient Education. The Patient Education section helps the nurse incorporate patient education designed to promote health into the overall treatment plan. • Drug monographs are provided for each major drug class. These monographs describe Actions, Uses, and Therapeutic Outcomes for each class. • A drug class–specic nursing implications section for each drug monograph highlights Premedication Assessment, Product Availability, Dosing Instructions, Common Adverse Effects, Serious Adverse Effects, and Drug Interactions.

SPECIAL FEATURES Basic Pharmacology for Nurses includes special features designed to foster effective learning and comprehension. • Chapter-opening features include lists of Objectives and Key Terms with pronunciations.

PREFACE

• Clinical Pitfall and Medication Safety Alert boxes highlight critically important clinical considerations to help students practice safety and reduce medication errors. • Clinical Goldmine boxes put a spotlight on tips and best practices for clinical procedures. • Life Span Considerations boxes focus on the implications of drug therapy for children, pregnant and breastfeeding women, and older adults. • Herbal Interactions boxes discuss well-documented interactions among drugs, herbal therapies, and dietary supplements. • A handy bulleted list of Key Points at the end of most chapters facilitates review of essential chapter content.

NEW TO THIS EDITION • This edition includes the latest US Food and Drug Administration (FDA) approvals, including up-todate clinical drug indications, guidelines for use, and recently released new drugs. • Increased emphasis on medication safety that stresses imperative information for patient protection. • Additional information on genetics, pharmacogenomics, and racial/gender factors in drug actions is included to highlight current research. • New gures have been added to illustrate proper medication administration. • End-of-chapter NCLEX-style questions that include NG types such as Cloze, Grid/Matrix, Drag and Drop, and Extended Multiple Response. These types cover the six cognitive skills: Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take Action, and Evaluate Outcomes.

TEACHING AND LEARNING PACKAGE

FOR STUDENTS • The Evolve Website provides free student resources, including answers and rationales for in-text Review Questions for the NCLEX® Examination, a math

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review, animations, video clips, a collection of Patient Teaching handouts, fully customizable Patient Self-Assessment Forms provided as “completable” PDF documents, and a collection of 500 NCLEXstyle Review Questions. • The revised Study Guide provides additional learning resources that complement those in the textbook. Questions for each chapter follow the objectives in the book for additional focus on these key concepts. Matching starts each chapter, and patient scenarios are included with the chapters that detail the medications. NG NCLEX-style questions are included, as are typical NCLEX questions. Each question includes the correct answer, rationale, NCLEX style used, and cognitive skill measured. Each question has a page number identied to help the student nd the answer in the textbook. Answers to the Study Guide questions are available from instructors.

FOR INSTRUCTORS The comprehensive Evolve Resources with TEACH Instructor Resource provides a rich array of resources that include the following: • Updated TEACH Lesson Plans, based on textbook learning objectives, provide ready-to-use lesson plans that tie together all of the text and ancillary components provided for Basic Pharmacology for Nurses. • The collection of PowerPoint Lecture Slides is specic to the text. • A Test Bank, delivered in ExamView, now provides an expanded collection of approximately 900 multiple-choice and alternate-format NCLEX-style questions. Each question includes the Correct Answer, Rationale, and corresponding text page numbers. • The Image Collection contains every reproducible image from the text. Images are suitable for incorporation into classroom lectures, PowerPoint presentations, or distance-learning applications. • Answer keys are provided for the Study Guide.

Special Features

Basic Pharmacology for Nurses focuses on medication safety through medication monitoring and patient education. Full-color art and design features accompany detailed, understandable discussions of drugs organized by body system.

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SPECIAL FEATURES

• Patient Education and Health Promotion is emphasized in the overall treatment plan. • Life Span Considerations boxes focus on implications of drug therapy for children, pregnant and breastfeeding women, and older adults. • Clinical Pitfall and Medication Safety Alert boxes highlight critically important clinical considerations. • Herbal Interactions boxes describe possible adverse effects of alternative therapies. • Chapters open with Objectives and Key Terms with pronunciations and page references.

STUDY GUIDE Includes Practice Questions for the NCLEX® Examination for each textbook chapter. Answers to the revised study guide are available from your instructor.

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Contents

Applying Pharmacology to Nursing Practice, 1 Drug Denitions, Standards, and Information Sources, 1 Basic Principles of Drug Action and Drug Interactions, 13 Drug Action Across the Life Span, 22 The Nursing Process and Pharmacology, 38 Patient Education to Promote Health, 50

27 Drugs Used to Treat Heart Failure, 438 28 Drugs Used for Diuresis, 454

Illustrated Atlas of Medication Administration, 60 Principles of Medication Administration and Medication Safety, 60 Percutaneous Administration, 83 Enteral Administration, 103 Parenteral Administration: Safe Preparation of Parenteral Medications, 119 Parenteral Administration: Intradermal, Subcutaneous, and Intramuscular Routes, 137 Parenteral Administration: Intravenous Route, 149

UNIT VI

UNIT I 1 2 3 4 5

UNIT II 6 7 8 9 10 11

Drugs Affecting the Autonomic and Central Nervous Systems, 180 Drugs Affecting the Autonomic Nervous System, 180 Drugs Used for Sedation and Sleep, 192 Drugs Used to Treat Neurodegenerative Disorders, 204 Drugs Used for Anxiety Disorders, 228 Drugs Used for Depressive and Bipolar Disorders, 238 Drugs Used for Psychoses, 262 Drugs Used for Seizure Disorders, 276 Drugs Used for Pain Management, 300

UNIT III 12 13 14 15 16 17 18 19

Drugs Affecting the Cardiovascular System, 330 Introduction to Cardiovascular Disease and Metabolic Syndrome, 330 Drugs Used to Treat Dyslipidemias, 338 Drugs Used to Treat Hypertension, 353 Drugs Used to Treat Dysrhythmias, 382 Drugs Used to Treat Angina Pectoris, 397 Drugs Used to Treat Peripheral Vascular Disease, 409 Drugs Used to Treat Thromboembolic Disorders, 417

UNIT IV 20 21 22 23 24 25 26

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Drugs Affecting the Respiratory System, 469 29 Drugs Used to Treat Upper Respiratory Disease, 469 30 Drugs Used to Treat Lower Respiratory Disease, 482 UNIT V

31 32 33 34

Drugs Affecting the Digestive System, 507 Drugs Used to Treat Oral Disorders, 507 Drugs Used to Treat Gastroesophageal Reux and Peptic Ulcer Disease, 516 Drugs Used to Treat Nausea and Vomiting, 530 Drugs Used to Treat Constipation and Diarrhea, 550

UNIT VII Drugs That Affect the Endocrine System, 561 35 Drugs Used to Treat Diabetes Mellitus, 561 36 Drugs Used to Treat Thyroid Disease, 596 37 Corticosteroids, 606 38 Gonadal Hormones, 615 UNIT VIII Drugs Affecting the Reproductive System, 624 39 Drugs Used in Obstetrics, 624 40 Drugs Used in Men’s and Women’s Health, 644 Drugs Affecting Other Body Systems, 670 Drugs Used to Treat Disorders of the Urinary System, 670 Drugs Used to Treat Glaucoma and Other Eye Disorders, 682 Drugs Used to Treat Cancer, 699 Drugs Used to Treat Musculoskeletal Disorders, 711 Drugs Used to Treat Infections, 724

UNIT IX 41 42 43 44 45

Drugs Affecting the General Health of the Body, 771 46 Nutrition, 771 47 Herbal and Dietary Supplement Therapy, 792 48 Substance Abuse, 809 UNIT X

Unit I

Applying Pharmacology to Nursing Practice

1

Drug Denitions, Standards, and Information Sources

https://evolve.elsevier.com/Willihnganz

Objectives 1. Differentiate between the chemical, generic, and brand names of drugs. 2. Identify the various methods used to classify drugs. 3. Identify sources of drug information available for healthcare providers.

4. Discuss the difference between prescription and nonprescription drugs. 5. Describe the process of developing and bringing new drugs to market. 6. Differentiate between the Canadian chemical names and the proper name of a drug.

Key Terms pharmacology (făr-mă-KŎL-ŏ-jē) (p. 1) therapeutic methods (thĕr-ă-PYŪ-tĭk MĔTH-ĕdz) (p. 1) drugs (p. 1) biologic therapies (p. 1) chemical name (KĔM-ĭ-kŭl) (p. 2)

generic name (jĕ-NĀR-ĭk) (p. 2) brand name (p. 2) prescription drugs (p. 2) nonprescription drugs (p. 2) over-the-counter (OTC) drugs (p. 2) illegal drugs (ĭl-LĒ-gŭl) (p. 2) biosimilars (p. 2)

Pharmacology (from the Greek pharmakon, meaning

“drugs,” and logos, meaning “science”) deals with the study of drugs and their actions on living organisms. Diseases that cause illness may be treated in several different ways, which are referred to as therapies. The various approaches to therapy are called therapeutic methods Examples of therapeutic methods include the following: • Drug therapy: Treatment with drugs • Diet therapy: Treatment with diet (e.g., a low-salt diet for patients with cardiovascular disease) • Physiotherapy: Treatment with natural physical forces (e.g., water, light, heat) • Psychological therapy: The identication of stressors and methods that can be used to reduce or eliminate stress Most illnesses caused by diseases require a combination of therapeutic methods for successful treatment. Drugs (from the Dutch droog, meaning “dry”) are chemical substances that have an effect on living organisms. Therapeutic drugs, which are often called medicines, are those drugs that are used for the prevention or treatment of diseases. Up until the early to mid-20th century, dried plants were the most abundant source of medicines, thus the word drug was applied to them.

schedules (SKĔD-jūlz) (p. 5) black box warnings (p. 8) orphan drugs (ŌR-făn) (p. 8) Food and Drugs Act and Regulations (p. 9) Controlled Drugs and Substances Act (p. 10)

Whereas most drugs are individual chemicals that cause a response in living tissues, a new class known as biologic therapies have been discovered that have transformed treatment of patients with disorders that attack the body’s own organs, tissues, and cells (autoimmune disorders), blood (hematologic disorders), and cancers. Biologic agents are large, complex proteins manufactured in a living system such as a microorganism, or within plant or animal cells. Biologics have added major therapeutic choices for the treatment of many diseases for which no effective therapies were available or previously existing therapies were clearly inadequate.

DRUG NAMES, STANDARDS, LEGISLATION, AND DEVELOPMENT IN THE UNITED STATES

DRUG NAMES All drugs have several names, which may cause confusion. When administering the prescribed drug, the spelling on the drug package must correspond exactly with the spelling of the drug ordered to ensure that the proper medicine is administered. 1

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UNIT I Applying Pharmacology to Nursing Practice

Each drug has three names: (1) a chemical name, (2) a generic name, and (3) a brand name. The chemical name is most meaningful to the chemist. By means of the chemical name, the chemist understands the exact chemical constitution of the drug and the exact placement of its atoms or molecular groupings. Before a drug becomes ofcial, it is given a generic name or common name. The generic name is simpler than the chemical name. It may be used in any country and by any manufacturer. The rst letter of the generic name is not capitalized. Students are strongly encouraged to learn and refer to drugs by their generic names because formularies (i.e., lists of medicines available through a pharmacy) are maintained by generic names. When a therapeutically equivalent drug becomes available in generic form, the generic medicine is routinely substituted for the brand-name medicine. Generic names are provided by the United States Adopted Names Council, which is an organization sponsored by the United States Pharmacopeial Convention, the American Medical Association, and the American Pharmacists Association. The ofcial name, which is virtually always the generic name in the United States, is the name under which the drug is listed by the US Food and Drug Administration (FDA). The FDA is empowered by federal law to generically name the drugs for human use in the United States. A trademark or brand name is followed by the symbol ®. This symbol indicates that the name is registered and that the use of the name is restricted to the owner of the drug, which is usually the manufacturer. Most drug companies place their products on the market under brand names rather than generic names. The brand names are deliberately made easier to pronounce, spell, and remember. The rst letter of the brand name is capitalized. Example of Chemical, Generic, and Brand Names for Drugs Chemical name: [2-[4-[(4-Chlorophenyl)phenylmethyl]1-piperazinyl]ethoxy]acetic acid dihydrochloride (Fig. 1.1) Generic name: cetirizine Brand name: Zyrtec Allergy

gastrointestinal system); their therapeutic use or clinical indications (e.g., antacids, antibiotics, antihypertensives, diuretics, laxatives); and their physiologic or chemical action (e.g., anticholinergics, beta-adrenergic blockers, calcium channel blockers, cholinergics). Drugs may be further classied as prescription or nonprescription. Prescription drugs require an order by a health professional who is licensed to prescribe drugs, such as a primary healthcare provider, a nurse practitioner, a physician assistant, a pharmacist, or a dentist. Nonprescription drugs, or over-the-counter (OTC) drugs, are sold without a prescription in a pharmacy or in the health section of department or grocery stores. Illegal drugs, sometimes referred to as recreational drugs, are drugs or chemical substances used for nontherapeutic purposes. These substances either are obtained illegally or have not received approval for use by the FDA. See Chapter 48 for further information about substance abuse. A biosimilar is a biologic product that is close in structure and function to an existing approved biologic product, known as a reference product. For example, infliximab-dyyb (Inectra) and iniximab-abda (Renexis) are biosimilars for the reference product iniximab (Remicade) used to treat rheumatoid arthritis. With many patents for biologics expiring, biosimilar agents will become available. In 2010 legislation created an abbreviated licensure pathway for biologic products that are demonstrated to be biosimilar. Biosimilars offer an opportunity to increase access to biologics while lowering the cost of therapy. However, unlike generic medicines in which the active ingredients are identical to the reference smallmolecule drugs, biosimilars will not be identical to the reference biologics. This is due to the inherent complexity of biologic proteins. Biosimilars made by different manufacturers will differ from the reference product and from each other, making each biosimilar a unique therapeutic option for patients (Table 1.1). Biosimilars are not generics and are not interchangeable. These agents cannot be substituted for the original reference molecule.

DRUG CLASSIFICATIONS

Drug products made by different manufacturers or in different batches by the same manufacturer must be uniformly pure and potent. The United States Pharmacopeial Convention is a nongovernment organization that promotes public health by establishing stateof-the-art standards to ensure the quality of medicines and other healthcare technologies. These standards are developed by a unique process of public involvement, and they are accepted worldwide. The Convention publishes a single-volume text, the United States Pharmacopeia (USP)/National Formulary (NF), which is revised annually. The primary purpose of this volume is to provide standards for the identity, quality, strength, and purity of substances used in the practice of healthcare. The standards described in the USP/NF are enforced by the FDA as the

Drugs may be classied by a variety of methods according to the body system that they affect (e.g., the central nervous system, the cardiovascular system, the O

COOH

N N

Cl

Fig. 1.1 Cetirizine, an antihistamine.

SOURCES OF DRUG STANDARDS AND DRUG INFORMATION

Drug Denitions, Standards, and Information Sources CHAPTER 1

3

Table 1.1 Comparing and Contrasting Biosimilar and Generic Products PROPERTIES Size

BIOSIMILAR DRUGS (BIOLOGICS) Large

Structure

Complex with potential structural variations

Simple and well dened

Manufacturing

Unique bank of living cells Unlikely to achieve identical copy

Predictable chemical reaction Identical copy can be made

Complexity

Difcult to fully characterize

Easy to fully characterize

Stability

More sensitive to storage and handling conditions

Less sensitive to storage and handling conditions

Immunogenicity (promotes immune response; potential for allergy)

Higher potential

Lower potential

Approval requirements

Large clinical trials in patients

Small clinical trials for safety in healthy volunteers

ofcial standards for the manufacture and quality control of medicines and nutritional supplements produced in the United States. The USP/NF is also recognized by the Canadian Food and Drugs Act as an authoritative source of drug standards in Canada. Table 1.2 lists and describes the common sources of drug information available for the professional healthcare provider; additional resources are described in the following sections. PACKAGE INSERTS Manufacturers of drugs are required to develop a comprehensive but concise description of the drug, indications and precautions for clinical use, recommendations for dosage, known adverse reactions, contraindications, and other pharmacologic information relating to the drug. Federal law mandates that this material be approved by the FDA before the product is released for marketing and that it be presented on an insert that accompanies each package of the product. The FDA adopted a format for package inserts to help reduce medication errors and to improve patient education. The labeling reduces practitioners’ time looking for information, decreases the number of preventable medication errors, and improves treatment effectiveness and patient education. Because this labeling represents considerable effort and is most critical for newer and less familiar drugs, the formatting applies only to relatively new prescription drug products, developed since 2006.

Clinical Goldmine DailyMed (see Online Resources), which is sponsored by the US National Library of Medicine, provides a database for new package inserts that is searchable by product name, indications, dosage and administration, warnings, description of drug product, active and inactive ingredients, and how the drug is supplied. See the section Electronic Databases.

NURSING JOURNALS Many specialty journals have articles about drug therapy as it relates to a specic eld of interest (e.g.,

GENERICS (SMALL-MOLECULE DRUGS) Small

Geriatric Nursing, American Journal of Critical Care). Nursing journals such as RN and American Journal of Nursing provide drug updates and articles that discuss nursing considerations related to drug therapy and drugs. Nurses must keep in mind that the purpose of using resources such as journals is to obtain professional knowledge of current evidence-based practice changes and they should not be used as a primary source for drug information. Nurses must be mindful of the accuracy of the information contained and should check the dates on articles to validate the currency of the information. ELECTRONIC DATABASES With the exponential growth of information about medicines and health, it is almost impossible to make the information available without the use of electronic databases. The National Library of Medicine (NLM) provides Medline and other searchable databases at no cost. Databases incorporated into the NLM include information on drugs and other chemicals that breastfeeding mothers may be exposed to and the levels in breast milk and infant blood with the possible adverse effects in the nursing infant. They also provide suggested therapeutic alternatives to the drugs. Information regarding the development and reproductive toxicology of drugs covering teratology is included. Most of the drug information sources listed in Table 1.2 are also available via electronic retrieval from libraries. Many college libraries subscribe to the Cumulative Index to Nursing and Allied Health Literature (CINAHL). These databases give nurses access to a wealth of information from sources published in the United States and other countries. Databases for practitioners are also available by subscription. UpToDate, Lexicomp, and ePocrates are three vendors with several different packages of regularly updated information (see Online Resources). Lexicomp has a particularly strong database because the American Hospital Formulary Service is available through its portal.

4

UNIT I Applying Pharmacology to Nursing Practice

Table 1.2 Sources of Drug Information for Healthcare Providers SOURCES OF DRUG INFORMATION AHFS Drug Information

DESCRIPTION Contains monographs about virtually every single-entity drug available in the United States Describes therapeutic uses of drugs, including approved and unapproved uses Online version available

Drug Facts and Comparisons

Contains drug monographs that describe all drugs in a therapeutic class Monographs are formatted as tables to allow comparison of similar products, brand names, manufacturers, cost indices, and available dosage forms Online version available

ASHP’s Handbook on Injectable Drugs

Collection of monographs about 360 injectable drugs with sections on available concentrations, compatibility with other drugs, dosage and rate of administration, stability, pH, and other useful information Interactive version available

Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care

Most comprehensive text available about over-the-counter medications that can be purchased in the United States Online version available

Martindale: The Complete Drug Reference

Considered one of the most comprehensive texts available for information about drugs in current use throughout the world Contains extensive referenced monographs about the international names, pharmacologic activity, and side effects of more than 6400 drugs Online subscription available

Natural Medicines Comprehensive Database

Scientic gold standard for evidence-based information about herbal medicines and combination products involving herbal medicines Only available in an online database by subscription or at libraries

CANADIAN DRUG STANDARDS European Pharmacopoeia Pharmacopée Française

All recognized by the Canadian Food and Drugs Act as authoritative sources of drug standards

The International Pharmacopoeia (Ph. Int.) British Pharmacopoeia Canadian Formulary The National Formulary Pharmaceutical Codex United States Pharmacopeia-National Formulary CANADIAN DRUG INFORMATION Compendium of Pharmaceuticals and Specialties (CPS)

Published annually by the Canadian Pharmacists Association Comprehensive list of the pharmaceutical products distributed in Canada, as well as other practical information e-CPS available

Patient Self-Care: Helping Patients Make Therapeutic Choices

Published by the Canadian Pharmacists Association Provides comprehensive information for health professionals and consumers about nonprescription drug products available in Canada e-Therapeutics available

Compendium of Self-Care Products (CSCP)

Nonprescription companion to CPS and Patient Self-Care Offers at-a-glance comparative tables for thousands of products and monographs about hundreds of commonly used nonprescription products

AHFS, American Hospital Formulary Service; ASHP, American Society of Health-System Pharmacists; USP, United States Pharmacopeia.

The DailyMed system (see Online Resources) was developed in collaboration with federal agencies— including the FDA, the NLM, the Agency for Healthcare Research and Quality, the National Cancer Institute in the US Department of Health and Human Services, and the US Department of Veterans Affairs—to provide high-quality information about marketed drugs. DailyMed makes available to healthcare providers

and the public a standard, comprehensive, up-to-date resource about medicines.

UNITED STATES DRUG LEGISLATION Drug legislation approved by Congress provides the legal basis (Table 1.3) for drug manufacturing and protects the consumer from false claims made by a drug

Drug Denitions, Standards, and Information Sources CHAPTER 1

5

Table 1.3 Selected Major US Legislation Pertaining to Safety of Medicines LEGISLATION (LAW)

PURPOSE AND EFFECT

Food, Drug, and Cosmetic Act of 1938

Requires that new drugs be safe, as well as pure (but did not require proof of efcacy). Enforcement by FDA.

Durham-Humphrey Amendment (1951) to the Food, Drug, and Cosmetic Act

Gives the FDA the power to determine which products may be sold with and without a prescription.

Kefauver-Harris Amendment (1962) to the Food, Drug, and Cosmetic Act

Requires proof of efcacy as well as safety for medicines released since 1938; establishes guidelines for reporting of information about adverse reactions, clinical testing, and advertising of new drugs.

Comprehensive Drug Abuse Prevention and Control Act (1970) (Controlled Substances Act, 1970)

Outlines strict controls in the manufacture, distribution, and prescribing of habit-forming drugs; establishes drug schedules and programs to prevent and treat drug addiction. Established the Drug Enforcement Administration (DEA).

Dietary Supplement Health and Education Act (1994) (DSHEA Act–1994)

Under this act, almost all herbal medicines, vitamins, minerals, amino acids, and chemicals used for health are reclassied as dietary supplements, a food category. The legislation allows the label to include information about how these products affect the human body. Labels must contain a statement that the product has not been evaluated by the FDA for treating, curing, or preventing any disease. The law does not prevent nonlicensed personnel from making founded or unfounded claims about the therapeutic effects of supplement ingredients. The result is that dietary supplements are not required to be safe and effective, and unfounded claims of therapeutic benet abound. See Chapter 47

manufacturer. The FDA is the administrative body that oversees the drug evaluation process in the United States and grants approval for or removal of drug products from the market. CONTROLLED SUBSTANCES ACT The Comprehensive Drug Abuse Prevention and Control Act, which is commonly referred to as the Controlled Substances Act, is designed to improve the administration and regulation of the manufacturing, distribution, and dispensing of drugs that require tighter control by the government because of their higher incidence of abuse and potential for addiction. The basic structure of the Controlled Substances Act consists of ve classications, or schedules, of controlled substances. The degree of control, the conditions of record keeping, the particular order forms required, and other regulations depend on which schedule the individual drug is assigned (Box 1.1). Drugs that are listed as Schedule I are not available for other than highly controlled research purposes because of their very high potential for abuse and addiction. Drugs in Schedule II have a high potential for abuse and addiction, but are available by prescription only, in limited quantities, usually with no more than a 7- to 30-day supply. The prescription cannot be relled; a new prescription must be issued for continued use. Drugs categorized as Schedule III, IV, or V have a lower potential for abuse and addiction and may be ordered by prescription with a

Box 1.1

Examples of Medicines in the Controlled Substances Drug Schedules

SCHEDULE I DRUGS Examples: lysergic acid diethylamide (LSD), peyote, heroin, hashish SCHEDULE II DRUGS Examples: amphetamines, morphine, hydrocodone/ acetaminophen (Vicodin), hydrocodone/acetaminophen (Lortab), hydrocodone/acetaminophen (Norco), methadone, oxycodone/aspirin (Percodan), methylphenidate (Ritalin), amphetamine/dextroamphetamine (Adderall) SCHEDULE III DRUGS Examples: aspirin/codeine (Empirin with codeine), aspirin/ butalbital/caffeine (Fiorinal), acetaminophen/codeine (Tylenol with codeine) SCHEDULE IV DRUGS Examples: phenobarbital, chlordiazepoxide, diazepam, urazepam, temazepam SCHEDULE V DRUGS Example: atropine/diphenoxylate (Lomotil, Virtussin AC)

maximum supply of 30 days of medicine. If so written by the prescriber, the prescription may be relled up to ve times but outdates at 6 months, at which time a new prescription is required if the medicine is to be continued. Prescription medicines that are not classied as controlled substances may be relled for up to a period of time dened by individual state law, if

6

UNIT I Applying Pharmacology to Nursing Practice

approved by the prescriber. Most state laws mandate that a prescription outdates in 1 year and must be rewritten if therapy is to be continued.

education through support of national and state professional organizations, consumer advocacy groups, and local, state, and county health departments.

Drug Enforcement Administration The US Drug Enforcement Administration (DEA) was organized to enforce the Controlled Substances Act, to gather intelligence, to train its ofcers, and to conduct research in the area of dangerous drugs and drug abuse. Every manufacturer, primary healthcare provider, nurse practitioner, physician assistant, dentist, pharmacy, and hospital that manufactures, prescribes, or dispenses any of the drugs listed in the ve schedules must register biannually with the DEA. A healthcare provider’s prescription for substances named in this law must contain the healthcare provider’s name, address, DEA registration number, and signature; the patient’s name and address; and the date of issue. The pharmacist cannot ll such a prescription for a controlled substance without this information on the prescription.

NEW DRUG DEVELOPMENT

Possession of Controlled Substances by Individuals Federal and state laws make the possession of controlled substances without a valid prescription a crime, except in specically exempted cases. The law makes no distinction between professional and practical nurses with regard to the possession of controlled drugs. Nurses may give controlled substances only under the direction of a healthcare provider who has been licensed to prescribe or dispense these agents. Nurses may not have controlled substances in their possession unless the following conditions are met: (1) the nurse is giving them to a patient under an order from a healthcare provider, (2) the nurse is a patient for whom a healthcare provider has prescribed scheduled drugs, or (3) the nurse is the ofcial custodian of a limited supply of controlled substances on a unit or for a department of the hospital. Controlled substances that are ordered for patients but not used must be returned to the source from which they were obtained (i.e., the primary healthcare provider or pharmacy). Violation of or failure to comply with the Controlled Substances Act is punishable by ne, imprisonment, or both and by the possible loss of professional licensing.

PRECLINICAL RESEARCH AND DEVELOPMENT STAGE The preclinical research phase of new drug development begins with the discovery, synthesis, and purication of the drug. The goal at this stage is to use laboratory studies to determine whether the experimental drug has therapeutic value and whether the drug appears to be safe in animals. Enough data must be gained to justify testing the experimental drug in humans. The preclinical phase of data collection may require 1 to 3 years, although the average length of time is 18 months. Near the end of this phase, the investigator (often a pharmaceutical manufacturer) submits an Investigational New Drug (IND) application to the FDA; this application describes all of the studies completed to date, discusses the expected safety of the drug, and explains the testing that is planned for human subjects. Within 30 days, the FDA must make a decision on the basis of safety considerations about whether to allow the human study to proceed. Only about 20% of the chemicals tested in the preclinical phase advance to the clinical testing phase.

EFFECTIVENESS OF DRUG LEGISLATION The effectiveness of drug legislation depends on the interest and determination used to enforce these laws, the appropriation by government of adequate funds for enforcement, and the vigor used by proper authorities in enforcement. The interest and cooperation of healthcare professionals and the public with regard to the benets of appropriate drug use and the possible consequences of indiscriminate use of drugs can be very benecial. Many individuals assist in this

It currently takes an average of 8 to 15 years and more than $2 billion in research and development costs to bring a single new drug to market; healthcare professionals and consumers alike often have a lack of understanding about this process. The Pharmaceutical Research and Manufacturers of America estimates that only 1 of 10,000 chemicals investigated is actually found to be “safe and effective” and ultimately brought to the pharmacist’s shelf. The Food, Drug, and Cosmetic Act of 1938 charged the FDA with the responsibility of regulating new drugs. Rules and regulations evolved by the FDA divide new drug development into four stages: (1) preclinical research and development; (2) clinical research and development; (3) New Drug Application (NDA) review; and (4) postmarketing surveillance (Fig. 1.2).

CLINICAL RESEARCH AND DEVELOPMENT STAGE The stage in which humans are rst tested (i.e., the clinical research or IND stage) is usually subdivided into three phases. Phase 1 studies determine an experimental drug’s pharmacologic properties, such as its pharmacokinetics, metabolism, safe dosage range, potential for toxicity at a certain dosage, and safe routes of administration. The study population is composed of normal volunteers or the intended treatment population, such as those patients for whom the standard

Drug Denitions, Standards, and Information Sources CHAPTER 1

Preclinical Research and Development FDA

Clinical Research and Development

7

Postmarketing Surveillance

NDA Review

Discovery

Adverse reaction reporting

PHASE 1 PHASE 2

PHASE 4

Animal testing PHASE 3

SHORT TERM

TREATMENT–USE

Surveys/sampling testing

LONG TERM

Range: 1-3 years Average: 18 months

Range: 2-10 years Average: 5 years

FDA time: 30-day safety review

Inspections

Range: 2 months to 7 years Average: 24 months NDA submitted

NDA approved

Industry time

Fig. 1.2 The new drug review process. FDA, US Food and Drug Administration; NDA, New Drug Application.

treatments of certain cancers or dysrhythmias have been ineffective. Phase 1 studies usually require 20 to 100 subjects who are treated for 4 to 6 weeks. If phase 1 trials are successful, the drug is moved to phase 2 trials, which involve a smaller population of patients who have the condition that the drug is designed to treat. Studies at various dosages are conducted to determine the success rate and safety of a drug for its intended use. If successful, the drug is advanced to phase 3 trials, in which larger patient populations are used to ensure the statistical signicance of the results. Phase 3 studies also provide additional information about proper dosing and safety. The entire clinical research phase may require 2 to 10 years, with the average experimental drug requiring 5 years. Each study completed is reviewed by the FDA to help ensure patient safety and efcacy. Only one of ve drugs that enter clinical trials makes it to the marketplace. The others are eliminated because of efcacy or safety problems or a lack of commercial interest. Fast Tracking To expedite the development and approval of drugs for the treatment of life-threatening illnesses (e.g., acquired immunodeciency syndrome), the FDA has drafted rules that allow certain INDs to receive the highest priority for review within the agency.

This procedure is sometimes known as fast tracking. Additional rules allow INDs to be used for the treatment of a life-threatening disease in a particular patient—even if the patient does not t the study protocol for the drug—when there is no alternative therapy. These cases are known as treatment INDs. A potentially lifesaving drug may be allowed for treatment IND status during late phase 2 studies, during phase 3 studies, or after all clinical studies have been completed but before marketing approval. Parallel Tracking Another mechanism to make INDs available to patients with life-threatening illnesses is known as parallel tracking. With this procedure, an IND may be used for patients who cannot participate in controlled clinical trials and when there is no satisfactory standard therapeutic alternative. Parallel track studies are conducted along with the principal controlled clinical trials; however, unlike a controlled study, the parallel track study does not involve a concurrent control group. Investigators and patients must realize that there may be greater uncertainty regarding the risks and benets of therapy with agents that are in relatively early stages of testing and development. Parallel tracking is similar to the treatment IND process but allows for access to investigational agents when there is less accumulated evidence of efcacy than required for a treatment

8

UNIT I Applying Pharmacology to Nursing Practice

IND. A drug may be released through the parallel track mechanism when phase 2 trials have been given approval to proceed but have not necessarily been started. NEW DRUG APPLICATION REVIEW When sufcient data have been collected to demonstrate that the experimental drug is both safe and effective, the investigator submits an NDA to the FDA to formally request approval to market a new drug for human use. Thousands of pages of NDA data are reviewed by a team of pharmacologists, toxicologists, chemists, primary healthcare providers, and others (as appropriate), who then make a recommendation to the FDA about whether the drug should be approved for use. The average NDA review takes 24 months. After a drug is approved by the FDA, it is the manufacturer’s decision as to when to bring a product to the marketplace. POSTMARKETING SURVEILLANCE STAGE If the manufacturer decides to market the medicine, the postmarketing surveillance stage begins; this is the fourth stage of drug product development. This process consists of an ongoing review of adverse effects of the new drug and periodic inspections of the manufacturing facilities and the resulting products. Other studies completed during the fourth stage include identifying other patient populations for whom the drug may be useful, rening dosing recommendations, and exploring potential drug interactions.

Clinical Goldmine Healthcare providers make a signicant contribution to the knowledge of drug safety by reporting adverse effects to the FDA using the MedWatch program for the voluntary reporting of adverse events and product problems (see Online Resources).

BLACK BOX WARNING Although the FDA’s drug approval process is one of the most stringent in the world, the value of ongoing safety review of medicines has been demonstrated through the use of the MedWatch program. If safety concerns are identied after a drug is approved for marketing, the FDA can issue black box warnings to the package insert of the product. When a medication’s risks and known dangers outweigh its benets, the FDA and/or the manufacturer may decide that the product should be withdrawn from the market. The probability of a drug acquiring a new black box warning or being withdrawn from the market within 25 years of being released is estimated at 20%. Consequently, it is the responsibility of all healthcare professionals to constantly monitor their patients for adverse effects of drugs and to complete a MedWatch form when adverse effects are suspected. More than 200,000 MedWatch forms are led with the FDA annually. Health Canada has a program for reporting adverse effects (Canada

Vigilance Program: https://www.canada.ca/en/healthcanada/services/drugs-health-products/medeffectcanada/canada-vigilance-program.html). From a safety standpoint, prescribers and patients should be aware that recently marketed medicines carry a risk of causing unsuspected serious adverse effects. Even with the high probability that there will be no serious complications, the devastating—and sometimes fatal—consequences cannot be ignored. When choosing medicines for treatment, it becomes important to consider whether an equally effective alternative drug is already available. At a minimum, this reduces the risk of an undiscovered adverse drug reaction, and it is often less expensive. At a maximum, the patient, the family, and the prescriber are saved the anguish of an avoidable adverse drug reaction. RARE DISEASES AND THE DEVELOPMENT OF ORPHAN DRUGS The National Organization for Rare Disorders, which is a coalition of 140 rare-disease groups, estimates that more than 6000 rare health conditions exist in about 20 million Americans. Examples of these rare diseases are cystic brosis, Hansen disease (leprosy), sickle cell anemia, blepharospasm, infant botulism, and Pneumocystis jiroveci pneumonia (see Online Resources). Historically, pharmaceutical manufacturers have been reluctant to develop products that could be used to treat these illnesses. The medicines that are developed for these conditions are known as orphan drugs because the manufacturers have been unable to recover the costs of the research on account of the very limited use of the nal product. Because no companies were willing to “adopt” the diseases to complete extensive research to develop products for treatment, the diseases became known as health orphans. In 1983 Congress passed the Orphan Drug Act to stimulate the development and market availability of products that are used for the treatment of rare diseases. The act denes the term rare disease as a condition that affects fewer than 200,000 people in the United States. The FDA’s Ofce of Orphan Products Development (OOPD) promotes the development of products that demonstrate promise for the diagnosis or treatment of rare diseases or conditions. The OOPD interacts with medical and research communities, professional organizations, academia, and the pharmaceutical industry, as well as with rare-disease groups. The OOPD administers the major provisions of the Orphan Drug Act, which provide incentives for sponsors to develop products for rare diseases. The law provides research grants, protocol development assistance by the FDA, special tax credits for the cost of clinical trials, and 7 years of exclusive marketing rights after the product has been approved. On average, an orphan drug receives FDA approval 10 to 11 months sooner than a nonorphan drug. The act has been quite successful: more than 200 new drugs have been approved by the FDA for rare diseases, beneting several million people. Examples include

Drug Denitions, Standards, and Information Sources CHAPTER 1

pentamidine and atovaquone for Pneumocystis jiroveci pneumonia, thalidomide for Hansen disease, zidovudine for the human immunodeciency virus, dornase alfa (Pulmozyme) for cystic brosis, and cladribine (Leustatin) for hairy cell leukemia.

DRUG NAMES, STANDARDS, AND LEGISLATION IN CANADA

CANADIAN DRUG NAMES OFFICIAL DRUG The term ofcial drug pertains to any drug for which a standard is described specically in the Food and Drug Regulations or in any publication named in the Food and Drugs Act as being satisfactory for ofcially meeting the standards for drugs in Canada. CHEMICAL NAME The chemical name is most meaningful to the chemist. By means of the chemical name the chemist understands the exact chemical constitution of the drug and exact placing of its atoms or molecular groupings. The chemical name is the same in both Canada and the United States. PROPER NAME OR GENERIC NAME The proper name is the nonproprietary (generic) name, which is used to identify an ofcial drug in Canada. The generic name is the same in both Canada and the United States. BRAND NAME The brand name (or proprietary name) is the name assigned to the drug by its manufacturer to distinguish the drug for advertisement and sale. Brand names for the same generic drug product are frequently different between Canada and the United States. The following example and Fig. 1.3 depict the application of terminology to drug nomenclature. Example of Canadian Drug Names Chemical name: 4-dimethylamino-1,4,4a,5,5a,6,11,12aoctahydro-3,6,10,12,12a-pentahydroxy-6-methyl1,11,dioxo-2-napthacene carboxamide (see Fig. 1.3) Proper name: tetracycline Ofcial name: Tetracycline, USP Brand names: Apo-Tetra; Nu-Tetra OH

O

OH O OH 2

7

6

H3C

OH

5

O C

NH2

OH N

H3C

CH3

Fig. 1.3 Tetracycline, an antibiotic.

9

SOURCES OF CANADIAN DRUG STANDARDS The Food and Drugs Act recognizes the standards described by international authoritative books as being acceptable for ofcial drugs in Canada (see Table 1.2).

CANADIAN DRUG LEGISLATION FOOD AND DRUGS ACT AND REGULATIONS The Food and Drugs Act (1927) and Regulations (1953, 1954, 1979) empower Health Canada to protect the public from foreseeable risks related to the manufacture and sale of drugs, cosmetics, food, and therapeutic devices. The legislation provides for a review of the safety and efcacy of drugs before their clearance for marketing in Canada and determines whether the medicine is prescription or nonprescription. Also included in this legislation are requirements for good manufacturing practices, adequate labeling, and fair advertising. In Canada (as in the United States), an effort has been made to align the provincial drug schedules so that the conditions for the sale of medicines are consistent across Canada. The National Association of Pharmacy Regulatory Authorities (NAPRA) governs national drug schedules but each province’s regulatory body can regulate how a particular drug can be soldsold/dispensed. The National Association of Pharmacy Regulatory Authorities (NAPRA) proposed a new national drug scheduling model. This model is in various stages of implementation across the provinces and territories of Canada. With the use of this model, all medicines in Canada are assigned to one of four categories: Schedule I: All prescription drugs, including narcotics Schedule II: Restricted-access nonprescription drugs Schedule III: Pharmacy-only nonprescription drugs Unscheduled: Drugs that are not assigned to the previous categories Schedule II drugs are available for sale directly from the pharmacist and are kept “behind the counter.” Examples include insulin, pseudoephedrine, glucagon, loperamide (for children younger than age 12 years), and nitroglycerin sublingual spray and tablets (other dosage forms are Schedule I). These medications are in two categories: (1) those that patients may require urgently and cannot delay taking until after an appointment with a prescriber (e.g., insulin, nitroglycerin, glucagon); and (2) those that require appropriate counseling to avoid improper use (e.g., loperamide, pseudoephedrine). Placement with a pharmacist does not allow for patient self-selection and allows for pharmacist intervention for these medications. This restriction is meant to ensure the following: (1) that patients are not self-diagnosing medically serious diseases (e.g., diabetes mellitus, angina); and (2) that patients are educated about the proper use of these drugs through appropriate counseling from the pharmacist. Schedule III drugs are pharmacy-only nonprescription drugs. These medicines can be sold only

10

UNIT I Applying Pharmacology to Nursing Practice

through pharmacies and include levonorgestrel emergency contraception, diphenhydramine, child preparations of antihistamines, and the low-dose histamine-2 antagonists. It is expected that if patients have questions, they could easily consult with a pharmacist. Medicines that are not categorized in Schedule I, II, or III are considered to be “unscheduled” (e.g., nicotine gum and patches, acetylsalicylic acid, lower-dose ibuprofen, some lower-dosage “cough and cold” preparations) and can be sold at any retail outlet. Adequate information is available for the patient to make a safe and effective choice, and labeling is sufcient to ensure the appropriate use of the drug without professional supervision. Drugs requiring a prescription—except for controlled drugs—are listed on Schedule F of the Food and Drug Regulations. Schedule F drugs may be prescribed only by qualied healthcare providers because they would normally be used most safely under supervision. Most antibiotics, antineoplastics, corticosteroids, cardiovascular drugs, and antipsychotics are Schedule F drugs. CONTROLLED DRUGS AND SUBSTANCES ACT The Controlled Drugs and Substances Act (1997) established the requirements for the import, production, export, distribution, and possession of substances classied as narcotics and substances of abuse in Canada. The Controlled Drugs and Substances Act describes eight schedules of controlled substances. Assignment to a schedule is based on the potential for abuse and the ease with which illicit substances can be manufactured in illegal laboratories. The degree of control; the conditions of record keeping; assignment of penalties for possession, trafcking, and manufacturing; and other regulations depend on these classications. (Note that Schedules I, II, and III under the US Food and Drugs Act as described earlier are different from Schedules I through VIII of the Canadian Controlled Drugs and Substances Act). Examples of controlled substances schedule assignment are as follows: Schedule I: Opium poppy and its derivatives (e.g., heroin, morphine); coca and its derivatives (e.g., cocaine), pethidine (meperidine), methadone, fentanyl Schedule II: Cannabis

Schedule III: Amphetamines, methylphenidate, lysergic acid diethylamide (LSD), methaqualone, psilocybin, mescaline Schedule IV: Sedative-hypnotic agents (e.g., barbiturates, benzodiazepines); butorphanol, anabolic steroids Schedule V: Propylhexedrine, phenylpropanolamine, pyrovalerone Schedule VI: Part I class A precursors (e.g., ephedrine, pseudoephedrine, norephedrine [phenylpropanolamine], ergotamine) and part II precursors (e.g., acetone, ethyl ether, hydrochloric acid, sulfuric acid, toluene) Schedule VII: Cannabis resin (3 kg); cannabis (marijuana) (3 kg) (must be read in conjunction with Schedule II) Schedule VIII: Cannabis resin (1 g); cannabis (marijuana) (30 g) (must be read in conjunction with Schedule II) The Controlled Drugs and Substances Act and accompanying regulations provide for the nonprescription sale of certain codeine preparations (e.g., Tylenol No. 1 with codeine, Benylin with codeine). The content must not exceed the equivalent of 8 mg of codeine phosphate per solid dosage unit or 20 mg per 30 mL of a liquid preparation, and the preparation must also contain two additional nonnarcotic medicinal ingredients. These preparations may not be advertised or displayed, and they may be sold only by pharmacists (see previous discussion of Schedule II drugs). In hospitals, the pharmacy usually requires strict inventory control of these products and other narcotics. Requirements for the legitimate administration of drugs to patients by nurses are generally similar in Canada and the United States. Individual hospital policy determines specic record-keeping requirements on the basis of federal and provincial laws. Violations of these laws will result in nes or imprisonment in addition to the loss of professional licensing. NONPRESCRIPTION DRUGS The NAPRA drug schedules list three categories of nonprescription drugs: Schedule II, Schedule III, and unscheduled drugs (see discussion under Food and Drugs Act and Regulations).

Drug Denitions, Standards, and Information Sources CHAPTER 1

11

Clinical Judgment and Next-Generation NCLEX ® Examination-Style Questions Key Points • In the classication system used in the United States, each drug has three names: a chemical name, a generic name, and a brand name. The chemical name is most meaningful to the chemist. The generic name is simpler than the chemical name. The rst letter of the generic name is not capitalized. The brand names are selected by the manufacturer and deliberately made easier to pronounce, spell, and remember. A brand name is followed by the symbol ®. The rst letter of the brand name is capitalized. • Drugs may be classied by a variety of methods according to the body system that they affect (e.g., the central nervous system, the cardiovascular system, the gastrointestinal system); their therapeutic use or clinical indications (e.g., antacids, antibiotics, antihypertensives, diuretics, laxatives); and their physiologic or chemical action (e.g., anticholinergic agents, beta-adrenergic blockers, calcium channel blockers, cholinergic agents). • Table 1.2 lists and describes the common sources of drug information available for the healthcare provider. • Prescription drugs require an order by a healthcare provider who is licensed to prescribe drugs, such as a primary healthcare provider, a nurse practitioner, a physician assistant, a pharmacist, or a dentist. Nonprescription or over-the-counter (OTC) drugs are sold without a prescription in a pharmacy or in the health section of department or grocery stores. • Rules and regulations evolved by the FDA divide new drug development into four stages: (1) preclinical research and development; (2) clinical research and development; (3) new drug application review; and (4) postmarketing surveillance (see Fig. 1.2). • In Canada, the proper name is the nonproprietary (generic) name, which is used to identify an ofcial drug. The generic name is the same in both Canada and the United States.

Additional Learning Resources

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Cla yton) for additional online resources.

Online Resources • DailyMed: https://dailymed.nlm.nih.gov/dailymed/index. cfm • ePocrates: http://www.epocrates.com/ • iPharmacy: https://itunes.apple.com/us/app/ipharm acy-drug-guide-pubmed-direct/id378721295 • Lexicomp: http://www.wolterskluwercdi.com/lexic omp-online/ • MedicinesComplete: https://about.medicinescomplete. com/#/

• MedWatch: https://www.fda.gov/Safety/MedWatch/default .htm • National Organization for Rare Disorders (NORD): https://ra rediseases.org/ • UpToDate: https://www.uptodate.com/home • US National Library of Medicine: https://www.nlm.nih.gov/ Online Resources for Canadian Practitioners • Controlled Substances and Drugs Act (Justice Laws Website): http://laws-lois.justice.gc.ca/eng/acts/c-38.8/ • Drug Product Database: https://www.canada.ca/en/health-canada/services/drugshealth-products/drug-products/drug-productdatabase.html • National Association of Pharmacy Regulatory Authorities (NAPRA) proposal for drug schedule outlines: http://napra.ca/national-drug-schedules

Clinical Judgment and Next-Generation NCLEX ® Examination-Style Questionsn The National Council of State Boards of Nursing (NCSBN) is the body that develops and administers the NCLEX (National Council Licensure Exam). Recent studies indicate that graduates need to develop the skill of clinical decision making, so the NCLEX examination is changing with different types of questions that are designed to develop clinical judgment in patient situations. These type of questions are referred to as Next Generation NCLEX or NGN. The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. Within each chapter the NCLEX section will identify the objective associated with it, the type of NCLEX question that will be used, and the cognitive skill associated with the item type. Six essential cognitive skills of clinical judgment are being tested: recognize cues; analyze cues; prioritize hypotheses; generate solutions; take action; and evaluate outcomes. These six clinical judgment skills build on and expand the nursing process (NCSBN, 2019).

TRADITIONAL NCLEX-TYPE QUESTIONS

NGN-TYPE QUESTIONS

Multiple Choice Test Item

•  Enhanced Hot Spot Test Item •  Cloze Test Item •  Extended Multiple Response Test Item •  Extended Drag and Drop Test Item •  Matrix Text Item

Multiple Response Test Item Ordering Test Item

1. A patient has received a prescription from his primary care provider for the drug metoprolol (Lopressor). He asks the nurse why there are two names for the same drug. The nurse responds with which statements(s)? (Select all that apply.) 1. “One of the names is the brand name of the drug, and the other is the generic name.”

12

UNIT I Applying Pharmacology to Nursing Practice

2. “When drugs are discovered, all drugs are given a detailed chemical name and a simple generic name. If the company that discovered the drug brings it to the marketplace for sale, the manufacturer will give it a distinctive brand name.” 3. “Lopressor is the generic name, and metoprolol is the brand name.” 4. “The two names are used to determine whether the drug is a Schedule III or a Schedule IV drug.” 5. “Generally, the generic product of the drug is less expensive than the brand name product.” Objective: Differentiate between the chemical, generic, and brand names of drugs. NCLEX test item: Multiple response Cognitive skill: Application 2. Drugs can be classied using various methods; identify the different classication and examples as indicated. Choose the most likely option for the information missing from the statements below by selecting from the list of options provided. Medications such as _________1_____________ are classied by the _________2____________ method, whereas medications such as ________1__________ are classied by the _______2__________ method.

OPTIONS FOR 1

OPTIONS FOR 2

antacids antibiotics calcium channel blockers Diuretics Cholinergics

body systems chemical action clinical indication

Objective: Identify the various methods used to classify drugs. NGN test item: Cloze Cognitive skill: Analyze cues 3. A young mother with a 2-month-old infant tells the nurse that she is concerned about the use of any medications because she is breastfeeding her baby. The nurse reviews the possible information sources to discuss with the mother. Indicate with an X in the “recommended by the nurse” column the source of drug information listed in the left column the nurse can recommend for the mother to use. Note that not all drug information sources will be used.

DRUG INFORMATION SOURCE Nursing journals Electronic databases Package inserts Natural medicines database

RECOMMENDED BY THE NURSE

Objective: Identify sources of drug information available for healthcare providers. NGN test item: Extended drag and drop Cognitive skill: Take action 4. The nurse knows which of these factors are the differences between prescription and nonprescription drugs? (Select all that apply.) 1. Nonprescription drugs are available over-the-counter. 2. Prescription drugs are those drugs that may be prescribed by dentists, pharmacists, nurse practitioners, and primary healthcare providers. 3. Recreational drugs are available by prescription only. 4. Over-the-counter drugs are available at a pharmacy or health section of grocery stores. 5. Prescription drugs have been approved for use by the FDA. Objective: Discuss the difference between prescription and nonprescription drugs. NCLEX test item: Multiple response Cognitive skill: Application 5. During which stage of the process of new drug development does testing on humans start? 1. 2. 3. 4.

The preclinical research and development stage The postmarketing surveillance stage The postclinical research and development stage The clinical research and development stage

Objective: Describe the process of developing and bringing new drugs to market. NCLEX test item: Multiple choice Cognitive skill: Knowledge 6. A nurse is teaching a patient from Canada the names of her medications and reviews the differences between Canadian names. Which statement indicates that the patient understands the instructions? 1. “The proper name of the medication is the same as the brand name in Canada.” 2. “The proper name of the medication is the same as the generic name in Canada.” 3. “The chemical name is the one used the most when buying medications in Canada.” 4. “The chemical names and the brand names are the only names used in Canada.” Objective: Differentiate between the Canadian chemical name and the proper name of a drug. NCLEX test item: Multiple choice Cognitive skill: Evaluation

Basic Principles of Drug Action and Drug Interactions

2

https://evolve.elsevier.com/Willihnganz

Objectives 1. Identify common drug administration routes. 2. Identify the meaning and signicance of the term half-life when used in relation to drug therapy. 3. Describe the process of how a drug is metabolized in the body. 4. Compare and contrast the following terms that are used in relationship to medications: desired action, common

adverse effects, serious adverse effects, allergic reactions, and idiosyncratic reactions. 5. Identify what is meant by a drug interaction. 6. Differentiate among the terms additive effect, synergistic effect, antagonistic effect, displacement, interference, and incompatibility. 7. Identify one way in which alternatives in metabolism create drug interactions.

Key Terms receptors (rē-SĔP-tĕrz) (p. 13) pharmacodynamics (făr-mă-kō-dīNĂM-ĭks) (p. 13) agonists (ĂG-ŏ-nĭsts) (p. 13) antagonists (ăn-TĂG-ŏ-nĭsts) (p. 13) partial agonists (PĂR-shŭl ĂG-ŏ-nĭsts) (p. 13) enteral (ĔN-tĕr-ăl) (p. 14) parenteral (pă-RĔN-tĕr-ăl) (p. 14) percutaneous (pĕr-kū-TĀ-nē-ŭs) (p. 14) pharmacokinetics (făr-mă-kō-kĭ-NĔTĭks) (p. 14) absorption (ăb-SŎRP-shŭn) (p. 14) distribution (dĭs-trĭ-BŪ-shŭn) (p. 15)

drug blood level (p. 15) metabolism (mĕ-TĂB-ō-lĭz-ĕm) (p. 15) excretion (ĕks-KRĒ-shŭn) (p. 15) half-life (p. 16) onset of action (p. 17) peak action (p. 17) duration of action (p. 17) desired action (p. 17) side effects (p. 17) common adverse effects (ĂD-vŭrs ĕ-FĔKTS) (p. 17) serious adverse effects (p. 17) idiosyncratic reaction (ĭd-ē-ō-sĭnKRĂT-ĭk rē-ĂK-shŭn) (p. 18)

BASIC PRINCIPLES RELATED TO DRUG THERAPY DRUG RESPONSES IN THE BODY When administered to the body, drugs do not create new responses but rather alter existing physiologic activity in several different ways. Usually the drug forms chemical bonds with specic sites, called receptors, within the body. This bond forms only if the drug and its receptor have similar shapes and if the drug has a chemical afnity for the receptor. The relationship between a drug and a receptor is similar to that seen between a key and lock (Fig. 2.1A). The study of the interactions between drugs and their receptors and the series of events that result in a pharmacologic response is called pharmacodynamics Most drugs have several different atoms within each molecule that interlock into various locations on a receptor. The better the t between the receptor and the drug molecule, the better

allergic reactions (ă-LŬR-jĭk) (p. 18) drug interaction (p. 18) unbound drug (ŭn-BŎWND) (p. 18) additive effect (ĂD-ĭ-tĭv) (p. 19) synergistic effect (sĭn-ĕr-JĬS-tĭk) (p. 19) antagonistic effect (ăn-tăg-ŏ-NĬST-ĭk) (p. 19) displacement (dĭs-PLĀS-měnt) (p. 19) interference (ĭn-tŭr-FĒR-ĕns) (p. 19) incompatibility (ĭn-kŏm-păt-ĭ-BĬL-ĭ-tē) (p. 19)

the response from the drug. The intensity of a drug response is related to how well the drug molecule ts into the receptor and to the number of receptor sites that are occupied. Drugs that interact with a receptor to stimulate a response are known as agonists (Fig. 2.1B). Drugs that attach to a receptor but do not stimulate a response are called antagonists (Fig. 2.1C). Drugs that interact with a receptor to stimulate a response but inhibit other responses are called partial agonists (Fig. 2.1D). Drug response must be stated in relation to the physiologic activity expected in response to the drug therapy (e.g., an antihypertensive agent is successful if the patient’s blood pressure is lower after receiving the drug than it was before the drug was started). Therefore it is important to perform a thorough nursing assessment to identify the baseline data. After that is done, results from regular assessments can be compared 13

UNIT I Applying Pharmacology to Nursing Practice

14

characteristics. The study of the mathematical relationships among the ADME features of individual medicines over time is called pharmacokinetics

Receptor

Drug

A

C

B

D

Fig. 2.1 (A) Drugs act by forming chemical bonds with specic receptor sites, similar to a key and lock. The better the t, the better the response. (B) Drugs with complete attachment and response are called agonists. (C) Drugs that attach but do not elicit a response are called antagonists. (D) Drugs that attach and elicit a small response but also block other responses are called partial agonists.

Table 2.1 Drug Therapy Used in Disease Management a DISEASES/ILLNESSES Cancer

CLASSIFICATION OF THE DRUGS USED Chemotherapy, immunotherapy

Mental illness

Antidepressants and antipsychotic agents

Hypertension

Antihypertensive agents

Diabetes

Antidiabetic agents

Infections

Antimicrobial agents

Inammatory diseases

Antiinammatory agents

Nausea and vomiting

Antiemetic agents

Constipation

Laxatives

Diarrhea

Antidiarrheal agents

GERD

Antacids

aList

is not inclusive. GERD, Gastroesophageal reux disease.

with the baseline data by the primary healthcare provider, the nurse, and the pharmacist to evaluate the effectiveness of the drug therapy. Table 2.1 lists examples of drug therapies and their related diseases. ROUTES OF DRUG ADMINISTRATION The most common routes of drug administration are the enteral, parenteral, and percutaneous routes. When using the enteral route, the drug is administered directly into the gastrointestinal (GI) tract by the oral, rectal, or nasogastric route. The parenteral route bypasses the GI tract with the use of subcutaneous (subcut), intramuscular (IM), or intravenous (IV) injection. The percutaneous route involves drugs being absorbed through the skin and mucous membranes. Methods of the percutaneous route include inhalation, sublingual (under the tongue), and topical (on the skin) administration. LIBERATION, ABSORPTION, DISTRIBUTION, METABOLISM, AND EXCRETION After they have been administered, all drugs go through ve stages: liberation, absorption, distribution, metabolism, and excretion (LADME). After liberation from the dosage form, each drug has its own unique ADME

Liberation Regardless of the route of administration, a drug must be released from the dosage form (i.e., liberated) and dissolved in body uids before it can be absorbed into body tissues. For example, before a solid drug that is taken orally can be absorbed into the bloodstream for transport to the site of action, the dosage form (usually a capsule or tablet) must disintegrate and the active drug must dissolve in the GI uids so that it can be transported across the stomach or intestinal lining into the blood. The process of converting the drug into a form that will activate a response can be partially controlled by the pharmaceutical dosage form used (e.g., solution, suspension, capsule, tablet [with various coatings]). This conversion process can also be inuenced by administering the drug with or without water or food in the patient’s stomach. Absorption Absorption is the process whereby a drug is transferred from its site of entry into the body to the circulating uids of the body (i.e., blood and lymph) for distribution around the body. The rate at which this occurs depends on the route of administration, the blood ow through the tissue where the drug is administered, and the solubility of the drug. It is therefore important to do the following: (1) administer oral drugs with an adequate amount of uid (usually a large [8-ounce] glass of water); (2) give parenteral forms properly so that they are deposited in the correct tissue for enhanced absorption; and (3) reconstitute and dilute drugs only with the diluent recommended by the manufacturer in the package literature so that drug solubility is not impaired. Equally important are nursing assessments that reveal poor absorption (e.g., if insulin is administered subcutaneously and a lump remains at the site of injection 2 to 3 hours later, absorption from that site may be impaired). The rate of absorption when a drug is administered by a parenteral route depends on the rate of blood ow through the tissues. Circulation or blood ow must be determined before the administration of drugs by the parenteral route to identify any circulatory insufciency. If any such insufciency is noted, injections will not be absorbed properly, and the drug will not be effective. Subcut injections have the slowest absorption rate, especially if peripheral circulation is impaired. IM injections are more rapidly absorbed because of greater blood ow per unit weight of muscle compared with subcut tissue. Cooling the area of injection slows the rate of absorption, whereas heat or massage hastens the rate of absorption. Drugs are dispersed throughout the body most rapidly when they are administered by IV injection. The nurse must be thoroughly educated

Basic Principles of Drug Action and Drug Interactions CHAPTER 2

regarding the responsibilities and techniques associated with administering IV medications. It is important to remember that after a drug enters the patient’s bloodstream, it cannot be retrieved. The absorption of topical drugs that have been applied to the skin can be inuenced by the drug concentration, the length of contact time, the size of the affected area, the thickness of the skin surface, the hydration of the tissue, and the degree of skin disruption. Percutaneous (i.e., across-the-skin) absorption is greatly increased in newborns and young infants, who have thin, well-hydrated skin. When drugs are inhaled, their absorption can be inuenced by the depth of the patient’s respirations, the neness of the droplet particles, the available surface area of the patient’s mucous membranes, the contact time, the hydration state, the blood supply to the area, and the concentration of the drug itself. Distribution The term distribution refers to the ways in which a drug is transported throughout the body by the circulating body uids to the sites of action or to the receptors that the drug affects. Drug distribution refers to the transport of the drug throughout the entire body by the blood and lymphatic systems and the transport from the circulating uids into and out of the uids that bathe the receptor sites. Organs with the most extensive blood supplies (e.g., heart, liver, kidneys, brain) receive the distributed drug most rapidly. Areas with less extensive blood supplies (e.g., muscle, skin, fat) receive the drug more slowly. After a drug has been dissolved and absorbed into the circulating blood, its distribution is determined by the chemical properties of the drug and how it is affected by the blood and tissues that it contacts. Two factors that inuence drug distribution are protein binding and lipid (fat) solubility. Most drugs are transported in combination with plasma proteins (especially albumin), which act as carriers for relatively insoluble drugs. Drugs that are bound to plasma proteins are pharmacologically inactive because the large size of the complex keeps them in the bloodstream and prevents them from reaching the sites of action, metabolism, and excretion. Only the free, or unbound, portion of a drug is able to diffuse into tissues, interact with receptors, and produce physiologic effects; it is also only this portion that can be metabolized and excreted. The same proportions of bound and free drug are maintained in the blood at all times. Thus as the free drug acts on receptor sites or is metabolized, the decrease in the serum drug level causes some of the bound drug to be released from protein to maintain the ratio between bound and free drug. When a drug leaves the bloodstream, it may become bound to tissues other than those with active receptor sites. The more lipid-soluble drugs have a high afnity for adipose tissue, which serves as a

15

repository site for these agents. Because there is a relatively low level of blood circulation to fat tissues, the more lipid-soluble drugs tend to stay in the body much longer. Equilibrium is established between the repository site (i.e., lipid tissue) and the circulation so that as the drug blood level drops as a result of binding at the sites of physiologic activity, metabolism, or excretion, more drug is released from the lipid tissue. By contrast, if more drug is given, a new equilibrium is established among the blood, the receptor sites, the lipid tissue repository sites, and the metabolic and excretory sites. Distribution may be general or selective. Some drugs cannot pass through certain types of cell membranes, such as the blood-brain barrier (i.e., the central nervous system) or the placental barrier (i.e., the placenta), whereas other types of drugs readily pass into these tissues. The distribution process is very important because the amount of drug that actually gets to the receptor sites determines the extent of pharmacologic activity. If little of the drug actually reaches and binds to the receptor sites, the response will be minimal. Metabolism Metabolism is the process whereby the body inactivates drugs. The enzyme systems of the liver are the primary sites for the metabolism of drugs, but other tissues and organs (e.g., white blood cells, GI tract, lungs) metabolize certain drugs to a minor extent. Genetic, environmental, and physiologic factors are involved in the regulation of drug metabolism reactions. The most important factors for the conversion of drugs to their metabolites are genetic variations of enzyme systems, the concurrent use of other drugs, exposure to environmental pollutants, concurrent illnesses, and age. (For more information, see Chapter 3.) Excretion The elimination of drug metabolites and, in some cases, of the active drug itself from the body is called excretion. The two primary routes of excretion are through the GI tract into the feces and through the renal tubules into the urine. Other routes of excretion include evaporation through the skin, exhalation from the lungs, and secretion into saliva and breast milk. Because the kidneys are major organs of drug excretion, the nurse should review the patient’s chart for the results of urinalysis and renal function tests. A patient with renal failure often has an increase in the action and duration of a drug if the dosage and frequency of administration are not adjusted to allow for the patient’s reduced renal function. Fig. 2.2 shows a schematic review of the ADME process of an oral medication. It is important to note how little of the active ingredient actually reaches the receptor sites for action.

UNIT I Applying Pharmacology to Nursing Practice

16

Capsule dissolved by GI fluids (Some is lost by degradation)

Undissolved capsule taken orally

Drug in solution in intestines (Some is absorbed; some is lost to degradation or by binding to intestinal contents and excreted)

Drug absorbed by intestines and goes to the liver (Some is lost by secretion into bile; some is lost by biotransformation; some is bound to tissue and becomes inactive)

Drug reaches general circulation (Some is lost by biotransformation; some is bound to plasma protein and becomes inactive)

Drug is distributed to the entire body (Some is lost by biotransformation and excretion; some is distributed to other tissues and organs; some reaches receptor sites, triggering a pharmacologic response)

Fig. 2.2 Factors that modify the quantity of drug that reaches a site of action after a single oral dose. GI, Gastrointestinal.

HALF-LIFE Drugs are eliminated from the body by means of metabolism and excretion. A measure of the time required for elimination is the half-life. The half-life is dened as the amount of time required for 50% of the drug to be eliminated from the body. For example, if a patient is given 100 mg of a drug that has a half-life of 12 hours, the following would be observed: TIME (HOURS)

HALF-LIFE

DRUG REMAINING IN BODY (%)

0 12 24 36 48 60

— 1 2 3 4 5

100 mg (100) 50 mg (50) 25 mg (25) 12.5 mg (12.5) 6.25 mg (6.25) 3.12 mg (3.12)

Note that as each 12-hour period (i.e., one half-life) passes, the amount remaining is 50% of what was there 12 hours earlier. After six half-lives, more than 98% of the drug has been eliminated from the body.

The half-life is determined by an individual’s ability to metabolize and excrete a particular drug. Because most patients metabolize and excrete a particular drug at approximately the same rate, the approximate half-lives of most drugs are now known. When the half-life of a drug is known, dosages and frequency of administration can be calculated. Drugs with long half-lives (e.g., digoxin, with a half-life of 36 hours) need to be administered only once daily, whereas drugs with short half-lives (e.g., aspirin, with a half-life of 5 hours) need to be administered every 4 to 6 hours to maintain therapeutic activity. For patients who have impaired hepatic or renal function, the half-life may become considerably longer because of their reduced ability to metabolize or excrete the drug. For example, digoxin has a half-life of about 36 hours in a patient with normal renal function; however, it has a half-life of about 105 hours in a patient with complete renal failure. Monitoring diagnostic tests that measure renal or hepatic function is important. Whenever laboratory data reect impairment of

Basic Principles of Drug Action and Drug Interactions CHAPTER 2

Toxicity

Drug concentration

Supratherapeutic MDR (peak) Intensity

Desired therapeutic range MEC

Duration of action

Onset

Subtherapeutic

Termination Time

Fig. 2.3 A time-response curve, which is also known as a drug concentration–time prole, demonstrates the relationship between the administration of a drug and the patient’s response. If the drug level does not reach the minimum effective concentration (MEC), there will be no pharmacologic effect. If the peak level exceeds the toxicity threshold, toxic effects will result. The optimal drug concentration is in the middle of the therapeutic range. MDR, Maximum drug response (peak effect).

either function, the nurse should notify the healthcare provider.

DRUG ACTIONS All drug actions have an onset, peak, and duration of action. The onset of action is when the concentration of a drug at the site of action is sufcient to start a physiologic (pharmacologic) response. Many factors—such as the route of administration and the rates of absorption, distribution, and binding to receptor sites—affect the onset of action. In general, increasing the dose of the drug hastens the onset of action by shortening the time required to achieve the necessary concentration of drug at the target site. Peak action is the time at which the drug reaches the highest concentrations on the target receptor sites, thereby inducing the maximal pharmacologic response for the dose given. The duration of action is how long the drug has a pharmacologic effect. The onset, peak, and duration of action of a drug are often illustrated by a time-response curve, which is also known as a drug concentration–time prole (Fig. 2.3). A time-response curve demonstrates the relationship between the administration of a drug and the associated response. If the drug level does not reach the minimum effective concentration, there will be no pharmacologic effect. If the peak level exceeds the toxicity threshold, toxic effects will result. Generally, the drug concentration is targeted to be in the middle of this range, between the minimum effective response and the toxic response; this is referred to as the therapeutic range. DRUG BLOOD LEVEL When a drug is circulating in the blood, a blood sample may be drawn and assayed to determine the amount of

17

drug present. This is known as a drug blood level. It is important for certain drugs (e.g., anticonvulsants, aminoglycoside antibiotics) to be measured to ensure that the drug blood level is within the therapeutic range. If the drug blood level is low, the dosage must be increased, or the medicine must be administered more frequently. If the drug blood level is too high, the patient may develop signs of toxicity; in this case, the dosage must be reduced or the medicine administered less frequently. ADVERSE EFFECTS OF DRUGS No drug has a single action. When a drug enters a patient and is then absorbed and distributed, the desired action (i.e., the expected response) usually occurs. However, all drugs have the potential to affect more than one body system simultaneously, thereby producing responses that are known as side effects or common adverse effects, which are mild, or serious adverse effects, which can lead to toxicity. The World Health Organization’s denition of an adverse drug reaction (ADR) is “any noxious, unintended, and undesired effect of a drug, which occurs at dosages used in humans for prophylaxis, diagnosis, or therapy.” A more common denition is as follows: “Right drug, right dose, right patient, bad effect.” ADRs should not be confused with medication errors or adverse drug events (ADEs), which are dened as “an injury resulting from medical intervention related to a drug.” (For more information, see Chapter 6.) Recent studies have indicated the following: • ADRs may be responsible for more than 100,000 deaths among hospitalized patients per year, which makes them one of the top six leading causes of death in the United States. • An average of 6% of hospitalized patients experience a signicant ADR at some point during their hospitalizations. • Between 5% and 9% of hospitalization costs are attributable to ADRs. • The most commonly seen ADRs are rash, nausea, itching, thrombocytopenia, vomiting, hyperglycemia, and diarrhea. • The classes of medicines that account for the largest number of ADRs are antibiotics, cardiovascular medicines, cancer chemotherapy agents, analgesics, and antiinammatory agents. Most ADEs are predictable because of the pharmacologic effects of a drug, and patients should be monitored so that dosages can be adjusted to allow for the maximum therapeutic benets with a minimum of adverse effects. As described in Units III through X of this text, each drug has a series of parameters (e.g., therapeutic actions to expect, adverse effects, probable drug interactions) that should be monitored by the nurse, primary healthcare provider, pharmacist, and patient to optimize therapy while reducing the possibility of serious adverse effects. Accurate and appropriate drug-drug interaction information must be available to prescribers, and continual attention is currently focused on this issue. Further

18

UNIT I Applying Pharmacology to Nursing Practice

population-based studies still need to be conducted to meet federal initiatives to promote the meaningful use of information technologies and to integrate knowledge databases with clinical decision systems. Ideally, clinical decision systems and the databases of drug interactions that interface with them help the prescriber to identify and avoid potential medication interactions. All hospitals have internal mechanisms for reporting suspected ADRs, and healthcare providers should not hesitate to report possible reactions. By monitoring and tracking the occurrences of ADRs, clinical protocols and improved patient screening will reduce the frequency of recurrence. The US Food and Drug Administration’s MedWatch program is also available for the voluntary reporting of adverse events. (For more information, see MedWatch on Evolve.) Idiosyncratic Reaction Two other types of drug actions are much more unpredictable: idiosyncratic reactions and allergic reactions. An idiosyncratic reaction occurs when something unusual or abnormal happens when a drug is rst administered. The patient usually demonstrates an unexpectedly strong response to the action of the drug. This type of reaction is generally the result of a patient’s inability to metabolize a drug because of a genetic deciency of certain enzymes. Fortunately, this type of reaction is rare.

Drug interactions are elicited in two ways: (1) by agents that, when combined, increase the actions of one or both drugs; and (2) by agents that, when combined, decrease the effectiveness of one or both drugs. Some drug interactions are benecial, such as the use of caffeine, a central nervous system stimulant, with an antihistamine, a central nervous system depressant. The stimulatory effects of the caffeine counteract the drowsiness caused by the antihistamine without eliminating the antihistaminic effects. The mechanisms of drug interactions can be categorized as those that change the absorption, distribution, metabolism, or excretion of a drug and those that enhance the pharmacologic effect of a drug. CHANGES IN ABSORPTION Most drug interactions that change absorption take place in the GI tract, usually the stomach. Examples of this type of interaction include the following: • Antacids inhibit the dissolution of ketoconazole tablets by increasing the gastric pH. The interaction is managed by giving the antacid at least 2 hours after ketoconazole administration. • Aluminum-containing antacids inhibit the absorption of tetracycline. Aluminum salts form an insoluble chemical complex with tetracycline. The interaction is managed by separating the administration of tetracycline and antacids by 3 to 4 hours.

Allergic Reaction Allergic reactions, which are also known as hypersensitivity reactions, occur in about 6% to 10% of patients who are taking medications. Allergic reactions occur among patients who have previously been exposed to a drug and whose immune systems have developed antibodies to the drug. On reexposure to the drug, the antibodies cause a reaction; this reaction is most commonly seen as raised, irregularly shaped patches on the skin known as hives, which cause severe itching, known as urticaria. Occasionally, a patient has a severe, life-threatening reaction that causes respiratory distress and cardiovascular collapse; this is known as an anaphylactic reaction. This condition is a medical emergency, and it must be treated immediately. Fortunately, anaphylactic reactions occur much less often than the more mild urticarial reactions. If a patient has a mild reaction, it should be understood as a warning to not take the medication again. The patient is much more likely to have an anaphylactic reaction during their next exposure to the drug. Patients should receive information about the drug name and be instructed to tell healthcare providers that they have had such reactions and that they must not receive the drug again. In addition, patients should wear a medical alert bracelet or necklace that explains the allergy.

CHANGES IN DISTRIBUTION Drug interactions that cause a change in distribution usually affect the binding of a drug to an inactive site (e.g., circulating plasma albumin, muscle protein). When a drug is absorbed into the blood, it is usually transported throughout the body bound to plasma proteins. It often binds to other proteins, such as those in muscle. A drug that is highly bound (e.g., >90% bound) to a protein-binding site may be displaced by another drug that has a higher afnity for that binding site. Signicant interactions can take place this way because little displacement is required to have a major impact. Remember, only the unbound drug is pharmacologically active. If a drug is 90% bound to a protein, then 10% of the drug is providing the physiologic effect. If another drug is administered with a stronger afnity for the protein-binding site and it displaces just 5% of the bound drug, there is now 15% unbound for physiologic activity; this is the equivalent of a 50% increase in dosage (i.e., from 10% to 15% active drug). For example, the anticoagulant action of warfarin is increased by administration with furosemide, which is a loop diuretic. Furosemide displaces warfarin from albumin-binding sites, thereby increasing the amount of unbound anticoagulant. This interaction is managed by decreasing the warfarin dosage.

DRUG INTERACTIONS

CHANGES IN METABOLISM Drug interactions usually result from a change in metabolism that involves inhibiting or inducing (stimulating)

A drug interaction is said to occur when the action of one drug is altered or changed by the action of another drug.

Basic Principles of Drug Action and Drug Interactions CHAPTER 2

the enzymes that metabolize a drug. Medicines known to bind to enzymes and to slow the metabolism of other drugs include verapamil, ketoconazole, amiodarone, cimetidine, and erythromycin. Serum drug levels usually increase as a result of inhibited metabolism when these drugs are given concurrently, and the dosages of the inhibited drugs usually must be reduced to prevent toxicity. For example, erythromycin inhibits the metabolism of theophylline; therefore the dose of theophylline must be reduced on the basis of theophylline serum levels and signs of toxicity. Because erythromycin (an antibiotic) is usually administered only in short courses, the theophylline dosage usually needs to be increased when the erythromycin is discontinued. Common drugs that bind to enzymes and increase the metabolism of other drugs (enzyme inducers) are phenobarbital, carbamazepine, rifampin, and phenytoin. Rapidly metabolized drugs include doxycycline, warfarin, metronidazole, theophylline, and verapamil. When administered with enzyme inducers, the dosages of the more rapidly metabolized drugs should generally be increased to provide therapeutic activity. The patient must be monitored closely for adverse effects. For example, if a woman who is taking oral contraceptives (see Chapter 40) requires a course of rifampin antimicrobial therapy, the rifampin will induce the enzymes that metabolize both the progesterone and estrogen components of the contraceptive, thereby causing an increased incidence of menstrual abnormalities and reduced effectiveness of conception control. This interaction is managed by advising the patient to use an additional form of contraception while she is receiving rifampin therapy. Adverse effects may also occur if an enzyme inducer is discontinued. The metabolism of the induced drug then decelerates, leading to accumulation and toxicity if the dosage is not reduced.

19

CHANGES IN EXCRETION Drug interactions that cause a change in excretion usually act in the kidney tubules by changing the pH to enhance or inhibit excretion. The classic example of altered urine pH is the combination of acetazolamide (which elevates urine pH) and quinidine. The alkaline urine produced by acetazolamide causes quinidine to be reabsorbed in the renal tubules, which potentially increases the physiologic and toxic effects of quinidine. The frequent monitoring of quinidine serum levels and assessments for signs of quinidine toxicity are used as guides for reducing quinidine dosage. DRUGS THAT ENHANCE THE PHARMACOLOGIC EFFECTS OF OTHER DRUGS Major drug interactions also occur between drugs. This may occur when one drug enhances the physiologic effects of another drug. Alcohol and sedativehypnotic agents both cause sedation, but when used together can cause signicant central nervous system depression. Another drug interaction that can have serious consequences is the interaction between aminoglycoside antibiotics (gentamicin, tobramycin) and a neuromuscular blocking agent such as pancuronium. When used together, the antibiotic increases the neuromuscular blockade, prolonging return to normal respirations and recovery time. Table 2.2 denes the terminology related to drug-drug interactions. Because it is impossible to memorize all possible drug interactions, the nurse must check for drug interactions when they are suspected. The nurse must take the time to consult drug resource books and pharmacists to ensure that a patient who is receiving multiple medications does not experience unanticipated drug interactions.

Table 2.2 Terminology Related to Drug-Drug Interactions TERM Additive effect

DEFINITION Two drugs with similar actions are taken for an increased effect.

EXAMPLE hydrocodone + acetaminophen = added analgesic effect

Synergistic effect

The combined effect of two drugs is greater than the sum of the effect of each drug given together.

aspirin + codeine = much greater analgesic effect

Antagonistic effect

One drug interferes with the action of another.

tetracycline + antacid = decreased absorption of the tetracycline

Displacement

The displacement of the rst drug from protein-binding sites (i.e., bound drugs are inactive) by a second drug increases the activity of the rst drug because more unbound drug is available.

warfarin + valproic acid = increased anticoagulant effect

Interference

The rst drug inhibits the metabolism or excretion of the second drug, thereby causing increased activity of the second drug.

probenecid + ampicillin = prolonged antibacterial activity of ampicillin because probenecid blocks the renal excretion of ampicillin

Incompatibility

The rst drug is chemically incompatible with the second drug, thereby causing deterioration when the drugs are mixed in the same syringe or solution or are administered together at the same site. Signs include haziness, formation of a precipitate, or a change in the color of the solution when the drugs are mixed.

ampicillin + gentamicin = ampicillin inactivates gentamicin

UNIT I Applying Pharmacology to Nursing Practice

20

Clinical Judgment and Next-Generation NCLEX ® Examination-Style Questions Key Points • The most common routes of drug administration are the enteral, parenteral, and percutaneous routes. • The half-life of a drug is dened as the amount of time required for 50% of the drug to be eliminated from the body. • After administration, all drugs go through ve stages: liberation, absorption, distribution, metabolism, and excretion (LADME). The enzyme systems of the liver are the primary sites for the metabolism of drugs, but other tissues and organs (e.g., white blood cells, GI tract, lungs) metabolize certain drugs to a minor extent. • When a drug enters a patient and is absorbed and distributed, the desired action usually occurs. However, all drugs have the potential to affect more than one body system simultaneously, causing common adverse effects, which are generally mild, or serious adverse effects, which can be more severe and lead to toxicity. • Drug interactions are elicited in two ways: (1) by agents that, when combined, increase the actions of one or both drugs; and (2) by agents that, when combined, decrease the effectiveness of one or both of the drugs. • The mechanisms of drug interactions can be categorized as those that change the absorption, distribution, metabolism, or excretion of a drug and those that enhance the pharmacologic effect of a drug.

Additional Learning Resources

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/ Willihnganz) for additional online resources.

Clinical Judgment and Next-Generation NCLEX ® Examination-Style Questions The following questions are typical of the NCLEX exam and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types and formats. 1. A nurse is reviewing the drug route for an order written to be given via nasogastric tube and understands that this means that the drug will be administered by which route? 1. 2. 3. 4.

Enteral Parenteral Percutaneous Intramuscular

Objective: Identify common drug administration routes. NCLEX test item: Multiple choice Cognitive skill: Knowledge 2. A patient takes 50 mg of a drug that has a half-life of 12 hours. What percentage of the dose remains in the body 36 hours after the drug is administered? 1. 50 mg (100%)

2. 25 mg (50%) 3. 12.5 mg (25%) 4. 6.25 mg (12.5%) Objective: Identify the meaning and signicance of the term halflife when used in relation to drug therapy. NCLEX test item: Multiple choice Cognitive skill: Comprehension 3. The nurse reviews the patient’s charts for laboratory tests that relate to how well the patient’s organ systems are working because drug metabolism is inuenced by certain body systems. Choose the most likely options for the information missing from the sentence below by selecting from the lists of options provided. Metabolism is the process that deactivates drugs; sites for metabolism of drugs are ________ 1__________ and ___________ 1_____________ and __________ 1________, and factors that inuence these drug metabolism reactions are __________ 2_________ and __________ 2________. OPTIONS FOR 1

OPTIONS FOR 2

kidneys white blood cells GI tract liver heart

exercise tolerance environmental pollutants repository sites concurrent use of other drugs receptor sites

Objective: Describe the process of how a drug is metabolized in the body. NGN test item: Cloze Cognitive skill: Recognize cues 4. When an antihypertensive drug causes a drop in blood pressure to the normal range, what is this effect called? 1. 2. 3. 4.

Antagonistic effect Desired therapeutic effect Side effect Additive effect

Objective: Compare and contrast the following terms that are used in relationship to medications: desired action, common adverse effects, serious adverse effects, allergic reactions, and idiosyncratic reactions. NCLEX test item: Multiple choice Cognitive skill: Understanding 5. The nurse noticed that, after administering an antibiotic ampicillin in the patient’s IV line, the solution in the tubing started to turn milky and hazy after injecting another drug in the same tubing. The precipitate that was created meant the nurse needed to do what next? (Select all that apply.) 1. Recognize that the two drugs are incompatible and notify the healthcare providers. 2. Flush the line still connected to the patient until the precipitate is gone. 3. Stop the infusion, disconnect the IV line, ush the precipitate out, and reconnect the line. 4. Request that the drugs be placed on different schedules so that they are not administered at the same time. 5. Recognize that the two drugs are having a synergistic effect and notify the healthcare providers.

Basic Principles of Drug Action and Drug Interactions CHAPTER 2 Objective: Differentiate among the terms: additive effect, synergistic effect, antagonistic effect, displacement, interference, and incompatibility. NCLEX test item: Multiple response Cognitive skill: Application 6. A patient is experiencing a rash over their torso and legs accompanied by severe itching after receiving an antibiotic for an ear infection. What does the nurse suspect is happening? Select all that apply. 1. 2. 3. 4. 5. 6. 7.

The patient is having an idiosyncratic reaction. The patient is having an antagonistic effect. The patient is having an allergic reaction. The patient is having a common adverse effect. The patient is having the desired effect. The patient is having a serious adverse effect. The patient is having an anaphylactic reaction.

Objective: Compare and contrast the following terms that are used in relationship to medications: desired actions, common adverse effects, serious adverse effects, allergic reactions, and idiosyncratic reactions. NGN test item: Extended multiple response Cognitive skill: Recognize cues 7. When a patient who was prescribed warfarin and valproic acid begins experiencing an increased effect of warfarin (bruising on arms, bleeding gums), what is this known as? 1. 2. 3. 4.

Synergistic effect Antagonistic effect Idiosyncratic effect Displacement effect

Objective: Compare and contrast the following terms that are used in relationship to medications: desired action, common adverse effects, serious adverse effects, allergic reactions, and idiosyncratic reactions. NCLEX test item: Multiple choice Cognitive skill: Knowledge 8. The nurse is aware that a patient who has an increased metabolic rate (e.g., hyperthyroidism) generally requires what type of dosage? 1. 2. 3. 4.

Normal dosage Lower-than-normal dosage Higher-than-normal dosage A dosage that is based on the patient’s thyroid function levels

Objective: Identify one way in which alternatives in metabolism create drug interactions. NCLEX test item: Multiple choice Cognitive skill: Comprehension 9. The nurse studied the terms for drug interactions and recognized that there are medications that will create an antagonistic effect when given together. Choose the most likely option for the information missing from the statements below by selecting from the list of options provided. An example of the drug interaction that causes an antagonistic effect is between _______ 1___________ and _________ 2________ in which there is a decrease in the absorption of the second drug.

OPTIONS FOR 1

OPTIONS FOR 2

antacid warfarin probenecid aspirin

codeine ampicillin tetracycline valproic acid

21

Objective: Differentiate among the following terms: additive effect, synergistic effect, antagonistic effect, displacement, interference, and incompatibility. NGN test item: Cloze Cognitive skill: Analysis cues 10. The nurse is aware of enzymes that affect metabolism and therefore affect drug actions that are caused by alterations in enzyme activity. Indicate with an arrow (up or down) whether the reaction by the enzyme activity will increase or decrease metabolism of a drug.

ENZYME ACTIVITY

CHANGE IN DRUG ACTION CAUSED BY ALTERED METABOLISM

Enzyme inhibitors Enzyme inducers Enzyme enhancers Enzyme metabolizers

Objective: Identify one way in which alternatives in metabolism create drug interactions. NGN test item: Extended Drag and Drop Cognitive skill: Recognize cues 11. The nurse reviews terms used to describe the therapeutic effects of drugs and knows they include the additive effect and the synergistic effect. Choose the most likely option for the information missing from the statements below by selecting from the list of options provided. An example of a synergistic effect is one that is caused by the combination of ________ 1_________ and _________ 2___________, which increases the therapeutic analgesic effect of the drugs. OPTIONS FOR 1

OPTIONS FOR 2

antacid warfarin probenecid aspirin

codeine ampicillin tetracycline valproic acid

Objective: Differentiate among the following terms: additive effect, synergistic effect, antagonistic effect, displacement, interference, and incompatibility. NGN test item: Cloze Cognitive skill: Analysis cues

3

Drug Action Across the Life Span

https://evolve.elsevier.com/Clayton

Objectives 1. Explain the impact of the placebo effect and the nocebo effect. 2. Identify the importance of drug dependence and drug accumulation. 3. Discuss the effects of age on drug absorption, distribution, metabolism, and excretion. 4. Explain the gender-specic considerations of drug absorption, distribution, metabolism, and excretion.

5. Describe where a nurse will nd new information about the use of drugs during pregnancy and lactation. 6. Discuss the impact of pregnancy and breastfeeding on drug absorption, distribution, metabolism, and excretion. 7. Discuss the role of genetics and its inuence on drug action.

Key Terms gender-specic medicine (JĔN-dŭr spĕ-SĬ-fĭk) (p. 23) placebo effect (plă-SĒ-bō ĕf-FĔKT) (p. 23) nocebo effect (nō-SĒ-bō) (p. 23) placebo (plă-SĒ-bō) (p. 23) tolerance (TŎL-ŭr-ŭns) (p. 24) drug dependence (dē-PĔN-dĕns) (p. 24) drug accumulation (ă-kyū-mū-LĀshŭn) (p. 24)

carcinogenicity (kăr-sĭn-ō-jĕn-ĬS-ǐ-tē) (p. 24) passive diffusion (PĂ-sǐv dǐ-FYŪshŭn) (p. 25) hydrolysis (hī-DRŎ-lǐ-sǐs) (p. 25) intestinal transit (ǐn-TĔS-tǐ-năl TRĂNsǐt) (p. 25) protein binding (PRŌ-tēn BĪN-dǐng) (p. 26) drug metabolism (mĕ-TĂB-ō-lĭz-ĕm) (p. 26) metabolites (mĕ-TĂB-ŏ-līts) (p. 27)

FACTORS THAT AFFECT DRUG THERAPY Patients often say “That drug really knocked me out!” or “That drug didn’t touch the pain!” The effects of drugs are unexpectedly potent in some patients, whereas other patients show little response at the same dosage. In addition, some patients react differently to the same dosage of a drug that is administered at different times. Because of individual patient variation, exact responses to drug therapy are difcult to predict. The following factors have been identied as contributors to the variable response to drugs. AGE Infants and the very old tend to be the most sensitive to the effects of drugs. There are important differences with regard to the absorption, distribution, metabolism, and excretion of drugs in premature neonates, full-term newborns, and children. The aging process brings about changes in body composition and organ function that can affect the older patient’s response to drug therapy. Thus the age of the patient can have a 22

therapeutic drug monitoring (thĕră-PYŪ-tĭk) (p. 27) polypharmacy (pŏl-ē-FĂR-mă-sē) (p. 31) teratogens (TĔR-ă-tō-jĕnz) (p. 31) genetics (jĭ-NĔT-ĭks) (p. 35) genome (JĒ-nōm) (p. 35) polymorphisms (pŏl-ē-MŎR-fǐz-ǐmz) (p. 35) pharmacogenetics (făr-mă-kō-jĭ-NĔTĭks) (p. 35)

signicant impact on drug therapy. When discussing the effect of age on drug therapy, it is helpful to subdivide the population into the following categories: AGE

STAGE

3 or 5), thus slowing the absorption of certain types of medicines (e.g., aspirin). A slower gastric emptying time may allow the drug to stay in contact with the absorptive tissue longer, thereby allowing for more absorption and a higher serum concentration. Women also have lower gastric levels of the enzyme alcohol dehydrogenase, which is needed to metabolize ingested alcohol. Thus larger amounts of ingested alcohol may be absorbed instead of metabolized in the stomach, thereby leading to a higher blood alcohol level in a woman than in a man for equal amounts of ingested alcohol. Other factors, such as body weight and drug distribution (see the next section of this chapter), may

26

UNIT I Applying Pharmacology to Nursing Practice

Table 3.2 Proportions of Body Water a AGE (WEIGHT) Premature (1.5 kg)

EXTRACELLULAR WATER (%) 60

INTRACELLULAR WATER (%) 40

TOTAL BODY WATER (%) 83

Full term (3.5 kg)

56

44

74

5 mo (7 kg)

50

50

60

1 yr (10 kg)

40

60

59

Adult male

40

60

60

aDevelopmental

changes from birth to adulthood. Extracellular and intracellular water values are expressed as percentages of total body weight. Data from Friis-Hansen B. Body composition during growth. Pediatrics. 1971;47(suppl 2):264.

aggravate the higher blood alcohol level and state of intoxication in women compared with men. DISTRIBUTION The term distribution refers to the ways in which drugs are transported by the circulating body uids to the sites of action (receptors), metabolism, and excretion. Distribution is dependent on pH, body water concentrations (i.e., intracellular, extracellular, and total body water), the presence and quantity of fat tissue, protein binding, cardiac output, and regional blood ow. Age and Gender Most medicines are transported either dissolved in the circulating water (i.e., in blood) of the body or bound to plasma proteins within the blood. Total body water content of a preterm infant is 83%, whereas that of an adult man is 60%; this drops to 50% in older persons. The signicance of this is that infants have a larger volume of distribution for water-soluble drugs and thus require a higher dose on a milligram-per-kilogram basis than an older child or an adult (Table 3.2). With aging, lean body mass and total body water decrease and total fat content increases. The body weight of a preterm infant may be composed of 1% to 2% fat, whereas a full-term newborn may have 15% fat. Adult total body fat ranges from 18% to 36% for men and 33% to 48% for women between the ages of 18 and 35 years. Drugs that are highly fat soluble (e.g., antidepressants, phenothiazines, benzodiazepines, calcium channel blockers) require a longer onset of action and accumulate in fat tissues, thereby prolonging their action and increasing the potential for toxicity. For water-soluble drugs (e.g., ethanol, aminoglycoside antibiotics), a woman’s greater proportion of body fat produces a higher blood level compared with that of a man when the drug is given as an equal dose per kilogram of body weight. In the case of ethanol, this effect tends to cause a higher level of ethanol in the brain cells, which results in greater intoxication. Highly fatsoluble medicines (e.g., diazepam) must be given in smaller milligram-per-kilogram dosages to low-birthweight infants, because there is less fat tissue to bind the drug, thereby leaving more drug to be active at receptor sites.

Drugs that are relatively insoluble are transported in the circulation by being bound to plasma proteins (albumin and globulins), especially albumin. Protein binding is reduced in preterm infants because of decreased plasma protein concentrations, lower binding capacity of protein, and decreased afnity of proteins for drug binding. Drugs that are known to have lower protein binding in neonates than in adults include phenobarbital, phenytoin, theophylline, propranolol, lidocaine, and penicillin. Because serum protein binding is diminished, the drugs are distributed over a wider area of the neonate’s body, and a larger loading dose is required than is needed in older children to achieve therapeutic serum concentrations. Several drugs that are used to treat neonatal conditions may compete for binding sites. Little difference exists between albumin protein in men and women, although there are some differences between the globulin proteins (i.e., corticosteroid-binding and sex-hormone–binding globulins). In adults who are more than 40 years old, the composition of body proteins begins to change. Although the total body protein concentration is unaffected, albumin concentrations gradually decrease and other protein levels (e.g., globulins) increase. As albumin levels diminish, the level of unbound active drug increases. Increased levels of naproxen and valproate have been found in older adults, presumably as a result of decreased albumin levels. Disease states such as cirrhosis, renal failure, and malnutrition can lower albumin levels. Initial doses of highly protein-bound drugs (e.g., warfarin, phenytoin, propranolol, diazepam) should be reduced and then increased slowly if there is evidence of decreased serum albumin. Lower protein binding may also lead to a greater immediate pharmacologic effect because more active drug is available; however, the duration of action may be reduced because more of the unbound drug is available for metabolism and excretion. METABOLISM Drug metabolism is the process whereby the body in-

activates medicines. It is controlled by factors such as genetics, diet, age, health, and the maturity of enzyme systems. Enzyme systems, primarily in the liver, are the major pathways of drug metabolism.

Drug Action Across the Life Span CHAPTER 3

27

Age All enzyme systems are present at birth, but they mature at different rates, taking several weeks to a year to fully develop. Liver weight, the number of functioning hepatic cells, and hepatic blood ow decrease with age; this results in the slower metabolism of drugs in older adults. Reduced metabolism can be seriously aggravated by the presence of liver disease or heart failure. Drugs that are extensively metabolized by the liver (e.g., morphine, lidocaine, propranolol) can have substantially prolonged durations of action if hepatic blood ow is reduced. Dosages usually must be reduced or the time interval between doses extended to prevent the accumulation of active medicine and potential toxicity. Drug metabolism can also be affected in all age groups by genetics, smoking, diet, gender, other medicines, and diseases (e.g., hepatitis, cirrhosis). Liver enzymes are monitored to determine any elevated levels during the course of drug therapy. No specic laboratory tests are available for measuring liver function that can be used to adjust drug dosages (Table 3.3). Renal function must be assessed and dosages adjusted based on creatinine clearance.

blood ow caused by atherosclerosis and reduced cardiac output, a loss of glomeruli, and decreased tubular function and urine-concentrating ability. However, there is a great degree of individual variation with regard to changes in renal function, and no prediction of renal function can be made solely on the basis of a person’s age. The renal function of older adult patients should be estimated using equations that factor in the patient’s age. More optimally, renal function should be calculated by measuring urine creatinine levels over time. Serum creatinine can give a general estimate of renal function, but in older adult patients these determinations tend to exaggerate actual functional capability. This happens because the production of creatinine depends on muscle mass, which is diminished in older adults. Signicant elevations occur only when there has been major deterioration of renal function. Blood urea nitrogen concentration is also a poor predictor of renal function because it is signicantly altered by diet, status of hydration, and blood loss (Table 3.4).

Gender It is now recognized that males and females differ with regard to the concentrations of enzyme systems throughout life. The CYP3A4 component of the cytochrome P450 (CYP) system of enzymes metabolizes more than 50% of all drugs, and it is 40% more active in women. Drugs such as erythromycin, prednisolone, verapamil, and diazepam are metabolized faster in women than in men.

drug’s concentration in biologic uids to correlate the dosage administered and the level of medicine in the body with the pharmacologic response. Assays of blood (serum) samples for drug concentrations are most commonly used, but assays that involve the use of saliva are being perfected for some medicines. Saliva samples have the advantage of the easy collection of specimens without pain or the loss of blood that may require replacement by transfusion at a later date. Therapeutic drug monitoring is essential for neonates, infants, and children to ensure that drugs are within an appropriate therapeutic range, given the major physiologic changes that affect drug absorption, distribution, metabolism, and excretion. The dosage and the frequency of administration must often be adjusted to help maintain therapeutic serum concentrations. Therapeutic drug monitoring is routine for conditions such as epilepsy (e.g., phenytoin, carbamazepine, valproic acid, phenobarbital), stroke (e.g., warfarin), heart failure (e.g., digoxin), and antimicrobial therapy (e.g., gentamicin, tobramycin, vancomycin) to prevent toxicities and to ensure that dosages are adequate to provide appropriate therapeutic levels. Blood levels of drugs can be measured if toxicity is suspected. The extent to which a serum drug level is elevated may dictate how the toxicity should be treated (e.g., acetaminophen, digoxin). Blood and urine samples can also be obtained for legal purposes if it is suspected that drugs (e.g., ethanol, amphetamines, marijuana, benzodiazepines, cocaine) have been consumed illicitly. The timing of the drug’s administration and the collection of the specimen are crucial to the accurate interpretation of the data obtained after assay. Certain

EXCRETION Metabolites of drugs, which are the products of metabolism—and, in some cases, the active drug itself— are eventually excreted from the body. The primary routes are through the renal tubules into the urine and through the GI tract into the feces. Other generally minor routes of excretion include evaporation through the skin, exhalation from the lungs, and secretion into the saliva and breast milk. Age At birth, a preterm infant has up to 15% of the renal capacity of an adult, whereas a full-term newborn has approximately 35% of that capacity. The ltration capacity of an infant increases to about 50% of adult capacity at 4 weeks of age and is equivalent to full adult function at 9 to 12 months. Drugs that are excreted primarily by the kidneys (e.g., penicillin, gentamicin, tobramycin, vancomycin) must be administered in increased dosages or given more often to maintain adequate therapeutic serum concentrations as renal function matures. As the body ages, important physiologic changes take place in the kidneys, including decreased renal

THERAPEUTIC DRUG MONITORING Therapeutic drug monitoring is the measurement of a

28

UNIT I Applying Pharmacology to Nursing Practice

Table 3.3 Medications That Require Hepatic Monitoring a b GENERIC NAME acetaminophen

BRAND NAME Tylenol

GENERIC NAME methotrexate

amiodarone

Pacerone

methsuximide

Celontin

atorvastatin

Lipitor

naproxen

Naprosyn

azathioprine

Imuran

nevirapine

Viramune

carbamazepine

Tegretol

niacin

Niaspan

diclofenac

Voltaren

oxcarbazepine

Trileptal

efavirenz

Sustiva

pentamidine

Pentam

ethosuximide

Zarontin

pioglitazone

Actos

ethotoin

Peganone

piroxicam

Feldene

felbamate

Felbatol

pravastatin

Pravachol

fenobrate

Tricor

rifampin

Rifadin

uvastatin

Lescol

ritonavir

Norvir

gembrozil

Lopid

rosiglitazone

Avandia

griseofulvin

Gris-PEG

rosuvastatin

Crestor

indinavir

Crixivan

simvastatin

Zocor

isoniazid

Nydrazid

tacrine

Cognex

ketoconazole

Nizoral

terbinane

Lamisil

lamivudine

Epivir

tizanidine

Zanaex

leunomide

Arava

tolcapone

Tasmar

valproic acid

Depakote

lovastatin

Mevacor

meloxicam

Mobic

BRAND NAME Rheumatrex

a

usually at the beginning of therapy and then every few weeks to months thereafter (see individual monographs). bEnzymes that are routinely monitored for liver function are alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase. If the patient’s levels become elevated, the primary healthcare provider should be notied for individualized treatment. Data from Tice SA, Parry D. Medications that require hepatic monitoring. Hosp Pharm. 2001;36(4):456-464; Tice SA, Parry D. Medications that require hepatic monitoring. Hosp Pharm. 2004;39(6):595-606; Porter RS, Kaplan JL, eds. The Merck Manual of Diagnosis and Therapy. 19th ed. Whitehouse Station, NJ: Merck; 2012; American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-2246.

medicines (e.g., aminoglycosides, gentamicin, tobramycin) require that blood be drawn before and after the administration of the drug to assess subtherapeutic levels and the potential for toxicity. One sample is drawn immediately before the next dose is to be administered to obtain the trough, or lowest, blood level of medicine, and another is drawn 20 minutes after the medicine has been administered intravenously or 60 minutes after the medicine has been administered orally to obtain the peak, or highest, blood level. All institutions have policies that prescribe the best approach to therapeutic drug monitoring with specic medicines to ensure the accuracy and usefulness of results. To coordinate blood draws with the timing of drug administration, institutional policies regarding the handling of laboratory requests should be checked.

NURSING IMPLICATIONS WHEN MONITORING DRUG THERAPY Chapter 4 discusses in detail the nursing process as it applies to pharmacology. In this chapter, which discusses drug action across the life span, it is appropriate

to discuss nursing actions that relate to high-risk populations, such as pediatric patients, older adult patients, pregnant patients, and breastfeeding patients. MONITORING PARAMETERS All medicines have a number of parameters (e.g., expected therapeutic actions, common adverse effects, serious adverse effects, and any drug interactions) that a nurse must be knowledgeable about before taking on the responsibility of administering medications to patients. When peak and trough blood levels for a medication have been ordered, it is important that the nurse check the laboratory results in a timely manner and make sure that the prescriber is notied of the laboratory results. The next dose of the medication should not be given until the dosage has been claried on the basis of the blood levels measured. Although many of the same monitoring parameters (e.g., vital signs, urine output, renal function tests) are used to plan dosages and to monitor the effects of drug therapy in patients of all ages, it is absolutely crucial that the normal values for these monitoring parameters and laboratory tests be related to the age of the

Drug Action Across the Life Span CHAPTER 3

29

Table 3.4 Overview of Factors That Inuence Drug Actions With Regard to Age and Gender FACTOR Absorption

Distribution

Metabolism

Excretion

AGE/GENDER Infants

PHYSIOLOGIC VARIABLES •  Erratic absorption for intramuscular (IM) medications resulting from underdeveloped muscles •  Topical medications absorbed faster because skin underdeveloped •  Reduced gastric acidity and prolonged transit time for medications orally

Elderly

•  Unpredictable absorption for IM medications; muscle mass, blood ow, and muscle activity are factors •  Topical medications affected by skin thickness, tissue perfusion •  Reduced gastric acidity, slower gastric emptying time for oral medications

Gender

•  Women have slower gastric emptying time

Infants

•  Greater total body water content •  Total fat content low •  Protein binding lower, with lower circulating plasma proteins

Elderly

•  Lower total body water content •  Total fat content increases as one ages •  Protein binding lower, albumin levels diminish after 40 yr of age

Gender

•  Women have greater proportion of body fat than men

Infants

•  Liver enzyme systems are immature

Elderly

•  Liver function decreases with age, slowing metabolism

Gender

•  Women have more active cytochrome P450 enzymes, which metabolize drugs faster than men

Infants

•  Renal capacity is 15% of that of an adult at full-term birth; lower with preterm birth

Elderly

•  Renal function based on serum creatinine; creatinine production is based on muscle mass, which may be lower in the elderly

Gender

•  Both renal blood ow and glomerular ltration rate (GFR) are higher in men than in women •  Women show a slower clearance of drugs that are eliminated via the kidneys •  During pregnancy the GFR may double, requiring an increased dosage or more frequent administration of drugs excreted by glomerular ltration to maintain a therapeutic effect

patient being monitored. For example, neonates have higher respiratory and heart rates and lower normal blood pressures than adults. As with all medications, patient education is important. Involving the appropriate family members, caregivers, and the school nurse in the overall health teaching plan is essential (see Chapter 5). Pediatric Patients Children are not just smaller versions of adults; therefore the principles of drug therapy cannot be extrapolated to infants and children only on the basis of size. Infants and children are at greater risk for complications from drug therapy because their body and organ functions are in an ongoing state of development. General principles that a nurse can apply to the care of a pediatric patient include the following: • Although infants and young children have a higher total body water content, they are more susceptible to dehydration from fever, vomiting, or diarrhea. • Weight variations and growth spurts are expected in pediatric patients during normal maturation. Dosage adjustments are frequently necessary for patients who are taking medicine on a regular basis (e.g., seizure medicines, allergy medicines) because

they outgrow their dosages (see Appendix A for a nomogram for estimating body surface area). Therefore it is important to obtain accurate height and weight measurements on a regular basis. • Therapeutic drug monitoring is essential for neonates, infants, and children to ensure that drugs are within an appropriate therapeutic range. The nurse must document the precise times that blood samples are drawn and the time over which the medicine was infused for accurate interpretation of the results. • It is often difcult to assess the therapeutic response to the medicines administered to neonates, infants, and young children because these patients are often nonverbal or cannot tell us where it hurts. The nurse must rely more on laboratory values and assessment parameters such as temperature, pulse, respirations, heart sounds, lung sounds, bowel sounds, intake and output data, appetite, general appearance, and responsiveness. • Nurses may nd it difcult to measure and administer doses of oral medicines to pediatric patients accurately. The volume delivered by a household teaspoon ranges from 2.5 to 7.5 mL and may vary when the same spoon is used by different caregivers. The

30

•

•

•

• •

UNIT I Applying Pharmacology to Nursing Practice

American Academy of Pediatrics recommends the use of appropriate devices for liquid administration, such as a medication cup, an oral dropper, or an oral syringe. Although tablets and capsules can usually be swallowed by a child who is 5 years old or older, the nurse should evaluate each child’s ability to swallow a tablet before administration. Tablets that are not sustained-release or entericcoated formulations may be crushed. Most capsules may be opened and the contents sprinkled on small amounts of food (e.g., applesauce, jelly, pudding). Box 3.1 provides selected pediatric administration guidelines for oral administration. Oral and parenteral medicines available in powder form must be diluted properly in accordance with the manufacturer’s directions to allow for the accurate measurement of doses and to prevent hyperosmolar solutions from being administered. When taken orally, hyperosmolar solutions may cause diarrhea and dehydration. Many medicines are not approved by the FDA for use in children. Primary healthcare providers may still legally prescribe medicines for what is termed off-label use, but it is important for the nurse to question a specic dose of medicine if it is not readily available for cross-checking with reference texts or with the drug information service in the pharmacy. The nurse must document in the nurses’ notes that the drug order was veried before the prescribed medicine was administered. Nurses must be well versed in the monitoring parameters of the drug, and report adverse effects to the healthcare provider. In general, salicylates (aspirin) should not be administered to pediatric patients from infancy through adolescence. These children are susceptible to a lifethreatening illness known as Reye syndrome if they ingest aspirin at the time of or shortly after viral infection with chickenpox or inuenza. Medicines that are routinely used for analgesia and antipyresis (fever reduction) in pediatric patients are ibuprofen and acetaminophen. Allergic reactions can occur rapidly in children, particularly if the medicine is administered intravenously. Reactions occur most commonly to antibiotics, especially penicillins. The nurse needs to be observant for responses to medication administration; if an event should occur, prompt intervention is needed. The rst symptoms may be intense anxiety, weakness, sweating, and shortness of breath. Other symptoms may include hypotension, shock, dysrhythmia, respiratory congestion, laryngeal edema, nausea, and defecation. The nurse should summon assistance (call a code if severity warrants), stay with the child to provide comfort, facilitate breathing (administer oxygen, as needed), and, if the child stops breathing, initiate cardiopulmonary resuscitation.

Box 3.1

Selected Guidelines for the Administration of Oral Medicine to Pediatric Patients a

INFANTS • Use a calibrated dropper or an oral syringe. • Support the infant’s head while holding the infant in the lap. • Give small amounts of medicine to prevent choking. • If desired, crush non–enteric-coated or slow-release tablets into a powder and then sprinkle the powder on small amounts of food. • Provide physical comforting while administering medications to help calm the infant. TODDLERS • Allow the toddler to choose a position in which to take the medication. • If necessary, disguise the taste of the medication with a small volume of avored drink or a small amount of food; also, a rinse with a avored drink or water will help remove any unpleasant aftertaste. • Use simple commands in the toddler’s jargon to obtain cooperation. • Allow the toddler to choose which medication to take rst if more than one is being taken. • Provide verbal and tactile responses to promote cooperation. • Allow the toddler to become familiar with the oral dosing device. PRESCHOOL CHILDREN • If possible, place a tablet or capsule near the back of the tongue, and then provide water or a avored liquid to help with the swallowing of the medication. • If the child’s teeth are loose, do not use chewable tablets. • Use a straw to administer medications that could stain teeth. • Use a follow-up rinse with a avored drink to help minimize any unpleasant aftertaste. • Allow the child to help make decisions about the dosage formulation, the place of administration, which medication to take rst, and the type of avored drink to use. aFor

all age groups listed, use a liquid dosage form, if available. From Brown LM, Isetts BJ. Patient assessment and consultation. In: Krinsky DL, Berardi RR, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2012:27. Reproduced with permission from the American Pharmacists Association.

Geriatric Patients Geriatric patients represent an ever-increasing portion of the population. Although people who are more than 65 years old represent about 14% of the US population, they consume more than 25% of all prescription medicines and 33% of all nonprescription medicines sold. The prevalence of prescription medication use in the ambulatory adult population increases with advancing age. A recent study of the US noninstitutionalized adult population has indicated that more than 90% of persons 65 years old or older use at least one medication per week. More than 40% use 5 or more

Drug Action Across the Life Span CHAPTER 3

medications and 12% use 10 or more different medications per week.

Life Span Considerations Older Adults It is important that healthcare professionals understand the physiologic and pathologic changes that develop with advancing age and adjust drug therapy for the individual patient accordingly. Factors that place older adults at greater risk for drug interactions or drug toxicity include reduced renal and hepatic function, chronic illnesses that require multidrug therapy (polypharmacy), and a greater likelihood of malnourishment.

Unfortunately, a lack of complete understanding of the effects of medicines in older adults also leads to a problem that is the opposite of overuse: underuse. Caregivers walk a ne line between polypharmacy and undertreatment because of the complexity of chronic illnesses, changes in physiology and nutrition, compliance with multidrug regimens, and the pharmacokinetic factors associated with drug therapy during the later decades of a person’s life. Although medicines may impair an older patient’s quality of life, medicines are also the most cost-effective treatment for preventing illness and disability in the geriatric population. When caring for a geriatric patient, it is important to complete a thorough drug history that includes the patient’s use of nonprescription and herbal medicines (especially laxatives and antacids), nutritional and herbal supplements, and alternative therapies (e.g., aromatherapy, heat therapy, cold therapy). Similarly, a thorough nutrition history should be completed for the patient. Determine whether the patient’s diet is balanced with regard to carbohydrates, fats, proteins, and vitamins. Assess whether a loss of teeth or loose-tting dentures could interfere with chewing. A functional health assessment that includes sight and ne-motor control should be completed to assess the patient’s ability to self-medicate. When evaluating a new symptom in a geriatric patient, determine rst whether it was induced by medicines that the patient is taking. The adjustment of dosages or the elimination of certain medicines is often the easiest, quickest, and most cost-effective therapy available. When discontinuing drug therapy, it is important to taper the dosage when appropriate (e.g., beta blockers, antidepressants) to prevent symptoms that could occur as a result of sudden discontinuation. When initiating therapy with a geriatric patient, remember the following: • Start at one-third to one-half of the normal adult recommended dosage, and then gradually increase the dosage at appropriate intervals to assess for the therapeutic effect and the development of adverse effects.

31

• Keep multidrug regimens simple; use aids such as a calendar or a pillbox with time slots to prevent confusion. • Use therapeutic drug monitoring when serum drug level data are available for a particular medicine. • Offer assistance with destroying expired prescriptions to minimize confusion with the current medication regimen. • Periodically review the regimen to see whether any medications can be discontinued (e.g., allergy medicines outside of allergy season). Ask whether new prescriptions from other healthcare providers or nonprescription or herbal medicines have been started. • Be alert to prescriptions for the medications listed in Table 3.5. This list of medicines is part of the Beers Criteria, which are used to evaluate prescription quality and safety in nursing homes. These medicines are considered to be potentially inappropriate (but not contraindicated) for older patients. Their use should be documented as the best alternative for a patient’s particular needs. The Centers for Medicare and Medicaid Services has incorporated the Beers Criteria into federal safety regulations for long-term care facilities. • Geriatric patients may have difculty with swallowing large tablets or capsules. Tablets may need to be broken in half or crushed if there is a score mark on the tablet. Remember that timed-release tablets, enteric-coated tablets, and sublingual tablets should never be crushed because of the effect on the absorption rate and the potential for toxicity. Applesauce, ice cream, pudding, and jelly are good foods to use to administer crushed medications. • It is extremely important that patients understand the purposes of the medications that they are taking and any complications that could occur if they discontinue their drugs. • When handing a patient a new prescription to be lled, inquire about their ability to pay for the new medicine. Do not let an inability to pay be a barrier to therapy; refer the patient to social services, as needed. Pregnant Patients During pregnancy, the fetus is exposed to most medicines and foreign substances that are circulating in the mother’s blood. Fetuses are particularly sensitive to toxic substances while in utero for the following reasons: (1) they have few circulating proteins that can bind drugs; (2) their enzyme systems, which will later metabolize drugs, are not yet developed or are immature; and (3) their excretory systems are only minimally functioning. Some drugs known as teratogens will cause the abnormal development of key tissues (i.e., birth defects) if they are taken at a certain time during pregnancy (Table 3.6).

32

UNIT I Applying Pharmacology to Nursing Practice

Table 3.5 Potentially Inappropriate Drugs for Older Adult Patients a GENERIC NAME MEDICATIONS TO AVOID Antidepressants amitriptyline

BRAND NAME

RATIONALE

Elavil

Highly anticholinergic Sedating and cause orthostatic hypotension

doxepin greater than 6 mg paroxetine

Paxil

Antihistamines chlorpheniramine

Chlor-Trimeton

cyproheptadine

Highly anticholinergic Risk of confusion, dry mouth, and constipation Diphenhydramine used for acute treatment of severe allergic reactions may be appropriate

diphenhydramine

Benadryl

hydroxyzine

Vistaril

Antiinfective nitrofurantoin

Macrobid

Potential for pulmonary toxicity, hepatoxicity, and peripheral neuropathy, especially with long-term use; safer alternatives available Avoid in individuals with creatinine clearance of less than 30 mL/min or for long-term suppression of bacteria

Antispasmodics dicyclomine

Bentyl

Highly anticholinergic

hyoscyamine

Levsin

Antipsychotics First Generation (Typical) uphenazine haloperidol

Haldol

Second Generation (Atypical) aripiprazole

Abilify

quetiapine

Seroquel

Benzodiazepines Short and Intermediate Acting alprazolam

Xanax

lorazepam

Ativan

temazepam

Restoril

Long Acting clonazepam

Klonopin

diazepam

Valium

All increase risk of cerebrovascular accident and greater cognitive decline and mortality in patients with dementia Do not use for behavior problems of dementia or delirium Avoid, except for schizophrenia, bipolar disorder, or as antiemetic during chemotherapy

Older patients are very sensitive to benzodiazepines and have decreased ability to metabolize long-acting benzodiazepines All benzodiazepines increase risk of cognitive impairment, delirium, falls, and fractures Long-acting benzodiazepines may be appropriate for seizure disorders, ethanol withdrawal, severe generalized anxiety disorder

urazepam Cardiovascular Drugs Antiarrhythmics amiodarone

Pacerone

Amiodarone is effective for maintaining sinus rhythm but has greater toxicities than other antiarrhythmics; avoid as rst line unless patient has heart failure

digoxin

Lanoxin

Digoxin may be associated with increased mortality in atrial brillation and heart failure; do not use rst line and limit dose to less than 0.125 mg/day High risk of orthostatic hypotension; avoid use to treat hypertension

Peripheral Alpha-1 Blockers doxazosin

Cardura

terazosin

Hytrin High risk of central nervous system effects; may cause bradycardia and orthostatic hypotension; not recommended to routinely treat hypertension

Central Alpha Blockers

clonidine

Catapres Continued

Drug Action Across the Life Span CHAPTER 3

33

Table 3.5 Potentially Inappropriate Drugs for Older Adult Patients a—cont’d GENERIC NAME Gastrointestinal Drugs metoclopramide

BRAND NAME

RATIONALE

Reglan

Can cause extrapyramidal effects, including tardive dyskinesia; risk may be greater in frail older adults and with prolonged exposure Avoid, unless for gastroparesis do not used for more than 12 wk.

Proton-pump inhibitors

Risk of Clostridium difcile infection and bone loss and fractures Do not use for >8 wk unless for high-risk patients (e.g., oral corticosteroids or chronic NSAID use, Barret esophagitis)

Nonsteroidal Antiinammatory Drugs aspirin greater than 325 mg

Increased gastrointestinal bleeding Avoid chronic use

ibuprofen

Motrin

naproxen

Naprosyn

Nonbenzodiazepines eszopiclone

Lunesta

zolpidem

Ambien

Have adverse effects similar to benzodiazepines

aThese

medicines are still approved for use; however, it is believed that the adverse effects are generally more common, and thus the medicines should be avoided in older adult patients unless treatment has failed with other medicines. Data from American Geriatrics Society 2019 Beers Criteria Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694.

Table 3.6 Drugs Known to Be Teratogens DRUG CLASS Androgenic and estrogenic hormones

EXAMPLE(S) oral contraceptives, diethylstilbestrol, conjugated estrogens, clomiphene, exemestane

Angiotensin-converting enzyme inhibitors

benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, ramipril, trandolapril

Angiotensin II receptor antagonists

azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

Anticonvulsants

carbamazepine, phenytoin, trimethadione, valproic acid

Antimanic agents

lithium

Antithyroid drugs

propylthiouracil, methimazole

Chemotherapeutic agents

busulfan, cyclophosphamide, methotrexate

Hydroxymethylglutaryl coenzyme A reductase inhibitors (statins)

atorvastatin, uvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Other teratogens

ambrisentan, anastrozole, azathioprine, cocaine, dronedarone, dutasteride, ethanol (high dose, frequent use), isotretinoin, alitretinoin, ribavirin, tetracycline, thalidomide, vitamin A (>18,000 units/day), warfarin

Because of the potential for injury to the developing fetus, drug therapy during pregnancy should be avoided if at all possible. However, studies indicate that about two-thirds of women take at least one drug while pregnant and that about two-thirds of the medicines are nonprescription self-care remedies. The medicines that are most commonly taken include acetaminophen, antacids, and cold and allergy products. Because few data are available for determining the safety of medicines in humans during pregnancy, very few medicines can be considered completely safe for use during pregnancy. In 2015 the FDA instituted new rules for drug labels that replace the lettered categories with new categories on pregnancy, lactation, and reproductive potential. In addition to including information that summarizes the

risks of using a drug during pregnancy (increasing the risk to the fetus for birth defects, called teratogenicity) and lactation, labeling must now include relevant information about contraception, pregnancy testing, and infertility to inform the healthcare provider prescribing drugs for females and males of reproductive potential (and for the consumer). It will be several years before the older system is completely phased out, but the new format will allow for consistency of information regarding risks and benets of prescription drugs used during pregnancy and lactation and by females and males of reproductive potential. Information regarding drug use in pregnancy, in lactation, and in females and males of reproductive potential is found in section 8 of the package insert and in other online drug information resources such as ePocrates and Lexicomp. Two

UNIT I Applying Pharmacology to Nursing Practice

34

Table 3.7 Drugs and Nursing Infants DRUGS’ POTENTIAL ADVERSE EFFECTS Drugs that may interfere with the metabolism of a nursing infant

EXAMPLES cyclophosphamide, cyclosporine, doxorubicin, methotrexate, capecitabine, cytarabine, gemcitabine, pemetrexed

Drugs of abuse reported to have adverse effects on nursing infants

amphetamine, cocaine, heroin, marijuana, phencyclidine, ethanol

Drugs for which effect on nursing infants is unknown but may be of concern Antianxiety medications

Benzodiazepines: alprazolam, diazepam, quazepam

Antidepressants

Cyclic antidepressants: amitriptyline, clomipramine, nortriptyline, desipramine, imipramine, doxepin, bupropion, trazodone Serotonin reuptake inhibitors: uoxetine, uvoxamine, paroxetine, sertraline Antipsychotic drugs: chlorpromazine, clozapine, haloperidol, mesoridazine, triuoperazine

Others Drugs associated with signicant effects on nursing infantsa aDrugs

amiodarone, lamotrigine, metronidazole aspirin, beta-adrenergic blocking agents (acebutolol, atenolol), clemastine, lithium, phenobarbital, primidone

for which the effect on nursing infants is unknown but may be of concern. Give to nursing mothers with caution.

excellent resources—LactMed and DART—are available on the National Library of Medicine’s TOXNET website. These resources include information on nonprescription medications, whereas the new labeling requirements do not provide information on these drugs. (See Online Resources for links.) General principles that a nurse can apply to the care of a pregnant patient include the following (see also Chapter 39): • When taking a history, be alert to the possibility of pregnancy in any woman of childbearing age, especially in those showing symptoms of early pregnancy, including nausea, vomiting (especially in the morning), and frequent urination. • Complete a thorough drug history, including the use of nonprescription and herbal medicines and nutritional supplements. • Complete a thorough nutrition history; assess for a diet that is balanced with regard to carbohydrates, fats, proteins, and vitamins. Good nutrition with the appropriate ingestion of vitamins (especially folic acid) and minerals (calcium and phosphorus) is particularly important for preventing birth defects. • Instruct the patient to avoid drugs in general at any stage of pregnancy, unless such use is recommended by the patient’s primary healthcare provider. • Advise against the consumption of alcohol during pregnancy. Excessive use may cause the child to be born with fetal alcohol syndrome, which is a lifelong condition that can be avoided by eliminating alcohol during pregnancy. If the woman is planning to become pregnant, it is recommended that she stop using alcohol 2 to 3 months before the planned conception. • Advise against the use of tobacco. Mothers who smoke have a higher frequency of miscarriage, stillbirths, premature births, and low-birth-weight infants.

• Before they use medicines, advise pregnant women to try nonpharmacologic treatments. For morning sickness, the patient can try lying down when she feels nauseated; ingesting crackers or sipping small quantities of liquids before arising; eating small, frequent meals that are high in carbohydrates; and lowering fat content of meals. Pregnant women with morning sickness should avoid spicy foods, dairy products, and smells or situations that might cause vomiting. • Herbal medicines that have not been scientically tested in women during pregnancy should be avoided. Breastfeeding Infants Many drugs are known to enter the breast milk of nursing mothers and have the potential to harm the infant. The American Academy of Pediatrics provides a list of medicines and their potential effects on nursing infants (Table 3.7). Nurses should keep in mind when caring for patients who are breastfeeding that although drug levels in breast milk may be safe, it is always best for the mother to discuss all medicines she uses—including prescription, nonprescription, and herbal products— with a healthcare provider before taking them. If medicine is being taken, encourage the mother to take it immediately after the infant nishes breastfeeding or just before the infant’s longer sleep periods. Educate the mother about what adverse effects of the drug might occur in the infant so that other therapy can be considered.

GENETICS AND DRUG METABOLISM Genetic composition serves as the basic foundation for all drug responses and their duration of action in

Drug Action Across the Life Span CHAPTER 3

the body throughout the person’s lifetime. Many other factors have an impact on drug action and duration, but the foundation starts with the genetic blueprint. Genetics is the study of how living organisms inherit the characteristics or traits of their ancestors, such as hair color, eye color, and skin pigmentation. Other much less obvious—but extremely important—traits of inheritance include the function of the metabolic pathways and susceptibility to illnesses (e.g., heart disease or cancer). A genome is the complete package of genetic coding of an organism. The human genome is composed of 23 chromosome pairs, 22 of which are known as autosomal (i.e., not gender related) pairs; the remaining pair is the X or Y chromosome that determines the presence of male or female sex characteristics. Twentythree chromosomes each are donated by the biologic mother and father. Genetic information is carried on the chromosomes by a large molecule called deoxyribonucleic acid (DNA), which is copied and passed on to future generations. Traits are carried in DNA as instructions for building and operating an organism. These instructions are contained in segments of DNA called genes. The sequence of the DNA linkages in a gene determines what traits the gene controls. The sequence of DNA is similar to a sequence of words that are linked together to form a meaningful sentence. Several genes are frequently responsible for a specic trait or function. The sequence of genes is known as the genetic code. The organism reads the sequence of these units and decodes the instructions. Polymorphisms are naturally occurring variations in the structures of genes and the instructions that they give to the organism. In 1989 the National Center for Human Genome Research was created to lead the US contribution to the Human Genome Project, an international public effort to sequence all 3 billion DNA base pairs of the human genetic blueprint. The Human Genome Project was completed in April 2003, and the database is now available for worldwide biomedical research. An unfolding science based on genetics is pharmacogenetics, which is the study of how drug response may vary in accordance with inherited differences. As

35

described in Chapter 2, drug action depends on ve factors: liberation, absorption, distribution, metabolism, and excretion. Each of these factors is greatly inuenced by genetic polymorphisms, but each also varies on the basis of such factors as age, gender, organ function, other drug therapy, and drug interactions. Research has shown signicant differences among racial and ethnic groups with regard to the metabolism, clinical effectiveness, and side effect proles of different medications. Most studies to date have concentrated on cardiovascular and psychiatric drugs, analgesics, antihistamines, and ethanol. The research so far primarily applies to African Americans, whites, and Asians, but more research is now focusing on Hispanic Americans because they represent the largest racial or ethnic group after whites in the United States. It is anticipated that discoveries in pharmacogenetics will allow a blood sample to be analyzed for specic gene characteristics (genotyped) that are important determinants of drug pharmacokinetics and pharmacodynamics, thereby allowing drug selection to be tailored to the individual patient’s genetic makeup. Monoclonal antibodies are early examples of medicines that were synthesized to attack certain types of cancers on the basis of the presence of genetically determined types of cells in some cancers. Laboratory tests are used to determine the presence of these proteins in a patient’s cancer cells and whether the cancer cells will be susceptible to the monoclonal antibody. Another recent discovery is the potential for fatal skin reactions (i.e., Stevens-Johnson syndrome, toxic epidermal necrolysis) that can be caused by carbamazepine therapy in patients with the human leukocyte antigen allele HLA-B*1502. This allele is most common in persons of Asian and South Asian Indian ancestry (see the discussion of carbamazepine in Chapter 18). The FDA maintains a website that lists genomic biomarkers that have been identied (see Online Resources). These can be tested for before the initiation of drug therapy to target therapy or prevent potentially fatal drug reactions.

36

UNIT I Applying Pharmacology to Nursing Practice

Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions Key Points • The placebo effect occurs when a patient believes they had a positive response to a drug, even though the patient did not have any chemically active drug. The nocebo effect occurs when the patient has negative expectations about therapy and the patient believes that a drug is not working. • Drug dependence occurs when a patient develops physical withdrawal symptoms if the drug is withdrawn for a certain period, or when a patient is emotionally attached to a drug. • The age of the patient has signicant effects on the absorption, distribution, metabolism, and excretion of the drug. Pediatric patients and elderly patients are more susceptible to the effects of drugs than adult patients. Physical changes that occur during the aging process can alter the effect drugs will have on the elderly patient. • Men and women often do not respond to drugs or physical disease states in the same way, and gender differences can alter the effect of drugs. • Pregnant and breastfeeding women need to be aware that any drug they take will have an effect on their unborn fetus and/or infant. • Pharmacogenetics currently focuses on determining the appropriate drug to use based on the individual’s genetic composition.

Additional Learning Resources

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier .com/Clayton) for additional online resources. Online Resources •  DART: https://toxnet.nlm.nih.gov/newtoxnet/dart.htm • LactMed: https://toxnet.nlm.nih.gov/newtoxnet/lactmed. htm • Pharmacogenomic biomarkers: https://www.fda.gov/Drug s/ScienceResearch/ucm572698.htm

Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types. 1. A patient who has been asked to participate in a study asks the nurse what the term placebo means. What would be an appropriate response by the nurse? 1. “The word placebo refers to the type of abnormal response that may occur when taking medications.” 2. “That term means the body has built up a resistance to a drug and that more of the drug is needed to get the same response.”

3. “The term placebo refers to a dosage form that has no active ingredients; these are frequently used in studies to determine the effect of a new medication.” 4. “The word placebo comes from Latin and means ‘I will harm.’ ” Objective: Explain the impact of the placebo effect and the nocebo effect. NCLEX test item: Multiple choice Cognitive skill: Evaluation 2. Why is it important for the nurse to understand the difference between drug dependence and drug accumulation? 1. Drug accumulation can be detected more easily than drug dependence. 2. Drug accumulation may result in drug toxicity, and drug dependence can result in cell mutation. 3. Drug dependence can be prevented, and drug accumulation is inevitable. 4. Drug dependence can be the result of taking addictive substances for a prolonged time, and drug accumulation can result in drug overdose. Objective: Identify the importance of drug dependence and drug accumulation. NCEX test item: Multiple choice Cognitive skill: Understanding 3. The nurse knows that drug absorption in the elderly is affected by which of these physiologic factors? (Select all that apply.) 1. 2. 3. 4. 5.

Changes in albumin levels Increased ltration capacity of the kidneys Reduced cardiac output Higher gastric pH Decreased GI motility

Objective: Discuss the effects of age on drug absorption, distribution, metabolism, and excretion. NCLEX test item: Multiple response Cognitive skill: Application 4. Which nursing action(s) would be essential when monitoring drug therapy in the geriatric patient? (Select all that apply.) 1. Monitoring renal and liver function 2. Monitoring for drug interactions 3. Completing a thorough drug history, including over-thecounter and alternative therapies 4. Inquiring about the ability to pay for medications 5. Educating the patient and caregivers about all drugs and potential complications Objective: Discuss the effects of age on drug absorption, distribution, metabolism, and excretion. NCLEX test item: Multiple response Cognitive skill: Application 5. The nurse caring for an elderly patient understands that when giving medications there are aging factors that affect how the drug will work. Indicate with an X the factors that inuence drug actions related to aging.

Drug Action Across the Life Span CHAPTER 3

AGING FACTORS AND OTHER EFFECTS

DRUG ABSORPTION

DRUG DISTRIBUTION

DRUG METABOLISM

37

DRUG EXCRETION

Genetics, smoking, diet, gender, other medications and diseases Albumin levels diminish Decreased renal blood ow Muscle inactivity and changes in muscle mass

Objective: Discuss the effects of age on drug absorption, distribution, metabolism, and excretion. NGN test item: Matrix Cognitive skill: Recognize cues 6. While discussing with a mother the importance of administering furosemide orally to an infant with a cardiac abnormality, the nurse would recognize the need for further explanation if the mother makes which statement? 1. “I know that my baby needs this drug every day at approximately the same time.” 2. “My baby will have no problem taking this tablet.” 3. “I will check to make sure that the furosemide is working by monitoring the number of wet diapers.” 4. “I understand that my baby will continue to grow even while taking this drug.” Objective: Discuss the effects of age on drug absorption, distribution, metabolism, and excretion. NCLEX test item: Multiple choice Cognitive skill: Comprehension 7. The nurse recognized there are gender considerations to keep in mind with regard to drug actions. Choose the most likely options for the information missing from the sentence below by selecting from the lists of options provided. The gender considerations to keep in mind with regard to drug actions are that _______1____________ will affect ___________2___________ and that ___________1____________ will affect ________2_________, as well as that ______1___________ will affect _______2___________. OPTIONS FOR 1

OPTIONS FOR 2

women have longer life spans women have greater proportion of body fat women have slower gastric emptying time women have more active cytochrome P450 enzymes

distribution excretion metabolism absorption

Objective: Explain the gender-specic considerations of drug absorption, distribution, metabolism, and excretion. NGN test item: Cloze Cognitive skill: Analyze cues

8. A pregnant woman asked a nurse at the obstetrician’s clinic how she could determine which drug was safe to take during pregnancy. What would be an appropriate response by the nurse? 1. “Because there are few studies done to determine the safe use of drugs during pregnancy, it is okay to keep taking what was previously prescribed by your primary healthcare provider.” 2. “Because there are few studies done to determine the safe use of drugs during pregnancy, it is advisable to ask your primary healthcare provider or pharmacist regarding taking prescription and over-the-counter drugs.” 3. “You are not to take any drugs during pregnancy.” 4. “It would be ne to take over-the-counter drugs, since they never cause any issues.” Objective: Describe where a nurse will nd new information about the use of drugs during pregnancy and lactation. NCLEX test item: Multiple choice Cognitive skill: Comprehension 9. An expecting mother asks the nurse if it would be okay for her to take some cold medicine. What would be an appropriate response by the nurse? 1. “There are not a lot of studies done with regard to how safe medications are to take during pregnancy.” 2. “I am sure it is safe to take, no problem.” 3. “I believe the cold medication is contraindicated for pregnant women.” 4. “Animal studies have revealed no evidence of harm to the fetus using these drugs.” Objective: Discuss the impact of pregnancy and breastfeeding on drug absorption, distribution, metabolism, and excretion. NCLEX test item: Multiple choice Cognitive skill: Understanding 10. A patient was discussing with the nurse the idea that in the future we will be able to determine which drug will be effective depending on a person’s genetic makeup. Which term does this refer to? 1. 2. 3. 4.

Polymorphisms Pharmacogenetics Genome coding Pharmacokinetics

Objective: Discuss the role of genetics and its inuence on drug action. NCLEX test item: Multiple choice Cognitive skill: Knowledge

4

The Nursing Process and Pharmacology

https://evolve.elsevier.com/Willihnganz

Objectives 1. Discuss the components and purpose of the nursing process. 2. Explain what the nurse does to collect patient information during an assessment. 3. Discuss how nursing diagnosis statements are written. 4. Differentiate between a nursing diagnosis and a medical diagnosis. 5. Discuss how evidence-based practice is used in planning nursing care.

6. Differentiate between nursing interventions and outcome statements. 7. Explain how Maslow’s hierarchy of needs is used to prioritize patient needs. 8. Compare and contrast the differences between dependent, interdependent, and independent nursing actions. 9. Discuss how the nursing process applies to pharmacology.

Key Terms nursing process (NŬR-sĭng PRŎ-sĕs) (p. 38) assessment (ă-SĔS-mĕnt) (p. 39) nursing diagnosis (NŬR-sĭng dī-ăgNŌ-sĭs) (p. 40) dening characteristics (dĕ-FĪN-ĭng kăr-ăk-těr-ĬS-tĭks) (p. 41) medical diagnosis (p. 41) focused assessment (FŌ-kŭst ă-SĔSmĕnt) (p. 41) planning (p. 41) nursing care plan (p. 42) critical pathways (KRĬ-tĭ-kŭl PĂTHwāz) (p. 42) evidence-based practice (ĔV-ĭ-dĕns BĀSD PRĂK-tĭs) (p. 42)

core measures (p. 42) priority setting (prī-ŌR-ĭ-tē SĔT-tĭng) (p. 42) measurable outcome statement (MĔ-zhŭr-ĕ-bŭl GŌL STĀT-mĕnt) (p. 42) implementation (ĭm-plĕ-mĕn-TĀshŭn) (p. 44) nursing interventions (p. 44) nursing actions (p. 44) dependent actions (dē-PĔN-dĕnt) (p. 44) interdependent actions (ĭn-tŭr-dēPĔN-dĕnt) (p. 44) independent actions (ĭn-dē-PĔNdĕnt) (p. 44)

The NursiNg Process The practice of nursing is an art and science that uses a systematic approach to identify and solve the potential problems that individuals may experience as they strive to maintain basic human function along the wellness-illness continuum. The focus of all nursing care is to help individuals maximize their potential for maintaining the highest possible level of independence for the meeting of self-care needs. The nursing process is the foundation for the clinical practice of nursing. It provides the framework for consistent nursing actions and involves the use of a problem-solving approach. The nursing process also provides a method for evaluating the outcomes of the therapy delivered. 38

drug history (HĬS-tō-rē) (p. 45) primary source (PRĪ-măr-ē SŌRS) (p. 45) subjective data (sŭb-JĔK-tĭv DĀ-tă) (p. 45) objective data (ŏb-JĚK-tĭv DĀ-tă) (p. 45) secondary sources (SĔK-ŏn-dār-ē SŌR-sĕz) (p. 45) tertiary sources (TĔR-shē-ăr-ē) (p. 45) drug monographs (MŎN-ō-grăfs) (p. 45) therapeutic intent (thěr-ă-PYŪ-tĭk) (p. 46)

Many nursing education programs and healthcare facilities use a ve-step nursing process model: (1) assessment, (2) nursing diagnosis, (3) planning, (4) implementation, and (5) evaluation. These ve steps are actually an overlapping process (Fig. 4.1). Information from each step is used to formulate and develop the next step in the process. Box 4.1 illustrates the process that is used to assemble data and organize information into categories to identify the patient’s strengths and problem areas. Thereafter, nursing diagnosis statements can be developed and focused nursing assessments can be initiated. Planning can be individualized, and measurable goals can be identied. Individualized nursing interventions can be developed to coincide with the individual’s abilities and resources, as well as

The Nursing Process and Pharmacology CHAPTER 4

Evaluation 1. Document/revise outcome attainment 2. Continue care or start referral to communitybased health agency or discharge process

Implementation 1. Meet physical and emotional needs 2. Provide for patient safety 3. Perform/modify nursing interventions 4. Monitor for potential complications 5. Perform ongoing assessments 6. Document care delivered and patient responses

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Assessment (data collection) 1. Nursing history, medical history 2. Professional observations 3. Physical examination 4. Diagnostic test results

Holistic Care Needs

Nursing diagnosis 1. Identify defining characteristics, high-risk factors, or problems 2. Perform focused assessment 3. Formulate nursing diagnosis statements 4. Identify and seek orders/directions from appropriate health team members for collaborative problems

Planning 1. Set priorities 2. Develop written outcome statements 3. Formulate nursing interventions 4. Formulate anticipated therapeutic outcomes 5. Integrate outcomes/classification systems into critical pathways and/or care plans

Fig. 4.1 The nursing process and the holistic needs of the patient.

the disease processes being treated. During the implementation process, the individual’s physical, psychosocial, and cultural needs must be considered. The assessment process should continue to focus not only on the evolving changes in the presenting symptoms and problems but also on the detection of potential complications that may occur. Nurses should familiarize themselves with the nurse practice act in the state in which they practice to identify the educational and experiential qualications that are necessary for the performing of assessments and the development of nursing diagnoses. The formulation of nursing diagnoses requires a broad knowledge base to make the discriminating judgments needed to identify the individual patient’s care needs. All members of the healthcare team need to contribute data regarding the patient’s care needs and their response to the prescribed treatment regimen. Just as body functions are constantly undergoing adjustments to maintain homeostasis in the internal

and external environments, the nursing process is an ongoing cyclic process that must respond to the changing requirements of the patient. The nurse must continually interact with people in a variety of settings to establish and execute nursing functions creatively and cooperatively to meet the holistic care needs of patients (see Fig. 4.1). Assessment Assessment is the rst phase of the ve-step nursing process. It is the problem-identifying phase of the nursing process. The initial assessment must be performed by a registered nurse with the necessary skills to complete the physical examination. The assessment identies patient problems based on dening characteristics (i.e., signs, symptoms, and clinical evidence). In addition, the nurse should identify risk factors that make an individual vulnerable to developing certain problems in response to a disease process or to its prescribed therapy (e.g., adverse effects of drugs).

40

Box 4.1

UNIT I Applying Pharmacology to Nursing Practice

Principles of the Nursing Process and Their Application to Pharmacologic Needs

AssessmeNT • Collect all relevant data associated with the individual patient’s symptoms; their history and physical, laboratory, and diagnostic data; and medical diagnosis to detect actual and risk/high-risk problems that require intervention. • Data sources can be primary, secondary, or tertiary. • Specic assessments related to the patient’s pharmacologic needs include collecting the drug history; allergies; height and weight; age and disease process; hepatic function results (AST, ALT, alkaline phosphatase, LDH, bilirubin [total and direct]); and renal function results (serum creatinine, creatinine clearance, BUN, urinalysis, protein [total and 24-hour urine]), as well as discussing the patient’s understanding of drug therapy and the treatment plan and determining their readiness to learn. NursiNg DiAgNosis • On the basis of the data collected, formulate a statement about the behaviors or problems of concern and their cause. • Formulate nursing diagnosis statements for problems that are amenable to nursing actions. • Identify and seek orders or direction from appropriate healthcare team members for collaborative problems.a PlANNiNg • Prioritize the problems identied from the assessment data, with the most severe or life-threatening problems addressed rst. Other problems are arranged in descending order of importance. (Maslow’s hierarchy of needs is frequently used as a basis for prioritizing; other approaches may be equally valid.) • Develop short- and long-term patient goals and outcomes in measurable statements that are appropriate to the clinical setting and the length of stay. • Identify the monitoring parameters to be used to detect possible complications of the disease process or the treatments being used. • Plan nursing approaches to correlate with each identied patient goal or outcome. • Integrate outcomes and classication systems into critical pathways or standardized care plans to be used in clinical settings. • Specic planning related to the patient’s pharmacologic needs includes examining drug monographs and developing an individualized teaching plan.

imPlemeNTATioN • Perform the nursing intervention planned to achieve the established goals or outcomes. • Monitor the patient’s response to treatments, and monitor for complications related to existing pathophysiology. • Provide for patient safety. • Perform ongoing assessments on a continuum. • Document the care given and any additional ndings on the patient’s chart.b • Specic interventions related to the patient’s pharmacologic needs include administering the prescribed drug using the seven rights: verifying the right patient, the right drug, the right dose, the right route, the right time, the right indication, and the right documentation. The nurse also will be monitoring the patient using diagnostic parameters; monitoring for adverse effects of medications; and performing and documenting health teaching, which includes having the patient understand the drug name, the dose, the route of administration, the anticipated therapeutic response, the adverse effects, what to do if a dose is missed, and how to ll a prescription. evAluATioN • Evaluation is an ongoing process that occurs at every phase of the nursing process. Establish target data to review and analyze at intervals prescribed by guidelines in the practice setting. • Review and analyze the data regarding the patient, and modify the care plan so that goals and outcomes of care, which are used to return the patient to the highest level of functioning, are attained. • Evaluate outcomes with the use of the classication systems, critical pathways, or standardized care plans that are used in the clinical setting. • Follow a systematic approach to recording progress, depending on the setting and charting methodology. • Continue the nursing process, initiate referral to a community-based health agency, or execute discharge procedures as ordered by the healthcare provider. • Specic evaluation criteria related to the patient’s pharmacologic needs include evaluating the patient’s tolerance of drug therapy and their understanding of the treatment regimen.

aBecause

not all patient problems are amenable to resolution by nursing actions, those complications or problems associated with medical diagnosis or that result from treatment-related issues are placed in a category known as “Collaborative Problems,” which the nurse monitors. bIntegrate the classication system that is currently in use in the clinical setting when charting (e.g., Nursing Minimum Data Set, Omaha System, Home Health Care Classication System). ALT, Alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; LDH, lactate dehydrogenase.

During the assessment, the nurse collects a comprehensive information base about the patient from the physical examination, the nursing history, the medication history, and professional observations. Formats commonly used for data collection, organization, and analysis are the head-to-toe assessment, body systems assessment, and Gordon’s Functional Health Patterns Model. The head-to-toe and body systems approaches

focus on the patient’s physiology, whereas the Gordon’s Functional Health Patterns Model (Box 4.2) includes sociocultural, psychological, spiritual, and developmental factors that affect the individual’s needs. nursing DiAgnosis Nursing diagnosis is the second phase of the ve-step nursing process. NANDA International (NANDA-I,

The Nursing Process and Pharmacology CHAPTER 4

Box 4.2

Gordon’s Functional Health Patterns Model

Health Perception–Health Management Pattern Nutrition-Metabolic Pattern Elimination Pattern Activity-Exercise Pattern Cognitive-Perceptual Pattern Sleep-Rest Pattern Self-Perception–Self-Concept Pattern Role-Relationship Pattern Sexuality-Reproductive Pattern Coping–Stress Tolerance Pattern Value-Belief Pattern Adapted from Gordon M. Manual of Nursing Diagnosis. 11th ed. Sudbury, MA: Jones & Bartlett; 2007.

formerly the North American Nursing Diagnosis Association) approved the following ofcial denition of the term nursing diagnosis: “[a] clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.” Using knowledge and skills related to anatomy, physiology, nutrition, psychology, pharmacology, microbiology, nursing practice skills, and communication techniques, the nurse analyzes the data collected during the assessment phase to identify whether certain major and minor dening characteristics (i.e., manifestations or signs and symptoms) relate to a particular patient problem. This analysis determines which data is important to act on and which data is to be monitored. The nurse may conclude that certain actual problems are present and identies them with a nursing diagnosis. Nursing diagnoses provide the basis for the selection of nursing interventions or actions needed to treat the patient. Not all patient problems identied during an assessment are treated by the nurse alone. Many of these problems require a multidisciplinary approach. A medical diagnosis is a statement of the patient’s alterations in structure and function, and this results in the diagnosis of a disease or disorder that impairs normal physiologic function. A nursing diagnosis usually refers to the patient’s ability to perform activities of daily living (ADLs) in relation to the impairment induced by the medical diagnosis; it identies the individual’s response to the illness. A medical diagnosis also tends to remain unchanged throughout the illness, whereas nursing diagnoses may vary, depending on the patient’s state of recovery. Concepts that help distinguish a nursing diagnosis from a medical diagnosis include the following: 1. Conditions described by nursing diagnoses can be accurately identied by nursing assessment methods. 2. Nursing treatments or methods of risk-factor reduction can resolve the condition described by a nursing diagnosis. 3. Nurses assume accountability for outcomes within the scope of nursing practice.

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4. Nurses assume responsibility for the research required to clearly identify the dening characteristics and causative factors of conditions described by nursing diagnoses. 5. Nurses engage in improving methods of treatment and treatment outcomes for conditions described by nursing diagnoses. The wording of an actual nursing diagnosis takes the form of a three-part statement. These statements consist of the following: (1) a patient problem summarizing the issue; (2) the contributing factors or cause, which may include decits in ADLs or the medical diagnosis; and (3) the dening characteristics (i.e., manifestations or signs and symptoms). An example related to pharmacology would state: Insufcient knowledge related to polypharmacy as evidenced by inability to state what prescribed medications are used for. The risk nursing diagnosis statement consists of two parts: (1) the diagnostic label from the NANDA-I–approved list and (2) the risk factors that make the individual more susceptible to the development of the problem. A risk diagnosis is validated by the presence of risk factors that would contribute to the individual developing the stated problem. Further discussion of the philosophy and clinical use of nursing diagnoses can be found in other primary texts and references, especially in those developed solely for the purpose of explaining nursing diagnoses. Not all patient problems identied by the nurse can be resolved by nursing actions; many care plans include multidisciplinary input and planning to maximize patient outcomes. However, the nurse is responsible for monitoring the patient on a continuum for potential complications that are associated with the medical diagnosis, the diagnostic procedures, or the treatments prescribed. Fcd A A focused assessment is the process of collecting additional data specic to a patient or family that validates a suggested problem or nursing diagnosis. The questions asked or the data collected are used to conrm or rule out the dening characteristics associated with a specic nursing diagnosis statement. During the focused assessment, prescriptive orders can be identied that the nurse can implement and that are within the nurse’s scope of practice. PlAnning Planning is the third phase of the ve-step nursing process. After the patient has been assessed and problems have been diagnosed, plans should be formulated to meet the patient’s needs. Planning usually encompasses four phases: (1) priority setting, (2) the development of measurable goal and outcome statements, (3) the formulation of nursing interventions, and (4) the formulation of anticipated therapeutic outcomes that can be used to evaluate the patient’s status. The written or

42

UNIT I Applying Pharmacology to Nursing Practice Maslow’s hierarchy of needs morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

5

self-esteem, confidence, achievement, respect of others, respect by others

4

friendship, family, sexual intimacy, sense of connection

3

security of body, employment, resources, morality, family, health, property

2

breathing, food, sex, sleep, homeostasis, excretion

1

Self-actualization Self-esteem Love and belonging

Safety and security

Physiological needs

Fig. 4.2 Maslow’s Hierarchy of Needs Pyramid. (Copyright iStock.com/PyTyCzech.)

computer-generated document that evolves from this planning process is called the nursing care plan Critical pathways are standardized, automated care plans that integrate protocols, interventions, goals, and outcomes. Critical pathways are also referred to as integrated care plans, care maps, or clinical maps. These documents are comprehensive standardized plans of care that are individualized on admission by the healthcare provider and/or the nurse case manager. A critical pathway describes a multidisciplinary plan that is used by all caregivers to track the patient’s progress toward expected outcomes within a specied period. Standardized outcomes and timetables require healthcare providers to make assessments regarding the patient’s progress toward the goals of discharge while maintaining quality care. Revisions are made as necessary and communicated to all healthcare team members so that patient care continues uninterrupted toward the discharge goals. edc-Bad Pacc Evidence-based practice is the application of data from scientic research to make clinical decisions about the care of individual patients. Evidence-based decision making is based on the vast array of clinical studies that have been completed and the existence of large databases, which can be quickly accessed and searched for the best scientic evidence when making healthcare decisions. An example of this concept that is seen in today’s healthcare institutions is the quality measures known as core measures Core measures are measures of care that are tracked to show how often hospitals and healthcare providers use the care recommendations identied by evidence-based practice standards for patients who are being treated for conditions such as heart attack, heart failure, and pneumonia or for patients who are undergoing surgery. Hospitals voluntarily submit data from the medical records of adults who have been treated for these conditions to help track standards of care and clinical outcomes. Py s After the nursing diagnoses have been identied, they must be prioritized. Maslow’s hierarchy of needs is

a model that is often used for establishing priorities. Maslow identied ve levels of needs: 1. Physiologic needs, which include eating, breathing, sleeping, elimination, and so on 2. Safety and security needs, which include feeling safe, being employed, and having resources 3. Love and belonging needs, which include having a sense of connection with people 4. Self-esteem needs, which include respecting self and others and being condent 5. Self-actualization needs, which include being spontaneous and creative and being able to problem solve (Fig. 4.2) Nurses can use Maslow’s hierarchy to perform the priority setting of an individual patient’s needs, determining which care aspect needs to be addressed rst. These care delivery options are often organized in relation to their direct effects on the maintenance of homeostasis. Thus after determining that the patient is oxygenating appropriately by pulse oximetry (rst priority), the nurse can then increase the patient’s activity (second priority). Box 4.3 lists the priority ranking of subcategories of Maslow’s hierarchy of human needs. maab oc ga sa After the patient’s needs have been prioritized, goals must be established and statements written. Goals are usually divided into short-term and long-term plans, depending on the length of stay and the clinical site. The measurable outcome statement starts with an action word (i.e., a verb) that is followed by the behavior or behaviors to be performed by the patient or the patient’s family within a specic amount of time. These outcome statements need to be Specic, Measurable, Attainable, Realistic and Timely, using the acronym SMART the nurse can remember the components for making proper outcome goal statements. There should be one outcome goal statement for each nursing diagnosis. All outcome statements must be individualized and based on the patient’s abilities. An example of a goal statement that follows the nursing diagnosis of knowledge decit would be: The patient will create a list of all the medications that are currently prescribed along with the reasons for taking them, by the end of the day. The nurse

The Nursing Process and Pharmacology CHAPTER 4

Box 4.3

Priority Ranking of Subcategories of Maslow’s Hierarchy of Human Needs

Physiologic NeeDs • Oxygen, circulation • Water-salt balance • Food balance • Acid-base balance • Waste elimination • Normal temperature • Sleep, rest, relaxation • Activity, exercise • Energy • Comfort • Stimulation • Cleanliness • Sexuality sAfeTy NeeDs • Protection from physical harm • Protection from psychological threat • Freedom from pain • Stability • Dependence • Predictable, orderly world BeloNgiNg NeeDs • Love, affection • Acceptance • Warm, communicating relationship • Approval from others • Unity with loved ones • Group companionship self-esTeem NeeDs • Recognition • Dignity • Appreciation from others • Importance, inuence • Reputation of good character • Attention • Status • Dominance over others self-AcTuAlizATioN NeeDs • Personal growth and maturity • Awareness of potential • Increased learning • Full development of potential • Improved values • Religious, philosophic satisfaction • Increased creativity • Increased reality perception and problem-solving abilities • Less rigid conventionality • Less of the familiar, more of the novel • Greater satisfaction in beauty • Increased pleasantness • Less of the simple, more of the complex From Campbell C. Nursing Diagnosis and Intervention in Nursing Practice. New York: John Wiley & Sons; 1978. This material is reproduced with permission of John Wiley & Sons.

must also refer to critical pathways when establishing the parameters. Statements must take into consideration the degree of rehabilitation that is realistic for the

43

patient to expect for the amount of time during which care will be delivered. It is sometimes difcult to accept that not everyone can return to their preillness health status; therefore the nurse must be realistic when setting a measurable goal and strive to assist the patient with obtaining an optimal degree of functioning that is consistent with that patient’s abilities. When goals are being established, it is important to include the patient and appropriate signicant others in decision making because the patient and their support systems will be responsible for accomplishing the goals. Involvement of the patient is essential to promote cooperation and compliance with the therapeutic regimen and to provide the patient with a sense of control over the disease process and the course of treatment. The goals that are established should be patient goals rather than nursing goals for the patient. With the advent of shorter hospital stays, most of the goal statements will involve short-term goals. The nurse must keep in mind the usual length of hospitalization and be realistic about the number and types of goals and outcomes being established. Short-term goals should serve as a bridge to meet the long-term goals established in a care plan. Long-term goals can be established with assistance from referral agencies in accordance with the individual’s needs and circumstances. Long-term goals are then implemented in long-term care settings, rehabilitation centers, mental health facilities, and community-based home healthcare delivery settings. Most goal statements are based on the patient’s need to do the following: 1. Reduce or resolve the symptoms (usually the chief complaint) of the disease that caused the person to seek medical attention. 2. Understand the disease process and its effect on lifestyle and ADLs. 3. Gain knowledge and skills associated with the treatment procedures in an effort to attain the highest level of functioning possible (e.g., nutrition, comfort measures, medication regimen, physical therapy). 4. Have reasonable expectations of the therapy, including understanding signs and symptoms of improvement versus complications that require consultation with a healthcare provider. 5. Identify monitoring parameters that should be maintained on a written record that reects the response to the prescribed therapy. 6. Establish a schedule for follow-up evaluation. Outcome goal statements are measured along the continuum of care and include therapeutic outcome statements that are developed to document the effectiveness of the care delivered. In the previous example, the patient will do the following: • Improve the ability to perform coughing technique. • Maintain an adequate uid intake as evidenced by achieving a mutually set goal of 2000 mL within 24 hours.

44

UNIT I Applying Pharmacology to Nursing Practice

• Attain a respiratory rate between 18 and 24 breaths/ min. • Perform ADLs without feeling fatigued. Therapeutic outcomes have been identied throughout this book for each drug classication. These can be used by the student to identify the outcomes that are anticipated from the use of the drugs listed in a particular classication. exap f a thapc oc Using the nursing diagnosis “Anxiousness related to hospitalization and unknown prognosis,” the primary therapeutic outcome expected from the benzodiazepine antianxiety agents is a decrease in the level of anxiety to a manageable level for the patient. This decreased anxiety may be manifested by a reduction in physical signs of anxiety, such as a worried look or pacing, and an improvement in coping. imPlementAtion Implementation of nursing interventions is the fourth phase of the nursing process, and it consists of carrying out the established plan of care. Nursing care is directed at meeting the physical and emotional needs of the patient, providing for patient safety, monitoring for potential complications, and performing ongoing assessments as part of the continual process of data collection. Nursing actions are suggested by the etiology of the problems identied in the nursing diagnoses, and they are used to implement plans. They may include activities such as counseling, teaching, providing comfort measures, coordinating, referring, using communication skills, and performing the actions listed in a healthcare provider’s orders. Documentation of all care given, including patient education and the patient’s apparent response, should be performed regularly—both to assist with evaluation and reassessment and to make other healthcare professionals aware of the patient’s changing needs. Within the nursing process are three types of nursing actions: (1) dependent, (2) interdependent, and (3) independent. Dependent actions are those performed by the nurse on the basis of the healthcare provider’s orders, such as the administration of prescribed medications and treatments. It is important to note that even though these are dependent functions, the nurse is still responsible for exercising professional judgment when performing these actions. Interdependent actions are those nursing actions that the nurse implements cooperatively with other members of the healthcare team for restoring or maintaining the patient’s health. This allows the nurse to coordinate their interventions with those of other healthcare professionals to maximize knowledge and skills from various disciplines for the well-being of the patient. Collaborative communication among multidisciplinary team members is essential for

maximizing patient outcomes in today’s healthcare environment. Independent actions are those nursing actions that a nurse can provide by virtue of the education and licensure that they have attained. These actions are usually written in the nursing care plan and originate from the nursing diagnosis. n Ac  i sa Nursing action or intervention statements list in a concise format exactly what the nurse will do to achieve each goal that has been developed for each nursing diagnosis. A nursing action is a statement that describes nursing interventions that are applicable to any patient (e.g., promote adequate respiratory ventilation). Nursing orders describe how specic actions, including time intervals, will be implemented for an individual patient. Example of Nursing Interventions for Patient With Respiratory Issues (date): Cough, turn, deep breathe: 0800, 1000, 1200, 1400, 1600, 1800, 2000, 2200 (date): Educate patient re: abdominal breathing, splinting the abdomen, pursed-lip breathing, and assuming correct position to facilitate breathing (date): Auscultate breath sounds: 0800, 1200, 1600, 2000 (date): Increase patient’s uid intake to at least 2000 mL/24 hr: 0700–1500: 1000 mL 1500–2300: 800 mL 2300–0700: 200 mL (date): Assess respiratory depth and rate: 0800, 1200, 1600, 2000, 2400 eaa Evaluation is the fth and nal phase of the ve-step nursing process. Evaluation involves the nurse determining whether the expected outcomes were met. Evaluation of the outcome goal statement is important so the nurse can determine whether the interventions were effective in meeting the goal. For the evaluation process to be successful, the participants (i.e., the patient, the patient’s family and signicant others, and the nurse) must be willing to receive feedback. Therefore plans for evaluation must involve the patient, the family, and signicant others from the beginning and should recognize the needs of a culturally diverse population with varying beliefs about healthcare. Although the evaluation phase is the last step in the nursing process, it is not an end in itself. Evaluation recognizes the successful completion of previously established goals, but it also provides a means for the input of new signicant data that indicate the development of additional problems or a lack of therapeutic responsiveness, which may require additional nursing diagnoses or collaboration with the healthcare provider or other professionals on the healthcare team as plans for therapy are revised.

The Nursing Process and Pharmacology CHAPTER 4

relATiNg The NursiNg Process To PhArmAcology Assessment Assessment is an ongoing process that starts with the admission of the patient and continues daily until the patient no longer requires care. With regard to relating the nursing process to the nursing functions associated with medications, assessment includes taking a drug history, which includes current prescription and nonprescription medications, as well as the presence of drug allergies. The drug history is important for three reasons: (1) to evaluate the patient’s need for medication; (2) to obtain their current and past use of overthe-counter medications, prescription medications, herbal products, and street drugs; and (3) to identify problems related to drug therapy. Nurses will also want to identify risk factors such as allergies to certain medications (e.g., penicillins) or the presence of other diseases that may limit the use of certain types of drugs (e.g., sympathomimetic agents in patients with hypertension). The nurse draws on three sources to build the medication-related information base. Whenever the patient is able to provide reliable information, the patient should be used as the primary source of information. Subjective and objective data serve as the baseline for the formulation of drug-related nursing diagnoses. Subjective data are pieces of information provided by the patient (e.g., “Whenever I take this medicine, I feel sick to my stomach”). Objective data are gained from observations that the nurse makes with the use of physiologic parameters (e.g., “skin pale, cold, and moist; temperature, 99.2°F orally”). Other required objective information is the patient’s height and weight, which may be needed to select drug regimens and to use as a monitoring parameter for drug therapy later during the patient’s treatment. In some cases, it is necessary to obtain information from secondary sources (e.g., relatives, signicant others, medical records, laboratory reports, nurses’ notes, other healthcare professionals). Secondary sources of information are subject to interpretation by someone other than the patient. Data collected from secondary sources should be analyzed with the use of other portions of the database to validate the conclusions that are reached. Tertiary sources of information (e.g., a literature search) provide an accurate depiction of the characteristics of a disease, the nursing interventions and diagnostic tests used, the pharmacologic treatment prescribed, the dietary interventions and physical therapy undertaken, and other factors pertinent to the patient’s care requirements. When using these sources, the nurse should be aware that the patient has individual needs and that the plan of care must be adapted to t the patient’s identied needs. Assessment related to drug therapy continues throughout the hospitalization period. Examples of

45

ongoing assessment activities include visiting with the patient, determining the need for and administering as-needed (PRN) medications, monitoring vital signs, and observing for therapeutic effects in addition to common and adverse effects and potential drug interactions. In preparation for the patient’s eventual discharge and their need for education about new health-related responsibilities, the assessment process should include the collection of data related to the patient’s health beliefs, existing health problems, prior compliance with prescribed regimens, readiness for learning (both emotionally and experientially), and ability to learn and execute the skills required for self-care. nursing DiAgnoses To deal effectively with identied problems (i.e., diagnoses), the nurse must recognize both the causative and contributing factors. The etiology and contributing factors are those clinical and personal situations that can cause the problem or inuence its development. Situations can be organized into ve categories: (1) pathophysiologic, (2) treatment related, (3) personal, (4) environmental, and (5) maturational (Carpenito, 2013). When identifying problems related to medication therapy, the nurse should review the drug monographs starting in Chapter 12. These are detailed explanations of the purpose for which a drug is intended, and assist the nurse to identify common and adverse effects and drug interactions for patient monitoring. Several nursing diagnoses can be formulated on the basis of the patient’s drug therapy. Although the most commonly observed problems are those associated with the drug treatment of a disease or the adverse effects of drug therapy, nursing diagnoses can also originate from pathophysiology caused by drug interactions. Example of a Nursing Diagnosis Drugs prescribed for Parkinson disease are administered to provide relief of symptoms (e.g., muscle tremors, slowness of movement, muscle weakness with rigidity, alterations in posture and equilibrium). An actual nursing diagnosis of Compromised mobility related to neuromuscular impairment (Parkinson disease) would be formulated on the basis of the dening characteristics established for this nursing diagnosis. The evaluation of the expected outcomes from the prescribed medications is based on the degree of improvement noted in the symptoms that are present. A second nursing diagnosis would be Potential for injury related to amantadine adverse effects (confusion, disorientation, dizziness, lightheadedness). In this example, common adverse effects of the drug amantadine, which is prescribed for treatment of the symptoms of Parkinson disease, are also the basis of the second nursing diagnosis. The second nursing diagnosis requires the nurse to monitor the patient for

46

UNIT I Applying Pharmacology to Nursing Practice

the development of these adverse effects. In other words, a patient with Parkinson disease is at risk for developing the dening characteristics. When the dening characteristics are observed, notication of these to the healthcare provider is required, and the nurse would need to intervene to provide for the patient’s safety. Two nursing diagnoses that apply to all types of medications prescribed are as follows: • Insufcient knowledge (actual, risk) related to the medication regimen (patient education) • Noncooperation (actual, risk) related to the patient’s value system, cognitive ability, cultural factors, or economic resources PlAnning Planning, with reference to the prescribed medications, must include the following steps: 1. The identication of the therapeutic intent of each prescribed medication. Determine why the drug was prescribed and what symptoms will be relieved. 2. Review of the drug monographs provided in this text, starting in Chapter 12, to identify the common and adverse effects that can be alleviated or prevented by actions of the nurse or patient and that will require immediate planning for patient education. The nurse should continuously monitor the patient for adverse effects of drug therapy and report these suspected adverse effects to the prescriber. 3. The identication of the recommended dosage and route of administration. The nurse should compare the recommended dosage with the dosage ordered and conrm that the route of administration is correct and that the dosage form ordered can be tolerated by the patient. 4. The scheduling of the administration of the medication is based on the prescriber’s orders and the policies of the healthcare facility. Medications prescribed must be reviewed for drug-drug interactions and drug-food interactions; laboratory tests may also need to be scheduled if serum levels of the drug have been ordered. 5. Teaching the patient to keep written records of their responses to the prescribed medications using the Patient Self-Assessment Form (see Appendix B for more information). 6. Providing additional education as needed about techniques of self-administration (e.g., injection, the use of topical patches, the instillation of drops), as well as information as needed about proper storage and how to rell a medication. When deciding what to teach the patient the nurse keeps in mind several factors: (1) the patient’s concerns, their health belief system, and the patient’s priorities; (2) the urgency or time available for the learning to take place; (3) a sequence that allows the patient to move from simple to more complex concepts; and (4) a review of the overall needs of the individual. The content

taught to the patient should be well planned and delivered in increments that the patient is capable of mastering. Example of Planning Medication Education Mr. Jones will be able to state the following for each prescribed medication by (date) and will show retention of this information by repeating it on (date): 1. Drug name 2. Dosage 3. Route and administration times 4. Anticipated therapeutic response 5. Common adverse effects 6. Serious adverse effects 7. What to do if a dose is missed 8. When, how, or whether to rell the medication To attain this goal, the patient’s ability to name all of these factors would need to be checked at the initial time of exposure and on subsequent meetings to validate retention. After the goals have been formulated, they should not be considered nal but rather should be reevaluated as needed throughout the course of treatment. imPlementAtion Nursing actions applied to pharmacology may be categorized as dependent, interdependent, or independent. Dpd n Ac Dependent nursing actions are directly related to the orders that are written by the healthcare provider. These orders include diagnostic procedures and medications for the immediate well-being of the patient. The healthcare provider reviews data on a continuing basis to determine the risks and benets of maintaining or modifying the medication orders. The maintenance or modication of the medication orders is the healthcare provider’s responsibility. The nursing action of carrying out the medication orders is considered dependent because the nurse must follow a written order. idpd n Ac The nurse performs baseline and subsequent focused assessments that are valuable for establishing therapeutic goals, the duration of therapy, the detection of drug toxicity, and the frequency of reevaluation. The nurse should approach any problems related to the medication prescribed collaboratively with appropriate members of the healthcare team. Whenever the nurse is in doubt about medication calculations, monitoring for therapeutic efcacy and adverse effects, or the establishment of nursing interventions or patient education, another qualied professional should be consulted. The pharmacist reviews all aspects of the drug order, prepares the medications, and then sends them to the unit for later administration. If any portion of the drug order or the rationale for therapy is unclear, the nurse and the pharmacist should consult with each other or the healthcare provider for clarication.

The Nursing Process and Pharmacology CHAPTER 4

The frequency of medication administration is dened by the healthcare provider in the original order. The nurse and the pharmacist establish the schedule of the medication on the basis of the standardized administration times used at the practice setting. The nurse (and occasionally the pharmacist) also coordinates the schedule of medication administration and the collection of blood samples with the laboratory phlebotomist to monitor drug serum levels. As soon as laboratory and diagnostic test results are available, the nurse and the pharmacist review them to identify values that could have an inuence on drug therapy. The results of the tests are conveyed to the healthcare provider. The nurse should also have current assessment data available for the collaborative discussion of signs and symptoms that may relate to the medications prescribed, the dosage, the therapeutic efcacy, or any adverse effects. Patient education, including discharge medications, requires that an established plan be developed, written in the patient’s medical record, implemented, documented, and reinforced by all those who are delivering care to the patient (see the sample teaching plan in Chapter 5, Box 5.2). idpd n Ac The nurse visits with the patient and obtains the nursing history, which includes a medication history as described earlier in the section on Relating the Nursing Process to Pharmacology, under Assessment. The nurse veries the drug order with the medication administration record or the electronic medical record. The nurse formulates appropriate nursing diagnoses and actions to monitor for therapeutic effects and adverse effects of medications. To do this, the nurse may need to review drug monographs to formulate the diagnosis and goal statements. The criteria for therapeutic response should describe the improvements expected in the symptoms of the disease for which the medication was prescribed. The nurse prepares the prescribed medications with the use of procedures that are meant to ensure patient safety. As part of this process, nursing professional judgments must include the following: 1. The selection of the correct supplies (e.g., needle gauge and length, type of syringe) for the administration of the medications. 2. The verication of all aspects of the medication order before preparing the medication. The order should be veried again immediately after preparation and again before actual patient administration

3.

4.

5.

6. 7.

47

(patients should always be identied immediately before the administration of the medication). One of the National Patient Safety Goals established by The Joint Commission is to improve the accuracy of patient identication. It is now recommended that two patient identiers be used when administering medications. For example, best practice would be to look at the patient’s name band for identity and to request that the patient state their name and birth date. The collection of appropriate data, also known as premedication assessment, to serve as a baseline for later assessments of therapeutic effectiveness and to detect adverse effects of drugs. The administration of the medication by the correct route at the correct site. The selection and rotation of sites for medication should be based on established practices for the rotation of sites and on principles of drug absorption, which in turn may be affected by the presence of pathophysiologic characteristics (e.g., poor tissue perfusion). The documentation in the chart of all aspects of medication administration. Subsequent assessments to identify the drug efcacy and the development of any adverse effects should be documented. The implementation of nursing actions to minimize common adverse effects and to identify serious adverse effects to be reported promptly. The education of patients on medications and gaining their cooperation. When noncompliance is identied, the nurse should attempt to ascertain the patient’s reasons, and the nurse and the patient should collaboratively discuss approaches to the problems viewed by the patient as hindrances. The nurse needs to be cognizant of the belief systems of a culturally diverse population regarding medications, illness, and aging among patients and their families, along with language and other barriers that may impede communication with healthcare providers.

evAluAtion Evaluation associated with drug therapy is an ongoing process that assesses the patient’s response to the medications prescribed, observes for signs and symptoms of recurring illness, evaluates for therapeutic effects or the development of adverse effects of the medication, determines the patient’s ability to receive patient education and to self-administer medications, and notes the potential for compliance. Box 4.1 presents examples of how the nursing process is applied to the nursing responsibilities associated with drug therapy.

UNIT I Applying Pharmacology to Nursing Practice

48

Cca Jd ad nx-ga nCleX ® exaa-sy Q K Pnt • The components of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation, and they provide a framework for nursing actions. • The nurse collects assessment data by completing the physical examination. • Nursing diagnosis statements include a patient problem summarizing the issue; the contributing factors or cause, which may include decits in ADLs or the medical diagnosis; and dening characteristics. • A medical diagnosis is a statement of the patient’s alterations in structure and function, and results in the diagnosis of a disease or disorder that impairs normal physiologic function. • The goal of evidence-based practice is to improve patient outcomes by implementing best practices, which have evolved from scientic studies. • Maslow’s hierarchy of needs is a model that is often used for establishing patient care priorities. • There are three types of nursing actions: dependent, interdependent, and independent. • Two nursing diagnoses apply to all types of medications prescribed:  • Insufcient knowledge (actual, risk) related to the medication regimen (patient education)  • Noncooperation (actual, risk) related to the patient’s value system, cognitive ability, cultural factors, or economic resources

Addtna lann r

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situa tions, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/ Willihnganz) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Exam ination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Genera tion) and traditional questions. See Chapter 1 for further information regarding question types. 1. What is the nurse evaluating during the evaluation step of the nursing process? 1. 2. 3. 4.

The nursing diagnosis The interventions The outcome statement The medical diagnosis

objt: Discuss the components and purpose of the nursing process. NcleX tt t: Multiple choice cnt k: Understanding

2. Arrange the components of the nursing process in the proper order. 1. 2. 3. 4. 5.

Implementation Assessment Diagnosis Evaluation Planning

objt: Discuss the components and purpose of the nursing process. NcleX tt t: Ordering cnt k: Application 3. The nurse applies the nursing process by gathering patient information to assess the patient using which of the following methods? (Select all that apply.) 1. 2. 3. 4. 5.

Body systems assessment Head-to-toe assessment Critical pathway Evidence-based practice Gordon’s Functional Health Patterns Model

objt: Explain what the nurse does to collect patient information during an assessment. NcleX tt t: Multiple response cnt k: Application 4. The nurse understands that it is important to learn the nursing process, which includes nursing diagnoses. Choose the most likely options for the information missing from the sentence below by selecting from the lists of options provided. The nursing diagnosis “Excess uid volume” is related to __________1_________ as evidenced by _________2___________ and ___________2___________.

oPTioN 1

oPTioN 2

(Contributing Factors) increased exercise adverse effects of new medication increased appetite

(Defining Characteristics) loss of 2 pounds overnight +2 edema present bilaterally below knees knee pain on standing gain of 5 pounds in the last 24 hours decreased peripheral pulses

objt: Discuss how nursing diagnosis statements are written. NgN tt t: Cloze cnt k: Recognize cues 5. The nurse understands it is important to know the difference between a nursing diagnosis and a medical diagnosis because of which factor? 1. The nursing diagnosis needs to match the medical diagnosis. 2. The nursing diagnosis needs to be approved by the primary health care provider before use.

The Nursing Process and Pharmacology CHAPTER 4

3. The nursing diagnosis refers to how the patient is responding to an illness identied in the medical diagnosis. 4. The medical diagnosis refers to how the patient is recovering from the illness that the nursing diagnosis has established. objt: Differentiate between a nursing diagnosis and a medical diagnosis. NcleX tt t: Multiple choice cnt k: Understanding 6. The use of evidence-based practice to guide the formulation of nursing interventions based on research and clinical expertise is part of which component of the nursing process? 1. 2. 3. 4.

Planning Assessment Evaluation Nursing diagnosis

objt: Discuss how evidence-based practice is used in planning nursing care. NcleX tt t: Multiple choice cnt k: Comprehension 7. Nurses need to use the nursing process to provide quality patient care. Using the parts of the nursing process of goal planning and creating an outcome statement, as well as writing interventions, mark an X under the column to identify which statement is a nursing intervention and which is an outcome statement.

NursiNg iNTerveNTioN

ouTcome sTATemeNT

Monitoring for potential complications Changes observed in the patient behavior Specic actions to be performed

9. The nurse understands that the actions the nurse takes can be determined to be from various sources. For each nursing action indicate with an X whether it is a dependent, an interdependent, or an independent action.

NursiNg AcTioN

DePeNDeNT

iNTerDePeNDeNT

iNDePeNDeNT

Administering medications Educating a patient on discharge medications Documenting the patient’s response to a medication Consulting the pharmacist about a medication order Discussing with the healthcare provider the request from the patient regarding a change in medications

objt: Compare and contrast the differences between dependent, interdependent, and independent nursing actions. NgN tt t: Matrix cnt k: Analyze cues 10. Match the step of the nursing process with the actions of the nurse.

Prioritized goals to be identied Expected responses to be observed

objt: Differentiate between nursing interventions and outcome statements. NgN tt t: Matrix cnt k: Recognize cues 8. When the nurse decides that the patient needs to rest before ambulating, the decision is based on what factor? 1. 2. 3. 4.

The patient’s wishes The family’s inuences The prioritization of physiologic needs The healthcare provider’s orders

objt: Explain how Maslow’s hierarchy of needs is used to prioritize patient needs. NcleX tt t: Multiple choice cnt k: Knowledge

49

NursiNg Process

NursiNg AcTioNs

Assessment

Analysis of the patient data to determine patient need Identify the therapeutic intent of the medication Take a drug history Determine patient education needed for medication side effects Identify the patient and administer medications

Diagnosis Planning Interventions Evaluation

objt: Discuss how the nursing process applies to pharmacology. NgN tt t: Matrix cnt k: Recognize cues

5

Patient Education to Promote Health

https://evolve.elsevier.com/Willihnganz

Objectives 1. Differentiate among the cognitive, affective, and psychomotor learning domains. 2. Identify the main principles of learning that are applied when teaching a patient, family, or group. 3. Describe the essential elements of patient education in relation to prescribed medications.

4. Describe the nurse’s role in fostering patient responsibility for maintaining well-being and for adhering to the therapeutic regimen. 5. Identify the types of information that should be discussed with the patient or signicant others.

Key Terms cognitive domain (KŎG-nĭ-tĭv dō-MĀN) (p. 50) affective domain (ă-FĔK-tĭv) (p. 50)

psychomotor domain (sī-kō-MŌ-tŏr) (p. 51) objectives (ŏb-JĔK-tĭvz) (p. 51) teach-back (p. 52)

An important nursing responsibility is making certain that patients receive correct healthcare information. Because patient education is a key component of what nurses do, understanding the principles of how people learn is important. Nurses need to learn how to instruct patients correctly, making information specic to the individual, and also determine whether the information is understood by the patient.

Three Domains of Learning The three domains of learning that all adults use when acquiring new knowledge are the cognitive domain, the affective domain, and the psychomotor domain (Fig. 5.1). Cognitive Domain The cognitive domain is the level at which basic knowledge is learned and stored. It is the thinking portion of the learning process, and it incorporates a person’s previous experiences and perceptions. Previous experiences with health and wellness inuence the learning of new materials. Prior knowledge and experience are the foundation of the addition of new concepts. Thus the learning process begins by identifying what experiences the person has had with the subject. However, learning involves more than the delivery of new information or concepts. A person must build relationships between prior experiences and new concepts to formulate new meanings. At a higher level 50

health teaching (p. 52) ethnocentrism (ĕth-nō-SĔN-trĭz-ŭm) (p. 55)

of the learning process, the new information is used to question something that is uncertain, to recognize when to seek additional information, and to make decisions using real-life situations. affeCtive Domain The affective domain is the most intangible portion of the learning process. It refers to the feelings and beliefs a patient has about what they understand. The affective domain includes opinions and values that the patient brings to their understanding of the world. When a patient says, “I don’t know what meds I’m on, I let my spouse deal with that,” they are expressing the value that learning about medications are not important to them. It is well known that individuals view events from different perspectives. People often choose to internalize feelings rather than to express them. The nurse must be willing to approach patients in a nonjudgmental fashion, to listen to their concerns, to recognize the nonverbal messages being given, and to assess patient needs with an open mind.

Clinical Goldmine The development of a sense of trust and condence in healthcare providers can have a powerful effect on the attitude of the patient and their family members. This can inuence the patient’s response to the new information that is being taught. The nurse should be positive and accepting, and involve the patient in a discussion to draw out their views regarding solutions to problems.

Patient Education to Promote Health CHAPTER 5

Box 5.1

Cognitive

Psychomotor

Affective

Knowledge Comprehension

Observing Imitation

Receiving Responding

Application Analysis Synthesis

Practicing Adapting Originating

Valuing Organization Characterization

Evaluation

Fig. 5.1 The Three Domains of Learning. (Redrawn from Black BP. Professional Nursing. 7th ed. Philadelphia, PA: Saunders; 2014, and Washington CM, Leaver DT. Principles and Practice of Radiation Therapy. 4th ed. St. Louis, MO: Mosby; 2016.)

PsyChomotor Domain The psychomotor domain involves the learning of a new procedure or skill. It is often referred to as the doing domain. Teaching is usually done by demonstration of the procedure or task using a step-by-step approach. For example, the nurse can explain how to use an incentive spirometer and the patient will demonstrate their learning by doing it correctly.

PrinciPLes of Teaching anD Learning Patient education is an important nursing responsibility that carries legal implications if there is a failure to provide and document all relevant patient education. Providing information to patients so that they can understand and manage healthcare-related situations is now considered a basic patient right, and it has been mandated by The Joint Commission since 1996. Patient education involves establishing goals with the patient and family based on the healthcare needs of the patient so the patient can learn to manage their care at home. Principles of teaching and learning are important to keep in mind when teaching patients (Box 5.1). foCus the Learning The patient must be allowed to focus on the material or task to be learned. The environment must be conducive

• • • • • • • • • • • • •

51

Principles of Teaching and Learning

Focus the learning. Consider learning styles. Organize teaching sessions and materials. Motivate the patient to learn. Determine the patient’s readiness to learn. Space the content. Use repetition to enhance learning. Consider the patient’s education level. Incorporate cultural and ethnic diversity. Teach appropriate use of the Internet. Encourage adherence. Use relevant content. Communicate goals and expectations.

to learning (i.e., quiet, well lit, and equipped for a teaching session). The patient requires repetition of new information to master it. Nurses may feel obligated to teach the patient or family members everything that they know about a disease or procedure, thereby overwhelming them with information. Instead, nurses must rst glean what information is essential and then consider what the patient wants to know. When the patient starts to ask questions about any medications or procedures, this is considered a teachable moment, and it is important to recognize it as such. By beginning with what the patient brings up, the nurse is able to give the patient some control over learning and increase active participation in the process. ConsiDer Learning styLes Learning styles vary. Some people can read and readily comprehend directions, whereas others need to see, feel, hear, touch, and think to master a task. To be effective, the nurse must t the teaching techniques to the learner’s style. Therefore a variety of materials should be made available for healthcare education, which will include all domains of learning. The nurse can select the instructional approach to be used from written materials such as pamphlets, photographs, and charts for the cognitive domain. The use of video recordings, models, and computers by the nurse to teach a task or procedure, and evaluation of a return demonstration by the patient, can correspond to the psychomotor domain. organize teaChing sessions anD materiaLs In most clinical settings, patient education materials are developed by the staff and then reviewed by a committee for adoption. Specic objectives should be formulated for patient education sessions. The objectives should state the purpose of the activities and the expected outcomes. Objectives may be developed in conjunction with a nursing diagnosis statement (e.g., Imbalanced nutrition: Less than

52

UNIT I Applying Pharmacology to Nursing Practice

body requirements), or they can be developed for common conditions that require care delivery (e.g., care of the patient who is receiving chemotherapy). Regardless of the format used, these instructional materials have established content that is given in outline form, and they are arranged so that one nurse can initiate the teaching and document the degree of understanding, and then another nurse can continue the teaching during a different shift or on a different day. The rst nurse should check off what has been accomplished so that the next nurse knows where to resume the lesson. At the start of each subsequent teaching session, it is important to review what has been covered previously and to afrm the retention of information from the previous lessons. The method known as teachback refers to asking the patient to explain in their own words what instruction was just received. This is an important part of patient education that will identify gaps in learning and help focus the nurse on what needs to be instructed. When psychomotor skills are being taught, return demonstrations by the patient are key to helping the patient practice and gain condence in performing the task. Giving the patient immediate feedback about the skills and then giving them time to practice the skills that are more difcult allows the patient time to improve on mastering the procedure. If appropriate, equipment may be left with the patient for practice before the next session. Sometimes it is particularly useful to set up a video of skill demonstrations for the patient to view alone at a convenient time. At the next meeting, the patient can review the video together with the nurse, and important points can be discussed and claried if the patient expresses confusion or uncertainty. This technique reinforces what has been said, reviews what has been learned, and provides the learner with repetition, which is necessary for learning. motivate the Patient to Learn Before initiating a teaching plan, the nurse should be certain that the patient can focus and concentrate on the tasks and materials to be learned. The patient’s basic needs (e.g., food, oxygen, pain relief) must be met before they can focus on learning. The nurse must recognize the individual’s health beliefs when trying to motivate the patient. Because health teaching requires the integration of the patient’s beliefs, attitudes, values, opinions, and needs, an individualized teaching plan must be developed based on the patient’s beliefs and needs (Box 5.2). Teaching does not require a formal setting. Some of the most effective teaching can be done while care is being delivered. The patient can be exposed to a skill, a treatment, or facts that must be comprehended in small increments. The nurse who explains a certain procedure and informs the patient

why the procedure is being performed reinforces the need for it and motivates the patient to learn. When the patient understands the personal benefits of performing a task, their willingness to do it is strengthened. Determine reaDiness to Learn A patient’s perception of their health and health status may differ from the nurse’s judgment; therefore the values of healthcare to each patient may differ greatly. The patient may not realize that a healthy lifestyle will provide signicant benets. A person who commonly indulges in alcohol, smoking, or a high-fat diet and leads a sedentary lifestyle may not consider the consequences of these practices in relation to health. Not everyone is interested in the concept of healthy living. The nurse must respect the individuality of the patient, family, or group being treated; the nurse should accept that not everyone is motivated by the possibility of a higher level of wellness. The nurse can positively inuence the learning process by being enthusiastic about the content to be taught. A patient’s response to the new information will vary and depends on several factors, including the following: the need to know, the patient’s life experiences and self-concept, the effect of the illness on the patient’s lifestyle, the patient’s experience with learning new materials, and the patient’s readiness to learn. Consideration must be given to the patient’s psychosocial adaptation to illness and their ability to focus on learning. For example, during the denial, anger, or bargaining stages of grieving, the patient usually is neither prepared nor willing to accept the limitations imposed by the disease process. During the resolution and acceptance stages of the grieving process, the patient moves toward accepting responsibility and develops a willingness to learn what is necessary to attain an optimal level of health. The nurse can use encouragement and support the patient’s attempts to learn new, challenging, or difcult procedures (Fig. 5.2). For teaching activities that are conducted with children, psychosocial, cognitive, and language abilities must be considered. Cognitive and motor development, as well as the patient’s language usage and understanding, must be assessed. Age denitely inuences the types and amounts of self-care activities that the child is capable of learning. The nurse should consult a text that addresses developmental theory for further information. Adult education is usually oriented toward learning what is necessary to maintain a particular lifestyle. In general, adults need to understand why they must learn something before they undertake the effort to learn it. When planning the educational needs of the patient, the nurse must assess what the patient already knows and what additional information is desired.

Patient Education to Promote Health CHAPTER 5

Box 5.2

Sample Teaching Plan for a Patient With Diabetes Mellitus Taking One Type of Insulin a

UnDersTanDing of heaLTh conDiTion • Assess the patient’s and the family’s understanding of diabetes mellitus. • Clarify the meaning of the disease in terms that the patient is able to understand. • Establish learning goals through mutual discussion. Teach the most important information rst. Set dates for the teaching of content after discussion with the patient. fooD anD fLUiDs • Arrange for the patient and their family members and signicant others to attend nutrition lectures and demonstrations about food preparation. • Reinforce knowledge of dietary restrictions with the use of tactful questioning and by giving the patient a chance to practice food selections for daily meals from the menus provided. • Explain how to manage the diabetic diet during illness (e.g., with nausea and vomiting, patient should increase uid intake) and when to contact the healthcare provider. • Stress the interrelationship of food with the onset, peak, and duration of the prescribed insulin. moniToring TesTs • Demonstrate how to collect and test blood glucose samples and, as appropriate, urine. • Validate understanding by having the patient collect, test, and record the results of the testing for the remainder of the hospitalization. • Stress serum glucose testing before meals and at bedtime. • Explain the importance of regular follow-up laboratory studies (e.g., fasting plasma glucose testing, postprandial hemoglobin A1c) to monitor the patient’s degree of control. meDicaTions anD TreaTmenTs • Teach the name, dosage, route of administration, desired action, and storage and relling procedures for the type of insulin prescribed. • Explain the principles of insulin action, onset, peak, and duration (see Chapter 35). • Demonstrate how to prepare and administer the prescribed dose of insulin. • Teach site location and self-administration of insulin. • Give specic instructions that address the reading of the syringe to be used at home. • Teach the patient how to obtain supplies (e.g., disposable syringes, needles, glucometer, glucose monitoring strips, insulin pen). • Discuss the usual timing of reactions, the signs and symptoms of hypoglycemia or hyperglycemia, and the management of each complication. • Validate the patient’s understanding of common adverse effects and serious adverse effects. • Teach and validate family members’ and signicant others’ understanding of the signs and symptoms of hypoglycemia and hyperglycemia and the management of each complication. a

53

• Teach a general approach to the management of illnesses (e.g., the actions required if nausea and vomiting or fever occur; stress glucose monitoring before meals and at bedtime); discuss the situations when there is a need to call a healthcare provider. PersonaL hygiene • Discuss the great importance of managing personal hygiene, and emphasize the need to consult a healthcare provider for guidance and discussion:  • Regular foot care  • Meticulous oral hygiene and dental care  • Care of cuts, scratches, and minor and major injuries  • Stress management and needed alterations in insulin dosage during an illness acTiviTies • Help the patient develop a detailed time schedule for usual activities of daily living. Incorporate diabetic care needs into this schedule. • Encourage maintaining all usual activities of daily living. Discuss anticipated problems and possible interventions. • Discuss personal care needs not only at home but also in the work setting, as appropriate. (Consider involving the industrial nurse, if available, in the work setting.) • Discuss the effects of an increase or decrease in activity level on the management of diabetes mellitus. home or foLLow-UP care • Arrange for outpatient or healthcare provider follow-up appointments and schedule ordered laboratory tests. • Advise the patient to seek assistance from the healthcare provider or from the nearest emergency department service for problems that may develop. • Arrange appropriate referrals to community health agencies, if needed. • Complete a diabetic alert card or another means (e.g., an identication necklace or bracelet) of alerting people to the individual’s needs in case of an emergency. • Discuss an exercise program with the healthcare provider. sPeciaL eqUiPmenT anD insTrUcTionaL maTeriaL • Develop a list of equipment and supplies to be purchased; have a family member purchase and bring these to the hospital for use during teaching sessions (e.g., blood glucose monitoring supplies, syringes, insulin pen, needles, alcohol wipes). • Show audiovisual materials that address insulin preparation, storage, and administration, as well as serum glucose testing. • Develop a written record (see Chapter 35), and assist the patient with maintaining data during hospitalization. oTher • Teach measures to make travel easier. • Tell the patient about the American Diabetes Association and about the materials available from this resource.

Each item listed must be assessed for the individual’s current knowledge base and level of understanding throughout the course of teaching. The process is reassessed and the teaching continued until the patient masters all facets of self-care needs. With the advent of shorter hospitalizations, inpatient and outpatient teaching may be necessary, and it may include referral to community-based healthcare agencies, as needed. Discharge charting and referral should carefully document those facets of the teaching plan that have been mastered and those that need to be taught. The healthcare provider should be notied of decits in the patient’s learning ability or in their mastery of needed elements in the teaching plan.

54

UNIT I Applying Pharmacology to Nursing Practice

Life Span Considerations Older Adults

Teaching Older Adults The older adult needs to be further assessed before the implementation of healthcare teaching; these assessments should include vision, hearing, and short- and long-term memory. If a task is to be taught, ne and gross motor abilities need to be evaluated as well. An older patient may also have major concerns regarding the cost of the proposed treatments in relation to available resources. A patient will often evaluate the benets of planned medical interventions and their overall effect on the quality of life. Any of these situations can affect the ability of the patient to focus on the new information to be taught, thus inuencing their response to and the overall outcome of the teaching. Older adults have often expe rienced losses and may be facing social isolation, physical (functional) losses, and nancial constraints. Because older adults often have more chronic health problems, a new diagnosis, an exacerbation of a disease, or a new crisis may be physically and emotionally overwhelming. Therefore the timing of patient instruction is of great signicance. When teaching an older patient, it is prudent to slow the pace of the presentation and to limit the length of each session to prevent overtiring. Older adults can learn the material, but they often process things more slowly than younger people do because their short-term memory may be more limited. The nurse must work with the patient to develop ways to remember what is being taught. The more that the older person is involved in forming the associations that will be used to remember new ideas and to connect these ideas with past experiences, the better the outcome.

Many patients are embarrassed by their inability to master a task. Asking them if they understand is not going to be effective because they will not admit their embarrassment or that they do not understand. The nurse should provide information in small increments and allow for practice, review, practice, review, and practice until success is achieved. The nurse can stop at appropriate intervals and reschedule sessions to meet the patient’s learning needs. Teach-back can be used as an important tool to help the nurse verify what information has been understood. When the patient becomes anxious, the presentation of new information can be slowed, repeated, or stopped and the session rescheduled. Fear and anxiety often impair a person’s ability to focus on the task or content being presented, so creating an environment that is conducive to learning is important. When anxiety is high, the ability to focus on details is reduced. The nurse should anticipate periods during hospitalization when teaching can be more effective. Some teaching is most successful when it is done spontaneously, such as when the patient asks direct questions about their progress toward discharge. The nurse also must learn to anticipate inopportune times to initiate teaching, such as when a patient becomes withdrawn after learning about a diagnosis with a poor prognosis. With reduced hospital stays, the ability to time patient

Fig. 5.2 A patient does a return demonstration of an insulin injection after being taught by the nurse. (Courtesy Jim Varney, North Yorkshire, UK.)

education ideally and to perform actual teaching is a challenge. It is imperative that the nurse document those aspects of healthcare teaching that have been mastered and—of equal importance—those that have not been; the nurse must then request referral to an appropriate agency for follow-up teaching and assistance.

Clinical Goldmine Consider the lighting so that there is no glare on reading materials, face the learner for better eye contact, and speak directly and in a clear tone, without shouting. Be calm, use tact and diplomacy if frustrations develop, and try to instill condence in the learner’s ability to surmount any problems.

sPaCe the Content Spacing or staggering the amount of material given during one session should be considered, regardless of the age of the person being taught. People tend to remember what is learned rst. With this principle in mind, the nurse can provide multiple short sessions rather than a few longer sessions that may overwhelm the patient. use rePetition to enhanCe Learning It is important for the nurse to recognize that patients need repetition to learn new content. The nurse needs

Patient Education to Promote Health CHAPTER 5

to repeat what was previously taught to help the patient understand what is important to remember and build on it to the next level. ConsiDer eDuCation LeveL An important consideration to keep in mind when teaching adult patients is their literacy level. Just giving the patient a pamphlet to read may not be appropriate if the patient cannot read it. Instead, the nurse could review the pamphlet with the patient and then determine the level of the patient’s understanding of the information. Medical terms may not be understood, and written instructions left at the bedside may be misinterpreted or not read at all. Some patients may be illiterate, whereas others may read at a rst-grade, seventh-grade, or collegiate level. Therefore if written materials are used, it is important to consider these wide variations in literacy. inCorPorate CuLturaL anD ethniC Diversity Many healthcare providers have a limited understanding of what other cultures believe and the importance of these benets to the learning process. Ethnocentrism is the assumption that one’s culture provides the right way, the best way, and the only way to live. Briey, people who believe in the theory of ethnocentrism assume that their way of viewing the world is superior to that of others (Leininger, 2002). As an understanding of cultural diversity increases, healthcare providers must expand their knowledge of the basic tenets of the belief systems that they may encounter among their patients. Because there are differing beliefs, it is important that the nurse explore the meaning of an illness with the patient. Members of other cultures do not always express themselves when their views are in conict with those of another culture. Unless a careful assessment of psychosocial needs is performed, the true meaning of an illness or the proposed intervention may never be uncovered. Even the assessment process has obstacles attached. Patients in some cultures do not believe that family information should be shared outside of the family. For example, some Eastern European cultures prefer not to reveal any history of psychiatric illness or treatment and are usually reluctant to share any sexual history. Others, such as the Native American cultures, believe that only the affected individual may reveal information. Communication is vitally important within any cultural group. However, verbal and nonverbal types of communication mean different things to different cultures. For example, whites tend to value eye contact, whereas in other cultures (e.g., Native Americans, Asians) direct eye contact is a sign of disrespect or rudeness. As a part of communication, knowing how to address the patient is also important. African American patients often prefer to have their formal names used rather than their rst names, especially older family members. Chinese people tend to be more formal than Americans, and spouses do not necessarily have the

55

same last name. The simple gesture of asking the patient how they prefer to be addressed is both helpful and respectful. Working with an interpreter when a language barrier exists presents several additional challenges to understanding. The nurse should rst explain the educational session to the interpreter and then discuss the types of questions that will be asked of the patient. Whenever a third person enters into the communication cycle, a lack of clarity and misinterpretation can occur. The nurse should keep questions brief and ask them one at a time to give the interpreter an opportunity to rephrase the question and obtain a response. Sometimes supplementing questions with pictures and pantomime gestures may be helpful. When using an interpreter, the nurse should look directly at the patient (not at the interpreter) while conversing. The members of the healthcare team should always try to ascertain the patient’s beliefs about illness. The following should be taken into consideration: • Is “good health” dened as the ability to work or to fulll family roles, or is it a reward from God or a balance with nature? • Does the patient believe that healthcare can improve health outcomes, or does fate determine the outcome? • Are any cultural or religious disease prevention approaches used in the household? • Do family members wear talismans or charms for protection against illness? • Are cultural healers important (e.g., Chinese herbalists, Native American medicine men)? As part of the cultural assessment, the nurse should determine factors that relate to the cultural beliefs of the family. Inquire as to whether other family members should be included in the discussion of the patient’s medical care. Be sure to include the decision makers in the teaching session so that the teaching will not be wasted. Always remain sensitive to the patient’s and family’s cultural beliefs and practices. Nurses can demonstrate understanding, empathy, respect, and patience for the patient’s cultural values through their communication and actual delivery of healthcare. Consult assessment textbooks for more extensive coverage of ethnic and cultural issues. With increasing globalization becoming more common, educational materials are being adapted to meet a variety of cultural considerations. Unfortunately, this does not solve all of the problems. Interpreting written materials still leaves room for misunderstanding because many people cannot read or do not read at the level of the provided materials.

sTraTegies for heaLThcare Teaching teaCh aPProPriate use of the internet It has become common for consumers to access the Internet for healthcare inquiries, including medical

56

UNIT I Applying Pharmacology to Nursing Practice

consultation from an online primary healthcare provider about a particular healthcare concern. Consumers can purchase medications online and research healthcare treatments. The convenience of accessing electronic healthcare information is a powerful resource for consumers, and it is one that provides anonymity and that may serve to empower the patient. Valid healthcare information can assist patients with the making of informed healthcare decisions (Table 5.1). Today, many patients present to the healthcare provider’s office with some knowledge of their disease, treatment, and medications. This has altered the nurse’s role as a provider of healthcare education to resemble that of a consultant. It is the nurse’s role to teach patients to use the Internet effectively, to evaluate websites for validity, and to assist patients with understanding the information that they have accessed. The nurse should also provide patients with the tools to evaluate websites for validity and to tell them about reputable sites that are specific to their healthcare needs. With the abundance of health- and disease-related information on the Internet, the quality of information varies. Therefore it is essential that the nurse maintain an educational partnership with the patient and their caregivers. enCourage aDherenCe Healthcare providers and educators tend to think that a patient should change behaviors and adhere to a new therapeutic regimen simply because the nurse said so. However, patients do have the right to make their own life choices, and they often do. Unfortunately, there is no way to ensure adherence unless the patient recognizes its value. Success with a healthcare regimen is enhanced when the nurse conveys an enthusiastic attitude, appears positive about the subject matter, and shows condence in the abilities of the patient to understand the lesson. Reinforcing positive accomplishments fosters successful achievement. The patient’s response to the therapeutic regimen (including medications) and their degree of compliance are inuenced by several variables, including the following: • Beliefs about the seriousness of the illness • Perceptions of the benets of the proposed treatment plans • Personal beliefs, values, and attitudes toward health, the provider of the medication, and the healthcare system, including prior experience with the system • Effects of the proposed changes on personal lifestyle • Acceptance (or denial) of the illness and its associated problems; other psychological issues, such as anger about the illness, apathy, depression, forgetfulness, and confusion

Table 5.1 Sources of Patient Information soUrce Health on the Net Foundation (https://www.hon.ch)

DescriPTion Leading organization that promotes and guides the deployment of useful and reliable online medical and healthcare information and its appropriate and efcient use

Healthcare institution intranet

Data available through an institution-specic intranet Provides an online resource for drug information (e.g., Micromedex) Often includes information about diseases and diagnostic testing Information may be printed by the nurse and used for patient education

Krames Online (https:/ /dhch.kramesonline. com/)

Patients access this site on their own Includes information about diseases, conditions, treatments, procedures, surgeries, and medications, including prescription medications and overthe-counter products

Compendium of Therapeutic Choices (CTC)

Published by the Canadian Pharmacists Association Extensive handbook that describes major diseases and their treatment Discussions of medical conditions are brief Focuses on goals of therapy, management algorithms, and the discussion of nonpharmacologic and pharmacologic therapies

• High stress or daily stresses, such as dysfunctional families, difcult living situations, poverty, long working hours in a tense environment, and problematic parenting issues • Comprehension and understanding of the healthcare regimen or frequent changes in the regimen; the inability to read written instructions • Multiple healthcare providers prescribing medications • Costs of treatment in relation to resources and possible difculty with getting prescriptions lled • Support of signicant others or problems with assistance needed in the home • Amount of control that the patient experiences with regard to the disease or condition • Side effects of the treatment and the degree of inconvenience, annoyance, or impairment in functioning that they produce

Patient Education to Promote Health CHAPTER 5

• Degree of positive response achieved • Physical difculties that limit access to or use of medication, such as difculty swallowing tablets, difculty with opening containers or handling small tablets, or the inability to distinguish colors or identifying markings on different medications • Concerns about taking drugs and the fear of addiction Evaluating the ability of a patient to comply with a proposed healthcare regimen is a complex process that involves using established criteria to reach a conclusion. The ultimate goal is to assist patients with achieving the greatest degree of control possible within the context of their beliefs, values, and needs. Healthcare professionals can offer support and encouragement, be complimentary about positive achievements, and encourage an examination of the available options and the benets of a healthy lifestyle. It is vital to assist patients with exploring options when a problem or complication arises rather than giving up on the treatment because information about alternatives is lacking. Financial considerations may also affect the patient’s decisions. If a problem, many manufacturers have patient assistance plans to provide medicines at a lower expense. s  ic adc The challenge for nursing is to increase the adherence of patients to their healthcare regimen and to minimize hospital readmission and suffering from complications. It is estimated that poor adherence to medical therapy accounts for about $300 billion in unnecessary healthcare expenses each year. One model that has been used to induce behavioral change in patients is called the Case Management Adherence Guidelines, version 2. This project, developed by Pzer and the Case Management Society of America, is a series of tools that are used by case managers (many of whom are nurses) to assess the patient’s motivation level and their knowledge of prescribed medications and other therapies. It also assesses a patient’s social support system. The tools help identify those who are more at risk for nonadherence so that interventions can be initiated early during the care process. A key principle of this model is that the nurse must recognize that the patient will make the nal decisions. The nurse must negotiate with (not dictate to) the patient to implement actions that may result in positive change. This approach gives the nurse and patient ownership of the goals to be achieved. Another type of research technique used to study adherence is ethnography. When a patient is not meeting expected outcomes, an ethnographer may visit the patient at home to observe how the patient administers their healthcare regimen. Observations are made with regard to how and which procedures are accomplished and what errors are being made.

57

Industry has used these methods for many years to help design work ow for production, and it has been discovered that this is also a valuable tool in healthcare for improving patient outcomes. It is important to remember that the patient may not be purposefully nonadherent; rather, the home environment may not be set up to allow the patient to follow care instructions. use reLevant Content Nurses tend to think that patients will do what is suggested simply because they have been told that it will be benecial. In the hospital, the nurse and other healthcare members reinforce the basic therapeutic regimen; at discharge, however, the patient leaves the controlled environment and is free to choose to follow the prescribed treatment or to alter it as deemed appropriate on the basis of personal values and beliefs. For learning to take place, the patient must perceive the information as being relevant. Whenever possible, the nurse should start with simple and attainable goals to build the patient’s condence. It is important to correlate the teaching with the patient’s perspective of the illness and their ability to control the signs and symptoms or the course of the disease process. CommuniCate goaLs anD exPeCtations of theraPy Before discharge, reasonable responses to the planned therapy should be discussed. The patient should know what signs and symptoms may be altered by the prescribed medications. The precautions necessary when taking a medication must be explained by the nurse and understood by the patient (e.g., to use caution when operating power equipment or a motor vehicle, to avoid direct sunlight, to ensure that follow-up laboratory studies are carried out). C  epc Changes in the patient’s expectations should be assessed as therapy progresses and as the patient gains understanding and skill with regard to managing the diagnosis. The expectations of therapy for patients with acute illnesses may vary widely from those of patients with chronic illnesses. Cp gl s An attitude of shared input into goals and outcomes can encourage the patient to enter into a therapeutic alliance. Therefore the patient should be taught to help monitor the parameters that are used to evaluate therapy. It is imperative that the nurse nurture a cooperative environment that encourages the patient to do the following: (1) keep records of the essential data that are needed to evaluate the prescribed therapy and (2) contact the healthcare

58

UNIT I Applying Pharmacology to Nursing Practice

provider for advice rather than alter the medication regimen or discontinue the medication entirely. For each major class of drugs in this book, written records (located on Evolve) are provided to help the nurse identify essential data that the patient needs to understand and record. In the event that the patient and their family or significant others do not understand all aspects of the continuing therapy prescribed, they may be referred to a communitybased agency for help with achieving long-term healthcare requirements.

Dc Pl d tc A summary statement of the patient’s unmet needs must be written and placed in the medical chart. The healthcare provider should be consulted about the possibility of a referral to a community-based agency for continued monitoring or treatment. The nurse’s discharge notes must identify the nursing diagnoses that have not been met and the potential problems that require continued monitoring and intervention. All counseling information should be carefully drafted in a manner that the patient can read and understand.

Clcl Jd d n-g nCLex® e-sl Q K Pt • The three domains of learning are the cognitive, affective, and psychomotor domains. • The main principles of learning include the patient’s attitudes toward learning, readiness to learn, and individual learning style. • Patient education in relation to medications includes understanding the benets of the medications, the common adverse effects, and potential drug interactions. • Nurses play an important role in teaching patients about how they can maintain and improve their own well-being by understanding the intent of the therapies prescribed. • The types of information discussed with the patient and their family include the medications and treatments to be continued after discharge and activities, special equipment, and follow-up care. • Specic techniques used to facilitate patient education include determining the patient’s readiness to learn, repetition of information, motivating the patient, and understanding the patient’s culture.

addtl L ru

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situa tions, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Wil lihnganz) for additional online resources.

cll Judt d nxt-gt ncLeX® ext-stl qut The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types.

1. Match the examples of patient behavior after the nurse has given healthcare teaching instructions with the domain of learning. Domain of Learning

PaTienT behavior

Cognitive

•  Patient demonstrates the correct way to use a device such as a peak ow meter • Patient verbalizes an understanding of the potential side effects • Patient correctly demonstrates a skill such as placing medications in the proper box when lling a daily drug box • Patient discussed with spouse how the treatment proposal affects their life

Affective

Psychomotor

ojt: Differentiate among the cognitive, affective, and psychomotor learning domains. ngn tt t: Drag and drop ct kll: Recognize cues 2. The nurse is developing a teaching plan for a patient who will have limited activity at home after a recent fall. What principle of learning is involved when teaching this patient? 1. The timing of the teaching is important for learning to take place. 2. Teaching is effective when all family members are present. 3. The affective domain is particularly useful when dealing with patients who have limited activity. 4. Constantly reminding patients what they should do at home is critical. ojt: Identify the main principles of learning that are applied when teaching a patient, family, or group. ncLeX tt t: Multiple choice ct kll: Comprehension

Patient Education to Promote Health CHAPTER 5

3. The nurse was reviewing the discharge medication list with a patient who recently had been hospitalized for heart failure. The patient states that the medications were not new and that everything is ne. What would be appropriate responses by the nurse? (Select all that apply.)

59

6. The patient presents with educational information about medication that has been obtained from the Internet. What does the role of the nurse as consultant include? (Select all that apply.)

1. “It is important to understand all your medications, as they are intended to keep you healthy.” 2. “The doctor wants you to remember all of your medications so when you go back to the clinic you will know the list.” 3. “It is important to remember to take your doses every day.” 4. “I have to tell you all these medications before you can go home.” 5. “I would like for you to explain them to me, so I can determine whether I need to add any more information.”

1. Evaluating websites the patient uses for validity 2. Assisting the patient with purchasing medications online 3. Assisting the patient with understanding the information accessed 4. Providing the patient with tools to evaluate websites for validity 5. Encouraging the use of one search engine 6. Asking the patient to demonstrate how they look up information on the Internet 7. Discouraging the use of Google for looking up medications 8. Discussing what to look for when determining which websites are useful

ojt: Describe the essential elements of patient education in relation to prescribed medications. ncLeX tt t: Multiple response ct kll: Application

ojt: Identify the types of information that should be discussed with the patient or signicant others. ngn tt t: Extended multiple response ct kll: Recognize cues

4. Which patient is most ready to begin a patient teaching session? 1. A patient who has had nausea and vomiting for the past 24 hours 2. A patient who has just been told that he needs to have major surgery 3. A patient who has voiced a concern about how insulin injections will affect her lifestyle 4. A patient who is complaining bitterly about a low-fat, lowcholesterol diet after his heart attack ojt: Describe the essential elements of patient education in relation to prescribed medications. ncLeX tt t: Multiple choice ct kll: Comprehension 5. Which of the following information about medications is important to teach patients? (Select all that apply.) 1. The name, dosage, and route of administration of the medication 2. The laboratory studies that need to be monitored while on the medication 3. The common adverse effects and possible serious adverse effects to watch for 4. The correct pharmacy to obtain the medication from 5. The correct schedule or timing of the medication to follow ojt: Describe the nurse’s role in fostering patient responsibility for maintaining well-being and for adhering to the therapeutic regimen. ncLeX tt t: Multiple response ct kll: Application

7. Which statement is an example of an objective of healthcare teaching that involves the affective domain of learning? 1. The patient will verbalize an understanding of the reason for taking the medication furosemide. 2. The patient will demonstrate the correct way to use the metered-dose inhaler. 3. The patient will discuss with the family the treatment options proposed. 4. The patient will teach the nurse the same content just learned in the session. ojt: Differentiate among the cognitive, affective, and psychomotor learning domains. ncLeX tt t: Multiple choice ct kll: Comprehension

Unit II

Illustrated Atlas of Medication Administration

6

Principles of Medication Administration and Medication Safety

https://evolve.elsevier.com/Willihnganz

Objectives 1. Identify the legal and ethical considerations for medication administration. 2. Compare and contrast the various systems used to dispense medications. 3. Identify what a narcotic control system entails. 4. Identify common types of medication errors and actions that can be taken to prevent them.

5. Identify precautions used to ensure the right drug is prepared and given to the right patient. 6. Identify the appropriate nursing documentation of medications, including the effectiveness of each medication.

Key Terms nurse practice act (p. 60) standards of care (p. 61) summary section (SŬM-ă-rē) (p. 61) consent section (kŏn-SĔNT) (p. 62) order section (ŌR-dŭr) (p. 62) history and physical examination section (HĬS-tō-rē and FĬZ-ĭ-kŭl ĕgzăm-ĭ-NĀ-shŭn) (p. 62) progress notes (PRŎ-grĕs) (p. 62) nurses’ notes (p. 62) laboratory tests record (LĂB-ōr-ătōr-ē) (p. 62) graphic record (GRĂ-fĭk) (p. 62) ow sheets (FLŌ SHĒTS) (p. 63) consultation reports (kŏn-sŭl-TĀshŭn) (p. 63) medication prole (PRŌ-fīl) (p. 63) medication administration record (MAR) (p. 64) PRN (p. 64)

patient education record (PĀ-shĕnt ĕd-jū-KĀ-shŭn) (p. 64) nursing care plan (p. 65) Kardex (KĂR-dĕks) (p. 66) oor or ward stock system (FLŌR or WŌRD STŎK SĬS-tĕm) (p. 67) individual prescription order system (ĭn-dĭ-VĬD-jū-ăl prē-SKRĬPshŭn) (p. 67) unit-dose drug distribution system (YŪ-nĭt DŌS DRŬG dĭs-trĭBYŪ-shŭn) (p. 67) computer-controlled dispensing system (kŏm-PYŪ-tŭr kŏn-TRŌLD dĭ-SPĔN-sĭng) (p. 68) bar codes (BĂR KŌDZ) (p. 68) long-term care unit-dose system (p. 68) narcotic control systems (năr-KŎ-tĭk kŏn-TRŌL) (p. 69)

Before edictions re dinistered, the nurse ust understnd the professionl responsibilities ssocited with ediction dinistrtion, drug orders, ediction delivery systes, nd the nursing process s it reltes to drug therpy. Ignornce of the nurse’s overll responsibilities s prt of the syste y result in delys in the receiving nd dinistering of edictions nd serious dinistrtion errors. In either cse, cre is coproised, nd the ptient y suffer unnecessrily. 60

disposal of unused medicines (dĭsPŌ-zŭl of ŭn-YŪZD MĔD-ĭ-sĕnz) (p. 71) stat order (STĂT ŌR-dŭr) (p. 72) single order (SĬN-gŭl) (p. 72) standing order (STĂN-dĭng) (p. 72) PRN order (p. 72) computerized provider order entry (CPOE) systems (p. 72) medication safety (p. 72) medication errors (ĀR-ŭrz) (p. 72) adverse drug events (p. 72) high-alert medications (HĪ-ă-LŬRT) (p. 73) medication reconciliation (rĕ-kŏnsĭl-ē-Ă-shĕn) (p. 73) handoffs (HĂND-ŏfs) (p. 73) verication (văr-ĭ-fĭ-KĀ-shĕn) (p. 74) transcription (trăn-SKRĬP-shĕn) (p. 74)

LEGAL AND ETHICAL CONSIDERATIONS The prctice of nursing under  professionl license is  privilege, not  right. When ccepting this privilege, the nurse ust understnd tht this responsibility includes ccountbility for one’s ctions nd judgents during the execution of professionl duties. An understnding of the nurse practice act nd the rules nd regultions estblished by the stte bords of nursing for the vrious levels of entry (i.e., prcticl nurse, registered nurse, nd nurse prctitioner) is  solid

Principles of Medication Administration and Medication Safety CHAPTER 6

foundtion for beginning prctice. Mny stte bords hve developed specic guidelines for nurses to use when prcticing nursing. STANDARDS OF CARE Standards of care re guidelines tht hve been developed for the prctice of nursing. These guidelines re dened by the nurse prctice ct of ech stte, by stte nd federl lws tht regulte helthcre fcilities, by The Joint Coission, nd by professionl orgniztions such s the Aericn Nurses Assocition nd other specilty nursing orgniztions (e.g., the Infusion Nurses Society). Nurses ust lso be filir with the estblished policies of the eploying helthcre gency. Policies developed by the helthcre gency ust dhere to the iniu stndrds of stte regultory uthorities; however, gency policies y be ore stringent thn those tht re recognized by the stte. Eployent by the gency iplies the willingness of the nurse to dhere to estblished stndrds nd to work within estblished guidelines. Exples of policy stteents tht re relted to ediction dinistrtion include the following: 1. Educational requirements for professionals who are authorized to administer medications. Mny helthcre fcilities require the pssing of  written test to conr the knowledge nd skills needed for ediction clcultion, preprtion, nd dinistrtion before grnting pprovl to n individul to dinister ny edictions. 2. Approved lists of intravenous (IV) solutions and medications that the nurse can start or add to an existing infusion. 3. Lists of restricted medications (e.g., antineoplastic agents, magnesium sulfate, allergy extracts, RhoGAM [Rho(D) immune globulin (human)], heparin) that may be administered only by certain staff members with specic credentials or training. 4. Lists of abbreviations that are not to be used in documentation to avoid medication errors (see the pge fcing the inside bck cover of this book). Before dinistering ny ediction, the nurse ust hve  current license to prctice,  cler policy stteent tht uthorizes the ct, nd  ediction order signed by  prctitioner who is licensed with prescriptive privileges t tht institution. The nurse ust understnd the individul ptient’s dignosis nd syptos tht correlte with the rtionle for drug use. The nurse should lso know why  prticulr ediction is ordered nd its expected ctions, usul dosing, proper dilution, route nd rte of dinistrtion, dverse effects, nd the contrindictions for its use. If drugs re to be dinistered with the use of the se syringe or t the se IV site, drug coptibility should be conred before dinistrtion. If the nurse is unsure bout ny of these key ediction points, then they ust consult n uthorittive resource or the hospitl phrcist before dinistering  ediction. The

61

nurse ust be ccurte when clculting, prepring, nd dinistering edictions. The nurse ust ssess the ptient to be certin tht therpeutic nd dverse effects ssocited with the ediction regien re reported. Nurses ust be ble to collect ptient dt t regulrly scheduled intervls nd to record observtions in the ptient’s chrt when evluting  tretent’s effectiveness. Cliing unfilirity with ny of these nursing responsibilities when n voidble copliction rises is uncceptble; in fct, it is considered negligence of nursing responsibility. Nurses ust tke n ctive role in educting the ptient, the fily, nd signicnt others in preprtion for the ptient’s dischrge fro the helthcre environent. A person’s helth will iprove only to the extent tht the ptient understnds how to perfor self-cre. Specic teching gols should be developed nd ipleented. Nursing observtions nd the ptient’s progress towrd the stery of skills should be chrted to docuent the ptient’s degree of understnding.

PATIENT CHARTS The ptient’s chrt or the electronic edicl record (EMR) is  priry source of infortion tht is necessry for the ptient ssessent so tht the nurse cn crete nd ipleent plns for ptient cre. It is lso where the nurse provides the docuenttion of the nursing ssessents perfored, the observtions reported to the priry helthcre provider for further veriction, the bsic nursing esures ipleented (e.g., dily tretents), the ptient teching perfored, nd the observed responses to therpy. This record serves s the couniction link ong ll ebers of the helthcre te regrding the ptient’s sttus, the cre provided, nd the ptient’s progress. The chrt is  legl docuent tht describes the ptient’s helth, lists dignostic nd therpeutic procedures initited, nd describes the ptient’s response to these esures. The chrt ust be kept current s long s the ptient is in the hospitl. After the ptient’s dischrge, this record is intined ccording to policies within the institution. The ptient record y be used for reserch to copre responses to selected therpies in  spling of ptients with siilr dignoses. CONTENTS OF PATIENT CHARTS Although ech helthcre fcility uses  slightly different fort, the bsic ptient chrt consists of the following eleents. Summary Section The summary section gives the ptient’s ne, ddress, dte of birth, ttending helthcre provider, gender, ritl sttus, llergies, nerest reltive, occuption nd eployer, insurnce crrier nd other pyent infortion, religious preference, dte nd tie of dission to the hospitl, previous hospitl dissions,

62

UNIT II Illustrated Atlas of Medication Administration

nd ditting proble or dignosis. The dte nd tie of dischrge re dded when pproprite. Consent Section The dission consent section grnts perission to the helthcre fcility nd the helthcre provider to provide tretent. Other types of consent fors re used during the course of  hospitliztion, such s n opertive procedure perit or consent, n invsive procedure consent,  blood-product consent, nd  consent to bill the ptient’s insurnce crrier. Order Section All procedures nd tretents re ordered by the helthcre provider in the order section. These orders include generl cre (e.g., ctivity, diet, frequency of recording vitl signs), lbortory tests to be copleted, other dignostic procedures (e.g., rdiogrphy, electrocrdiogrphy, coputed toogrphy), nd ll edictions nd tretents (e.g., physicl or occuptionl therpy). History and Physical Examination Section During dission to the hospitl, the ptient is interviewed by  helthcre provider nd given  physicl exintion. The helthcre provider records the ndings on the history and physical examination section nd lists the probles to be corrected (e.g., the dignoses). The history nd physicl exintion for is often referred to s “the H&P.” Progress Notes The ttending helthcre provider records frequent observtions of the ptient’s helth sttus in the progress notes. The progress notes re updted dily to docuent the ptient’s clinicl events, nd how well the ptient is progressing towrd helth during their sty in the institution. In ost hospitls, other helth professionls (e.g., phrcists, dietitins, physicl nd respirtory therpists) y record observtions nd suggestions in the progress notes. Nurses’ Notes Although the fort vries ong institutions, the nurses’ notes generlly strt with the nursing history. On dission, the nurse perfors  coplete helth ssessent of the ptient. This process includes  hedto-toe physicl ssessent, nd it lso incorportes  ptient nd fily history tht provides insights into individul nd fily needs, life ptterns, psychosocil nd culturl dt, nd spiritul needs. This ssessent will serve s the bsis for the developent of the individulized cre pln nd s  bseline for coprison when ongoing ssessent dt re gthered. Nurses record the following in their notes: ongoing ssessents of the ptient’s condition; responses to nursing interventions ordered by the priry helthcre provider (e.g., tretents or edictions)

or to those initited by the nurse (e.g., skin cre, ptient eduction); evlutions of the effectiveness of nursing interventions; procedures copleted by other helthcre professionls (e.g., wound clening by  priry helthcre provider, tting for  prosthesis by  prosthetist); nd other pertinent infortion (e.g., priry helthcre provider or fily visits, ptient’s responses fter these visits). Entries y be de on the nurses’ notes or ow sheets throughout  shift, but generl guidelines include the following: (1) copleting records, including vitl signs, ieditely fter ssessing the ptient upon dission, nd following ny dignostic procedure; (2) recording ll “s needed” (PRN) edictions ieditely fter dinistrtion nd ddressing the effectiveness of the ediction; (3) recording chnge in the ptient’s sttus nd who ws notied (e.g., helthcre provider, nger, ptient’s fily); (4) discussing the tretent of  sudden chnge in the ptient’s sttus; nd (5) recording infortion bout the trnsfer, dischrge, or deth of  ptient. In ddition to the ccurte chrting of the observtions in  cler nd concise nner, the nurse should report signicnt chnges in  ptient’s sttus to the chrge nurse. The chrge nurse then kes  nursing judgent regrding the notiction of the ttending helthcre provider. Coputerized chrting ethods re coon nd llow the nurse to docuent ndings nd bsic cre delivered using ultiple screens of dt nd checklist-type forts. Laboratory Tests Record The laboratory tests record hs ll the lbortory test results in one section of the chrt. Hospitls tht use coputerized reports y list consecutive vlues of the se test if tht test hs been repeted severl ties (e.g., electrolytes). Coputerized lbortory dt ccess provides online lbortory results s soon s the tests re copleted. Other hospitls y ttch sll report fors to  full-sized bcking sheet s ech report returns fro the lbortory. Becuse soe ediction doses re bsed on dily blood studies, it is iportnt to be ble to locte these dt within the ptient’s chrt. Graphic Record The graphic record (Fig. 6.1A) is n exple of the nul recording of teperture, pulse, respirtion, nd blood pressure. Fig. 6.1B is n electronic dtbse– generted exple of the vitl signs, uid intke nd output, glucose, dietry intke, nd other infortion to be used for the ongoing ssessent of the ptient’s sttus. Pin ssessent, which is considered the fth vitl sign, cn lso be recorded in  grphic for. In ddition to the grphic recording of pin, ssessents of pin cn be found on other ow sheets in the chrt tht will record the detils of the pin events.

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GRAPHIC SHEET PATIENT LABEL

A Fig. 6.1 (A) Manual vital signs record. (Courtesy St. Mary’s Health Center, St. Louis, MO.)

Flow Sheets Flow sheets re  condensed for for recording infortion for the quick coprison of dt. Exples of ow sheets in coon use re dibetic, pin, nd neurologic ow sheets. The grphic record tht is used for recording vitl signs is nother type of ow sheet (see Fig. 6.1A). Consultation Reports When other helthcre professionls re sked to consult bout  ptient, the specilist’s sury of ndings, dignoses, nd recoendtions for tretent re recorded in the consultation reports section of the chrt.

Other Diagnostic Reports Reports of surgery, electroencephlogrphy, electrocrdiogrphy, pulonry function tests, rdioctive scns, nd rdiogrphy re usully recorded in the other dignostic reports section of the ptient’s chrt. Medication Profile and Medication Administration Record The medication prole, lso clled the ediction worklist when in n electronic fort, lists ll edictions to be dinistered. The prole is intined in the ptient’s coputerized dtbse, ensuring tht the phrcist nd the nurse hve identicl ediction proles for the ptient. The edictions re usully

64

UNIT II Illustrated Atlas of Medication Administration

B Fig. 6.1 (B) Electronic charting of vital signs and intake and output. (Courtesy Creighton University Medical Center, Omaha, NE.)

grouped ccording to the following ctegories: edictions scheduled to be given on  regulr bsis (e.g., every 6 hours, twice dily), prenterl edictions, stt edictions (fro the Ltin statim, ening “ieditely”), nd preopertive orders. PRN edictions (fro the Ltin pro re nata, ening “s circustnces require”) re those edictions tht re given on n “s needed” bsis nd re usully listed t the botto of the prole, or they y be found on  seprte pge s unscheduled ediction orders. The medication administration record (MAR) is  record of the tie tht the ediction ws dinistered nd identies who gve it (Fig. 6.2A). Generlly, the nurse records nd initils the tie tht the ediction ws given. Mediction proles re kept in  notebook or clipbord le on the ediction crt for the 24-hour period tht they re in use; they then becoe  pernent prt of the ptient’s chrt. In the cute cre setting,  new prole is generted every 24 hours t the se tie tht the unit-dose crt is relled. Fig. 6.2B is n exple of n electronic dtbse–generted MAR tht lists ll scheduled edictions for n 8-hour shift. By clicking the cursor on the highlighted re (i.e., scheduled regulr insulin in this illustrtion),  window opens to revel detils of the order. In the long-ter cre setting the MAR uses the se principles; however, it generlly provides  spce for edictions to be recorded for up to 1 onth. The

MAR lso includes the ne of the phrcy tht dispensed the prescribed edictions nd the ssigned prescription nuber. Medictions tht re prescribed for residents in the long-ter cre setting ust be reviewed on  scheduled bsis; therefore the MAR identies the reviewer nd the dte of review. PRN or Unscheduled Medication Record PRN edictions, or those tht re given s needed, y be recorded on  seprte ediction record rther thn the MAR to record the dte, the tie, the PRN ediction dinistered, the dose, the reson for dinistering the PRN ediction, nd the ptient’s response to the drug given. However, in ost clinicl settings tht involve the use of electronic fors of chrting, the PRN edictions re recorded on the se MAR. Patient Education Record The patient education record provides  ens of docuenting the helth teching provided to the ptient, the fily, or signicnt others, nd it includes stteents bout the ptient’s stery of the content presented. Additional Patient Chart Records Additionl records in  ptient’s chrt y include the following: seprte MARs; opertive nd nesthesiology

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MARTINDALE HOMETOWN HOSPITAL MEDICATION ADMINISTRATION RECORD NAME: Joseph Lorenzo ID NO: 016-28-3978 DIAGNOSIS: Myocardial Infarction SEX: M PHYSICIAN: M. Martin, M.D. Ht: 6’

RM-BD: 621-2 AGE: 62

Init

Signature

Title

Wt: 200 lb

**SCHEDULED MEDICATIONS** DATES:

MEDICATION—STRENGTH—FORM—ROUTE

0730-1529

1530-0029

1/25/yr

RANITIDINE ZANTAC 150 MG TABLET ORAL TWICE A DAY

0030-0729

0900

1800

1/25/yr

DILTIAZEM HYDROCHLORIDE CARDIZEM 90 MG TABLET ORAL 4 TIMES DAILY

0900 1300

1800 2100

1/25/yr

WARFARIN SODIUM COUMADIN 1 MG TABLET ORAL EVERY OTHER DAY

1/25/yr

CEFTAZIDIME (FORTAZ) 1 G IV SODIUM CHLORIDE 0.9% 50 ML EVERY 8 HOURS INFUSE: 20 MIN

0200

1000

1/25/yr

GENTAMICIN PREMIX 80 MG IV ISO-OSMOTIC SOLN 100 ML BY IV PUMP EVERY 12 HOURS INFUSE: 30 MIN

0200

1400

1/25/yr

BY IV PUMP 1 DSW-5/0.2 NACl

NOT GIVEN

TODAY

**IV AND PIGGYBACK ORDERS** 1800

IV 1000 ML RATE: 100 ML/HR

**PRN MEDICATIONS** 1/25/yr

ACETAMINOPHEN TYLENOL 650 MG (23325) TABLET ORAL EVERY 4 HOURS AS NEEDED PRN

1/25/yr

MAGNESIUM HYDROXIDE MILK OF MAGNESIA 60 ML (CONC) ORAL CONC AS NEEDED PRN

1/25/yr

ALBUTEROL PROVENTIL INHALER 90 MCG/INH AEROSOL INH AS NEEDED PRN SEE RESPIRATORY THERAPY NOTES AT BEDSIDE

Age/Sex 62/ M Room-Bd 621 2

HT WT Date 6’0” 200 lb 1/25/yr Name Joseph Lorenzo

ALLERGIES: CODEINE

A Fig. 6.2A Medication prole. Note the separation of scheduled orders, intravenous (IV), and as-needed (PRN) medications. (Courtesy Creighton University Medical Center, Omaha, NE.)

records; recovery roo records; physicl, occuptionl, or speech therpy records; inhltion therpy reports; nd  person with dibetes’ dily record of insulin dosge nd blood glucose (sugr) test results. Ech pge tht is plced in the ptient’s chrt is iprinted with the ptient’s ne, registrtion nuber, nd unit or roo nuber. Nurses often use dt fro ll of the chrt sections to forulte  nursing cre pln. Nursing Care Plans After the initil dt collection, the nurse develops n individulized nursing care plan. Cre plns incorporte nursing dignoses, criticl pthwy infortion,

nd helthcre provider–ordered nd nursing-ordered cre (see Nursing Cre Pln). Most cute cre fcilities require the nurse to chrt ginst ech identied nursing dignosis stted in the cre pln every 8 hours. Cre plns re evluted nd odied on  continuu throughout the course of tretent. The pln should be shred with the helthcre te to ensure n interdisciplinry pproch to cre. Mny institutions hve developed stndrdized cre plns for the vrious nursing dignoses. It is the nurse’s responsibility to identify those dignoses, interventions, nd outcoes tht re pproprite for the ptient.

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B Fig. 6.2B Electronically generated medication sheet listing all scheduled medications for an 8-hour shift. By clicking the cursor on the highlighted area (“4 UNIT SUB” in this illustration), a window opens to reveal details of the order. (Courtesy Creighton University Medical Center, Omaha, NE.)

KARDEX RECORDS The Kardex in pper for is  lrge index-type crd tht is usully kept in  ip le or  seprte holder tht contins pertinent infortion such s the ptient’s ne, dignosis, llergies, tretents, nd the nursing cre pln. When the unit-dose syste is used, edictions re not listed on the Krdex; rther, they re listed seprtely on the ediction prole. Although the Krdex is used pririly by nurses, ptient dt cn be quickly ccessed by ll ebers of the helthcre te. The Krdex is often copleted in pencil nd updted regulrly. Becuse it is not  legl docuent, it is destroyed when the ptient is dischrged fro the institution. Electronic Krdex infortion is prt of the electronic dtbse tht kes up the EMR. This is used to give nurse-to-nurse shift reports nd is continully updted throughout ech shift. CHARTING METHODOLOGIES Regrdless of the ethod of chrting used, the docuenttion process needs to dhere to The Joint Coission stndrds tht incorporte estblished

stndrds of cre. The Joint Coission requires tht ll chrting ethodologies incorporte nursing process criteri nd evidence of teching nd dischrge plnning. When ore thn one helthcre discipline is providing ptient cre,  ultidisciplinry cre pln ust be copleted. This fcilittes couniction ong interdisciplinry te ebers nd helthcre providers. Iproving ptient sfety t the point of cre hs becoe stndrd in every helthcre institution. The fort nd extent of use of electronic dtbse chrting vry widely ong institutions, but ech ethod incorportes the stndrds of cre nd The Joint Coission requireents. Soe clinicl sites hve extensive online electronic chrting developed, wheres others hve little or none. For exple, one hospitl y elect to cobine ll of the eleents forerly found in the Krdex, the cre pln, the MAR, nd the criticl pthwys into one docuent known s  patient prole tht the nurse cn ccess during ech shift. Regrdless of the ethodology used, the dge “If you didn’t chrt it, it didn’t hppen” still holds true.

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DRUG DISTRIBUTION SYSTEMS Before dinistering edictions, it is iportnt tht the nurse understnd the overll ediction delivery syste tht is used t the eploying helthcre gency. Although no two drug distribution systes function in exctly the se wy, the following generl types re used. FLOOR OR WARD STOCK SYSTEM In the oor or ward stock system, ll but the ost dngerous or rrely used edictions re stocked t the nursing sttion in stock continers. This syste hs generlly been used in very sll hospitls nd hospitls in which there re no direct chrges to the ptient for edictions (e.g., in soe governent hospitls). Soe dvntges of this syste re the redy vilbility of ost drugs, fewer inptient prescription orders, nd the inil return of edictions. The disdvntges re s follows: • Incresed potentil for ediction errors becuse of the lrge rry of stock edictions fro which to choose nd the lck of review by the phrcist of  ptient’s ediction order • Incresed dnger of the unnoticed pssing of expirtion dtes nd drug deteriortion, s well s incresed quntities of expired drugs to be discrded • Econoic loss cused by isplced or forgotten chrges nd the ispproprition of ediction by hospitl personnel • Need for lrger stocks nd frequent totl drug inventories • Storge probles on the nursing units of ny hospitls INDIVIDUAL PRESCRIPTION ORDER SYSTEM With the individual prescription order system, edictions re dispensed fro the phrcy with the receipt of  prescription or drug order for n individul ptient. The phrcist usully sends  3- to 5-dy supply of ediction in  bottle tht is lbeled for  specific ptient. After the prescriptions re received t the nurses’ sttion, edictions re plced in the ediction cbinet in ccordnce with institutionl prctices. Generlly, the ediction continers re rrnged lphbeticlly by the ptient’s ne, but they y be rrnged nuericlly by the ptient’s roo or bed nuber. This syste provides greter ptient sfety becuse of the review of prescription orders by the phrcist nd nurse before dinistrtion; it lso involves less dnger of drug deteriortion, esier inventory control, sller totl inventories, nd reduced revenue loss becuse of iproved chrging systes nd less pilferge. Although dispensing ediction to individul ptients is better thn the oor or wrd stock syste, the jor disdvntges of this syste re the tie-consuing procedures tht re used to

Fig. 6.3 Unit-dose cabinet.

schedule, prepre, dinister, control, nd record the drug distribution nd dinistrtion process. UNIT-DOSE SYSTEM The unit-dose drug distribution system uses single-unit pckges of drugs tht re dispensed to ll ech dose requireent s it is ordered. Ech pckge is lbeled with the drug’s generic nd brnd nes, the nufcturer, the lot nuber, nd the expirtion dte. When they re dispensed by the phrcy, the individul pckges re plced in lbeled drwers tht re ssigned to individul ptients. The drwers re kept in  lrge unit-dose cbinet (Fig. 6.3) tht is kept t the nurses’ sttion; in soe institutions, individulized continers or envelopes y be locked in  cbinet in the ptient’s roo. With ost unit-dose systes,  phrcist rells the drwers every 24 hours. In long-ter cre fcilities, these drwers re usully exchnged on  3- or 7-dy schedule. Advntges of the syste include the following: • The tie tht is norlly spent by nursing personnel prepring drugs for dinistrtion is drsticlly reduced. • The phrcist hs  prole of ll edictions for ech ptient nd is therefore ble to nlyze the prescribed edictions for drug interctions or contrindictions. This ethod increses the phrcist’s involveent nd kes better use of their extensive drug knowledge. • Counting drugs fro ultidose pckets is no longer necessry s  result of unit-dose pckging, thereby reducing errors. • It is the nurse’s responsibility to check drugs nd clculte dosges (see the infortion under Right Dose lter in this chpter), thereby reducing errors.

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• There is less wste nd ispproprition becuse single units re dispensed. • Credit is given to the ptient for unused edictions becuse ech dose is individully pckged. (Under the individul prescription order syste, returned bottles of unused edictions re destroyed out of fer of contintion.) The unit-dose ediction is prepred under rigid controls, nd it is dispensed only fter phrcists hve copleted qulity control procedures. Nurses should lwys check edictions before dinistrtion. If there is  discrepncy between the ediction prole nd the ediction in the crt, then the phrcist nd the originl prescriber’s order should be consulted. At the tie of dinistrtion, the nurse should check ll spects of the ediction order s stted on the ediction prole ginst the ediction continer reoved fro the ptient’s drwer for dinistrtion. The nuber of doses reining in the drwer for the shift should lso be checked. If the nuber of reining doses is incorrect, the ediction order should be checked before continuing with the drug dinistrtion. It is lwys possible tht the drug hs been discontinued or tht soeone else hs given the dose, oitted  dose, or given the wrong ptient the wrong ediction. If n error hs been de, it should be reported in ccordnce with hospitl policies. COMPUTER-CONTROLLED DISPENSING SYSTEM A coon syste for ediction ordering nd dinistrtion is  computer-controlled dispensing system, such s Pyxis (Fig. 6.4), tht uses the unit-dose syste described erlier. It is resupplied by the phrcy dily nd is stocked with single-unit pckges of edicines. When  drug order is received in the phrcy for  ptient, it is entered into the coputerized syste. The nurse—who is using  security code nd pssword nd, with newer systes,  ngerprint— ccesses the syste nd selects the ptient’s ne, the ediction prole, the ptient’s ediction drwer, nd the drugs tht re due for dinistrtion. The drug order ppers on the screen, nd  specic section of the crt opens so tht the nurse cn tke  single dose of edicine out of the crt (Fig. 6.5A). This process continues until ll drugs ordered for  specic tie of dinistrtion re retrieved. During the ctul dinistrtion process t the bedside, the nurse uses  hndheld scnner tht reds the bar codes on the nurse’s identiction bdge, the ptient’s wristbnd, nd the unit-dose ediction pcket, thereby linking this infortion with the ptient dtbse (Fig. 6.5B). If there is n error (e.g., wrong dose, wrong tie of dinistrtion, wrong ptient), n lert pops up on the coputer nd the user is unble to continue until the error is corrected. If the process is correct nd the edicine is dinistered, there is utotic docuenttion in the ptient’s MAR of the dinistrtion.

Fig. 6.4 Electronic dispensing system: the Pyxis system. (Courtesy and © Becton, Dickinson and Company, Franklin Lakes, NJ.)

Controlled drugs re lso kept in this utoted dispensing crt. The syste provides  detiled record of the controlled substnce dispensed, including the dte, the tie, nd by who it ws ccessed. A second qulied nurse ust witness the disposl of  portion of  dose of  controlled substnce or the return to the utoted dispensing crt of ny controlled substnce tht is not used. The utoted dispensing syste is currently the sfest nd ost econoicl ethod of drug distribution in hospitls nd long-ter cre fcilities. Long-Term Care Unit-Dose System The long-term care unit-dose system is n dpttion of the syste tht is used in the cute cre setting. The unit-dose crt is designed with individul drwers to hold one resident’s ediction continers for 1 week. The drwer is lbeled with the resident’s ne nd roo nuber, the phrcy’s ne nd telephone nuber, nd the ne of the helthcre fcility. The phrcist lls the ediction continer with the prescribed drug. Ech continer hs enough coprtents to contin the prescribed nuber of doses of the drug for ech dy of the week. The individul coprtents y be lbeled with the dys of the week. The ediction crt hs other coprtents for storing bottles

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 regulr bsis. Medictions should be chrted s soon s they re dinistered. The ediction ide hs specic liittions on the types of edictions tht they cn dinister; therefore nurses should be thoroughly filir with the lws nd guidelines of their stte. The nurse is ultitely responsible for verifying the qulictions of the individul who is being supervised in the ediction-ide cpcity nd for the edictions tht the ediction ide is dinistering.

A

B Fig. 6.5 (A) The nurse removes a single dose of medicine from the electronic dispensing system. (B) A single-dose, bar-coded medication package is scanned by the nurse before it is administered. (Courtesy and © Becton, Dickinson and Company, Franklin Lakes, NJ.)

of ediction tht cnnot be plced in ptients’ drwers. The crt hs  storge re for ediction cups,  edicine crusher, drinking cups, strws, lcohol wipes, syringes, nd other necessities for the preprtion nd dinistrtion of the edictions prescribed. The entire crt hs  locking syste tht should be secured when the ediction crt is not in use or when it is unttended while edictions re being dispensed. At the tie of dinistrtion, the nurse or ediction ide checks ll spects of the ediction order (s stted on the ediction prole) ginst the ediction continer tht hs been reoved fro one of the drwers. The nuber of doses reining in the holder is checked ginst the dys of the week tht rein for the ediction to be dinistered. If the resident refuses the ediction, it ust be chrted on the record with the reson tht the ediction ws refused. In  long-ter cre setting,  resident seldo wers n identiction bnd; therefore third-prty identiction of the resident ust be relied on until the nurse or ediction ide is ble to identify the resident. If pictures of the residents re used s identiers, the institution should hve  policy in plce to updte the photos on

NARCOTIC CONTROL SYSTEMS As described in Chpter 1, lws regulting the use of controlled substnces hve been encted in the United Sttes nd Cnd nd re rigidly enforced in hospitls nd long-ter cre fcilities with the use of narcotic control systems. It is  stndrd policy tht controlled substnces re issued in single-unit pckges nd kept in  locked cbinet. If n utoted dispensing syste is not vilble,  designted individul is responsible for the key to the cbinet. When controlled substnces re issued to  nursing unit, they re ccopnied by n inventory control record (Fig. 6.6) tht lists ech type of controlled substnce being supplied. This record is used to ccount for the disposition of ech type of ediction issued. When the controlled substnce supply is dispensed to the nursing unit by the phrcist, the nurse receiving the drug supply is responsible for counting nd verifying the nuber nd types of controlled substnces received. The nurse then signs  record ttesting to the ccurcy nd receipt of the controlled substnces nd locks the in the controlled substnces (nrcotic) cbinet. When  controlled substnce is ordered for  prticulr ptient, the nurse cring for the ptient uses  key to the cbinet to obtin nd prepre the ediction for dinistrtion. At the tie of reovl fro the cbinet, the inventory control record (see Fig. 6.6) ust be copleted; it ust indicte the tie, the ptient’s ne, the drug, nd the dose, nd it ust include the signture of the nurse who is responsible for checking out the controlled substnce. If  portion of the ediction is to be discrded becuse of  sller prescribed dose, two nurses ust check the dose, the preprtion, nd the portion discrded. Both nurses ust then cosign the inventory control record to verify the trnsction. The cbinet is relocked, the edicine is dinistered, nd the docuenttion is copleted. Before the dinistrtion of ny controlled substnce, the ptient’s chrt should be checked to verify tht the tie intervl since the lst use of the drug hs elpsed s specied in the helthcre provider’s orders (see Chpter 19 for detils bout the onitoring of pin nd the use of nlgesics). Ieditely fter the dinistrtion of  controlled substnce, the nurse who is dinistering the ediction should coplete the chrting. At pproprite intervls fter the dinistrtion of  controlled substnce, the degree nd durtion of effectiveness should be recorded.

UNIT DATE

No

DELIVERED BY

DOSE (mg) DISCARDED (mg)

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70

By ________________________________RN

NURSE’S SIGNATURE

By ________________________________ Pharmacist

Fig. 6.6 Controlled substances inventory control record. (Courtesy University Hospital, The University of Nebraska Medical Center; © Board of Regents of the University of Nebraska, Lincoln, NE.)

At the end of ech shift, the contents of the controlled substnces cbinet or the controlled substnces crt re counted (inventoried) by two nurses: one fro the shift tht is bout to end nd the other fro the oncoing shift. Ech continer is counted, nd the reining nubers of tblets, pules, nd prelled syringes re dded to the ount used in ccordnce with the inventory control record. The ount of ech drug reining plus the ount recorded s being dinistered to individul ptients should equl the totl nuber issued. During the counting procedure, pckges of unopened prelled syringes re visully inspected to verify tht the sel nd cellophne coverings re intct. If the pckge sel is broken, closer scrutiny of the pckge is required. These observtions should include tilting  pckge of prelled syringes to observe the rte of ir bubble oveent inside the brrel, the unifority of color of the solutions in ech of the brrels, nd the siilrity in uid levels in ech of the brrels. The se ediction in the se type

of syringe should be the se color nd trvel through the brrel t the se rte, nd ll uid levels should be siilr. Discrepncies in the nuber of reining doses re checked with nursing personnel on the unit to see if ll controlled substnces used hve been chrted. If this does not revel the source of the inccurcy, ech ptient’s chrt is checked to be certin tht ll controlled substnces recorded on the individul ptient’s chrt for the shift coincide with the controlled substnces inventory record. If the error is still not found, the phrcy nd the nursing service ofce should be contcted in ccordnce with institution policy. If the count ppers to be ccurte but tpering with the contents of the continers is suspected,  report should be de to the phrcy nd the nursing service ofce. When the controlled substnces inventory is coplete, the two nurses who re counting sign the inventory control shift record to verify tht the records nd inventory re ccurte t tht tie. With the controlled

Principles of Medication Administration and Medication Safety CHAPTER 6

substnce crt, the coputer genertes n end-of-shift report tht lso identies discrepncies so tht the stff involved cn ccount for the use of controlled substnces. When n utoted dispensing crt such s Pyxis (see Fig. 6.4) is used, the shift chnge nrcotic check is not done. At the tie of dinistrtion, the nurse will verify the correct count of the drug desired before reoving the drug fro the crt. At tht tie, the syste will be ctivted if  discrepncy occurs. Discrepncies re trcked by nursing nd phrcy, nd they re resolved s soon s they re discovered. The phrcy lso checks for discrepncies when controlled substnces re restocked in the utoted dispensing syste.

DISPOSAL OF UNUSED MEDICINES In recent yers, environentl concerns hve risen bout the proper disposal of unused medicines, becuse trce levels of edicines hve been found in rivers, lkes, nd counity wter supplies. Concerns hve been expressed bout the ppropriteness of the coon prctice of ushing unused edicines down the toilet, becuse ny people ssue tht this is the priry source of wter contintion. However, the US Food nd Drug Adinistrtion’s Center for Drug Evlution nd Reserch hs stted tht drugs found in ground wter re pririly drugs tht hve been incopletely bsorbed nd etbolized by the body fter hun consuption nd tht hve entered the environent fter pssing through wste-wter tretent plnts. Scientists fro the Environentl Protection Agency hve found no evidence of dverse hun helth effects fro unetbolized drugs in the environent. The US Food nd Drug Adinistrtion, working in conjunction with the White House Ofce of Ntionl Drug Control Policy, issued the following guidelines ddressing prescription nd nonprescription ediction disposl: • Follow specic disposl instructions on the drug lbel or in the ptient infortion leet tht ccopnies the ediction. Do not ush prescription drugs down the toilet unless speciclly instructed to do so by the nufcturer. • If no instructions re given, throw the drugs in the household trsh, but rst:  • Epty the drugs fro the continer, nd then ix the with n undesirble substnce, such s used coffee grounds or kitty litter. This kes the product considerbly less ppeling to children nd pets nd less recognizble to people who y intentionlly go through trsh (e.g., dupster divers).  • Put this ixture in  selble bg, n epty cn, or nother continer to prevent the ediction fro leking out of the grbge bg.

71

CLAYTON’S PHARMACY 213 West Third Street Grand Island, Nebraska NAME

enzo

ADDRESS

AGE Adult DATE

Rx ERYTHROMYCIN TABS 250 mg ENTERIC #40 COATED sig: TAB i q 6 h DISPENSE AS WRITTEN

SUBSTITUTION PERMISSIBLE

THIS PRESCRIPTION WILL BE FILLED GENERICALLY UNLESS PHYSICIAN SIGNS ON THE LINE STATING “DISPENSE AS WRITTEN”

Fig. 6.7 Prescription showing patient name and age, patient address, date, drug and strength, number of tablets, directions for use, and the healthcare provider’s signature.

• Use counity drug tke-bck progrs tht llow the public to bring unused drugs to  centrl loction for proper disposl. The drugs re often destroyed using  biohzrd-controlled incinertor. • Before throwing out n epty prescription bottle, scrtch out ll identifying infortion on the lbel to ke it unredble. This will help protect ptient identity nd helth infortion. • Controlled substnces (e.g., opite nlgesics) should be ushed down the toilet to reduce the dnger of unintentionl use or overdose nd illegl buse. An exple is the fentnyl ptch, which, even fter it hs been used by the ptient for 3 dys, cn still contin enough edicine to cuse severe respirtory depression in bbies, children, nd pets. Environentlly friendly drug disposl bgs (e.g., Deterr) tht dectivte edictions re used to prevent drug diversion nd potentil overdose. Additionl guidelines for the disposl of drugs tht re clssied s hzrdous edictions (e.g., cheotherpeutic gents) hve lso been dened. Refer to gency policies for proper disposl.

MEDICATION ORDERS Medictions for ptient use ust be ordered by licensed priry helthcre providers, dentists, nurse prctitioners, nd physicin ssistnts cting within their res of professionl trining. Plcing n order for  ediction or tretent is known s issuing a prescription. Initilly,  prescription y be issued verblly or in written for. Prescriptions tht re issued for nonhospitlized ptients use  for tht is siilr to tht shown in Fig. 6.7, wheres prescriptions for hospitlized ptients re written on the institution’s ediction order for. All prescriptions ust contin the following eleents: the ptient’s full ne, the dte, the drug ne, the route of dinistrtion, the dose, the durtion of the order, nd the signture of the prescriber. Additionl infortion y be required for certin types of edictions (e.g., for IV dinistrtion, the

72

UNIT II Illustrated Atlas of Medication Administration

concentrtion, dilution, nd rte of ow should be specied in ddition to the ethod [i.e., “IV push” or “continuous infusion”]). TYPES OF MEDICATION ORDERS Mediction orders fll into four ctegories: stt, single, stnding, nd PRN orders. The stat order is generlly used on n eergency bsis. It ens tht the drug is to be dinistered s soon s possible, but only once. For exple, if  ptient is hving  seizure, the priry helthcre provider y order “dizep 10 g IV stt,” which ens tht the drug is to be given ieditely nd one tie only. The single order ens dinistrtion t  certin tie but only one tie. For exple,  one-tie order y be written for “furoseide 20 g IV to be given one tie t 7 am.” Furoseide would then be dinistered t tht tie, but once only. The standing order indictes tht  ediction is to be given for  specied nuber of doses: for exple, “cefzolin 1 g q6h × 4 doses.” A stnding order y lso indicte tht  drug is to be dinistered until it is discontinued t  lter dte: for exple, “picillin 500 g PO q6h.” In the interest of ptient sfety, however, ll ccredited helthcre gencies hve policies tht utoticlly cncel n order fter  certin nuber of doses re dinistered or fter  certin nuber of dys of therpy hve pssed (e.g., surgery, fter 72 hours for nrcotics, fter one dose only for nticogulnts, fter 7 dys for ntibiotics). A PRN order ens “dinister if needed.” This order llows  nurse to judge when  ediction should be dinistered on the bsis of the ptient’s need nd when it cn be sfely dinistered. Verbal Orders Helthcre gencies hve policies regrding who y ccept verbl orders nd under wht circustnces they should be ccepted, usully in eergency situtions only. The prctice is strongly discourged nd should be voided whenever possible to prevent ediction errors. The prescriber ust cosign nd dte ny verbl order, usully within 24 hours. Electronic Transmission of Patient Orders Mny priry helthcre providers’ ofces fx new orders to the re where the ptient is ditted or trnsferred. These fx trnsissions ust hve n originl signture within  specied tie, often 24 hours. Hospitl units lso nd it useful to fx orders to the nursing hoe where the individul is being trnsferred. This llows the receiving gency to prepre for the ptient or resident, nd the originl orders, which hve been signed by the priry helthcre provider, then ccopny the individul t the tie of trnsfer. Computerized provider order entry (CPOE) systems

re used to trnsit orders electroniclly. Softwre hs been developed tht llows for the use of CPOE nd

Box 6.1

Examples of Medication Errors

PRESCRIBING ERRORS • Suboptimal drug therapy decisions • Drug prescribed for patient with known allergy or intolerance • Incorrect dose for diagnosis • Unauthorized drug prescribed DISPENSING • Wrong drug or dose sent to nursing unit • Wrong formulation or dosage form ADMINISTRATION • Incorrect strength (dose) given • Extra dose given or missed dose • Wrong administration time • Incorrect administration technique MONITORING • Suboptimal monitoring • Suboptimal assessment of drug response or revision of regimen • Suboptimal patient education

clinicl decision-king support systes (CDSSs). The coputerized syste integrtes the ordering syste with the phrcy, the lbortory, nd the nurses’ sttion, thereby providing ccess instntly to online infortion tht y ffect  ptient’s cre needs.

MEDICATION SAFETY Medication safety is freedo fro ccidentl injury fro

edictions. The nurse should be wre of how to properly hndle certin edictions (e.g., cheotherpy drugs, topicl horones), which cn cuse  rection when they coe in contct with the skin. The nurse lso needs to be wre of how to correctly prepre nd dinister edictions to prevent injury (e.g.,  needlestick). Medication errors cn be dened s the filure of  plnned ction to be copleted s intended or the use of  wrong pln to chieve  gol. Mediction errors include prescribing errors, trnscription or order couniction errors, dispensing errors, dinistrtion errors, nd errors of onitoring or eduction for proper use (Box 6.1). Mediction errors cn result in serious coplictions known s adverse drug events. In 2005 the nuber of deths fro ediction errors s reported to the US Food nd Drug Adinistrtion ws 15,107 (Moore, 2007). The Ntionl Acdey of Medicine, forerly clled the Institute of Medicine, hs been working on inititives to reduce these events nd nge the outcoes by exploring how they occur nd deterining wys to prevent the. TECHNOLOGY AND PREVENTION OF ADVERSE DRUG EVENTS Adverse drug events occur ost coonly during ordering nd t the dinistrtion stge. Therefore

Principles of Medication Administration and Medication Safety CHAPTER 6

preventive esures re being ipleented tht include substntil chnges in the ordering syste used for edictions nd lbortory studies. The use of the CPOE technology checks for potentil drug interctions nd the ppropriteness of drug dosges ordered, s well s for lbortory ndings (e.g., therpeutic drug levels t the tie of order entry). Autoted ordering nd dispensing systes hve been developed to iniize ediction errors. Autoted systes use robotics nd br-coding technology to ll the orders entered by the priry helthcre provider. Robotics in the phrcy cn free soe of the phrcists for deployent to clinicl units, where they cn ke ptient rounds, check for ediction response, review current lbortory dt, nd work with the prescriber to select, dose, nd onitor drug therpy. HIGH-ALERT MEDICATIONS The Institute for Sfe Mediction Prctices (ISMP) hs conducted  survey of severl cute cre hospitls to deterine which edictions cuse serious ptient hr or deth. As  result of this study, edictions nd clssictions tht pose signicnt risk in the cute clinicl setting were identied. These re now known s high-alert medications, nd they include insulin, heprin, opioids, injectble potssiu or potssiu phosphte concentrte, neurousculr blocking gents, nd cheotherpeutic gents. Although istkes y or y not be ore coon with these edicines, the consequences of n error re uch ore devstting to ptients. The ISMP continues to onitor the frequency of drug errors in the clinicl literture to updte the list of high-lert edictions. High-lert edictions, the role they ply in ediction errors, nd recoended prctices to id in prevention include the following: (1) stndrdizing processes within the institution; (2) developing processes to ke errors stnd out (i.e., king stff ore lert nd wre to ctch errors before they rech the ptient); nd (3) developing ethods to iniize the consequences of errors tht rech the ptient. Cohen lso discussed severl prctices to proote ediction sfety, including the following: (1) the use of technology, including CPOE, br-coded drug dinistrtion, nd srt pups for controlled dinistrtion; (2) the restriction of high-lert edictions during the dispensing process (e.g., reoving neurousculr blocking gents fro redily vilble oor stock); (3) the voidnce of verbl orders for high-lert edicines; (4) the use of checklists for high-lert drugs; (5) the use of generic nd brnd nes on the MAR to void errors with sound-like drugs; (6) the stndrdizing of drug concentrtions nd dosing infusion chrts; nd (7) the perfornce of double-checking before dinistrtion nd ptient eduction. The Institute for Helthcre Iproveent lso kes recoendtions for highlert ediction sfety prctices (http://www.ihi.org

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/topics/highlertedictionsfety/pges/defult.s px). MEDICATION RECONCILIATION Another process tht involves the gol of eliinting ediction errors is medication reconciliation, which involves copring  ptient’s current ediction orders with ll of the edictions tht the ptient is ctully tking. This process kes use of  single, shred, nd updted ediction nd llergy list for ptients cross the continuu of inptient nd outptient cre tht is to be used during handoffs, or the trnsition of ptients during cre. Reconcilition is to prevent oissions, duplictions, differences in dosing, nd drug interctions. It should be copleted s prt of every trnsition of cre during which new edictions re ordered or existing orders re rewritten. Trnsitions in cre include chnges in setting, service, prctitioner, or level of cre (e.g., criticl cre to generl cre to rehbilittion services). Mediction reconcilition is  ve-step process: (1) develop  list of current edictions being dinistered, (2) develop  list of edictions tht were prescribed, (3) copre the edictions on the two lists, (4) ke clinicl decisions on the bsis of this coprison, nd (5) counicte the new list to pproprite cregivers nd to the ptient. Accurte nd coplete ediction reconcilition cn prevent ny prescribing nd dinistrtion errors. Filure to reconcile edictions y be copounded by the prctice of writing blnket orders (e.g., “resue preop edictions”), which re known to result in dverse drug events. Such orders re explicitly prohibited by The Joint Coission’s ediction ngeent stndrds. SOUND-ALIKE MEDICATIONS The ISMP regulrly reports ediction errors tht re the result of the siilrity of sound-like nes (e.g., Mucoyst nd Mucinex; Evist nd Avinz). Mnufcturers hve  responsibility to void using brnd nes tht re siilr to those of other edicines to help void errors. As recoended by the ISMP, both the generic ne nd the brnd ne should be included on the CPOE screen. Most products with sound-like nes re used for different purposes. It is iportnt for the nurse to be filir with ptients’ dignoses nd to know wht edicines re used for these conditions so tht they re ble to question why  prticulr edicine y hve been prescribed when  ptient does not hve  dignosis tht requires tht edicine. For exple, the generic ne for Evist is rloxifene, which is used to prevent osteoporosis in postenopusl woen; lterntively, Avinz is n extended-relese for of orphine sulfte tht is used for severe pin. Seeing Evist dispensed for  person who requires opioid nlgesi should rise  question of ediction error; it should not be dinistered until the need for the edicine

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UNIT II Illustrated Atlas of Medication Administration

hs been clried. (Note the “do not confuse” icon throughout this text in the pproprite drug onogrphs nd tbles.) NURSE’S RESPONSIBILITIES The iportnce of ccurcy t every step during ordering, trnscribing, dinistering, nd onitoring drug therpy cnnot be overephsized. Verification With the nonutoted order nd distribution systes, fter  prescription order hs been written for  hospitlized ptient, the nurse interprets it nd kes  professionl judgent bout its cceptbility. Judgents ust be de regrding the type of drug, the therpeutic intent, the usul dose, the ssocited theticl clcultions, nd the physicl preprtion of the dose. The nurse ust lso evlute the ethod of dinistrtion in reltion to the ptient’s physicl condition, s well s ny ptient llergies nd the ptient’s bility to tolerte the dose for. If ny prt of n order is vgue, the prescriber who wrote the order should be consulted for clriction. Ptient sfety is of priry iportnce, nd the nurse ssues responsibility for the verication nd sfety of the ediction order. If, fter gthering ll possible infortion, the nurse concludes tht it is inpproprite to dinister the ediction s ordered, the prescriber should be notied ieditely. An explntion should be given s to why the order should not be crried out. If the prescriber cnnot be contcted or does not chnge the order, the nurse should notify the director of nurses, the nursing supervisor on duty, or both. The resons for the refusl to dinister the drug should be recorded in ccordnce with the policies of the eploying institution. Transcription The transcription of the prescriber’s order is necessry to put tht order into ction. After the veriction of n order,  nurse or nother designted person trnscribes the order fro the priry helthcre provider’s order sheet onto the Krdex or ediction prole. These dt y lso be entered into  coputerized ptient dtbse tht produces  Krdex or ediction prole. When this process is delegted to  wrd clerk or unit secretry, the nurse is still responsible for verifying ll spects of the ediction order. The nurse ust sign the originl ediction order to indicte tht the order hs been received, interpreted, nd veried. The nurse then sends  copy of the originl order to the phrcy, often by fx. A sll supply is issued, either in  unit-dose for or in  continer tht holds  dily supply. The continer is lbeled with the dte, the ptient’s ne nd roo nuber, nd the drug ne nd strength or dose. When the supply rrives fro the phrcy, it

is stored in the ediction roo or in the ptient’s ediction drwer of the ediction crt. In cses where the order is sent electroniclly, the trnscription phse is eliinted, s the order goes directly to the phrcy. The phrcist reviews nd lls the order, sending the edicine to the nurse who veries nd then dinisters the edicine. In the long-ter cre setting, crbon copies of new ediction orders re sent to the locl phrcy to be lled. If  stt dose is needed or if the ediction ust be strted very soon, the phrcy is notied vi telephone or fx nd written veriction of the edicines ordered is lso supplied to the phrcy. Becuse the locl phrcy genertes the ediction dinistrtion record only on  onthly bsis, new orders ust be dded to the current ediction record by the nurse who is trnscribing the order. Nurses lso send requests to the phrcy vi fx for drug reorders (e.g., PRN orders). Using stndrd drug dinistrtion ethodology, the nurse prepres nd dinisters  drug by following the order on the ediction prole in ccordnce with the seven rights of drug dinistrtion. With the new CPOE tht is supported by CDSSs, both the veriction nd trnscription of the ediction orders re built into the syste. It should be ephsized tht br coding nd hndheld devices do not eliinte the need for the nurse to use stndrd dinistrtion procedures for edictions (e.g., checking ll spects of the drug order). Reporting Variance When  ediction error does occur, n incident report—which includes the dte, the tie tht the drug ws ordered, the drug ne nd dose, the route of dinistrtion, nd the therpeutic response or dverse clinicl observtions—should be subitted. The dte nd tie tht the prescriber is notied of the error nd ny prescriber’s orders given should lso be recorded. It is iportnt to be fctul nd not to stte opinions on the incident report. Current prctices for reporting ediction errors hve fcilities use  nonpunitive ction when  ediction error occurs. It is uch ore iportnt to deterine why the error occurred nd to educte ll personnel regrding how to prevent repet errors.

SEVEN RIGHTS OF DRUG ADMINISTRATION The seven rights of drug dinistrtion re s follows: right drug, right indiction, right tie, right dose, right ptient, right route, nd right docuenttion. RIGHT DRUG The nurse needs to verify tht the drug given is the one ordered. Triple-checking the drug ne is one of the iportnt steps tht the nurse tkes to prevent ediction errors.

Principles of Medication Administration and Medication Safety CHAPTER 6

Clinical Pitfall Many drugs have similarly spelled names and variable concentrations. A signicant number of medication errors occur as a result of look-alike packaging and similar drug names. Therefore before administering a medication, it is imperative to compare the exact spelling and concentration of the prescribed drug with the medication prole and the medication container. Regardless of the drug distribution system used, the drug label should be read at least three times: (1) before removing the drug from the shelf or unit-dose cart; (2) before preparing or measuring the actual prescribed dose; and (3) before replacing the drug on the shelf or before opening a unit-dose container (i.e., just before administering the drug to the patient).

RIGHT INDICATION The nurse hs the responsibility to verify the reson tht the ptient is receiving the ediction. It is iportnt to understnd the indiction, which is relted to the edicl dignosis. If in doubt bout the reson for the order, the nurse ust verify the ediction order with the prescriber before dinistrtion. RIGHT TIME When scheduling the dinistrtion tie of  ediction, fctors such s tiing bbrevitions, stndrdized ties, consistency of blood levels, bsorption, dignostic testing, nd the use of PRN edictions ust be considered. Standard Timing Abbreviations The drug order species the frequency of drug dinistrtion. Stndrd bbrevitions tht re used s prt of the drug order specify the ties of dinistrtion. The nurse should lso check institutionl policy concerning ediction dinistrtion. Hospitls often hve stndrdized interprettions for bbrevitions (e.g., “q6h” y en 0600, 1200, 1800, nd 2400; “qid” y en 0800, 1200, 1600, nd 2000). The nurse ust eorize nd use stndrd bbrevitions to interpret, nd dinister edictions ccurtely. Standardized Administration Times For ptient sfety, certin edictions re dinistered t specic ties. This llows lbortory work or electrocrdiogrphy to be copleted rst so tht ny djustent to the next dose cn be deterined. For exple, wrfrin or digoxin y be dinistered t 1300 if ordered by the prescriber. The ediction dinistrtion ties need to be stndrdized throughout  clinicl fcility, with ll units using the se tie schedule to help prevent ediction errors. Maintenance of Consistent Blood Levels The schedule for the dinistrtion of  drug should be plnned to intin consistent blood levels of the drug to xiize the drug’s therpeutic effectiveness.

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If blood drws to estblish the current seru blood level of  specic drug re ordered, the nurse should follow the guidelines stted in the drug onogrph for the specic tie t which the blood sple should be drwn in reltion to the drug dose dinistrtion schedule. Maximum Drug Absorption The schedule for the orl dinistrtion of drugs ust be plnned to prevent incoptibilities nd to xiize bsorption. Certin drugs require dinistrtion on n epty stoch nd thus re given 1 hour before or 2 hours fter  el. Other edictions should be given with food to enhnce bsorption or reduce irrittion, nd still other drugs re not given with diry products or ntcids. It is iportnt to intin the recoended schedule of dinistrtion for xiu therpeutic effectiveness. Diagnostic Testing It is necessry to deterine whether ny dignostic tests hve been ordered for copletion before inititing or continuing therpy. Before beginning ntiicrobil therpy, ll culture speciens (e.g., blood, urine, wound) need to be collected. If  helthcre provider hs ordered seru levels of  certin drug to be obtined, the dinistrtion tie of the ediction should be coordinted with the tie t which the phlebotoist is going to drw the blood sple. When copleting the requisition for  seru level of  ediction,  nottion should be de regrding the dte nd tie tht the drug ws lst dinistered. Tiing is iportnt; if tests re not conducted t the se tie intervls for the se ptient, the dt gined re of little vlue. PRN Medications Before the dinistrtion of ny PRN ediction, the ptient’s chrt should be checked to ensure tht soeone else hs not dinistered the drug nd tht the specied tie intervl hs pssed since the ediction ws lst dinistered. When  PRN ediction is given, it should be chrted ieditely, including the reson for dinistrtion (e.g., nuse, pin). The ptient’s response to the ediction should lso be recorded. RIGHT DOSE Check the drug dosge ordered ginst the rnge specied in the reference books vilble t the nurses’ sttion or the institutionlly ccepted websites, nd coplete drug clcultions s indicted. Abnormal Hepatic or Renal Function The heptic nd renl function of the specific ptient who will receive the drug should lwys be considered. Depending on the rte of drug etbolis nd the route of excretion fro the body, certin

76

UNIT II Illustrated Atlas of Medication Administration

drugs require  reduction in dose to prevent toxicity. Conversely, ptients who re being dilyzed y require higher-thn-norl doses. Whenever  dosge is outside of the norl rnge for tht drug, it should be verified before dinistrtion. After verifiction hs been obtined,  brief explntion should be recorded in the nurses’ notes or ediction profile so tht others dinistering the ediction will hve the infortion nd the helthcre provider will not be repetedly contcted with the se questions. The following lbortory tests re used to onitor liver function: sprtte inotrnsferse (AST), lnine inotrnsferse (ALT), g-glutyl-trnsferse (GGT), lkline phosphtse, nd lctte dehydrogense (LDH). The blood ure nitrogen (BUN), seru cretinine (Crs), nd cretinine clernce (Ccr) re used to onitor renl function. Pediatric and Older Patients Specic dosges for soe drugs hve not yet been rly estblished for the older dult or peditric ptient. The nurse should question ny order outside of the norl rnge before dinistrtion. For peditric ptients, the ost relible ethod is by proportionl ount of body surfce re or body weight (see Appendix A). Nausea and Vomiting If  ptient is voiting, orl edictions should be held nd the prescriber should be contcted for lterntive ediction orders, becuse the prenterl or rectl route y be preferred. Investigte the onset of the nuse nd voiting. If it begn fter the strt of the ediction regien, considertion should be given to rescheduling the orl ediction. Adinistrtion with food usully decreses gstric irrittion. Accurate Dose Forms Do not brek  tblet. Consult with the phrcist bout the need for scoring ny tblets nd hve the phrcy prepre the ediction, or sk for other vilble dosge fors. Accurate Calculations When clculting drug dosges, ccurcy is essentil to intin ediction sfety. Do not hesitte to hve ny clcultions checked by nother helthcre professionl.

Correct Measuring Devices The ccurte esureent of the volue of ediction prescribed is essentil. Frctionl doses require the use of  tuberculin syringe, wheres insulin is generlly esured in n insulin syringe tht corresponds with the nuber of units in 1 L (i.e., U-100 insulin is esured in  U-100 syringe). There re nuerous types of infusion pups vilble, nd the nurse needs to be filir with the opertion of the type used in the clinicl setting. If in doubt, hve nother cre provider with expertise in the device’s use check ll settings before dinistering  ediction. RIGHT PATIENT When using  unit-dose syste, the ne on the ediction prole should be copred with the individul’s identiction brcelet. Alwys check the brcelet for llergies. Soe institutionl policies require tht the individul be clled by ne s  ens of identiction. This prctice ust tke into considertion the ptient’s entl lertness nd orienttion. It is always uch sfer to check the identiction brcelet. The Joint Coission recoends tht t lest two ptient identiers be used (e.g., the ptient stting both their ne nd birth dte). Pediatric Patients Children should never be sked their ne s  ens of positive identiction. They y chnge beds, try to void the stff, or seek ttention by identifying theselves s soeone else. Identiction brcelets should be checked every time. Older Patients It is iportnt not only to check identiction brcelets, but lso to conr nes verblly. In  long-ter cre setting, residents usully do not wer identiction brcelets. In these cses, only  person who is filir with  specic resident should conr their identity for the purpose of dinistering ediction.

Clinical Pitfall It is important to check the patient’s identication bracelet every time that a medication is administered. The adverse effects of the administration of the wrong medication to the wrong patient and the potential for a lawsuit can thus be avoided. Although automated technology will help reduce the frequency of medication errors, this technology does not eliminate the nurse’s responsibility for checking the patient’s identity and other aspects of the drug order.

Clinical Pitfall Whenever a dosage is questionable or when fractional doses are calculated, check the dose with another qualied indi vidual. Most hospital policies require that certain medications (e.g., insulin, heparin, IV digoxin) be checked by two qualied nurses before they are administered.

RIGHT ROUTE The drug order should specify the route to be used for the dinistrtion of the ediction. One dosge for of ediction should never be substituted for nother unless the prescriber is speciclly consulted

Principles of Medication Administration and Medication Safety CHAPTER 6

nd n order for the chnge is obtined. There cn be  gret vrition in the bsorption rte of the ediction through different routes of dinistrtion. The IV route delivers the drug directly into the bloodstre. This route provides not only the fstest onset, but lso the gretest dnger of potentil dverse effects (e.g., tchycrdi, hypotension). The intrusculr (IM) route provides the next fstest bsorption rte, which is bsed on the vilbility of the blood supply. This route cn be pinful, s is the cse with ny ntibiotics. The subcutneous (subcut) route is the next fstest, nd it is lso bsed on blood supply. In soe cses, the orl route y be s fst s the IM route, depending on the ediction being given, the dose for (liquids re bsorbed fster thn tblets), nd whether there is food in the stoch. The orl route is usully sfe if the ptient is conscious nd ble to swllow. The rectl route should be voided, if possible, becuse of the resultnt irrittion of ucosl tissues nd errtic bsorption rtes. In cse of error, the orl nd rectl routes hve the dvntge of recoverbility for  short tie fter dinistrtion. The drug cn be reoved by gstric lvge or by inducing voiting if tken orlly. If dinistered rectlly,  drug cn be diluted nd rinsed out by n ene.

Clinical Pitfall To ensure that the right drug is prepared at the right time for the right patient using the right route, it is important to maintain the highest standards of drug preparation and administration. Attention should be focused on the calculation, preparation, and administration of the ordered medication. A drug that is reconstituted by a nurse should be clearly labeled with the patient’s name, the dose or strength per unit of volume, the date and time that the drug was reconstituted, the amount and type of diluent used, the expiration date or time, and the initials or name of the nurse who prepared it. Once a drug has been reconstituted, it should be administered as soon as possible; if not given right away, it should be stored in accordance with the manufacturer’s recommendations.

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bout the reson for the refusl nd to integrte these resons into the cre pln. In soe cses, it y be becuse of drug side effects nd  lck of understnding bout how to llevite the. Other cuses could include the cost of the edicine, n inbility to selfdinister  drug, or the belief tht the drug is ineffective. Helthcre providers ust be sensitive to situtions when the cuse y involve  culturl belief. • When  drug is refused, DO record ll infortion pertining to the incident in the nurses’ notes, nd notify the prescriber of the fcts involved. • DO NOT record in the nurses’ notes tht n incident report hs been copleted when  ediction error hs occurred. However, dt regrding clinicl observtions of the ptient relted to the occurrence should be chrted to serve s  bseline for future coprisons.

Clinical Goldmine CHECK the label of the container for the drug name, the concentration, and the appropriate route of administration. CHECK the patient’s chart, Kardex, medication prole, or identication bracelet for allergies. If no information is found, ask the patient, before administering the medication, if they have any allergies. CHECK the patient’s chart, Kardex, or medication prole for rotation schedules of injectable or topically applied medications. CHECK medications to be mixed in one syringe with a list approved by the hospital or the pharmacy for compatibility. Normally, all drugs mixed in a single syringe should be administered within 15 minutes after mixing. Immediately before administration, always check the contents of the syringe for clarity and the absence of any precipitate; if the solution is not clear or if a precipitate is present, do not administer the contents of the syringe. CHECK the patient’s identity using two identiers every time a medication is administered.

Clinical Goldmine RIGHT DOCUMENTATION The docuenttion of nursing ctions nd ptient observtions hs lwys been n iportnt ethicl responsibility, but now it is becoing  jor edicolegl considertion s well. The chrt should lwys hve the following infortion: the dte nd tie of ediction dinistrtion; the ne of the ediction; nd the dose, route, nd site of dinistrtion. The docuenttion of drug ction should be recorded s prt of the regulrly scheduled ssessents for chnges in the disese syptos tht the ptient is exhibiting. Adverse syptos observed should be proptly recorded nd reported. Helth teching perfored should be docuented, nd the degree of understnding exhibited by the ptient should be evluted nd recorded. • DO record when nd why  drug is not dinistered. • Under soe circustnces,  ptient y refuse  ediction. If this occurs, DO try to obtin infortion

DO approach the patient in a rm but kind manner that conveys the feeling that cooperation is expected. DO adjust the patient to the most appropriate position for the route of administration. For example, for oral medications, sit the patient upright to facilitate swallowing. Have appropriate uids ready before administration. DO remain with the patient to be certain that all medications have been swallowed. DO use every opportunity to teach the patient and family about the drug being administered. DO give simple and honest answers or explanations to the patient regarding the medication and the treatment plan. DO use a plastic container, a medicine cup, a medicine dropper, an oral syringe, or a nipple to administer oral medications to an infant or small child. DO reward the child who has been cooperative by giving praise; comfort and hold the uncooperative child after completing the medication administration.

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UNIT II Illustrated Atlas of Medication Administration

Clinical Pitfall DO NOT prepare or administer a drug from a container that is not properly labeled or from a container on which the label is not fully legible. DO NOT give any medication that has been prepared by an individual other than the pharmacist. Always check the drug name, dose, frequency, and route of administration against the order. Student nurses must know the practice limitations instituted by the hospital or school and which medications can be administered under what level of supervision. DO NOT return an unused portion or dose of medication to a stock supply bottle. DO NOT attempt to orally administer any drug to a comatose patient. DO NOT leave a medication at the patient’s bedside to be taken “later”; remain with the individual until the drug is taken and swallowed. (Note: A few exceptions to this rule are available. One is that nitroglycerin may be left at the bedside for the patient’s use. Second, in a long-term care setting, certain patients are allowed to take their own medications. In both cases, a specic healthcare provider’s order is required for self-medication, and the nurse must still chart the medications taken and the therapeutic response achieved.) DO NOT dilute a liquid medication form unless there are specic written orders to do so.

Nursing Care Plan

Discharge Medication Teaching 1. Explin the proper ethod of tking prescribed edictions to the ptient (e.g., do not crush or chew enteric-coted tblets or ny cpsules; sublingul ediction is plced under the tongue nd is not tken with wter). 2. Stress the need for punctulity with regrd to the dinistrtion of edictions nd wht to do if  dose is issed. 3. Tech the ptient to store edictions seprtely fro other continers nd personl hygiene ites. 4. Provide the ptient with written instructions tht reiterte ediction nes, schedules, nd how to obtin rells. Write the instructions in lnguge tht is understood by the ptient, nd use LARGE, BOLD LETTERS when necessry. 5. Identify the nticipted therpeutic response. 6. Instruct the ptient, the fily ebers, or signicnt others regrding how to collect nd record dt to onitor the response to drugs nd other tretent odlities. 7. Give the ptient (or nother responsible individul)  list of signs nd syptos tht should be reported to the helthcre provider. 8. Stress esures tht cn be initited to iniize or prevent nticipted dverse effects to the prescribed ediction. It is iportnt to do this to further encourge the ptient to be coplint with the edictions prescribed.

Risk for Infection

ASSESSMENT Mrs. Spicer ws ditted to the edicl nursing unit 3 dys go with  dignosis of lypho. She received her rst dose of ultigent cheotherpy yesterdy. Jess Rlston is the student nurse who is cring for Mrs. Spicer. He begins his shift by conducting  focused ssessent. Assessment Activities

Findings/Defining Characteristics

Review the patient’s chart for laboratory data that reflect immune function.

The data show a reduction in the number of white blood cells (i.e., leukopenia).

Ask the patient to describe her appetite and to review her food intake for the last 24 hour. Weigh the patient and measure her height.

The patient reports that she has not had an interest in eating for a couple of weeks. She has lost approximately 6 pounds. Her current weight is 125 pounds, and her height is 5 7″. Her food intake yesterday consisted of a small cup of applesauce, half of a bowl of soup, some crackers, and two glasses of juice. The patient states, “I get full easily and lose interest in food.”

Palpate the patient’s cervical and clavicular lymph nodes.

Her lymph nodes are enlarged and painless.

Review the effects of chemotherapy in a drug reference.

Multiagent chemotherapy causes drug-induced pancytopenia.

NURSING DIAGNOSIS Risk for infection relted to cheotherpy nd reduced food intke s evidenced by leukopeni nd loss of ppetite PLANNING Goals 1. Ptient will rein free fro syptos of infection by the dischrge dte. 2. Ptient will becoe knowledgeble bout infection risks before dischrge.

Principles of Medication Administration and Medication Safety CHAPTER 6

Nursing Care Plan

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Risk for Infection—cont’d

INTERVENTIONS Nursing Actions

Rationale

Monitor the patient’s body temperature routinely, inspect her oral cavity for lesions, inspect IV access site for drainage, and observe for evidence of cough; ask about any unusual discharge or burning on urination.

Interventions are designed to prevent infection and ensure the early detection of infection in a patient who is at risk.

Teach the patient how to perform hand hygiene by handwashing or the use of alcohol-based hand rubs.

Rigorous hand hygiene reduces bacterial counts on the hands.

Consult with a dietitian about providing a highcalorie, high-protein, low-bacteria diet. Minimize the patient’s intake of salads, raw fruits and vegetables, undercooked meat, pepper, and paprika. Offer the patient small, frequent meals.

Maintaining calorie and protein intake will prevent weight loss. Foods high in bacteria should be avoided because they increase the risk for gastrointestinal infection.

The patient can easily come in contact with infectious agents that can cause infection.

Instruct the patient to report any of the following to Signs of infection are indicative of local or systemic infection. the healthcare provider:  • A temperture of >100°F (38°C)  • Shaking and chills  • A persistent cough with or without sputum; pus or foul-selling dringe fro  body site  • The presence of an abscess  • Urine that is cloudy or foul smelling  • Burning during urintion Teach the patient to do the following activities at home:  • Avoid crowds nd lrge gtherings of people.  • Bathe daily.  • Do not share personal toiletry items (e.g., toothbrush, wshcloth, deodornt stick) with fily ebers.  • Practice hand hygiene.  • Do not drink water that has been standing for >15 inutes.  • Do not reuse cups or glsses without wshing

These measures are designed to prevent infection in those patients with impaired immune function.

the rst.

EVALUATION Nursing Actions

Patient Response/Finding

Achievement of Outcome

Compare the patient’s body temperature and other physical findings with baseline data.

The patient remains afebrile and denies The patient has no active infection at this having a cough or burning during time. urination. There are no signs of drainage or discharge from body sites.

Ask the patient to describe the signs and symptoms that should be reported to a healthcare provider.

The patient is able to identify the temperature range to report. Patient was able to describe a cough but unable to identify signs of urinary infection or local discharge.

Ask patient to explain the measures to take at home to reduce exposure to infectious agents.

The patient is able to discuss the need The patient has a partial understanding to avoid sharing personal hygiene of restrictions. The nurse will obtain articles. Patient asked for a listing of printed guidelines to give to the other precautions and requested that patient and include the patient’s spouse be included in the discussion. family in a discussion.

The patient has a partial understanding of the signs and symptoms to report. Additional instruction is required and an information sheet was offered.

Adapted from Ackley BJ, Ladwig GB, Makic MB. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. 11th ed. St. Louis: Mosby; 2017.

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UNIT II Illustrated Atlas of Medication Administration

Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions Key Points • The nurse should know why a medication is ordered and its expected actions, usual dosing, proper dilution, route and rate of administration, adverse effects, and the contraindications for the use of a particular drug. • Medications can be dispensed by use of a oor or ward stock system, an individual prescription order system, a unit-dose system, or a computer-controlled dispensing system, which uses the unit-dose system. • Narcotic control systems include the inventory control record, a means to keep the narcotic locked separately, and ways of verifying the correct count of the drug. • The four categories of medication orders are stat, single, standing, and PRN orders. • Medication errors include prescribing errors, transcription or order communication errors, dispensing errors, administration errors, and errors of monitoring or education for proper use. • The name on the medication prole should be compared with the individual’s identication bracelet using two patient identiers to ensure the right drug is given to the right patient. • The seven rights of drug administration are as follows: right drug, right indication, right time, right dose, right patient, right route, and right documentation. • Appropriate documentation should always have the following information: the date and time of medication

administration; the name of the medication; and the dose, route, and site of administration.

Additional Learning Resources

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/ Willihnganz) for additional online resources.

Online Resources • Centers for Medicare & Medicaid Services: https://www.cms.gov • ISMP List of High-Alert Medications in Acute Care Settings: https://www.ismp.org/recommendations/h igh-alert-medications-acute-list • ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings: https://www.ismp.org/recommendations/h igh-alert-medications-long-term-care-list • ISMP List of High-Alert Medications in Community/ Ambulatory Settings: https://www.ismp.org/recommendati ons/high-alert-medications-community-ambulatory-list • The Joint Commission National Patient Safety Goals: https ://www.jointcommission.org/standards_information/npsgs. aspx

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Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional ques tions. See Chapter 1 for further information regarding question types. 1. What are the legal responsibilities of the nurse for correctly preparing and administering medications to patients? (Select all that apply.) 1. The nurse must ensure that the patient fully understands all the effects of the medication. 2. The nurse must understand the patient’s diagnosis and symptoms correlating to the medication. 3. The nurse must assess the patient for adverse effects of the medication. 4. The nurse must be accurate in calculating and preparing medications. 5. The nurse must administer all medication orders without question. Objective: Identify the legal and ethical considerations for medication administration. NCLEX item type: Multiple response Cognitive skill: Application 2. The nurse was orienting a new nurse to the advantages and disadvantages of the drug distribution system that the unit used for administering medication to patients. Using an arrow, match the drug distribution system with the advantage or disadvantage for each system (more than one system may apply to the answer).

DRUG DISTRIBUTION SYSTEM

ADVANTAGES AND DISADVANTAGES OF SYSTEMS

Floor or ward stock system

• Requires security code

An individual prescription order system A unit-dose system

• Each drug package is

Computer-controlled dispensing system

• Potential for medication

and password labeled

• 3- to 5-day supply is available

errors from lack of review by pharmacists

Objective: Compare and contrast the various systems used to dispense medications. NGN item type: Drag and drop Cognitive skill: Recognize cues 3. The nurse preparing the narcotic hydromorphone (Dilaudid) injection needs to get assistance from another licensed healthcare provider when what occurs? 1. The patient receives the injected medication and then becomes nauseated and vomits the drug. 2. The medication is ordered in a dose smaller than what is available in a prelled syringe cartridge. 3. The patient states that the drug will not work and refuses to take it. 4. The medication ordered is locked in the narcotic drawer.

Objective: Identify what a narcotic control system entails. NCLEX item type: Multiple choice Cognitive skill: Knowledge 4. The nurse had just nished lling out the form that is used to report a medication error, and was recalling the ways to prevent errors. Using an arrow, match the type of medication error with the action used to prevent it.

TYPE OF MEDICATION ERROR Prescribing errors

Administration errors Dispensing errors Monitoring errors

WAYS USED TO PREVENT ERRORS • Taking the time to carefully review drug name and dose • Following routine procedures • Assessing the patient before giving medications • Being familiar with medications before administration

Objective: Identify common types of medication errors and actions that can be taken to prevent them. NGN item type: Drag and drop Cognitive skill: Recognize cues 5. List in order what steps the nurse takes when preparing and administering a patient’s morning medications. 1. Document the administration of the medications. 2. Check the order to verify the medication is correct. 3. Obtain the medications for administration from the medication room. 4. Identify the patient using two patient identiers before administration. 5. Triple-check that the correct medication was prepared. Objective: Identify precautions used to ensure the right drug is prepared and given to the right patient. NCLEX item type: Ordering Cognitive skill: Application 6. What process is used to eliminate medication errors in the healthcare environment as patients transition from one clinical setting to another? 1. 2. 3. 4.

Case management Triple checks Verication Medication reconciliation

Objective: Identify the legal and ethical considerations for medication administration. NCLEX item type: Multiple choice Cognitive skill: Understanding

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82

7. The nurse has nished administering morning medications to a patient and will need to document which important aspect(s) of medication administration? (Select all that apply.) 1. 2. 3. 4. 5. 6.

All seven rights Dose and route of drug Time and name of drug Triple checks Adverse effects observed Health teaching performed

Objective: Identify the appropriate nursing documentation of medications, including the effectiveness of each medication. NCLEX item type: Multiple response Cognitive skill: Application 8. A patient refuses an essential heart medication that has been prescribed. List in order what the nurse will do next. 1. 2. 3. 4. 5.

Noties the prescriber Reports the refusal to the charge nurse Seeks patient reasons for refusal Documents refusal on the MAR Explains importance of medication

Objective: Identify precautions used to ensure the right drug is prepared and given to the right patient. NCLEX item type: Ordering Cognitive skill: Comprehension

9. Immediately after administering morning medications for a patient, the nurse is expected to perform which action next? 1. 2. 3. 4.

Document the medications administered. Evaluate the effectiveness of the medications. Educate the patient on the adverse effects to expect. Complete the nursing care plan for the day.

Objective: Identify the appropriate nursing documentation of medications, including the effectiveness of each medication. NCLEX item type: Multiple choice Cognitive skill: Knowledge

7

Percutaneous Administration

https://evolve.elsevier.com/Willihnganz

Objectives 1. Identify the equipment needed and the techniques used to apply each of the topical forms of medications to the skin. 2. Describe the purpose of and the procedure used for performing patch testing. 3. Identify the equipment needed, the sites and techniques used, and the patient education required when nitroglycerin ointment is prescribed. 4. Identify the equipment needed, the sites and techniques used, and the patient education required when transdermal patch medication systems are prescribed.

5. Describe the dose forms, the sites and equipment used, and the techniques for the administration of medications to the mucous membranes. 6. Compare the technique used to administer eardrops to patients who are less than 3 years old with that used for patients who are 3 years and older. 7. Describe the purpose, the precautions necessary, and the patient education required for those patients who require medications via inhalation. 8. Identify the equipment needed, the site, and the specic techniques required to administer vaginal medications or douches.

Key Terms creams (KRĒMZ) (p. 83) lotions (LŌ-shŭnz) (p. 83) aqueous (Ā-kwē-ŭs) (p. 83) ointments (ŌYNT-měnts) (p. 84) powders (p. 84)

patch testing (PĂCH) (p. 85) allergens (ĂL-ěr-jěnz) (p. 85) transdermal patch (ĂL-ěr-jěnz) (p. 89) buccal (BŬK-ăl) (p. 90) ophthalmic (ŏf-THĂL-mĭk) (p. 91)

Th rs f drg dmsr c b clssd  hr cgrs: rl, prrl, d prcs. Th rm percutaneous administration rfrs  h pplc f mdcs  h sk r mcs mmbrs fr bsrp. Th bsrp f pcl mdcs c b cd by h drg’s ccr, hw lg h mdc s  cc wh h sk, h sz f h ffcd r, h hckss f h sk, h hydr f h sss, d h dgr f sk dsrp. Mhds f prcs dmsr cld h fllwg: h pcl pplc f ms, crms, pwdrs, r ls  h sk; rsdrml pchs, h sll f sls  h mcs mmbrs f h mh, y, r, s, r vg; d h hl f rslzd lqds r gss fr bsrp hrgh h lgs. Th prmry dvg f h prcs r s h h c f h drg,  grl, s lclzd  h s f pplc, whch rdcs h cdc f sysmc sd ffcs. Ufrly, h mdcs r smms mssy d dfcl  pply. I dd, hy slly hv  shr dr f c d hs rqr frq rpplc.

otic (Ō-tĭk) (p. 92) aerosols (ĂR-ō-sŏlz) (p. 95) metered-dose inhaler (MDI) (MĒ-tŭrd DŌS ĭn-HĀL-ŭr) (p. 96) dry powder inhaler (DPI) (DRĪ PŎWdŭr ĭn-HĀL-ŭr) (p. 96)

AdministrAtion of topicAl medicAtions to the skin Dose Forms C Creams r smsld mlss h c mdcl gs fr xrl pplc. Th crm bs s grlly grsy, d  c b rmvd wh wr. My vr-h-cr crms r sd s msrzg gs. L Lotions r aqueous (wr-bsd) prprs h

c sspdd mrls. Ls r cmmly sd s shg gs  prc h sk d  rlv rshs d chg. Sm ls hv  clsg c, whrs hrs hv  srg r drwg ffc. Ls shld b gly b rmly pd  h sk rhr h rbbd  h sk  prv crsd crcl d chg. Shk ll ls hrghly mmdly bfr pplc, d s hm sprgly  vd ws. 83

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UNIT II Illustrated Atlas of Medication Administration

o Ointments r smsld prprs f mdcl

sbscs   ly bs, sch s ll r prlm. Ths yp f prpr c b ppld drcly  h sk r mcs mmbr, d  grlly c b rmvd sly wh wr. Th bs hlps  kp h mdcl sbsc  prlgd cc wh h sk. Pwd Powders r ly grd prcls f mdc h r cd   r bs pwdr. Thy grlly prdc  clg, dryg, r prcv ffc whr ppld. Clmpg ccrs f h pwdr lyr s  hck, prvg cmpl cvrg. Pwdrs r sly rmvd wh wshg. Dressings Svrl yps f drssgs r sd  r wds, sch s dry gz spgs, dhr gz drssgs (.g., Tlf), slf-dhsv rspr lms h c s  scd sk (.g., Tgdrm), d hydrclld drssgs (.g., DDERM). Hydrgl drssgs r sd  prl-hckss d fll-hckss wds d  sk h hs b dmgd by brs. Thr r ls xd bsrbrs sch s clcm lg drssgs (.g., AlgDERM, Kls, Srbs) mfcrd frm swd h c b sd  fcd wds. Wd cr prdcs d wd cr hv bcm  cmplx scc. (Rfr  fdmls f rsg, mdcl-srgcl rsg, d grrc rsg xbks fr dscsss f h prcpls f wd cr.) Drssg rcmmds fr rg prssr jrs r vlbl frm h Agcy fr Hlhcr Rsrch d Qly, h US Pblc Hlh Srvc, d h US Dprm f Hlh d Hm Srvcs.

Clinical Goldmine A major principle of wound healing is the need for a moist environment to promote the epithelialization of the wound, which is further enhanced by a diet that is high in protein, vitamin A, vitamin C, and zinc.

ProCeDure ProtoCoL Th rm procedure protocol wll b sd s pr f h mdc dmsr chq fr h scs  hs chpr. Ths rm clds h fllwg rsg rvs: 1. Assmbl h pprpr qpm d h prfrm hd hyg. 2. Us h seven rights f drg prpr d dmsr hrgh h prcdr: rgh p, rgh drg, rgh dc, rgh r, rgh ds, rgh m, d rgh dcm. 3. Prvd prvcy fr h p d gv  hrgh xpl f h prcdr d wh  xpc.

4. Prfrm  prmdc ssssm bfr pplyg y pcl prpr. S dvdl drg mgrphs fr mr frm.

AdministrAtion of CreAms, Lotions, Powders, And ointments Tpcl prprs c b sd  d h fllwg: • Cls d dbrd  wd • Rhydr h sk • Rdc mm • Rlv lclzd sgs d sympms, sch s chg d rsh • Prvd  prcv brrr • Rdc  hckg f h sk, sch s h vlvd wh clls frm equiPment • Prscrbd crm, l, pwdr, r m • 2 × 2–ch gz spgs • C-ppd pplcrs • Tg bld • Glvs • Mdc dmsr rcrd (MAR) d mdc prl sites Sk srfcs ffcd by h dsrdr bg rd. teChnique 1. Fllw h prcdr prcl dscrbd rlr. 2. Ps h p s h h srfc whr h pcl mrls r  b ppld s xpsd. Assss h crr ss f h p’s sympms. Prvd fr p cmfr bfr srg hrpy. 3. Cleansing: Fllw h spcc rdrs f h hlhcr prvdr r clcl s plcs fr clsg h s f pplc. Afr h r s xpsd d clsd, prfrm  wd ssssm. 4. Application: Wr glvs drg h pplc prcss. My f h gs sd my b bsrbd hrgh h sk f bh h p d h prs wh s pplyg h mdc.  • Lotions: Shk wll l  frm pprc f h ssps s bd. Apply l rmly b gly by dbbg h srfc.  • Ointments or creams: Us  g bld  rmv h dsrd m frm  wd-mhd cr. Alrvly, sqz h m dd   g bld r c-ppd pplcr frm  b-yp cr. Apply ms d crms wh  glvd hd sg rm b gl srks. Crms r  b gly rbbd  h r.  • Powders: Cl d dry h sk. Shk h clsd pwdr cr  brk p clmps f pwdr. Usg glvd hds, pply drcly  h sk by shkg h p cr lghly vr

Percutaneous Administration CHAPTER 7

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7.

8. 9.

h rm r. Cr ms b k   llw h pwdr  bcm rbr d hld. Isrc h p  r hr hd r s  wl s  brrr  vd hlg pwdr. Dressings: Chck spcc rdrs rgrdg h yp f drssg  b sd. If  drssg s  b ppld, sprd h prscrbd m f m drcly  h drssg mrl wh  g bld; h mprgd drssg mrl c h b ppld  h ffcd sk srfc. Scr h drssg  plc. Wet dressings: Alwys cmplly rmv h prvs drssg. Wrg  w drssgs  prv drppg, d pply h gz   sgl lyr drcly  h wd srfc. Fr dpr wds, pck h wd lsly wh ms gz spgs s h ll srfcs r  cc wh h msr. Apply  lyr f dry gz spgs d  bsrb pd  h r. T scr  drssg h rqrs rpd chgs, pply  bdr r s Mgmry ps. Cl h r d h qpm sd, d mk sr h h p s cmfrbl fr h pplc prcdr. (Note: Srl sppls, glvs, d qpm r sd fr sm wds; hwvr, cl rhr h srl ms [.g., gz, glvs] my b sd wh pplyg ms yps f drssgs [.g.,   prssr jry]. Alwys chck sl plcs d s clcl jdgm.) Rmv glvs d dsps f hm  ccrdc wh sl plcy. Prfrm hd hyg.

Patient teaChing 1. If pprpr, ch h p hw  pply h mdc d drssgs. 2. Tch prsl hyg msrs h r pprpr  h drlyg cs f h sk cd (.g., c, cc drms, fc). 3. Wh drssgs r rdrd, sggs h prchs f gz d hr cssry sppls. 4. Srss glss d mdr wh rgrd  h m f mdc  b ppld. 5. Emphsz h h p ms vd chg r scrchg h ffcd r. 6. Tll h p  wsh hr hds bfr d fr chg h ffcd r r pplyg h mdc. Srss h prv f h sprd f fc. DoCumentation Prvd h rgh dcm f h mdc dmsrd d h p’s rsps  drg hrpy. 1. Chr h d, m, drg m, dsg, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f h rm’s hrpc ffcvss (.g., chg  sz f ffcd r, rdcd drg, dcrsd chg, lwrd mprr wh  fc).

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3. O h p’s rcrd, dcm y sgs d sympms f dvrs drg ffcs, d prvd  rrv dscrp f h r bg rd. 4. Dvlp  wr rcrd fr h p  s wh chrg prgrss fr h vl f h ffcvss f h rms bg sd. Ls h p’s sympms (.g., rsh  h lwr lg wh rdss d vscls prs, prssr jry  h scrm). Ls h d  b cllcd rgrdg h mdc prscrbd d s ffcvss (.g., vscls w crsd, wpg, r ppr  b dryg; rdss  lwr lg s lssg; msr h r f dcbs  cmrs [cm] d dc f h wd s xdg, rmg h sm, r shrkg). 5. Edc h p  wh  xpc d wh  d f dvrs sympms dvlp.

PAtCh testing for ALLergens Patch testing s  mhd h s sd  dfy 

p’s ssvy  cc mrls (.g., sps, plls, dys). Th sspcd allergens (gs) r plcd  drc cc wh h sk srfc d cvrd wh sszg, bsrb p. Ulss prcd rr pprs, h pch s slly lf  plc fr 48 hrs d h rmvd. Th s s lf p  r fr 15 ms d h “rd.” A psv rc s d by h prsc f rdss d swllg, clld  wheal (Fg. 7.1), whch dcs  llrgy  h spcc llrg. I my b cssry  rd h rs fr 3 dys d g fr 7 dys  dc dlyd rcs. Irdrml ss my ls b sd  drm h p’s llrgy  spcc gs. S Chpr 10 fr mr frm b h rdrml dmsr f llrgs. Prfrm prsg ssssms (s frm prvdd wh sppld llrg sls).

Fig. 7.1 Example of a wheal for allergy testing. (From Rich RR etal. Clinical Immunology. 5th ed.. St. Louis: Elsevier; 2019.)

86

UNIT II Illustrated Atlas of Medication Administration

equiPment • Alchl fr clsg h r • Sls f sspcd gs • 1 × 1–ch gz pds • Drpprs • Mrl r lv l • Wr • Clpprs • Hypllrgc p • Rcrd fr chrg d b h sbscs ppld d h p’s rspss • MAR, cmpr prl, r rdr sh sites Th bck, rms, r hghs r cmmly sd. (Do not pply  h fc r rs h r sscpbl  frc frm clhg.) Slcd rs r spcd 2  3 chs pr. Th yp f llrg ppld d h s f pplc r dcmd  h p’s chr (Fg. 7.2). Hr s clppd frm ss  sr h h llrg s kp  cls cc wh h sk srfc, hrby prvg  fls-gv rc. teChnique Caution: D  sr y yp f llrgy sg lss mrgcy qpm (cldg pphr) s vlbl  h mmd r  cs f  phylcc rsps. Nrss shld b fmlr wh h prcdr  fllw f  mrgcy ds rs. 1. Fllw h prcdr prcl dscrbd rlr. 2. Chck wh h p bfr srg h sg  sr h  hsms r mmry gs (.g., spr, bprf, dphhydrm, crcsrds) hv b k fr 24  48 hrs bfr h s. If h p hs k  hsm r  mmry g, csl h hlhcr prvdr bfr prcdg wh h sg. Rvw h chr  sr h h p s    mmcmprmsd s s  rsl f dss r rms sch s chmhrpy r rd hrpy. 3. Ps h p s h h srfc  whch h s mrls r  b ppld s hrzl. Prvd fr h p’s cmfr bfr bgg h sg. 4. Cls h slcd sg r hrghly wh h s f  lchl wp. Us crclr ms, srg  h pld s f pplc d cg wrd  h prphry. Allw h r  r-dry. 5. Prpr h dsgd sls sg spc chq (hs rfrs  bg mdfl b prvg cm f h sl by sg ly cl r srl pplc mhds). 6. Fllw h spcc drcs f h mplyg hlhcr gcy rgrdg h pplc f lqd d sld frms f sspcd llrgs. A drppr s slly sd  pply sspcd lqd cc–yp



 

 7.

8.

9.

mrls; sld mrls r ppld drcly  h sk srfc d h msd wh mrl r lv l. Th fllwg mhds my b sd: • Dsgd ms f sdrdzd-srgh chmcl sls r rrgd  ml rcpcls h r bckd wh hypllrgc dhsv. Ths sls r h ppld  h slcd ss. I s mpr  dfy h cs f ch rcpcl crrcly. • Pchs h r mprgd wh dsgd llrgs r vlbl fr drc pplc  h prprd ss. • A pch s srs k s vlbl h cs rrg ccrs f llrgs h r pckgd  syrgs fr dsprsl. Alhgh h k cs 20 llrgs, y mbr f hm my b ppld  dvdl pchs r hldg dvcs, whch r h ppld  h p’s sk. • Afr pplc, fllw sl plcy fr cvrg h s s. Chr h ms, gs, ccrs, d ms ppld. Mk  dgrm  h p’s chr, d mbr ch lc (s Fg. 7.2B). Rcrd whch g d ccr wr plcd  ch s (s Fg. 7.2A). Sbsq rdgs f ch r r h prfrmd d chrd  hs rcrd. Fllw drcs rgrdg h m f h rdg f h sk sg bg prfrmd. Th sg ss shld b spcd  gd lgh. Grlly,  psv rc (.., h dvlpm f  whl)   dld srgh f  sspcd llrg s csdrd clclly sgc. Msr h dmr f h whl d y ryhm (.., rdss  h s f jc)  mllmrs, d plp d msr h sz f y dr (.., h hrdg f  r f h bdy  rsps mm). Th crl s shld hv  rc, whch shld b d. Rcrd h frm frm h sk s rdg  h p’s chr. Th fllwg s  ls f cmmly sd rdgs f rcs d hr pprpr symbls: +

(1+)

No wheal, 3-mm are

++

(2+)

2- to 3-mm wheal with are

+++

(3+)

3- to 5-mm wheal with are

++++

(4+)

>5-mm wheal

Patient teaChing 1. Tll h p h m, d, d plc f h rr vs fr hvg h s ss rd. 2. Tll h p   bh r shwr l h pchs r rd d rmvd. Expl h d  vd cvs h cld cs xcssv prspr.

Percutaneous Administration CHAPTER 7

87

Fig. 7.2 Patch test for contact dermatitis. (A) Reading chart for patch testing. (B) Patch testing sites.

3. If h p dvlps  r f svr brg r chg, lf h pch d gly wsh h r. Tll h p  rpr mmdly h dvlpm f y brhg dfcly, svr hvs, r rshs. Th p shld b ld  g  h rs mrgcy dprm f hy r bl  rch h hlhcr prvdr wh prscrbd h sk ss. DoCumentation Prvd h rgh dcm f h llrg sg ss d h p’s rspss  h llrgs h wr ppld. 1. Chr h d, m, llrgs (cldg g, ccr, d dsg), d s f dmsr (s Fg. 7.2A). 2. Rd ch s  24, 48, d 72 hrs fr pplc s drcd by h hlhcr prvdr r h plcy f h hlhcr gcy. Addl rdgs my b rqrd fr p  7 dys fr pplc. 3. Chr d rpr y sgs d sympms f dvrs llrg ffcs. 4. Prfrm d vld ssl p dc rgrdg h sg d hr ssl spcs f rv fr h llrgy h s ffcg h dvdl.

AdministrAtion of nitrogLyCerin ointment Dose Form Nrglycr m (Nr-Bd) prvds rlf f gl p fr svrl hrs lgr h sblgl prprs. Wh prprly ppld, rglycr m s prclrly ffcv gs crl cks f gl p. Spcc srcs fr rglycr m r rvwd  hs x bcs  s h ly m h s crrly vlbl fr whch dsg s crcl  h sccss f s (s Chpr 24). Prfrm prmdc ssssm; s dvdl drg mgrph fr dls.

1

2

3

5

4

7

9

8

6

10

Fig. 7.3 Sites for nitroglycerin application; numbering indicates rotation schedule.

equiPment • Cl glvs • Nrglycr m • Applcr ppr • Nllrgc dhsv p • MAR d mdc prl sites Ay r wh hr my b sd. Ms ppl prfr h chs, k, r ppr rm r. Dvlp  r schdl fr s f h m (Fg. 7.3). Do not shv  r  pply h m; shvg my cs sk rr. teChnique 1. Fllw h prcdr prcl dscrbd rlr. 2. Apply cl glvs.

UNIT II Illustrated Atlas of Medication Administration

88

1"

2"

Clinical Pitfall Applying Nitroglycerin Ointment

Printed side down

A

Printed side up Ointment side against skin

B Fig. 7.4 Administering nitroglycerin topical ointment. (A) Lay the applicator paper print-side down on a hard surface and measure the ribbon of ointment. (B) Apply the applicator to the skin site, ointmentside down. Spread the ointment in a uniform layer under the applicator, and leave the paper in place.

3. Ps h p s h h srfc  whch h pcl mrl s  b ppld s xpsd. Prvd fr h p’s cmfr bfr srg hrpy. (Note: Wh rpplyg m, rs rmv h plsc wrp d ds-msrg pplcr ppr frm h prvs ds, d cls h r f rmg m  h sk srfc. Slc  w s fr h pplc f h mdc, d h prcd wh sps 4 hrgh 7.) 4. Ly h ds-msrg pplcr ppr wh h pr sd down    srfc (Fg. 7.4A). Th m wll smr h pr. 5. Sqz  rbb f m f h prpr lgh  h pplcr ppr. 6. Plc h msrg pplcr ppr  h sk srfc  h s chs  h r schdl, m sd down. Sprd   h, frm lyr dr h pplcr. DO NOT RUB IN. Lv h ppr  plc. Note: Us f h pplcr ppr llws y  msr h prscrbd ds d prvs bsrp hrgh h grps s y pply h mdc (s Fg. 7.4B). 7. Cvr h r whr h ppr s plcd  ccrdc wh sl plcy (hs my cld cvrg h ppr wh plsc wrp), d h p h ppr  plc. 8. Rmv glvs d dsps f hm  ccrdc wh sl plcy. 9. Prfrm hd hyg.

To promote personal safety, the nurse should always wear gloves, whether applying nitroglycerin ointment paper or handling transdermal patches. When nitroglycerin transdermal patches are applied, chart the specic site of the application. Occasionally, patients may move the transdermal patch themselves because of convenience, skin irritation, or confusion. If the patch is not found at the original location at the scheduled time of removal, examine other areas of the body to nd it; do not assume that the patch fell off or was removed. Tolerance and loss of antianginal response could develop if another patch is placed on the patient while the rst patch is still on. Always dispose of used nitroglycerin paper or transdermal patches in a receptacle in which the patient, children, and pets will not have access. A substantial amount of nitroglycerin remains on the patch and can be toxic.

Patient teaChing 1. Hlp h p lr hw  pply h m d sr h h p drsds h s r schdl. 2. Tll h p h h mdc my dsclr clhg. Th s f clr plsc wrp prcs clhg. 3. Wh h dsg s rgld prprly, h m my b sd vry 3  4 hrs d  bdm. Rmd h p h hr shld b  drg-fr prd (slly 10  12 hrs) vry 24 hrs s rcmmdd by h hlhcr prvdr. 4. Tll h p  wsh hr r hs hds fr pplc  rmv y rglycr h cm  cc wh h grs. 5. Wh rmg h s f hs pcl m, h dsg d frqcy f pplc shld b grdlly rdcd vr  4-  6-wk prd. Tll h p  cc h hlhcr prvdr f djsm s hgh  b cssry. Ecrg h p   dsc h mdc brply (s Chpr 24). DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  drg hrpy. 1. Chr h d, m, drg m, dsg, s, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f hrpc ffcvss (.g., bld prssr, pls, p, dgr d dr f p rlf   scl f 0  10). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy.

Percutaneous Administration CHAPTER 7

3. 4. A

C

B

D

Fig. 7.5 Applying a nitroglycerin topical patch. (A) Carefully pick up

5.

the system lengthwise, with the tab up. (B) Remove the clear plastic backing from the system at the tab. Do not touch the inside of the exposed system. (C) Place the exposed adhesive side of the system on the chosen skin site. Press rmly with the palm of the hand. (D) Circle the outside edge of the system with one or two ngers.

AdministrAtion of trAnsdermAL drug deLivery systems Dose Form Th transdermal patch (ls clld  rsdrml dsk) prvds fr h crlld rls f  prscrbd mdc (.g., rglycr, cld, srg, c, scplm, fyl) hrgh  smprmbl mmbr fr svrl hrs  3 wks wh ppld  c sk. Th ds rlsd dpds  h srfc r f h pch  cc wh h sk srfc d h dvdl drg. S spcc drg mgrphs fr h s d dr f c f drgs h s hs dlvry sysm. Prfrm prmdc ssssm; s dvdl drg mgrphs fr dls. equiPment • Cl glvs • Trsdrml pch • Clppg qpm s pprpr fr h s d h p’s sk cd • MAR d mdc prl sites Ay r wh hr my b sd. Ms ppl prfr h chs, k, r ppr rm. Dvlp  r schdl fr s f h pch (s Fg. 7.3 fr  xmpl f  rglycr r schdl). S mfcrr’s rcmmds fr lc d frqcy f pplc f pchs hr h rglycr. teChnique 1. Fllw h prcdr prcl dscrbd rlr. 2. Lbl h pch wh h d, h m, d h rs’s ls. If h dsg f h mdc s 

6. 7.

89

prd  h pch ppld,  s sfl  cld h dsg s pr f h lblg prcss. Apply cl glvs. Ps h p s h h srfc  whch h pcl mrls r  b ppld s xpsd. Prvd fr h p’s cmfr. (Note: Wh rpplyg  rsdrml pch, rmv h ld pch d cls h sk hrghly. Slc  w s fr pplc. I s spclly mpr  h ldr dl r h cfsd p  lk fr h ld pch f  s  whr h prr pplc s chrd. Th cfsd p my hv mvd  lswhr  h bdy r rmvd . Th ld pch c b csd  h glv s h rs rmvs ; hs shld h b dspsd f ccrdg  sl plcy.) Apply h smll dhsv pcl pch. Fg. 7.5 llsrs rglycr bg ppld   f h ss rcmmdd by h r schdl. Th frqcy f pplc dpds  h spcc mdc bg ppld v h rsdrml pch d h dr f c f h prscrbd mdc. Nrglycr s ppld c dly, whrs fyl s rppld vry 3 dys; cld d hyl srdl/rlgsrm (Orh Evr) r rppld c vry 7 dys. Hrm rplcm hrps my b ppld vry 4  7 dys. Rmv glvs d dsps f hm  ccrdc wh sl plcy. Prfrm hd hyg.

Patient teaChing 1. Tch h p hw d wh  pply h pchs. Note: Cr prdcs my b wr whl shwrg; hrs shld b rplcd fr bhg r shwrg. Rfr  h p dc srcs fr spcc pplc drcs. Scplm, whch s sd fr m sckss, ms b ppld  ls 4 hrs bfr rvl; cld rsdrml sysms r ppld c vry 7 dys. Orh Evr s  crcpv pch h s rppld wkly fr 3 wks, wh h frh wk bg pch fr;  w pch s h rs  hr cycl f hr pchs srs h fllwg wk. 2. If  pch bcms prlly dsldgd, h rcmmds fr h prdc shld b fllwd. (If  pch s prlly dsldgd r rmvd, rplc  wh  w pch, rg  s f  wr h ld , rmvg   h prvsly schdld m). Alrvly, cld rsdrml pchs cm wh  prcv dhsv vrly  b ppld vr h pch  sr sk cc wh h rsdrml sysm f h pch bcms lsd. S Chpr 40 fr frhr frm b h Orh Evr pch. 3. Ps wh r rcvg rglycr rsdrmlly my rqr sblgl rglycr fr gl cks, spclly whl h ds s bg

90

UNIT II Illustrated Atlas of Medication Administration

djsd. I grl, rglycr pchs r wr fr 10  14 hrs; hs s fllwd by  drg-fr prd f 10  12 hrs s h h rglycr wll m s ffcvss. 4. Fyl (Drgsc) my k p  12 hrs fr pplc  b ffcv fr h mgm f sbl, chrc p. Thrfr  shld b cmbd wh  shr-cg p mdc l  sfc bld lvl f h fyl s chvd. Fyl pchs r chgd vry 3 dys. Brkhrgh p shld b prmply rprd  h hlhcr prvdr. I my b cssry  crs h dsg  chv  ssfcry lvl f p rlf. DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  h drg hrpy. 1. Chr h d, m, drg m, dsg, r f dmsr, d lc f pch. 2. Prfrm d rcrd rglr p ssssms fr h vl f hrpc ffcvss (.g., bld prssr, pls, dgr d dr f p rlf   scl f 0  10). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc rgrdg h drg hrpy.

AdministrAtion of medicAtions to mucous membrAnes Drgs r wll bsrbd crss mcsl srfcs, d hrpc ffcs r sly bd. Hwvr, mcs mmbrs r hghly slcv wh rgrd  bsrpv cvy, d hy dffr  ssvy. I grl, qs sls r qckly bsrbd frm mcs mmbrs, whrs ly lqds r . Drgs  sppsry frm c b sd fr lcl r sysmc ffcs  h mcs mmbrs f h vg, h rhr, r h rcm. A drg my b hld d bsrbd hrgh h mcs mmbrs f h s d lgs. I my b dsslvd d bsrbd by h mcs mmbrs f h mh r ppld  h ys r rs fr lcl c. I my b pd, swbbd, r rrgd   mcsl srfc.

h sscd rpd bsrp d s f c: h drg psss drcly  h sysmc crcl, wh  mmd pss hrgh  h lvr, whr xsv mblsm slly ks plc. As ppsd  ms hr frms f dmsr  h mcs mmbrs, h c frm hs ds frms s slly sysmc rhr h lclzd  h mh. Prfrm prmdc ssssm; s dvdl drg mgrphs fr dls. equiPment • Prscrbd mdc (Note: Th mdcs vlbl  b dmsrd by hs r r frms f rglycr. Afr h slf-dmsr chq s gh, h p shld crry h mdc r kp  rdly vlbl  h bdsd fr s s dd.) • MAR d mdc prl site Admsr  h sblgl r (.., dr h g; Fg. 7.6A) r h bccl pch (.., bw h lwr mlr h d h chk; Fg. 7.6B). teChnique 1. Fllw h prcdr prcl dscrbd rlr. 2. P   cl glv, d plc h mdc dr h p’s g (.., sblgl; s Fg. 7.6A) r bw h p’s lwr mlr h d hr chk (.., bccl; s Fg. 7.6B). If h mcs mmbrs r dry ffr  sp f wr bfr dmsr. Th bl s m  dsslv  hs lcs. Ecrg h p  llw h drg  dsslv whr plcd d  hld slv  h mh l h bl s dsslvd. Do not ffr wr fr dmsr. 3. Rmv h glv d dsps f   ccrdc wh sl plcy. 4. Prfrm hd hyg. Patient teaChing Expl h xc plcm f h mdc, h dsg, d h frqcy f dss. Th p shld b frmd f dvrs ffcs, whr  crry h mdc, hw  sr h mdc, h mdc’s xpr d, d hw  rll h prscrp wh dd.

AdministrAtion of subLinguAL And buCCAL tAbLets Dose Forms Sblgl bls r dsgd  b plcd dr h g fr dssl d bsrp hrgh h vs wrk f bld vssls  hs r. Bccl bls r dsgd  b hld  h buccal cvy (.., bw h chk d h lwr mlr h) fr bsrp frm h bld vssls f h chk. Th prmry dvgs f hs rs f dmsr r

A

B

Fig. 7.6 Placing medication in the mouth. (A) Under the tongue (sublingual). (B) In the buccal pouch.

Percutaneous Administration CHAPTER 7

DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  drg hrpy. 1. Chr h d, m, drg m, ds, s, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f hrpc ffcvss (.g., bld prssr, pls, dgr d dr f p rlf, mbr f dss k). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy. Note: Wh h p s slf-dmsrg  mdc, h rs s sll rspsbl fr ll spcs f h chrg d mrg prmrs  dcm h drg hrpy d h rsps chvd.

AdministrAtion of eyedroPs And ointment Dose Form Mdcs fr s  h y r lbld ophthalmic If  drg s  lbld s sch,  shld  b dmsrd  h y. Ophhlmc sls r srl d sly dmsrd, d hy slly d  rfr wh vs wh hy r slld. Allw y mdc  wrm  rm mprr bfr dmsr. Ophhlmc ms d cs lrs  vsl cy. Hwvr, hy hv  lgr dr f c h sls. Alwys s  spr bl r b f y mdc fr ch p. Prfrm prmdc ssssm; s dvdl drg mgrphs fr dls. equiPment • Cl glvs • Eydrps, m prscrbd (chck srgh crflly) • Drppr (s ly h drppr sppld by h mfcrr) • Tsss r srl y drssg (pd), s pprpr • Nrml sl sl, f dd, fr clg ff xds • MAR d mdc prl

4. 5.

6. 7.

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my b cssry f h chld s  yg  cpr vlrly. Alwys sr p sfy. Apply cl glvs. Ispc h ffcd y  drm h crr ss. As pprpr, rmv xd frm h yld d ylshs wh h s f srl sl sl. A cl wshclh my b sd, wh  spr pr f h clh sd fr ch y. Sr  h r chs d wp wrd. Exps h lwr cjcvl sc by pplyg gl rc  h lwr ld  h by rm f h rb. Apprch h y frm blw wh h mdc drppr r b f m. (Nvr ch h ydrppr r m p  h y r h fc.)

ill Dp  • Hv h p lk pwrd vr yr hd (Fg. 7.7).  • Drp h spcd mbr f drps  h cjcvl sc. Nvr drp h mdc drcly  h ybll.  • Afr sllg h drps, pply gl prssr sg  cl ss  h r chs f h yld gs h b fr pprxmly 1  2 ms. Ths prvs h mdc frm rg h cl, whr  wld b bsrbd  h vsclr mcs f h s d prdc sysmc ffcs. I ls srs  dq ccr f mdc  h y.  • Wh mr h  yp f ydrp s rdrd fr h sm y, w 1  5 ms bw h sll f h dffr mdcs. Us ly h drppr prvdd by h mfcrr. Apply  srl drssg s rdrd. apply o  • Gly sqz h m   srp fsh  h cjcvl sc (s Fg. 7.7), frm h r chs  h r chs. Do not llw h p f h mdc dspsr  ch h p.

site Ey(s) teChnique 1. Fllw h prcdr prcl dscrbd rlr. 2. Assmbl h phhlmc mdc d qpm. Esr h h mdc s lbld fr “Ophhlmc” r “Ey” s. 3. Ps h p s h h bck f hr hd s rmly spprd   pllw d s hr fc s drcd wrd h clg. Wh  chld, rsrs

Fig. 7.7 Administering ophthalmic ointment. To instill the ointment, gently pull the lower lid down as the patient looks upward. Squeeze the ophthalmic ointment into the lower sac. Avoid touching the tube to the eyelid.

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UNIT II Illustrated Atlas of Medication Administration

 • Tll h p  cls h ys gly d  mv h ys wh h lds sh, s f lkg rd h rm,  sprd h mdc. 8. A h ccls f hr prcdr, rmv glvs d dsps f hm  ccrdc wh sl plcy. 9. Prfrm hd hyg. Patient teaChing 1. Tch h p hw  pply hr w phhlmc mdc. 2. Tll h p  wp h ys gly frm h s wrd  prv cm bw h ys, s wll s h pssbl sprd f fc, d  s  spr ss  wp ch y. 3. Hv h p wsh hr hds f d vd chg h ys r h mmd srrdg rs, spclly wh  fc s prs. Dsps f sss   mr h prvs h sprd f fc. 4. Srss pcly wh rgrd  h dmsr f y mdcs, spclly wh h mdcs r bg sd  r fcs r crsd rclr prssr. 5. Tll h p  dscrd y mdcs h hv chgd clr r bcm cldy r h c prcls. (If h p’s vsl cy s rdcd, sm ls shld chck h mdcs fr clry.) 6. Th p ms  s vr-h-cr ywshs wh rs cslg h hlhcr prvdr wh s mgg h y dsrdr. 7. Emphsz h d fr h crfl fllw-p xm f y y dsrdr l h hlhcr prvdr rlss h p frm frhr cr. DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  drg hrpy. 1. Chr h d, m, drg m, dsg, s, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f hrpc ffcvss (.g., rdss, dscmfr, vsl cy, chgs  fc r mmry rc, dgr d dr f p rlf). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy.

AdministrAtion of eArdroPs Dose Form Erdrps r  sl h cs  mdc h s sd fr h rm f lclzd fc r mm f h r. Mdcs fr s  h r r

lbld otic. If  drg s  lbld s sch,  shld  b dmsrd  h r. Erdrps shld b wrmd  rm mprr bfr s, d  spr bl f rdrps shld b sd fr ch p. Prfrm prmdc ssssm; s dvdl drg mgrphs fr dls. equiPment • Cl glvs • Oc sl prscrbd; sr h  s lbld fr s • Drppr prvdd by h mfcrr • MAR d mdc prl site Er(s) teChnique 1. Fllw h prcdr prcl dscrbd rlr. 2. Assmbl h c mdc d drppr. Esr h h mdc s lbld fr “Oc” r “Er” s. Allw h mdc  wrm  rm mprr. 2. Ps h p s h h ffcd r s drcd pwrd. 3. Rvw h plcy f h prcc sg d fllw gdls rgrdg whhr glvs r  b wr drg h sll f r mdcs. Apply cl glvs  ccrdc wh sl plcy. 4. Assss h r cl fr wx ccml. If wx s prs, b  rdr  rrg h cl bfr sllg h rdrps. 5. Shk h mdc wll d h drw  p  h drppr. 6. Admsr h mdc.  • Fr chldr wh r lss h 3 yrs ld, rsr h chld, r h chld’s hd  h pprpr sd, d h gly pll h lwr rlb downward d back (Fg. 7.8A)  srgh h xrl dry cl. Isll h prscrbd mbr f drps  h cl. D  llw h drppr p  ch y pr f h r. Afr dmsr, prss gly  h rgs  hlp dsprs h mdc.  • Fr chldr wh r mr h 3 yrs ld d fr dls, ls cpr r rsr s cssry. Tr h hd  h pprpr sd, d h gly pll h ppr rlb vertically d back (Fg. 7.8B)  srgh h xrl dry cl. Isll h prscrbd mbr f drps  h cl. D  llw h drppr p  ch y pr f h r. Afr dmsr, prss gly  h rgs  hlp dsprs h mdc. 7. Isrc h p  rm  hr sd fr  fw ms fr sll; sr  c plg loosely, f rdrd.

Percutaneous Administration CHAPTER 7

A

93

B

Fig. 7.8 Administering eardrops. (A) Pull the lower earlobe downward and back for children who are less than 3 years old. (B) Pull the upper earlobe upward and back for patients who are more than 3 years old.

8. If rdrps r rdrd fr bh rs, llw 5  10 ms bw dmsrs wh h r h rcvd h mdc rs rmg “p.” Th rp h prcdr  h hr r. 9. Rmv glvs d dsps f hm  ccrdc wh sl plcy. 10. Prfrm hd hyg.

Clinical Goldmine Remember, for children who are less than 3 years old, pull the lower earlobe downward and back. For adults and children who are 3 years old and older, pull the upper earlobe up and back (see Fig. 7.8).

Patient teaChing 1. Expl h mprc f dmsrg h mdc s prscrbd. 2. Tch h p slf-dmsr, r ch h dmsr chq  hr prs, s pprpr. DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  drg hrpy. 1. Chr h d, m, drg m, dsg, s, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f hrpc ffcvss (.g., rdss, prssr, dgr d dr f p rlf, clr d m f drg). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs.

4. Prfrm d vld ssl p dc b h drg hrpy.

AdministrAtion of nose droPs Nsl sls r sd  r mprry dsrdrs h ffc h sl mcs mmbrs. Alwys s h drppr prvdd by h mfcrr, d gv ch p  spr bl f s drps. Prfrm prmdc ssssm; s dvdl drg mgrphs fr dls. equiPment • Cl glvs • Ns drps prscrbd • Drppr sppld by h mfcrr • Tss  blw h s • Plgh • MAR d mdc prl site Nsrl(s) teChnique 1. Fllw h prcdr prcl dscrbd rlr. 2. Rvw sl plcy d fllw h pprpr gdls rgrdg whhr glvs r  b sd drg h sll f s drps  prv pssbl cc wh bdy d scrs. Apply cl glvs  ccrdc wh sl plcy. 3. Expl h sps  h prcdr  hlp h dvdl lr fr slf-dmsr. 4. Admsr h mdc (Fg. 7.9).

UNIT II Illustrated Atlas of Medication Administration

94

A

B

C

Fig. 7.9 Administering nose drops. (A) Have the patient gently blow the nose. (B) Open the medication bottle and draw the medication up to the calibration mark on the dropper. (C) Instill the medication. Have the patient remain in this position for 2 to 3 minutes. Repeat in the other nostril, if necessary.

F adl d old Cld  • Isrc h p  blw h s gly lss hs s crdcd (.g., sblds, rsk f crsd rcrl prssr). Us  plgh  ssss h rs.  • Hv h p lie down and hang the head backward vr h dg f h bd r vr  pllw plcd dr h shldrs.  • Drw h mdc  h drppr. Hld h drppr js bv h srl, d sll h mdc.  • Afr  brf m, rp h dmsr prcss  h scd srl, f dd.  • Hv h p rm  hs ps fr 2  3 ms  llw h drps  rm  cc wh h sl mcs.

DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  drg hrpy. 1. Chr h d, m, drg m, dsg, s, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f h hrpc ffcvss (.g., sl cgs, dgr d dr f rlf chvd, mprvm  vrll ss), d rssss h cd f h rs prdclly. 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy.

F if d Y Cld  • Ps h f r smll chld wh h hd vr h dg f  bd r pllw, r s h “fbll” hld  mmblz h f.  • Admsr s drps  h sm mr s s sd fr  dl.  • Fr  chld wh s cprv, ffr prs. Prvd pprpr cmfrg d prsl cc fr ll chldr d fs.  • Hv ppr sss vlbl fr s f  s bslly cssry fr h p  blw hr s. 5. Rmv glvs d dsps f hm  ccrdc wh sl plcy. 6. Prfrm hd hyg.

AdministrAtion of nAsAL sPrAy

Patient teaChing Tch h p b h slf-dmsr f s drps, f cssry. Tll h p h h vrs f s drps c cs  rbd ffc, whch css sympms  bcm wrs. If sympms hv  rslvd fr  wk f sl drp hrpy, h hlhcr prvdr shld b csld g.

Th mcs mmbrs f h s bsrb qs sls vry wll. Wh ppld s  spry, h smll drpls f  sl h cs mdc c h mmbrs d r rpdly bsrbd. Th dvg f spry vr drps s h hr s lss ws f mdc bcs sm f h drps f r dw h bck f h p’s hr bfr bsrp c k plc. Ech p shld hv  prsl cr f spry. Prfrm prmdc ssssm; s dvdl drg mgrphs fr dls. equiPment • Cl glvs • Nsl spry prscrbd • Ppr sss  blw h s • Plgh • MAR d mdc prl site Nsrl(s)

Percutaneous Administration CHAPTER 7

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Fig. 7.10 Administering nasal spray. (A) Have the patient gently blow the nose. (B) Block one nostril; shake the medication bottle. Insert the tip of the bottle into the patient’s nostril and squeeze a puff of spray while the patient inhales through the open nostril. (C) Repeat procedure on other nostril.

teChnique 1. Fllw h prcdr prcl dscrbd rlr. 2. Rvw sl plcy d fllw h pprpr gdls rgrdg whhr glvs r  b sd drg h sll f sl sprys. Apply cl glvs  ccrdc wh sl plcy. 3. Isrc h p  gly blw h s (Fg. 7.10A), lss hs s crdcd (.g., sblds, rsk f crsd rcrl prssr). 4. Hv h p ssm h upright sitting position. Us  plgh  spc h rs. 5. Blck  srl. 6. Shk h spry bl whl hldg  prgh. 7. Immdly fr shkg h bl, sr h p  h srl (Fg. 7.10B). Ask h p  hl hrgh h p srl, d sqz  pff f spry  h srl  h sm m. 8. Rp h dmsr prcss  h scd srl, f dd (Fg. 7.10C). 9. Hv ppr sss vlbl fr s f  s bslly cssry fr h p  blw hr s fr s f h sl spry. 10. Rmv glvs d dsps f hm  ccrdc wh sl plcy. 11. Prfrm hd hyg. Patient teaChing Tch h p h slf-dmsr f sl spry, f cssry. Tll h p h h vrs f sl spry c cs  rbd ffc, whch css h sympms  bcm wrs. If sympms hv  rslvd fr  wk f sl spry hrpy, h hlhcr prvdr shld b csld g. DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  drg hrpy. 1. Chr h d, m, drg m, dsg, s, d r f dmsr.

2. Prfrm d rcrd rglr p ssssms fr h vl f hrpc ffcvss (.g., sl cgs, dgr d dr f rlf chvd, mprvm  vrll ss). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy.

AdministrAtion of mediCAtions by inhALAtion Th rsprry mcs my b mdcd v h hl f sprys r rsls. Aerosols s  w f r r xyg dr prssr  dsprs h drg hrgh h rsprry rc. Oly prprs shld  b ppld  h rsprry mcs, bcs h l drpls my b crrd  h lgs d cs lpd pm. Isl prcls shld rc crr sdrds f vrsl prcs  prv f rsmss f rbr phgs fr ll ps d hlhcr prsl. Fllw hs prcdrs fhflly  prv h rsmss f dss. Ths mdcs r dlvrd wh h s f  blzr (Fg. 7.11). Prfrm prmdc ssssm; s spcc drg mgrphs fr dls. Assss h p’s bly  mpl h blzr. equiPment • Cl glvs • Lqd rsl r spry frms f mdcs • MAR d mdc prl site Rsprry rc teChnique 1. Fllw h prcdr prcl dscrbd rlr.

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UNIT II Illustrated Atlas of Medication Administration

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Fig. 7.12 (A) Metered-dose inhaler (MDI). (B) Dry powder inhaler (DPI).

Fig. 7.11 Example of a nebulizer.

2. Rvw sl plcy d fllw h pprpr gdls rgrdg whhr glvs r  b sd drg h dmsr f mdc by hl. Apply cl glvs  ccrdc wh sl plcy. 3. Hv h p ssm  sg ps. Ths llws fr mxmm lg xps. 4. Prpr h mdc ccrdg  h prscrbd drcs, d ll h blzr wh dl. (Ths my b d bfr sg h p p f m s  fcr fr h p’s wll-bg.) 5. Acv h blzr wh cmprssd xyg r r l   ms s wg; hs wll slly k p  8  10 lrs f xyg r r. 6. Plc blzr msk vr p’s s d mh d sk p  brh rmlly. 7. Allw gh m fr ll h mdc  h blzr  b dmsrd; hs shld k pprxmly 10 ms. 8. Assss h p whl sll sg  drm ffcvss. 9. Cl h qpm  ccrdc wh h mfcrr’s drcs. 10. Rmv glvs d dsps f hm  ccrdc wh sl plcy. 11. Prfrm hd hyg. Patient teaChing 1. As pprpr  h crcmscs, ch h p,  fmly mmbr, r  sgc hr hw  pr h blzr h s  b sd  hm. 2. Expl h pr d clsg f h qpm. 3. Bfr h p s dschrgd, hv h p,  fmly mmbr, r  sgc hr dmsr

sg h qpm crrcly d vrblz h mdcs h hv b prscrbd fr -hm s. 4. Srss h d  prfrm h prcdr xcly s prscrbd d  rpr y dfcls h r xprcd fr dschrg fr h hlhcr prvdr’s vl. DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  drg hrpy. 1. Chr h d, m, drg m, dsg, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f hrpc ffcvss (.g., bld prssr, pls, mprvm r qly f brhg, cgh d prdcvy, lg sds, dgr d dr f p rlf, bly  pr h blzr, cvy d xrcs rsrcs). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy.

AdministrAtion of mediCAtions by orAL inhALAtion Dose Forms Brchdlrs d crcsrds my b dmsrd by hl hrgh h mh wh h s f  rslzd, prssrzd metered-dose inhaler (MDI) r  dry powder inhaler (DPI) (Fg. 7.12). Th dvgs f h hlrs r h h mdcs c b ppld drcly  h s f c (h brchl smh mscl), smllr dss r sd, d h drg s rpdly bsrbd. Th vlv f h prssrzd cr (.., h MDI) r h dry pwdr pck f h DPI ls hlps  sr h h sm ds f mdc s dmsrd wh ch hl. Apprxmly 25% f ps d  s MDIs prprly d hrfr d  rcv h mxml b f h mdc. Dvcs kw s extenders

Percutaneous Administration CHAPTER 7

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r spacers (Fg. 7.13) hv b dsgd fr ps wh c crd h rls f h mdc wh hl. Th xdr dvcs c b dpd  ms prssrzd csrs f MDIs. Ths dvcs rp h rslzd mdc   chmbr hrgh whch h p hls wh  fw scds fr rlsg h mdc  h chmbr. Prfrm prmdc ssssm; s dvdl drg mgrphs fr dls. equiPment • Cl glvs • Prscrbd mdc pckgd   MDI r DPI • MAR d mdc prl site Rsprry rc teChnique alzd md-D il 1. Fllw h prcdr prcl dscrbd rlr. 2. Rvw sl plcy d fllw h pprpr gdls rgrdg whhr glvs r  b sd drg h dmsr f mdc by rl hl. Apply cl glvs  ccrdc wh s plcy. 3. Th fllwg prcpls pply  ll MDIs. Rd d dp hs chqs  h drcs prvdd by h mfcrr fr  spcc hlr d xdr, f dd.  • If h mdc s  ssps, shk h csr. Ths dsprss d mxs h cv brchdlr d prpll.  • Hv h p p hr mh d h plc h csr l 2  4 chs  fr f h mh. Ths spc llws h prpll  vpr d prvs lrg prcls frm slg  h mh. Wh sg  xdr, hv h p plc  d f h xdr  h mh d cls h lps rd . Ach h hr d f h xdr  h hlr dvc.  • Acv h MDI, d src h p  hl dply vr 10 scds  sr h rwys r p d h h drg s dsprsd s dply s pssbl.  • Hv h p hld hr brh d h xhl slwly  prm h drg  sl  plmry ss.  • If prscrbd, rp  2  3 ms. Usg smll dss wh w r hr hls hlps h drg dsprs  h smllr prphrl rwys fr  lgr hrpc ffc.  • If h hld mdc s  crcsrd, hv h p rs h mh wh wr wh dmsr s cmpl. 4. Cls h pprs ccrdg  h mfcrr’s rcmmds.

Fig. 7.13 Metered-dose inhaler with an extender or spacer. (From Lilley LL, Collins SR, Snyder JS. Pharmacology and the Nursing Process. 7th ed. St. Louis: Mosby; 2014.)

5. Rmv glvs d dsps f hm  ccrdc wh sl plcy. 6. Prfrm hd hyg. Dy Pwd il 1. Fllw h prcdr prcl dscrbd rlr. 2. Rvw sl plcy d fllw h pprpr gdls rgrdg whhr glvs r  b sd drg h dmsr f mdc by rl hl. Apply cl glvs  ccrdc wh sl plcy. 3. Th fllwg prcpls pply  ll DPIs. Rd d dp hs chqs  h drcs prvdd by h mfcrr fr  spcc hlr d xdr, f dd.  • Rmv h cvr, d chck h h dvc d h mhpc r cl.  • Mk h mdc vlbl ccrdg  h mfcrr’s srcs fr ch spcc prdc. Kp h hlr hrzl.  • Hv h p brh , wy frm h dvc.  • Plc h mhpc gly  h p’s mh, d hv h p cls h lps rd .  • Hv h p brh  qckly, frcflly, d dply l  fll brh hs b k.  • Rmv h hlr frm h p’s mh.  • Hv h p hld h brh fr b 10 scds bfr brhg .  • Alwys chck h mbr  h ds cr wdw  s hw my dss rm.  • If h p drps h hlr r brhs   fr h ds hs b ldd, h ds my b ls. T sr prpr dsg, ld hr ds  h hlr bfr sg . 4. Cl h dvc ccrdg  h mfcrr’s srcs. 5. Rmv glvs d dsps f hm  ccrdc wh sl plcy. 6. Prfrm hd hyg.

98

UNIT II Illustrated Atlas of Medication Administration

Health Promotion Relling the Prescription The patient should not wait until the canister is empty before having the prescription relled. The last few doses in a canister are often subtherapeutic because of an imbalance in the remaining amounts of medication and propellant. Consult the manufacturer’s information on how to determine whether the canister is almost empty. The commonly used oat test is inaccurate for many aerosolized MDIs.

Patient teaChing Expl h prcdr, d llw h p  dmsr h chq. Tchg ds fr MDIs d DPIs wh cv grds r vlbl frm h phrmcy dprm  crg ps  prcc h chq bfr mdc dmsr. I dd  chq, h p shld b frmd b dvrs ffcs, hw  crry h mdc, hw  sr , d hw  hv  rlld wh dd. Hv h p prfrm h slf-dmsr f h prscrbd m f rdrd mdc. Hv h p dmsr h bly  rd h csr cr  drm h m f mdc rmg  h cr. DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  drg hrpy. 1. Chr h d, m, drg m, ds, s, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f hrpc ffcvss (.g., bld prssr, pls, mprvm f qly f brhg, cgh d prdcvy, dgr d dr f p rlf, bly  pr h MDI r DPI, cvy d xrcs rsrcs). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy.

Life Span Considerations Medicines Administered by Inhalation When muscle coordination is not fully developed (e.g., in a younger child or when dexterity has diminished in an older adult patient), it may be benecial to use an extender or spacer device (see Fig. 7.13) for medicines that are administered by aerosol inhalation. When administering medicines by aerosol therapy to an older adult, make sure that the patient has the strength and dexterity to self-operate the equipment before discharge.

AdministrAtion of vAginAL mediCAtions Wm wh gyclgc dsrdrs my rqr h dmsr f  mdc rvglly.

Vgl mdcs my b crms, jlls, bls, fms, sppsrs, r rrgs (.., dchs; s Admsr f  Vgl Dch lr). Th crms, jlls, bls, d fms r srd wh h s f spcl pplcrs h r prvdd by h mfcrr; sppsrs r slly srd wh  glvd dx gr. Prfrm prmdc ssssm; s dvdl drg mgrphs fr dls. equiPment • Prscrbd mdc • Vgl pplcr • Prl pd • Wr-slbl lbrc (fr sppsry) • Cl glvs • Ppr wls • MAR d mdc prl site Vg teChnique 1. Fllw h prcdr prcl dscrbd rlr. 2. Hv h p vd  sr h h blddr s mpy. 3. Apply cl glvs. 4. Fll h pplcr wh h prscrbd bl, jlly, crm, r fm. 5. Plc h p  h lhmy ps, d lv hr hps wh  pllw. Drp h p  prv cssry xpsr. 6. Admsr h mdc.  • For tablets, creams, foams, and jellies, s h glvd dm hd  sprd h lb d xps h vg. Assss h ss f h prsg sympms (.g., clr d vlm f dschrg, dr, lvl f dscmfr). Lbrc h pplcr. Gly sr h vgl pplcr s fr s pssbl  h vg, d psh h plgr  dps h mdc (Fg. 7.14). Rmv h pplcr, d wrp    ppr wl fr clg lr.  • For suppositories, wrp  vgl sppsry h hs b wrmd  rm mprr, d lbrc  wh  wr-slbl lbrc. Lbrc h glvd dx gr f h dm hd. Wh h glvd dm hd, sprd h lb  xps h vg. Isr h sppsry (rdd d rs) s fr  h vg s pssbl wh h dm dx gr. 7. Rmv h glv by rg  sd ; plc    ppr wl fr lr dspsl. 8. Apply  prl pd  prv drg  h p’s clhg r bd. 9. Isrc h p  rm   sp ps wh h hps lvd fr 5  10 ms  llw fr h mlg d sprdg f h mdc.

Percutaneous Administration CHAPTER 7

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AdministrAtion of A vAginAL douChe Dchs (.., rrgs) r sd  wsh h vg. Ths prcdr s  cssry fr rml fml hyg, b  my b rqrd f  vgl fc d dschrg r prs. I shld ls b d h dchg s   ffcv mhd f brh crl. Prfrm prmdc ssssm; s dvdl drg mgrphs fr dls. equiPment • IV pl • Cl glvs • Wr-slbl lbrc • Dch bg wh bg d zzl • Dch sl • MAR d mdc prl site Vg Fig. 7.14 Applying vaginal medication. Gently insert the vaginal applicator as far as possible into the vagina, and then push the plunger to deposit the medication.

10. Dsps f ll ws  ccrdc wh sl plcy. 11. Prfrm hd hyg. Patient teaChing 1. Tch h p hw  dmsr h mdc crrcly. 2. Th pplcr shld b wshd  wrm spy wr after each use. 3. Rvw prsl hyg msrs sch s wpg frm h fr  h bck fr vdg r dfcg. 4. Tll h p   dch d  bs frm sxl rcrs fr srg h mdc. 5. Wh ms yps f fcs, bh ml d fml prrs rqr rm. T prv rfc, ps shld bs frm sxl rcrs l ll prrs r crd. DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  drg hrpy. 1. Chr h d, m, drg m, dsg, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f h hrpc ffcvss (.g., yp f dschrg prs, rr f lb, dscmfr, dgr d dr f p rlf). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy.

teChnique 1. Fllw h prcdr prcl dscrbd rlr. 2. Ask h p  vd bfr h prcdr. 3. If h rs s chg hs prcdr   p fr hm s, h p wld csmrly rcl   bhb. Dpdg  h p’s cd  h hspl, hs  cld ccr. Hwvr,  my b cssry  plc h p   bdp d drp fr prvcy. 4. Fll h dch bg wh dch sl d hg h dch bg   IV pl,   lvl b 12 chs bv h vg. Apply cl glvs. Apply wr-slbl lbrc   plsc vgl p. 5. Cls h vlv by llwg  smll m f sl  w vr h vlv d bw h lb. 6. Gly sr h zzl  h vg, drcg h p bckwrd d dwwrd 2  3 chs. 7. Hld h lb ghr  fcl llg h vg wh sl. R h zzl prdclly  hlp rrg ll prs f h vg. 8. Irmly rls h lb, llwg h sl  w . 9. Wh ll f h sl hs b sd, rmv h zzl. Hv h p s p d l frwrd  mpy h vg hrghly. 10. P h xrl r dry. 11. Cl ll qpm wh wrm spy wr after every use; rs h qpm wh clr wr, d llw   dry. 12. Thrghly cl d dsfc h bhb, f sd. 13. Rmv glvs d dsps f hm  ccrdc wh sl plcy. 14. Prfrm hd hyg. Patient teaChing 1. Tch h p hw  dmsr h dch crrcly.

100

UNIT II Illustrated Atlas of Medication Administration

2. Expl h h bg d bg shld b wshd  wrm spy wr fr ch s s h hy d  bcm  src f rfc. 3. Rvw prsl hyg msrs, sch s wpg frm h fr  h bck fr vdg r dfcg. 4. Expl h dchg s  rcmmdd drg prgcy. 5. Wh ms yps f fcs, bh ml d fml prrs rqr rm. T prv rfc, ps shld bs frm sxl rcrs l ll prrs r crd. DoCumentation Prvd h rgh dcm f h mdc dmsr d h p’s rspss  drg hrpy.

1. Chr h d, m, drg m, dsg, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f hrpc ffcvss (.g., yp f dschrg prs, rr f lb, dscmfr, dgr d dr f p rlf). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy.

Percutaneous Administration CHAPTER 7

101

Clcl Jd d nx-g nclx® ex-syl q K P • Topical forms of medication include creams, lotions, ointments, and powders and may require the use of sponges, cotton-tipped applicators, or a tongue blade to apply. • Patch testing is performed to determine the presence of allergy. Allergens are applied to the skin using a patch test kit, and results are read 24 to 72 hours later. • Nitroglycerin ointment is applied using specic dosemeasuring ointment paper, covered with plastic, and taped in place. Patient education includes proper application technique and timing of the nitroglycerin ointment. • Patient education involving the transdermal patch medications includes discussing rotating the site of application and emphasizing the timing of the medication. • Medications administered via the mucous membranes include sublingual and buccal tablets; eyedrops, eardrops, and nose drops; inhaled medications; and vaginal medications. • Eardrops administered to a patient younger than 3 years old require the lower earlobe to be pulled down and back, compared with patients 3 years and older, where the upper earlobe is pulled upward and back. • Patient education necessary for inhaled medications includes demonstrating the proper use of the equipment, including nebulizers, MDIs, and DPIs. • Vaginal medications come in the form of creams, foams, and jellies that are applied using an applicator.

Aal La rc

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Willihng anz) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types. 1. The nurse was preparing to administer topical forms of medications and reviewed the various types of topical forms.

ojc: Identify the equipment needed and the techniques used to apply each of the topical forms of medications to the skin. ngn  : Matrix C kll: Recognize cues 2. When performing a patch test for allergens, the nurse will follow the correct procedure. Place in order the proper steps to use when performing a patch test: 1. Have emergency equipment available in case of an anaphylactic response. 2. Apply the designated patches to the skin. 3. Recognize when a wheal has formed. 4. Cleanse the area for testing with alcohol. 5. Ask the patient if they have taken any antihistamines or antiinammatory agents. ojc: Describe the purpose of and the procedure used for performing patch testing. nCLeX  : Ordering C kll: Application 3. The nurse assesses the patient for the treatment effectiveness of the percutaneous medication nitroglycerin and documents which assessment ndings? (Select all that apply.) 1. 2. 3. 4. 5.

Temperature Blood pressure Urine output Location of patch Anginal pain relief

ojc: Identify the equipment needed, the sites and techniques used, and the patient education required when nitroglycerin ointment is prescribed. nCLeX  : Multiple response C kll: Application 4. Fentanyl patches do not usually achieve a sufcient blood level for pain control until how many hours after their initial application? 1. 2. 3. 4.

6 hours 12 hours 18 hours 24 hours

ojc: Identify the equipment needed, the sites and techniques used, and the patient education required when transdermal patch medication systems are prescribed. nCLeX  : Multiple choice C kll: Knowledge

Mark an X to identify the technique and equipment used for each topical dose form.

5. A patient is to receive a medication via the buccal route. Which action does the nurse plan to implement?

gentLy smooth CAn be neCessAry over the shAKe to use ContAiner sKin when removed gLoves APPLying by wAter first

1. Place the medication inside the pouch between the patient’s lower molar and the cheek. 2. Crush the medication before administration. 3. Offer the patient a glass of water or juice after administration. 4. Use sterile technique to administer the medication.

tyPes of toPiCAL forms Creams Lotions Powders Ointments

ojc: Describe the dose forms, the sites and equipment used, and the techniques for the administration of medications to the mucous membranes. nCLeX  : Multiple choice C kll: Comprehension

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UNIT II Illustrated Atlas of Medication Administration

6. A nurse is preparing to administer eardrops to a 2-year-old child. Choose the most likely options for the information missing from the sentence below by selecting from the lists of options provided. The nurse knows that the proper technique to use for a 2-year-old child is to pull the lower earlobe ________1___________ and ________1___________ and the proper technique to use for an adult is to pull the upper earlobe ________2_______ and __________2__________.

oPtions for 1

oPtions for 2

downward forward upward inward

back up straight out

ojc: Compare the technique used to administer eardrops to patients who are less than 3 years old with that used for patients who are 3 years and older. ngn  : Cloze C kll: Recognize cues 7. The nurse teaching a patient how to use an inhaler prescribed for asthma knows that further teaching is needed after the patient makes which statement? 1. “I will hold my breath for 10 seconds before breathing out.” 2. “I will take a slow deep breath and let it out quickly.” 3. “I will check the number on the dose counter window to see how many more puffs I have left.” 4. “I will notify my primary healthcare provider if I notice that I am coughing a lot more than usual.” ojc: Describe the purpose, the precautions necessary, and the patient education required for those patients who require medications via inhalation. nCLeX  : Multiple choice C kll: Comprehension

8. When administering vaginal medications, the nurse knows the patient needs to be in which position? 1. 2. 3. 4.

Left lateral recumbent position Trendelenburg position Lithotomy position Prone position

ojc: Identify the equipment needed, the site, and the specic techniques required to administer vaginal medications or douches. nCLeX  : Multiple choice C kll: Knowledge

8

Enteral Administration

https://evolve.elsevier.com/Willihnganz

Objectives 1. Describe general principles of administering solid forms of oral medications. 2. Compare the different techniques that are used with a unit-dose distribution system and a computer-controlled dispensing system. 3. Identify general principles used for liquid-form oral medication administration.

4. Cite the equipment needed, techniques used, and precautions necessary when administering medications via gastrointestinal tubes. 5. Cite the equipment needed and the technique required when administering rectal suppositories and disposable enemas.

Key Terms gastrointestinal tubes (p. 103) capsules (KĂP-sŭlz) (p. 103) lozenges (LŎ-zĕn-jĕz) (p. 104) tablets (TĂB-lĕts) (p. 104) caplet (KĂP-lĭt) (p. 104) orally disintegrating tablet (ŌR-ăl-ē dĭs-ĬN-tĕ-grāt-ĭng) (p. 104)

elixirs (ĕ-LĬK-sŭrz) (p. 105) emulsions (ĕ-MŬL-shĕnz) (p. 105) suspensions (sŭ-SPĔN-shĕnz) (p. 105) syrups (SĬR-ĕps) (p. 105) unit-dose packaging (YŪ-nĭt DŌS PĂK-ĕj-ĭng) (p. 105) bar code (BĂR KŌD) (p. 105)

Th rus f drug adminisrain can b classid in hr cagris: nral, parnral, and prcuanus. Wih h enteral route, drugs ar adminisrd dircly in h gasrinsinal (GI) rac by h ral, rcal, r GI tube mhds. Th ral ru is saf, cnvnin, and rlaivly cnmical, and ds frms ar radily availabl fr ms mdicains. In cas f a mdicain rrr r an inninal drug vrds, much f h drug can b rrivd fr a rasnabl im afr adminisrain. Th majr disadvanag f h ral ru is ha i has h slws and las dpndabl ra f absrpin f h cmmnly usd rus f adminisrain bcaus f frqun changs in h GI nvirnmn ha ar prducd by fd, min, and physical aciviy. Anhr limiain f his ru is ha a fw drugs (.g., insulin, gnamicin) ar dsryd by digsiv uids and mus b givn parnrally fr hrapuic aciviy. Th nral ru shuld n b usd if h drug may harm r disclr h h r if h pain is vmiing, has gasric r insinal sucin, is likly  aspira, r is uncnscius and unabl  swallw. Fr pains wh cann swallw r wh hav had ral surgry, h GI ub mhd may b usd. Th primary purps f GI ubs is  bypass h muh and h pharynx. Advanags and disadvanags ar

soufé cup (sū-FLĀ KŬP) (p. 105) medicine cup (MĔD-ĭ-sĭn KŬP) (p. 105) medicine dropper (MĔD-ĭ-sĭn DRŎpŭr) (p. 106) oral syringe (ŌR-ăl sĭ-RĬNJ) (p. 106) suppository (sŭ-PŎZ-ĭ-tōr-ē) (p. 114)

similar  hs f h ral ru. Th irriain causd by h ub in h nasal passag and hra mus b wighd agains h rlaiv immbiliy assciad wih cninuus inravnus (IV) infusins, h xpns, and h pain and irriain f mulipl injcins. Fr pains wh rquir lng-rm drug and fding adminisrain, GI ubs ar usd. Th adminisrain f drugs via h rcal ru has h advanags f bypassing h digsiv nzyms and aviding irriain f h muh, sphagus, and smach. I may als b an accpabl alrnaiv whn nausa r vmiing is prsn. Absrpin via his ru varis dpnding n h drug prduc, h abiliy f h pain  rain h suppsiry r nma, and h prsnc f fcal marial.

ADMINISTRATION OF ORAL MEDICATIONS DOSE FORMS Capsules Capsules ar small, cylindrical, glain cnainrs ha hld dry pwdr r liquid mdicinal agns (Fig. 8.1). Thy ar availabl in a variy f sizs, and hy ar a cnvnin way f adminisring drugs ha hav an 103

104

UNIT II Illustrated Atlas of Medication Administration

A

B Fig. 8.1 Various sizes and numbers of gelatin capsules (actual size). (Courtesy Oscar H. Allison, Jr.) Color coat Acid-resistant coat Active ingredient

C

Fig. 8.3 (A) Scored tablet. (B) Layered tablet. (C) Enteric-coated Fig. 8.2 Timed-release capsule.

unplasan dr r as. Thy d n rquir caings r addiivs  imprv h as. Th clr and shap f h capsuls, as wll as h manufacurr’s symbl n h capsul surfac, ar mans f idnifying h prduc. Timed-release capsules and tablets. Timd-rlas r

susaind-rlas capsuls and abls prvid a gradual bu cninuus rlas f a drug bcaus h granuls in h capsul r h ingrdins f a abl disslv a diffrn ras (Fig. 8.2). Th advanag f his dlivry sysm is ha i rducs h numbr f dss adminisrd pr day, usually  vry 12 r 24 hurs.

Medication Safety Alert Timed-release capsules and tablets should not be crushed or chewed or have their contents emptied into food or liquids because this may alter the absorption rate and could result in a drug overdose or subtherapeutic activity.

Lozenges Lozenges ar a disks ha cnain a mdicinal agn in a suiably avrd bas. Th bas may b a hard sugar candy r a cmbinain f sugar wih sufcin glainus subsancs  giv i frm. Lzngs ar hld in h muh  disslv slwly, hrby rlasing h hrapuic ingrdins. Pills Pills ar an bsl ds frm ha is n lngr manufacurd bcaus f h dvlpmn f capsuls and cmprssd abls. Hwvr, h rm is sill usd  rfr  abls and capsuls. Tablets Tablets ar drid pwdrd drugs ha hav bn cmprssd in small disks. In addiin  h drug, abls cnain n r mr f h fllwing ingrdins:

tablet.

bindrs, which ar adhsiv subsancs ha allw h abl  hld ghr; disingrars, which ar subsancs ha ncurag dissluin in bdy uids; lubricans, which ar rquird fr fcin manufacuring; and llrs, which ar inr ingrdins ha mak h siz f h abl cnvnin. Tabls ar smims scrd r grvd (Fig. 8.3A); h indnain may hn b usd  divid h ds. Whn pssibl, i is bs  rqus ha h xac ds b availabl rahr han  amp  divid vn a scrd abl. Tabls can b crushd, using a variy f mhds (i.. pill crushrs, hn h pwdrd frm can b adminisrd in a sluin, if slubl, r i may b mixd wih a small amun f fd (.g., applsauc). A caplet is a abl shapd in h frm f a capsul. Many prducs ha wr prviusly sld in capsul frm hav bn rfrmulad  capls (slid dsag frms in h shap f a capsul)  prvn h abiliy  pn a capsul and cnamina h cnns f h capsul. (Auhr’s n: Sarch nlin fr h Chicag Tylnl murdrs.) Tabls can b frmd in layrs (Fig. 8.3B). This mhd allws hrwis incmpaibl mdicains  b adminisrd a h sam im. An nric-cad abl has a spcial caing ha rsiss dissluin in h acidic pH f h smach bu ha is radily disslvd in h alkalin pH f h insins (Fig. 8.3C). Enric-cad abls ar fn usd fr adminisring mdicains ha ar dsryd in an acid pH nvirnmn such as h smach. A abl ha rapidly disslvs (usually wihin scnds) whn placd n h ngu is knwn as an orally disintegrating tablet Ths ar diffrniad frm lzngs and frm sublingual and buccal abls, which ak mr han a minu  disslv. Orally disingraing abls may b usd fr hir rapid ns f acin (.g., fr h ramn f migrain hadach); fr pains wh hav difculy swallwing (.g., pains wih parkinsnism r Alzhimr disas, r afr

Enteral Administration CHAPTER 8

105

a srk); and fr hs fr whm adminisrain mus b nsurd (.g., pains wih schizphrnia, wh fn amp  avid prscribd mdicain). An xampl is h sublingual lm placd undr h ngu fr vry rapid disingrain. This dsag frm is usd  adminisr Subxn (buprnrphin plus nalxn), which is usd  manag pia addicin. Th rapid disingrain f h lm prvns rrival f h prduc fr lar sal n h sr.

Medication Safety Alert Enteric-coated tablets must not be crushed or chewed because their active ingredients will be released prematurely and destroyed in the stomach.

Fig. 8.4 Unit-dose packages. (Courtesy Chuck Dresner.)

Elixirs Elixirs ar clar liquids ha ar cmpsd f drugs ha hav bn disslvd in alchl and war. Elixirs ar usd primarily whn h drug will n disslv in war aln. Afr h drug is disslvd in h lixir, war and avring agns ar fn addd  imprv as. Th alchl cnn f lixirs is highly variabl, dpnding n h slubiliy f h drug. Many cugh mdicins and muhwashs ar lixirs cnaining alchl. Emulsions Emulsions ar disprsins f small drpls f war in il r small drpls f il in war. Th disprsin is mainaind by an mulsifying agn such as sdium lauryl sulfa, glain, r acacia. Emulsins ar usd  mask bir ass,  mak h prduc fl br (palaabl) in h muh and hra (hus imprving adhrnc), r  mak crain drugs mr slubl. Suspensions Suspensions ar liquid ds frms ha cnain slid, inslubl drug paricls disprsd in a liquid bas. All suspnsins shuld b shakn wll bfr adminisrain  nsur h hrugh mixing f h paricls. Many ral liquid anacids [calcium carbna, (Maalx), aluminum hydrxid, magnsium hydrxid, simhicn, (Mylana Classic)] and liquid anibiics [amxicillin clavulana, (Augmnin), ryhrmycin succina (EryPd)] ar suspnsins. Syrups Syrups cnain mdicinal agns ha hav bn dis-

slvd in a cncnrad sluin f sugar (usually sucrs) and war. Syrups ar paricularly ffciv fr masking h bir as f a drug. Many prparains fr pdiaric pains ar syrups bcaus childrn nd  lik h swr avrd bas. EQUIPMENT Unit Dose or Single Dose Unit-dose packaging, r singl-ds packaging, prvids a singl ds f mdicain in n packag ha is

Fig. 8.5 Most unit-dose package labels include a bar code for the electronic charting of medication administration and inventory control. (Copyright 2003, McKesson Corporation, San Francisco, CA and/or one of its subsidiaries. All rights reserved.)

rady fr dispnsing (Fig. 8.4). Th packag is labld wih bh h gnric and brand nams, h manufacurr, h l numbr, and h da f xpirain. Dpnding n h disribuin sysm, h pain’s nam may b addd  h packag by h pharmacy. Ms uni-ds packag labls includ a bar code fr adminisrain, h lcrnic charing f mdicain adminisrain, and invnry cnrl (Fig. 8.5). Soufflé Cup A soufé cup is a small papr cup ha is usd  ranspr slid mdicain frms such as capsuls and abls  h pain  prvn cnaminain by handling (Fig. 8.6). Medicine Cup A medicine cup is a plasic cnainr wih scals (mric, hushld) fr masuring liquid mdicains (Fig. 8.7). Examin h mdicin cup carfully bfr puring any mdicain  nsur ha h prpr scal is bing usd fr masurmn (Tabl 8.1). Th mdicin cup shuld b placd n a hard surfac whn masuring liquid mdicain and hn rad a y lvl. Th mdicin cup is inaccura fr masuring dss f lss han 1 aspn, alhugh i is rasnably accura fr largr vlums. A syring cmparabl  h vlum  b masurd

106

UNIT II Illustrated Atlas of Medication Administration

2.0 mL 1.5 mL

Fig. 8.6 Medicine cup (left) and soufé cup (right). (Courtesy Chuck Dresner.)

1.0 mL 0.5 mL

1 oz

2 tbs

30 mL

1/ 2

oz

1 tbs

15 mL

1/ 4

oz

1 tsp

5 mL

Fig. 8.8 Medicine dropper.

Fig. 8.7 Measuring scales on a medicine cup. Fig. 8.9 Measuring teaspoon.

Table 8.1 Commonly Used Measurement Equivalents HOUSEHOLD MEASUREMENTA 2 Tbsp

METRIC MEASUREMENT 30 mL

1 Tbsp

15 mL

2 tsp

10 mL

1 tsp

5 mL

mL, Milliliter; oz, ounce; Tbsp, tablespoon; tsp, teaspoon. a3 tsp = 1 Tbsp; 2 Tbsp = 30 mL = 1 oz.

shuld b usd fr smallr vlums. Fr vlums f lss han 1 mL, a ubrculin syring shuld b usd. Medicine Dropper Th medicine dropper may b usd  adminisr ydrps, ardrps, and, ccasinally, pdiaric mdicains (Fig. 8.8). Thr is gra variain wih rgard  h siz f h drp frmd, s i is impran  us nly h drppr supplid by h manufacurr fr a spcic liquid mdicain. Bfr drawing mdicain in a drppr, i is ncssary  bcm familiar wih h calibrains n h barrl. Afr h mdicain is drawn in h barrl, h drppr shuld n b ippd upsid dwn bcaus h mdicain will run in h bulb, hrby causing sm lss f h mdicain. Mdicains shuld n b drawn in h drppr and hn ransfrrd  anhr cnainr fr adminisrain bcaus par f h mdicain will adhr  h scnd cnainr, hus diminishing h ds dlivrd. Teaspoon Dss f ms liquid mdicains ar prscribd in rms using h aspn as h uni f masur (Fig. 8.9). Hwvr, hr is gra variain bwn h vlums masurd by varius spns in h hm. In h hspial, 1 aspn is cnvrd  5 mL (s Tabl 8.1), and his is rad n h mric scal f h mdicin cup. Fr hm us, an ral syring is rcmmndd. If his

Fig. 8.10 Plastic oral syringes. (Courtesy Chuck Dresner.)

is n availabl, a aspn ha is usd spcically fr baking may b usd as an accura masuring dvic. Oral Syringe A plasic oral syringe may b usd  masur liquid mdicains accuraly (Fig. 8.10). Varius sizs ar availabl  masur vlums frm 0.1  15 mL. N ha a ndl will n  n h ip. Nipple An infan fding nippl may b usd fr adminisring ral mdicains  infans (Fig. 8.11). (S als Gnral Principls f Liquid-Frm Oral Mdicain Adminisrain—Fr an Adul r Child lar in his chapr.)

ADMINISTRATION OF SOLID-FORM ORAL MEDICATIONS PROCEDURE PROTOCOL Th rm procedure protocol will b usd as par f h mdicain adminisrain chniqu fr h rus f adminisrain dscribd in his chapr. This rm includs h fllwing nursing inrvnins:

Enteral Administration CHAPTER 8

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• Chck prinn pain mniring paramrs (.g., apical puls, rspirary ra). 8. Hand h mdicain  h pain and allw him r hr  rad h packag labl. 9. Offr h pain a sip f war  facilia h swallwing f h mdicain. Rriv h unids packag, pn i, and plac h cnns in h pain’s hand r a mdicain cup fr placmn in h muh. 10. Prfrm hand hygin. Fig. 8.11 Nipple. (Courtesy Chuck Dresner.)

1. Assmbl h apprpria quipmn and hn prfrm hand hygin. 2. Us h seven rights f mdicain prparain and adminisrain hrughu h prcdur: righ pain, righ drug, righ indicain, righ ru, righ ds, righ im, and righ dcumnain. 3. Prvid privacy fr h pain and giv a hrugh xplanain f h prcdur and wha  xpc. 4. Prfrm a prmdicain assssmn bfr adminisring any nral mdicain. S individual drug mngraphs fr mr infrmain.

UNIT-DOSE SYSTEM Prfrm prmdicain assssmn; s individual drug mngraphs fr dails. EQUIPMENT • Mdicain car • Mdicain prl TECHNIQUE 1. Fllw h prcdur prcl dscribd arlir. 2. Rad h pain mdicain prl fr h prscribd drugs and ims f adminisrain. 3. Obain h prscribd mdicain frm h drawr in h mdicain car ha is assignd  h pain. 4. Cmpar h labl n h uni-ds packag wih h pain mdicain prl. Chck h xpirain da n all mdicain labls. 5. Chck h numbr f dss rmaining in h drawr. (If h numbr f dss rmaining is n cnsisn, invsiga.) 6. Recheck h svn righs f mdicain adminisrain agains h pain mdicain prl and h uni-ds packag as i is rmvd frm h drawr. 7. Prcd  h pain’s bdsid.  • Chck h pain’s idnicain bracl and vrify i agains h mdicain prl. Hav h pain sa hir nam and birh da r w hr idnirs.  • Carfully xplain  h pain h drugs bing givn; sa hir nams and prvid ducain abu h drugs bing adminisrd.

COMPUTER-CONTROLLED DISPENSING SYSTEM Prfrm prmdicain assssmn; s individual drug mngraphs fr dails. EQUIPMENT • Cmpur-cnrlld dispnsing sysm • Mdicain prl TECHNIQUE 1. Fllw h prcdur prcl dscribd arlir. 2. Rad h mdicain prl fr h prscribd drugs and ims f adminisrain. 3. Accss h cmpur-cnrlld dispnsing sysm using h scuriy accss cd and passwrd. 4. Slc h pain’s nam frm h lis f pains n h uni. 5. Rviw h pain’s n-scrn prl and slc h mdicains  b adminisrd a his im. 6. Chck all aspcs f h n-scrn rdr agains h mdicain prl. 7. Chck h labl n h uni-ds packag agains h pain mdicain prl. Chck h xpirain das n all mdicain labls. 8. Recheck h svn righs f mdicain adminisrain agains h pain mdicain prl and h uni-ds packag as i is rmvd frm h drawr. 9. Prcd  h pain’s bdsid.  • Chck h pain’s idnicain bracl and vrify i agains h mdicain prl. Hav h pain sa hir nam and birh da r w hr idnirs.  • Wih a cmpurizd scannr sysm, scan h pain idnificain, h bar cd n h uni-ds mdicain packag, and h nurs’s badg, r us h prcl fr h insiuin.  • Carfully xplain  h pain h drugs bing givn; sa hir nams and prvid ducain abu h drugs bing adminisrd.  • Chck prinn pain mniring paramrs (.g., apical puls, rspirary ra). 10. Hand h mdicain  h pain and allw him r hr  rad h packag labl. 11. Offr h pain a sip f war  facilia h swallwing f h mdicain. Rriv h unids packag, pn i, and plac h cnns in h

108

UNIT II Illustrated Atlas of Medication Administration

Fig. 8.12 Tablet crusher. (From Potter PA, Perry AG. Fundamentals of Nursing. 7th ed. St. Louis: Mosby; 2008.)

pain’s hand r a mdicain cup fr placmn in h muh. 12. Prfrm hand hygin.

GENERAL PRINCIPLES OF SOLID-FORM MEDICATION ADMINISTRATION 1. Allw h pain  drink a small amun f war  misn h muh s ha swallwing h mdicain is asir. 2. Hav h pain plac h mdicain wll ward h back f hir ngu. Offr apprpria assisanc. 3. Giv h pain liquid  swallw h mdicain. Encurag h pain  kp hir had frward whil swallwing. 4. Drinking a full glass f uid shuld b ncuragd  nsur ha h mdicain rachs h smach and ha i is dilud  dcras h pnial fr irriain. 5. Always rmain wih h pain whil h mdicain is akn. Do not lav h mdicain a h bdsid unlss an rdr xiss  d s (.g., mdicain such as nirglycrin may b rdrd fr h bdsid). 6. Discard h mdicain cnainr (.g., a sufé cup, a uni-ds packag). 7. If h pain has difculy swallwing and if liquid mdicains ar n an pin, us a abl-crushing dvic (Fig. 8.12). Ensur ha h mdicain is n a capsul and ha i is n a imd-rlas r nriccad prduc. Fllw h guidlins fr using h crushing dvic. Mix h crushd mdicain in a small amun f sf fd such as applsauc, ic cram, cusard, r jlly; his will hlp cunrac h bir as and cnsisncy f h mixur. DOCUMENTATION Prvid h righ dcumnain f mdicain adminisrain and f h pain’s rspnss  drug hrapy. If using an cmpur-cnrlld dispnsing sysm, h da, im, drug nam, ds, and ru f adminisrain ar aumaically chard in h

lcrnic mdicain adminisrain rcrd whn h nurs signs in, scans h pain’s idnicain bracl, and h bar-cdd uni-ds mdicain packag. 1. Char h da, im, drug nam, dsag, and ru f adminisrain. 2. Prfrm and rcrd rgular pain assssmns fr h valuain f h hrapuic ffcivnss (.g., bld prssur, puls, inak and upu, imprvmn r qualiy f cugh and prduciviy, dgr and durain f pain rlif). 3. Char and rpr any signs r sympms f advrs drug ffcs. 4. Prfrm and valida ssnial pain ducain abu h drug hrapy.

ADMINISTRATION OF LIQUID-FORM ORAL MEDICATIONS

UNIT-DOSE SYSTEM Prfrm prmdicain assssmn; s individual drug mngraphs fr dails. EQUIPMENT • Mdicain car • Mdicain prl TECHNIQUE 1. Fllw h prcdur prcl dscribd arlir. 2. Rad h pain mdicain prl fr h prscribd drugs and ims f adminisrain. 3. Obain h prscribd mdicain frm h drawr in h mdicain car ha is assignd  h pain. 4. Chck h labl n h uni-ds packag agains h pain mdicain prl. Chck h xpirain das n all mdicain labls. 5. Chck h numbr f dss rmaining in h drawr. (If h numbr f dss rmaining is n cnsisn, invsiga.) 6. Recheck h svn righs f mdicain adminisrain agains h pain mdicain prl and h uni-ds packag as i is rmvd frm h drawr. 7. Prcd  h pain’s bdsid.  • Chck h pain’s idnicain bracl and vrify i agains h mdicain prl. Hav h pain sa hir nam and birh da r w hr idnirs.  • Carfully xplain  h pain h drugs bing givn; sa hir nams and prvid ducain abu h drugs bing adminisrd.  • Chck prinn pain mniring paramrs (.g., apical puls, rspirary ra). 8. Hand h mdicain  h pain and allw him r hr  rad h packag labl.

Enteral Administration CHAPTER 8

109

mL 30 15

Meniscus

1

Fig. 8.13 Reading a meniscus. The meniscus is caused by the surface tension of the solution against the walls of the container. The surface tension causes the formation of a concave or hollowed curvature on the surface of the solution. Read the level at the lowest point of the concave curve.

9. Rriv h uni-ds packag, pn i, and plac h cnainr in h pain’s hand fr h placmn f h cnns in h pain’s muh. 10. Prfrm hand hygin. LIQUID-FORM ORAL MEDICATIONS IN MULTIDOSE CONTAINERS Sm liquid dsag frms (.g., pdiaric dsags) ar n availabl in uni-ds packaging bcaus h vlum is  small. A small mulids cnainr may b includd in h uni-ds drawr wih insrucins n masuring h ds in a mdicin cup r an ral syring. 1. Fllw h prcdur prcl dscribd arlir. 2. Rad h pain mdicain prl fr h prscribd drugs and ims f adminisrain. 3. Obain h prscribd mdicain frm h drawr in h mdicain car ha is assignd  h pain. 4. Chck h labl n h mulids cnainr agains h pain mdicain prl. Chck h xpirain das n all mdicain labls. 5. Chck h numbr f dss rmaining in h cnainr. (If h numbr f dss rmaining is n cnsisn, invsiga.) Rmv h lid frm h cnainr. Measuring With a Medicine Cup  • Hld h bl f liquid s ha h labl is in h palm f h hand; his prvns h cnns frm smaring h labl during puring.  • Examin h mdicin cup and lca h xac plac whr h masurd vlum shuld b masurd.  • Plac h mdicin cup n a hard surfac; pur h prscribd vlum a y lvl.  • Rad h vlum accuraly a h lvl f h mniscus (Fig. 8.13). Measuring With an Oral Syringe S Chapr 9 fr mr infrmain abu rading h calibrains f a syring.  • Slc a syring f a siz ha is cmparabl  h vlum  b masurd.  • Method 1: Wih a larg-br ndl aachd  h syring, draw up h prscribd vlum f

Fig. 8.14 Filling a syringe with medication directly from a bottle.

Fig. 8.15 Filling a syringe with medication directly from a medicine cup.

6. 7. 8. 9. 

mdicain (Fig. 8.14). Th ndl is n ncssary if h bl pning is larg nugh  rciv h syring.  • Method 2: Pur h amun f mdicain ndd in a mdicin cup; hn us a syring  draw up h prscribd vlum (Fig. 8.15). Rplac h lid n h cnainr. Recheck h svn righs f mdicain adminisrain agains h pain mdicain prl and h mulids cnainr as i is rmvd frm h drawr. Rurn h mdicain cnainr  h uni-ds car. Prcd  h pain’s bdsid whn all mdicains ar assmbld fr adminisrain. • Chck h pain’s idnicain bracl and vrify i agains h mdicain prl. Hav h pain sa hir nam and birh da r w hr idnirs.

110

UNIT II Illustrated Atlas of Medication Administration

 • Nipple: Whn h infan is awak (and prfrably hungry), plac h nippl in h infan’s muh. Whn h baby sars  suck, plac h mdicain in h back f h nippl wih a syring r drppr, and allw h baby  suck i in (s Fig. 8.16). Fllw h mdicain wih milk r frmula, if ncssary. 5. Prfrm hand hygin.

Fig. 8.16 Position the infant with the head slightly elevated. Place the nipple in the infant’s mouth. When the baby starts to suck, place the medication in the back of the nipple, and allow the baby to suck.



• Carfully xplain  h pain h drugs bing givn; sa hir nams and prvid ducain abu h drugs bing adminisrd.  • Chck prinn pain mniring paramrs (.g., apical puls, rspirary ra). 10. Hand h mdicain cup  h pain fr h placmn f h cnns in hir muh, r adminisr h mdicain via h ral syring. 11. Prfrm hand hygin.

GENERAL PRINCIPLES OF LIQUID-FORM ORAL MEDICATION ADMINISTRATION FOR AN ADULT OR CHILD 1. Nvr dilu a liquid mdicain unlss spcically rdrd  d s. 2. Always rmain wih h pain whil h mdicain is akn. Do not lav h mdicain a h bdsid unlss an rdr xiss  d s. FOR AN INFANT 1. Chck h infan’s idnicain bracl and vrify i agains h mdicain card r prl. 2. B crain ha h infan is alr. 3. Psiin h infan s ha hir had is slighly lvad (Fig. 8.16). 4. Adminisrain:  • Oral syringe or dropper: Plac h syring r drppr bwn h pain’s chk and gums, halfway back in h muh. This placmn will rduc h chanc ha h infan will spi u h mdicain wih ngu mvmns. Slwly injc h mdicain and allw h infan  swallw i. (Rapid adminisrain may caus chking and aspirain.)

DOCUMENTATION Prvid h righ dcumnain f h mdicain adminisrain and h pain’s rspnss  drug hrapy. 1. Char h da, im, drug nam, dsag, and ru f adminisrain. 2. Prfrm and rcrd rgular pain assssmns fr h valuain f hrapuic ffcivnss (.g., bld prssur, puls, upu, imprvmn r qualiy f cugh and prduciviy, dgr and durain f pain rlif). 3. Char and rpr any signs and sympms f advrs drug ffcs. 4. Prfrm and valida ssnial pain ducain abu h drug hrapy and hr ssnial aspcs f inrvnin fr h disas prcss ha is affcing h individual. If h mdicain is fr a child, prvid and valida ssnial pain ducain  h cargivr and child, kping in mind h child’s dvlpmnal lvl. This shuld addrss h drug hrapy and hr ssnial aspcs f inrvnin fr h disas prcss ha is affcing h individual.

ADMINISTRATION OF MEDICATIONS BY GASTROINTESTINAL TUBES GI ubs ar usd  adminisr mdicains  pains wh hav impaird swallwing,  hs wh ar cmas, r  hs wh hav a disrdr f h sphagus. GI ubs ha ar insrd in hrugh h ns ar calld nasgasric (NG) ub, nasdudnal (ND) ub, r nasjjunal (NJ) ub. GI ubs ha ar surgically insrd hugh h abdmn in h smach ar calld gasrsmy ubs r G-ubs. Th rm percutaneous endoscopic gastrostomy (PEG) sands fr h prcdur during which h gasrsmy ub is insrd, and shuld n rfr  h ub islf. During h PEG prcdur a ub may b insrd in h small insin; his ub is calld a jjunsmy ub r J-ub. J-ubs, ND ubs, and NJ ubs ar smims rfrrd  as small bwl ubs (Fig. 8.17). Whnvr pssibl, h liquid frm f a drug shuld b usd fr GI ub adminisrain. If i is ncssary  us a abl r capsul, h abl shuld b crushd r h capsul pulld apar and h pwdr sprinkld in apprximaly 10  15 mL f war. (Do not crush nric-cad abls r pn imdrlas capsuls.) Th ub shuld b ushd wih a las 30 mL f war bfr and afr h mdicin is

Enteral Administration CHAPTER 8

Nasogastric

A

Nasoduodenal/nasojejunal

B

Gastrostomy

C

111

Jejunostomy

D

Fig. 8.17 Types of gastrointestinal tubes. (A) Nasogastric tube is passed from the nose into the stomach. (B) Weighted nasoduodenal/nasojejunal tube is passed through the nose into duodenum/jejunum. (C) Gastrostomy tube is introduced through a temporary or permanent opening on the abdominal wall (stoma) into the stomach. (D) Jejunostomy tube is passed through a stoma directly into the jejunum.

adminisrd. This clars h ub fr drug dlivry, facilias drug ranspr  h insin, and indicas whhr h ub has bn clard. Whn mr han n mdicain is  b adminisrd a abu h sam im, ush 5  10 mL f war bwn ach mdicain. (Rmmbr  includ h war ha is usd  ush h ubing as par f h al war rquirmns fr h pain fr a 24-hur prid.) Prfrm prmdicain assssmn; s individual drug mngraphs fr dails. EQUIPMENT • Glass f war • Tw 60-mL cahr ip syrings • Masuring cnainr r graduad cylindr • Pill crushr (as ndd whn mdicains ar n liquid) • Twl r small incninnc pad • pH ap and clr vricain • Glvs TECHNIQUE Rfr  h scins abu h adminisrain f slidfrm r liquid-frm ral mdicains fr infrmain abu h prparain f dss. 1. Fllw h prcdur prcl dscribd arlir. 2. Prcd  h pain’s bdsid whn all mdicains ar assmbld fr adminisrain.  • Chck h pain’s idnicain bracl and vrify i agains h mdicain prl. Hav h pain sa hir nam and birh da r w hr idnirs.  • Carfully xplain  h pain h prcdur fr h adminisrain f mdicains in h GI ub. Sa h drug nams and prvid ducain abu h drugs bing adminisrd.

3. Apply clan glvs. 4. Psiin h pain uprigh and chck h lcain f h GI ub bfr adminisring any liquid. (Note: Radigraphic cnrmain f GI ub placmn is prfrmd whn h ub is iniially insrd. Thrafr, pH and clr sing may b usd  cnrm placmn.) pH and Color Testing of Gastrointestinal Contents to Check for Tube Placement • Aspira par f h GI cnns using h 60-mL cahr ip syring. If unabl  aspira h GI cnns, rpsiin h pain n hir lf sid and ry aspiraing again. • Chck h clr f h aspirad uid. Clr vricain guidlins ar as fllws:  • Gasric uid = grn wih sdimn r ff-whi  • Insinal uid = yllw (bil-clrd)  • Plural uid = clar  sraw-clrd  • Trachbrnchial uid = ff-whi r an • Chck h pH f h GI cnns. Th smach pH is lss han 3, h insinal fluid pH is 6  7, and h rspirary fluid pH is grar han 7. Hisamin-2 (H2) anagniss (.g., raniidin, cimidin, famidin, nizaidin) affc h pH f h aspirad fluid in h fllwing ways:  • Ppl n rciving H2 blckrs: gasric pH = 1  4; insinal pH ≥ 6  • Ppl rciving H2 blckrs: gasric pH = 1  6; insinal pH ≥ 6; rachbrnchial r plural aspira pH ≥ 7 • Rurn h GI cnns afr h cnrmain f crrc ub placmn. 5. Afr h placmn f h GI ub in h prpr lcain is cnrmd, adminisr h mdicain.

112

UNIT II Illustrated Atlas of Medication Administration

Two-Syringe Technique for Medication Administration • Draw up 60 mL f pid war in h cahr ip syring. This will b h ush syring. • Plac a wl r small incninnc pad undr h GI ub  prc h pain frm any pssibl war spills. • Discnnc h GI ub frm sucin (if i was n sucin) and pinch ub  prvn any backw f liquid. Aach ush syring. • Flush wih 30 mL f war  clar h ub. Plac ush syring, sill cnncd  GI ub, n wl and bain scnd syring. Fllw agncy prcl, as vlums may vary. • Wih scnd 60-mL syring, draw up liquid mdicain  b adminisrd; r (if ndd) crush abls, suspnd in war (apprximaly 5  10 mL), and hn draw up in syring.  • Whn adminisring mulipl mdicains, giv hm n a a im. D n mix h mdicains ghr in n syring bcaus his may clg h GI ub.  • I is bs  hav mulipl mdicain syrings laid u in rdrly fashin fr as f adminisrain. • Whn scnd syring is prpard, pinch h GI ub, discnnc h ush syring, aach syring wih mdicain, and adminisr mdicain, kping cahr ip vrical. • Pinch GI ub  prvn backw, swich  ush syring, and ush ub wih 10 mL f war fllwing mdicain adminisrain. • Cninu adminisring mdicains and ushing bwn hm unil all mdicains ar adminisrd. • Flush h GI ub wih 30 mL f war whn nishd and clamp ub. Tub shuld rmain clampd fr 30  60 minus  allw fr absrpin. • Prvid ral hygin fr h pain, if ndd. 6. Rmv glvs and prfrm hand hygin. DOCUMENTATION Prvid h righ dcumnain f mdicain adminisrain and h pain’s rspnss  drug hrapy. 1. Char h vricain f h GI ub placmn. 2. Char h da, im, drug nam, dsag, and ru f adminisrain. Includ all uids givn (including h uid usd  ush h ub) n h inak rcrd. 3. Prfrm and rcrd rgular assssmns fr hrapuic ffcivnss (.g., bld prssur, puls, upu, imprvmn r qualiy f cugh and prduciviy, dgr and durain f pain rlif). 4. Char and rpr any signs and sympms f advrs drug ffcs. 5. Prfrm and valida ssnial pain ducain abu h drug hrapy.

ADMINISTRATION OF ENTERAL FEEDINGS VIA GASTROSTOMY OR JEJUNOSTOMY TUBE DOSE FORM Enral frmulas ar availabl in a variy f mixurs  m h individual pain’s nds. Th fur gnral cagris ar as fllws: (1) inac nurin (plymric); (2) lmnal; (3) disas r cndiin spcic; and (4) mdular nurin. Th yp f frmula rdrd will b slcd by h halhcar prvidr  m h pain’s nrgy rquirmns  mainain bdy funcins and grwh dmands and  rpair issu ha has bn damagd r dpld by illnss r injury (s Chapr 46). EQUIPMENT • Prscribd nral frmula • Dispsabl r rady--hang bag fr cninuus adminisrain • Infusin pump spcic fr nral frmulas • Bld glucs sing marials (if bld glucs lvls rdrd) • 60-mL cahr ip syring • 50 mL f war • Masuring cnainr r graduad cylindr • pH indicar ap • Clamp (C clamp r smy plug) • Twl r small incninnc pad TECHNIQUE Psiin h pain in h smi-Fwlr psiin wih a 30-dgr had-f-bd lvain. 1. Fllw h prcdur prcl dscribd arlir. 2. Prcd  h pain’s bdsid.  • Chck h pain’s idnicain bracl and vrify i agains h frmula prl. Hav h pain sa hir nam and birh da r w hr idnirs.  • Carfully xplain  h pain h prcdur usd fr adminisring nral fdings and prvid ducain abu h frmula bing insilld. 3. Chck pain psiining and drap h pain  avid unncssary xpsur. Plac a wl r small incninnc pad undr h fding ub ara  prc h ara in cas f accidnal spills. 4. Apply clan glvs. 5. If h sma si nds clansing, clans h si as pr insiuinal plicy. 6. Vrify ub placmn and iniia h fding:  • Gastrostomy tube (Fig. 8.17C): Aach a 60-mL cahr ip syring  h clampd ub; rlas h clamp. Slwly wihdraw h plungr  aspira h rsidual marial. Obsrv h clr and chck h pH f h aspirad cnns. (Us h principls dscribd prviusly in h scin

Enteral Administration CHAPTER 8

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Fig. 8.18 Example of feeding tube with Luer-Lok ends for use with Luer-Lok syringes.

n pH and Clr Tsing f Gasric Cnns  Chck fr Tub Placmn undr Adminisrain f Mdicains by Nasgasric Tub  aspira gasric cnns.) Nify h halhcar prvidr if h rsidual is grar han 100 mL (r amun spcid) sinc h las blus fding 4 hurs arlir. Rinrduc h gasric cnns ha wr aspirad.  • Jejunostomy tube (Fig. 8.17D): Aspira h insinal scrins using h sam mhd as dscribd fr a gasrsmy ub. Obsrv h clr and chck h pH. 7. Flush h ub wih 30 mL f war. 8. Clamp h ub (gasrsmy r jjunsmy). 9. Prcd wih n f h fllwing fding chniqus. Intermittent Tube Feeding  • Using a dispsabl r rady--hang bag, ll h bag wih h prscribd amun f frmula and allw  infus by graviy by hanging h bag n an IV pl. In gnral, his will infus vr 30 minus. Chck frqunly  nsur ha h frmula is running.  • Flush h ubing wih 50  60 mL f war afr h bag is mpy and h frmula is gn. This rmvs h frmula frm h ubing, mainains h pancy f h ub, and prvns h frmula ha rmains in h ub frm suppring bacrial grwh.  • Clamp r plug h smy ub. Tll h pain  rmain in h smi-Fwlr psiin r urn n hir righ sid fr 30  60 minus  hlp wih h nrmal digsin f frmula and  prvn gasric rux (wih pssibl aspirain) r lakag.

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• Wash and dry all rusabl quipmn and sr i in a clan ara in h pain’s nvirnmn unil h nx fding. Chang h quipmn (.g., syrings) in accrdanc wih insiuinal plicy (fn vry 24 hurs).

Continuous Tube Feeding  • Fill a dispsabl fding cnainr wih nugh f h prscribd frmula fr an 8-hur prid. Sr h rmaining frmula in h rfrigrar. Labl h cnainr wih h da and im ha h fding was iniiad. Th frmula mus b a rm mpraur a h im f iniiain.  • Fding ubs may hav Lur-Lk nds fr asir aachmn  syrings, prvning h syrings frm falling u afr bing cnncd (Fig. 8.18).  • Prlld fding frmulas ar als availabl using spikd ubing  cnnc  h bag.  • Hang h cnainr n an IV pl, clar air frm h ubing, and hrad h ubing hrugh h pump in h mannr prscribd by h pump’s manufacurr.  • Cnnc h ub frm h nral fding surc  h nd f h fding ub. Rlas h clamp frm h ub.  • S h w ra f h nral frmula a h prscribd ra  dlivr h frmula in h crrc vlum vr h spcid im span. Whn iniiaing ub fdings, h ra is iniially slw and gradually incrasd a spcid inrvals.  • Wash and dry all rusabl quipmn and sr i in a clan ara in h pain’s nvirnmn unil h nx fding. Chang h quipmn vry 24 hurs. 10. Bld glucs drminain may b prfrmd and h lvl rcrdd vry 6 hurs during h iniiain f ub fdings. Assssmns ar cninud unil glucs lvls ar mainaind wihin a spcid rang fr a 24-hur prid afr h ra f nral fding has rachd h prscribd maximum w. 11. Whn pains hav a GI ub, inspc h nars a rgular inrvals  dc any prssur injury crad by h fding ub. Inspc h issu surrunding a gasrsmy r jjunsmy ub fr signs f brakdwn r infcin. 12. Bfr h nx schduld fding, a gasric rsidual vlum shuld b chckd wih syring fr aspirain  nsur ha h frmula is laving h smach and passing in h insin fr absrpin. Fr rsidual vlums f lss han 100 mL h rsidual can b radminisrd and h fding can b rsumd. If h rsidual vlum is grar han 100 mL, h halhcar prvidr shuld b nid. If h rsidual is “cff-grund” in clr, h halhcar prvidr shuld als b nid bcaus his may b an indicain f blding dvlping. 13. Prfrm hand hygin.

114

UNIT II Illustrated Atlas of Medication Administration

Medication Safety Alert Enteral formulas should be properly labeled with the time, date, type of formula, and strength. Check the date and time of preparation on a formula that is mixed in the hospital pharmacy, and discard any unused portion after 24 hours. Commercially prepared vacuum-sealed formulas are generally stored at room temperature until used. Check the expiration date and return the product if it is outdated. If the product has been opened, discard it in accordance with the manufacturer’s recommendations or institutional policy. For patients who are receiving enteral nutrition via intermittent tube feedings (using institutional guidelines), remember the following:  • Check the residual volume before each feeding.  • Check to ensure the presence of bowel sounds. The absence of bowel sounds indicates the need to contact the healthcare provider for orders before proceeding.  • Check the position of the tube to ensure that it is still in the stomach or intestine.  • During the initiation of enteral feedings by intermittent or continuous methods, blood glucose testing may be ordered.

DOCUMENTATION Prvid h righ dcumnain f h frmula adminisrd, h clansing f h sma, and h pain’s hrapuic rspns  h nral fdings. 1. Char h da and im; h amun, clr, and pH f h rsidual ha is aspirad; h amun, yp, and srngh f h frmula ha is insilld; and h amun f war ha is usd  ush h ubing.

ADMINISTRATION OF RECTAL SUPPOSITORIES DOSE FORM A suppository (Fig. 8.19) is a slid frm f mdicain ha is dsignd fr inrducin in a bdy ric. A bdy mpraur, h subsanc disslvs and is absrbd by h mucus mmbrans. Suppsiris shuld b srd in a cl plac  prvn sfning. If a suppsiry bcms sf and h packag has n y bn pnd, hld h fil-wrappd suppsiry undr cld running war r plac i in ic war fr a shr im unil i hardns. Rcal suppsiris shuld gnrally n b usd fr pains wh hav had rcn prsa r rcal surgry r fr hs wh hav xprincd rcn rcal rauma. Prfrm prmdicain assssmn; s individual drug mngraphs fr dails.

Fig. 8.19 Rectal suppositories.

EQUIPMENT • Glvs • War-slubl lubrican • Prscribd suppsiry TECHNIQUE 1. Fllw h prcdur prcl dscribd arlir. 2. Prcd  h pain’s bdsid.  • Chck h pain’s idnicain bracl and vrify i agains h mdicain prl. Hav h pain sa hir nam and birh da r w hr idnirs.  • Explain carfully  h pain h prcdur usd fr adminisring suppsiris. Tll h pain h drug’s nam and prvid ducain abu h drug bing adminisrd.  • Chck prinn pain mniring paramrs (.g., im f las dfcain, svriy f nausa r vmiing, rspirary ra) as apprpria  h mdicain  b adminisrd. 3. Whnvr pssibl, hav h pain dfca bfr h suppsiry is adminisrd. 4. Prvid fr pain privacy; psiin and drap h pain  avid unncssary xpsur (Fig. 8.20A). Gnrally, h pain is placd n hir lf sid (i.., lf laral rcumbn psiin). 5. Apply clan glvs. 6. Ask h pain  bnd h upprms lg ward h wais. 7. Unwrap h suppsiry, and apply a small amun f war-slubl lubrican  is ip (Fig. 8.20B and C). If lubrican is n availabl, us plain war  misn h mdicain. Do not us prlum jlly r minral il bcaus i may rduc h absrpin f h mdicin. 8. Plac h ip f h suppsiry a h rcal nranc. Ask h pain  ak a dp brah and  hn xhal hrugh h muh (many pains will xprinc an invlunary rcal gripping whn h suppsiry is prssd agains h rcum). Gnly insr h suppsiry abu an inch bynd h ric and pas h inrnal sphincr (Fig. 8.20D). Whn insring h suppsiry, us h indx ngr fr an adul r h furh ngr fr an infan. 9. Ask h pain  rmain lying n hir sid fr 15  20 minus  allw fr h mling and absrpin f h mdicain.  • Fr childrn, i is ncssary  cmprss h bucks gnly bu firmly and  hld hm in plac fr 15  20 minus  prvn xpulsin. 10. Discard usd marials and rmv glvs. 11. Prfrm hand hygin. DOCUMENTATION Prvid h righ dcumnain f mdicain adminisrain and h pain’s rspnss  drug hrapy.

Enteral Administration CHAPTER 8

1. Char h da, im, drug nam, dsag, and ru f adminisrain. 2. Prfrm and rcrd rgular pain assssmns fr h valuain f hrapuic ffcivnss. Fr xampl, whn a mdicain is givn as a laxaiv, char h clr, amun, and cnsisncy f sl. If a drug is givn fr pain rlif, char h dgr and durain f pain rlif. If h suppsiry is givn as an animic, char h dgr and durain f rlif f nausa and vmiing. 3. Char and rpr any signs and sympms f advrs drug ffcs. 4. Prfrm and valida ssnial pain ducain abu h drug hrapy.

ADMINISTRATION OF A DISPOSABLE ENEMA DOSE FORM Th ds frm is a prpackagd, dispsabl nma sluin f h yp prscribd by h halhcar prvidr. Prfrm prmdicain assssmn; s individual drug mngraphs fr dails. EQUIPMENT • Til issu • Bdpan, if pain is n ambulary • War-slubl lubrican • Glvs • Prscribd dispsabl nma ki TECHNIQUE 1. Fllw h prcdur prcl dscribd arlir. 2. Prcd  h pain’s bdsid.  • Chck h pain’s idnicain bracl and vrify i agains h mdicain prl. Hav h pain sa hir nam and birh da r w hr idnirs.  • Explain carfully  h pain h prcdur usd fr adminisring an nma and prvid

A

B

 3. 4. 5. 6. 7. 8. 9.

10. 11.

115

ducain abu h sluin bing adminisrd. Dpnding n h purps f h nma, ask h pain  dfca if hr is an urg prir  h prcdur. • Chck prinn pain mniring paramrs (.g., h im f las dfcain). Psiin h pain n hir lf sid, and drap h pain  avid unncssary xpsur (Fig. 8.21A). Apply clan glvs. Rmv prciv cvring frm h nd f h nma and lubrica h nd (Fig. 8.21B). Insr h lubricad nd in h pain’s rcum and hn dispns h sluin by cmprssing h plasic cnainr (Fig. 8.21C). Rplac h usd cnainr in is riginal packag fr dispsal (Fig. 8.21D). Encurag h pain  hld h sluin fr abu 30 minus bfr dfcaing. Assis h pain  a siing psiin n h bdpan r  h bahrm, as rdrs prmi. Tll h pain not  ush h il. Th rsuls f h nma nd  b dcumnd. Insruc h pain rgarding h lcain f h call ligh in cas assisanc is ndd. Rmv and discard glvs. Prfrm hand hygin.

DOCUMENTATION Prvid h righ dcumnain f mdicain adminisrain and h pain’s rspnss  drug hrapy. 1. Char h da, im, drug nam, dsag, and ru f adminisrain. 2. Prfrm and rcrd rgular pain assssmns fr h valuain f h hrapuic ffcivnss (.g., clr, amun, and cnsisncy f sl). 3. Char and rpr any signs and sympms f advrs drug ffcs. 4. Prfrm and valida ssnial pain ducain abu h drug hrapy.

C

D

Fig. 8.20 Administering a rectal suppository. (A) Position the patient on their left side and then drape the patient. (B) Unwrap the suppository and remove it from its package. (C) Apply water-soluble lubricant to the suppository. (D) Gently insert the suppository about 1 inch past the internal sphincter. (Courtesy Chuck Dresner.)

116

UNIT II Illustrated Atlas of Medication Administration

A

B

C

D Fig. 8.21 Administering a disposable enema (Fleet enema). (A) Place the patient in a left lateral position, unless a kneechest position has been specied. (B) Remove the protective covering from the end of the enema and lubricate the end. (C) Insert the lubricated end into the patient’s rectum and dispense the solution by compressing the plastic container. (D) Replace the used container in its original wrapping for disposal.

Enteral Administration CHAPTER 8

117

Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions Key Points • Solid dose forms of medications include capsules, timedrelease capsules, lozenges, tablets, caplets, and orally disintegrating tablets and lms. • Liquid dose forms for medications include elixirs, emulsions, suspensions, and syrups. • The unit-dose system uses individual packaged medications that are distributed to each patient using a medication cart. The computer-controlled dispensing system uses unit-dose medications distributed in a locked, password-protected medication system using a computer and bar code scanner system. • Liquid forms of medications are administered by unit-dose container or oral syringe, or by GI tube. • Medications administered via GI tubes require checking placement of the tube before administration and using the correct technique to ensure all medication is given accurately. Tube feedings are administered via GI tubes also and proper technique for handling formulas and checking residuals need to be followed. • Rectal suppositories and enemas are administered with the patient positioned on their left side and inserted with a water-based lubricant.

Additional Learning Resources

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Willihn ganz) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types. 1. Choose the most likely options for the information missing from the sentence below by selecting from the lists of options provided. When administering medications via the enteral routes the nurse uses the ___________1__________ or _______1__________ route, and the nurse may have to crush the _______2__________ or ________2____________ dosage forms for easier delivery. OPTIONS FOR 1

OPTIONS FOR 2

intravenous

tablets

gastrointestinal

lozenges

oral

caplets

rectal

timed-release capsules

Objective: Describe the general principles of administering solid forms of oral medications. NGN test item: Cloze Cognitive skill: Recognize cues

2. A nursing instructor reviewed the different types of techniques used when getting medications from different systems. Mark an X under the correct column for the procedures used in the unit-dose system and the computer-controlled system.

PROCEDURES

UNIT-DOSE SYSTEM

COMPUTERCONTROLLED SYSTEM

Compares the label with the patient prole Uses bar code scanner to connect the nurse, patient, and medication Checks expiration date on label Uses security access code Obtains medications from cart with drawer assigned to patient

Objective: Compare the different techniques that are used with a unit-dose distribution system and computer-controlled distribution system. NGN test item: Matrix Cognitive skill: Recognize cues 3. The nurse needs to administer guaifenesin syrup to a 5-year-old. List in order the steps the nurse will take. 1. Pour the correct volume of liquid in a medicine cup reading the meniscus at eye level. 2. Document the administration of the medicine in the patient’s chart. 3. Hold the bottle containing the liquid so the label is covered with the palm of the hand. 4. Review the order for the number of milligrams of medicine or the volume the liquid to be administered. 5. Identify the patient through two identiers and hand the medication to the patient for ingestion. 6. Check the expiration date on the medicine. 7. Review the label to assure correct medicine and appropriate concentration of the liquid (e.g., number of mg per mL) and calculate the volume to be poured into the cup. Objective: Identify general principles used for liquid-form medication administration. NCLEX test item: Ordering Cognitive skill: Application 4. The nurse is to administer several medications to the patient via a GI tube. What is the nurse’s rst action? 1. 2. 3. 4.

Add the medication to the tube feeding being given. Crush all tablets and capsules before administration. Administer all of the medications mixed together. Check for the placement of the tube.

UNIT II Illustrated Atlas of Medication Administration

118

Objective: Cite the equipment needed, techniques used, and precautions necessary when administering medications via a GI tube. NCLEX test item: Multiple choice Cognitive skill: Knowledge 5. When administering an intermittent enteral feeding to an adult patient, the nurse nds that the residual aspirate returned is “coffee-ground” in color. What does the nurse do? 1. 2. 3. 4.

Administer the next scheduled feeding Stop feeding the patient for 30 minutes Notify the healthcare provider Reinstill the aspirate and start a new feeding

Objective: Cite the equipment needed, techniques used, and precautions necessary when administering medications via a GI tube. NCLEX test item: Multiple choice Cognitive skill: Comprehension 6. The nurse received an order to administer a rectal suppository. Indicate with an X the correct technique and correct equipment necessary for proper administration.

TECHNIQUE/EQUIPMENT Gently insert suppository past the internal sphincter Position the patient on their left side Obtain a water-soluble lubricant Ask the patient to remain on their side for 20 minutes Remove suppository from unit-dose wrapper Explain the procedure and educate the patient on the drug being administered Obtain clean gloves

CORRECT TECHNIQUE

CORRECT EQUIPMENT

Objective: Cite the equipment needed and the technique required when administering rectal suppositories and disposable enemas. NCLEX test item: Drag and drop Cognitive skill: Application 7. Why is it important for the nurse to not crush medications that are considered long-acting? 1. Medications that are crushed are harder to swallow, making it harder to activate the effect. 2. Medications that are crushed release the drug immediately, stopping the long-acting effect, potentially causing an overdose. 3. Medications that are crushed will not be absorbed properly, inactivating the long-acting effect. 4. Medications that are crushed will become powder and lose all the effectiveness of the drug. Objective: Describe principles of administering solid forms of oral medications. NCLEX test item: Multiple choice Cognitive skill: Understanding 8. The nurse is aspirating the patient’s GI tube to check the contents. What can the nurse expect for results if the contents are gastric uid? 1. 2. 3. 4.

pH of 8, clear colored pH of 3, green with sediment pH of 7, yellow colored pH of 4, off-white colored

Objective: Cite the equipment needed, techniques used, and precaution necessary when administering medication via a GI tube. NCLEX test item: Multiple choice Cognitive skill: Knowledge

Parenteral Administration: Safe Preparation of Parenteral Medications

9

https://evolve.elsevier.com/Willihnganz

Objectives 1. Identify safe administration practices for parenteral medications. 2. Compare and contrast the volumes of medications that can be measured in a tuberculin syringe and those of larger-volume syringes. 3. Describe how to select the correct needle gauge and length.

4. Compare and contrast the advantages and disadvantages of using prelled syringes. 5. Differentiate among ampules, vials, and Mix-O-Vials. 6. Describe the technique used to prepare two different drugs in one syringe (e.g., insulin).

Key Terms barrel (BĂ-rŭl) (p. 120) plunger (PLŬN-jŭr) (p. 120) tip (p. 120) milliliter scale (MĬL-ĭ-lē-tŭr) (p. 120) tuberculin syringe (tū-BĔR-kū-lĭn sĭRĬNJ) (p. 120)

insulin syringe (ĬN-sŭ-lĭn) (p. 121) prelled cartridges and syringes (prē-FĬLD) (p. 122) insulin pen (p. 122) needle gauge (NĒ-dŭl GĀJ) (p. 124)

Th rus f drug adminisrain can b classid in hr cagris: nral, parnral, and prcuanus. Th rm parenteral mans adminisrain by any ru hr han h nral—r gasrinsinal—rac. As rdinarily usd, h rm parenteral route rfrs  inra drmal (ID), subcuanus (subcu), inramuscular (IM), r inravnus (IV) injcins. Whn drugs ar givn parnrally rahr han rally, h fllwing facrs ar invlvd: (1) h ns f drug acin is gnrally mr rapid bu f shrr durain; (2) h dsag is fn smallr bcaus drug pncy nds n  b alrd immdialy by h smach r livr; and (3) h cs f drug hrapy is f n highr. Drugs ar adminisrd by injcin whn all f h drug mus b absrbd as rapidly and cm plly as pssibl, whn h drug mus b absrbd a a sady and cnrlld ra, r whn a pain is unabl  ak a mdicain rally bcaus f nausa and vmiing.

Safe PreParation, adminiStration, and diSPoSal of Parenteral medicationS and SuPPlieS Drug prparain and adminisrain rrrs hav bn idnid as cnribuing facrs  h high incidnc f advrs drug vns as discussd in Chapr 6. Th acual ra f rrrs ha ccur during h prparain and adminisrain f mdicains is n knwn, bu

safety devices (SĀF-tē dĕ-VĪ-sĕz) (p. 126) ampules (ĀM-pyūlz) (p. 126) vials (VĪ-ălz) (p. 126) Mix-O-Vials (MĬKS Ō VĪ-ălz) (p. 128)

h pnial is high. Thus h nurs mus b dilign  prvn rrrs frm ccurring. Th rl f h nurs in prviding accura drug adminisrain rquirs anin  dail in all facs f pharmachrapy. I is ssnial ha nurss wh ar prparing and adminisring mdicains fcus n h fllwing: (1) h basic knwldg ndd rgarding h individual drugs bing rdrd, prpard, and ad minisrd; (2) h sympms fr which h mdicain is prscribd and h cllcin f baslin daa  b usd fr h valuain f h hrapuic ucms dsird fr h prscribd mdicin; and (3) h nurs ing assssmns ncssary  dc, prvn, r am lira advrs vns. Finally, h nurs mus xrcis clinical judgmn rgarding h schduling f nw drug rdrs, missd dss, mdid drug rdrs, h subsiuin f hrapuically quivaln mdicins by h pharmacy, r changs in h pain’s cndiin ha rquir cnsulain wih a physician, halhcar prvidr, r pharmacis. Injcin f drugs rquirs skill and spcial car bcaus f h rauma a h si f ndl puncur, h pssibiliy f infcin, h chanc f allrgic rac in, and h fac ha, afr i is injcd, h drug is irrrivabl. Thrfr mdicains mus b prpard and adminisrd carfully and accuraly. Aspic chniqu is usd during injcin  avid infcin. Crrc ra f drug adminisrain and crrc si f injcin ar fllwd  avid injuris such as abscss 119

120 Tip

UNIT II Illustrated Atlas of Medication Administration Barrel

Plunger

Fig. 9.1 Parts of a syringe.

frmain, ncrsis, skin slughing, nrv injuris, and prlngd pain. Thus h parnral adminisrain f mdicains rquirs spcializd knwldg and man ual skills  nsur safy and hrapuic ffcivnss fr pains. Halhcar prfssinals plac h safy f hir pains rs, bu h Occupainal Safy and Halh Adminisrain (OSHA) has rprd ha mr han 5 millin wrkrs in h halhcar indusry and rlad ccupains ar a risk fr ccupainal xpsur  bldbrn pahgns ha can caus dvasaing disass, including human immun dcincy virus, hpaiis B virus, and hpaiis C virus. Sudis hav indicad ha as many as n hird f all sharps injuris (i.., frm ndls, lan cs, and scalpls) ar rlad  h dispsal prcss and ha nurss susain h majriy f hs injuris. Cnsqunly, nurss hav hr primary safy cn crns: fr h pain, fr hmslvs, and fr hr halhcar wrkrs. Paramun  h saf adminis rain f mdicins is h nd fr nurss  fllw sablishd plicis and prcdurs whil chcking and vrifying rdrs; prparing, adminisring, r crding, and mniring hrapuic rspnss  drug hrapy; and prprly dispsing f parnral supplis and quipmn.

equiPment uSed for Parenteral adminiStration SyringeS Syrings ar gnrally mad f hard plasic; glass sy rings ar rarly usd in clinical pracic. A syring has hr pars (Fig. 9.1). Th barrel is h ur prin n which h calibrains fr h masurmn f h drug vlum ar lcad (Fig. 9.2). Th plunger is h innr cylindrical prin ha s snugly in h barrl. This prin is usd  draw up and jc h sluin frm h syring. Th tip is h prin ha hlds h ndl. Syrings ar cnsidrd  b sril whn h packag is sill inac frm h manufacurr. Th nurs will r mv h ur shah ha cvrs h syring and hn hld h barrl; h usid f h barrl is hn cnsid rd unsril r cnaminad, whras h insid f h barrl rmains sril. Nurss mus kp h ip f h syring sril whn cnncing ndls. All syrings, rgardlss f hir manufacurr, ar availabl wih a LurSlip r LurLk ip. Th Lur sysm cnsiss f w pars: h mal aprd nd (Fig. 9.3A) and h rvrsaprd fmal cnncr wih an ur ang (Fig. 9.3B).

1 2

1 1 2 30M

1 2

2

0.5 mL 0.1 mL

3

mL

1 2

3 mL

Fig. 9.2 Reading the calibrations of a 3-mL syringe.

Th w yps f syring ips ar h LurSlip, which has a mal aprd nd (Fig. 9.4A), and h LurLk (Fig. 9.4B), which has a hradd lcking cllar usid f h mal LurSlip ha will lck h ang f h fmal cnncr scurly. Whn h fmal cnnc r is placd n a mal LurSlip wih a lcking cllar and givn a half wis, i is scurly lckd in plac (s Fig. 9.3C r Fig. 9.4B). Hwvr, if a fmal adapr is placd n a mal LurSlip wihu a cllar (s Fig. 9.4A), h cnncin is nly rlaivly scur. S Cabat A syring is calibrad in millilirs (mL) (s Fig. 9.2). Th ms cmmnly usd syrings ar 1, 3, and 5 mL, bu syrings f 10, 20, and 50 mL ar als avail abl. (N: Tchnically, h millilir is a masur f vlum.) Reading the calibration of the syringe m s. Th milliliter scale rprsns h unis

whrby mdicains ar ruinly rdrd. Fr vl ums f 1 mL r lss, us a 1mL r ubrculin syring fr h mr prcis masurmn f h drug (Fig. 9.5). Millilirs ar rad n h scal markd “mL” (s Figs. 9.2 and 9.5). Th shrr lins rprsn 0.1 mL, and h lngr lins ach rprsn 0.5 mL. t sg. Th tuberculin syringe, r 1mL syring, was riginally dsignd  adminisr ubr culin inculains (s Fig. 9.5). Tday i is usd  masur small vlums f mdicain accuraly. This yp f syring hlds a al f 1 mL; ach f h lng s lins rprsns 0.1 ({1/10}) mL, h inrmdia

Parenteral Administration: Safe Preparation of Parenteral Medications CHAPTER 9

121

Flange

3mL

21/2

2

11/2

1

1/

A

2

Male tapered end

B Hub

Reverse-tapered female connector

3mL

21/2

2

11/2

1

C

1/ 2

Threaded locking collar

Fig. 9.3 The Luer system consists of two parts: the male tapered end (A) and the reverse-tapered female connector with an outer ange (B). (C) When the two components are joined together, the hub of the female connector slips over the male tapered end and is twisted so that the ange on the hub locks into the threads of the locking collar.

A Avoid touching

1

2

3

4

5

Measure dose here

Keep sterile

Fig. 9.6 Reading the measured amount of medication in a plastic syringe.

B Fig. 9.4 (A) Male slip adapter tip (Luer-Slip). (B) Male slip adapter with outer locking collar (Luer-Lok). (Courtesy and © Becton, Dickinson and Company, Franklin Lakes, NJ.)

Fig. 9.5 Tuberculin syringe calibration.

lins rprsn 0.05 ({5/100}) mL, and h shrs lins rprsn 0.01 ({1/100}) mL. Vlums in dispsabl plasic syrings ar rad a h pin whr h rubbr ang f h syring plung r is paralll  h calibrain scal f h barrl (Fig. 9.6). In addiin, n h ara f h ndl  kp sril and h ara n h syring plungr  avid uching. is sg. Th insulin syringe has a scal ha has bn spcically calibrad fr h masurmn f insulin. Insulin is nw manufacurd wih a U100 cn cnrain in h Unid Sas. Th U100 syring (Fig. 9.7A) hlds 100 unis f insulin pr millilir. Variains may b nicd in h way ha unis ar markd n h scal, bu in gnral h shrr lins rprsn 2 unis f insulin, whras h lngr lins masur 10 unis f insulin. Lwds insulin syrings (Fig. 9.7B) may b usd fr pains wh ar rciving 50 unis r lss f U100 insulin. Th shrr lins n h scal f h lwds insulin syring masur 1 uni, whras h lngr lins ach rprsn 5 unis. Whn ravling abrad, pains shuld b awar ha U40 cncnra in insulin (i.., 40 unis f insulin/mL) is cmmnly availabl. A spcic insulin syring ha has bn cali brad fr U40 insulin shuld b usd wih h U40 insulin. Insulin dlivry aids (.g., nnvisual insulin masurmn dvics, syring magnirs, ndl guids, vial sabilizrs) ar availabl fr ppl wih

122

UNIT II Illustrated Atlas of Medication Administration

10 Units

5 Units

2 Units

1 Unit

A

B

Fig. 9.7 Calibration of insulin syringes. (A) U-100 insulin syringe. (B) Low-dose insulin syringe. Low-dose syringes are available in 25-, 30-, and 50-unit sizes to measure U-100 insulin more accurately.

visual impairmns. Infrmain abu hs prducs is availabl in h Amrican Diabs Assciain’s an nual diabs rsurc guid, which is publishd ach January.

Life Span Considerations Tuberculin Syringe The tuberculin syringe (see Fig. 9.5), which makes use of the metric system of measurement, will provide the most accurate measurement for doses of parenteral medications of 1 mL or less. The practice of adding 0.2 mL of air bubbles to thoroughly empty all of the medication contained in the needle of a syringe can signicantly increase a drug dose, especially when small volumes of medicine are being administered to neonates or infants. Check institutional policy regarding medication administration for the procedure to be used.

P Cats a Ss Svral manufacurrs supply a prmasurd amun f mdicain ihr in prsald carridgndl unis r in prlld cmpl syrings. Bh ar usd nc and hn discardd. Advanags f h prelled cartridges and syringes includ h im savd in pr paring a sandard amun f mdicain fr n injc in and h diminishd chanc f cnaminain b wn pains and hspial prsnnl. Disadvanags includ addiinal xpns and h limiain f h vlum if a scnd mdicain is  b addd  h carridg r syring. Th prlld carridgndl unis ar markd undr h brand nam Carpujc. Th carridg cn ains h amun f drug fr n sandard ds f mdicain. Th drug nam, cncnrain, and vl um ar clarly prind n h carridg. Th Carpujc prlld carridgs rquir a hldr ha crrspnds

wih h yp f carridg usd (Fig. 9.8). Exampls f drugs dispnsd in prlld carridgs ar mrphin, krlac, hydrmrphn, ndansrn, and hparin. Ohr mdicins (.g., spcic vaccins, nxaparin, dalparin, diclfnac, amidarn) ar shippd frm h manufacurr in a syring fr as f us. Many hspial pharmacis prll syrings fr spcic dss f mdicain fr pains wih spcic cndiins. Th syring is labld wih h drug nam and dsag, h pain’s nam and rm numbr, and h das f prparain and xpirain. Insulin is als availabl in a prlld syring knwn as an insulin pen (Fig. 9.9). Whn cappd, hs pns lk vry much lik ink pns, which allws h pain  carry insulin in a discr mannr. Whn ndd, h cap is rmvd, a ndl is aachd, air bubbls ar r mvd, h ds is diald in, h ndl is insrd in h subcu issu, and a riggr is pushd  injc h masurd ds. Whn nishd, h ndl is rmvd and h cap rplacd, and h dvic again aks n h apparanc f a pn. Ths pns ar availabl in a variy f clrs and syls, including a prlld, dis psabl mdl; a smallr, lwds mdl; and a rll abl mdl in which a nw carridg can b insrd whn ndd. Th pain shuld b insrucd rgard ing h crrc mhd f hlding h pn and rading h dsing dial as indicad by h manufacurr; his will hlp prvn dsing rrrs. Anhr yp f prlld syring is h EpiPn (Fig. 9.10). This syring is a dispsabl aumaic injcin dvic ha has bn prlld wih pinphrin fr us in an mrgncy, such as ha causd by an allrgic rac in  insc sings r bis, fds, r drugs. Whn hld prpndicularly agains h high and acivad, a n dl pnras h skin in h muscl, and a singl ds f pinphrin is injcd in h muscl. This prduc is availabl in adul and pdiaric dsags fr us a hm r whn ravling fr hs wh hav srng rac ins whn hy ar xpsd  allrgns. I is impr an  duca hs wh ar carrying hs prlld syrings  mnir h xpirain da f his mdica in n a rgular basis. Afr h pinphrin has bn adminisrd, h prsn shuld g  a hspial mr gncy dparmn bcaus addiinal ramn may b ncssary. Ohr rcnly rlasd prducs f injcabl pinphrin fr allrgis ar AuviQ and Impax. The needle Pats  t n Th ndl pars ar h hub, h shaf, and h bvld ip (Fig. 9.11). Th angl f h bvl can vary; h ln gr h bvl, h asir h ndl pnrain. Ndls ar sril whn hy arriv frm h man ufacurr. Nurss mus pay carful anin  kp h pars f h ndl sril and  avid cnamina in. If cnaminain is suspcd during h prcss f wihdrawing mdicains, discard h ndl in a sharps cnainr and sar again wih a nw n.

Parenteral Administration: Safe Preparation of Parenteral Medications CHAPTER 9

A

123

B

C D

E

F

Fig. 9.8 (A) Carpuject cartridge holder and prelled sterile cartridge with needle. (B) Assemble the Carpuject by inserting the prelled cartridge inside the Carpuject holder; lay the white ange of the syringe over one end and lock the blue end down to keep the syringe in place. (C) Twist the white end to screw into the prelled cartridge. (D and E) Remove the green cover from the tip of the cartridge (D); keeping this end sterile, attach the needle to the cartridge (E). (F) Needle is now attached to the prelled cartridge in a Carpuject cartridge holder.

Fig. 9.9 An insulin pen. (Copyright Eli Lilly and Company, Indianapolis,

Fig. 9.10 Prelled syringe and needle containing epinephrine for use

IN. All rights reserved. Used with permission.)

during emergencies. (Courtesy Mylan Inc., Canonsburg, PA.)

124

UNIT II Illustrated Atlas of Medication Administration Beveled tip

Table 9.1 Selection of Syringe and Needle

Shaft

route Intradermal

Volume (ml) 0.01–0.1

GauGe 26–29

lenGth ⅜ to ½ inch

Subcutaneous

0.5–2

25–27

Individualized on the basis of the depth of the appropriate tissue at the site

Intramuscular

0.5–2b

20–25c

Individualized on the basis of the depth of the appropriate tissue at the site

Hub aWhen

Fig. 9.11 Parts of a needle. Gauge 15G 18G 20G 22G 23G 25G 26G 28G

Length

11 2" 2 "

11 2" 2 " 1" 11 2" 1" 11 2"

1" 11 2 "

5 8"

1 2"

3 8"

1 2"

3 8"

Fig. 9.12 Needle length and gauge.

judging the needle length, allow an extra ¼ to ½ inch to remain above the skin surface when the injection is administered. In the rare event of a needle breaking, this allows a length of needle to protrude above the skin to grasp for removal. bDivided doses are generally recommended for volumes that exceed 2 to 3 mL, particularly for medications that are irritating to the tissues. cUse larger gauge (smaller bore) needles for thinner, more frail patients with smaller muscle mass.

ndl lngh fr h dlivry f h mdicain  h crrc si (.g., ID, subcu, IM, r IV). Tabl 9.1 may b usd as a guid  slc h prpr vlum f syring and h lngh and gaug f ndl fr adul pains. In small childrn and ldr infans, h usual maxi mum vlum fr an IM injcin a n si is 1 mL. In small infans, h muscl mass may nly b abl  l ra a vlum f 0.5 mL using a ½inch–lng ndl. Fr ldr childrn, h vlum shuld b individual izd; gnrally, h largr h muscl mass, h grar h similariy  h adul vlum fr n injcin si. Pdiaric IM injcins ruinly us a 25  27gaug ndl ha is 1  1½ inchs lng, dpnding n h as sssmn f h dph f h muscl mass f h child. Als availabl fr pdiaric us ar 31gaug, ½inch ndls.

n ga Th needle gauge is h diamr f h hl hrugh h ndl. Th largr h gaug numbr, h smallr h hl. Th gaug numbr is markd n h hub f h ndl and n h usid f h dispsabl packag. Th prpr ndl gaug is usually slcd n h basis f h viscsiy (hicknss) f h sluin  b injcd. A hickr sluin rquirs a largr diamr, s a smallr gaug numbr is chsn (Fig. 9.12). Finr ndls (.g., 27, 29, 31, and 32 gaug) ar availabl fr spcialy us.

Sct  n lt Assss h dph f h pain’s issu fr adminisra in (.g., muscl issu fr IM adminisrain, subcu issu fr subcu injcin), and chs a ndl lngh ha crrspnds  h ndings. Example of How to Select Needle Length Cmpar h muscl dph f a 250pund, bs, sdnary wman wih h muscl dph f a 105pund, dbiliad adul pain. An individual wh is bs may rquir a 2½  3inch ndl, and h frail prsn may nd a 1  1½inch ndl. A child may rquir a 1inch ndl (Fig. 9.13).

SeleCTion of The Syringe And needle Th siz f h syring usd is drmind by h vl um f mdicain  b adminisrd, h dgr f accuracy ndd fr h masurmn f h ds, and h yp f mdicain  b adminisrd. Ndl slcin shuld b basd n h crrc gaug fr h viscsiy f h sluin and h crrc

PACkAging of SyringeS And needleS Th sriliy f h syring and ndl  b usd shuld always b inspcd and vrid whn prparing and adminisring a parnral mdicain. Wrapprs shuld b chckd fr hls, signs f misur pn rain f h wrappr, and h xpirain da. Wih prpackagd dispsabl ims, h cninuiy f h

Parenteral Administration: Safe Preparation of Parenteral Medications CHAPTER 9

A

Overweight adult

Ideal weight adult

125

Child

3" Epidermis Dermis

11 2 "

Epidermis Dermis

1" Epidermis

Subcutaneous Subcutaneous

Dermis Subcutaneous

Muscle

Muscle

Muscle

B Fig. 9.13 Use body size (A) to estimate needle length for an intramuscular injection (B).

wrappr, ls lids r ndl guards, and any pn rain f h papr r plasic cnainr by h ndl shuld als b chckd. Shuld cnaminain b sus pcd, d n us h syring.

Safety SyStemS for Parenteral PreParation, adminiStration, and diSPoSal Th US Cngrss passd h Ndlsick Safy and Prvnin Ac in 2000 in rspns  sharps injuris frm mdical dvics, ms cmmnly ndlsicks. This ac rquirs OSHA  upda is sandards n bldbrn pahgns fr h clsr mniring and rpring f ndlsick injuris and  manda h dvlpmn f nw safy quipmn fr h halh car indusry. On f h majr dvlpmns has bn

h bradr us f ndllss sysms. In accrdanc wih OSHA rgulains, ndllss sysms ar r quird fr h fllwing: (1) fr h cllcin f bdy uids r h wihdrawal f bdy uids afr iniial v nus r arrial accss is sablishd; (2) fr h admin israin f mdicain r uids; r (3) fr any hr prcdur invlving h pnial fr ccupainal x psur  bldbrn pahgns as a rsul f prcu anus injuris frm cnaminad sharps. Ndllss sysms prvid an alrnaiv  ndls fr ruin prcdurs, hrby rducing h risk f injury invlv ing cnaminad sharps. Anhr dlivry sysm un dr dvlpmn is a j injcin sysm ha dlivrs subcu injcins f liquid mdicain (.g., insulin, vaccin) hrugh h skin wihu rquiring h us f a ndl.

126

UNIT II Illustrated Atlas of Medication Administration

slv is pulld frward fully  lck h shild prma nnly in plac  cvr h ndl. Anhr yp f safy shilding dvic aachs  h ndl hub (Fig. 9.16). Afr h mdicin is injcd, h halhcar prvidr pushs h hingd shild frward, hrby cvring h ndl. Ohr safy shild dvics ar als availabl fr shr ndls (Fig. 9.17) and fr clsur wih “hands fr” dvics (Fig. 9.18). Th BD Ingra Syring Sysm is a springladd syring ha rracs h ndl in h syring afr injcin. This sysm als uss a chnlgy calld TruLk chnlgy, which invlvs an apparaus ha is similar  LurLk chnlgy. I allws fr h changing f h ndl bwn aspirain and adminis rain, i lcks h syring and ndl ghr scurly, and i has a vry lw was spac in h hub (s Fig. 9.18). Lik all safydsignd syrings and ndls, i is ncs sary  rad h accmpanying liraur fr adjusmns ha nd  b mad whn praing hs dvics.

A

b

B

a

c

Fig. 9.14 Needle-free access devices. (A) INTERLINK Vial Access Cannula entering a universal vial adapter. (B) CLAVE Access System. a, A needle-free multidose vial adapter. b, The device snaps onto the top of a standard 20-mm medication vial. c, A single-dose vial adapter. (A, Courtesy Baxter Healthcare Corporation, Mountain Home, AR. All rights reserved. B, Courtesy ICU Medical Inc., San Clemente, CA.)

BlunT ACCeSS deviCeS Th blun accss dvic (.g., h spik) is a safy innva in ha was crad  rduc h frquncy f ndl in juris (Fig. 9.14). N in ha ndllss accss dvics d n hav a sainlss sl ndl ha is suiabl fr injcin (Fig. 9.14A). Th spik is usd whn drawing liquid frm a rubbr diaphragm–cvrd vial (Fig. 9.14B). Anhr yp f blun accss dvic ha is mr cmmnly knwn as a lter needle lks similar  hr spiks, bu i cnains an inrnal lr. This dvic is usd  wihdraw liquid frm a glass ampul. Th lr scrns u glass paricls ha may hav falln in h ampul whn h p was brkn ff (s Fig. 9.23). In addiin  prvning ndlsick injuris, hs blun accss dvics hav h advanag f drawing largr uid vlums frm h cnainr mr rapidly. Afr h spik is usd  draw up a mdicain, i is rmvd and h apprprialy sizd ndl is aachd  h syring if h mdicain is inndd fr injcin dircly in h pain. SAfeTy deviCeS Safety devices hav bn dvlpd fr syrings and ndls. Sm prducs hav a slv ha is srd arund h syring barrl whil h syring is bing lld hrugh h ndl (Fig. 9.15). Afr adminisrain, h

APProPriATe diSPoSAl Th apprpria dispsal f usd syrings and ndls— including hs wih ndl prcin dvics—is cru cial  h prvnin f ndl injury and h ransfr f bldbrn pahgns. T hlp minimiz accidnal ndlsicks, a ndl dispsal cnainr is cmmnly usd fr all sharps (Fig. 9.19). Whn h cnainr is full, h lid says in plac and h nir cnainr is dispsd f in a spcic mannr  cmply wih OSHA sandards. I is impran  ach slfinjcing pains hw  prc hmslvs and hrs frm accidnal ndlsick injury. Pains ar ncuragd  purchas a Sharps Dispsal by Mail Sysm a hir pharmacy fr h dispsal f syrings, ndls, and lancs. I is criical ha pains us hs sysms  prvn h accidnal xpsur f saniain wrkrs  ndls. Th mail sysm includs a sharps cnainr, an ur shipping bx, and a prpaid psag labl s ha, whn h cnainr is lld, i can b maild  an apprpria dispsal cnr. If a pain is uncrain abu h safs prcdur fr h dispsal f usd syrings and ndls, hy shuld cnac h lcal saniain srvic r dparmn.

Parenteral doSe formS All parnral drug ds frms ar packagd s ha h drug is sril and rady fr rcnsiuin (if nd d) and adminisrain. AmPuleS Ampules ar glass cnainrs ha usually cnain a sin gl ds f a mdicain. Th cnainr may b scrd (Fig. 9.20A) r hav a darknd ring arund h nck (Fig. 9.20B)  indica whr h ampul shuld b brkn pn fr wihdrawing h mdicain. viAlS Vials ar glass r plasic cnainrs ha cnain n r mr dss f a sril mdicain. Th unusd vial is sald wih

Parenteral Administration: Safe Preparation of Parenteral Medications CHAPTER 9

Flanges

Safe lock indicator

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Sleeve

A

B

C

D

E

Fig. 9.15 An example of a safety syringe that includes a full protective sheath. (A) Syringe showing a sheath that covers the needle with a safe lock indicator. (B) Assemble the device by holding the needle and the syringe by the anges (wings) and twisting the needle until it is rmly seated. (C) During aspiration, press the index nger against the anges to prevent sleeve movement. (Note: If it is necessary to transport a lled syringe to the point of administration, use a safe, passive, one-handed recapping technique, per Occupational Safety and Health Administration standards, to cover the needle before transporting it to the point of use.) (D) After injection, grasp the sleeve rmly, and twist the anges to loosen the sleeve. (E) Fully retract the needle into the sleeve until it locks in the protected position. When the green band fully covers the red band and an audible click is heard, the sleeve is locked into position. Place in sharps container.

A

B A

Bevel up = Lever arm up

C

B

D

Fig. 9.16 An example of a safety syringe that includes a shielding mechanism. (A) Attach the needle and shield assembly to any standard Luer-Lok or Luer-Slip syringe. Twist it until it is rmly seated, and then pull the shield straight off of the needle to avoid damaging the needle’s point. (B) Aspirate the medication into the syringe per the usual technique. (Note: If it is necessary to transport a lled syringe to the point of administration, use a safe, passive, one-handed recapping technique, per Occupational Safety and Health Administration standards, to cover the needle before transporting it to the point of use.) (C) Administer the injection in accordance with established technique. Note that the needle bevel is oriented to the lever arm. (D) After injection, immediately apply a single nger stroke to the activation-assist lever arm to activate the shielding mechanism. Place in sharps container. (Note: Activate the device away from yourself and others, listen for the click, and visually conrm that the needle tip is fully covered.)

C

D

Fig. 9.17 Another example of a safety syringe that includes a shielding mechanism. (A) Aspirate the medication into the syringe per the usual technique. The safety arm can be rotated for scale readability. (B) Administer the injection. To facilitate a low angle of injection, the safety arm can be rotated so that it is oriented to the needle bevel. (C) After injection, apply a single nger stroke to activate the safety arm by moving it completely forward. (D) The safety arm is locked and fully extended when you hear the click and the needle tip is covered.

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A

B

Fig. 9.18 Hands-free safety device. (A) safety shield open with needle exposed, close needle cover by placing end on table or hard surface and folding shield over needle (B) safety shield covering the needle Lid

Fig. 9.19 Needle disposal container, also known as a sharps container.

Rubber diaphragm

A

B

Fig. 9.21 (A) Vial protected by metal lid. (B) Rubber diaphragm exposed when lid is removed.

Scored

A

Ringed

B

Fig. 9.20 (A) Scored ampule. (B) Ringed ampule.

a mal lid  nsur sriliy (Fig. 9.21A). Th muh f h vial is cvrd wih a hick rubbr diaphragm hrugh which a ndl is passd  rmv h mdicain (Fig. 9.21B). Th mdicain in h vial may b in sluin, r i may b a sril pwdr  b rcnsiud jus bfr adminisrain. Th drug als can b wihdrawn frm h vial using a spik aachd  h syring (s Fig. 9.14). mix-o-viAlS Mix-O-Vials ar glass cnainrs wih w cmpar mns (Fig. 9.22). Th lwr chambr cnains h drug (slu), and h uppr chambr cnains a sril dilu n (slvn); bwn h w aras is a rubbr sp pr. A singl ds f mdicain is nrmally cnaind

Fig. 9.22 Mix-O-Vial.

in h MixOVial. A h im f us, prssur is ap plid  h p rubbr diaphragm plungr. This frcs h slvn and h rubbr sppr  fall in h b m chambr, whr h dilun mixs wih h pw dr, hrby disslving h drug.

PreParation of Parenteral medication equiPmenT • Drug in a sril, sald cnainr

Parenteral Administration: Safe Preparation of Parenteral Medications CHAPTER 9

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D

B

E

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Fig. 9.23 Withdrawing from an ampule with a lter needle. (A) Obtain a lter needle and displace the medication from the top portion of the ampule. (B) Cover the ampule neck area with an antiseptic alcohol wipe remaining in its cover. (C and D) Snap off the top of the ampule sharply in one swift motion. (E) Using a lter needle, withdraw the medication from the ampule. (F) Note that the needle must be lowered to withdraw all of the solution from the ampule.

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Syring f h crrc vlum Ndls f h crrc gaug and lngh Ndllss accss dvic Anispic alchl wip Mdicain prl

ProCedure ProToCol Th sandard prcdurs fr prparing all parnral mdicains ar as fllws: 1. Prfrm hand hygin before prparing any mdica in r handling sril supplis. During h acual prparain f a parnral mdicain, h primary rul  rmmbr is “sril  sril” and “unsr il  unsril” whn handling h syring and h ndl. 2. Us h seven rights f mdicain prparain and adminisrain hrughu h prcdur: righ pa in, righ drug, righ indicain, righ ru, righ ds, righ im, and righ dcumnain. 3. Chck ha h drug ds frm availabl is wha is rdrd. 4. Chck cmpaibiliy chars r cnac h pharma cis bfr mixing w mdicains r bfr adding mdicain  an IV sluin.

5. Chck mdicain calculains. Whn in dub abu a ds, chck i wih anhr qualid nurs. (Ms hspial plicis rquir fracinal dss f mdicains and dss f hparin and insulin  b chckd by w qualid prsnnl bfr adminisrain.) 6. Knw h insiuinal plicy rgarding limiains n h yps f mdicains  b adminisrd by nursing prsnnl. 7. Chck h xpirain da n h mdicain cnainr. 8. Afr cmpling h sandard prcdurs fr pr paring all parnral mdicains, cncnra n h prcdur a hand  nsur accuracy during prparain. 9. Prpar h drug in a clan, wllli ara and us aspic chniqu hrughu h nir prcdur. TeChniqueS Ppa a mcat f a Ap 1. Mv all h sluin  h bm f h ampul, and ick h sid f h glass cnainr wih h n grs  displac h mdicain frm h p prin f h ampul (Fig. 9.23A).

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UNIT II Illustrated Atlas of Medication Administration

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G Fig. 9.24 Removal of a volume of liquid from a vial for reconstitution of a powder. (A) Cleanse the rubber diaphragm of the vial. (B) Pull back on the plunger of the syringe to ll with an amount of air that is equal to the volume of the solution to be withdrawn. (C) Insert the needle through the rubber diaphragm; inject the air with the vial sitting in a downward position. (D) Invert the syringe and vial and withdraw the volume of diluent required to reconstitute the drug. (E) Move the needle downward within the rubber diaphragm to facilitate the removal of all of the diluent. (F) Tap the container with the powdered drug to break up the caked powder. (G) Wipe the rubber diaphragm of the vial of the powdered drug with a new antiseptic alcohol wipe. (H) Insert the needle of the syringe with the diluent into the rubber diaphragm, and inject the diluent into the powdered drug. (I) Mix thoroughly to ensure that the powdered drug is dissolved before withdrawing the prescribed dose.

2. Cvr h ampul nck ara wih an anispic alc hl wip in is slv whil braking h p ff (Fig. 9.23B–D). Discard h wip and h ampul p in a sharps cnainr. 3. Wih h us f a lr ndl, wihdraw all h mdicain frm h ampul (Fig. 9.23E and F). 4. Rmv h lr ndl frm h ampul and pin i vrically. Pull back n h plungr (his allws air  nr h syring), and hn rplac h lr ndl wih a nw sril ndl f h apprpria gaug and lngh fr adminisrain. 5. Push h plungr slwly unil h mdicain ap pars a h ip f h ndl r masur h amun f air  b includd  allw fr h al claranc f h mdicain frm h ndl whn injcd.

(Nvr add air  a syring ha is  b usd  ad minisr an IV mdicain.) Drugs in a vial may b in sluin rady fr admin israin, r hy may b in pwdrd frm fr rcn siuin bfr adminisrain. Ppa a mcat f a va Reconstitution of a sterile powder

1. Rad h accmpanying liraur frm h mdi cain’s manufacurr, and fllw spcic insruc ins fr rcnsiuing h drug ha has bn rdrd. Add nly h dilun spcid by h manufacurr. 2. Clans h rubbr diaphragm f h vial f dilu n wih an anispic alchl wip (Fig. 9.24A).

Parenteral Administration: Safe Preparation of Parenteral Medications CHAPTER 9

3. Pull back n h plungr f h syring  ll i wih an amun f air qual  h vlum f slu in  b wihdrawn (Fig. 9.24B). 4. Insr h ndl r ndllss accss dvic hrugh h rubbr diaphragm and injc h air (Fig. 9.24C). 5. Wihdraw h masurd vlum f dilun r quird  rcnsiu h pwdrd drug (Fig. 9.24D and E). Rmv h ndl frm h dia phragm f h dilun cnainr. 6. Rchck h yp and vlum f dilun  b in jcd agains h yp and amun rquird. 7. Tap h vial cnaining h pwdrd drug  brak up h cakd pwdr (Fig. 9.24F). Wip h rubbr diaphragm f h vial f pwdrd drug wih a nw alchl wip (Fig. 9.24G). 8. Insr h ndl r ndllss accss dvic in h diaphragm and injc h dilun in h pwdr (Fig. 9.24H). 9. Rmv h syring and ndl frm h rubbr diaphragm. 10. Mix the powdered drug and diluent thoroughly  n sur ha h pwdr is nirly disslvd before wihdrawing h ds (Fig. 9.24I). 11. Labl h rcnsiud mdicain, and includ h da and im f rcnsiuin, h vlum and yp f dilun addd, h nam f h rcnsiud drug, h cncnrain f h rcnsiud drug, h x pirain da and im, and h nam f h prsn wh rcnsiud h drug. Sr h mdicain in accrdanc wih h manufacurr’s insrucins. Removal of a volume of liquid from a vial (see Fig. 9.24A–E)

1. Calcula h vlum f mdicain rquird fr h prscribd ds f mdicain  b adminisrd. 2. Clans h rubbr diaphragm f h vial f drug wih an anispic alchl wip. 3. Pull back n h plungr f h syring  ll i wih an amun f air qual  h vlum f sluin  b wihdrawn. 4. Insr h ndl r ndllss accss dvic hrugh h rubbr diaphragm and injc h air. 5. Wihdraw h vlum f drug rquird  adminis r h prscribd ds. 6. Rchck all aspcs f h drug rdr. 7. Rmv h ndl r h ndllss accss dvic frm h syring. Aach a nw sril ndl f h apprpria gaug and lngh  adminisr h mdicain  h pain. Ppa a d f a m-o-va 1. Chck h drug rdr agains h mdicain avail abl fr adminisrain. 2. Tap h cnainr in yur hand a fw ims  brak up h cakd pwdr. 3. Rmv h plasic lid prcr (Fig. 9.25A)  ac css h diaphragm plungr (Fig. 9.25B).

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Fig. 9.25 Using a Mix-O-Vial. (A) Remove the plastic lid protector to expose the diaphragm plunger. (B) The powdered drug is in the lower half; the diluent is in the upper half. (C) Push rmly on the diaphragm plunger; downward pressure dislodges the divider between the two chambers.

4. Push dwn rmly n h diaphragm plungr. Th dwnward prssur will disldg h dividr b wn h w chambrs (Fig. 9.25C). 5. Mix hrughly  nsur ha h pwdr is completely dissolved bfr drawing up h mdicain fr adminisrain. 6. Clans h rubbr diaphragm and rmv h drug in h sam mannr as dscribd fr h rmval f a vlum f liquid frm a vial (s Fig. 9.24A–E). Ppa Tw mcats  o S Occasinally, w mdicains may b drawn in h sam syring fr a singl injcin. This is usually dn whn prparing a prpraiv mdicain r whn w yps f insulin ar rdrd  b adminisrd a h sam im. Mixing insulin is a ruin prcdur, s i will b usd  illusra his chniqu. Bfr adminisring insulin, h nurs always valuas h pain’s bld glucs lvl. 1. Chck h cmpaibiliy f h w yps f in sulin  b mixd bfr saring  prpar h mdicains. 2. Chck h labls f h insulin vials agains h in sulin rdr. Chck h insulin rdr and h cal culains f h prparain wih anhr qualid nurs in accrdanc wih insiuinal plicy. 3. Chck h fllwing:  • Type: Rgular, nural pramin Hagdrn (NPH), hr  • Concentration: U100 (U100 = 100 unis/mL)  • Expiration date: D NOT us h insulin if h x pirain da has passd.  • Appearance: Clar? Cludy? Prcipia prsn? Insulin suspnsins shuld b cludy. All hr insulin sluins shuld b clar. S Tabl 35.5.  • Temperature: Th insulin shuld b a rm mpraur. 4. T rsuspnd insulin suspnsins (NPH, Humulin, Nvlin, Humalg, Nvlg insulin), rll h vial r pn bwn h palms f h hands r gnly

UNIT II Illustrated Atlas of Medication Administration

132

R

N

A

B

C

D

R

N N

N

R

E

F

R

N

Insulin Reg. 15 units NPH 10 units

G

H

NPH 10 units 5

10

Reg. 15 units 15

20

25

Total = 25 units

I Fig. 9.26 Preparing two drugs in one syringe. (A) Check the insulin order and then cleanse the tops of both vials with an antiseptic alcohol wipe. (B) Pull back on the plunger to an amount that is equal to the volume of the longer-acting insulin. (C) Insert the needle through the rubber diaphragm of the longer-acting insulin and inject the air. Remove the syringe and needle; do not remove the insulin. (D) Pull back the plunger on the syringe to a point that is equal to the volume of the shorter-acting insulin ordered. (E) Insert the needle through the rubber diaphragm and inject the air. (F) Invert the bottle and withdraw the volume of the rapid-acting insulin ordered. Remove the syringe and needle. Check the amount withdrawn against the amount ordered. (G) Rewipe the top of the longer-acting insulin vial. (H) Insert the needle; withdraw the specied amount of longer-acting insulin. (I) Remove the syringe and needle. Recheck the drug order against the labels on the insulin containers and the amount in the syringe. R, Regular insulin; N, neutral protamine Hagedorn (NPH) insulin.

invr h vial svral ims  mix h cnns hrughly. S Tabl 35.6 n cmpaibiliy f cmbining insulins. 5. Th Amrican Diabs Assciain’s 2017 guidlins rcmmnd drawing up h rapid acing insulin in h syring hn adding h inrmdiaacing insulin.  • Whn aching a pain  mix insulin fr slf adminisrain, using a cnsisn mhd f prparing h mixur shuld b srssd s ha his bcms a habi fr h pain. This

can hlp prvn h pain frm inadvrnly rvrsing h ds f rapid and lngracing insulin in h mixur. 6. Clans h ps f both vials wih spara ani spic alchl wips (Fig. 9.26A). 7. Pull back h plungr n h syring  an amun ha is qual  h vlum f h lngracing insulin ha has bn rdrd (Fig. 9.26B). 8. Insr h ndl hrugh h rubbr sal f h lngracing insulin bl, and injc h air (Fig. 9.26C). D n bubbl air hrugh h insulin

Parenteral Administration: Safe Preparation of Parenteral Medications CHAPTER 9

9. 10. 11.

12. 13.

14. 15.

16.

sluin, bcaus i migh brak up insulin pari cls. Rmv h syring and ndl. D n wih draw insulin a his im. Pull back h plungr n h syring  an amun ha is qual  h vlum f h shrracing in sulin ha has bn rdrd (Fig. 9.26D). Insr h ndl hrugh h rubbr sal f h sc nd bl and injc h air (Fig. 9.26E). Invr h bl, and wihdraw h vlum f rap idacing insulin (Fig. 9.26F). (Note: Laving h ndl in h bl, chck fr bubbls in h insulin in h syring. Flick h sid f h syring wih h ngrs  displac h bubbls, and hn rchck h amun f insulin in h syring.) Rmv h syring and ndl. Chck h mdicain rdr agains h labl f h cnainr and h amun in h syring. Wip h lid f h lngracing insulin cnainr again (Fig. 9.26G). Rchck h drug rdr agains his cnainr. Insr h ndl f h syring cnaining h rapidacing insulin, and wihdraw h spcid amun f lngracing insulin (Fig. 9.26H). B carful not  injc any f h rs yp f insulin alrady in h syring in h lngracing insu lin vial. Rmv h syring and ndl. Rchck h drug rdr agains h labls n h insulin cnainrs and h amun in h syring (Fig. 9.26I). Draw back a small amun f air in h syring, and hn mix h w mdicains, rlling h sy ring bwn h palms f yur hands and gnly invring h syring svral ims  mix h cn ns hrughly. Rmv air carfully s ha par f h mdicain is n displacd. Adminisr h insulin  h pain by h subcu ru.

guidelineS for PrePAring mediCATionS for uSe in The STerile field during A SurgiCAl ProCedure ds us  t opat r • All mdicains usd during an praiv prc dur mus rmain sril. • All mdicain cnainrs (.g., ampuls, vials, piggyback cnainrs, bld bags) usd during h surgical prcdur shuld rmain in h p raing rm unil h nir prcdur is cm pld. If a qusin ariss, h cnainr is hn availabl. • Do not save any unusd prin f mdicain fr us during anhr surgical prcdur. Discard his unusd mdicain a h nd f h surgical prc dur, r snd h pain’s mdicain  h pain car uni wih h pain, if apprpria (.g., ani biic inmn fr a pain wh is having phhal mic surgry).

133

• Adhr  hspial plicis ha addrss h han dling and srag f mdicains in h praing rm. • Always ll h surgn h nam and dsag r cn cnrain f h mdicain r sluin ha is bing handd  him r hr. • Always rpa h nir mdicain rdr back  h surgn whn h rqus is mad  vrify all aspcs f h rdr. If in dub, rpa his infrma in again unil accuracy is crain. ds us  t St Sca f • Prpar h drug prscribd in accrdanc wih h dircins. • Always chck h accuracy f h drug rdr agains h mdicain bing prpard a las hr ims during h prparain phas: (1) whn i is rs rmvd frm h drug srag ara; (2) immdialy bfr rmving h slu in fr us in h sril ld; and (3) immdia ly afr cmpling h ransfr f h mdicain r sluin  h sril ld. Always ll h sur gn h nam and ds r cncnrain f h mdicain r sluin whn passing i  him r hr fr us. • Th circulaing (nnsril) nurs rrivs h md icain frm srag, rcnsius i as ndd, and urns h mdicain cnainr s ha h scrubbd (sril) prsn can rad h labl. I is bs  rad h labl alud  nsur ha bh individuals ar vrifying h cnns agains h vrbal rdr frm h surgn. • Th mdicain is ransfrrd  h sril ld by n f w mhds. Method 1

1. Th circulaing (nnsril) nurs clanss h p f h vial r braks ff h p f h ampul, as dscribd prviusly. 2. Th scrubbd (sril) prsn chss a syring f h crrc vlum fr h mdicain  b wih drawn and aachs a largbr ndl  facilia h rmval f h sluin frm h cnainr. 3. Th circulaing (nnsril) nurs hlds h ampul r vial in such a way ha h scrubbd (sril) pr sn can asily insr h sril ndl ip in h mdicain cnainr (Fig. 9.27A). 4. Th scrubbd prsn pulls back h plungr n h syring unil all f h mdicain prscribd has bn wihdrawn frm h cnainr and frm h ndl usd  wihdraw h mdicain. 5. Th ndl is discnncd frm h syring and lf in h vial r ampul (s Fig. 9.27B). 6. Th mdicain cnainr is again shwn  h scrubbd prsn and rad alud  vrify all cm pnns f h drug prpard agains h mdica in r sluin rqusd.

134

UNIT II Illustrated Atlas of Medication Administration

Method 2

A

B

Fig. 9.27 Preparing a medication in the operating room. (A) The circulating (nonsterile) nurse holds the vial to facilitate the scrubbed (sterile) person inserting the sterile needle tip into the medication container. (B) The needle is disconnected from the syringe and left in the vial.

1. Th circulaing (nnsril) nurs rmvs h n ir lid f h vial wih a bl pnr, clanss h rim f h vial, and purs h mdicain dircly in a sril mdicin cup hld by h scrubbd nurs. 2. Th scrubbd prsn cninus drug prparain n h sril ld in accrdanc wih h inndd us (.g., irrigain, injcin). Rgardlss f h mhd usd  ransfr h mdi cain  h sril ld, bh h sril scrubbd pr sn and h nnsril circulaing nurs shuld knw h lcain and h xac dispsiin f ach mdica in n h sril ld.

Parenteral Administration: Safe Preparation of Parenteral Medications CHAPTER 9

135

Cca Jt a nt-gat nClex® eaat-St qsts k Pts • A syringe has three parts: the barrel, the plunger, and the tip that holds the needle. Types of safety syringes and needles include the Luer-Lok and needleless systems of blunt needles and shields over the needles. • To correctly determine the gauge and length of the needle to use, the site of injection and the size of the patient are factored in, as well as the volume of medication to be administered. • The tuberculin syringe is used to measure volumes of less than 1 mL; the standard syringe sizes are 1, 3, and 5 mL. • Prelled cartridge-needle units and syringes contain a standard dose of a medication and are a time saver for the nurse, but more expensive than a multidose vial of medication. Cartridges require a special cartridge holder to administer the medication. • Ampules are glass containers of medications that need to be opened by snapping (breaking) the neck of the ampule before use. • Vials have a rubber diaphragm that a needle passes through to access the medication. • Mix-O-Vials are glass containers with two compartments. The lower compartment contains the medicine in powder form, and the upper compartment contains the diluent needed to dissolve the medicine. The two chambers are separated by a rubber plug. To mix the medicine, a rubber stopper on the top chamber is pushed, forcing the rubber stopper between the chambers to drop into the lower chamber, along with the diluent. Shaking the container dissolves the medicine, allowing it to be drawn up into a syringe for administration. • Insulin can be mixed in one syringe by drawing up the short-acting insulin rst, then adding the longer-acting insulin to the same syringe using a specic method.

a lg rss

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Willihng anz) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types. 1. The nurse preparing an IM injection to be administered will provide accurate and safe medication practices by following which principles? (Select all that apply.) 1. Performing premedication assessment 2. Being knowledgeable about the reason the medication is given

3. 4. 5. 6.

Administering the injection using clean technique Understanding how the medication will work Evaluating the therapeutic outcome desired Exercising clinical judgment regarding changes in the patient’s condition

ojv: Identify safe administration practices for parental medications. ncleX s : Extended multiple response cgv sk: Application 2. The nurse is preparing to give an injection into the patient’s abdomen for the early morning insulin dose. Which needle length and gauge is most appropriate to use? 1. 2. 3. 4.

18 gauge, 1½ inch 120 gauge, 1 inch 22 gauge, ⅝ inch 25 gauge, ⅝ inch

ojv: Identify the parts of a syringe and needle, as well as examples of the safety-type syringes and needles. ncleX s : Multiple choice cgv sk: Knowledge 3. The nurse in the medication room preparing an injection recognized that the needle needed for the injection must be the correct gauge and length. Indicate with an X the correct needle to use in each situation. 1- to 1½inch needle

1½to 2inch needle

⅝to 1inch needle

25- to 27GauGe needle

23- to 25GauGe needle

21- to 23GauGe needle

Insulin syringe IM injection for thin, frail adult IM injection for pediatric patient IM injection for obese adult

ojv: Describe how to select the correct needle gauge and length. nGn s : Matrix cgv sk: Recognize cues

UNIT II Illustrated Atlas of Medication Administration

136

4. The nurse discussing with an orientee the advantages of the prelled cartridge-needle units and syringes. Which statements by the nurse are accurate? (Select all that apply.) 1. “The prelled syringes require special cartridge holders.” 2. “The prelled syringes diminish the chance of contamination of the medication.” 3. “The prelled syringes are cheaper than the multidose vials.” 4. “The prelled syringes save the nurse the time it takes to prepare the injection.” 5. “The prelled syringes contain a standard volume and strength of medication.” ojv: Compare and contrast the advantages and disadvantages of using prelled syringes. ncleX s : Multiple response cgv sk: Understanding 5. The nurse needs to determine the difference between an ampule, a vial, and a Mix-O-Vial. Indicate with an arrow the technique used for the different parenteral dose forms. doSaGe form

technique uSed

Ampules

•  Inject air equal to the volume of medication to be removed •  Use a needleless spike for removing the medication •  Use a lter needle or lter straw to ensure that no glass particles are drawn into the syringe •  Depress the top rubber diaphragm to displace the stopper

Vials Mix-O-Vial

ojv: Differentiate among ampules, vials, and Mix-O-Vials. nGn s : Drag and drop cgv sk: Comprehension 6. The nurse is teaching the patient how to prepare 10 units of regular insulin and 5 units of NPH insulin for injection. List in the correct order the proper sequence for preparation that the nurse will describe to the patient. 1. Inject appropriate volumes of air into the NPH vial and the regular insulin vial. 2. Withdraw 10 units of regular insulin into the syringe. 3. Wipe the tops of the insulin vials with alcohol. 4. Withdraw 5 units of NPH insulin into the syringe to mix with the regular insulin.

5. Inject the insulin in the proper subcut site. 6. Mix the two insulins in the syringe by rolling between the palms and gently inverting the syringe several times. ojv: Describe the technique used to prepare two different drugs in one syringe (e.g., insulin). ncleX s : Ordering cgv sk: Application 7. The nurse needs to determine which medications need to be in a tuberculin syringe and which need to be in a larger volume syringe. Indicate with an X which syringe would work. tuberculin SyrinGe

larGer Volume SyrinGe

Subcutaneous injection (1.5 mL) Subcutaneous injection (0.5 mL) Intradermal Mantoux test (0.1 mL) IM injection for nausea (2 mL)

ojv: Compare and contrast the volumes of medications that can be measured in a tuberculin syringe and those of larger-volume syringes. nGn s : Drag and drop cgv sk: Recognize cues 7. The nurse needs to mix two medications in the same syringe so that the patient will only have to get one shot. List in order the steps necessary to mix two medications in one syringe. Withdraw the medication from the second vial. Wipe off the tops of both vials. Check the compatibility of the two drugs. Inject air into each vial equal to the volume to be withdrawn. 5. Withdraw the medication from the rst vial. 6. Mix the two medicines in the syringe by rolling between the palms and gently inverting the syringe several times. 1. 2. 3. 4.

ojv: Describe the technique used to prepare two different drugs in one syringe (e.g., insulin). ncleX s : Ordering cgv sk: Application

Parenteral Administration: Intradermal, Subcutaneous, and Intramuscular Routes

10

https://evolve.elsevier.com/Willihnganz

Objectives 1. Describe the technique that is used to administer a medication via the intradermal route. 2. Identify the equipment needed and describe the technique that is used to administer medication via the subcutaneous route. 3. Describe the techniques used to administer medications intramuscularly.

4. Describe the landmarks that are used to identify the vastus lateralis muscle, the rectus femoris muscle, the ventrogluteal area, and the deltoid muscle sites before medication is administered. 5. Identify suitable sites for the intramuscular administration of medication in an infant, a child, an adult, and an older adult.

Key Terms intradermal (ĭn-tră-DŬR-măl) (p. 137) erythema (ĕr-ĭ-THĒ-mă) (p. 139) induration (ĭn-dĕ-RĀ-shĕn) (p. 139) anergic (ăn-ĔR-jĭk) (p. 139) subcutaneous (sŭb-kū-TĀ-nē-ŭs) (p. 139)

intramuscular (ĭn-tră-MŪS-kyū-lăr) (p. 141) vastus lateralis (VĂS-tŭs lăt-ĕr-Ă-lĭs) (p. 142) rectus femoris (RĔK-tŭs FĔ-mŭr-ĭs) (p. 142)

ADMINISTRATION OF MEDICATION BY THE INTRADERMAL ROUTE Intradermal jcs r md  h drml ly-

r f sk js blw h pdrms (Fg. 10.1). Smll vlms, slly 0.1 mL, r jcd. Th bsrp frm rdrml ss s slw, hrby mkg  h r f chc fr llrgy ssvy ss, dssz jcs, lcl shcs, d vccs. Prfrm prmdc ssssms; s dvdl drg mgrphs fr dls. EQUIPMENT • Mdc  b jcd r sls f sspcd llrgs • Tbrcl syrg wh 26-gg, ¼-ch, r 28-gg, ½-ch dl, r  spcl dl d syrg fr llrgs • Mrc rlr, f prfrmg sk-sg prcdr • Glvs • Rcrd fr chrg d b h sbscs ppld d h p’s rspss • Aspc lchl wp • Prscrbr’s rdr r mdc prl SITES Irdrml jcs my b md  y sk srfc, b h s shld b hrlss d rcv ll frc frm clhg. Th ppr chs, h scplr

ventrogluteal area (vĕn-trō-GLOO-tēăl) (p. 142) deltoid muscle (DĔL-tōyd MŬS-ŭl) (p. 143) Z-track method (ZĒ TRĂK MĔTH-ĭd) (p. 145)

rs f h bck, d h r spc f h frrms r h ms cmmly sd rs (Fg. 10.2A d B). TECHNIQUE Ths xmpl f  rdrml jc chq vlvs llrgy ssvy sg. Tw mhds c b sd  dmsr llrgy sg. O mhd rqrs h rdrml jc f h llrgs; h hr s cmpld by sg h sk prck mhd. Caution: D  sr y yp f llrgy sg lss mrgcy qpm (cldg pphr) s vlbl  h mmd r  cs f  phylcc rsps. Nrss shld b fmlr wh h prcdr  fllw f  mrgcy ds rs. 1. Fllw h prcdr prcl  Chpr 9 (s Prpr f Prrl Mdc). 2. Vrfy h dy f h p sg w drs. 3. Chck wh h p bfr srg h sg  sr h hy hv  k y hsms r mmry gs (.g., spr, bprf, crcsrds) d h hy hv  rcvd mmspprss hrpy fr 24  48 hrs bfr h ss. If h p hs k hsms, cr slp mdcs (.g., dxylm, dphhydrm), r mmry gs, chck wh h hlhcr prvdr bfr prcdg wh h sg. 137

UNIT II Illustrated Atlas of Medication Administration

138

4. Prvd fr p prvcy. 5. Prfrm hd hyg d pply cl glvs. 6. Cls h r slcd fr sg hrghly wh  spc lchl wp. Us crclr ms, srg  h pld s f jc d Epidermis Bleb Dermis 15 degrees

Muscle

Subcutaneous

Fig. 10.1 Intradermal injection technique.

1 9 17 21

cg wrd  crclr ms  h prphry. Allw h r  r-dry. Intradermal Injection Method  • Prpr h dsgd sls fr jc sg spc chq. Usl vlms  b jcd rg bw 0.01 d 0.05 mL. A psvcrl sl h cs hsm d  gv-crl sl h cs sl r h dl f h llrg r ls dmsrd.  • Isr h dl   15-dgr gl wh h dl bvl pwrd. (Note: Thr s  crvrsy rgrdg whhr h dl bvl shld b pwrd r dwwrd. Chck h prcdr ml fr fcly plcy.) Th sl bg jcd s dpsd  h spc mmdly blw h sk; rmv h dl qckly. A smll blb wll ppr  h srfc f h sk s h sl rs h rdrml r (s Fg. 10.1). B crfl   jc  h

2 3 4 5 6 7 8 10 11 12 13 14 15 16 18 19 20 22 23 24

25 26 27 28 29 30

43 44 45 46 47 48

49 50 51 52 53 54

31 32 33 34 35 36

37 38 39

40 41 42

A

55 56 57

58 59 60

B

Reading Chart for Intradermal Testing Patient Name: Identification Number: Physician Name: DATE:

TIME:

AGENT

CONCENTRATION DOSAGE

SITE NUMBERa

Reading Time in Hours or Minutes 30 min or 24, 48, or 72 hr

a

Refer to diagram of sites (Fig.10.2A–B). • Follow directions for the “reading” of the skin testing performed • Inspect sites in a good light. 2+ • Record reaction in upper half of box using the following guidelines, e.g., No wheal, 3 mm flare + (1+) 2 to 3 mm wheal with flare ++ (2+) 3 to 5 mm wheal with flare +++ (3+) >5 mm wheal ++++ (4+) • Record measurement of induration (process of hardening) in mm in lower half of box, e.g.,

C

5 mm

Fig. 10.2 Intradermal sites. (A) Posterior view. (B) Anterior view. (C) Reading chart for intradermal testing.

Parenteral Administration: Intradermal, Subcutaneous, and Intramuscular Routes CHAPTER 10

sbcs spc d d  wp h s wh lchl fr jc.  • Do not rcp y dls h hv b sd. Acv h sfy dvc f  h syrg. Dsps f sd dls d syrgs   pcr-rss dl dspsl cr  ccrdc wh sl plcy. Skin Prick Test Method  • Mk  grd f  ls fr sqrs, mr f dd,  h s s  2-cm rvls wh  p.  • Plc  drp f ch llrg   f h grd sqrs f h sg s. A psv-crl sl h clds hsm d  gvcrl sl h clds sl r h dl f h llrg r ls dmsrd.  • Usg  lc wh  1-mm p, prck h sk hrgh h llrg drp. Wp h lc wh dry gz bw ch prck  prv h crryvr f h llrg frm h prvs s.  • Gly bl h xcss llrg ff f h s.  • Th sk prck s c b rd 10  20 ms fr dmsr, dpdg  prcl. 7. Rmv glvs d dsps f hm  ccrdc wh sl plcy. Prfrm hd hyg. 8. Chr h ms, gs, ccrs, d ms dmsrd (s Fg. 10.2C). Mk  dgrm  h p’s chr, d mbr ch lc. Rcrd wh g  wh ccr ws jcd  ch s. (Sbsq rdgs f ch r r h prfrmd d chrd  hs rcrd.) 9. Fllw h drcs rgrdg h m f h rdg f h sk sg bg prfrmd. Th spc f h jc ss shld b prfrmd  gd lgh. Grlly,  psv rc (.., h dvlpm f  whl; s Fg. 7.1)   dld srgh f  sspcd llrg s csdrd clclly sgc. Msr h dmr f h whl d y erythema (.., rdss  h s f jc)  mllmrs, d plp d msr h sz f y induration (.., h hrdg f  r f h bdy  rsps  mm). N rc  h llrgs, spclly  h psv crl, s kw s  anergic reaction. Argy s sscd wh mmdccy dsrdrs. 10. Rcrd h frm frm h sk s rdg  h p’s chr. Th fllwg s  ls f cmmly sd rdgs f rcs d hr pprpr symbls: + ++ +++ ++++

(1+) (2+) (3+) (4+)

No wheal, 3-mm are 2- to 3-mm wheal with are 3- to 5-mm wheal with are >5-mm wheal

Grlly,  psv rc  dlyd hyprssvy sk sg ( vl vv cll-mdd

139

mmy) rqrs  dr f  ls 5 mm  dmr. PATIENT TEACHING 1. Fr rdrml jcs, ll h p h m, d, d plc  rr  hv h s ss rd. 2. Tll h p   wsh r scrb h r l h jcs hv b rd. 3. If h p dvlps  r f svr brg r chg, hy shld ry   scrch . Tll h p  rpr mmdly h dvlpm f y brhg dfcly, svr hvs, r rshs d  g  h rs mrgcy dprm f hy r bl  rch h hlhcr prvdr wh prscrbd h sk ss. DOCUMENTATION Prvd h rgh dcm f h llrg sg ss d h p’s rspss  h llrgs h wr jcd. 1. Chr h d, m, llrgs (cldg g, ccr, d m), d s f dmsr (s Fg. 10.2). 2. Prfrm  rdg f ch s fr h pplc f h s s drcd by h hlhcr prvdr r h plcy f h hlhcr gcy. 3. Chr d rpr y sgs d sympms f dvrs llrg ffcs. 4. Prfrm d vld ssl p dc b h sg.

ADMINISTRATION OF MEDICATION BY THE SUBCUTANEOUS ROUTE Subcutaneous (sbc) jcs r md  h

ls ccv ss bw h drms d h msclr lyr (Fg. 10.3). Absrp s slwr d drg c s grlly lgr wh sbc jcs cmprd wh rmsclr (IM) r rvs (IV) jcs. If h p’s crcl s dq, h h drg s cmplly bsrbd frm h ss. My drgs c b dmsrd by hs r bcs rdrly  mr h 2 mL c b dpsd   sbc s. Th drgs ms b q slbl d p gh  b ffcv   smll vlm wh csg sgc ss rr. Drgs cmmly jcd  h sbc ss r hpr, xpr, d sl. Prfrm prmdc ssssms; s dvdl drg mgrphs fr dls. EQUIPMENT • Mdc  b jcd • Syrg f crrc vlm • Ndl f crrc lgh d gg • Glvs • Aspc lchl wp

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UNIT II Illustrated Atlas of Medication Administration

45 degrees Epidermis

1 2 3 4 5 6

Dermis

Subcutaneous

19 20 21 22 23 24

Muscle

Fig. 10.3 Subcutaneous injection. Inject at a 45- to 90-degree angle depending on the depth of subcutaneous tissue, the length of the needle, and the volume to be injected.

• Prscrbr’s rdr • Mdc prl Syringe Size Chs  syrg h crrspds wh h vlm f drg  b jcd   s. Th sl m jcd sbcsly   s s 0.5  2 mL. Crrl h syrg sz wh h sz f h p d h ss mss. Needle Length Assss ch p s h h dl lgh slcd wll dps h mdc  h sbc ss rhr h h mscl ss. Ndl lghs f ⅜, ½, d ⅝ ch r rly sd. I s prd  lv  xr ¼ ch f dl xdg bv h sk srfc  cs h dl brks. Needle Gauge Cmmly sd ggs fr sbc jcs r 25  29 gg. SITES Cmm ss sd fr h sbc dmsr f mdcs cld h ppr rms, h rr hghs, d h bdm (Fg. 10.4). Lss cmm rs r h bcks d h ppr bck r scplr rg. A pl fr rg jc ss shld b dvlpd fr ll ps wh rqr rpd jcs (s Fg. 10.4). Th rr vw (s Fg. 10.4B) llsrs rs h r sly ccssbl fr slf-dmsr. Th psrr vw (s Fg. 10.4A) llsrs lss cmmly sd rs h my b sd by  crgvr wh s jcg h mdc  h p. Wh dmsrg sl sbcsly,  s mpr  r h jc ss  prv lphyprrphy r lprphy, whch slws h bsrp

A

7 8 9 10 11 12

13 14 15 16 17 18

B

Fig. 10.4 Subcutaneous injection sites and rotation plan. (A) Posterior view. (B) Anterior view illustrating commonly used subcutaneous sites for self-administration. The anterior view also provides an example of a numbered rotation schedule for insulin injection, using one site systematically before proceeding to the next site of administration.

r f h sl. Th Amrc Dbs Assc Clcl Prcc Rcmmds s h sl jc ss shld b rd sysmclly wh  r bfr prgrssg   w s fr jc (s Fg. 10.4B);  s hgh h hs wll dcrs vrs  sl bsrp. Absrp s kw  b fss wh h sl s dmsrd  h bdm; hs s fllwd by h rms, hghs, d bcks. Bcs xrcs s ls kw  ffc h r f sl bsrp, s slc shld k hs fcr  csdr. TECHNIQUE 1. Fllw h prcdr prcl  Chpr 9 (s Prpr f Prrl Mdc). 2. Vrfy h dy f h p sg w drs. Esr h h p ds  hv  llrgy  h mdc. 3. Chck h ccrcy f h drg rdr gs h mdc bg prprd  ls hr ms drg h prpr phs: (1) wh rs rmvg h drg frm h srg r, (2) mmdly fr prpr, d (3) mmdly bfr dmsr. 4. Csl h msr r schdl fr h p s h h drg s dmsrd  h crrc s. 5. Expl crflly  h p wh  xpc. 6. Prvd fr h p’s prvcy d ps h p pprprly. 7. Prfrm hd hyg d pply cl glvs. 8. Exps h slcd s d lc h ldmrks. 9. Cls h sk srfc wh  spc lchl wp srg  h jc s d wrkg wrd   crclr m wrd h prphry. Allw h r  r-dry.

Parenteral Administration: Intradermal, Subcutaneous, and Intramuscular Routes CHAPTER 10

10. Chck h s f jc d h lgh f h dl. Assss whhr h jc s ms pprprly dmsrd   45-  90-dgr gl fr sbc dlvry. 11. Isr h dl qckly   45-  90-dgr gl; slwly jc h mdc. Th Amrc Dbs Assc Clcl Prcc Rcmmds s h “h dvdls r chldr my d  pch h sk d jc   45-dgr gl  vd IM jc, spclly  h hgh r.” 12. Whdrw h dl. Gl prssr my b ppld  h s wh  spc lchl wp, b do not rb. 13. Do not rcp y dls h hv b sd. Acv h sfy dvc. Dsps f sd dls d syrgs   pcr-rss dl dspsl cr  ccrdc wh sl plcy. 14. Rmv glvs d dsps f hm ccrdg  fcly plcy. Prfrm hd hyg. PATIENT TEACHING Prfrm pprpr p chg s dscrbd  h rld drg mgrphs. DOCUMENTATION Prvd h rgh dcm f h mdc dmsr d h p’s rsps  drg hrpy. 1. Chr h d, m, drg m, ds, s, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f h hrpc ffcvss (.g., bld prssr, pls, p, mprvm r qly f cgh d prdcvy, dgr d dr f p rlf). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy.

ADMINISTRATION OF MEDICATION BY THE INTRAMUSCULAR ROUTE Intramuscular jcs r md by prg 

dl hrgh h pdrms, drms, d sbc ss  h mscl lyr. Th jc dpss h mdc dp wh h mscl mss (Fg. 10.5). Absrp s mr rpd h h sscd wh sbc jcs bcs mscl ss hs  grr bld spply. S slc s spclly mpr wh IM jcs bcs h crrc plcm f h dl my cs dmg  rvs r bld vssls. Cmplcs frm mprpr chq f IM jcs cld hmm (wh  v s pcrd) d p (wh  rv s chd). A lrg, hlhy mscl h s fr frm fcs d wds shld b sd.

141

90 degrees

Epidermis Dermis

Subcutaneous Muscle

Fig. 10.5 Intramuscular injection technique.

Prfrm prmdc ssssms; s dvdl drg mgrphs fr dls. EQUIPMENT • Mdc  b jcd • Syrg f crrc vlm • Ndl f crrc lgh d gg • Glvs • Aspc lchl wp • Prscrbr’s rdr • Mdc prl Syringe Size Chs  syrg h crrspds wh h vlm f drg  b jcd   s. Th sl m jcd rmsclrly   s s 0.5  3 mL. I fs d chldr h m shld rg bw 0.5 d 1 mL, d  shld  xcd 1 mL. Crrl h syrg sz wh h sz f h p d h ss mss. I dls, dvdd dss r grlly rcmmdd fr ms  xcss f 3 mL; 1 mL s h mxmm m  b jcd  h dld r. Ohr fcrs h flc syrg sz d dl gg cld h yp f mdc, h s f dmsr, h hckss f h sbc fy ss, d h g f h dvdl. Needle Length Assss ch p s h h dl lgh slcd wll dps h mdc  h msclr ss (s Fg. 10.5). Thr s  sgc dffrc mg h dl lghs h r pprpr fr  bs p,  f, r  mcd r dbld p. Ndls h r cmmly sd r 1  1½ chs lg, lhgh lgr lghs my b rqrd fr bs ps.

142

UNIT II Illustrated Atlas of Medication Administration Femoral artery Femoral vein Greater trochanter

Greater trochanter

Femoral artery

Sciatic nerve

Femoral vein

Rectus femoris muscle

Sciatic nerve

Femoral artery

Vastus lateralis

Femoral vein Patella

Patella

A

B

A

B

Fig. 10.6 Vastus lateralis muscle. (A) Child or infant. (B) Adult.

Fig. 10.7 Rectus femoris muscle. (A) Child or infant. (B) Adult.

Needle Gauge Cmmly sd ggs fr IM jcs r 20  23 gg.

mjr bld vssls (s Fg. 10.7). If h mscl s  wll dvlpd, jcs  hs s my ls cs csdrbl dscmfr d pl jry.

SITES Vastus Lateralis Muscle Th vastus lateralis mscl s lcd  h rr lrl hgh, wy frm rvs d bld vssls (Fg. 10.6). Th mdpr s  hdbrdh blw h grr rchr d  hdbrdh bv h k (s Fg. 10.6B). Ths s grlly h prfrrd s fr IM jcs  fs bcs  hs h lrgs mscl mss fr h g grp. Ths mscl s ls  gd chc fr  jc s  hlhy, mblry dls. I ccmmds  lrg vlm f mdc, d  llws fr gd drg bsrp. I h ldr, dbld, r mblry dl, h mscl shld b crflly ssssd bfr jc bcs sgcly lss mscl mss my b prs. If mscl mss s sfc,  lrv s shld b slcd. Rectus Femoris Muscle Th rectus femoris mscl (Fg. 10.7) ls js mdl  h vss lrls mscl, b  ds  crss h mdl f h rr hgh. Th jc s s lcd  h sm mr s s sd fr h vss lrls mscl. Ths mscl my b sd  bh chldr d dls wh hr ss r vlbl. A prmry dvg  s s s h  my b sd mr sly by ps fr slf-dmsr. A dsdvg s h h mdl brdr s cls  h scc rv d

Life Span Considerations Injection Sites  • The vastus lateralis site is preferred in infants. In the older, debilitated, or nonambulatory adult, carefully assess the sufciency of the muscle mass before using this site for injection.  • The ventrogluteal site is also appropriate for infants and adults, and it may be used as often as needed.  • The deltoid site is preferred when administering 1 mL or less because of the convenience of the arm muscle.

Gluteal Area Th gll r s  cmmly sd s f jc bcs  s fr f mjr rvs d bld vssls. Th drsgll r ms  b sd  chldr wh r lss h 3 yrs ld bcs h mscl hs  y b wll dvlpd frm wlkg. Th vrgll r s  pprpr s fr jcs  chldr wh r lss h 3 yrs ld; hwvr, hs s s  sd s f s h vss lrls mscl bcs f h cvc f h hgh mscl. Th r my b dvdd  w dsc jc ss: (1) h vrgll r d (2) h drsgll r. Ventrogluteal area. Th ventrogluteal area s sly c-

cssbl wh h p s   pr, sp, r sdlyg ps. I s lcd by plcg h plm f h

Parenteral Administration: Intradermal, Subcutaneous, and Intramuscular Routes CHAPTER 10

143

Iliac crest Anterior superior iliac spine Gluteus medius Greater trochanter 45° 70° 90°

A

B Fig. 10.8 Ventrogluteal site. (A) Child or infant. (B) Adult.

Fig. 10.9 Patient lying in the prone position. The toes are pointed inward to promote muscle relaxation.

hd  h lrl pr f h grr rchr wh h hmb pg wrd h gr, h dx gr  h rr sprr lc sp, d h mddl gr xdd  h lc crs. Th jc s md  h cr f h “V” h s frmd bw h dx d mddl grs, wh h dl drcd slghly pwrd wrd h crs f h lm (Fg. 10.8). P  jc c b mmzd f h mscl s rlxd. Th p c hlp wh hs rlx by pg h s wrd whl lyg   pr ps (Fg. 10.9) r by xg h ppr lg f lyg  hr sd (Fg. 10.10).

Fig. 10.10 Patient lying on the side. Flexing the upper leg promotes muscle relaxation.

rr. C ms ls b xrcsd  vd h clvcl, h hmrs, h crm, h brchl v d rry, d h rdl rv. Th jc s (Fg. 10.11) f h dld mscl s lcd by plpg h crm prcss r p f h shldr d msrg dw w  hr grbrdhs. I s dvsbl  plp h mscl f h dld, whch s rghly rglr  shp,  drm h hcks pr f h mscl, whch wll h b h r fr h jc.

Dorsogluteal area. Th s f hs s s dscrgd

SITE ROTATION A msr pl fr s r shld b dvlpd d sd fr ll ps wh rqr rpd jcs (Fg. 10.12).

Deltoid Muscle Th deltoid muscle s f sd bcs f h s f ccss  hs r wh h p s  h sdg, sg, r pr ps. Hwvr,  shld b sd  fs ly wh h vlm  b jcd s smll, h drg s rrg, d h ds wll b qckly bsrbd. I dls, h vlm shld b lmd  1 mL r lss d h sbsc ms  cs

TECHNIQUE Standard Method 1. Fllw h prcdr prcl  Chpr 9 (s Prpr f Prrl Mdc). 2. Vrfy h dy f h p sg w drs. Esr h h p ds  hv  llrgy  h mdc. 3. Chck h ccrcy f h drg rdr gs h mdc bg prprd  ls hr ms drg h prpr phs: (1) wh rs

d  prccd  y gr x bcs f h pssbl dmg  h scc rv.

144

UNIT II Illustrated Atlas of Medication Administration

Clavicle Acromion process Scapula Deltoid muscle Axilla Radial nerve Brachial artery Humerus

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B Fig. 10.11 Deltoid muscle site. (A) Child or infant. (B) Adult.

4.

5. 6. 7. 8. 9.

rmvg h drg frm h srg r, (2) mmdly fr prpr, d (3) mmdly bfr dmsr. Clcl d drw p h mdc. Chck h sl plcy rgrdg whhr 0.1 r 0.2 mL f r shld b ddd  h syrg after ccrly msrg h prscrbd vlm f drg fr dmsr. (Note: Th rl fr ddg h r s h  wll rsl  h dl bg cmplly clrd f ll mdc  h m f jc. Cvrsly, f h vlm s cmplly drw  h syrg bfr chgg h dl, h drg vlm rdrd wll sll b dmsrd s lg s h sm sz dl s sd fr drwg p d jc. Ths h dl shld  d  b cmplly clrd f mdc by r drg dmsr. Ths ss c b crcl wh smll vlms f p drgs r rpdly dmsrd  fs.) Csl h msr r schdl fr h p s h h drg s dmsrd  h crrc s (s Fg. 10.12). Expl crflly  h p wh wll b d. Prvd fr h p’s prvcy; ps h p pprprly (s Fgs. 10.9 d 10.10 fr rlx chqs). Prfrm hd hyg d pply cl glvs. Exps h slcd s d lc h ldmrks.

10. Cls h sk srfc wh  spc lchl wp srg  h jc s d wrkg wrd   crclr m wrd h prphry. Allw h r  r-dry. 11. Usg h dm hd, sprd h sk d hld dw  psh sbc ss wy d llw grr dl pr. 12. Isr h dl   90-dgr gl sg  qck, dr-hrwg c. 13. Ijc h mdc sg gl, sdy prssr  h plgr d w fr  c f 3 bfr rmvg h dl. Ths wll sr h ll h mdc hs b dlvrd. (Note: Th d  spr bfr jc s  lgr prccd;  hs b fd  cs mr dmg d s csdrd cssry.) 14. Afr rmvg h dl, pply gl prssr  h s. Mssg c crs h p f h mscl mss s srssd by h m f mdc gv. 15. Do not rcp y dls h hv b sd. Acv h sfy dvc. Dsps f sd dls d syrgs   pcr-rss dl dspsl cr  ccrdc wh sl plcy. 16. Apply  smll bdg  h s. 17. Prvd ml sppr  h p. Chldr shld b cmfrd drg d fr h jc. Smms lg  chld hld yr hd r sy

Parenteral Administration: Intradermal, Subcutaneous, and Intramuscular Routes CHAPTER 10

5 Rectus femoris

3

6

1

4

2

Rectus femoris

Ventrogluteal Vastus lateralis

A

5

Deltoid

1

3

B

6

2

Ventrogluteal

4

Vastus lateralis

Fig. 10.12 Intramuscular master rotation plan. (A) Infant or child. Note that the deltoid site may also be used in an infant or child; however, the volume of medication must be small and the drug nonirritating. (B) Adult. In an adult, avoid using the rectus femoris site because of the pain produced.

“ch” hlps. Prs h p fr hr sssc d cpr. 18. Rmv glvs d prfrm hd hyg. Z-Track Method Th s f  Z-track method (Fg. 10.13) my b pprpr fr mdcs h r prclrly rrg r h s h ss. Chck fcly plcy rgrdg whch prsl my dmsr mdcs sg hs mhd.

145

1. Prvd fr h p’s prvcy; ps h p pprprly. 2. Prfrm hd hyg d pply cl glvs. 3. Exps h vrgll s r vss lrls s (Fg. 10.13A). Nvr jc  h p’s rm. 4. Clcl d drw p h mdc; dd 0.5 mL f r  sr h h drg wll clr h dl. 5. Cls h sk srfc wh  spc lchl wp srg  h jc s d wrkg wrd   crclr m wrd h prphry. Allw h r  r-dry. 6. Srch h p’s sk pprxmly 1 ch   sd (Fg. 10.13B). 7. Isr h dl. I s mpr  chs  dl f sfc lgh  sr dp mscl pr. 8. Gly jc h mdc d h w pprxmly 10 scds (Fg. 10.13C). 9. Rmv h dl d llw h sk  rr  s rml ps (Fg. 10.13D). 10. Do not mssg h jc s. 11. If frhr jcs r  b md, lr mg ss pr h msr r schdl. 12. Do not rcp y dls h hv b sd. Dsps f sd dls d syrgs   pcr-rss dl dspsl cr  ccrdc wh sl plcy. 13. Rmv glvs d dsps f hm ccrdg  fcly plcy. Prfrm hd hyg. 14. Tch h p h wlkg wll hlp wh h mdc’s bsrp. Vgrs xrcs r prssr  h jc s (.g., gh-g clhg) shld b mprrly vdd. PATIENT TEACHING Prfrm pprpr p chg s dscrbd  rld drg mgrphs. DOCUMENTATION Prvd h rgh dcm f h mdc dmsr d h p’s rsps  drg hrpy. 1. Chr h d, m, drg m, ds, s, d r f dmsr. 2. Prfrm d rcrd rglr p ssssms fr h vl f h hrpc ffcvss (.g., bld prssr, pls, p, mprvm r qly f cgh d prdcvy). 3. Chr d rpr y sgs d sympms f dvrs drg ffcs. 4. Prfrm d vld ssl p dc b h drg hrpy.

146

UNIT II Illustrated Atlas of Medication Administration Subcutaneous fat Skin Muscle

A

B

C

D

Fig. 10.13 Z-track method of intramuscular injection. (A) Alignment of layers before starting Z-tracking. (B) Stretch the skin slightly to one side by approximately 1 inch. (C) Inject the medication and then wait approximately 10 seconds. (D) Remove the needle and allow the skin to return to its normal position. Do not massage the injection site.

Parenteral Administration: Intradermal, Subcutaneous, and Intramuscular Routes CHAPTER 10

147

Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions Key Points • Intradermal injections are made into the dermal layer just below the epidermis and are usually 0.1 mL in volume. • Subcutaneous injections are made into the subcutaneous tissue or fatty layer between the dermis and the muscle. The volume of injection should be no greater than 2 mL. • Intramuscular injections are made into the muscle below the subcutaneous tissue. Care must be taken to ensure that the muscle is injected. • The sites for administration of IM injections include the vastus lateralis muscle, the rectus femoris muscle, the ventrogluteal area, and the deltoid muscle. Generally, an immunization is only 0.5 mL and can be given in the deltoid muscle for most adults. • The most suitable sites for an IM injection for children are the vastus lateralis muscle, the rectus femoris muscle, or the ventrogluteal area. In adults, the sites are the same as for a child, but also include the deltoid muscle. • The Z-track method is one way to deliver an IM injection when irritating medications need to be administered.

Additional Learning Resources

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Willihng anz) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types. 1. The instructor asks the student nurse to gather the equipment needed to perform an intradermal injection. Which items are appropriate? (Select all that apply.) 1. 2. 3. 4. 5. 6.

3-mL syringe Tuberculin syringe ¼-inch needle 21-gauge needle 26-gauge needle ⅝-inch needle

Objective: Describe the technique that is used to administer a medication via the intradermal route. NCLEX test item: Extended multiple response Cognitive skill: Evaluate cues

2. A student nurse has been practicing subcutaneous injections in the laboratory and is about to administer her rst insulin injection. List in correct order the proper sequence to follow when administering a subcut injection. 1. 2. 3. 4. 5. 6. 7. 8. 9.

Withdraw the needle Inject the insulin Explain procedure to patient Dart the needle in at a 45- to 90-degree angle Prepare the insulin per prescriber’s orders Document the administration Cleanse the site with alcohol Identify the patient using two identiers Locate the appropriate site for administration

Objective: Identify the equipment needed and describe the technique that is used to administer medication via the subcutaneous route. NGN test item: Ordering Cognitive skill: Application 3. Why will a nurse who administers an IM medication of iron use the Z-track method of administration? 1. 2. 3. 4.

It will provide faster absorption of the medication. It will reduce discomfort from the needle. It can provide more even absorption of the drug. It will prevent the drug from staining or irritating sensitive tissue.

Objective: Describe the techniques used to administer medications intramuscularly. NCLEX test item: Multiple choice Cognitive skill: Comprehension 4. The nurse is nding the landmark of the acromion process and measuring down two to three ngerbreadths to administer an IM injection into which site? 1. 2. 3. 4.

Vastus lateralis muscle Rectus femoris muscle Deltoid muscle Ventrogluteal site

Objective: Describe the landmarks that are used to identify the vastus lateralis muscle, the rectus femoris muscle, the ventrogluteal area, and the deltoid muscle sites before medication is administered. NCLEX test item: Multiple choice Cognitive skill: Knowledge 5. A student nurse reads an order to give a 69-year-old patient an IM injection. Which muscles could be used for injection sites for an adult? (Select all that apply.) 1. 2. 3. 4. 5.

Deltoid Dorsogluteal Ventrogluteal Vastus lateralis Rectus femoris

Objective: Identify suitable sites for the intramuscular administration of medication in an infant, a child, an adult, and an older adult. NCLEX test item: Multiple response Cognitive skill: Application

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UNIT II Illustrated Atlas of Medication Administration

6. The nurse needs to administer an IM injection and chooses the rectus femoris muscle. What landmarks will the nurse use for the injection?

7. The nurse is preparing to administer an IM injection to an elderly patient; what considerations need to be practiced? (Select all that apply.)

1. Two ngerbreadths below the acromion process 2. One handbreadth below the greater trochanter and one handbreadth above the knee 3. Between the V of the index nger and middle nger when on the trochanter 4. Between the anterior superior iliac spine and the iliac crest

1. The muscle needs to be palpated to determine whether the muscle mass is sufcient. 2. The length of the needle may need to be adjusted because the patient is older and the muscle mass may be insufcient. 3. The amount of the injection must be limited to 1 mL or less. 4. The injection needs to be in the deltoid muscle only. 5. A site rotation plan should be consulted before administration.

Objective: Describe the landmarks that are used to identify the vastus lateralis muscle, the rectus femoris muscle, the ventrogluteal area, and the deltoid muscle sites before medication is administered. NCLEX test item: Multiple choice Cognitive skill: Knowledge

Objective: Identify suitable sites for the intramuscular administration of medication in an infant, a child, an adult, and an older adult. NCLEX test item: Multiple response Cognitive skill: Application

Parenteral Administration: Intravenous Route

11

https://evolve.elsevier.com/Willihnganz

Objectives 1. Discuss the different intravenous (IV) access devices used for IV therapy. 2. Differentiate between isotonic, hypotonic, and hypertonic IV solutions and explain their clinical uses. 3. Identify the general principles for administering medications via the IV route. 4. Compare and contrast the differences between a peripheral IV line and a central IV line. 5. Describe the correct techniques for administering medications by means of a saline lock, an IV bag, an infusion pump, and a secondary piggyback set.

6. Identify baseline assessments for IV therapy and proper maintenance of patency of IV lines and implanted access devices. 7. Explain the signs, symptoms, and treatment of the complications associated with IV therapy (e.g., phlebitis, thrombophlebitis, localized infection, septicemia, inltration, extravasation, air in tubing, pulmonary edema, catheter embolism, and “speed shock”).

Key Terms intravenous (ĭn-tră-VĒ-nŭs) (p. 149) intracellular (ĭn-tră-SĔL-yĕ-lĕr) (p. 150) intravascular (ĭn-tră-VĂS-cū-lĕr) (p. 150) interstitial (ĭn-tĕr-STĬ-shĕl) (p. 150) extracellular (ĕk-strĕ-SĔL-yĕ-lĕr) (p. 150) IV administration set (p. 150) macrodrip (p. 150) microdrip (p. 150) programmable infusion pumps (prō-GRĂM-ă-bŭl ĭn-FŪzhăn PŬMPZ) (p. 152) syringe pumps (sĭ-RĬNJ) (p. 152) peripheral devices (pĕ-RĬF-ĕr-ăl dĕVĪ-sĕz) (p. 153) midline catheters (MĬD-līn KĂTH-ĕtŭrz) (p. 153) central devices (SĔN-trŭl dĕ-VĪ-sĕz) (p. 153) implantable venous infusion ports (ĭm-PLĂNT-ă-bŭl VĒ-nŭs

ĭn-FŪ-zhăn PŌRTS) (p. 153) winged, buttery, or scalp needles (WĬNGD, BŬT-ŭr-ī, SKĂLP NĒ-dŭlz) (p. 153) over-the-needle catheters (p. 153) saline lock or medlock (SĀ-lēn-lŏk, MĔD-lŏk) (p. 153) in-the-needle catheters (p. 153) peripherally inserted central venous catheters (PICCs) (pĕRĬF-ŭr-ăl-ē ĭn-SŬR-tĕd SĔN-trŭl VĒnŭs KĂTH-ĕ-tŭrz) (p. 154) tunneled central venous catheters (TŬN-ŭld) (p. 154) implantable infusion ports (ĭmPLĂNT-ă-bŭl ĭn-FŪ-zhăn PŌRTZ) (p. 155) intravenous (IV) solutions (ĭn-tră-VĒnŭs sŏl-Ū-shŭnz) (p. 156) electrolytes (ĕ-LĔK-trō-līts) (p. 156) isotonic (ī-sō-TŎN-ĭk) (p. 156) hypotonic (hī-pō-TŎN-ĭk) (p. 156)

Th rm intravenous (IV) adminisrain rfrs  h inrducin f uids dircly in h vnus bldsram. Th advanag f his chniqu is ha larg vlums f uids can b rapidly adminisrd in h vin fr vlum xpansin in cass f shck, r mr rapid ns f mdicains adminisrd inravnusly in cass f mrgncy. IV adminisrain is h ms rapid f

hypertonic (hī-pĕr-TŎN-ĭk) (p. 156) tandem setup, piggyback, or IV rider (TĂN-dĕm, PĬ-gē-băk, RĪ-dŭr) (p. 157) SASH guideline (SĂSH GĪD-līn) (p. 160) phlebitis (ĕ-BĪ-tĭs) (p. 174) thrombophlebitis (thrŏm-bō-ĕ-BĪtĭs) (p. 174) Inltration Scale (ĭn-fĭl-TRĀ-shŭn SKĀL) (p. 174) septicemia (sĕp-tĭ-SĒ-mē-yŭ) (p. 175) inltration (ĭn-fĭl-TRĀ-shŭn) (p. 175) extravasation (ĕks-tră-vă-SĀ-shŭn) (p. 175) air embolism (ĀR ĔM-bō-lĭz-ŭm) (p. 176) pulmonary edema (PŬL-mō-nār-ē ĕ-DĒ-mŭ) (p. 176) pulmonary embolism (PŬL-mō-nār-ē ĔM-bō-lĭz-ŭm) (p. 176) “speed shock” (SPĒD SHŎK) (p. 176)

all parnral rus bcaus i bypasss all barrirs  drug absrpin. Drugs may b givn by dirc injcin wih a ndl in h vin, bu hy ar mr cmmnly adminisrd inrminly r by cninuus infusin hrugh an sablishd priphral r cnral IV lin. An advanag f IV adminisrain cmpard wih hr frms f parnral adminisrain is ha i is 149

UNIT II Illustrated Atlas of Medication Administration

150

C

A

A C B A

C

Fig. 11.1 Fluid compartments of the body. (A) Intracellular spaces (e.g., the spaces within the cells). (B) Vascular spaces (e.g., within arteries, veins, and capillaries). (C) Interstitial spaces (e.g., the spaces between the cells). The body maintains a water and electrolyte balance among these compartments for homeostasis.

gnrally mr cmfrabl fr h pain, spcially whn svral dss f mdicains mus b adminisrd daily. Hwvr, disadvanags  h IV ru includ nurss nding h skill  sablish and mainain an IV si. In addiin, h pain nds  b lss mbil wih IV adminisrain, and hr is a grar pssibiliy fr infcin and fr svr advrs racins  h drug. Frm a physilgic sandpin, h war in h bdy is disribud amng hr cmparmns: (1) h intracellular cmparmn—wihin h clls (Fig. 11.1A); (2) h intravascular cmparmn—wihin h vascular sysm (.g., h arris, vins, and capillaris) (Fig. 11.1B); and (3) h interstitial cmparmn— wihin h spacs bwn h clls ha ar usid f h vascular cmparmn (Fig. 11.1C). Th extracellular cmparmn (h spacs usid h clls) is cmpsd f h inravascular and inrsiial cmparmns, and i cnains abu n-hird f h al bdy war, whras h inracllular cmparmn (wihin h clls) cnains abu w-hirds f h al bdy war. All IV hrapy rquirs a wrin rdr frm a halhcar prvidr ha is dad and ha spcis h yp f sluin r mdicain  b adminisrd, h dsag, and h ra and frquncy f adminisrain. Sm hspials us infusin hrapy ams fr adminisrain via h IV sysm, bu many nw assign h rspnsibiliy fr infusin hrapy  nurss wih arnd crdnials. Th nurs wh is prfrming vnipuncur (iniiain f an IV lin) and infusin hrapy mus b wll vrsd in h guidlins sablishd by h Infusin Nurss Sciy. Th Infusin Nurss Sciy, a prfssinal nursing rganizain, publishs h Infusin Nursing Sandards f Pracic rlad  qualiy assuranc, chnlgy and applicain, uids and lcrlys, pharmaclgy, infcin cnrl, pdiarics, nclgy, and parnral nuriin. Ms sa laws rcgniz h rl f h licnsd pracical nurs/licnsd vcainal nurs (LPN/LVN) in IV hrapy, bu dlga

h scp f pracic  b dnd in h plicis and prcdurs f individual clinical pracic sings. Th nurs shuld chck wih hir paricular sa bard f nursing  drmin h currn guidlins and ducain rquirmns. In gnral, LPN/LVN rspnsibiliis d n includ h adminisrain f IV mdicain, bld prducs, r aninplasic agns. Bfr any nurs adminisrs IV hrapy, hy shuld ask h fllwing qusins: • “Ds h law in his sa dlga his funcin  h nurs?” • “Ds h wrin plicy f h insiuin r agncy hrugh which I am mplyd, wih h apprval f h mdical saff, prmi a nurs wih my lvl f ducain and xprinc  adminisr IV hrapy?” • “Ds h insiuin r agncy plicy limi h yps f uids and mdicains ha I may adminisr?”

EquipmEnt usEd for intravEnous thErapy Intravenous admInIstratIon sets An IV administration set is an apparaus ha cnncs a larg vlum f parnral sluin wih h IV accss dvic in h pain’s vin. All ss (Fig. 11.2) hav an insrin spik, a drip chambr, plasic ubing wih a racnrl clamp, a rubbr injcin pral (als rfrrd  as a Y pr), a ndl adapr, and a prciv cap vr h ndl adapr. Dpnding n h manufacurr, h ss ar availabl in a variy f syls (.g., diffrn vlums and sizs f drip chambr, “piggyback” prals, lrs, and syls f cnrl clamps [Fig. 11.3]). Th yp f sysm usd by a paricular insiuin is usually drmind by h manufacurr f h IV sluins usd by h insiuin. Each manufacurr maks adaprs   a spcic yp f plasic r glass larg-vlum sluin cnainr. A crucial pin  rmmbr abu adminisrain ss is ha h drps dlivrd by drip chambrs vary amng manufacurrs. Macrodrip chambrs (s Fig. 11.2A and B) prvid 10, 15, r 20 drps/mL f sluin, whras microdrip chambrs (s Fig. 11.2C) dlivr 60 drps/mL f sluin. Micrdrip adminisrain ss ar usd whn a small vlum f uid is bing adminisrd, paricularly whn accuracy f vlum adminisrain is indicad (.g., wih nnaal and pdiaric ppulains; fr hs pains wih uid vlum cncrns). Vlumcnrl chambrs (s Fig. 11.2A and C) ar als usd as a safy facr  limi h vlum adminisrd. In many clinical sings, micrdrip ss ar usd fr all vlums f IV uid rdrd ha ar adminisrd a lss han 100 mL/hr. I is ssnial  rad h labl n h packag bfr pning i  nsur ha h crrc IV adminisrain s has bn slcd. Th nurs mus b abl  calcula h w ra fr any IV sluin. Th w ras ha ar usd fr

Parenteral Administration: Intravenous Route CHAPTER 11

Vent

Vent

Glass bottle

Plastic bag

Macrodrip chamber

Primary port Roller clamp

151

Glass bottle

Microdrip chamber

Slide clamp

Insertion spike Macrodrip chamber

Volume control chamber

Volume control chamber

Roller clamp

Filter Macrodrip chamber

Needle adapter and protective cap Roller clamp

Secondary port Secondary port

A

Microdrip chamber

B

C

Fig. 11.2 (A and B), Different types of intravenous (IV) administration sets that make use of a macrodrip chamber. (C) An IV administration set that includes a microdrip chamber.

infusin pumps ar gnrally in millilirs pr hur (mL/hr). A ypical w ra prblm wuld b as fllws: A wha ra will h nurs s h infusin pump if h rdr rads, “Infus 1000 mL f D5W vr 8 hurs”? Calcula h ra f infusin using a simpl frmula: mL dividd by hurs. 1000 mL 8 hr

= 125 mL / hr

Th nurs ss h pump ra fr 125 mL/hr, making sur  n h im h infusin sard. This infrmain is ky  pass n  h nx shif if h infusin is n cmpld wihin h im fram ha h nurs wh sard h infusin will b prsn. Th primary pars f h IV adminisrain s nd  b labld; h IV uid nds a labl ha indicas whn i nds  b changd (usually in 24 

48 hurs), and h IV ubing nds a labl indicaing whn i nds  b changd (usually in 72  96 hurs). ei u i Cjci Wi I t A larg variy f cnncr and accss dvics ar availabl fr varius cmpnns f infusin hrapy. Th nurs mus bcm familiar wih h IV accss sysms and h rms usd fr hs sysms a h clinical pracic sing. Knwing which pars f h sysm ar clan and which pars ar  rmain sril is crucial fr h prvisin f saf IV hrapy. types of InfusIon-Control pumps Prcis infusin ras ar impran fr crain hrapuic ffcs (.g., wih a cninuus hparin infusin

UNIT II Illustrated Atlas of Medication Administration

152

fr anicagulain) r whn mniring h adminisrain f mdicains  prvn xiciy (.g., nphrxiciy, xiciy). Prgrammabl infusin pumps ar usd  nsur h saf adminisrain f IV uids and mdicains (Fig. 11.4).

A

B

Fig. 11.3 Control clamps for intravenous administration sets. (A) Roller clamp. (B) Slide clamp. (A, From Perry AG, Potter PA, Ostendorf WR. Clinical Nursing Skills and Techniques. 8th ed. St. Louis: Mosby; 2014. B, From Otto SE. Pocket Guide to Intravenous Therapy. 4th ed. St. Louis: Mosby; 2001.)

p Th programmable infusion pumps apply xrnal prssur  h adminisrain s ubing  squz h sluin hrugh h ubing a a spcic ra (.g., a crain numbr f mL/min r mL/hr). Ths pumps ar prgrammd fr a spcic vlum vr im. Ths pumps hav an alarm sysm ha sunds if hr is rsisanc in h IV lin causd by a dvlping cclusin as a rsul f hrmbus frmain r a kink in h adminisrain s lin causd by pain mvmn. Disadvanags f pumps ar h cs f h quipmn and h raining f prsnnl, h cs f mainnanc, h nd fr mr quipmn a h bdsid, and h pnial fr srius IV inlrain. si p Syringe pumps hld a prlld syring and apply psiiv prssur  h plungr  dlivr a spcic vlum f mdicin vr a s im. Syring pumps ar mr cmmnly usd whn small vlums nd  b adminisrd (Fig. 11.4C). Exampls f small syring pumps ar hs ha cninually infus insulin in h subcuanus issu f pains wih diabs mllius and pain-cnrlld analgsia pumps, which allw pains wh ar rciving pain mdicains  adminisr cninual infusins and inrmin bluss f h mdicin fr cmfr. Syring pumps ar asy  us, and hir us is augh  pains nding hm infusin hrapy,

A

C

B Fig. 11.4 (A) Infusion controller. (B) Infusion pump. (C) Syringe pump. (A, Courtesy Hospira, Inc., Lake Forest, IL. B, Courtesy Baxter Healthcare Corporation, Mountain Home, AR. All rights reserved. C, Courtesy Smiths Medical, Minneapolis, MN.)

Parenteral Administration: Intravenous Route CHAPTER 11

whn pains slf-adminisr mdicains hrugh an impland infusin pr. I is impran ha h nurs bcm familiar wih h spcic dvics ha ar usd in h clinical sing fr saf and fcin pain car. Intravenous aCCess devICes IV accss dvics ar fn subdividd in fur grups n h basis f h lcain f h rminal ip f h accss dvic: (1) peripheral devices ar fr shrrm us in priphral vins in h hand r frarm; (2) midline catheters ar fr us vr 2  4 wks and ar insrd in inrmdia-sizd vins and advancd in largr vssls; (3) central devices ar insrd in inrmdia-sizd vssls and advancd in cnral vins whr h ip f h cahr ypically will b in h suprir vna cava  allw fr maximal mixing wih larg vlums f bld; and (4) implantable venous infusion ports, which ar surgically placd in cnral vins fr lng-rm hrapy. pi acc dic All ndls—if hy ar lng nugh—may b usd  adminisr mdicains r uids inravnusly. Hwvr, spcial quipmn has bn dsignd fr his purps. Winged needles, which ar als knwn as buttery r scalp needles, ar shr, sharp-ippd ndls (Fig. 11.5) ha wr riginally dsignd fr vnipuncur f small vins in infans and fr griaric us. Ths ndls ar availabl in sizs ha rang frm 17  29 gaug, and hav bn dsignd  minimiz issu injury during insrin. Th wingd ara is pinchd ghr  frm a handl whil h ndl is bing insrd. Th wings ar hn laid a agains h skin  frm a bas ha can b anchrd wih ap. Tw yps f hs ndls ar nw availabl: n wih a shr lngh f plasic ubing and a prmannly aachd rsalabl injcin pr and n wih a variabl lngh f plasic ubing wih a fmal Lur adapr fr h aachmn f a syring r an adminisrain s (s Fig. 11.5). Th pancy f h ndl is mainaind

Fig. 11.5 Winged needle with a female Luer adapter. (Courtesy Narang Medical Limited, New Delhi, India.)

153

wih h us f a hparin r salin ush ruin in accrdanc wih faciliy plicy. Over-the-needle catheters, which ar als knwn as short peripheral venous catheters, ar rcmmndd fr ruin priphral infusin hrapy. Th ndls ar sainlss sl and cad wih a Tn-lik plasic cahr (Fig. 11.6A). Afr h ndl pnras h vin in h hand r frarm, h cahr is advancd in h vin and h mal ndl is rmvd, hrby laving h plasic cahr in plac. An IV adminisrain s is hn aachd  h cahr fr cninuus infusin. This uni is usd whn IV hrapy is xpcd  cninu fr a fw days. Th rainal fr h us f h plasic cahr is ha i ds n hav a sharp ip ha culd caus vnus irriain and xravasain. Whn a pain n lngr rquirs IV uid hrapy bu vnus accss is sill ndd fr mdicain adminisrain, an xnsin ub wih an injcin pr is aachd  h cahr and h IV uid is discninud. This yp f IV accss dvic is calld a saline lock r a medlock (i.., medication lock). Nrmal salin (NS) ushing rahr han hparin is sufcin  prvn cling and mainain h priphral cahr ingriy. Gnrally, priphral cahrs shuld b changd vry 72  96 hurs  prvn infcin and phlbiis. Bld sampls shuld n b drawn frm priphral cahrs. If sis fr vnus accss ar limid and n vidnc f infcin is prsn, priphral vnus cahrs can rmain in plac, alhugh h pain and h insrin si shuld b mnird clsly fr signs and sympms f phlbiis, inlrain, and infcin. Th Cnrs fr Disas Cnrl and Prvnin (CDC) rcmmnds ha priphral cahrs n b changd fr pdiaric pains unlss his is clinically indicad. In-the-needle catheters mak us f larg-br ndls fr vnipuncur (Fig. 11.6B). A 4-  6-inch sril, smallr-gaug, plasic cahr is hn advancd hrugh h ndl in h vin. Th ndl is wihdrawn, and h skin frms a sal arund h plasic cahr. Th IV adminisrain s is aachd dircly  h plasic cahr. In-h-ndl cahrs ar sldm usd day fr priphral IVs bcaus f h risk f sharing h hrugh-h-ndl cahr. Midlin accss cahrs ar slcd fr us if i is anicipad ha IV accss will b ndd fr 7 days r mr. Ths cahrs ar fn lf in plac fr 2  4 wks. Midlin cahrs ar xibl and 3  8 inchs lng, and ar insrd a h ancubial fssa in h cphalic r basilic vin and advancd  h disal subclavian vin. Thy d n nr h suprir vna cava. Midlin cahrs appar  b assciad wih lwr ras f phlbiis han shr priphral cahrs; hy hav a lwr ra f infcin, and hy cs lss han cnral vnus cahrs. Th CDC rcmmnds h rplacmn f h cahr and h rain f h injcin si n mr frqunly han vry 72  96 hurs, bu h CDC ds n prvid rcmmndains rgarding h maximum lngh f im ha h cahr

UNIT II Illustrated Atlas of Medication Administration

154

Needle guard

Needle

Needle

Needle hub Collar Catheter

Catheter

Protective sleeve

Protective cover Catheter hub

Catheter adapter

Needle hub

A

Protective cap

Flow control plug

B

Fig. 11.6 (A) Over-the-needle catheter. This unit is the most commonly used type of catheter when intravenous therapy is expected to continue for several days. (B) In-the-needle catheters make use of a large-bore needle for venipuncture. A 4- to 6-inch sterile, small-gauge, plastic catheter is then advanced through the needle and into the vein. The needle is withdrawn, and the skin forms a seal around the plastic catheter. The intracatheter is infrequently used today.

may rmain in plac. Many insiuins rquir ha h halhcar prvidr wri an rdr ha indicas ha h IV infusin may b lf in plac fr mr han 72 hurs. Midlin cahrs ar usd fr cninuus accss, rpad accss, r IV sluins wih high w ras. This yp f cahr nds  b ushd wih salin and hparin sluin afr ach us, r a las nc daily if i is n in us. Bld shuld n b drawn hrugh his cahr. C acc dic Cnral IV accss dvics, which ar als knwn as indwelling catheters, ar usd in h fllwing siuains: whn h purps f hrapy dicas hir us (.g., larg vlums f mdicain, fr irriaing mdicin such as chmhrapy, r whn hyprnic sluins such as al parnral nuriin [TPN] ar  b infusd); whn priphral sis hav bn xhausd as a rsul f rpad us r h cndiin f h vins fr accss is pr; whn lng-rm r hm hrapy is rquird; r whn mrgncy cndiins manda adqua vascular accss. Th cnral vnus sis ha ar ms cmmnly usd fr cnral vnus cahrs ar h subclavian and jugular vins. Whn h uppr bdy vins ar n accpabl, h fmral vins may b accssd fr shr-rm r mrgncy us. A primary halhcar prvidr can als lc  prfrm a vniscin r a cudwn  insr his yp f cahr in h basilic r cphalic vins in h ancubial fssa. Thr yps

f dvics, basd n h placmn f h cahr’s prximal ip, ar ruinly usd fr cnral cahrs: priphral dvics, unnld dvics, and implanabl dvics. Peripherally inserted central venous catheters (PICCs) ar insrd in h ancubial spac r frm

h uppr arm accssing h cphalic r basilar vins nding in h suprir vna cava r jus usid h righ arium. PICCs prvid an alrnaiv  subclavian r jugular vnus cahrizain and ar usd fr infusin hrapy and bld draws. PICCs ar availabl in sizs ha rang frm 14  28 gaug, wih varius lnghs, hrby making hm availabl fr pdiaric us. Th cahr islf can hav an pn ip r a valvd (Grshng) ip, and i cms wih a singl r dubl lumn. Th PICC lin has h advanag f as f insrin bcaus h prcdur can b prfrmd a h bdsid by a qualid nurs. PICCs ar assciad wih fwr mchanical cmplicains (.g., hrmbsis, hmhrax), hy cs lss han hr cnral vnus cahrs, hy ar asir  mainain han shr priphral cahrs (bcaus hr is lss frqun inlrain and phlbiis), and hy rquir lss frqun si rain. PICC lins ruinly rmain in plac fr 1  3 mnhs, bu hy can las fr 1 yar r mr if hy ar card fr prprly. Whn h dvic is n in us, h IV infusin is discnncd and h cahr is ushd and cappd. Th lin shuld b ushd wih a salin-hparin sluin afr vry us r daily, if n usd, in accrdanc wih insiuinal plicy. Tunneled central venous catheters ar surgically placd during an upain prcdur wih h pain undr lcal anshsia. Th rminal ip f h cahr is insrd hrugh an incisin and in h subclavian vin, whr i is hn advancd  h suprir vna cava. Th prximal nd f h cahr is unnld abu 6 inchs away undr h skin n h chs  xi mid chs. A Dacrn cuff is fn placd arund h cahr undr h skin, which anchrs h cahr and frms a sal arund h cahr as h skin hals, hrby hlping  kp h unnl sril. Thr yps f cahrs ha ar frqunly usd ar h Hickman, Brviac, and Grshng cahrs (Fig. 11.7). Th Brviac cahr is a singl-lumn cahr wih a largr xrnal diamr and a sandard nd hl. Th Hickman cahr is largr in diamr han h Brviac cahr, bu i cnains w r hr lumns; i als has a sandard nd hl. Whn hy ar n in us, bh f hs cahrs ar clampd  prvn cnaminain, cling, and air mblism. Ths cahrs mus als b ushd wih a salin-hparin sluin afr vry mdicain adminisrain, r a las nc daily if hy ar n in us. Th Grshng cahr cnains n  hr lumns, and ach n has a rundd valvd ip. Th Grshng valv pns inward fr bld sampling and uward fr infusin, bu i rmains clsd whn i is n in us. Bcaus h valv rmains clsd whn i is n in us, i sals

Parenteral Administration: Intravenous Route CHAPTER 11

155

A Fig. 11.8 Silicone venous catheter with infusion ports. (From Potter PA, Perry AG. Basic Nursing: Theory and Practice. 5th ed. St. Louis: Mosby; 2001.)

B

C Fig. 11.7 (A) Hickman catheter. (B) Broviac catheter. (C) Groshong catheter. (Courtesy Chuck Dresner.)

h uid insid h cahr and prvns i frm cming in cnac wih h pain’s bld. Thus wkly ushing wih salin sluin is all ha is rquird  kp h cahr pan. Th valv als liminas h nd fr ruin clamping f h cahr, alhugh i shuld rmain cappd whn i is n bing usd. Implantable infusion ports (.g., Infus-A-Pr, PrA-Cah) ar usd whn lng-rm hrapy is rquird and inrmin accssing f h cnral vin is rquird fr h adminisrain f IV uids, mdicains, TPN, chmhrapy, and bld prducs. Th implanabl dvics ar similar  unnld dvics wih rgard  placmn; hwvr, h prximal nd f h singl- r dubl-lumn cahr is aachd  a singl- r dubl-lumn accss pr (Fig. 11.8) and hn impland and suurd in a subcuanus pck in h chs ara r h uppr arm. Th dubl prs ar dsignd  allw fr h adminisrain f w IV sluins, w IV mdicains, r n f ach simulanusly. On pr can als b rsrvd fr drawing bld sampls. Th prs cnain a slf-saling silicn rubbr spum ha has bn spcically dsignd fr rpad injcins vr an xndd prid f im.

A spcial nncring, 90-dgr-angl Hubr ndl is usd  pnra h skin and h spum f h impland dvic  minimiz damag  h slf-saling spum. T prlng h lif f h spum, nly h smalls-gaug nncring ndls shuld b usd. Th chs pr is simad  wihsand up  2000 puncurs, whras h arm pr has an simad lif f 1000 puncurs. An impland cnral vnus accss cahr may rmain in plac fr mr han 1 yar, and i rquirs nly a salin-hparin sluin ush afr vry accss r nc mnhly. Bcaus h nir pr and cahr ar undr h skin, n daily mainnanc is ndd, alhugh h si shuld b mnird visually n a rgular basis  chck fr swlling, rdnss, r drainag. This yp f cnral vnus cahr givs h pain h gras xibiliy in rms f daily aciviis and xrcis, including swimming; hwvr, cnac sprs shuld b avidd. All cnral vnus accss dvics rquir ps insrin radigraphy  vrify h lcain f h dvic and  chck fr h prsnc f a pnumhrax fr cahrs ha ar unnld n h chs. Th CDC rcmmnds ha cnral vnus cahrs n b ruinly rplacd  prvn cahr-rlad infcin.

intravEnous dosE forms Rviw Chapr 9 fr infrmain abu h us f ampuls, vials, and Mix-O-Vials. All parnral drug ds frms ar packagd s ha h drug is sril and rady fr rcnsiuin (if ndd) and adminisrain. types of Intravenous solutIons Undr nrmal and halhy cndiins, h bdy lss war and lcrlys daily hrugh urin, prspirain, and fcs. Fluids ar rplnishd as a rsul f h absrpin f war in h gasrinsinal rac frm h liquids and fds ha ar cnsumd. Hwvr, as a rsul f many diffrn disas sas (.g., vmiing, diarrha, gasrinsinal sucining, hmrrhag, drainag frm a wund, dcrasd inak, nausa, anrxia, fvr, xcss lss frm disas [.g., uncnrlld diabs mllius, diabs insipidus]), pains ar unabl  ings sufcin quaniis f uid and

156

UNIT II Illustrated Atlas of Medication Administration

lcrlys  ffs hs lsss. Whn his happns, h IV infusin f sluins may b ncssary fr rplacmn. S a mdical-surgical nursing xbk fr mr infrmain abu pain assssmns fr dcin uid vlum. Intravenous (IV) solutions (Bx 11.1) cnsis f war (.g., a slvn) ha cnains n r mr yps f disslvd paricls (.g., slus). Th slus ha ar ms cmmnly disslvd in IV sluins ar sdium chlrid, dxrs, and passium chlrid. Th slus ha disslv in war and disscia in in paricls (.g., Na+, K+, Cl ) ar calld electrolytes bcaus hs ins giv war h abiliy  cnduc lcriciy. TPN sluins cnain all h lcrlys ncssary in

Box 11.1

Types of Intravenous Solutions and Their Ingredientsa

ElEctrolytE SolutionS • 5% dextrose in water (D5W) • 10% dextrose in water (D10W) • 0.45% sodium chloride (0.45 NS) • 0.9% sodium chloride (normal saline; NS) • Lactated Ringer solution (LR) • 5% dextrose in 0.2% sodium chloride (D5/0.2 NS) • 5% dextrose in 0.45% sodium chloride (D5/0.45 NS) • 5% dextrose in 0.9% sodium chloride (D5/0.9 NS) • 5% dextrose in lactated Ringer solution (D5/LR) • 5% dextrose in 0.2% sodium chloride with 20 mEq of potassium chloride (D5/0.2 NS + 20 KCl) nutriEnt Solution cabae • Dextrose 5% to 25% (D5–25) A As (tae naes) • Aminosyn • Travasol • ProcalAmine • NephrAmine • TrophAmine • HepatAmine lps (tae nae) • Intralipid • Nutrilipid • Omegaven • SMOFlipid B-Ve Epaes • Hetastarch • Dextran • Albumin • Plasma • Tetrastarch Aazg Ss • Sodium bicarbonate • Tromethamine (tris[hydroxymethyl]aminomethane [THAM]) • Sodium lactate Ag S • Ammonium chloride a

This is a representative listing; it is not intended to be complete.

addiin  nugh carbhydras (usually dxrs), amin acids, and fay acids  susain lif. Th spnanus mvmn f war acrss h inravascular cmparmn capillary mmbrans  h inrsiial spacs and acrss h cll mmbrans and back  h inravascular capillary spac is calld osmosis. Th war mvs frm an ara f high cncnrain f war (.g., f lw lcrly cncnrain)  an ara f lw war cncnrain (.g., f high lcrly cncnrain). Th lcrly and prin cncnrains f ach uid cmparmn ar wha draw war in h cmparmn unil hr is quilibrium bwn cmparmns. Th frc causd by h lcrlys and prins is calld osmotic pressure. Th cncnrain f h disslvd paricls in ach cmparmn is knwn as h osmolality. Nrmal bld srum smlaliy is 295  310 millismls pr lir (mOsm/L). Bcaus IV sluins als cnain disslvd paricls, hy als hav an smlaliy. If h IV sluin and h bld hav apprximaly h sam smlaliy, hn h sluin is said  b isotonic. Sluins ha hav fwr disslvd paricls han h bld ar cnsidrd  b hypotonic, and hs wih a highr cncnrain f disslvd paricls ar hugh f as hypertonic. A 0.9% sluin f sdium chlrid, which is als knwn as normal saline (NS) r physiologic saline, is an isnic sluin wih an smlaliy f 308 mOsm/L. Tabl 11.1 liss cmmnly usd IV sluins, hir lcrly cncnrains, and hir smlaliis. Ths sluins wih smlaliis blw 270 mOsm/L ar hypnic, hs wih valus frm 270  310 mOsm/L ar isnic, and hs wih valus f mr han 310 mOsm/L ar hyprnic. Isnic sluins (.g., 0.9% sdium chlrid, lacad Ringr) ar idal rplacmn uids fr h pain wih an inravascular uid dci (.g., acu bld lss as a rsul f hmrrhag, gasrinsinal blding, r rauma). This yp f uid is usd fr hypvlmic, hypnsiv pains  incras vascular vlum  suppr bld prssur; hwvr, hs pains mus b mnird fr uid vrlad (pnial pulmnary dma), spcially if h pain has cngsiv har failur. Anhr isnic sluin, dxrs 5% wih 0.2% sdium chlrid (D5/0.2 NS), is a sandard sluin fr mainaining hydrain and lcrlys (.g., passium chlrid), adminisring cninuus infusin IV mdicains, and  kp pn (TKO) IV hrapy fr h inrmin adminisrain f mdicains. D5/0.2 NS sluins ar infusd as isnic sluins, bu hy rapidly bcm hypnic sluins as h dxrs is mablizd. Thrfr D5/0.2 NS sluins—vn hugh hy ar iniially isnic—shuld n b usd  mainain vascular vlum in a pain wh is hypvlmic and hypnsiv. Hypnic sluins (.g., 0.2% r 0.45% sdium chlrid) hav lwr smlaliy han srum. This yp f sluin cnains fwr lcrlys and mr fr war, s h war is rapidly pulld frm h vascular

Parenteral Administration: Intravenous Route CHAPTER 11

157

cmparmn in h inrsiial and inracllular uid cmparmns. Alhugh hs sluins ar usful in cndiins f cllular dhydrain, adminisring hm  rapidly may caus a suddn shif f uids bing drawn frm h inravascular spac in h hr cmparmns. Hyprnic sluins hav an smlaliy ha is highr han ha f h srum. Alhugh hypnic and isnic sluins ar usd in paricular siuains bcaus f hir niciy, hyprnic sluins ar rarly usd in his way bcaus hy hav h pnial  pull uid frm h inracllular and inrsiial cmparmns in h inravascular cmparmn, hrby causing cllular dhydrain and vascular vlum vrlad. In cass f xravascular vlum vrlad, hs sluins ar usd  diurs pains bcaus hs sluins will draw uid in h vascular cmparmn, which hn can b xcrd by h kidnys, usually wih h hlp f diurics such as fursmid. Hyprnic sluins als hav h disadvanag f causing phlbiis and vnus spasm, wih inlrain and xravasain ccurring in h priphral vins. In gnral, sluins wih smlaliis f mr han apprximaly 600  700 mOsm/L shuld n b adminisrd in priphral vins. Hyprnic sluins (.g., parnral nuriin sluins) mus b adminisrd hrugh cnral infusin lins, whr h sluin can b rapidly dilud by larg vlums f rapidly wing bld (.g., in h suprir vna cava nar h nranc  h righ arium).

f h cnainr, i is rplacd wih air. Ohr brands mak us f a xibl plasic cnainr (s Fig. 11.2B). As h sluin runs u f h bag, h xibl cnainr cllapss. Plasic bags ar smwha diffrn in ha h nir bag and sluin ar sald insid anhr plasic bag ha is rmvd jus bfr adminisrain. Whn h insrin spik is frcd in h spcially markd pral, an inrnal sal is brkn, which allws h sluin  w in h ubing.

large-volume solutIon ContaIners IV sluins ar availabl in bh plasic and glass cnainrs in a variy f yps and cncnrains (s Tabl 11.1 and Bx 11.1) and in vlums ha rang frm 100  2000 mL. Bh h glass and plasic cnainrs ar vacuum sald. Th glass bls ar sald wih a hard rubbr sppr and hn a mal disk, and his is fllwd by a mal cap. Righ bfr us, h mal cap and disk ar rmvd, hrby xpsing h hard rubbr sppr. Th insrin spik f h IV adminisrain s is pushd in a spcically markd ara n h rubbr sppr. Sm brands als hav anhr pning in h rubbr sppr ha srvs as an air vn (s Fig. 11.2A and C). As h sluin runs u

dose forms Mdicains fr IV adminisrain ar availabl in ampuls, vials, prlld syrings, and larg-vlum IV sluin bags. B crain ha h labl spcically sas ha h mdicain is fr IV us. IV uid and lcrly sluins cm in a variy f vlums and cncnrains in glass and plasic cnainrs (s Bx 11.1).

small-volume solutIon ContaIners Sm mdicins (.g., anibiics) ar adminisrd by inrmin infusin hrugh an apparaus knwn as a tandem setup, piggyback, r IV rider (Fig. 11.9). Ths mdicins ar givn by a sup ha is hung in andm and cnncd wih h primary sup. Th scndary sup may cnsis f a drug infusin frm a small vlum f uid in a small bag r bl (≤250 mL; s Fig. 11.9) r frm a vlum cnrl s (Burrl, Vlurl; s Fig. 11.2A and C). A vlum cnrl s is cmpsd f a calibrad chambr ha is hung undr h primary IV sluin cnainr and ha can prvid h ncssary 50  250 mL f dilun pr ds f drug. Ms inrmin dilud drug infusins ar infusd vr 20  60 minus.

administration of mEdications by thE intravEnous routE

equIpment • Mdicain prl • Prscribr’s rdr • Glvs • Turniqu

Table 11.1 Intravenous Solutions, Electrolyte Concentrations, and Osmolality Solution 0.45 Normal saline

nA+ (mEq/l) 77

cl− (mEq/l) 77

GlucoSE (G/l) 0

oSmolAlity (moSm/l) 154

0.9 Normal saline

154

154

0

308

5% Dextrose in 0.2% sodium chloride

34

34

50

320

5% Dextrose in 0.45% sodium chloride

77

77

50

405

5% Dextrose in 0.9% sodium chloride

154

154

50

560

Lactated Ringer solutiona

130

109

0

273

aAlso

contains the following: K + (4 mEq/L), lactate (28 mEq/L), Ca 2+ (3 mEq/L).

158

UNIT II Illustrated Atlas of Medication Administration Piggyback

Piggyback

Full

Empty

Basilic vein Cephalic vein

Primary infusion container

Primary infusion container Clamp open

Clamp open

Clamp open

Check valve

Clamp open

Dorsal metacarpal veins

Dorsal venous network

Dorsal digital veins

Check valve

Fig. 11.10 Intravenous sites on the hand. (Redrawn from Williams PL, Warwick R, Dyson M, Bannister LH, eds. Gray’s Anatomy. 37th ed. New York: Churchill Livingstone; 1989.)

Fig. 11.9 Piggyback intermittent administration setup. Note that the smaller bag is hung higher than the primary bag.

• Adminisrain s wih syring, apprpria ndl r ndllss cnncr (if giving by blus), drip chambr, and lr • Mdicain • Physilgic sluin rdrd • Sril drssing marials • Anispic sluin • Salin lck adapr • Arm bard (if indicad) • Tap • Sandard IV pl • Salin sluin, piggyback, and addiinal sluins as apprpria Addiinal supplis may b rquird  accss, ush, r chang IV adminisrain ss, inlin lrs, r drssings, dpnding n h yp f priphral, cnral, r implanabl dvic bing usd. sItes pi I acc Whn slcing an IV si, cnsidr h fllwing: h lngh f im ha h IV infusin will b rquird; h cndiin and lcain f h vins; h purps f h infusin (.g., rhydrain, dlivry f nuriinal nds [.g., TPN], chmhrapy, and anibiics); and h pain’s saus, cprain lvl, and prfrnc

fr and amun f slf-car ndd fr h injcin si (if apprpria). Priphral IV dvics includ h wing-ippd ndl (s Fig. 11.5), h vr-h-ndl cahr (s Fig. 11.6A), and h in-h-ndl cahr (s Fig. 11.6B). Th vr-h-ndl cahrs ar h ms cmmnly usd vnus accss sysms fr nring h priphral vins. If a prlngd curs f ramn is anicipad, sar h rs IV infusin in h hand (Fig. 11.10). Th macarpal vins, h drsal vin nwrk, h cphalic vin, and h basilic vin ar cmmnly usd. T avid irriain and lakag frm a prvius puncur si, h subsqun vnipuncur sis shuld b mad abv h arlir si. Fig. 11.11 shws h vins f h frarm ara ha culd b usd fr addiinal vnipuncur sis. C I acc Cnral IV accss dvics ar usd fr h fllwing siuains: whn h purps f hrapy dicas (.g., larg-vlum, high-cncnrain, r hyprnic sluins ar  b infusd); whn priphral sis hav bn xhausd as a rsul f rpad us r whn h cndiin f h vins fr accss is pr; whn lng-rm r hm hrapy is rquird; r whn an mrgncy cndiin mandas adqua vascular accss. Th cnral vins ha ar ms cmmnly usd fr cnral vnus cahrs ar h subclavian and jugular vins. Whn uppr bdy vins ar n accpabl, h

Parenteral Administration: Intravenous Route CHAPTER 11

In infraclavicular fossa

In deltopectoral groove

Cephalic vein Medial cutaneous nerve of forearm Median cubital vein Lateral cutaneous nerve of forearm

Basilic vein Medial cutaneous nerve of forearm, ulnar branch

Accessory cephalic vein

Basilic vein

Cephalic vein

Median vein of forearm

Fig. 11.11 Veins in the forearm that are used as intravenous sites. (Redrawn from Williams PL, Warwick R, Dyson M, Bannister LH, eds. Gray’s Anatomy. 37th ed. New York: Churchill Livingstone; 1989.)

fmral vins may b accssd fr shr-rm r mrgncy us. general prInCIples of Intravenous medICatIon admInIstratIon • Th nurs shall hav passd a skill cmpncy ha dmnsras hir knwldg f h IV adminisrain prcdur. • If i is insiuinal plicy  us a lcal anshic  anshiz h IV si bfr insrin, h nurs mus drmin h pain’s allrgis  anshic agns. • Us apprpria barrir prcauins (.g., univrsal bld and bdy uid prcauins)  prvn h ransmissin f any infcius disass, as rcmmndd by h CDC.

159

• Glvs shuld b wrn hrughu h vnipuncur prcdur. Car shuld b akn  wash h skin surfac if h ara is cnaminad wih bld. • Whn h prcdur is cmpl, rmv glvs and disps f hm in accrdanc wih h plicis f h pracic sing. Prfrm hand hygin as sn as h glvs ar rmvd. Car shuld b akn  avid cnaminaing h IV ubing and h ra rgular. • Any usd ndls, syrings, vnipuncur cahrs, r vascular accss dvics shuld b placd in a puncur-rsisan ndl dispsal cnainr in h immdia viciniy fr dispsal in accrdanc wih h plicis f h pracic sing. Ndl safy dvics shuld b acivad bfr placing in h dispsal cnainr. • Nvr rcap, bnd, r brak usd ndls bcaus f h dangr f inadvrnly puncuring h skin. • Whnvr pssibl, us ndl prcr sysms such as blun ndls, injcin prs, ndl shahs, r ndllss sysms  prvn inadvrn ndlsicks, as wll as h risk f inrducing pahgns in nslf. • B crain ha mdicains  b adminisrd inravnusly ar hrughly disslvd in h crrc vlum and yp f sluin. Always fllw h manufacurr’s rcmmndains. • Ms clinical pracic sings nw us ransparn drssings vr h IV insrin si ha ar changd in accrdanc wih hspial plicis, gnrally vry 72  96 hurs. Sm clinical pracic sings sill us gauz drssings. Whn gauz is usd, h fur dgs f h drssing shuld b sald wih ap. Always chck h spcic plicis f h mplying insiuin, as wll as h halhcar prvidr’s rdrs, wih rgard  h frquncy f drssing changs. • D n us pical anibiic inmns r crams n insrin sis bcaus f h pnial  prm fungal infcins and animicrbial rsisanc. • A h im f h drssing chang fr any yp f IV si, h ara shuld b hrughly inspcd fr any drainag, rdnss, ndrnss, irriain, r swlling. Th prsnc f any f hs sympms shuld b rprd  h halhcar prvidr immdialy. (In addiin, ak h pain’s vial signs and rpr hs a h sam im.) • Us inlin lrs as rcmmndd by h manufacurr f h drug  b infusd. • Do not adminisr any drug r IV sluin ha is hazy r cludy r ha has frign paricls r prcipia in i. • Do not mix any hr drugs wih bld r bld prducs (.g., albumin).

160

UNIT II Illustrated Atlas of Medication Administration

• Do not adminisr a drug in an IV sluin if h cmpaibiliy is n knwn. • Us aspic chniqu, including h us f a cap, mask, sril gwn, sril glvs, and a larg sril sh, fr h insrin f cnral vnus cahrs (including PICCs) and fr guidwir xchangs. • A drug mus b nirly infusd hrugh h IV lin bfr adding a scnd mdicain  h IV lin.  • Drugs ha ar givn by IV push r blus gnrally ar givn in accrdanc wih h SASH guideline—Salin ush rs; Adminisr h prscribd drug; Salin ush afr h drug; Hparin ush h lin (dpnding n h yp f lin [.g., Hickman cahr]; chck insiuinal plicy).  • Th SAS chniqu is similar  h SASH guidlin bu wihu h hparin: Salin ush rs; Adminisr h prscribd drug; Salin ush afr h drug. • Afr a mdicain has bn mixd, knw h lngh f im ha i rmains sabl; all unusd IV sluins shuld b rurnd  h pharmacy if hy ar n usd wihin 24 hurs. • Chck h insiuinal plicy fr h dniin f TKO I is usually inrprd as an infusin ra f 10  20 mL/hr, and lss han 500 mL/24 hr shuld b infusd. • Shad IV sluins ha cnain drugs ha shuld b prcd frm ligh. All IV sluin bags r bls shuld b changd vry 24  48 hurs (chck insiuinal plicy)  minimiz h dvlpmn f nw infcins. Labl all IV sluins wih h da and im iniiad. Do not us marking pns dircly n plasic IV cnainrs, bcaus h ink may pnra h plasic and nr h IV sluin. • IV adminisrain ss ha ar usd  dlivr bld r bld prducs shuld b changd afr h uni is adminisrd. Ss ha hav bn usd  infus lipids r TPN shuld b changd vry 24 hurs. Adminisrain ss ha ar usd nly fr physilgic IV uids (.g., D5/0.2 NS) may b changd vry 72  96 hurs (chck insiuinal plicy). Th ss r ubing mus b labld wih h da and im iniiad, and h da upn which  chang h s. • Whnvr a pain is rciving IV uids, mnir hir inak and upu accuraly. Rpr dclining hurly upus, as wll as hs f lss han 30 mL/hr. • Nvr spd up an IV w ra  cach up whn h vlum  b infusd has falln bhind. In crain cass his culd b dangrus. Th halhcar prvidr shuld b cnsuld, paricularly fr pdiaric pains and fr hs wh hav cardiac, rnal, r circulary impairmn.

Clinical Pitfalls  • Note: Never start an IV infusion in an artery!  • Whenever possible, initiate the IV infusion in accordance with the patient’s preference or in their nondominant arm.  • Do not initiate an IV infusion in an arm with compromised lymphatic or venous ow (e.g., after mastectomy or axillary node dissection) or in an extremity with a dialysis or apheresis catheter or shunt inserted.  • Avoid the use of blood vessels over bony prominences or joints unless absolutely necessary.  • In the older adult, using the veins in the hand area may be a poor choice because of the fragility of the skin and veins in this area.  • Veins that are commonly used in infants and children for IV administration are on the back of the hand, the dorsum of the foot, or the temporal region of the scalp (Fig. 11.12). The scalp veins are to be used as a last resort for infants.

Frontal vein

Superficial temporal vein Posterior auricular vein Occipital vein

Fig. 11.12 Veins in infants and children that are used as intravenous sites. (Redrawn from Hankins J, Lonsway RA, Hedrick C, Perdue M, eds. Infusion Therapy in Clinical Practice. 2nd ed. Philadelphia: Saunders; 2001.)

 • When possible, avoid using the veins of the lower extremities because of the danger of the development of thrombi and emboli.

PrEPArinG An intrAVEnouS Solution for infuSion dose form Chck h halhcar prvidr’s rdr fr h spcic IV sluin rdrd and fr any mdicain  b addd  h cnainr. If h rdr has n alrady bn prpard by h pharmacy, chck h accuracy f h drug rdr agains h mdicain r sluin bing prpard a las hr ims during h prparain phas: (1) whn rs rmving h drug r sluin frm h srag ara; (2) immdialy afr prparain; and (3) immdialy bfr adminisrain. Chck h xpirain da n any addiivs and n h primary sluin. If an IV mdicain is  b addd, nsur ha h drug is apprvd fr adminisrain by nurss. Prfrm pr–IV accss assssmns (s Vnipuncur).

Parenteral Administration: Intravenous Route CHAPTER 11

equIpment • Prscribr’s rdr • Adminisrain s wih apprpria ndl r ndllss cnncr, apprpria drip chambr (micrdrip r macrdrip; s Fig. 11.2), IV cahr, and inlin lr (if usd); h primary lin adminisrain s is usually labld “univrsal” r “cninuus w” • Mdicains fr IV dlivry and labls • Physilgic sluin rdrd • IV pl r pump teChnIque 1. Assmbl quipmn and prfrm hand hygin. 2. Chck h pain’s vin fr h siz and yp f ndl rquird  accss h vin slcd fr vnipuncur r fr h yp f ndl rquird  accss an impland accss dvic fr h dlivry f h IV sluin r mdicain. 3. Chck h halhcar prvidr’s rdr agains h physilgic sluin chsn fr adminisrain. 4. Inspc h IV cnainr fr cludinss, disclrain, and h prsnc f any prcipia. Vrify h xpirain da n h IV uid cnainr. 5. Rmv h plasic cvr frm h IV cnainr, and inspc h plasic IV bag  b crain ha i is inac; squz i gnly  dc any puncurs. Inspc a glass cnainr f IV sluin fr any cracks. 6. Chs h adminisrain s ha is apprpria fr h yp f sluin rdrd, fr h ra f dlivry rqusd (.g., micrdrip r macrdrip), and fr h yp f IV cnainr bing usd. Plasic bag IV cnainrs do not rquir an air vn in h adminisrain s. Glass cnainrs fr IV dlivry mus b vnd r hav an adminisrain s wih an air lr vn in i. Rmv h adminisrain s frm is packaging, and inspc i fr any fauls r cnaminain. 7. Mv h rllr r slid clamp  h uppr prin f h IV lin 6  8 inchs frm h drip chambr; cls h clamp. 8. Cnnc h IV adminisrain s r ubing  h IV sluin.  • Plastic IV bags: Rmv h ab frm h spik rcivr pr, rmv h ab frm h adminisrain s spik, and insr h spik rmly in h bag pr. Mainain h sriliy f h pr and spik hrughu h prcss.  • Glass IV bottle: Pl back h mal ab and lif h prciv mal disk frm h cnainr; rmv h lax-yp cvring (if prsn) frm h p f h rubbr sppr. As h lax diaphragm is rmvd, a suddn nis shuld b hard as h vacuum wihin h glass cnainr is rlasd. If h nis is n hard, h cnns f h IV cnainr may n b sril and shuld b discardd. Rmv h ab frm h adminisrain s spik; insr h spik rmly in h

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12.

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pr in h rubbr sppr. Mainain h sriliy f h pr and spik hrughu h prcss. • Note: Whn addiiv mdicains ar rdrd, hy shuld b addd  h larg-vlum cnainr bfr ubing is aachd  hlp nsur a unifrm mixing f h mdicain and h physilgic sluin. If mdicain is addd  an xising IV sluin, clamp h lin bfr adding h mdicain  h cnainr, and mak sur ha adqua mixing aks plac bfr h infusin is sard again. (S Adding a Mdicain  an Inravnus Bag, Bl, r Vlum Cnrl Dvic.) Hang h sluin n an IV pl, squz h drip chambr, and ll i halfway. Prim h IV lin by rmving h prciv ab r cap frm h disal nd f h IV lin, invr h Y pr, pn h rllr r slid clamp, and allw h sluin  run unil all f h air is rmvd frm h lin. If using a pump, prim h ubing in accrdanc wih insiuinal plicy. Cvr h nd f h IV ubing wih a sril cap. Inspc h nir lngh f ubing  b crain ha all air is rmvd frm h lin. (Note: I may b ncssary  add inlin lrs  h sup if his is rcmmndd fr h adminisrain f h rdrd mdicain. Purg air frm h lin bfr aaching h lr, hn run sluin hrugh h lr  rmv air frm h lr.) Labl h cnainr wih h pain’s nam alng wih h da and im f prparain. If mdicain has bn addd, all dails f h mdicain mus b markd n h cnainr’s labl: h drug nam and ds, h ra f adminisrain rqusd in h halhcar prvidr’s rdr. Labl h IV ubing wih h da and im ha i is pnd and h da and im ha i is  b changd. Th CDC rcmmnds ha IV ubing b changd vry 72 hurs. Adminisrain ss ha ar usd  dlivr bld r bld prducs may b changd afr ach uni is infusd, as dnd by insiuinal plicy, r wihin 24 hurs f iniiaing h infusin. Lipid sluins hav spcial ubing ha shuld b changd vry 24 hurs if hy ar adminisrd by cninuus infusin r afr vry uni if hy ar adminisrd inrminly. Fllw insiuinal plicis. Th IV sluin can nw b akn  h bdsid fr aachmn afr a vnipuncur is prfrmd r fr addiin  an xising IV sysm. Fr safy, all aspcs f h IV rdr shuld b chckd again immdialy bfr aaching h IV sluin fr infusin.

intrAVEnouS fluid monitorinG Th infusin f IV uids rquirs carful mniring fr pains f all ags. Th micrdrip chambr, which dlivrs 60 drps (g)/mL, is usd whnvr a small

162

UNIT II Illustrated Atlas of Medication Administration

vlum f IV sluin is rdrd  b infusd vr a spcic im. Many clinical pracic sings inrpr a small vlum as lss han 100 mL/hr. In pdiaric unis, vlum cnrl chambr dvics (.g., a Burrl, a SluS) and syring pump cnrllrs ar cmmnly usd  rgula h vlum f uid ha is infusd.

basic GuidElinEs for thE intravEnous administration of mEdications equIpment • Mdicain prl • Prscribr’s rdr • Turniqu • Clan glvs • Drug in a sril, sald cnainr • Syring f h crrc vlum • Ndls f h crrc gaug and lngh • Anispic alchl wips • Tap • Chang labl • Spcial quipmn basd n h ru f adminisrain (.g., a radipaqu vr-h-ndl cahr fr insrin; infusin pump) • Transparn drssing supplis premedICatIon assessment 1. Knw basic pain daa, h pain’s diagnsis, h sympms f h disrdr r disas prcss fr which h mdicain is rdrd, and h dsird acin f h drug fr h paricular individual. 2. Obain baslin vial signs. 3. Chck fr any ap, lax, and drug allrgis r prir drug racins. 4. Chck h accuracy f h drug rdr agains h mdicain r sluin bing prpard a las hr ims during h prparain phas: (1) whn rs rmving h drug r sluin frm h srag ara; (2) immdialy afr prparain; and (3) immdialy bfr adminisrain. 5. Chck fr laks, clariy, and xpirain da n h IV sluin and n h drug  b addd  h sluin. 6. Rviw h individual drug mngraph  idnify labrary sudis rcmmndd bfr r inrminly during hrapy, h calculain f h ds, h advrs ffcs, h mniring paramrs rcmmndd fr h spcic drug prscribd, and hr cnsidrains. (Wih crain ligh-snsiiv mdicains [.g., amphricin B, nirprussid], i is ncssary  shild h IV bag wih a dark plasic bag  prvn h dgradain f h drug.) 7. Knw h yp f IV accss ha h pain has in plac, h da and im f insrin, h yp f IV uid r mdicain running, and h ra f w prscribd.

proCedure protoCol Th sandard prcdurs fr prparing all parnral mdicains ar as fllws: 1. Prfrm hand hygin bfr prparing any mdicain r handling sril supplis. During h acual prparain f a parnral mdicain, h primary rul is “sril  sril” and “unsril  unsril” whn handling h syring and ndl. 2. Us h seven rights f mdicain prparain and adminisrain hrughu h prcdur: righ pain, righ drug, righ indicain, righ ru, righ ds, righ im, and righ dcumnain. 3. Chck h drug ds frm rdrd agains h surc usd fr h prparain. 4. Chck cmpaibiliy chars r cnac h pharmacis bfr mixing w mdicains r adding mdicains  an IV sluin. 5. Chck mdicain calculains. Whn in dub abu a ds, chck i wih anhr qualid nurs. (Ms insiuinal plicis rquir fracinal dss f mdicains and dss f hparin and insulin  b chckd by w qualid individuals bfr adminisrain.) 6. Knw h insiuinal plicy rgarding limiains n h yps f mdicains  b adminisrd by nursing prsnnl. Bfr adminisring an IV drug, h nurs shuld chck h lis f drugs apprvd fr adminisrain by nurss in h clinical car sing. 7. Prpar h drug in a clan, wll-lighd ara wih h us f aspic chniqu hrughu h nir prcdur. 8. Cncnra n h prcdur; nsur accuracy during prparain. 9. Chck h xpirain da f h mdicain. 10. Rsarch h mdicain rdrd as an IV addiiv; his prcdur als applis fr dirc push r blus adminisrain.  • Nam f drug.  • Usual ds (ak in cnsidrain h pain’s ag, wigh, and hydrain sa).  • Cmpaibiliy f h drug wih xising IV drugs ha ar currnly infusing.  • Fr IV push r blus, ds h drug nd  b dilud, r can i b givn undilud? If i shuld b dilud, wha yps and amuns f dilun can b usd? If i is bing addd  an xising IV infusin, is h drug cmpaibl wih h primary sluin?  • Rcmmndd ra f infusin.

VEniPuncturE Prfrm h fllwing pr–IV accss assssmns: • Assss h pain’s dmanr. Ds h pain appar cpraiv, r will assisanc b ndd? (Always hav sufcin assisanc whn wrking wih pdiaric pains.)

Parenteral Administration: Intravenous Route CHAPTER 11

• Chck fr and avid prviusly usd IV sis, aras f impaird circulain, and any sulas ha may b prsn in h xrmiis. • Examin h xrmiis fr pnial sis and sima h siz f h vins ha ar availabl fr us. equIpment • Mdicain prl • Prscribr’s rdr • IV sar s • Anispic alchl wips • On pair f glvs • Si labl • Tap • Transparn drssing marials • Tw gauz spngs, 2 × 2 inchs • On rll f ransparn ap • Lax urniqu • On chang labl • Arm bard (whn indicad) • As apprpria, mdicains and physilgic sluins rdrd fr IV dlivry and IV quipmn ndd (s Prparing an Inravnus Sluin fr Infusin) • Fr a salin lck r a mdlck, bain h crrc xnsin ubing and injcin cap, as apprpria (s Adminisrain f Mdicain by a Salin Lck r Mdlck lar); us salin and hparin ush sluins in accrdanc wih insiuinal plicy (us 10mL syrings ha cnain an apprpria vlum f sluin fr ushing) • IV pump, if rquird sci   C  B n Whn slcing a cahr r bury ndl fr us, chs h smalls siz ha is fasibl fr adminisring h spcic yp f uid ha has bn rdrd. Cahrs ar availabl in sizs ranging frm 27 gaug, ⅝ inch  14 gaug, ½ inch, and bury ndls ar availabl in sizs 17  29 gaug. A mr viscus uid such as bld rquirs a largr-diamr cahr. As wih hr ndls, h lwr h numbr f h gaug, h largr h diamr f h pning f h cahr. During h assssmn prcss, h nurs ns h siz f h vin  b accssd. teChnIque for estaBlIshIng an Intravenous lIne 1. Prfrm h prmdicain assssmn and fllw h prcdur prcl dscribd. 2. Assmbl h ncssary quipmn and prfrm hand hygin. 3. Chck all aspcs f h halhcar prvidr’s rdrs. 4. Rchck h siz and yp f cahr r bury ndl ndd  accss h vin slcd and any xnsin ubing r injcin caps ha ar ndd  prpar h si fr fuur inrmin r cninuus us fr h prscribd IV hrapy.

163

5. If rdrd, h IV sluin and mdicain shuld b prpard and akn  h bdsid fr aachmn afr a vnipuncur has bn prfrmd. Fr safy, all aspcs f h IV hrapy rdrs shuld b chckd again immdialy bfr iniiaing h vnipuncur and bfr aaching h IV sluin fr infusin. (Note: Always idnify h pain by chcking hir ID bracl bfr iniiaing any prcdur. Hav h pain sa his r hr nam and birh da r hr idnirs. Explain h prcdur, and prvid ducain abu h drug bing adminisrd.) 6. Psiin h pain apprprialy. Immbiliz an infan r child fr pain safy, if ncssary. (B sur ha h pain is waring h yp f hspial gwn ha has pnings n h shuldr sams.) 7. Cu ap fr sabilizing h IV cahr r bury ndl bfr saring h prcdur. Turn h nds f h ap back n hmslvs  frm a ab ha will n adhr  a glv whn h ap is  b applid r rmvd. (Note: Th nurs mus cnsidr hir glvs  b cnaminad whn hy cm in cnac wih bld. If h glvs cm in cnac wih h ap and drssing marials ha hav bn usd a h vnipuncur si, h usid f h drssings and ap ar hn pnially cnaminad. Thrfr during h prcdur, h nurs mus fcus n allwing cnaminain nly f h dminan glvd hand; h nndminan hand mus b mainaind as uncnaminad  handl h aping and sabilizain f h priphral accss dvic. Afr h ndl r cahr is sabilizd, h glvs can b rmvd; prfrm hand hygin and apply h gauz r h cclusiv yp f drssing marials in accrdanc wih pracic sing plicis.) 8. Whn xnsin ubing is usd wih h cahr r h bury ndl, ll h xnsin ubing wih salin and purg i f all air. 9. Apply h urniqu using a slipkn 2  6 inchs abv h si chsn (his is h shadd ara in Fig. 11.13A). Inspc h ara  idnify a vin f sufcin siz  accmmda h cahr and prvid adqua anchrag. 10. Pu n nnsril glvs. As h vin dilas, palpa h vin  fl is dph and dircin (Fig. 11.13B and C). T dila h vin, i may b ncssary  plac h xrmiy in a dpndn psiin. Massag h vin agains h dircin f bld w, hav h pain pn and cls h hand rpadly, r rmv h urniqu and apply a haing pad r warm w wls  h xrmiy fr 15  20 minus, and hn rsar h prcss. 11. Clans h skin surfac wih h anispic alchl wip, saring a h si f nry and wrking uward in a circular min ward h priphry (Fig. 11.13D). D n ruch h ara whr h puncur si will b mad. (Alrnaivs ar  pu a sril

164

UNIT II Illustrated Atlas of Medication Administration

A

B

C

D Blood in flashback chamber

Needle External catheter

E

10 degrees

G

F

H

Fig. 11.13 (A) Apply a tourniquet using a slipknot that is placed 2 to 6 inches above the chosen (shaded) area. (B) Allow the veins to dilate. (C) Palpate the vein to feel its depth and direction. (D) Cleanse the skin surface with an antiseptic alcohol wipe, starting at the anticipated site of entry and working outward in a circular motion to the periphery. (E) For an over-the-needle catheter, hold the ashback chamber with the thumb and forenger and insert the catheter with the needle at a 10- to 30-degree angle (or at the angle as specied in manufacturer’s directions), with the bevel up. (F) Withdraw the needle from the catheter. (G) Apply gentle pressure over the catheter tip to prevent the excessive backow of blood while the needle is removed and the intravenous line is attached. (H) Secure the connection of the intravenous tubing to the hub of the catheter.

glv n n hand s ha h si can b uchd again r  prpar h ngrip wih anispic.) 12. Allw h ara  air-dry. 13. Hld h cahr r bury ndl  b insrd in h dminan hand, and rmv h prciv

cvr whil mainaining h sriliy f h ndl. Apprach h vin dircly frm abv r frm slighly  n sid f h vin. Prvid nsin n h skin surfac  srch h skin and sabiliz h vin.

Parenteral Administration: Intravenous Route CHAPTER 11

pi o--n C Ii (s fi. 11.6a)  • Inspc h IV cahr and lsn h cahr ndl by raing h cahr.  • Hld h ashback chambr wih h humb and frngr and insr h cahr wih h ndl a a 10-  30-dgr angl wih h bvl up (Fig. 11.13E). Chck h manufacurr’s prduc insrucins fr h rcmmndd angl f nry and assss h dph f h vin; h dpr h vin, h grar h angl f nry ndd  puncur h skin and vnus wall.  • Wach fr bld in h ashback chambr; afr bld is sn, advanc h ndl and cahr an addiinal {1/16}  ¼ inch in h vin.  • Wihdraw h ndl frm h cahr (Fig. 11.13F), lwr h angl f h cahr slighly, and advanc h cahr in h vin.  • Hld h cahr hub in plac whil applying gnl prssur n h cahr ip  prvn h xcssiv backw f bld whil h ndl is rmvd frm h cahr and h cahr and IV sluin ar aachd (Fig. 11.13G). B n Ii  • Prpar h si as dscribd prviusly.  • Hld h bury ndl by h abs and align h ndl, bvl up, wih h vin ha has bn slcd.  • Puncur h skin and vin surfac as dscribd prviusly.  • Afr h vin is nrd, lwr h angl and advanc h ndl in h vin unil h abbd ara f h bury is adjacn  h puncur si. 14. Rlas h urniqu and scur h cnncin f h IV ubing  h vr-h-ndl plasic ndl hub (Fig. 11.13H) r  h bury apparaus. 15. Clans h ara  limina any bld ha may hav cnacd h skin r IV ubing. Rmv h glvs and anchr h ndl and ubing  h arm r hand wih ap and drssing, as prscribd by h clinical pracic sing plicy. (Bcaus i is difcul  handl ap wih glvs n, i is hlpful  hav a scnd prsn  anchr h ndl and ubing and  adjus h w ra.) 16. If n cninuusly wing IV sluin is aachd, ush h cahr in accrdanc wih clinical pracic sing plicy. 17. Th individual wh is prfrming h vnipuncur can disps f all sild drssings and cnaminad supplis in accrdanc wih h clinical pracic sing’s plicy. 18. Adjus h ra f w sluin r s h ra n h pump. 19. Rgardlss f h apparaus usd, mark h labl wih h da and im f insrin.

165

20. In a way ha is apprpria  h ag, si, and physical rinain f h individual, aach a paddd arm bard  suppr and sabiliz h infusin si. patIent teaChIng 1. Tach h pain abu any sympms ha shuld b rprd a h insrin si (.g., pain, swlling, discmfr). 2. Srss h impranc f n rying  slf-adjus h ra f an IV sluin r f any IV mdicains ha ar bing adminisrd. 3. Explain h purps f h drssing ha has bn applid  h IV si and h nd  lav h drssing inac. doCumentatIon Prvid h righ dcumnain f h vnipuncur (.g., IV sard r IV mdicain adminisrd and rspns  drug hrapy). 1. Char h da and im; h siz and yp f bury r IV cahr usd; h si accssd; and h numbr f amps mad  prfrm h vnipuncur. Mak nris n h apprpria IV si w shs ha ar usd a h clinical pracic sing. 2. On h pain’s mdicain adminisrain rcrd (MAR), char h yp and amun f IV uid sard r addd  an xising lin; h ra f adminisrain; and, if mdicain was addd, h da, h drug nam, h amun addd (.g., h ds), and h da and im f prparain and iniiain. 3. Prfrm and rcrd rgular pain assssmns fr h valuain f hrapuic ffcivnss (.g., bld prssur, puls, upu, lung ld sunds, dgr and durain f pain rlif). 4. Char any signs and sympms f h advrs ffcs f h drugs givn r prblms ncunrd during h vnipuncur prcdur. If mr han n amp was rquird  prfrm h vnipuncur, rcrd h rlvan dails. 5. Rcrd any pain aching ha was dn. 6. If h IV accss dvic was ushd, i shuld b dcumnd n h w sh and n h pain’s MAR.

AdminiStrAtion of mEdicAtion By A SAlinE lock or A mEdlock A salin lck r mdlck may b usd fr adminisrain f mdicains r wihdrawing bld sampls (Fig. 11.14). Prfrm prmdicain assssmns and fllw prcdur prcl as dscribd arlir in his chapr. In addiin, rfr  h individual drug mngraphs. equIpment • Mdicain prl • Prscribr’s rdr

166

UNIT II Illustrated Atlas of Medication Administration

Fig. 11.14 Heparin lock/saline lock/medlock with an extension tubing taped in place and ready for access.

• • • • • • •

Mdicain fr IV dlivry and labl Exnsin ubing and injcin cap, as apprpria Syrings and ndllss cnncrs Salin and hparin ush sluins Glvs Anispic alchl wips Sharps safy cnainr fr usd ndl and rcpacl fr ld drssing marial ha is rmvd

teChnIque for Intravenous Bolus medICatIons WIth Capped Intravenous lIne 1. Slc a syring ha is svral millilirs largr han rquird fr h vlum f h drug. This allws rm fr h aspirain f bld  nsur h prpr placmn f h ndl r cahr in h vin and  allw bld  mix wih h drug sluin. Plac a ndllss accss dvic n h syring (Fig. 11.15) r us a syring ha is usd wih a ndllss sysm (Fig. 11.16). 2. Rsarch and prpar h mdicain as dscribd prviusly. Prpar h salin in syrings wih ndllss accss dvics  ush h lin bfr and afr mdicain adminisrain in accrdanc wih insiuinal plicy. I is rcmmndd ha 10-mL syrings ha cnain a fw millilirs f ush sluin b usd fr ushing  rduc h prssur xrd in h vin r cahr. 3. Idnify h pain by chcking hir ID bracl. Rchck h mdicain rdr, xplain h prcdur, and prvid ducain abu h drug bing adminisrd. Hav h pain sa hir nam and birh da r w hr idnirs. 4. Apply clan glvs. 5. Swab h slf-saling pral f h injcin si wih an anispic alchl wip fr 15 scnds, and aach h syring via h injcin cap. Sm halhcar agncis us an anispic cap which has bn sakd in chlrhxidin ha rmains cvring h injcin si, in his cas rmv h cap  accss h pr. N nd  swab h ara.

Fig. 11.15 Syringe with a blunt-access cannula, attached by a LuerLok, approaching a portal on an intravenous administration set. (Courtesy Baxter Healthcare Corporation, Mountain Home, AR. All rights reserved.)

Fig. 11.16 The Baxter CLEARLINK Access System features an integrated clamp to help protect patients from the effects of accidental disconnection and ensure minimal uid displacement with proper technique. Clear housing allows easy identication of residuals, which may indicate need for replacement. A double seal provides effective barrier to microbial ingress. A at septum with tight t to housing helps reduce the risk of microbial contamination and eases cleansing. (Courtesy Baxter Healthcare Corporation, Mountain Home, AR. All rights reserved.)

6. Accss h injcin pral r cap wih a syring ha cnains ush sluin and gnly pull back n h plungr fr bld rurn. If rurn is n baind r if rsisanc is fl, sp and valua h caus. D n frc h insrin f h sluin r a cl culd b disldgd. 7. Whn bld rurn is sablishd, injc h salin fr h ush fllwd by h mdicain a h ra spcid by h manufacurr. Always carefully check the drug order and a reliable reference for the proper dilution and recommended rate of administration of the drug. Watch the clock and time the injection rate as accurately as possible!

Parenteral Administration: Intravenous Route CHAPTER 11

8. Obsrv h IV si a h cahr ip fr swlling and mnir h pain fr cmplains f discmfr. 9. Afr adminisrain, wihdraw h ndllss dvic frm h injcin pr and disps f i in a sharps safy cnainr. 10. Accss h injcin cap and insr anhr syring ha cnains (usually) 1  2 mL f NS  ush h rmaining drug frm h cahr. Raach a nw clan anispic cap accrding  agncy plicy. 11. Optional: In accrdanc wih insiuinal plicy, ush h lck wih 1 mL f hparin (10  100 unis/mL). Mainain cnsan prssur n h plungr f h syring whil simulanusly wihdrawing h ndl frm h injcin pr  prvn h backw f bld. Always vrify h hparin ds wih anhr qualid nurs. 12. Clans h si f any bld r uids. Rmv glvs and disps f hm prprly. Prfrm hand hygin. Disps f quipmn in accrdanc wih Occupainal Safy and Halh Adminisrain sandards. Th salin lck r mdlck shuld b ushd whn i is iniially placd, afr adminisrain f mdicains, afr wihdrawing bld sampls, r daily if mdicains ar n adminisrd mr frqunly. Chck h insiuinal plicy  drmin hw lng a lck may rmain in plac bfr i is changd. Mnir h vnipuncur si fr any advrs ffcs r cmplicains. patIent teaChIng Explain  h pain h purps f h mdicain adminisrd and any advrs ffcs fr ha mdicain ha shuld b rprd. doCumentatIon 1. In h pain’s MAR, dcumn h da, im, drug, and dsag; h ushing prcdur; and any assssmn daa ha ar prinn (.g., hw wll h prcdur was lrad, bsrvains f h vnipuncur si). 2. Prfrm and rcrd rgular pain assssmns fr h valuain f hrapuic ffcivnss. 3. Char any signs and sympms f h advrs ffcs f h drugs givn r prblms ncunrd during h prcdur. 4. Rcrd any pain aching ha was dn.

Life Span Considerations Benzyl Alcohol Preservative Do not use bacteriostatic water or saline that contains the preservative benzyl alcohol to reconstitute or dilute medications or to ush the IV catheters of newborns because this preservative is toxic to these patients.

167

AdminiStrAtion of mEdicAtionS into An EStABliShEd intrAVEnouS linE Prfrm prmdicain assssmns and fllw prcdur prcl as dscribd arlir. In addiin, rfr  h individual drug mngraphs. equIpment • Mdicain prl • Prscribr’s rdr • Mdicain fr IV dlivry and labl • Glvs • Anispic alchl wips • Syring and ndllss cnncr • Salin sluin as apprpria teChnIque for Intravenous Bolus medICatIons WIth Intravenous solutIon runnIng 1. Rsarch and hn prpar h mdicain as dscribd in h prcdur prcl arlir in his chapr. Ensur ha h drug  b prpard is cmpaibl wih h IV sluin ha is currnly bing infusd. Always carfully chck h drug rdr and a rliabl rfrnc fr h prpr diluin and rcmmndd ra f adminisrain f h drug. Many mdicains rdrd as IV push r blus mus b adminisrd slwly vr svral minus. An xcssiv ra f adminisrain can rsul in shck and cardiac arrs. 2. Idnify h pain by chcking hir ID bracl. Explain h prcdur and prvid ducain abu h drug bing adminisrd. Hav h pain sa hir nam and birh da r w hr idnirs. 3. Rchck h mdicain rdr. 4. Pu n glvs whn hr is a pnial fr xpsur  bld r bdy uids. I is hlpful  kp n glvd hand uncnaminad. 5. Swab h slf-saling pral f h injcin si wih an anispic alchl wip fr 15 scnds and aach a syring via h injcin cap. 6. Using a ndllss dvic n h syring, puncur h Y pr si (s Fig. 11.15). Alrnaivly, fr an injcin cap (s Fig. 11.16), aach h syring wih mdicain dircly. 7. Injc h prscribd mdicain in h IV lin a h ra rcmmndd by h manufacurr. If the medication and the IV solution are not compatible:  • Swab the injection port nearest the catheter wih an alchl wip fr 15 scnds. If h halhcar agncy uss an anispic cap, rmv his; n nd  swab h pr.  • Insert a needleless device into the port; stop h primary infusin and injc 2 mL f 0.9% NS (.g., salin ush), in accrdanc wih insiuinal plicy, via IV push.  • Swab the port with an alcohol wipe; insert the ndllss dvic ha cnains mdicain and adminisr h drug a h prscribd ra.

168

UNIT II Illustrated Atlas of Medication Administration

 • Remove the medication syringe, swab the port again, and injc 2 mL f 0.9% NS (.g., salin ush), in accrdanc wih insiuinal plicy, via IV push. If injcing in a cnral lin, fllw insiuinal plicy rgarding h nd  irriga wih a salin and hparin sluin. Raach a nw clan anispic cap accrding  agncy plicy. 8. Whn all f h mdicain has bn adminisrd, pn h sablishd IV lin and radjus h flw ra  crrspnd wih h halhcar prvidr’s rdr. Rmv glvs and prfrm hand hygin.

• On 10-mL syring wih hparin (10  100 unis/mL), usually 2.5  5 mL; cnsul h insiuinal plicy manual fr h vlum usd in h faciliy • Sril 10-mL syring • Ndllss accss dvic • 18-  22-gaug (⅝-inch) ndl • Anispic sluin r swab sicks pr insiuinal plicy • Alchl swabs • Hubr ndl • Exnsin ubing • Sharps safy cnainr fr usd ndl and rcpacl fr ld drssing marial ha is rmvd

patIent teaChIng Explain  h pain h purps f h mdicain adminisrd and discuss any pnial advrs ffcs f h mdicain.

teChnIque for Intravenous medICatIons vIa Implanted venous aCCess devICe 1. Rsarch and prpar h mdicain as dscribd in h prcdur prcl arlir in his chapr. 2. Prpar a syring wih h mdicain r add h mdicain  an IV piggyback bag. 3. Insr h adminisrain s in h IV cnainr, prim h IV lin  rmv all air, and hn cvr h nd f h IV lin wih a sril cap. Lav h prscribd mdicain in a sril syring. 4. Tak all supplis and h IV mdicain  h pain’s bdsid. 5. Idnify h pain by chcking hir ID bracl. Explain h prcdur and prvid ducain abu h drug bing adminisrd. Hav h pain sa hir nam and birh da r w hr idnirs. 6. Rchck all aspcs f h mdicain rdr. 7. Prfrm hand hygin. 8. If h impland pr is n alrady accssd, palpa h si  idnify landmarks. 9. Opn h drssing ki, s up and prpar h ushing supplis, and prim h infusin s whil mainaining h sriliy f h Hubr ndl. 10. Apply sril glvs. 11. Us h nndminan glvd hand  clans h skin vr h impland pr wih alchl; clans frm h inndd si f insrin uward in widning circls. Rpa h clansing prcss w mr ims. Allw h alchl  dry and hn rpa h clansing prcss wih h us f anispic swab sicks. 12. Using h sril glvd hand, grasp h Hubr ndl by h wingd angs, aach i  h syring ha cnains salin, and insr h ndl prpndicular  h pain’s skin unil h ndl ip cms in cnac wih h bm f h pr. Suppr h Hubr ndl wih fldd 2 × 2–inch spngs. 13. Draw back n h plungr f h salin syring slighly unil bld rurns. Injc NS ( ush h pr f hparin, lf frm a prvius ush) and hn aach h syring ha cnains mdicain r h IV piggyback cnainr wih mdicin. If

doCumentatIon 1. In h pain’s MAR, dcumn h da, im, drug, and dsag and any assssmn daa ha ar prinn (.g., hw wll h prcdur was lrad, bsrvains f h vnipuncur si). 2. Prfrm and rcrd rgular pain assssmns fr h valuain f hrapuic ffcivnss. 3. Char any signs and sympms f h advrs ffcs f h drugs givn r prblms ncunrd during h prcdur. 4. Rcrd any pain aching ha was dn.

Clinical Pitfall Flushing the IV line by accelerating the IV infusion rate is not recommended because the medication that is still in the line will be administered too rapidly. This is contrary to the manufacturer’s safety recommendation. Sudden boluses of certain medications may also cause severe hypotension or other signs of toxicity.

AdminiStrAtion of mEdicAtion throuGh An imPlAntEd VEnouS AccESS dEVicE Prfrm prmdicain assssmns and fllw prcdur prcl as dscribd n p. 14 in his chapr. In addiin, rfr  h individual drug mngraphs. equIpment • Mdicain prl • Prscribr’s rdr • Mdicain fr IV dlivry and labl • IV piggyback bag • Drssing kis (a sm clinical pracic sings) • Tw pairs f sril glvs • Tw 10-mL syrings wih 0.9% NS, 2  10 mL; cnsul h insiuinal plicy manual fr h vlum usd in h faciliy

Parenteral Administration: Intravenous Route CHAPTER 11

14. 15. 16. 17.

adminisring frm h syring, us h IV blus chniqu. If adminisring as an infusin wih h IV piggyback cnainr (s Adding a Mdicain Wih a Piggyback S lar in his chapr), aach h primd adminisrain s  h Hubr ndl and adjus h ra f infusin. Prvid suppr fr h IV lin. Apply ransparn r gauz drssing and ap i in plac. Whn h mdicain adminisrain is cmpld, ush h lin wih salin and hparin in accrdanc wih insiuinal plicy. Mainain sady prssur n h plungr f h syring as h ndl is wihdrawn frm h accss dvic  prvn h backw f bld. Labl h si wih h da f accss, h siz and lngh f h Hubr ndl, and h da. If h Hubr ndl is rmvd frm a hald si a his im, clans h injcin si wih an alchl wip and apply an adhsiv bandag. Disps f usd ndls in a sharps safy cnainr. Disps f usd xnsin ubing and hr supplis in accrdanc wih insiuinal plicy. Rmv and disps f glvs prprly. Prfrm hand hygin.

patIent teaChIng 1. Explain  h pain h purps f h mdicain bing adminisrd and discuss h pnial advrs ffcs f ha mdicain. 2. Srss h impranc f prvning infcin in h pr; h pain shuld avid uching h si. If mdicain is bing givn inrminly wih h us f a pump, hav h pain pu h call ligh n whn h machin alarm sunds. doCumentatIon 1. In h pain’s MAR, dcumn h da, im, drug, and dsag and any assssmn daa ha ar prinn (.g., hw wll h prcdur was lrad, bsrvains f h injcin si). 2. Prfrm and rcrd rgular pain assssmns fr h valuain f hrapuic ffcivnss. 3. Char any signs and sympms f h advrs ffcs f h drugs givn r prblms ncunrd during h prcdur. 4. Rcrd any pain aching ha was dn.

AddinG A mEdicAtion to An intrAVEnouS BAG, BottlE, or VolumE-control dEVicE Prfrm prmdicain assssmns and fllw prcdur prcl as dscribd arlir. In addiin, rfr  h individual drug mngraphs. equIpment • Mdicain prl • Prscribr’s rdr • Mdicain fr IV dlivry and labl

169

• Glvs • Anispic alchl wips • Ndllss cnncr teChnIque for addIng medICatIons to Intravenous solutIons 1. Rsarch and prpar h mdicain as dscribd in h prcdur prcl arlir in his chapr. 2. Idnify h pain by chcking hir ID bracl. Explain h prcdur and prvid ducain abu h drug bing adminisrd. Hav h pain sa hir nam and birh da r w hr idnirs. 3. Rchck all aspcs f h mdicain rdr. 4. Prfrm hand hygin and apply glvs. 5. Idnify h injcin pr n h spcic yp f IV cnainr r vlum cnrl s ha is bing usd; clans h pral wih an anispic swab. 6. Clamp h IV ubing. 7. Insr h sril accss dvic in h pr and slwly add h prscribd mdicain  h IV sluin. Always chck  b crain ha h mdicain is bing addd  a cmpaibl sluin f sufcin vlum  nsur h prpr diluin f h mdicain as spcid by h manufacurr. Agia h bag, bl, r vlum cnrl dvic  disprs h mdicain in h uid hrughly. 8. Fr a vlum cnrl apparaus, ll h vlum chambr wih h spcid amun f IV sluin (s Fig. 11.2A and C) and hn clamp h ubing bwn h IV bl r bag and h vlum cnrl chambr. Add h mdicain, as dscribd prviusly, via h clansd injcin pr. B sur ha h mdicain is disprsd in h sluin and adjus h ra f h w sluin. 9. Afx a labl  h cnainr. Indica h mdicain’s nam and ds, h da and im, h prpard ra f infusin, and h lngh f infusin im.

Clinical Pitfall When IV medications are administered by a volume control apparatus, the calculation of the rate of infusion for administering the drug over the proper time must include an allowance for the volume of the uid in the IV tubing and for the volume of medication.

patIent teaChIng Explain  h pain h purps f h mdicain adminisrd and advis him r hr f any advrs ffcs f h mdicain. doCumentatIon 1. In h pain’s MAR, dcumn h da, im, drug, and dsag; h ra f adminisrain if a vlum-cnrl apparaus is usd; and any assssmn daa ha ar prinn (.g., hw wll h prcdur was lrad).

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UNIT II Illustrated Atlas of Medication Administration

2. Prfrm and rcrd rgular pain assssmns fr h valuain f hrapuic ffcivnss. 3. Char any signs and sympms f h advrs ffcs f h drugs givn r prblms ncunrd during h prcdur. 4. Rcrd any pain aching ha was dn.

AddinG A mEdicAtion with A PiGGyBAck SEt Prfrm prmdicain assssmns and fllw prcdur prcl. In addiin, rfr  h individual drug mngraphs. equIpment • Mdicain prl • Prscribr’s rdr • Mdicain fr IV dlivry and labl • IV piggyback bag • Adminisrain s wih ndllss cnncr • Anispic alchl wips

tEchniquE for intrAVEnouS PiGGyBAck mEdicAtionS 1. Rsarch and hn prpar h mdicain as dscribd in h prcdur prcl arlir in his chapr and hn add i  an IV piggyback bag.  • Rcnsiu a pwdr using a prassmbld IV mdicain sysm such as h ADD-Vanag Sysm (Fig. 11.17). This is a ndllss sysm wih w disincly spara cmpnns: (1) an ADD-Vanag dilun cnainr (.g., a plasic piggyback bag) ha cnains 0.9% NS, D5W, r 0.45% sdium chlrid; and (2) an ADD-Vanag drug vial ha cnains mdicain (.g., ampicillin pwdr).  • Hld h ADD-Vanag vial and plasic cnainr in a vrical psiin by h bm f h aachd drug vial (h vial is acually upsid dwn).  • Rach hrugh h xibl cnainr f dilun, grasp h innr sppr in h vial by h plasic ring ha surrunds i, and pull sraigh dwn n h ring; h sppr discnncs and falls in h dilun sluin. Th drug pwdr als falls u and, wih a fw squzs f h dilun bag, mixs wih h dilun  rcnsiu h drug.  • Th ADD-Vanag cnainr is nw rady fr h aachmn f h scndary IV ubing whn i is akn  h bdsid.  • Immdialy bfr us, chck all aspcs f h drug rdr agains h drug cnainr. 2. Idnify h pain by chcking hir ID bracl. Explain h prcdur and prvid ducain abu h drug bing adminisrd. Hav h pain sa hir nam and birh da r w hr idnirs.

Fig. 11.17 The ADD-Vantage drug delivery system. (Courtesy Bruce Clayton.)

3. Drmin h cmpaibiliy f h primary IV sluin and is addiivs wih ha f h piggyback mdicain r sluin. 4. Rchck all aspcs f h mdicain rdr. 5. Prfrm hand hygin. 6. Insr h adminisrain s in h piggyback cnainr and aach a ndllss dvic. 7. Cnnc  h primary IV ubing by arranging h piggyback cnainr s ha i is lvad highr han h primary cnainr (s Fig. 11.9). Clans h pral n h primary lin wih an anispic swab fr 15 scnds and insr h ndllss dvic cnncr (Fig. 11.18) by aaching h piggyback ubing  h pr f h ubing f h primary sluin. Scur his in plac. Sm halhcar agncis us anispic caps n hs Y prs in h IV lins; rmv cap, n nd  swab si and aach nd f piggyback ubing. 8. Lwr h piggyback cnainr blw h lvl f h primary sluin, pn h scndary ubing clamp, and slwly purg h scndary ubing f air wih h us f h backw mhd; his will allw h primary sluin  ll h scndary ubing. Plac h piggyback sluin highr han h primary IV sluin bfr adminisrain. 9. Chck h spcic rdrs fr h infusin ra and h squnc f h sluin r mdicain adminisrain. 10. Afx a labl  h cnainr. Indica h mdicain nam and ds, h da and im ha i was prpard, h ra f infusin, and h lngh f infusin im.

Parenteral Administration: Intravenous Route CHAPTER 11

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chAnGinG to thE nExt contAinEr of intrAVEnouS Solution Prfrm prmdicain assssmns and fllw prcdur prcl. In addiin, rfr  h individual drug mngraphs. equIpment • Mdicain prl • Prscribr’s rdr • IV sluin rdrd • Adminisrain s wih apprpria ndl r ndllss cnncr, drip chambr, and lr • Chang labl

Fig. 11.18 A male Luer-Lok with an INTERLINK lever lock cannula attached. This illustrates how a (needle-free) blunt plastic cannulatipped adapter can be used to attach a piggyback container to the portal of a primary intravenous administration set. (Courtesy Baxter Healthcare Corporation, Mountain Home, AR. All rights reserved.)

11. Whn h piggyback mpis, h chck valv in h primary lin rlass and h primary infusin rsums. If a pump is usd, h primary infusin will rsum whn h piggyback r scndary infusin is cmpl.

Clinical Pitfall One of the most common mistakes when using preassembled IV medication containers (for safety and ease of reconstitution) is forgetting to activate the system and mix the drug powder with the diluent before hanging it for administration.

patIent teaChIng Explain  h pain h purps f h mdicain ha is bing adminisrd and discuss wih him r hr any pnial advrs ffcs f h mdicain. doCumentatIon 1. In h pain’s MAR, dcumn h da, im, drug, and dsag and any assssmn daa ha ar prinn (.g., hw wll h prcdur was lrad). 2. Prfrm and rcrd rgular pain assssmns fr h valuain f hrapuic ffcivnss. 3. Char any signs and sympms f h advrs ffcs f h drugs givn r prblms ncunrd during h prcdur. 4. Rcrd any pain aching ha was dn.

teChnIque for ChangIng Intravenous solutIons 1. Mnir h ra f infusin and h IV insrin si a las nc hurly. Whn h cnainr nars cmplin, nify h nurs wh is rspnsibl fr adding h nx cnainr. 2. Slw h ra  kp h vin pn if h lvl f sluin in h cnainr is lw. 3. Chck h IV si, h das n h IV lins, and h cmpaibiliy f h IV sluin ha is running wih h nw cnainr f IV sluin  b addd. (Mdicains may hav bn addd  h IV sluin pr h halhcar prvidr’s rdrs.) 4. Prfrm hand hygin. 5. Prpar h IV sluin as dscribd prviusly. Hang h nw IV bag n h IV pl.  • If the same tubing is used, clamp h ubing n h primary IV lin. Using aspic chniqu, quickly xchang h nw cnainr fr h mpy n.  • If new tubing is used, aach h adminisrain s  h sluin cnainr, ll h chambr n h IV lin half full, prim h lin  purg h air, and aach i  h vnus accss dvic. Da and iniial h nw ubing wih h labl ha is usd in h clinical pracic sing. If a pump is usd, prim h IV ubing, cnnc h ubing  h vnus accss dvic, and sar h pump. 6. Unclamp h ubing and adjus h w ra as prviusly dscribd; inspc h vnipuncur si. 7. Rchck all aspcs f h IV rdr. patIent teaChIng Explain  h pain h purps f h IV sluin. doCumentatIon 1. In h pain’s MAR, dcumn h da and im, h IV sluin usd, and h ra f adminisrain. 2. Rcrd h amun f uid infusd n h inak and upu sh, as wll as n any w shs mainaind a h clinical pracic sing. 3. Rcrd prinn assssmn daa cllcd.

172

UNIT II Illustrated Atlas of Medication Administration

Clinical Pitfalls  • The ushing of central lines is an important aspect of maintaining the patency of the central venous access device. Two types of solutions are used to maintain the patency of vascular access devices: heparin is used to prevent clot formation, and 0.9% NS is used to clean the interior diameter of the device of blood or particles of medication. It is recommended that a 10-mL syringe be used for ushing lines and medication administration to prevent excessive pressure within the catheter that could result in rupture. Always follow institutional guidelines for recommended procedures to maintain line patency.  • Preventing infection is a major concern with all IV devices. Appropriate procedures for cleansing the area and the access device with the recommended antiseptics are mandatory.  • If unable to aspirate blood when performing a ush procedure, the catheter may be occluded. Never force the solution into the IV line.  • Start interventions by doing the simple things, like checking that the clamp is open and that the catheter and IV tubing are not kinked. Reposition the patient’s upper body, and have the patient perform a Valsalva maneuver.  • It may be necessary to remove the injection cap, attach a 20-mL syringe, and aspirate the blood clot. (Check institutional policy regarding the removal and replacement of the injection cap.) Immediately after the aspiration of the blood clot, replace the injection cap with a new sterile cap and institute 0.9% NS and heparin (100 units/mL) ushing of the catheter in accordance with institutional guidelines.  • Report any malfunctioning of the catheter to the healthcare provider. Radiographic evaluation and the instillation of a thrombolytic agent (e.g., alteplase) may be necessary.

diScontinuinG An intrAVEnouS infuSion equIpment • Turniqu (if usd in h halhcar agncy) • Sril spngs • Glvs • Drssing marials • Tap • Sharps safy cnainr fr ndls and bury r hr yps f IV cahrs • Exnsin ubing wih cap and a salin ush in a 10-mL syring if h infusin dvic is bing cnvrd  a salin lck r a mdlck teChnIque for removIng an Iv If h IV si is bing discninud cmplly, h fllwing shuld b dn: 1. Rviw insiuinal plicy rgarding h placmn f a urniqu. (Sm halhcar agncis sa ha a urniqu shuld b applid bfr h rmval f h ndl r IV cahr in cas h ip braks during rmval. Ohr agncis sa ha

h urniqu shuld b lsly aachd  h limb bu n ighnd unlss ncssary.) 2. Chck h halhcar prvidr’s rdrs. Vrify ha all IV sluins and mdicains hav bn cmpld. 3. Chck h pain’s idniy using hir ID bracl. Carfully xplain wha is bing dn and why. Hav h pain sa hir nam and birh da r w hr idnirs. 4. Prfrm hand hygin. 5. Adqualy xps h IV si. 6. Clamp h IV ubing and urn ff h lcrnic cnrllr r pump. 7. Prpar a gauz spng and ap fr us n h vnipuncur si. 8. Lsn h ap a h si whil simulanusly sabilizing h ndl  prvn vnus damag. If h IV si is cnaminad by bld r drainag, pu n glvs bfr handling h ap. 9. Apply clan glvs. 10. Wih h us f a gauz pad, gnly apply prssur wih h nndminan hand  h vnipuncur si. Wihdraw h ndl r cahr, pulling i u paralll  h skin surfac. Inspc h ip f h ndl r cahr  b sur ha i is inac. Rlas h urniqu, if n is in plac. Plac h ndl r cahr in h sharps safy cnainr. 11. Clans h ara if i has bn cnaminad wih any bld r uid. 12. Cninu  hld h IV si rmly unil all blding cass. If h vnipuncur si was in h ancubial fssa, hav h pain x h lbw  hld h gauz in plac. 13. Chck fr blding afr 1  2 minus. Rmv h gauz, and discard i wih hr cnaminad drssings. Clans h ara as apprpria. 14. Rmv and discard h glvs in accrdanc wih insiuinal plicy, and prfrm hand hygin. 15. Apply a small drssing r adhsiv bandag as sad by insiuinal plicy. 16. Prvid pain cmfr. If h IV si is  b cnvrd  a salin lck whn h larg-vlum sluin is discninud, h fllwing shuld b dn: 1. Prfrm sps 1 hrugh 5 as dscribd fr discninuing h IV si. 2. Prpar a salin ush, aach h syring  h xnsin ubing, purg air frm h ubing, and hn clamp h xnsin ubing. Lav h syring aachd. 3. Clamp h ubing n h IV lin, and hn shu ff h infusin quipmn, if prsn. 4. Pu n glvs and clans h cnncr si wih anispic alchl wip. L air-dry. 5. Sabiliz h cahr hub whil discnncing h IV primary ubing and hn quickly cnnc h xnsin ubing.

Parenteral Administration: Intravenous Route CHAPTER 11

6. Unclamp h xnsin ubing and ush h cahr wih salin in accrdanc wih insiuinal plicy; clamp h ubing as h las 0.5 mL is injcd. 7. Tap h si scurly and labl and da h xnsin ubing. doCumentatIon Prvid h righ dcumnain f h rminain f IV hrapy. 1. Char h da and im f h rminain f h IV si r f h cnvrsin  a salin lck. 2. Prfrm and rcrd rgular pain assssmns (.g., si daa, siz f si, clr f skin a vnipuncur si). 3. Char and rpr any signs f advrs ffcs (.g., rdnss, warmh, swlling, pain a vnipuncur si). 4. Rcrd h al amun infusd n h inak and upu rcrd and n any w shs usd in h clinical pracic sing. 5. Rcrd h salin ush n h pain’s MAR.

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monitorinG intravEnous thErapy Bfr iniiaing hrapy, prfrm baslin pain assssmns  valua h pain’s currn saus. Rpr a apprpria inrvals hrughu h curs f ramn. Immdialy afr rciving a rpr rgarding assignd pains, chck h MAR fr IV mdicains and IV infusin rdrs fr hs pains. Mak runds  prfrm a baslin assssmn. Daa ha shuld b gahrd and analyzd wih rfrnc  IV hrapy includ h fllwing: • Chck ha h rdrd IV sluin (wih r wihu mdicains) is bing adminisrd  h crrc pain a h crrc ra f infusin. • Chck h al amun infusd agains h amun ha shuld hav bn infusd. Is h vlum f infusd IV sluin r IV mdicain “n arg,” “ahad,” r “bhind”? • Calcula h drip ra  adminisr h mdicin vr h apprpria im inrval. Wih a prgrammabl infusin pump, nsur ha h pump is s  dlivr h prscribd vlum (mL) pr hur. • Chck fr inlin lrs. If n is rcmmndd fr h mdicin bing infusd, is i bing usd? • Chck h da and im ha h infusing IV sluin r IV mdicain was hung. Idnify whn h infusing IV sluin, adminisrain s and ubing, IV si, IV cahrs, and drssings ar  b changd in accrdanc wih h plicis f h clinical pracic sing. Th CDC rcmmnds ha vnipuncur si drssings b changd whn hy bcm damp, ls, r sild r whnvr h vnipuncur si is changd. • Chck h da and im ha prcdurs ar rdrd  mainain h pancy f h sablishd IV

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lins. (Fllw insiuinal plicis.) Th fllwing ar gnral guidlins: • Priphral inrmin IV lins ar usually ushd vry 8  12 hurs wih h us f 1  2 mL f salin sluin. Us psiiv prssur  prvn h backw f bld and pssibl cclusin. • Cnral vnus IV lins ar usually ushd wih a minimum f 10 mL f NS sluin whnvr hy ar irrigad. Us a push-paus mhd  irriga (rahr han cninuus prssur). T prvn xcssiv prssur wihin h lin, always us a las a syring wih a 10-mL capaciy  irriga and mainain h pancy f a cnral lin. Fllw insiuinal plicy fr h us f salin and hparin sluins. • Grshng cahrs hav a w-way valv ha prvns backw; hrfr hs cahrs d n rquir hparin. Grshng cahrs ar ushd wih 5 mL f NS wkly r a an inrval drmind by insiuinal plicy fr lumns ha ar n in us. Afr mdicain adminisrain r TPN infusin, ush wih 10 mL f NS. Afr bld sampl draws r bld prduc infusin, ush wih 20 mL f sril NS. • Th amun f sluin usd  ush a Hickman, Brviac, r Grshng cahr varis and mus b sufcin  qual w ims h vlum rquird  ll h cahr lumn plus h vlum f any xnsin ubing ha is bing usd. • Implanabl vascular accss prs (.g., Pr-ACah, Infus-A-Pr) rquir ha h pr b lld wih sril hparinizd sluin, usually 100 unis/mL, afr ach us. If h pr is n accssd rgularly, ushs may nly b prfrmd nc ach mnh r a an inrval cid by insiuinal plicy. • Prvn damag  cnral vnus cahrs by clamping nly h cahr wih a paddd hmsa r a smh-dgd clamp. • Chang h injcin caps fr lumn hubs n cnral vnus cahrs vry 72 hurs r as sad in h insiuinal plicy. • Chck h IV ubing fr any bsrucins r air in h lin. Th pain and h vnipuncur si shuld b chckd a las vry hur fr w ra, inlrain (.g., ndrnss, rdnss, pufnss), and advrs ffcs. Rpr and ak immdia acin if h infusin is inlrad, if i is imprprly infusing, r if signs f infcin xis. If h w ra is falling bhind schdul, d h fllwing: 1. Chck fr mchanical bsrucin f h ubing (.g., clsd clamp, kinking) r lr, and ihr irriga r chang h ubing. 2. Chck h drip chambr. If i is lss han half full, squz i  ll i mr cmplly. D n vrll.

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UNIT II Illustrated Atlas of Medication Administration

3. Chck  mak sur ha h IV cnainr is n mpy. Als, chck  mak sur ha h cnainr is mr han 3 f abv h vnipuncur si. Th high may b inadvrnly incrrc if h pain is rpsiind r if h bd high is radjusd. 4. Chck fr ubing ha has falln blw h vnipuncur si. If a signican lngh has falln, lva and carfully cil h ubing nar h si f h vnipuncur. • War glvs  inspc h IV si. Chck h ransparn drssing fr h da ha h infusin dvic was sard. Palpa gnly arund h cahr r ndl fr dma, clnss, r pain, which indica inlrain. Chck fr any signs f rdnss r ha, which indica ha an inammary prcss is ccurring. • Chck  drmin whhr h bvl f h ndl is pushing agains h wall f h vin. D his by cautiously raising r lwring h angl f h ndl slighly  s if w is rsrd. If s, rpsiin h ndl slighly wih h us f a gauz pad in h ms apprpria lcain. • Chck h mpraur f h sluin ha is bing infusd. Cld sluins can caus spasms in h vin. • Chck  nsur ha a rsrain r bld prssur cuff applid  h arm has n inrfrd wih h w. • If i appars ha h IV accss dvic is cld, do not amp  clar h ndl by ushing i wih uid. This will disldg h cl, which may caus a hrmbmblism. Th aspirain f h ndl r cahr wih a syring  disldg h cl is n lngr rcmmndd; rahr, h si shuld b discninud and h IV infusin rsard. • Rmain alr a all ims fr cmplicains assciad wih IV hrapy f any yp (.g., phlbiis, infcin, air in h ubing, circulary vrlad, pulmnary dma, pulmnary mblism, drug racins frm h IV mdicains). • Dcumn all ndings and prcdurs prfrmd in assciain wih IV hrapy. • During shif rpr, idnify h xac vlum f IV sluin r mdicain ha has bn infusd n h currn shif and h vlum rmaining  b infusd during h nx shif. In addiin, rpr any IV sis ha ar funcining prly r IV lins ha rquir frqun si changs. ComplICatIons assoCIated WIth Intravenous therapy Cmplicains ha can ccur wih IV hrapy includ phlbiis, hrmbphlbiis, lcalizd infcin, spicmia, inlrain, xravasain, air in h ubing, air mblism, circulary vrlad, pulmnary dma, cahr mblism, and “spd shck.”

pbii, tbbii,  lciz Ici Phlebitis is h inammain f a vin; thrombophlebitis is h inammain f a vin wih h frmain f a hrmbus in h ara f inammain. Th hr primary causs f phlbiis ar as fllws: 1. Irriain f h vin by h cahr (.g., cahr ha is  larg fr h vin, imprpr insrin, imprpr anchring wih xcssiv mvmn f h cahr). 2. Chmical irriain frm mdicins (.g., sluin infusd  rapidly r a a vlum ha was  larg fr h vin, sluin is irriaing  h vin). 3. Infcin causd by imprpr aspic chniqu during accssing r drssing changs, r frm lngrm cahr placmn. If signs f rdnss (ryhma), warmh, ndrnss, swlling, and burning pain alng h curs f h vin ar prsn, phlbiis r hrmbphlbiis and infcin may b dvlping (Tabl 11.2). Cnrm h prsnc f hs signs wih h suprvising nurs. Th ramn f phlbiis dpnds n h caus f vnus irriain. If h IV lin is priphral and hr is vidnc f inlrain using h Inltration Scale (Tabl 11.3), h IV cahr is discninud and a nw IV lin using all nw quipmn is insrd a a diffrn lcain. Fr ppl wih any yp f cnral cahr (.g., PICC), h halhcar prvidr shuld b nid. N all cnral cahrs ar rmvd whn infcin ccurs; sm may b rad wih anibiic hrapy. Many insiuins als rquir ha h infcin cnrl nurs b nid. If puruln drainag is prsn, a sampl f h drainag is baind fr culur and snsiiviy. If a fvr and chills (.g., signs f spicmia) accmpany hs sympms, culurs f h pain’s bld and h cahr ip may als b indicad. Chck insiuinal plicis rgarding whhr a halhcar prvidr’s rdr is ncssary  d his r whhr sanding rdrs xis as par f infcin cnrl prcdurs. Gnrally, fllw-up ramn includs lvain and h applicain f warm, mis cmprsss  h si.

Table 11.2 Assessing the Severity of Phlebitis ScorE 0

dEScriPtorS No clinical symptoms

1

Erythema at access site, with or without pain

2

Pain at the access site with erythema and/or edema

3

Pain at the access site with erythema, streak formation, and/or palpable venous cord ±1 inch long

4

Pain at the access site with erythema, streak formation, palpable venous cord >1 inch long, and/or purulent drainage

From Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2016, S45.

Parenteral Administration: Intravenous Route CHAPTER 11

Dcumn h ndings, h ramn ha is adminisrd, and h rsuls f nging assssmns.

Clinical Pitfall Only a Huber needle is used to access an implanted port.

sici Whn pahgns ha ar assciad wih a lcal infcin invad h bldsram, ar carrid  hr pars f h bdy, and riggr an inammary rspns (.g., fvr, chills), h infcin is n lngr lcal; i is nw sysmic, and his cndiin is calld septicemia Ppl wh alrady hav an infcin r wh ar immuncmprmisd ar a highr risk fr h dvlpmn f spicmia. Th impranc f mainaining aspic chniqu hrughu all aspcs f cahr insrin and mainnanc car cann b vrmphasizd. Th pnial fr cnaminain xiss during vry aspc f IV hrapy, saring a h im f h manufacur and packaging f IV uids and quipmn and cninuing hrughu h acual prparain and adminisrain f h IV hrapy. Th

Table 11.3 Inltration Scale GrAdE 0 1

clinicAl critEriA No symptoms Skin blanched Edema 6 inches in any direction Cool to touch Mild to moderate pain Possible numbness

4

Skin blanched, translucent Skin tight, leaking Skin discolored, bruised, swollen Gross edema >6 inches in any direction Deep pitting tissue edema Circulatory impairment Moderate to severe pain Inltration of any amount of blood product, irritant, or vesicant

From Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2016, S46.

175

risk f spicmia als incrass wih h frquncy wih which h cahr and si ar manipulad and wih hw lng an IV cahr rmains in plac. Prfrm cahr si inspcins in accrdanc wih insiuinal plicy. Suspc lcalizd infcin a h cahr si if rdnss, dma, r puruln drainag is prsn a h nry si r if h pain has an lvad mpraur r an lvad whi bld cll cun. Kp in mind ha immuncmprmisd pains r hs wh ar rciving an anipyric (.g., acaminphn, ibuprfn) may n dvlp a fvr. Suspc spicmia if h pain dvlps h fllwing: a suddn ns f ushing, fvr, chills, gnral malais, hadach, nausa, vmiing, hypnsin, shck, r a wak, rapid puls. Obain h pain’s vial signs and nify h halhcar prvidr immdialy f all ndings. Obain h halhcar prvidr’s rdrs, which will usually includ bld culurs, h discninuain f h IV cahr, and anibiic hrapy afr culurs ar baind. Rurn h unusd prin f h IV sluin  h pharmacy r labrary fr sing as spcid by insiuinal plicy. Dcumn h ndings, h ramn adminisrd, and h nging assssmns. Iii  exi Inltration is h lakag f an IV sluin in h issu ha surrunds h vin; extravasation is h lakag f an irrian chmical (.g., h mdicin bing infusd) in h issu ha surrunds h vin. Inlrain r xravasain may b accmpanid by rdnss and warmh, clnss and blanching f h skin, swlling, and a dull ach  a svr pain a h vnipuncur si (s Tabl 11.3). Inlrain r xravasain ccurs ms cmmnly whn a ndl ip puncurs h vin and h IV sluin laks in h issu ha surrunds h vin. Srius issu damag may ccur, paricularly if h mdicin in h sluin is irriaing  h issu (.g., a calcium sal) r causs vascnsricin (.g., lvarrnl)  h vasculaur in h ara. Th nurs shuld always duca h pain rgarding h signs and sympms f hs cndiins s ha h pain can rpr arly discmfr and arly inrvnins can b iniiad in h vn ha inlrain r xravasain ds ccur. Inspc h IV si a rgular inrvals fr inlrain. Whnvr a chang in h limb’s clr, siz, r skin ingriy is bsrvd, mak a cmparisn wih h ppsi limb. Gnral guidlins ar as fllws: • Fr inlrain, sp h infusin and lva h affcd limb. Assss fr circulary cmprmis: chck capillary rll and pulss prximal and disal  h ara f inlrain. If h inlrain is causd by an IV sluin, rmv h cahr as dircd by plicy and as dscribd arlir. Whhr cld r ha is applid  h si dpnds n h spcic yp f IV sluin and h yp f mdicain ha

176

UNIT II Illustrated Atlas of Medication Administration

has inlrad. Cnsul insiuinal guidlins and dscrib h pain’s cndiin using h inlrain scal (s Tabl 11.3). • Fr xravasain, h prcl will call fr h IV infusin  b sppd, bu h cahr is lf in plac. Wih auhrizain frm h halhcar prvidr, amps may b mad  aspira h mdicain, and rdrs fr ramn f phnlamin (Rgiin) which can b injcd alng h si f h xravasain  minimiz issu damag. Elva h xrmiy. Apply ic (pr insiuinal plicy) rahr han ha fr 24 hurs, xcp fr ramn f vincrisin r vinblasin xravasain, which rquirs ha rahr han cld. Dcumn h cndiin n h pain’s char as 4+ inlrain, and dscrib h visual apparanc and masurmns f h siz f h si whr xravasain has ccurrd. Phgraphs f h si may b par f h prcl. Afr h prcl fr xravasain is cmpl, rsar h IV sluin a a nw si prximal  h ara f xravasain. • Dcumn h ndings, h ramn adminisrd, and h nging assssmns. ai i  tbi  ai eb If an air bubbl is fund in h IV ubing, clamp h ubing immdialy. Swab h injcin si in h rubbr hub nar h ndl r h piggyback pral—whichvr is clsr  h air bubbl—wih an alchl wip. Using sril chniqu, insr a ndllss accss dvic n a syring in h pral blw h air bubbl, and wihdraw h air pck. An air embolism ccurs as a rsul f an air bubbl nring h cardivascular sysm. Sympms f an air mblism may includ pain cmplains f palpiains, chs pain, shrnss f brah, cyansis, hypnsin, and a wak, hrady puls. If air has acually nrd h pain via h IV ubing, urn h pain n hir lf sid wih h had in a dpndn psiin. Adminisr xygn and nify h halhcar prvidr immdialy. Mnir vial signs. B prpard fr pssibl rdrs  draw arrial bld gass and fr vnilary suppr, if ncssary. Air mbli can b prvnd by clamping cahrs whn hy ar n in us, insrucing h pain  prfrm h Valsalva manuvr during ubing and injcin cap changs, using prpr inlin lrs, n allwing IV cnainrs  run dry, and rmving all air frm ubing r syrings bfr cnncing hm  an IV accss dvic. Always purg h ush r mdicain syring f air bfr aachmn and injcin. Dcumn h ndings, h ramn adminisrd, and h nging assssmns. Cic o  p e Circulary vrlad ha lads  pulmonary edema is causd by infusing uid  rapidly r by giving  much uid, paricularly  ldr aduls, infans, r

pains wih cardivascular disas. Signs f circulary vrlad ar ngrgd nck vins, dyspna, rducd urin upu, dma, bunding puls, and shallw, rapid rspirains. Th signs f pulmnary dma ar dyspna, cugh, anxiy, cars crackls, pssibl cardiac dysrhyhmias, hrady puls, lvain r drp in bld prssur (dpnding n svriy), and frhy spuum. Whn hs sympms dvlp, slw h IV infusin immdialy  a TKO ra. Plac h pain in a high Fwlr’s psiin (had f bd 60  90 dgrs), sar xygn, bain vial signs, and summn h halhcar prvidr immdialy. During svr rspirary disrss, h pain may rquir inubain and a mchanical vnilar  imprv xygn dlivry. Anicipa h halhcar prvidr’s rdrs fr mdicains such as diurics, vasdilars, and mrphin sulfa. Dcumn h ndings, h ramn adminisrd, and h nging assssmns. p ebi A pulmonary embolism may ccur as a rsul f frign marials bing injcd in h vin r frm a bld cl ha braks ls and ravls  h lungs, whr i ldgs in h arrils. Sympms includ h suddn ns f apprhnsin and dyspna, pluriic pain, swaing, achycardia, cugh, unxplaind hmpysis, lw-grad fvr, and cyansis. Whn his cndiin is suspcd, immdialy plac h pain in a smiFwlr psiin, adminisr xygn, bain vial signs, and nify h halhcar prvidr. Anicipa rdrs fr h drawing f bld fr arrial bld gass, prfrming a lung scan  vrify h prsnc f h pulmnary mblism, and drmining h baslin prhrmbin im bfr iniiaing anicagulan hrapy. Frign-paricl mbli can b prvnd by using an inlin lr, using prpr diluns fr rcnsiuin, nsuring h cmpl dissluin f any mdicains ha ar addd  a sluin, and nsuring ha hr ar n visibl signs f frign mar in IV sluins. Thrmbmbli can b avidd by n using h vins in h lwr xrmiis in aduls and by using a 10mL syring whn ushing all cnral lins. A 10-mL syring dcrass h prssur ha is xrd wihin h vascular sysm. (Th smallr h syring, h grar h prssur xrd.) Whn ushing a cahr, nvr frc h ush sluin bcaus his may disldg a cl. Dcumn h ndings, h ramn adminisrd, and h nging assssmns. “s sck” “Speed shock” ccurs as a sysmic racin  a frign subsanc ha is givn  rapidly in h bldsram. This can ccur whn an IV drug is adminisrd  rapidly in h circulain, ms cmmnly by IV push. Th rapid dlivry f h IV drug cras a cncnrad plasma lvl in h pain ha may

Parenteral Administration: Intravenous Route CHAPTER 11

rsul in shck, syncp, and cardiac arrs. Diffrn rsurcs (.g., AHFS Drug Information, Physicians’ Desk Reference) and packag insrs ha accmpany mdicains sa h rcmmndd ra f injcin r w ra  prvn cmplicains ha may rsul frm a rapid infusin ra. Th nurs nds  im h adminisrain f an IV push mdicain by bsrving h infusin im n a clck r wach dircly. Th nurs als nds  frqunly chck h w ra f IV infusins, us infusin cnrl dvics, and rsis spding up mdicains r IV ras whn hrapy is bhind schdul. Assss h pain bfr iniiaing an IV drug  bain baslin daa (.g., vial signs), and cninu mniring during IV hrapy fr dizzinss; ushing; ighnss in h chs; rapid, irrgular puls; hypnsin; and anaphylacic shck. Whn spd shck is suspcd, immdialy sp h infusin, mainain IV pancy a a TKO ra, bain h pain’s vial signs, and nify h halhcar prvidr. Anicipa h ramn f shck by chcking insiuinal plicy. patIent teaChIng Always ach h pain and hir signican hrs abu h signs and sympms f cmplicains ha shuld b rprd immdialy  h halhcar prvidr. Dpnding n h yp f IV dlivry sysm ha is usd  adminisr h mdicain, insruc hs bing rad n an upain basis r in a hm halh sing whn  rurn fr h cahr  b changd and whn  rurn fr h nx visi  h halhcar prvidr r clinic.

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doCumentatIon Prvid h righ dcumnain f h mdicain adminisrain, h pain’s rspnss  drug hrapy, and any cmplicains f r unward racins  h prscribd hrapy. 1. Char h da and im, h drug nam and dsag, and h ru f adminisrain. 2. Prfrm and rcrd rgular pain assssmns fr h valuain f hrapuic ffcivnss (.g., bld prssur, puls, inak and upu, lung ld sunds, rspirary ra, pain a infusin si). 3. Prfrm rgular assssmns f h pain and h IV accss sis fr cmplicains assciad wih IV hrapy r h adminisrain f IV drug hrapy. 4. Char and rpr any signs and sympms f advrs drug ffcs rlad  hrapy. Nify h halhcar prvidr f any cmplicains. 5. Char any drssing changs prfrmd and rcrd any signs and sympms f cmplicains a h insrin si (.g., rdnss, ndrnss, swlling, drainag). 6. Char any difculy wih ushing f any vnus accss dvic and nify h halhcar prvidr as apprpria. 7. Char h das and ims ha prcdurs ar prfrmd  mainain h pancy f h IV si, ndl, priphral r midlin cahr, cnral vnus cahr, r pr (.g., hparinizd ush; salin ush fr a Grshng cahr). 8. Prfrm and valida ssnial pain ducain rgarding h drug hrapy and hr ssnial aspcs f inrvnin fr h disas prcss ha is affcing h individual.

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UNIT II Illustrated Atlas of Medication Administration

Ciic J  nx-gi nCleX ® exii-s qi ke Ps • Intravenous therapy involves the administration of uids and medications directly into the bloodstream. The three intravascular compartments are veins, arteries, and capillaries. The three uid compartments are intracellular spaces, intravascular spaces (e.g., arteries, veins, and capillaries), and interstitial spaces. • Intravenous access devices include peripheral IV lines, central catheters, and implantable infusion ports. • Intravenous solutions that are hypotonic are used for dehydration, isotonic solutions are used to maintain hydration, and hypertonic solutions may be used to draw uid into the intravascular compartment to support blood pressure and promote diuresis. • Principles of IV administration include the following:  • Review the chart to determine the medical and nursing diagnosis, the patient’s history and allergies, and the signicant presenting symptoms.  • Review the assessment of the patient’s baseline data, current vital signs, laboratory and diagnostic data, and type and use of any IV access. After the IV site is established, the IV solution or blood product is hung, or an IV medication is administered, an ongoing assessment is required to monitor the patient’s condition, the IV site, and response to the IV therapy that is being delivered. • Patient education needs to be implemented. All aspects of the patient’s care needs must be explained to the patient and their family. In addition, community resources must be arranged to assist with home infusion therapy. • Complications of IV therapy include phlebitis, thrombophlebitis, localized infection, septicemia, inltration, extravasation, air in the tubing, air embolism, circulatory overload, pulmonary edema, catheter embolism, and “speed shock.”

Aa leag reses

SG

Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Clayton) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types.

1. A nurse is starting a peripheral IV line for the rst time in an extremity of an elderly patient and knows which site is the best location for an IV line? 1. 2. 3. 4.

Near the antecubital space In the biggest vein that is visible In the dominant hand In the metacarpal vein, if it is large enough

objeve: Discuss the different IV access devices used for IV therapy. nclEx e pe: Multiple choice cgve s: Knowledge 2. The nurse knows that IV solutions have different clinical uses. Match the IV solution with the clinical use.

iV Solution tyPE

clinicAl uSE

Hypertonic

Patient with signs of peripheral dehydration Patient with signs of uid volume overload Patient recovering from surgery following trauma

Isotonic Hypotonic

objeve: Differentiate between isotonic, hypotonic, and hypertonic IV solutions and explain their clinical uses. nGn e pe: Drag and drop cgve s: Recognize cues 3. After changing a primary IV bag, the nurse nds that it will not run. What does the nurse do to problem-solve ? (Select all that apply.) 1. 2. 3. 4. 5.

Determine that the correct type of IV solution was hung Check that the clamps are open Adjust the height of the IV solution Prime a new IV tubing Adjust the position of the patient’s arm

objeve: Identify the general principles of administering medications via the IV route. nclEx e pe: Multiple response cgve s: Application

Parenteral Administration: Intravenous Route CHAPTER 11

4. Choose the most likely options for the information missing from the following sentence by selecting from the lists of options provided. The nurse checking a patient’s IV site notes that there was an area around the IV that looked ________1__________ and felt ________1___________ and recognized these to be symptoms of a/an __________2___________.

oPtionS for 1

oPtionS for 2

purulent drainage swollen and puffy cool to the touch warm to the touch

air in the tubing phlebitis inltration infection

objeve: Explain the signs, symptoms, and treatment of the complications associated with IV therapy (e.g., phlebitis, thrombophlebitis, localized infection, septicemia, inltration, extravasation, air in tubing, pulmonary edema, catheter embolism, and “speed shock”). nGn e pe: Cloze cgve s: Recognize cues 5. The nurse knows that there are different techniques used to administer medication in an IV. Indicate with an arrow which technique is associated with which IV type. tEchniquE for AdminiStrAtion of mEdicAtion Infusion line (IV tubing)

IV bag Secondary piggyback set

Saline lock

Aspirate for blood, ush the IV, infuse the med, ush again Attach med syringe into Y port, infuse the med Attach syringe to bag port, infuse into solution, agitate bag Connect tubing, backush from primary, open clamp, hang bag higher than primary, run medication

objeve: Describe the correct techniques for administering medications by means of a saline lock, an IV bag, an infusion pump, and secondary piggyback set. nGn e pe: Drag and drop cgve s: Application 6. To minimize the risk of air embolism with IV therapy, the nurse should routinely do which of the following? (Select all that apply.) 1. Cap off the IV catheter when not in use. 2. Instruct the patient to perform the Valsalva maneuver during tubing and injection cap changes. 3. Always use proper inline lters. 4. Allow IV containers to run dry to ensure all uid/ medication is given. 5. Remove all air from tubing or syringes before connecting to an IV access device.

179

objeve: Explain the signs, symptoms, and treatment of the complications associated with IV therapy (e.g., phlebitis, thrombophlebitis, localized infection, septicemia, inltration, extravasation, air in tubing, pulmonary edema, catheter embolism, and “speed shock”). nclEx e pe: Multiple response cgve s: Application 7. When administering a medication into a port with a Huber needle, what are the steps the nurse takes? List the steps in order. Administer the medication and ush port again Use sterile technique throughout the procedure Perform hand hygiene and apply sterile gloves Prepare a syringe with the medication Flush the port with push-pause technique Insert the Huber needle perpendicular to the patient’s skin 7. Apply a transparent dressing 1. 2. 3. 4. 5. 6.

objeve: Identify baseline assessments for IV therapy and proper maintenance of patency of IV lines and implanted access devices. nclEx e pe: Ordering cgve s: Application 8. The nurse knows to watch for which of the following signs and symptoms of speed shock? (Select all that apply.) 1. 2. 3. 4. 5.

Complaint of dizziness and ushing Engorged neck veins Rapid, irregular pulse Complaint of tightness in the chest Swollen, puffy area around the IV site

objeve: Explain the signs, symptoms, and treatment of the complications associated with IV therapy (e.g., phlebitis, thrombophlebitis, localized infection, septicemia, inltration, extravasation, air in tubing, pulmonary edema, catheter embolism, and “speed shock”). nclEx e pe: Multiple response cgve s: Application 9. The nurse has completed the administration of an IV injection of furosemide (Lasix) and will document this on the MAR by including what information? (Select all that apply.) 1. 2. 3. 4. 5. 6. 7.

The IV site used The time it took to infuse the drug The time of administration The date of administration The dosage administered The drug administered The provider who ordered the drug

objeve: Describe the correct techniques for administering medications by means of a saline lock, an IV bag, an infusion pump, and a secondary piggyback set. nclEx e pe: Extended multiple response cgve s: Evaluate cues

Unit III

Drugs Affecting the Autonomic and Central Nervous Systems

12

Drugs Affecting the Autonomic Nervous System

https://evolve.elsevier.com/Willihnganz

Objectives 1. Identify the most common neurotransmitters known to affect central nervous system function. 2. Explain the actions of anticholinergic agents and betaadrenergic blocking agents. 3. Describe clinical uses and the predictable adverse effects of anticholinergic agents.

4. Describe clinical uses and the predictable adverse effects of beta-adrenergic blocking agents. 5. Describe clinical uses and the predictable adverse effects of cholinergic agonists. 6. Describe clinical uses and the predictable adverse effects of adrenergic agonists.

Key Terms central nervous system (SĔN-trŭl NŬR-vŭs SĬS-tĕm) (p. 180) peripheral nervous system (pĕ-RĬFĕr-ăl) (p. 180) afferent nerves (ĂF-ĕ-rĕnt NŬRVZ) (p. 180) efferent nerves (ĔF-ĕ-rĕnt) (p. 180) autonomic nervous system (ŏ-tōNŎM-ĭk) (p. 180) neurons (NYŪR-ŏn) (p. 180) synapse (SĬN-ăps) (p. 180) neurotransmitters (nyūr-ō-TRĂNZ-mĭtŭrz) (p. 180)

receptors (rē-SĔP-tŭrz) (p. 180) norepinephrine (nōr-ĕp-ĭ-NĔF-rĭn) (p. 181) acetylcholine (ăs-ē-tĭl-KŌ-lēn) (p. 181) cholinergic bers (kō-lĭn-ŬR-jĭk FĪbŭrz) (p. 181) adrenergic bers (ăd-rĭn-ŬR-jĭk) (p. 181) cholinergic agents (kō-lĭn-ŬR-jĭk Ā-jĕnts) (p. 181) adrenergic agents (ăd-rĭn-ŬR-jĭk) (p. 181)

The CenTral and auTonomiC nervous sysTems The control of the human body as a living organism comes primarily from two major systems: the nervous system and the endocrine system. In general, the endocrine system controls the body’s metabolism. The nervous system regulates the body’s ongoing activities (e.g., heart and respiratory functions), its rapid response to sudden changes in the environment (e.g., skeletal muscles contracting to help an individual to avoid danger), and the rates of secretion of some glands. The nervous system is composed of the central nervous system (CNS), which consists of the brain and the spinal cord, and the peripheral nervous system, which includes the peripheral nerves subdivided into the afferent and efferent nerves. The afferent nerves conduct signals from sensory receptors (e.g., vision, pressure, pain, cold, warmth, touch, smell) throughout the body to the CNS. The CNS processes these signals and 180

anticholinergic agents (ăn-tē-kō-lĭnŬR-jĭk) (p. 181) adrenergic blocking agents (ăd-rĭnŬR-jĭk BLŎ-kĭng Ā-jĕnts) (p. 181) catecholamines (kăt-ĕ-KŌL-ă-mēnz) (p. 181) alpha receptors (ĂL-fă rē-SĔP-tŭrz) (p. 181) beta receptors (BĀ-tă rē-SĔP-tŭrz) (p. 181) dopaminergic receptors (dō-pămĭn-ŬR-jĭk rē-SĔP-tŭrz) (p. 181)

controls the body’s response by sending signals back through the efferent nerves of the peripheral nervous system. The peripheral nervous system is further subdivided into the somatic nervous system, which controls voluntary movement (e.g., skeletal muscle contractions), and the autonomic nervous system, which, as suggested by the name, works automatically and is not under voluntary control. Each nerve of the central and peripheral nervous systems is actually composed of a series of segments called neurons The junction between one neuron and the next is called a synapse The transmission of nerve signals or impulses occurs because of the activity of chemical substances called neurotransmitters (e.g., transmitters of nerve impulses). A neurotransmitter is released into the synapse at the end of one neuron, thereby activating receptors on the next neuron in the chain or, at the end of the nerve chain, stimulating receptors on the end organ (e.g., the heart, smooth muscle, or gland).

Drugs Affecting the Autonomic Nervous System CHAPTER 12

Neurotransmitters can be excitatory, which means that they stimulate the next neuron, or inhibitory, which means that they inhibit electrical impulses through the neuron. Because a single neuron releases only one type of neurotransmitter, the CNS is composed of different types of neurons that secrete separate neurotransmitters. Research indicates that there are more than 30 different types of neurotransmitters; the more common ones throughout the CNS are acetylcholine, norepinephrine, epinephrine, dopamine, glycine, gamma-aminobutyric acid, and glutamic acid. Substance P and the enkephalins and endorphins regulate the sensation of pain, and serotonin and dopamine regulate mood. Other neurotransmitters include prostaglandins, histamine, cyclic adenosine monophosphate, amino acids, and peptides. Neurotransmitter regulation by pharmacologic agents (e.g., medicines) is a major mechanism that allows for the control of disease processes caused by an excess or deciency of these neurotransmitters. The use of inhibitory and excitatory neurotransmitters to control illnesses is explained in the rest of the chapters in this unit.

The auTonomiC nervous sysTem With the exception of skeletal muscle, the autonomic nervous system controls most tissue function. This nervous system helps to control blood pressure, gastrointestinal (GI) secretion and motility, urinary bladder function, sweating, and body temperature. In general, it maintains a constant internal environment (homeostasis) and responds to emergency situations. There are two main branches of the autonomic nervous system: the sympathetic branch and the parasympathetic branch. The sympathetic and parasympathetic branches typically function in opposition with each other. However, this can be considered complementary in nature rather than antagonistic. The sympathetic branch speeds up normal processes, and the parasympathetic branch slows down these processes. The sympathetic division typically functions in actions that require quick responses during the “ght-or-ight” response. The parasympathetic division functions as part of actions that do not require immediate reaction during the “rest-and-digest” response. The two major neurotransmitters of the autonomic nervous system are norepinephrine and acetylcholine. The nerve endings that liberate acetylcholine are called cholinergic bers; those that secrete norepinephrine are called adrenergic bers Most organs are innervated by both adrenergic and cholinergic bers, but these bers produce opposite responses. For example, in the heart, the stimulation of adrenergic bers increases the heart rate, and the stimulation of cholinergic bers slows the heart rate; in the eyes, the stimulation of adrenergic bers causes pupillary dilation, and the stimulation of cholinergic bers causes pupillary constriction (Table 12.1). Medications that cause effects in the body similar to those produced by acetylcholine are called

181

cholinergic agents (muscarinic agents) or parasympa-

thomimetic agents, because they mimic the action produced by the stimulation of the parasympathetic division of the autonomic nervous system. Medications that cause effects similar to those produced by the adrenergic neurotransmitter are called adrenergic agents or sympathomimetic agents. Agents that block or inhibit cholinergic activity are called anticholinergic agents (antimuscarinic agents), and those that inhibit the adrenergic system are referred to as adrenergic blocking agents. Fig. 12.1 presents a diagram of the autonomic nervous system and its representative stimulants and inhibitors.

Drug Class: aDrenergiC agents Actions The adrenergic nervous system may be stimulated by two broad classes of drugs: catecholamines and noncatecholamines. The body’s naturally occurring neurotransmitter catecholamines are norepinephrine, epinephrine, and dopamine. Norepinephrine is secreted primarily from nerve terminals, epinephrine comes primarily from the adrenal medulla, and dopamine is found at selected sites in the brain, the kidneys, and the GI tract. All three agents are also synthetically manufactured and may be administered to produce the same effects as those that are naturally secreted. Noncatecholamines have actions that are somewhat similar to those of the catecholamines; however, they are more selective for certain types of receptors, they are not quite as fast acting, and they have a longer duration of action. As illustrated in Fig. 12.1, the adrenergic side of the autonomic nervous system can be subdivided into the alpha receptors, beta receptors, and dopaminergic receptors. In general, the stimulation of the alpha-1 receptors causes the vasoconstriction of blood vessels. The alpha-2 receptors appear to serve as mediators of negative feedback, thereby preventing the further release of norepinephrine. Stimulation of beta-1 receptors causes an increase in the heart rate, and stimulation of beta-2 receptors causes the relaxation of smooth muscle in the bronchi (bronchodilation), the uterus (relaxation), and the peripheral arterial blood vessels (vasodilation). Stimulation of the dopaminergic receptors in the brain improves the symptoms associated with Parkinson disease. Dopamine also increases urine output as a result of the stimulation of specic receptors in the kidneys that results in better renal perfusion. Uses As noted in Table 12.2, many drugs act on more than one type of adrenergic receptor. Fortunately, each agent can be used for a specic purpose without many adverse effects. If recommended doses are exceeded, however, certain receptors may be stimulated excessively, which can cause serious adverse effects. An example of this is terbutaline, which is primarily a beta stimulant. With

182

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Table 12.1 Actions of Autonomic Nerve Impulses on Specic Tissues tissue BlooD Vessels a Coronary Skin Renal Skeletal muscle Veins (Systemic) eye Radial muscle, iris

reCeptor type

aDrenergiC reCeptors (sympathetiC)

α1 β2

Constriction Dilation

α1

CholinergiC reCeptors (parasympathetiC)

Dilation

Constriction

Dilation

Constriction Dilation

—

Constriction Dilation

Dilation

α1 β2

Constriction Dilation

—

α1

Constriction (mydriasis)

—

α1 β1 and β2 α1 β2

Sphincter muscle, iris

—

—

Constriction (miosis)

Ciliary muscle

β

Relaxation for far vision

Constriction for near vision

gastrointestinal traCt Smooth muscle α1; β1 and β2

Relaxation

Constriction

Sphincters

Constriction

Relaxation

α1

Heart

β1

Increased heart rate, force of contraction

Decreased heart rate

Kidney

Dopamine

Dilates renal vasculature, thereby increasing renal perfusion

—

lung Bronchial muscle

β2

Smooth muscle relaxation (opens airways)

Smooth muscle constriction (closes airways)

α1 β2

Decreased secretions; increased secretions

Stimulation

Bronchial glands Metabolism

β2

Glycogenolysis (increases blood glucose)

—

urinary BlaDDer Fundus (detrusor)

β3

Relaxation

Constriction

Trigone and sphincter Uterus

α1

α1 β2

Constriction

Relaxation

Pregnancy: constriction (α); relaxation (β2)

Variable

α1, Alpha-1 receptor; β, beta receptor; β1, beta-1 receptor; β2, beta-2 receptor; β3, beta-3 receptor.

normal doses, terbutaline is an effective bronchodilator. However, in addition to bronchodilation, higher doses of terbutaline cause CNS stimulation, which results in insomnia and wakefulness. See Table 12.2 for a list of the clinical uses of the adrenergic agents. Nursing Implications for Adrenergic Agents See Chapters 29 and 30 for more information about the nursing implications for respiratory tract disease, bronchodilators, and decongestants. Premedication assessment

1. Obtain baseline vital signs: heart rate and blood pressure. 2. See Chapters 29 and 30 for the premedication assessments for respiratory tract disease, bronchodilators, and decongestants.

Availability

See Table 12.2. Common adverse effects. Adverse effects associated

with adrenergic agents are usually dose related and resolve when the dosage is reduced or the medication discontinued. Patients who are potentially more sensitive to adrenergic agents are those with impaired hepatic function, thyroid disease, hypertension, and heart disease. Patients with diabetes mellitus may also have an increased frequency of episodes of hyperglycemia. Cdvc Palpitations, tachycardia, skin ushing, dizziness, tremors. These adverse effects are usually mild, and they tend to resolve with continued therapy. Encourage the patient not to discontinue therapy without rst consulting the healthcare provider.

Drugs Affecting the Autonomic Nervous System CHAPTER 12

183

Autonomic nervous system

Adrenergic receptors (sympathetic)

Cholinergic receptors (parasympathetic) (+) (−) Acetylcholine Atropine

Alpha-1

Alpha-2

Beta-1

Beta-2

Beta-3

(+)

(+)

(+)

(+)

(+)

Dopamine Isoproterenol Dobutamine Epinephrine

Isoproterenol Terbutaline Albuterol

Mirabegron

Norepinephrine Dopamine Phenylephrine Epinephrine

Clonidine Guanfacine Methyldopa

(−) Phenoxybenzamine Phentolamine Carvedilol Labetalol Prazosin Terazosin Doxazosin Tamsulosin Silodosin Alfusosin

(−) Phenoxybenzamine Phentolamine

(−) Acebutolol* Atenolol* Betaxolol* Bisoprolol* Carvedilol Carteolol Esmolol Lebatalol Metoprolol* Nadolol Nebivolol* (Doses ≤ 10 mg) Pindolol Propranolol Sotalol Timolol

Dopaminergic (+)

(−)

Dopamine

(−) Labetalol Carvedilol Carteolol Nadolol Pindolol

Fig. 12.1 Receptors of the autonomic nervous system. (+) Stimulates receptors; (−) inhibits receptors; asterisks (*) indicate selective beta-1 antagonists.

Orthostatic hypotension. Although this condition is infrequent and generally mild, adrenergic agents may cause some degree of orthostatic hypotension, which is manifested by dizziness and weakness, particularly when therapy is initiated. Monitor the blood pressure daily with the patient in both the supine and standing positions. Anticipate the development of postural hypotension, and take measures to prevent an occurrence. Teach the patient to rise slowly from a supine or sitting position; encourage the patient to sit or lie down if they feel faint. Serious adverse effects

Cdvc Dysrhythmias, chest pain, severe hypotension, hypertension, anginal pain. Discontinue therapy immediately and notify the healthcare provider. Ask the patient if there has been a recent change in their regimen of prescription, nonprescription, or herbal medicines. g Nausea, vomiting. Notify the healthcare provider. Ask the patient if there has been a recent change in their regimen of prescription, nonprescription, or herbal medicines.

Drug interactions

a   c c d xc ffc. Monoamine oxidase inhibitors (e.g., phenelzine, tranylcypromine), tricyclic antidepressants (e.g., amitriptyline, imipramine), atropine, and halothane anesthesia may increase both therapeutic and toxic effects. Many over-the-counter medications (e.g., cold remedies, appetite suppressants/ diet pills [e.g., pseudoephedrine, ephedrine, ma huang]) contain adrenergic medicines that can have an additive effect when they are taken with a prescribed adrenergic agent. Monitor patients for tachycardia, serious dysrhythmias, hypotension, hypertension, and chest pain. a  b c cv. The concurrent use of beta-adrenergic blocking agents (e.g., propranolol, nadolol, timolol, pindolol, atenolol, metoprolol), and alpha-adrenergic blocking agents (e.g., phenoxybenzamine, phentolamine), with adrenergic agents is not recommended.

Drug Class: alpha- anD Beta-aDrenergiC BloCking agents Actions The alpha- and beta-adrenergic blocking agents act by plugging the alpha or beta receptors, which prevents

184

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Table 12.2 Adrenergic Agents aDrenergiC reCeptor β2

aCtion Bronchodilator

CliniCal uses Asthma, emphysema

Nebulizer: 15 mcg/2 mL in 2-mL vials

β2

Bronchodilator

Emphysema, chronic bronchitis

—

IV: 1 mg/mL (250 mL); 2 mg/ mL (250 mL); 4 mg/mL (250 mL); 12.5 mg/mL in 250-mg/20-mL vial; 500-mg/40-mL vial

β1, β2; α1

Cardiac stimulant

Inotropic agent

dopamine

—

α, β1 IV: 40 mg/mL in 5-, 10-mL Vasopressor ampules; dopaminergic 200, 400, and 800 mg in D5W (various volumes available)

ephedrinea

Bronkaid Max Akovaz

Tablets: 25 mg IV: 50 mg/mL in 1 mL ampules; 10, 25, 50, 100, 250 mg prelled syringes

α, β

Vasoconstrictor

Anesthesia-induced hypotension; postoperative nausea and vomiting

epinephrinea

Adrenalin, EpiPen

IV: 1 : 1000 in 1-mL ampules; 1 : 10,000 in 10-mL prelled syringes Solution Autoinjector; 03 mg/0.3 ml and 0.15 mg/0.3 ml

α, β

Allergic reactions, vasoconstrictor, bronchodilator, cardiac stimulant

Anaphylaxis, cardiac arrest; topical vasoconstrictor

formoterola

Perforomist Oxeze

Nebulizer: 20 mcg/2 mL in 2-mL container

β2

Bronchodilator

Asthma, emphysema, chronic bronchitis

indacaterola

Onbrez Breezhaler

Capsule for inhalation: 75 mcg

β2

Bronchodilator

Emphysema, chronic bronchitis

isoproterenol

Isuprel

Subcut, IM, IV: 0.2 mg/mL solution; 1-, 5-mL vials

β

Bronchodilator, cardiac stimulant

Shock, digitalis toxicity, bronchospasm

mirabegron

Myrbetriq

Tablets, extended release (24 hr): 25, 50 mg

B3

Bladder detrusor muscle relaxant

Overactive bladder

norepinephrine (levarterenol)

Levophed

IV: 1 mg/mL in 4-mL ampules; 4-, 8-, 16-mg/250 mL; 0.08 mg/10 mL prelled syringes

α1

Vasoconstrictor

Shock, hypotension

α1 Subcut, IM, IV: 10 mg/mL in 1-mL ampules and 5-mL vial Ophthalmic drops: 2.5%, 10% Nasal solutions: 0.25%, 0.5%, 1% Tablets: 10 mg Liquid: 2.5 mg/5 mL

Vasoconstrictor

Shock, hypotension, nasal decongestant; ophthalmic vasoconstrictor, mydriatic

generiC name albuterola

BranD name Proventil HFA, Ventolin HFA, ProAir HFA, ProAir RespiClick, ProAir Digihaler

aVailaBility Aerosol: 90 mcg/puff Tablets: 2, 4 mg Syrup: 2 mg/5 mL Tablets, extended release (12 hr): 4, 8 mg Nebulizer solution: 0.083%/3mL ampule, 0.5%/0.5-mL ampule and 20-mL bottle; 0.63-mg/3-mL ampule, 1.25-mg/3-mL ampule

arformoterola

Brovana

dobutamine

phenylephrineb

Shock, hypotension; inotropic agent

Continued

Drugs Affecting the Autonomic Nervous System CHAPTER 12

185

Table 12.2 Adrenergic Agents—cont’d generiC name salmeterol

terbutalinea

BranD name Serevent Diskus

aVailaBility Aerosol powder: 50 mcg/dose

Tablets: 2.5, 5 mg Subcut: 1 mg/mL in 1-mL ampules

aDrenergiC reCeptor β2 β2

aCtion Bronchodilator

CliniCal uses Asthma, emphysema, chronic bronchitis

Bronchodilator, uterine relaxant

Emphysema, asthma

aSee

also bronchodilators (Chapter 30). also decongestants (Chapter 29). α, Alpha; β, beta, IM, intramuscular; IV, intravenous; Subcut, subcutaneous. Available in Canada. High-alert medication. bSee

other agents—usually the naturally occurring catecholamines—from stimulating the specic receptors. The beta blockers can be subdivided into nonselective and selective beta antagonists. The nonselective blocking agents have an equal afnity for beta-1 and beta-2 receptors, and they inhibit both. These agents are propranolol, nadolol, pindolol, carteolol, sotalol, and timolol. The selective beta-1 blocking agents exhibit action against the heart’s beta-1 receptors (cardioselective) and do not readily affect the beta-2 receptors of the bronchi. The selective beta-1 antagonists are esmolol, metoprolol, acebutolol, betaxolol, bisoprolol, and atenolol. This selective action is benecial for patients in whom nonselective beta blockers may induce bronchospasm (e.g., those with asthma). However, it is important to note that the selectivity of these agents is only relative. In larger doses, these agents will also inhibit the beta-2 receptors. There are no selective beta-2 blockers available. Labetalol and carvedilol exhibit selective alpha-1 and nonselective beta-adrenergic blocking activity. The alpha and beta blockers are listed in Fig. 12.1. Uses Because one of the primary actions of the alphareceptor stimulants is vasoconstriction, it would be expected that alpha-blocking agents are indicated for patients with diseases that are associated with vasoconstriction. Alpha blockers (e.g., prazosin, terazosin, doxazosin) are sometimes used to treat hypertension (see Chapter 22). Alfuzosin, silodosin, and tamsulosin are used to relax the smooth muscle of the bladder and prostate; they are used to treat urinary obstruction caused by benign prostatic hyperplasia (see Chapter 40). Beta-adrenergic blocking agents (e.g., beta blockers) are used extensively to treat post–myocardial infarction. They may also be used for hypertension, angina pectoris, cardiac dysrhythmias, symptoms of hyperthyroidism, and stage fright. Nonselective beta blockers must be used with extreme caution in patients with respiratory conditions such as bronchitis, emphysema, asthma, or allergic rhinitis. A beta blockade produces severe bronchoconstriction and may aggravate wheezing, especially during pollen season.

Beta blockers should be used with caution in patients with diabetes and in those who are susceptible to hypoglycemia. Beta blockers further induce the hypoglycemic effects of insulin and reduce the release of insulin in response to hyperglycemia. All beta blockers mask most of the signs and symptoms of acute hypoglycemia. Beta-adrenergic blocking agents should be used only in patients with controlled heart failure. Further hypotension, bradycardia, or heart failure may develop. Nursing Implications for Beta-Adrenergic Blocking Agents See also the nursing implications for patients with antidysrhythmic therapy (Chapter 23) and for those with hypertension (Chapter 22). Premedication assessment

1. Obtain baseline vital signs: heart rate and blood pressure. 2. See also the premedication assessments for patients with antidysrhythmic therapy (Chapter 23) and for those with hypertension (Chapter 22). Availability, dosage, and administration

See Table 12.3. idvdz f d. Although the onset of activity is fairly rapid, it may take several days to weeks for a patient to show optimal improvement and to become stabilized on an adequate maintenance dosage. Patients must be periodically reevaluated to determine the lowest effective dosage that is necessary to control the disorder. sdd dc. Patients must be counseled against poor adherence or the sudden discontinuation of therapy without a healthcare provider’s advice. Sudden discontinuation has resulted in an exacerbation of anginal symptoms, and this has been followed in some cases by myocardial infarction. When discontinuing chronically administered beta blockers, the dosage should be gradually reduced over 1 to 2 weeks, with careful patient monitoring. If anginal symptoms develop or become more frequent, beta blocker therapy should be restarted temporarily.

186

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Table 12.3 Beta-Adrenergic Blocking Agents generiC name acebutolol

atenolol

BranD name Sectral

aVailaBility Capsules: 200, 400 mg

CliniCal uses Hypertension, ventricular dysrhythmias

Dosage range PO: initial, 400 mg daily; maintenance, 600–1200 mg daily

Tenormin Teva-Atenolol

Tablets: 25, 50, 100 mg Oral solution: 1, 2, 10 mg/mL

Hypertension, angina pectoris, after myocardial infarction

PO: initial, 50 mg daily; maintenance, ≤200 mg daily

Tablets: 10, 20 mg

Hypertension

PO: initial, 10 mg daily; maintenance, 20 mg daily

betaxolol bisoprolol

Monocor

Tablets: 5, 10 mg

Hypertension

PO: initial, 5 mg daily; maintenance, 10–20 mg daily

carvedilol

APO-Carvedilol

Tablets: 3.125, 6.25, 12.5, 25 mg Capsules, extended release (24 hr): 10, 20, 40, 80 mg

Hypertension, heart failure, myocardial infarction

PO: initial, 6.25 mg twice daily; maintenance, ≤50 mg daily PO: initial, 10 mg daily; maintenance, ≤80 mg daily Extended release: 10 mg daily

esmolol

Brevibloc

Injection: 10 mg/mL in 10-mL ampules; 10 mg/mL in 250-mL bag; 20 mg/mL in 100-mL bag

Supraventricular tachycardia, hypertension

IV: initial, 500 mcg/kg/min for 1 min followed by 50 mcg/kg/min for 4 min and then adjusted to patient’s needs

Trandate

Tablets: 100, 200, 300 mg Injection: 5 mg/mL in 4-, 20-, 40-mL vials

Hypertension

PO: initial, 100 mg twice daily; maintenance, ≤2400 mg daily

metoprolol

Lopressor, Toprol-XL Betaloc, Kapspargo Sprinkle

Tablets: 25, 37.5, 50, 100 mg Hypertension, myocardial Tablets, extended release (24): infarction, angina 25, 50, 100, 200 mg pectoris, heart Capsules, extended release failure (24 hr): 25-, 50-, 100-, 200mg sprinkles Oral solution: 10 mg/mL in 90 mL bottle Injection: 1 mg/mL in 5-mL ampules, prelled syringes

PO: 50 mg twice daily; maintenance dosing of ≤450 mg daily, divided

nadolol

Corgard Apo-Nadol

Tablets: 20, 40, 80, 120, 160 mg

Angina pectoris, hypertension

PO: initial, 40 mg daily; maintenance, 40–80 mg daily; maximum, 320 mg daily for hypertension; maximum, 240 mg for angina

nebivolol

Bystolic

Tablets: 2.5, 5, 10, 20 mg

Hypertension

PO: initial, 5 mg daily; maintenance, ≤40 mg daily

pindolol

Apo-Pindol Visken

Tablets: 5, 10 mg

Hypertension

PO: initial, 5 mg twice daily; maintenance, 10–30 mg daily; maximum, 60 mg daily

propranolol, Tablets: 10, 20, 40, 60, 80 mg Inderal LA Solution: 4.28/mL, 20, 40 Apo-Propranolol mg/5 mL Capsules, sustained release (24 hr): 60, 80, 120, 160 mg IV: 1 mg/mL in 1-mL ampules

PO, immediate release: initial, 40 mg Dysrhythmias, twice daily; maintenance, 120– hypertension, 640 mg daily in two to four divided angina pectoris, doses myocardial PO, sustained release: 80–160 mg infarction, daily; maximum 640 mg daily migraine, tremor, IV: 1–3 mg with close hypertrophic electrocardiographic monitoring subaortic stenosis

sotalol

Betapace, Sorine, Sotylize

Tablets: 80, 120, 160, 240 mg IV: 150 mg/10 mL Oral solution: 5 mg/mL

Dysrhythmias

timolol

TEVA-Timolol

Tablets: 5, 10, 20 mg

Hypertension, PO: initial, 10 mg twice daily; myocardial maintenance, ≤30 mg twice daily infarction, migraine

IV, Intravenous; PO, by mouth. Available in Canada. High-alert medication.

PO: initial, 80 mg twice daily; maintenance, ≤320 mg daily

Drugs Affecting the Autonomic Nervous System CHAPTER 12

Common adverse effects. Most of the adverse effects

associated with beta-adrenergic blocking agents are dose related. Response by individual patients is highly variable. Many of the adverse effects that do occur may be transient. Strongly encourage patients to see their healthcare providers before discontinuing therapy. Minor dosage adjustment may be all that is required to eliminate most adverse effects. edc Patients with diabetes. Monitor for symptoms of hypoglycemia, including headache, weakness, decreased coordination, general apprehension, diaphoresis, hunger, or blurred or double vision. Many of these symptoms may be masked by beta-adrenergic blocking agents. Notify the healthcare provider if any of the symptoms described appear intermittently.

Serious adverse effects

Cdvc Bradycardia, peripheral vasoconstriction (e.g., purple, mottled skin). Discontinue further doses until the patient is evaluated by a healthcare provider. Heart failure. Monitor patients for an increase in edema, dyspnea, crackles, bradycardia, and orthopnea. Notify the healthcare provider if these symptoms develop. r Bronchospasm, wheezing. Withhold additional doses until the patient has been evaluated by a healthcare provider. Drug interactions

av . All beta-blocking agents have hypotensive properties that are additive with antihypertensive agents (e.g., angiotensin-converting enzyme inhibitors, calcium-channel blockers, diuretics, angiotensin receptor blockers, methyldopa, hydralazine, and clonidine). If it is decided to discontinue therapy in patients who are receiving beta blockers and clonidine concurrently, the beta blocker should be withdrawn gradually for several days and then discontinued before gradually withdrawing the clonidine. The concern if this order is not followed is the development of severe hypertension resulting from unopposed alpha activity if clonidine is stopped rst (see clonidine monograph about “sudden discontinuation” of clonidine therapy). B-dc . Depending on the dosage, the beta stimulants (e.g., isoproterenol, terbutaline, albuterol) may inhibit the action of beta-blocking agents and vice versa. ldc, , dd, dx. When these drugs are occasionally used concurrently with betablocking agents, the patient must be monitored carefully for additional arrhythmias, bradycardia, and signs of heart failure. ez-dc . Enzyme-inducing agents (e.g., phenobarbital, pentobarbital, rifampin, phenytoin) enhance the metabolism of propranolol, metoprolol, pindolol, and timolol. This reaction probably does not

187

occur with nadolol or atenolol because they are not metabolized but rather are excreted unchanged. The dosage of the beta blocker may have to be increased to provide therapeutic activity. If the enzyme-inducing agent is discontinued, the dosage of the beta blocker will also require reduction. nd  . Indomethacin, salicylates, and possibly other prostaglandin inhibitors reduce the antihypertensive activity of propranolol and pindolol. This results in a loss of hypertensive control. The dose of the beta blocker may have to be increased to compensate for the antihypertensive inhibitory effect of indomethacin and perhaps other prostaglandin inhibitors.

Drug Class: CholinergiC agents Actions Cholinergic agents, which are also known as muscarinic or parasympathomimetic agents, produce effects that are similar to those of acetylcholine. Some cholinergic agents act by directly stimulating the parasympathetic nervous system, whereas others inhibit acetylcholinesterase, which is the enzyme that metabolizes acetylcholine after it has been released by the nerve ending. These latter agents are known as indirect-acting cholinergic agents. Some of the cholinergic actions are slow heartbeat; increased GI motility and secretions; increased contractions of the urinary bladder, with relaxation of the muscle sphincter; increased secretions and contractility of the bronchial smooth muscle; sweating; miosis (constriction) of the pupil, which reduces intraocular pressure; increased force of the contraction of skeletal muscle; and, sometimes, decreased blood pressure. Uses See Table 12.4. Nursing Implications for Cholinergic Agents See also the nursing implications for patients with disorders of the eyes (Chapter 42), glaucoma (Chapter 42), urinary system disease (Chapter 41), and respiratory tract disease (Chapters 29 and 30). Premedication assessment

1. Obtain baseline vital signs: heart rate and blood pressure. 2. See also the premedication assessments for patients with disorders of the eyes (Chapter 42), glaucoma (Chapter 42), urinary system disease (Chapter 41), and respiratory tract disease (Chapters 29 and 30). Availability, dosage, and administration

See Table 12.4. Common adverse effects. Because cholinergic bers

innervate the entire body, effects in most body systems can be expected. Fortunately, because all receptors do not respond to the same dosage, adverse effects are

188

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Table 12.4 Cholinergic Agents generiC name bethanechol

Duvoid

aVailaBility Tablets: 5, 10, 25, 50 mg

neostigmine

Bloxiverz Prostigmin

Injection: 1-, 2-mg/mL in various volume vials

Reverse nondepolarizing muscle relaxants (e.g., tubocurarine)

physostigmine

—

Injection: 1 mg/mL in 2-mL ampules

Reverse toxicity of overdoses of anticholinergic agents (e.g., pesticides, insecticides)

pilocarpine

Salagen Tablets Isopto Carpine

Tablets: 5, 7.5 mg

Treat symptoms of dry mouth due to salivary gland hypofunction following radiation therapy

pyridostigmine

BranD name

Mestinon Regonol

CliniCal uses Urinary retention

Ophthalmic solution: 1, 2, 4%

Glaucoma

Tablets: 30, 60 mg Solution: 60 mg/5 mL Tablets, sustained release: 180 mg Injection: 10 mg/2 mL

Treatment of myasthenia gravis Reversal of nondepolarizing muscle relaxants

Available in Canada.

not always seen. The higher the dosage, however, the greater the likelihood of adverse effects. g Nausea, vomiting, diarrhea, abdominal cramping. These symptoms are extensions of the pharmacologic effects of the medication, and they are dose related. Reducing the dosage may be effective for controlling these adverse effects without eliminating the desired pharmacologic effect. Cdvc Dizziness, hypotension. Monitor the patient’s blood pressure and pulse. To minimize hypotensive episodes, instruct the patient to rise slowly from a supine or sitting position, and have him or her perform exercises to prevent blood from pooling while they are standing or sitting in one position for a prolonged period. Teach the patient to sit or lie down if they feel faint. Serious adverse effects

r Bronchospasm, wheezing. Withhold the next dose until the patient is evaluated by a healthcare provider. Cdvc Bradycardia. Withhold the next dose until the patient is evaluated by a healthcare provider. D c Atropine, antihistamines. Atropine, other anticholinergic agents, and most antihistamines antagonize the effects of cholinergic agents.

Drug Class: antiCholinergiC agents Actions Anticholinergic agents, which are also known as cholinergic blocking agents or antimuscarinic agents or parasympatholytic agents, block the action of acetylcholine in

the parasympathetic nervous system. These drugs act by occupying receptor sites at parasympathetic nerve endings, which prevent the action of acetylcholine. The parasympathetic response is reduced, depending on the amount of anticholinergic drug that is blocking the receptors. The inhibition of cholinergic activity (e.g., anticholinergic effects) includes the following: mydriasis (dilation) of the pupil to increase intraocular pressure in patients with glaucoma; dry, tenacious secretions of the mouth, nose, throat, and bronchi; decreased secretions and motility of the GI tract; increased heart rate; and decreased sweating. Uses See Table 12.5. Nursing Implications for Anticholinergic Agents See also the nursing implications for patients with Parkinson disease (Chapter 14), disorders of the eyes (Chapter 42), and antihistamines (Chapter 29). Premedication assessment

1. All patients should be screened for closed-angle glaucoma because anticholinergic agents may precipitate an acute attack. Patients with open-angle glaucoma can safely use anticholinergic agents in conjunction with miotic therapy. 2. Check the patient’s history for an enlarged prostate. If this condition is present, anticholinergic agents may cause the patient to have a temporary inability to void. 3. Obtain baseline vital signs: heart rate and blood pressure. 4. See also the premedication assessments for patients with Parkinson disease (Chapter 14), disorders of the eyes (Chapter 42), and antihistamines (Chapter 29).

Drugs Affecting the Autonomic Nervous System CHAPTER 12

189

Table 12.5 Anticholinergic Agents generiC name atropine

BranD name Atropine Sulfate

aVailaBility Injection: 0.05, 0.1, 0.4, 0.8, 1 mg/mL

CliniCal uses Presurgery: to reduce salivation and bronchial secretions; to minimize bradycardia during intubation; adjuvant use with anticholinesterases (e.g., neostigmine) to decrease their adverse effects during reversal of neuromuscular blockade

Bentyl dicyclomine

Protylol

Tablets: 20 mg Capsules: 10 mg Injection: 10 mg/mL Solution: 10 mg/5 mL

Irritable bowel syndrome

glycopyrrolate

Cuvposa

Tablets: 1, 2 mg Oral solution: 1 mg/5 mL Injection: 0.2 mg/mL

Presurgery: to reduce salivation and bronchial secretions and to minimize bradycardia during intubation

Available in Canada.

Availability dosage and administration

See Table 12.5. Common adverse effects. Because cholinergic bers innervate the entire body, effects from blocking this system occur throughout most systems. Fortunately, because all receptors do not respond to the same dose, all adverse effects are not seen to the same degree with all cholinergic blocking agents. The higher the dosage, however, the greater the likelihood of more adverse effects. The following symptoms are the anticholinergic effects that are produced by these agents. Patients who are taking these medications should be monitored for the development of these adverse effects. s Blurred vision. Warn the patient that blurred vision may occur and make appropriate suggestions for the patient’s personal safety. g Constipation; dryness of the mucosa of the mouth, nose, and throat. Mucosal dryness may be alleviated by sucking hard candy or ice chips or by chewing gum. Give the patient stool softeners as prescribed. Encourage adequate uid intake and the eating of foods that provide sufcient bulk. Serious adverse effects

s Glaucoma. All patients should be screened for closed-angle glaucoma before the initiation of therapy. Patients with open-angle glaucoma can safely use anticholinergic agents. Monitor the patient’s intraocular pressures regularly.

pcc Confusion, depression, nightmares, hallucinations. Perform a baseline assessment of the patient’s degree of alertness and orientation to name, place, and time before initiating therapy. Make regularly scheduled subsequent evaluations of the patient’s mental status and compare ndings. Report the development of alterations and provide for patient safety during these episodes. A reduction in the daily medication dosage may control these adverse effects. Cdvc Orthostatic hypotension. Although orthostatic hypotension occurs infrequently and is generally mild, all anticholinergic agents may cause some degree of this condition, which is manifested by dizziness and weakness, particularly when therapy is initiated. Monitor the patient’s blood pressure daily in both the supine and standing positions. Anticipate the development of postural hypotension and take measures to prevent it. Teach the patient to rise slowly from a supine or sitting position, and encourage the patient to sit or lie down if they feel faint. Palpitations, dysrhythmias. Contact the healthcare provider for further evaluation. g Urinary retention. If the patient develops urinary hesitancy, assess the bladder for distention. Contact the healthcare provider for further evaluation. Drug interactions

ad, ccc d, z. These agents may potentiate anticholinergic adverse effects. Confusion and hallucinations are characteristic of excessive anticholinergic activity.

190

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Clinical Judgment and Next-Generation NCLEX ® Examination-Style Questions k p • The nervous system is one of two primary regulators of body homeostasis and defense. The CNS is composed of the brain and the spinal cord. • The peripheral nervous system is subdivided into the afferent and efferent nerve pathways. The afferent nerves conduct signals from sensory receptors (e.g., vision, pressure, pain, cold, warmth, touch, smell) throughout the body to the CNS. The CNS processes these signals and controls the body’s response by sending signals back through the efferent nerves of the peripheral nervous system. The efferent nervous system is subdivided into the somatic nervous system which controls voluntary skeletal muscle, and the autonomic nervous system, which regulates involuntary smooth muscle and heart muscle and controls secretions from certain glands. • Nerve impulses are passed between neurons and from neurons to end organs by neurotransmitters. The main neurotransmitters of the autonomic nervous system are acetylcholine and norepinephrine. Nerve endings that liberate acetylcholine are called cholinergic bers; those that secrete norepinephrine are called adrenergic bers. • The CNS is composed of systems of different types of neurons that secrete separate neurotransmitters, such as acetylcholine, norepinephrine, epinephrine, dopamine, serotonin, and gamma-aminobutyric acid. • The control of neurotransmitters is a primary way to alleviate the symptoms that are associated with many diseases. As shown in Table 12.1, the administration of one type of autonomic nervous system drug can affect several organ systems, and adverse effects can be numerous. Therefore the use of these drugs requires the monitoring of more than just the symptoms for which the medicine was prescribed.

add l rc

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Clayton) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. For Chapters 12 and beyond the use of case studies will be employed to further develop clinical judgment.

sc A 59-year-old patient came to see the primary healthcare provider regarding some discomfort that was being experienced as shooting down the left arm. The patient has a history of hypertension, asthma, and glaucoma. Currently the patient is taking the following medications: atenolol for hypertension, albuterol for asthma (as needed), and pilocarpine drops for glaucoma. 1. The nurse discussed with the patient in the scenario the effects of the medications that they are currently taking. When explaining this the nurse described the common neurotransmitters and how they affect the central nervous system by stating which of the following? (Select all that apply.) 1. “The major neurotransmitters of the autonomic nervous system are acetylcholine and norepinephrine.” 2. “You see, the medications you take have an effect on the neurotransmitters of the nervous system since this is what controls your heart rate and blood pressure.” 3. “The medication that you take for glaucoma stimulates the cholinergic receptors to decrease the intraocular pressure.” 4. “The cholinergic side of the nervous system is subdivided into alpha, beta, and dopamine receptors.” 5. “The two main branches of the autonomic nervous system are complementary, since one branch speeds processes up and the other slows things down.” objcv: Identify the most common neurotransmitters known to affect central nervous system function. nCleX  : Multiple response Cv : Application 2. A male patient was discussing with the nurse that he was experiencing problems urinating after taking an antihistamine that has anticholinergic properties and was wondering why this was happening. Which statement by the nurse explains this effect? 1. “Antihistamines are used to treat allergy symptoms, and do not affect the bladder.” 2. “This medication you are taking has the effect of causing dry mouth and sedation, but I never heard of it causing urinary retention.” 3. “I am sure your symptoms will get better if you wait a few weeks and let your body adjust to the medication.” 4. “Your medication is causing your bladder to relax because it is inhibiting the cholinergic receptors, therefore the bladder is slower to contract to expel the urine.” objcv: Explain the actions of anticholinergic agents and betaadrenergic blocking agents. ngn  : Multiple choice Cv : Recognize cues

Drugs Affecting the Autonomic Nervous System CHAPTER 12

3. The patient in the scenario is taking a cholinergic agent. Indicate which medication is being used, what clinical effect the nurse can expect, and for what adverse effect the nurse should monitor. Choose the most likely option for the information missing from the statements below by selecting from the list of options provided. The nurse will discuss with the patient the use of _________1________, which is used for _______2________ and will have the effect of _________2__________. The predictable adverse effect for this medication is _______3____________. option 1

option 2

option 3

atenolol albuterol

hypertension to reduce heart rate and blood pressure

diarrhea increased intraocular pressure bradycardia hypertension

pilocarpine

glaucoma reducing intraocular pressure relaxing the bronchioles asthma

tachycardia

objcv: Describe clinical uses and the predictable adverse effects of cholinergic agonists. nCleX  : Cloze Cv : Analyze cues 4. The patient in the scenario is taking an adrenergic agonist. Indicate which medication is being used, what effect the nurse can expect, and for what adverse effect the nurse should monitor. Choose the most likely option for the information missing from the statements below by selecting from the list of options provided. The nurse will discuss with the patient the use of ________1____________, which is used for ________2___________ and will have the effect of __________2_______. The predictable adverse effect for this medication is ________3___________. option 1

option 2

option 3

atenolol albuterol

hypertension to reduce heart rate and blood pressure

pilocarpine

glaucoma reducing intraocular pressure relaxing the bronchioles asthma

diarrhea increased intraocular pressure bradycardia hypertension tachycardia

objcv: Describe clinical uses and the predictable adverse effects of adrenergic agonists. nCleX  : Cloze Cv : Analyze cues

191

5. The patient in the scenario who has recently been prescribed a beta-adrenergic blocking agent now presents to the emergency department with shortness of breath. Which adverse effect from the medications is the patient likely exhibiting? 1. 2. 3. 4.

Pneumonia Pulmonary embolism Bronchoconstriction Bronchodilation

objcv: Describe clinical uses and the predictable adverse effects of beta-adrenergic blocking agents. nCleX  : Multiple choice Cv : Comprehension 6. The nurse reviewing a patient’s preoperative medications noted that atropine sulfate was listed. In which diagnoses should atropine sulfate be used with caution? (Select all that apply.) 1. 2. 3. 4. 5. 6.

Hypertension Asthma Closed-angle glaucoma Open-angle glaucoma Enlarged prostate Irritable bowel syndrome

objcv: Describe clinical uses and the predictable adverse effects of anticholinergic agents. nCleX  : Extended multiple response Cv : Recognize cues

13

Drugs Used for Sedation and Sleep

https://evolve.elsevier.com/Willihnganz

Objectives 1. Differentiate among the terms sedative and hypnotic; initial, intermittent, and terminal insomnia; transient, short-term, and chronic insomnia; and rebound sleep. 2. Discuss nursing interventions that can be implemented as an alternative to administering a sedative-hypnotic medication.

3. Compare the effects of benzodiazepines and nonbenzodiazepines on the central nervous system. 4. Identify the antidote drug used for the management of benzodiazepine overdose. 5. Identify laboratory tests that should be monitored when benzodiazepines are administered for an extended period.

Key Terms rapid eye movement (REM) sleep (p. 192)

insomnia (ĭn-SŎM-nē-ă) (p. 193) hypnotic (hĭp-NŎT-ĭk) (p. 193)

SLEEP AND SLEEP PATTERN DISTURBANCE Sleep is  stte of unconsciousness fro which  ptient cn be roused by n pproprite stiulus. It is  nturlly occurring phenoenon tht occupies bout one-third of n dult’s life. Adequte sleep tht progresses through the norl stges is iportnt to intin body function, including psychitric equilibriu nd the strengthening of the iune syste to wrd off disese. A norl sleep durtion for dults of 7 to 8 hours per night is thought to be optil for good helth. Studies lso show tht  reduced ount of sleep is ssocited with obesity, s well s the developent of risk fctors ssocited with crdiovsculr disese nd type 2 dibetes ellitus (see Chpter 20). Obesity itself is lso detrientl to helthy sleep ptterns, nd it cn contribute to the developent of sleep pne. Other studies show  strong connection between  shortened durtion of sleep nd crdiovsculr disese. Individuls who sleep less thn 5 hours per night hve  threefold incresed risk of hert ttcks. The Ntionl Helth Interview Survey lso deonstrtes  close reltionship between syptos of insoni nd coon dverse physicl nd entl helth conditions, including obesity, dibetes ellitus, hypertension, hert filure, nxiety, nd depression. The Healthy People 2030 progr hs s one of its objectives the prootion of sleep helth, which includes prooting optil sleep durtions nd reducing the prevlence nd effect of sleep disorders. 192

sedative (SĔD-ă-tĭv) (p. 193) rebound sleep (RĒ-bŏwnd SLĒP) (p. 194)

Nturl sleep rhythiclly progresses through phses tht provide both physicl nd entl rest. On the bsis of brin-wve ctivity, uscle ctivity, nd eye oveent, norl sleep cn be divided into two phses: non–rpid eye oveent (NREM) sleep nd rapid eye movement (REM) sleep. Most dults will enter sleep fro the drowsy stte vi NREM sleep. NREM sleep is divided into three substges, ech of which is chrcterized by  specic set of brin-wve ctivities: stge N1, stge N2, nd stge N3. Of note, older rules hd four stges of NREM sleep, but the previous NREM stge 3 nd NREM stge 4 hve been cobined s stge N3. Stge N1 is  trnsition phse between wkefulness nd sleep tht lsts only  few inutes. Soe people experience it s wkefulness, wheres others feel it s drowsiness. Approxitely 2% to 5% of sleep is stge N1 sleep. Stge N2 sleep kes up bout 50% of norl sleep tie. People often experience  drifting or floting senstion, nd if they re wkened during this stge, they will often deny being sleep, responding, “I ws just resting y eyes.” Stges N1 nd N2 re light sleep periods fro which  person is esily roused. Stge N3 is  trnsition fro the lighter to deeper sleep stte. Stge N3 sleep is dreless, very restful, nd ssocited with  10% to 30% decrese in blood pressure, respirtory rte, nd bsl etbolic rte. Stge N3 sleep is lso referred to s delta sleep on the bsis of the pttern of brin wves tht re observed during this stge. Stge N3 sleep kes up 10% to 15% of sleep tie in young, helthy dults. Stge N3 sleep

Drugs Used for Sedation and Sleep CHAPTER 13

diinishes in length s people ge, nd ny people who re ore thn 75 yers old do not deonstrte ny stge N3 sleep ptterns. Older dults lso tke longer to cycle through the relxtion stges of NREM sleep, with n incresed frequency nd durtion of wkenings. During  norl night of sleep,  person will rhythiclly cycle fro wkefulness through substges N1, N2, nd N3; the person will then go bck to stge N2, then to REM sleep over the course of bout 90 inutes (Fig. 13.1). The erly episodes of REM sleep lst only  few inutes. However, s sleep progresses, the ount of REM sleep increses, with REM periods becoing longer nd ore intense round 5 am. This type of sleep represents 20% to 25% of sleep tie, nd it is chrcterized by REM, dreing, incresed hert rte, irregulr brething, the secretion of stoch cids, nd soe usculr ctivity. REM sleep ppers to be n iportnt tie for the subconscious ind to relese nxiety nd tension nd reestblish  psychitric equilibriu. Insomnia is dened s the inbility to sleep. It is the ost coon sleep disorder known; 95% of ll dults experience insoni t lest once during their lives, nd up to 35% of dults will hve insoni during  given yer. In generl, insoni is not  disese but rther  sypto of physicl or entl stress. It is usully ild nd lsts only  few nights. Coon cuses re chnges in lifestyle or environent (e.g., hospitliztion), pin, illness, the excess consuption of products tht contin cffeine (e.g., coffee, energy drinks) or lcohol, eting lrge or rich els shortly before bedtie, nd stress. Initial insomnia is the inbility to fll sleep when desired, intermittent insomnia is the inbility to sty sleep, nd terminal insomnia is chrcterized by erly wkening with the inbility to fll sleep gin. Insoni is lso clssied in ccordnce with its durtion. A sleep disturbnce tht lsts only  few nights is considered to be transient insomnia. A sleep disturbnce tht lsts less thn 3 weeks is referred to s short-term insomnia, nd it is usully ssocited with trvel cross tie zones, illness, or nxiety (e.g., job-relted chnges, nncil stress, exintions, eotionl reltionships). Chronic insomnia requires t lest 1 onth of sleep disturbnce before the individul is dignosed with  sleep disorder. About 10% of dults nd up to 20% of older dults report hving chronic insoni. Woen report experiencing insoni twice s frequently s en. A higher incidence of insoni is reported by older dults, the uneployed, those of lower socioeconoic sttus, nd the recently seprted or widowed. As ny s 40% of ptients with chronic insoni lso hve psychitric disorders (e.g., nxiety, depression, substnce buse). People with chronic insoni often develop ftigue or drowsiness tht interferes with dytie functioning nd eployent responsibilities.

193

Stage N1 (2-5% of cycle) transition phase between wakefulness and sleep

Stage N2 (50% of cycle)

Stage N3 delta sleep

Stage N2

REM (20-25% of cycle) dream stage

Stage N2

Stage N3 delta sleep

Fig. 13.1 Sleep cycle. Stage N1 starts cycle transitions from wakefulness, into stage N2, light sleep; then into stage N3, deeper sleep, known as delta sleep; then back to stage N2; then rapid eye movement (REM) sleep, where dreaming occurs; then back to stage N2, stage N3, stage N2, and REM sleep. These cycles last about 90 minutes and the sleep cycle occurs four to ve times per night.

SEDATIVE-HYPNOTIC THERAPY Drugs tht re used in conjunction with ltered ptterns of sleep re known s sedative-hypnotic agents. A hypnotic is  drug tht produces sleep;  sedative quiets the ptient nd gives hi or her  feeling of relxtion nd rest, but this is not necessrily ccopnied by sleep. A good hypnotic should provide the following ctions within  short period of tie: the onset of

194

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

restful, nturl sleep;  durtion of ction tht llows  ptient to wken t the usul tie;  nturl wkening with no “hngover” effects; nd no dnger of hbit fortion. Unfortuntely, the idel hypnotic is not vilble. The ost coonly used sedtive-hypnotic gents increse totl sleeping tie, especilly the tie spent in stge N2 sleep (i.e., light sleep); however, they lso decrese the nuber of REM periods nd the totl tie spent in REM sleep. REM sleep is needed to help intin  entl blnce during dytie ctivities. When REM sleep is decresed, there is  strong physiologic tendency to ke it up. Copenstory REM sleep, or rebound sleep, sees to occur even when hypnotic gents re used for only 3 or 4 dys. After the chronic dinistrtion of sedtive-hypnotic gents, REM rebound y be severe nd ccopnied by restlessness nd vivid nightres. Depending on the frequency of hypnotic dinistrtion, norl sleep ptterns y not be restored for weeks. The effects of REM rebound y enhnce n individul’s chronic use of nd dependence on these gents to void the unplesnt consequences of rebound sleep. Becuse of this,  vicious cycle occurs s the norl physiologic need for sleep is not et nd the body ttepts to copenste. Becuse sedtive-hypnotic gents hve ny dverse effects, especilly with long-ter use, edictions tht re recognized for other priry uses re being used by helthcre providers for the tretent of insoni. Antidepressnts such s itriptyline, trzodone, nd irtzpine re prescribed in lower dosges for their sedtive effects to ssist ptients with getting to sleep (see Chpter 16). Anticonvulsnts tht re used in this wy include gbpentin nd topirte (see Chpter 18). Antipsychotic gents such s quetipine nd olnzpine re prescribed for ptients with psychoses who lso hve insoni (see Chpter 17). However, it is iportnt to note tht no extensive studies hve been copleted regrding the use of these ntidepressnts, ntipsychotics, nd nticonvulsnts for insoni, so their long-ter effects re unknown nd their use for treting chronic insoni cnnot be recoended. ACTIONS Sedtives, which re used to produce relxtion nd rest, nd hypnotics, which re used to produce sleep, re not lwys different drugs. Their effects y depend on the dosge nd the condition of the ptient. A sll dose of  drug y ct s  sedtive, wheres  lrger dose of the se drug y ct s  hypnotic nd produce sleep. Sedtive-hypnotic edictions y be clssied into two groups: benzodizepines nd nonbenzodizepine sedtive-hypnotic edictions. USES The priry uses of sedtive-hypnotic edictions re s follows: (1) to iprove sleep ptterns for the teporry tretent of insoni; nd (2) to decrese the

level of nxiety nd increse relxtion or sleep before dignostic or opertive procedures. NURSING IMPLICATIONS FOR SEDATIVEHYPNOTIC THERAPY Assessment Central nervous system function. Becuse sedtivehypnotic drugs depress overll centrl nervous syste (CNS) function, identify the ptient’s level of lertness nd orienttion, s well s their bility to perfor vrious otor functions. Vital signs. Obtin the ptient’s current blood pres-

sure, pulse, nd respirtion rtes before inititing drug therpy. Sleep pattern. Assess the ptient’s usul pttern of

sleep, nd obtin infortion bout the pttern of sleep disruption (e.g., difculty flling sleep, inbility to rein sleep the entire night, wkening during the erly orning hours nd unble to return to  restful sleep). Ask bout the ount of sleep (i.e., nuber of hours) tht the ptient considers norl nd how their insoni is nged t hoe. Does the ptient hve  regulr tie to go to bed nd wke up? If the ptient is tking edictions, deterine the drug, dosge, nd frequency of dinistrtion nd whether this y be contributing to sleeplessness. (Medicines tht y induce or ggrvte insoni include theophylline, cffeine, pseudoephedrine, nicotine, levodop, corticosteroids, nd selective serotonin reuptke inhibitor ntidepressnts.) Ptients with persistent insoni should be crefully onitored for the nuber of nps tken during the dy. Investigte the type of ctivities tht the ptient perfors ieditely before going to bed. Anxiety level. Assess the ptient’s exhibited degree of

nxiety. Is it relly  sedtive-hypnotic ediction tht the ptient needs, or does the ptient just need soeone to listen to the? Ask bout the stressors tht the ptient hs been experiencing in their personl nd work environents. Environmental control. Obtin dt relted to possi-

ble disturbnces present in the individul’s sleeping environent tht y interfere with sleep (e.g., roo teperture, lights, noise, trfc, restlessness,  snoring prtner). Nutritional needs. Obtin  dietry history to iden-

tify sources of cffeinted products tht y ct s stiulnts. Alcohol intake. Although lcohol cuses sedtion, it

disrupts sleep ptterns nd y cuse erly-orning wkening.

Drugs Used for Sedation and Sleep CHAPTER 13

195

Exercise. Obtin dt relted to the ptient’s usul de-

gree of physicl ctivity nd t wht ties during the dy tht they re ost ctive.

clen nd dry. Tke tie to eet the ptient’s individul needs nd to cl their fers. Foster  trusting reltionship.

Respiratory status. Ptients with respirtory disorders

Environmental control. Tell the ptient to sleep in n

nd those who snore hevily y hve low respirtory reserves nd should not receive hypnotic gents becuse of their potentil to cuse respirtory depression. Implementation Vital signs. Obtin the ptient’s vitl signs periodiclly s the sitution indictes. Preoperative medication. Give the ptient pre-

opertive edictions t the specied tie.

Monitoring effects. When  ediction is dinis-

tered, crefully ssess the ptient t regulr intervls for the drug’s therpeutic nd dverse effects. As-needed medications. If giving the ptient s-needed

(PRN) edictions, sk the ptient bout the effectiveness of previously dinistered therpy. It is soeties necessry to repet  ediction if n order perits doing so. This is done t the nurse’s discretion on the bsis of the evlution of  prticulr ptient’s needs. Patient Education: Promote Good Sleep Hygiene Bedtime. Encourge the ptient to choose  stndrd tie to go to bed to help the body estblish  rhyth nd routine. Nutrition. Tech

the ptient pproprite nutrition infortion concerning the US Food nd Drug Adinistrtion (FDA)’s recoendtions of MyPlte (see Chpter 46), dequte uid intke, nd vitin use. Counicte the infortion t the eductionl level of the ptient. Avoiding heavy meals during the evening. Alcohol nd

cffeine consuption should be reduced or discontinued, especilly within severl hours of bedtie. Educte the ptient bout decffeinted or herbl products tht cn be substituted for cffeinted foods. Help the ptient to void products tht contin cffeine, such s coffee, te, energy drinks, soft drinks, nd chocolte. Liit the totl dily intke of these ites, nd provide the ptient with wr ilk nd crckers s  bedtie snck. Protein foods nd diry products contin n ino cid tht synthesizes serotonin, which is  neurotrnsitter tht hs been found to increse sleep tie nd decrese the tie required to fll sleep. For insoni, suggest tht the ptient drink wr ilk bout 30 inutes before going to bed. Personal comfort. Position the ptient for xiu

cofort, provide  bck rub, encourge the ptient to epty the bldder, nd be certin tht the bedding is

environent tht prootes sleep, such s  quiet, drkened roo free fro distrctions, nd to void using the bedroo for wtching television, responding to e-ils, prepring work for the following dy, eting, nd pying bills. Provide dequte ventiltion, subdued lighting, nd  cofortble roo teperture nd control trfc in nd out of the ptient’s roo. For sfety, instruct the ptient to leve  night-light on nd not soke in bed fter tking ediction. Activity and exercise. Suggest the inclusion of exercise

in the ptient’s dily ctivities so tht the ptient obtins sufcient exercise nd is tired enough to sleep. For soe individuls, pln  quiet “unwinding” tie before retiring for the night. For children, ssist with sleep by providing  wr bth nd structure before bedtie. Try  bedtie story tht is plesnt nd soothing (rther thn one tht y cuse nxiety or fer). Stress management

• Explore personl nd work stressors tht could hve  bering on the ptient’s insoni. Soe stressors y exist in the work environent; therefore the involveent of the occuptionl helth nurse, long with  thorough explortion of work fctors, y be pproprite. Stress produced within the dynics of the fily y require professionl counseling. • Tech the ptient relxtion techniques nd personl cofort esures (e.g.,  wr bth) to relieve stress. Plying soft usic y lso proote relxtion. • Mke referrls for the stery of biofeedbck, edittion, or other techniques to reduce stress levels. • Encourge the ptient to openly express feelings bout their stress nd insoni. The djustent to this sitution involves working through gret personl fers, frustrtions, hostilities, nd resentents. • Explore the coping echniss tht the ptient uses in response to stress, nd identify ethods of chnneling these towrd positive relistic gols nd lterntives to the use of ediction. Fostering health maintenance. Throughout the course

of tretent, discuss ediction infortion nd how it will benet the ptient. Stress the iportnce of nonphrcologic interventions nd the long-ter effects tht coplince with the tretent regien cn provide. Provide the ptient or the ptient’s signicnt others with iportnt infortion tht is contined in the specic drug onogrphs for the edicines prescribed. Additionl helth teching nd nursing interventions for the coon dverse effects nd serious

196

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

dverse effects tht require contct with the helthcre provider re described in the following drug onogrphs (benzodizepines, nonbenzodizepine sedtive-hypnotic edictions). Patient self-assessment. Enlist the ptient’s help

with developing nd intining  written record of onitoring preters (e.g., extent nd frequency of insoni); see the Ptient Self-Assessent For for Sleeping Mediction on the Evolve website. Coplete the Preediction Dt colun for use s  bseline to trck the ptient’s response to drug therpy. Ensure tht the ptient understnds how to use the for, nd instruct the ptient to bring the copleted for to follow-up visits. During these follow-up visits, focus on issues tht will foster the ptient’s dherence with the therpeutic interventions tht hve been prescribed.

DRUG THERAPY FOR SLEEP DISTURBANCE

DRUG CLASS: BENZODIAZEPINES Benzodizepines hve been extreely successful products fro both the therpeutic nd sfety stndpoints. A jor dvntge of the benzodizepine sedtive-hypnotic gents is the wide sfety rgin between therpeutic nd lethl doses. Intentionl nd unintentionl overdoses well bove the norl therpeutic doses re well tolerted nd not ftl. More thn 2000 benzodizepine derivtives hve been identied, nd ore thn 100 hve been tested for sedtive-hypnotic or other therpeutic ctivity. Although there re ny siilrities ong the benzodizepines, they re difcult to chrcterize s  clss. Soe benzodizepines re effective nticonvulsnts, others serve s ntinxiety nd uscle-relxnt gents, nd others re used s sedtive-hypnotic drugs. Actions Benzodizepines exert their effects through stiultion of the g-inobutyric cid (GABA)–benzodizepine receptor coplex. GABA is n inhibitory neurotrnsitter tht exerts its effects t specic receptor subtypes designted GABA-A nd GABA-B. GABA-A is the priry receptor subtype in the CNS. The priry subunits involved in the ctions of benzodizepines re lph-1 nd lph-2 sites. Binding to lph-1 sites edites sleep, wheres binding to lph-2 sites results in uscle relxtion, ntinxiety effects, nd nticonvulsnt ctivity. Benzodizepines do not bind to GABA-B receptors. Uses Estzol, urzep, quzep, tezep, nd trizol re the benzodizepines tht hve been rketed for hypnosis. Trizol, which is  shorter-cting hypnotic, s well s estzol nd tezep, which re interedite-cting hypnotic gents, do not contin

ctive etbolites nd therefore do not ccuulte s redily fter severl nights of dosing. Flurzep nd quzep hve long hlf-lives nd ctive etbolites, thus king ptients uch ore susceptible to hngovers the dy fter use. Benzodizepines tht re used s sedtive-hypnotic gents increse stge N2 sleep nd decrese stge N3 sleep nd, to  lesser extent, REM sleep. When benzodizepine therpy is strted, ptients experience deep nd refreshing sleep. However, benzodizepine-induced sleep vries fro norl sleep in tht there is less REM sleep. With the chronic dinistrtion of benzodizepines, the ount of REM sleep grdully increses s tolernce develops to the REM-suppressnt effects of the drugs. When benzodizepines re discontinued,  rebound increse in REM sleep y occur despite the ptient’s tolernce. During the rebound period, the nuber of dres stys bout the se, but ny of the dres re reported to be bizrre. After long-ter use of ost benzodizepines, there is lso  rebound in insoni. Consequently, it is iportnt to use these gents only for short courses (i.e., usully no ore thn 4 weeks) of therpy. The short-cting benzodizepines (e.g., idzol, lorzep) re used prenterlly s preopertive sedtives nd intrvenously for conscious sedtion before short dignostic procedures or for the induction of generl nesthesi. Midzol hs  ore rpid onset of ction, produces  greter degree of nesi, nd hs  uch shorter durtion copred with dizep. Lorzep is used s n ntinxiety gent in generl, but it is prticulrly useful before dignostic procedures when  longer durtion of ction is required;  prenterl dosge for is vilble. It lso hs no ctive etbolites tht y prolong sedtion. Fluzenil is n ntidote tht is dinistered intrvenously for the coplete or prtil reversl of the effects of benzodizepines tht re used s generl nesthetics or during dignostic or therpeutic procedures. Fluzenil is lso used for the ngeent of n intentionl or ccidentl overdose of benzodizepines. The dinistrtion of uzenil hs been ssocited with the onset of convulsions in ptients who re relying on benzodizepine effects to control seizures, re physiclly dependent on benzodizepines, or who hve ingested lrge doses of other drugs. Therapeutic Outcomes The priry therpeutic outcoes sought fro benzodizepine therpy re s follows: 1. To produce ild sedtion 2. For short-ter use, to produce sleep 3. Preopertive sedtion with nesi Nursing Implications for Benzodiazepines Premedication assessment

1. Record the ptient’s bseline vitl signs (e.g., blood pressure, pulse, respirtions); esure the ptient’s blood pressure in both sitting nd lying positions.

Drugs Used for Sedation and Sleep CHAPTER 13

2. Check for  history of blood dyscrsis or heptic disese, nd deterine whether the ptient is in the rst triester of pregnncy. 3. Assess the ptient’s level of pin. Availability, dosage, and administration. See Tble 13.1.

Use of benzodizepines y result in physicl nd

197

psychologicl dependence when tken stedily for severl dys to weeks, even when tken in recoended dosges. Abuse nd isuse cn result in overdose or deth, especilly when benzodizepines re cobined with other edicines, such s opioid pin relievers, lcohol or illicit drugs, nd CNS depressnts (e.g., sedtives, hypnotics, uscle relxnts). The rpid discontinunce

Table 13.1 Benzodiazepines Used for Sedation and Hypnosis ADULT ORAL DOSAGE RANGE Hypnosis: 1–2 mg at bedtime

GENERIC NAME Estazolam

BRAND NAME —

AVAILABILITY Tablets: 1, 2 mg

urazepam

Som-Pam

Capsules: 15, 30 mg

Hypnosis: 15–30 mg Long acting; Schedule IV; used at bedtime for short-term treatment of insomnia for up to 4 wk; morning hangover may be signicant; rebound insomnia and rapid eye movement sleep occur less frequently

lorazepam Ativan Do not Do not confuse confuse Ativan with Ambien, lorazepam with or Atarax loperamide. Apo-Lorazepam

Tablets: 0.5, 1, 2 mg Oral solution: 2 mg/mL Injection: 2, 4 mg/mL in 1-, 10-mL vials

Hypnosis: 2–4 mg at bedtime

midazolam

—

Syrup: 2 mg/mL Suspension: 1 mg/mL Injection: 1, 5 mg/mL in 1-, 2-, 5-, 10-mL vials; 2 mg/2 mL in prelled syringes IV: 1 mg/mL in 100 mL container

Preoperatively: Short acting; Schedule IV; causes 0.07–0.08 mg/ amnesia in most patients; lower kg IM 1 hr before dosages for patients more than surgery 55 yr old Induction of Onset: IM, 15 min; IV, 3–5 min anesthesia: Duration: IM, 30–60 min; IV, 2–6 hr 0.2–0.3 mg/kg IV Conscious sedation: 0.5–2 mg IV slowly over 2 min; repeat every 2–3 min as needed

quazepam

Doral

Tablets: 15 mg

Hypnosis: 7.5– 15 mg at bedtime

temazepam

Restoril Do not confuse Restoril with Remeron, Risperdal, or Vistaril.

Capsules: 7.5, 15, 22.5, 30 mg

Hypnosis: 15–30 mg Intermediate acting; Schedule IV; at bedtime used to treat insomnia; minimal if any morning hangover; rebound insomnia may occur

triazolam

Halcion Do not confuse Halcion with Haldol. Apo-Triazo

Tablets: 0.125, 0.25 mg Hypnosis: 0.125– Short acting; Schedule IV; used 0.5 mg at bedtime to treat insomnia but tends to lose effectiveness within 2 wk; tapering therapy recommended to reduce rebound insomnia; rapid onset of action; no morning hangover

IM, Intramuscular(ly); IV, intravenous(ly). Available in Canada. Do not confuse.

COMMENTS Intermediate acting; Schedule IV; used to treat insomnia; tapering therapy recommended to reduce rebound insomnia; minimal morning hangover

Used primarily to treat insomnia but may also be used for preoperative anxiety, status epilepticus; IM and IV administration also available

Long acting; Schedule IV; used to treat insomnia; tapering therapy recommended to reduce rebound insomnia; morning hangover may be signicant

198

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

of benzodizepines fter long-ter use y result in syptos tht re siilr to those of lcohol withdrwl, such s wekness, nxiety, deliriu, nd tonic-clonic (grnd l) seizures. These syptos y not pper for severl dys fter discontinution. Discontinution of benzodizepines consists of grdul withdrwl over 2 to 4 weeks. Pregnancy and lactation. It is generlly recoended

tht benzodizepines not be dinistered during t lest the rst triester of pregnncy. There y be n incresed incidence of birth defects if these drugs re tken becuse these gents redily cross the plcent nd enter the fetl circultion. Mothers who re brestfeeding should not receive benzodizepines regulrly. These gents redily cross into brest ilk nd exert  phrcologic effect on the infnt. Common adverse effects

Neurologic Drowsiness, hangover, sedation, lethargy, decreased level of alertness. Ptients y coplin of “orning hngover” nd blurred vision. If the hngover effect continues nd becoes troublesoe, there should be  reduction in the drug dosge,  chnge in the ediction, or both. People who work round chinery, drive  cr, pour nd give edictions, or perfor other duties for which they ust rein entlly lert should not tke these edictions while working. Cardiovascular Transient hypotension when arising. Explin to the ptient the need to rst rise to  sitting position, to then sty sitting for severl oents until ny dizziness or lighthededness psses, nd to then stnd up slowly. Assistnce with bultion y be required. Serious adverse effects Psychological. Confusion, gittion, hllucintions, nesi. All benzodizepines hve the potentil to cuse these syptos, prticulrly in older ptients who hve been tking higher doses or tking the drugs for prolonged periods. Discuss the cse with the helthcre provider nd ke plns to coopertively pproch the grdul reduction of the ediction to prevent withdrwl syptos nd rebound insoni. Excessive use or abuse. The hbitul use of benzodizepines y result in physicl dependence. Discuss the cse with the helthcre provider nd ke plns to coopertively pproch the grdul withdrwl of the edictions tht re being bused. Assist the ptient with recognizing the buse proble. Identify the ptient’s underlying needs nd pln for the ore pproprite ngeent of those needs. Provide for the eotionl support of the individul nd disply n ccepting ttitude. Be kind but r. Blood dyscrasias. Blood dyscrsis re rre but hve been reported. Routine lbortory studies (e.g., red blood cell count, white blood cell [WBC] count,

differentil nd pltelet counts) should be scheduled. Stress tht the ptient should return for these tests. Monitor the ptient for the developent of  sore throt, fever, purpur, jundice, or excessive nd progressive wekness. Hepatotoxicity. The syptos of heptotoxicity re norexi, nuse, voiting, jundice, heptoegly, splenoegly, nd bnorl liver function tests (e.g., elevted levels of bilirubin, sprtte inotrnsferse [AST], lnine inotrnsferse [ALT], gglutyltrnsferse [GGT], nd lkline phosphtse [ALP]; incresed prothrobin tie [PT]). Drug interactions

Antihistamines, alcohol, analgesics, anesthetics, tranquilizers, narcotics, cimetidine, disulram, isoniazid, erythromycin, and other sedative-hypnotics. All of these gents increse the toxic effects of these drugs. Smoking and rifampin. Soking nd rifpin enhnce the etbolis of benzodizepines. Lrger doses y be necessry to intin sedtive effects in ptients who soke.

DRUG CLASS: NONBENZODIAZEPINE SEDATIVEHYPNOTIC AGENTS Actions The nonbenzodizepine sedtive-hypnotic drugs re listed in Tble 13.2. They represent  vriety of cheicl clsses, ll of which cuse CNS depression. These include the histine-1 blockers diphenhydrine nd doxyline (i.e., ntihistines); doxepin, which is  tricyclic ntidepressnt; benzodizepine receptor gonists (zleplon, zolpide, eszopiclone); eltonin, which is  horone secreted fro the pinel glnd (see Chpter 47); eltonin-receptor stiulnts (relteon, tsielteon); orexin receptor ntgonists (suvorexnt, leborexnt); nd vlerin, which is n herbl edicine (see Chpter 47). All of these drugs hve soewht vrible effects on REM sleep, tolernce developent, rebound REM sleep, nd insoni. Uses Antihistines—prticulrly diphenhydrine nd doxyline—hve sedtive properties tht y be used for the short-ter tretent of ild insoni. These drugs re coon ingredients in over-the-counter sleep ids. Becuse tolernce develops fter only  few nights of use, incresing the dose ctully cuses  ore restless nd irregulr sleep pttern. Doxyline hs  longer hlf-life of pproxitely 10 hours, which frequently cuses  orning hngover. Doxepin is  tricyclic ntidepressnt. At lower doses it works on histine-1 receptors, which is thought to proote nd intin sleep. It cn cuse dry outh nd constiption. Suvorexnt nd leborexnt re orexin receptor ntgonists. They iprove flling sleep nd intining

Drugs Used for Sedation and Sleep CHAPTER 13

199

Table 13.2 Nonbenzodiazepine Sedative-Hypnotic Agents AVAILABILITY

ADULT ORAL DOSAGE RANGE

GENERIC NAME ANTIHISTAMINES

BRAND NAME

COMMENTS

diphenhydramine Do not confuse diphenhydramine with dicyclomine or dipyridamole.

Banophen, Diphenhist, Tablets: 12.5 mg; Sedation: ZzzQuil Capsules: 25, 50 mg; 25–50 mg at Liquid: 6.25 mg/mL in bedtime Simply Sleep 30 mL bottle ; 12.5 mg/5 mL in various volumes; 50 mg/30 mL in 177 and 354 mL bottles

Over-the-counter availability; used for mild insomnia for up to 1 wk; tolerance develops, and increased dosage causes more adverse effects with no additional efcacy

doxylamine

Sleep Aid Unisom 2

Tablets: 25 mg

Sedation: 25 mg at bedtime

Over-the-counter availability; morning hangover may be signicant; see diphenhydramine above

TRICYCLIC ANTIDEPRESSANT doxepin Silenor

Tablets: 3, 6 mg

Hypnosis: 3–6 mg once daily within 30 min of bedtime

Avoid doses >6 mg/day Also used in depression but in higher doses

MELATONIN RECEPTOR STIMULANTS melatonin —

—

—

See Chapter 47 Do not take with or immediately after a high-fat meal

ramelteon Do not confuse ramelteon with Remeron, Remegel, Reminyl, or Renagel.

Rozerem Do not confuse Rozerem with Remeron, Remegel, Reminyl, or Renagel.

Tablets: 8 mg

Hypnosis: 8 mg within 30 min of bedtime

tasimelteon

Hetlioz

Capsule: 20 mg Suspension: 4 mg/mL

Hypnosis: 20 mg Used to treat non–24-hr once daily at sleep-wake disorder in the same time blind persons; may take each night weeks to months to be before bedtime effective due to variation in circadian rhythms

OREXIN RECEPTOR INHIBITORS lemborexant Dayvigo

Tablets: 5, 10 mg

Hypnosis: 5–10 mg

Initial dose: 5 mg at bedtime with at least 7 hr before planned awakening Maximum dose: 10 mg

suvorexant

Tablets: 5, 10, 15, 20 mg

Hypnosis: 10 mg once daily within 30 min of bedtime; may increase to a maximum of 20 mg once daily

Schedule IV drug: may be benecial in patients having problems falling asleep and staying asleep

Tablets: 1, 2, 3 mg

Hypnosis: 2–3 mg

Onset within 45 min; duration 5–8 hr Older adult patients should start with 1 mg

Capsules: 5, 10 mg

Hypnosis: 10 mg at bedtime; Maintenance: 5–20 mg

Schedule IV; short acting; onset within 30 min, duration 2–4 hr; older adults or low-weight patients should start with 5 mg

Belsomra

BENZODIAZEPINE-LIKE RECEPTOR AGONISTS eszopiclone Lunesta Imovane

zaleplon Do not confuse zaleplon with zolpidem.

—

200

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

Table 13.2 Nonbenzodiazepine Sedative-Hypnotic Agents—cont’d GENERIC NAME zolpidem Do not confuse zolpidem with zaleplon.

HERBAL MEDICINE valerian Do not confuse valerian with Valium.

BRAND NAME Ambien Do not confuse Ambien with Ativan or Atarax. (delete ML)

AVAILABILITY Tablets: 5, 10 mg

Ambien CR

Tablets, controlledrelease: 6.25, 12.5 mg

Edluar

Tablets, sublingual: 5, 10 mg

Zolpimist

Oral spray: 5 mg/ actuation

Intermezzo

Tablets, sublingual 1.75, 3.5 mg

—

—

ADULT ORAL DOSAGE RANGE Hypnosis: Women: 5 mg at bedtime Men: 5–10 mg at bedtime

COMMENTS Schedule IV; short acting; onset within 30 min, duration 3–5 hr; older adult patients should start with 5-mg immediaterelease tablets or 6.25-mg Hypnosis: controlled-release tablets; Women: 6.25 mg place a sublingual tablet at bedtime under tongue, where it will Men: 6.25–12.5 disintegrate in seconds; mg at bedtime do not chew, break, or Hypnosis: split the tablet; sublingual Women: 5 mg tablets and oral spray Men: 5–10 mg should not be administered with or immediately after a meal

—

See Chapter 47

Available in Canada. Do not confuse.

sleep by inhibiting binding of orexins to orexin receptors. Stiultion of orexin receptors prootes wkefulness. They re schedule IV controlled substnces. They re both contrindicted in nrcolepsy. Meltonin is vilble over the counter s  sleep id. It ppers to be prticulrly useful for ptients who hve been trveling through tie zones nd who re experiencing jet lg. Becuse this edicine is clssied s  dietry suppleent nd thus is not regulted by the FDA, there y be inconsistencies with regrd to its potency (see Chpter 47). Relteon nd tsielteon stiulte the eltonin receptors. Relteon is used to tret ptients with insoni who hve difculty flling sleep. Tsielteon is used for the tretent of non–24-hour sleep-wke disorder tht ffects up to 70% of persons who re totlly blind. It is  chronic sleep disorder rked by disruption of the circdin rhyth king it difcult to intin dy-night perception with norl sleep ptterns. Tsielteon stiultes eltonin 1 nd 2 receptors tht re thought to intin circdin rhyth with norl sleep ptterns. Relteon nd tsielteon re not ssocited with physicl dependence. Vlerin, which is n herbl edicine, hs been used for hundreds of yers s  ild sedtive. Its echnis of ction is unknown, but it y inhibit the enzye tht etbolizes GABA, thereby prolonging the inhibitory neurotrnsitter’s durtion of ction. Like eltonin, vlerin is clssied s  dietry

suppleent, nd thus it is not regulted by the FDA. There y be differences in the strength nd potency of this substnce ong distributors. As  result of their effect on sleep ptterns nd REM sleep, the use of benzodizepines is diinishing in fvor of the newer benzodizepine receptor gonists such s zleplon, zolpide, nd eszopiclone, which bind to different GABA receptors in the CNS. In contrst to benzodizepines, zleplon, zolpide, nd eszopiclone hve less effect on sleep stge N3 nd REM sleep. These gents re used s hypnotics to produce sleep. The recoended period of use for these benzodizepine receptor gonists is 7 to 10 dys, with reevlution of the ptient if use exceeds 2 to 3 weeks. Dytie drowsiness is generlly not  proble with these gents becuse of their short hlf-lives, lthough it is ore likely with eszopiclone. The return of insoni hs been reported fter the discontinution of these drugs. Zleplon hs  short onset of ction nd durtion of 2 to 4 hours. It is used cliniclly for people who hve difculty getting to sleep nd for those who wken in the iddle of the night. Zolpide hs  siilr onset of ction but durtion of 3 to 5 hours. It is ore effective for helping ptients get to sleep nd for prolonging sleep durtion without cusing  orning hngover. Zolpide is vilble in different forultions depending on ptient need. Iediterelese tblets (Abien), sublingul tblets (Edlur), nd Zolpiist orl spry re prescribed for ptients hving difculty flling sleep. The extended-relese

Drugs Used for Sedation and Sleep CHAPTER 13

tblets (Abien CR) re recoended for ptients who hve difculty flling sleep nd stying sleep throughout the night. Interezzo sublingul tblets re for ptients who hve iddle-of-the-night wkening followed by difculty returning to sleep. Interezzo y be tken under the tongue t tht tie to induce sleep when the ptient hs t lest 4 hours of sleep tie reining. Eszopiclone hs  slower onset of ction thn tht of the other two gents, but its durtion of ction is 5 to 8 hours, thus king it ore effective for ptients who wke up during the night or erly orning. It hs been reported to cuse orning hngover, especilly ong older ptients nd with higher doses. Therapeutic Outcomes The priry therpeutic outcoes sought fro nonbenzodizepine sedtive-hypnotic gents re s follows: 1. To produce ild sedtion 2. For short-ter use to produce sleep Nursing Implications of Nonbenzodiazepine Sedative-Hypnotic Agents Premedication assessment

1. Record the ptient’s bseline vitl signs (i.e., blood pressure, pulse, nd respirtions); esure the ptient’s blood pressure in both sitting nd lying positions. 2. Check for the ptient’s history of heptic disese. 3. Ask fele ptients if they re pregnnt or brestfeeding if ge pproprite. Availability, dosage, and administration. See Tble 13.2.

The hbitul use of sedtive-hypnotic gents y result in physicl dependence. Rpid discontinunce fter long-ter use y result in syptos tht re siilr to those of lcohol withdrwl, such s wekness, nxiety, deliriu, nd generlized seizures. Discontinution consists of grdul withdrwl over 2 to 4 weeks. Zleplon, zolpide, nd eszopiclone hve  very rpid onset of ction. These gents should be tken only ieditely before going to bed or fter the ptient hs gone to bed nd then hs difculty flling sleep.

Medication Safety Alert Rare but serious injuries, including death, have been associated with common medications used to treat insomnia. Complex abnormal sleep behaviors, including sleepwalking and sleep driving, have been reported. They appear to be more common with zaleplon, zolpidem, and eszopiclone. Avoid use in patients who have previously experienced an episode of complex sleep behavior with medicines used to treat insomnia.

201

Common adverse effects

Neurologic Hangover, sedation, lethargy, decreased level of alertness. Generl dverse effects include drowsiness, lethrgy, hedche, uscle or joint pin, nd entl depression. Soe people experience trnsient restlessness nd nxiety before flling sleep. Morning hngover coonly occurs fter the dinistrtion of hypnotic doses of doxyline, s well s the long-cting benzodizepines quzep nd urzep, nd it is lso being reported with eszopiclone. Ptients y disply dulled ffect, subtle distortion of ood, nd ipired coordintion. Ptients y coplin of orning hngover, blurred vision, nd trnsient hypotension on rising. If the hngover effect becoes troublesoe, the dosge should be reduced, the ediction should be chnged, or both. People who work round chinery, drive  cr, pour nd give edictions, or perfor other duties for which they ust rein entlly lert should not tke these edictions while working. Cardiovascular Transient hypotension when arising. Explin to the ptient the need to rst rise to  sitting position, to then sty sitting for severl oents until ny dizziness or lighthededness psses, nd to then stnd up slowly. Assistnce with bultion y be required. Psychological Restlessness, anxiety. These dverse effects re usully ild nd do not wrrnt discontinuing the ediction. Encourge the ptient to try to relx nd to let the sedtive effect tke over. Older ptients nd those in severe pin y respond prdoxiclly with exciteent, euphori, restlessness, nd confusion. Sfety esures such s the intennce of bed rest, side rils, nd observtion should be used during this period. Pin edictions y lso be dinistered, if indicted. Drug interactions

Antihistamines, alcohol, analgesics, anesthetics, tranquilizers, narcotics, cimetidine, disulram, isoniazid, erythromycin, ketoconazole, and other sedative-hypnotics. All these gents increse the toxic effects of ll sedtivehypnotic gents. Fluvoxamine. Fluvoxine speciclly inhibits the etbolis of relteon nd tsielteon, thus cusing excessive sedtion. Ptients who re receiving uvoxine should not tke relteon or tsielteon. Rifampin. Rifpin signicntly enhnces the etbolis of zolpide, eszopiclone, relteon, nd tsielteon, thereby reducing their therpeutic effect. Food. The presence of food—prticulrly food with  high ft content—slows the bsorption of zolpide, zleplon, eszopiclone, nd relteon, slowing the onset of ction. For  fster onset of ction, do not dinister these drugs with or ieditely fter  el.

202

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

Clinical Judgment and Next-Generation NCLEX ® Examination-Style Questions Key Points • There are many types of sleep disorders, but the most common is insomnia. • Most cases of insomnia are short lived and can be effectively treated by nonpharmacologic methods, such as a back rub, eating a lighter meal in the evening, eliminating naps, and reducing the use of alcohol and stimulants such as caffeine and nicotine. • People who have insomnia that lasts for more than 1 month and who also experience daytime impairment of their social and employment responsibilities should be referred to a healthcare provider for a complete history and physical assessment. There may be other underlying conditions that must be treated before the patient resorts to the use of sedative-hypnotic agents. • A variety of sedative-hypnotic drugs are available for pharmacologic treatment; however, the drugs of choice are the nonbenzodiazepines (e.g., zaleplon, zolpidem, eszopiclone) because of their wide margin of safety.

Additional Learning Resources

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Clayton) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 12 for further information regarding question types.

Scenario A patient who recently lost their job and is experiencing bouts of insomnia called the nurse line to discuss options for better sleep. 1. A patient was discussing a recent development of nightmares and restlessness since the discontinuation of triazolam (Halcion) with the nurse, who recognized the symptoms of which sleep disorder? 1. 2. 3. 4.

Rebound sleep Terminal insomnia Transient insomnia Initial insomnia

Objective: Differentiate among the terms sedative and hypnotic; initial, intermittent, and terminal insomnia; transient, short-term, and chronic insomnia; and rebound sleep. NCLEX item type: Multiple choice Cognitive skill: Comprehension

2. The nurse is reviewing an order for a sleep aid for a patient in the scenario who is complaining of insomnia. The nurse understands that a sedative is different from a hypnotic in which manner? 1. The sedative causes feelings of relaxation and rest, and the hypnotic agent causes feelings of restlessness and anxiety. 2. The sedative causes feelings of relaxation and rest, and the hypnotic agent produces sleep. 3. The hypnotic agent produces sleep, and the sedative causes no hangover effect. 4. The hypnotic agent causes feelings of relaxation and rest, and the sedative produces sleep. Objective: Differentiate among the terms sedative and hypnotic; initial, intermittent, and terminal insomnia; transient, short-term, and chronic insomnia; and rebound sleep. NCLEX item type: Multiple choice Cognitive skill: Understanding 3. A patient who has been receiving benzodiazepines for several years was told by the nurse that this may cause which condition as a complication? 1. 2. 3. 4.

Symptoms of renal impairment A rush of morning energy with repeated usage Withdrawal symptoms if the drug is discontinued rapidly Seizures during the time that the drug is being administered

Objective: Compare the effects of benzodiazepines and nonbenzodiazepines on the central nervous system. NCLEX item type: Multiple choice Cognitive skill: Comprehension 4. The nurse is making rounds at 2 am on the unit during the night shift and notes that one of the older patients is awake. The nurse reviews the patient’s bedtime medication and sees that 5 mg of zolpidem (Ambien) was administered at 9 pm. What interventions are appropriate for the nurse to do next? (Select all that apply.) 1. Repeat the dose if ordered. 2. Provide patient comfort measures (e.g., back rub, quiet room). 3. Determine what the patient normally does at home when unable to sleep. 4. Keep the patient awake to prevent rebound sleep. 5. Assess for paradoxical symptoms. 6. Provide safety measures. 7. Turn all the lights on to keep the patient from falling asleep. Objective: Discuss nursing interventions that can be implemented as an alternative to administering a sedative-hypnotic medication. NCLEX item type: Extended multiple response Cognitive skill: Prioritize hypotheses

Drugs Used for Sedation and Sleep CHAPTER 13

5. The nurse was discussing the difference between temazepam (Restoril) and zolpidem (Ambien) with a patient requesting drug therapy for sleep disturbance. Which of the following statements are appropriate? (Select all that apply.) 1. “When you take Restoril, it can cause rebound insomnia if you abruptly stop taking it without tapering the drug.” 2. “There is no difference between these drugs; you can take them without any worries.” 3. “Ambien is also available in a sublingual tablet form, which disintegrates in seconds.” 4. “The side effect of morning drowsiness is only caused by Restoril, not Ambien.” 5. “Ambien is used for short-term treatment of insomnia.” Objective: Compare the effects of benzodiazepines and nonbenzodiazepines on the central nervous system. NCLEX item type: Multiple response Cognitive skill: Application 6. The nurse taking care of a patient who was admitted for an overdose of lorazepam (Ativan) knows which antidote will be used? 1. 2. 3. 4.

Fluvoxamine Temazepam (Restoril) Flumazenil Selegiline (Zelapar)

Objective: Identify the antidote drug used for the management of benzodiazepine overdose. NCLEX item type: Multiple choice Cognitive skill: Comprehension 7. The nurse is monitoring laboratory results for a patient who has been taking quazepam (Doral) for several years. The following laboratory values on the patient’s chart are considered elevated; indicate with an X the ones that would alert the nurse to possible hepatotoxicity or blood dyscrasias.

LABORATORY VALUE

OF CONCERN FOR HEPATOTOXICITY

OF CONCERN FOR BLOOD DYSCRASIAS

AST (aspartate aminotransferase) Platelets ALP (alkaline phosphatase) WBC (white blood cells) ALT (alanine aminotransferase) PT/INR (prothrombin time/international normalized ratio)

Objective: Identify laboratory tests that should be monitored when benzodiazepines are administered for an extended period. NCLEX item type: Matrix Cognitive skill: Recognize cues

203

8. The patient in the scenario came to the clinic complaining of not being able to get a good night’s sleep for the past month, as he nds that he frequently awakens throughout the night, then will fall asleep again. The nurse recognizes this condition as which sleep disorder? 1. 2. 3. 4.

Initial insomnia Intermittent insomnia Terminal insomnia Transient insomnia

Objective: Differentiate among the terms sedative and hypnotic; initial, intermittent, and terminal insomnia; transient, short-term, and chronic insomnia; and rebound sleep. NCLEX item type: Multiple choice Cognitive skill: Knowledge

14

Drugs Used to Treat Neurodegenerative Disorders http://evolve.elsevier.com/Willihnganz

Objectives 1. Identify the signs and symptoms of Parkinson disease. 2. Identify the neurotransmitter that is found in excess and the neurotransmitter that is decient in people with parkinsonism. 3. Discuss the action of carbidopa-levodopa and dopamine agonists in Parkinson disease. 4. Explain the action of entacapone, opicapone, and the monoamine oxidase inhibitors (selegiline, sanamide,

and rasagiline) as it relates to the treatment of Parkinson disease. 5. Discuss the specic symptoms that should show improvement when anticholinergic agents are administered to the patient with Parkinson disease. 6. Explain the action of the agents used in the treatment of Alzheimer disease.

Key Terms Parkinson disease (PĂR-kĭn-sĕnz dĭZĒZ) (p. 204) dopamine (DŌ-pă-mēn) (p. 204) neurotransmitter (nyū-rō-TRĂNZ-mĭtĕr) (p. 204) acetylcholine (ăs-ē-tĭl-KŌ-lēn) (p. 204)

anticholinergic agents (ĂN-tē-kō-lĭnŬR-jĭk) (p. 206) tremors (TRĔ-mŭrz) (p. 207) dyskinesia (dĭs-kĭ-NĒ-zhă) (p. 207) propulsive, uncontrolled movement (prō-PŬL-sĭv ŭn-kŏnTRŌLD MŬV-mĕnt) (p. 207)

Parkinson Disease Parkinson disease is a chronic, progressive isorer of

the central nervous system. It is the secon most common neuroegenerative isease after Alzheimer isease. An estimate 1% of the US population that is more than 50 years ol, 2% of the population that is more than 60 years ol, an 4% to 5% of the population 85 years ol or oler have this isorer. Thirty percent of patients report an onset of symptoms before the age of 50 years; 40% report that the onset occurre between the ages of 50 an 60 years; an the remainer report that their symptoms began after the age of 60 years. The incience is slightly higher in men than women, an all races an ethnic groups are affecte. Characteristic motor symptoms inclue muscle tremors, slowness of movement (i.e., braykinesia) when performing activities of aily living (ADLs), muscle weakness with rigiity, an alterations in posture an equilibrium. The symptoms associate with parkinsonism are cause by a eterioration of the opaminergic neurons in the substantia nigra pars compacta, which results in a epletion of opamine along the nigrostriatal pathway that extens into neurons in the autonomic ganglia, the basal ganglia, an the spinal cor an causes progressive neurologic ecits. These areas of the brain are responsible for maintaining posture

204

akinesia (ă-kĭ-NĒ-zhă) (p. 207) livedo reticularis (lĭ-VĒ-dō rĭ-tĭk-yĕLĀR-ĭs) (p. 214) Alzheimer disease (ĂLZ-hī-mŭrz) (p. 222)

an muscle tone, as well as for regulating voluntary smooth muscle activity an other nonmotor activities. Normally, a balance exists between dopamine, which is an inhibitory neurotransmitter, an acetylcholine, which is an excitatory neurotransmitter. With a eciency of opamine, a relative increase in acetylcholine activity occurs an causes the symptoms of parkinsonism. About 80% of the opamine in the neurons of the substantia nigra pars compacta of the brain must be eplete for symptoms to evelop. Whereas the motor symptoms associate with parkinsonism have been consiere to be the hallmarks of the isease, subtle nonmotor symptoms are now being recognize as occurring as much as 10 years before the onset of motor symptoms. Nonmotor symptoms usually start with constipation, progressing over the next few years with orthostatic hypotension, nocturnal sleep isturbances with aytime somnolence, epression, an progressing ementia. It is not known yet whether early treatment with meicines that control the symptoms of Parkinson isease will slow the progression of the isease. There are two types of parkinsonism. Primary or iiopathic parkinsonism is cause by a reuction in opamine-proucing cells in the substantia nigra pars compacta. The causes are not yet known, but there appear to be both genetic an environmental factors

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

205

associate with its evelopment. Approximately 10% to 15% of cases appear to be inherite. Seconary parkinsonism is cause by hea trauma, intracranial infections, tumors, an recurrent exposure to rugs an pesticies. Meicines that eplete opamine an thus cause seconary parkinsonism inclue opamine antagonists such as haloperiol, phenothiazines, an metoclopramie. In most cases of rug-inuce parkinsonism, recovery is complete if the rug is iscontinue.

Life Span Considerations Parkinson Disease Parkinson disease, which is most often seen in geriatric patients, causes a relative excess of acetylcholine as a result of a deciency of dopamine. Drug therapy with dopaminergic agents increases dopamine availability, whereas anticholinergic medicines may be taken to counterbalance the excess availability of acetylcholine. Approximately 40% of patients with parkinsonism have some degree of clinical depression as a result of the reduced availability of the active metabolites of dopamine in the brain.

All rugs that are prescribe for the treatment of Parkinson isease prouce a pharmacologic effect on the central nervous system. An assessment of the patient’s mental status an physical functioning before the initiation of therapy is essential to serve as a baseline so that comparisons can be mae with subsequent evaluations. Parkinson isease is both progressive an incurable. The goals of treatment are to moerate the symptoms an to slow the progression of the isease. It is important to encourage the patient to take the meications as scheule an to stay as active an involve in ADLs as possible. Orthostatic hypotension is common with most of the meicines that are use to treat Parkinson isease. To provie for patient safety, teach the patient to rise slowly from a supine or sitting position, an encourage the patient to sit or lie own if they are feeling faint. Constipation is a frequent problem among patients with Parkinson isease. Instruct the patient to rink six to eight 8-ounce glasses of liqui aily an to increase bulk in the iet to prevent constipation. Bulkforming laxatives may also nee to be ae to the aily regimen. The motor symptoms of parkinsonism start insiiously an are almost imperceptible at rst, with weakness an tremors graually progressing to involve movement isorers throughout the boy (Fig. 14.1). The symptoms usually begin on one sie of the boy (i.e., asymmetric onset an progression) as a tremor of a nger or han, an they then progress to become bilateral. The upper part of the boy is usually affecte rst. Eventually the iniviual has postural an gait alterations that result in the nee for assistance with total care nees. Varying egrees of epression are the

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D

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C

E

Fig. 14.1 Stages of parkinsonism. (A) Flexion of the affected arm. The patient leans toward the unaffected side. (B) Slow, shufing gait. (C) The patient has increased difculty walking and looks for sources of support to prevent falls. (D) Further progression of weakness. The patient requires assistance from another person for ambulation. (E) Profound disability. The patient may be conned to a wheelchair as a result of increasing weakness.

most common (i.e., 40% to 50%) nonmotor symptom associate with Parkinson isease. Most patients with epression also evelop feelings of anxiety, an this sometimes inclues panic attacks. Chronic fatigue, which is another common symptom, may also contribute to epression. Dementia that resembles Alzheimer isease occurs in a signicant number of patients, but there is continuing ebate as to whether it is part of the Parkinson isease process or if it is cause by concurrent rug therapy, Alzheimer isease, or other factors. Dementia is characterize by the slowing of the thought processes, lapses in memory, an a loss of impulse control. The iagnosis of Parkinson isease is base on a careful history taking, a physical examination, an a positive response to opaminergic treatment. There are no laboratory tests or imaging stuies that can conrm the iagnosis.

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Nurses can have a major inuence in the positive use of coping mechanisms as the patient an family express varying emotional responses. The primary goal of nursing interventions shoul be to keep the patient socially interactive an participating in ADLs. This can be accomplishe through physical therapy, aherence to the rug regimen, an management of the course of treatment.

Drug TheraPy for Parkinson Disease Actions The goal of the treatment of parkinsonism is minimizing the symptoms because there is no cure for the isease. Pharmacologic goals are to relieve symptoms an to restore opaminergic activity an neurotransmitter function to as close to normal as possible. Treatment is usually starte when symptoms progress to the point that they interfere with the patient’s ability to perform at work or to function in social situations or they impair quality of life. The goal is to improve motor an nonmotor symptoms to optimize quality of life. Drug therapy inclues the use of the following: monoamine oxiase type B (MAO-B) inhibitors (rasagiline, sanamie, selegiline), which ecreases the metabolism of opamine; opamine agonists (carbiopa-levoopa, ropinirole, pramipexole, rotigotine, apomorphine), amantaine (opamine reuptake inhibitor that increases opamine release an may have anticholinergic properties), or catechol-O-methyltransferase (COMT) inhibitors (entacapone an opicapone), which reuce metabolism of opamine) in various combinations to enhance opaminergic activity; an anticholinergic agents to inhibit the relative excess of cholinergic activity (which causes tremors). Therapy must be iniviualize, an realistic goals must be set for each patient. It is not possible to eliminate all symptoms of the isease because the meications’ averse effects woul not be tolerate. The tren is to use the lowest possible ose of meication so that, as the isease progresses, osages can be increase an other meicines ae to obtain a combine effect. Unfortunately, as the isease progresses, rug therapy becomes more complex in terms of the number of meicines, osage ajustments, the frequency of osage aministration, an the frequency of averse effects. Therapies often have to be iscontinue because of the impact of averse effects on the quality of life. Uses An MAO-B inhibitor (rasagiline, sanamie, selegiline) may be use as a treatment of symptoms for people with early Parkinson isease. A opamine receptor agonist—often carbiopa-levoopa—is initiate when the patient evelops functional impairment. Carbiopa-levoopa continues to be the most effective

rug for the relief of symptoms; however, after 3 to 5 years, the rug’s effect graually wears off an the patient suffers from “on-off” uctuations in levoopa activity. A COMT inhibitor (entacapone, opicapone) or MAO-B inhibitor (rasagiline, sanamie, selegiline) may be ae to carbiopa-levoopa therapy to prolong the activity of the opamine by slowing its rate of metabolism. This prolonge uration of activity is useful as a-on therapies to ecrease motor uctuations (on-off perios) in patients taking carbiopa-levoopa. For severe off perios subcutaneous apomorphine, inhale levoopa or an aenosine receptor antagonist (istraefylline) can be use. Dyskinesias, involuntary muscle movements, can be treate by aing amantaine. Although selom use in oler aults, anticholinergic agents provie symptomatic relief from excessive acetylcholine. These agents are often use in combination to optimize motor function (e.g., to improve gait, posture, or speech) an to ecrease isease symptoms (e.g., tremors, rigiity, rooling). Fig. 14.2 presents an algorithm for the treatment for Parkinson isease. nUrsing implicAtions for pArkinson DiseAse therApy A Unied Parkinson’s Disease Rating Scale. The Unie Parkinson’s Disease Rating Scale (UPDRS) is often use to ientify the baseline of Parkinson isease symptoms at the time of iagnosis an to monitor changes in symptoms that may require meicine osage ajustment. The UPDRS evaluates the following: (1) mentation, behavior, an moo; (2) self-evaluation of ADLs; (3) motor examination; (4) complications of therapy; (5) moie Hoehn an Yahr staging; an (6) the Schwab an Englan ADL Scale. History of parkinsonism. Obtain a history of the patient’s exposure to known conitions associate with the evelopment of parkinsonian symptoms, such as hea trauma, encephalitis, tumors, an rug exposure (e.g., phenothiazines, metoclopramie, pesticies). In aition, ask if the person has a history of being expose to toxic levels of metals or carbon monoxie. Obtain ata to classify the extent of parkinsonism that the patient is exhibiting. A rating scale such as the UPDRS may be use to assess the severity of Parkinson isease on the basis of the egree of isability exhibite by the patient: • Stage 1: Involvement of one limb; slight tremor or minor change in speech, facial expression, posture, or movement; mil isease • Stage 2: Involvement of two limbs; early postural changes; some social withrawal; possible epression • Stage 3: Signicant gait isturbances; moerate generalize isability • Stage 4: Akinesia (i.e., an abnormal state of motor an psychic hypoactivity or muscle paralysis),

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

207

Management of Parkinson’s Disease

Pharmacologic Therapy in Early PD: Levodopa-carbidopa (Most effective) Dopamine agonists (Consider in age less than 65) MAO inhibitors Tremors only Anticholinergics (Tremors only)

Nonpharmacologic Therapy: Education Support services Exercise Nutrition

Choice of an adjunct to levodopa-carbidopa for people with PD who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy: Catechol-O-methyltransferase inhibitors MAO inhibitors Dopamine agonists Amantadine (primarily for dyskinesia) Unacceptable Control Consider: Enteral Levodopa-carbidopa suspension Surgery

Fig. 14.2 Management of Parkinson disease. Monoamine oxidase (MAO) inhibitors may be considered in patients with mild symptoms that have not yet begun to have a major impact on daily function and quality of life. Levodopa-carbidopa is the most effective agent for control of motor symptoms of Parkinson disease but also requires the most frequent dosing adjustment and is associated with the highest risk of motor complications. Dopamine agonists have intermediate potency for improving motor symptoms and have a lower risk of motor complications than levodopa; however, they carry a higher risk of somnolence, hallucinations, and impulse control disorders and are not well tolerated in older adults and those with cognitive dysfunction. Consider catechol-O-methyltransferase (COMT) inhibitors to extend levodopa’s duration of action. Consider enteral levodopa-carbidopa suspension or surgical intervention when Parkinson symptoms cannot be satisfactorily controlled with medical therapies.

rigiity, an severe isability; still able to walk or stan unassiste • Stage 5: Unable to stan or walk or to perform all ADLs; wheelchair boun or berien unless aie Motor function. Patients with Parkinson isease pro-

gress through the following symptoms. Tm. Tremors (uncontrolle shaking) are initially so minor that they are observe only by the patient. They occur primarily when the iniviual is at rest, but they are more noticeable uring emotional turmoil or perios of increase concentration. The tremors are often observe in the hans an may involve the jaw, lips, an tongue. A pill-rolling motion in the ngers an thumbs is characteristic. Tremors are usually reuce with voluntary movement. Assess the egree of tremor involvement an specic limitations in activities that are being affecte by the tremors. Obtain a history of the progression of the symptoms from the patient. Dk. Dyskinesia is the impairment of the iniviual’s ability to perform voluntary movements. This symptom commonly starts in one arm or han. It is usually most noticeable because the patient ceases to swing the arm on the affecte sie while walking. Involuntary movements of muscles can cause jerking, spastic symptoms that characterize chorea, which is often an averse response to treatment.

As yskinesia progresses, movement, especially in the small muscle groups, becomes slow an jerky. This motion is often referre to as cogwheel rigidity. Muscle soreness, fatigue, an pain are associate with the prolonge muscle contractions. The patient evelops a shufing gait an may have ifculty with halting steps while walking (i.e., festination). When starting movement, there may be brief moments of immobility calle freezing. Movements that were formerly automatic, such as getting out of a chair or walking, require a concentrate effort. In aition to the shufing gait, the hea an spine ex forwar, an the shoulers become roune an stoope. As mobility eteriorates, the steps quicken an become shorter. Propulsive, uncontrolled movement forwar or backwar is evient, an patient safety becomes a primary consieration. Obtain antislip pas for chairs an other positioning evices. Perform a safety check of the patient’s environment to prevent accients an falls (Table 14.1). Bdk. Braykinesia is the extremely slow boy movement that may eventually progress to akinesia (i.e., a lack of movement). ia • Implement planne interventions that are consistent with assessment ata; ientify the iniviual nees of the patient.

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UNIT III Drugs Affecting the Autonomic and Central Nervous System

Table 14.1 Additional Symptoms Involved in Parkinson Disease Bradykinesia

Bradykinesia is the extremely slow body movement that may eventually progress to aa (i.e., a lack of movement).

Facial appearance

The patient typically appears to be expressionless, as if wearing a mask. The eyes are wide open and xed in position.

Nutrition

Complete an assessment of the person’s dietary habits, any recent weight loss, and any difculties with eating.

Salivation

As the disease progresses, patients may be unable to swallow all secretions, and they will frequently drool. If the pharyngeal muscles are involved, the patient will have difculty chewing and swallowing.

Psychological

The chronic nature of the disease and its associated physical impairment produce mood swings and serious depression. Patients commonly display a delayed reaction time.

Stress

Obtain a detailed history of the manner in which the patient has controlled their physical and mental stress.

Safety and self-care Assess the level of assistance that is needed by the patient for mobility and for the performance of activities of daily living (ADLs) and self-care. Family resources

Determine what family resources are available, as well as the closeness of the family, during both daily and stress-producing events.

• Monitor an recor the patient’s vital signs, especially bloo pressure, uring the course of therapy. Report signicant changes in bloo pressure; these are most likely to occur uring perios of osage ajustment. Emphasize measures to prevent orthostatic hypotension. • Monitor the patient’s bowel function an implement measures to prevent constipation (e.g., aequate ui intake, bulk in iet, exercise, use of stool softeners). • Support the patient’s efforts to remain mobile. Provie a safe environment by removing clutter an throw rugs; use correct equipment an supportive evices. • Minimize eformities by encouraging the patient to maintain an erect posture. Maintain joint mobility with the use of both active an passive range-ofmotion exercises. • Nutritional nees must be carefully assesse, because ietary moications will be require as the isease progresses. Be vigilant for ifculty with swallowing an realize that the patient may be prone to the aspiration of foo or water. Weigh the patient weekly; evaluate an report uctuations in boy weight to the ietitian or healthcare provier. • Provie a restful environment an attempt to keep stressors at a minimum. • Monitor the patient’s moo an affect an be alert for signs of epression. Moo alterations an epression are seconary to isease progression (e.g., lack of ability to participate in sex, immobility, incontinence) an may be expecte, but they shoul not be ignore. • Provie for patient safety uring ambulation an prevent falls. • Stress that the effectiveness of meication therapy may take several weeks.

pa edua Nutrition. Teach the patient to rink at least six to eight glasses of water or ui per ay to maintain aequate hyration. Because constipation is often a problem, instruct the patient to inclue bulk in the iet an to use stool softeners as neee. As the isease progresses, the type an consistency of the foos eaten will nee to be ajuste to meet the iniviual’s nees. Because of fatigue an ifculty with eating, give assistance that is appropriate to the patient’s egree of impairment. Do not rush the iniviual when they are eating, an cut foos into bite-size pieces. Teach swallowing techniques to prevent aspiration. Plan six smaller meals aily rather than three larger meals. Instruct the patient to weigh himself or herself weekly. Ask the patient to state the guielines for weight loss or gain that shoul be reporte to the healthcare provier. Stress that vitamins shoul not be taken unless they have been prescribe by the healthcare provier. Pyrioxine (vitamin B6) will reuce the therapeutic effect of levoopa. Stress management. Explain to the patient an caregivers about the importance of maintaining an environment that is as free from stress as possible. Explain that symptoms such as tremors are enhance by anxiety. Self-reliance. Encourage patients to perform as many

ADLs as they can. Parkinson isease is a progressive isorer; explain to caregivers that it is important not to take over an that they shoul encourage patients’ self-maintenance, continue social involvement, an participation in activities such as hobbies. Use aaptive evices to help the patient with ressing, an purchase clothing with easy closures or fasteners such as Velcro. As mobility iminishes, use a bath chair an

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

hanhel shower nozzle to help the patient maintain their cleanliness. Exercise. Instruct the patient an caregiver about the importance of maintaining correct boy alignment, walking as erect as possible, an practicing the gait training taught by the physical therapy epartment. Gait training is essential if the patient is to elay the onset of shufing an gait propulsion. Patients shoul wear stury, supportive shoes an use a cane, walker, or other assistive evice to maintain mobility. Exercises to maintain the strength of facial muscles an of the tongue help the patient to maintain speech clarity an the ability to swallow. Active an passive range-ofmotion exercises of all joints help minimize eformities. Explain that maintaining the exercise program can increase the patient’s long-term well-being. Mood alterations. Explain to the patient an the

caregiver that epression an moo alterations are seconary to isease progression (e.g., inability to participate in sex, immobility, incontinence) an are to be expecte. Changes in mental outlook shoul be iscusse with the healthcare provier. Fostering health maintenance. Provie the patient an their signicant others with important information containe in the specic rug monographs for the meicines that are prescribe, incluing the name of the meication; its osage, route, an aministration time; potential averse effects; an rug-specic patient eucation. Provie information to the patient, family, an caregivers about resources, incluing the American Parkinson Disease Association an the services an information available from this source. There are support groups for patients an families that can serve as caring environments for people with similar experiences an concerns. Respite care may also be available, which provies temporary services to the epenent oler ault either at home or in an institutional setting to give the family relief from the emans of aily patient care. Patient self-assessment. Enlist the patient’s help

with eveloping an maintaining a written recor of monitoring parameters (e.g., egree of tremor relief, stability, changes in mobility an rigiity, seation, constipation, rowsiness, mental alertness, eviations from the norm); see the Patient Self-Assessment Form for Antiparkinson Agents on the Evolve website. Complete the Premeication Data column for use as a baseline to track the patient’s response to rug therapy. Ensure that the patient unerstans how to use the form, an instruct the patient to bring the complete form to follow-up visits. During follow-up visits, focus on issues that will foster aherence with the therapeutic interventions that have been prescribe.

209

Drug Class: MonoaMine oxiDase Type B inhiBiTors aa (ra-SA-ji-leen) Az (az-a-LECt) aad (sa-FIN-a-mide) Xada (Ex-a-da-go)  (se-LE-ji-leen) Zaa (zel-ah-par)

A Selegiline, sanamie, an rasagiline are potent MAO-B inhibitors that reuce the metabolism of opamine in the brain, thus allowing for greater opaminergic activity. Although there are reports that these agents may be neuroprotective, there is currently no conclusive proof of this from clinical trials. U A combination of carbiopa an levoopa is the current rug of choice for the treatment of Parkinson isease. Unfortunately, these agents lose effectiveness (i.e., the “on-off” phenomenon) an evelop more averse effects (i.e., yskinesias) over time. It is often necessary to a other opamine receptor agonists (e.g., pramipexole, ropinirole) or a COMT inhibitor (e.g., entacapone) to improve the patient’s response an tolerance. The MAO-B inhibitors have ajunctive activity similar to carbiopa-levoopa for the treatment of Parkinson isease. The MAO-B inhibitors may be use early uring the treatment of Parkinson isease to slow the progression of symptoms an to elay the initiation of levoopa therapy. In aition, they prolong the action of carbiopa-levoopa, thus making the MAO-B inhibitors useful a-on therapies to ecrease motor uctuations (e.g., on-off perios) in patients treate with carbiopa-levoopa. Selegiline aministere by a transermal patch is also approve for the treatment of epression. Selegiline, rasagiline, an sanamie have ifferent metabolic pathways an therefore somewhat ifferent averse effect proles. Selegiline tablets an capsules, when swallowe, are metabolize to amphetamines that cause cariovascular an psychiatric averse effects. The orally isintegrating tablet osage form allows the rug to be absorbe from the buccal area in the mouth, thereby avoiing much of the formation of these active metabolites. There is a notable ifference in strength between the tablets an the orally isintegrating tablets. A 10-mg tablet of selegiline is approximately equal in potency to a 1.25-mg orally isintegrating tablet of selegiline. Rasagiline an sanamie are not metabolize to amphetamines, so cariovascular an psychiatric averse effects are minimal.

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UNIT III Drugs Affecting the Autonomic and Central Nervous System

tau ou The primary therapeutic outcomes sought from MAO-B inhibitors for the treatment of parkinsonism are as follows: 1. Slowing the evelopment of symptoms an the progression of the isease 2. Establishing a balance of opamine an acetylcholine in the basal ganglia of the brain by enhancing the elivery of opamine to brain cells

immeiately place the orally isintegrating selegiline tablets on top of the tongue, where they will isintegrate in secons. Patients shoul avoi ingesting foo or liquis for 5 minutes before an 5 minutes after taking orally isintegrating selegiline tablets. After 2 to 3 ays of treatment, the osage of carbiopalevoopa shoul start being titrate ownwar. Carbiopa-levoopa osages may be able to be reuce by 10% to 30%.

nu ia  ma oxda t B ib ta

Common adverse effects. Selegiline, sanamie, an

Premedication assessment

1. Perform a baseline assessment of parkinsonism with the use of the UPDRS. 2. Obtain a history of gastrointestinal (GI) symptoms. 3. Perform a baseline assessment of the patient’s egree of alertness an orientation to name, place, an time before the initiation of therapy. 4. Check for any antihypertensive therapy that is currently prescribe. Monitor the patient’s bloo pressure aily in both the supine an staning positions. If antihypertensive meications are being taken, report this to the healthcare provier for possible osage ajustment. 5. Check other meications prescribe; see Drug Interactions for MAO-B inhibitors later in this section. Availability, dosage, and administration. The osage

must be ajuste accoring to the patient’s response an tolerance. Adult: PO (Table 14.2). Selegiline orally isintegrating tablets shoul be taken in the morning before breakfast, without liqui. Patients shoul not attempt to push selegiline orally isintegrating tablets through the foil backing. Patients shoul peel back the backing off one or two blisters (as prescribe) with ry hans an gently remove the tablets. Patients shoul

rasagiline cause relatively few averse effects. They may increase the averse opaminergic effects of levoopa (e.g., chorea, confusion, hallucinations). Dosage reuction of levoopa is usually the optimal treatment. gttt Constipation, stomach upset. Both of these effects may be minimize by a temporary reuction in osage, aministration with foo, an the use of stool softeners for constipation.

Serious adverse effects

nc Chorea, confusion, hallucinations. Selegiline, sanamie, an rasagiline may increase these averse opaminergic effects of levoopa, but these can be controlle by reucing the osage of levoopa. Make regularly scheule subsequent evaluations of the patient’s mental status an compare nings. Report alterations in moo. Provie patient safety, be emotionally supportive, an assure the patient that these averse effects usually issipate as tolerance evelops over the next few weeks. Cdc Orthostatic hypotension. Monitor the patient’s bloo pressure aily in both the supine an staning positions. Anticipate the evelopment of postural hypotension an take measures to prevent such an occurrence. Teach the patient to rise slowly from a supine or

Table 14.2 Monoamine Oxidase Inhibitors Type B generiC naMe rasagiline Do not confuse rasagiline with repaglinide, raloxifene, Risperdal, or risperidone.

BranD naMe Azilect

sanamide

Xadago

selegiline Do not confuse selegiline with Serentil, sertraline, or Salagen.

Do not confuse.

Zelapar

availaBiliTy Tablets: 0.5, 1 mg

Tablets: 50, 100 mg

iniTial Dosage (po) Monotherapy: 1 mg once daily

MaxiMuM Daily Dosage 1 mg

Adjunctive therapy: 0.5 mg once daily

1 mg

50 mg once daily

After 2 wk may increase to 100 mg once daily

Tablets: 5 mg

5 mg daily

5 mg twice daily

Tablets, orally disintegrating: 1.25 mg

1.25 mg once daily for at least 6 wk with concomitant levodopa/carbidopa dissolved on the tongue; withhold food and liquid for at least 5 min

2.5 mg before breakfast, at least 5 min before any liquid or breakfast

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

sitting position an encourage the patient to sit or lie own if feeling faint. Drug interactions

ld. MAO-B inhibitors an levoopa have aitive neurologic effects. These interactions may be benecial because they often allow for a reuction in the osage of levoopa. Md, tmd, mtd. Fatal rug interactions have been reporte between monoamine oxiase inhibitors (MAOIs) an these agents. Although these interactions have not been reporte with selegiline, sanamie, or rasagiline, it is recommene that selegiline, sanamie, an rasagiline not be aministere with any of these agents. Dtmt. Episoes of psychosis an bizarre behavior have been reporte with selegiline an extromethorphan. Do not aminister these rugs concurrently. Fd. Patients shoul avoi foos an beverages with high tyramine content (e.g., Chianti wine, fava beans, cheeses), particularly if they are receiving selegiline in excess of 9 mg/ay. Rare cases of hypertensive reactions have been reporte. att t. A osage ajustment of the antihypertensive agent is often necessary in response to excessive orthostatic hypotension. Cc. This antibiotic inhibits the metabolism of rasagiline, thus signicantly raising rasagiline serum levels an potentially causing signicant hypertension. Use the combination very cautiously. Reuce the ose of rasagiline by half to avoi complications. atdt (tccc tdt, ct t tk bt, t- tk bt, st. J’ Wt). Use these rugs with extreme caution in conjunction with MAO-B inhibitor therapy. Although rare, there is a potential for serotonin synrome, which is manifeste by behavioral an mental status changes, iaphoresis, muscular rigiity, hypertension, syncope, an eath. Many patients are receiving antiepressants for the treatment of epression that frequently accompanies parkinsonism. Closely monitor patients for these symptoms. smtmmtc m (d, dd, ). Cases of hypertensive crisis have rarely been reporte among patients who are concurrently taking sympathomimetic amines an MAO-B inhibitors. Concurrent therapy is not recommene.

Drug Class: DopaMine agonisTs abda (kăr-bĭ-DŌ-pă) and vda (lē-vō-DŌ-pă) s (SĬN-ĕ-mĕt) Do not confuse Sinemet with Senokot. ra (rye-TAR-ee) Dua (do-op-ah)

211

A Dopamine, when aministere orally, oes not enter the brain. However, levoopa does cross into the brain, where it is metabolize to opamine an replaces the opamine eciency in the basal ganglia. Dopamine stimulates D1, D2, an D3 opamine receptors. Carbiopa is an enzyme inhibitor that reuces the metabolism of levoopa, thus allowing for a greater portion of the aministere levoopa to reach the esire receptor sites in the basal ganglia. Carbiopa has no effect when it is use alone; it must be use in combination with levoopa. Sinemet an Rytary are combination proucts of carbiopa an levoopa that are use orally for treating the symptoms of Parkinson isease. Duopa, an enteral suspension of carbiopa-levoopa, is use to treat motor uctuations in patients with avance Parkinson isease. It is aministere into the jejunum through a nasojejunal tube or percutaneous enoscopic gastrostomy–jejunostomy (PEG-J) tube with a portable infusion pump. U About 75% of patients with parkinsonism respon favorably to levoopa therapy. However, after a few years the response iminishes an becomes more uneven, an it is accompanie by many more averse effects. This loss of therapeutic effect reects the progression of the unerlying isease process. Carbiopa is use to reuce the ose of levoopa require by approximately 75%. When aministere with levoopa, carbiopa increases plasma levels an the plasma half-life of levoopa. tau ou The primary therapeutic outcome sought from carbiopalevoopa for the treatment of parkinsonism is the establishment of a balance of opamine an acetylcholine in the basal ganglia of the brain by enhancing the elivery of opamine to brain cells. nu ia  cabda-lvda ta Premedication assessment

1. Perform a baseline assessment of parkinsonism with the use of the UPDRS. 2. Obtain a history of GI an cariovascular symptoms, incluing baseline vital signs (e.g., bloo pressure, pulse). 3. Ask specically about any symptoms of hallucinations, nightmares, ementia, or anxiety. 4. All patients shoul be screene for the presence of close-angle glaucoma before initiating therapy. Patients with open-angle glaucoma can safely use levoopa. Do not aminister the meicine to people with a history of glaucoma unless it has been specically approve by the patient’s healthcare provier.

212

UNIT III Drugs Affecting the Autonomic and Central Nervous System

5. Review the meicines that have been prescribe that may require ose ajustments. Plan to perform focuse assessments to etect responses to therapy that woul nee to be reporte to the healthcare provier. Availability. PO: Sinemet is a combination prouct that

contains both carbiopa an levoopa. The combination prouct is available in ratios of 10/100, 25/100, an 25/250 mg of carbiopa an levoopa, respectively. There is also a sustaine-release tablet that contains either 25/100 or 50/200 mg of carbiopa an levoopa, respectively. Rytary is an oral extene-release combination prouct that contains both carbiopa an levoopa. It is available in capsules in ratios of 23.75/95, 36.25/145, 48.75/195, an 61.25/245 mg of carbiopa an levoopa, respectively. Duopa is an enteral suspension of carbiopa 4.63 mg an levoopa 20 mg/mL in 100-mL containers. Dosage and administration. Adult: PO: For patients

who are not receiving levoopa initially, give Sinemet 10/100 or 25/100 mg three times aily, increasing by 1 tablet every other ay, until a osage of 6 tablets aily is attaine. As therapy progresses an patients show inications of neeing more levoopa, substitute Sinemet 25/250 mg, 1 tablet three or four times aily. Increase by 1 tablet every other ay to a maximum of 8 tablets aily. See the manufacturer’s guielines for converting a patient from the immeiate-release to the sustaine-release formulation of Sinemet. Aminister this meication with foo or milk to reuce gastric irritation. Therapy for at least 6 months may be necessary to etermine this meication’s full therapeutic benets. Extended-Release Formulations: Sinemet ExteneRelease Tablets: For patients not currently receiving levoopa initially, start with sustaine-release tablet 50 mg/200 mg twice aily at intervals of 6 hours or more. Following an interval of at least 3 ays between osage ajustments, increase or ecrease osage base on response. Most patients are aequately treate with a ose that provies 400 to 1600 mg of levoopa per ay in ivie oses at intervals of 4 to 8 hours while awake. If an interval of less than 4 hours is use an/ or if the ivie oses are not equal, give the smaller oses at the en of the ay. Rytary Extene-Release Capsules: For patients not currently receiving levoopa initially, start with Rytary 23.75/95 mg three times aily for 3 ays; on ay 4, increase to 36.25/145 mg three times aily. The ose may be increase up to 97.5/390 mg three times aily, an the frequency of osing may be increase to a maximum of ve times aily if neee an tolerate (maximum: 612.5/2450 mg per ay). See the manufacturer’s guielines for converting a patient from immeiate-release formulations to extene-release capsules. Enteral Formulation: Duopa:

• See the manufacturer’s guielines for calculation an titration of morning ose an continuous infusion oses. • Before initiation of therapy, convert patient from all forms of levoopa to oral immeiate-release carbiopa-levoopa tablets (1:4 ratio). Total aily ose of levoopa consists of the morning ose, a continuous ose an any extra oses. • See manufacturer’s recommenations on frozen storage, thawing in a refrigerator for 96 hours, protection from light, aministration by nasojejunal tube or PEG-J tube an type of pump to be use. • Following iscontinuation of the aily infusion, patients shoul receive their routine nighttime osage or oral immeiate release carbiopa-levoopa. Common adverse effects. Levoopa causes many averse effects, but most are ose relate an reversible. Averse effects vary greatly epening on the stage of the isease. gttt Nausea, vomiting, anorexia. These effects can be reuce by slowly increasing the ose, iviing the total aily osage into four to six oses, an aministering the meication with foo or antacis. See manufacturer’s precautions pertaining to potential GI complications associate with enteral infusions. Cdc Orthostatic hypotension. Although the effects are generally mil, levoopa may cause some egree of orthostatic hypotension; this is manifeste by izziness an weakness, particularly when therapy is initiate. Tolerance usually evelops after a few weeks of therapy. Monitor the patient’s bloo pressure aily in both the supine an staning positions. Anticipate the evelopment of postural hypotension an take measures to prevent such an occurrence. Teach patients to rise slowly from a supine or sitting position, an encourage them to sit or lie own if feeling faint. Serious adverse effects

nc Chewing motions, bobbing, facial grimacing, rocking movements. These involuntary movements occur in about half of the patients who take levoopa for more than 6 months. A reuction in osage may be benecial. pcc Nightmares, depression, confusion, hallucinations. Perform a baseline assessment of the patient’s egree of alertness an orientation to name, place, an time before initiating therapy. Make regularly scheule subsequent evaluations of mental status, an compare nings. Report alterations in moo. Provie for patient safety uring these episoes. Reucing the aily osage may control these averse effects. Cdc Tachycardia, palpitations. Take the patient’s pulse at regularly scheule intervals. Report any changes for further evaluation.

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

Drug interactions. Sinemet an Rytary may be use to treat parkinsonism in conjunction with opamine agonists, COMT inhibitors, or anticholinergic agents. The osages of all meications may nee to be reuce as a result of combine therapy. Mm d bt (z, tcm, cbzd, ). These MAOIs unpreictably exaggerate the effects of levoopa. They shoul be iscontinue at least 14 ays before the aministration of levoopa. izd. Use this rug with caution in conjunction with levoopa. Discontinue isoniazi if patients who are taking levoopa evelop hypertension, ushing, palpitations, an tremor. pd. Pyrioxine (vitamin B6) in oral oses of 5 to 10 mg may reuce the therapeutic an toxic effects of levoopa. Normal iets contain less than 1 mg of pyrioxine, so ietary restrictions are not necessary. However, the ingreients of multiple vitamins shoul be consiere. Dzm, cdzd, cd, t. These agents appear to cause a eterioration of the therapeutic effects of levoopa. Use them with caution for patients with parkinsonism, an iscontinue them if the patient’s clinical status eteriorates. ptz, d, d, mtcmd. An averse effect associate with these agents is a Parkinson-like synrome. Because this conition will nullify the therapeutic effects of levoopa, o not use the rugs concurrently. e, mtm. Levoopa may increase the therapeutic an toxic effects of these agents. Monitor the patient for tachycaria, ysrhythmias, an hypertension. Reuce the osage of these agents if necessary. att t. A osage ajustment of the antihypertensive agent is frequently necessary in response to excessive orthostatic hypotension. atcc t (bzt, ddm, td). Although these agents are use to treat parkinsonism, they increase gastric eactivation an ecrease the intestinal absorption of levoopa. The aministration of oses of anticholinergic agents an levoopa shoul be separate by 2 hours or more. Tt bw c. The metabolites of levoopa react with toilet bowl cleaners to turn the urine to shaes of re to black. This may also occur if the urine is expose to air for long perios. Inform the patient that there is no cause for alarm. aaad dd (a-MAN-ta-dēn) gv (go-cover-ee) ox er (oz-MO’-lex ER)

Amantaine is a compoun evelope originally to treat viral infections. It was aministere to a patient with inuenza A who also ha parkinsonism. During

213

the course of therapy for inuenza, the patient showe enite improvement in the parkinsonian symptoms. A The exact mechanism of action is unknown but appears to be unrelate to the rug’s antiviral activity. Amantaine seems to slow the estruction of opamine, thus making the small amount present more effective. It may also ai in the release of opamine from its storage sites. Unfortunately, about half of the patients who benet from amantaine therapy begin to notice a reuction in benet after 2 or 3 months. A osage increase or temporary iscontinuation followe by a reinitiation of therapy several weeks later may restore the therapeutic benets. When being iscontinue, amantaine shoul be graually withrawn. U Amantaine is use for the relief of symptoms associate with Parkinson isease an for the treatment of susceptible strains of viral inuenza A. Amantaine is available in extene-release proucts. Gocovri (amantaine) is inicate for the treatment of yskinesia in patients with Parkinson isease receiving levoopa-base therapy, with or without concomitant opaminergic meications. Osmolex (amantaine) ER is inicate for the treatment of Parkinson isease an for the treatment of rug-inuce extrapyramial reactions in ault patients. tau ou The primary therapeutic outcome sought from amantaine in treating parkinsonism is to establish a balance of opamine an acetylcholine in the basal ganglia of the brain by enhancing elivery of opamine to brain cells. nu ia  Aaad ta Premedication assessment

1. Perform a baseline assessment of parkinsonism using the UPDRS. 2. Amantaine shoul be use with caution in patients with a history of seizure activity, liver isease, uncontrolle psychosis, or congestive heart failure. Amantaine may cause an exacerbation of these isorers. 3. Take baseline bloo pressures in supine an staning positions. Availability. PO: 100-mg tablets; 100-mg capsules; 50 mg/5 mL syrup; 68.5, 137 mg extene-release (24 hours) capsules (Gocovri); 129, 193, 258 mg extene-release (24 hours) tablets (Osmolex ER). Dosage and administration. Adult: PO: Amantaine

tablets, capsules, syrup: Initially 100 mg two times aily; maximum aily ose is 400 mg. Because of the possibility of insomnia, plan the last ose to be aministere in the afternoon, not at betime.

214

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Extene-release proucts: • Gocovri (amantaine) (capsules): Initially 137 mg; after 1 week, increase to the recommene aily osage of 274 mg • Osmolex (amantaine) ER (tablets): Initially 129 mg orally once aily in the morning; may be increase in weekly intervals to a maximum aily ose of 322 mg once aily in the morning Common adverse effects. Most of the averse effects

of amantaine therapy are ose relate an reversible. nc Confusion, disorientation, hallucinations, mental depression. Perform a baseline assessment of the patient’s egree of alertness an orientation to name, place, an time before initiating therapy. Make regularly scheule subsequent evaluations of mental status an compare nings. Report any alterations to the healthcare provier Dizziness, lightheadedness. Provie patient safety uring perios of izziness or lightheaeness. gttt Anorexia, nausea, abdominal discomfort. These sie effects are usually mil an ten to resolve with continue therapy. Encourage the patient not to iscontinue therapy without rst consulting the healthcare provier. Cdc Livedo reticularis (skin mottling). A ermatologic conition known as livedo reticularis is occasionally observe in conjunction with amantaine therapy. It is characterize by iffuse rose-colore mottling of the skin, preominantly in the extremities an is often accompanie by ankle eema. It is more noticeable when the patient is staning or expose to col. It is reversible within 2 to 6 weeks after iscontinuation of amantaine. However, iscontinuing therapy is generally not necessary. These sie effects are usually mil an ten to resolve with continue therapy. Symptoms are enhance by exposure to the col or by prolonge staning. Encourage the patient not to iscontinue therapy without rst consulting the healthcare provier.

Serious adverse effects

gttt Hepatotoxicity. The symptoms of hepatotoxicity are anorexia, nausea, vomiting, jaunice, hepatomegaly, splenomegaly, an abnormal liver function tests (elevate bilirubin, aspartate aminotransferase [AST], alanine aminotransferase [ALT], gamma-glutamyltransferase [GGT], alkaline phosphatase [ALP], an prothrombin time [PT]). nc Seizure disorders, psychosis. Provie patient safety uring episoes of izziness; report symptoms for further evaluation. Cdc Dyspnea/edema. If amantaine is use with patients who have a history of heart failure, assess lung souns, aitional eema, an weight gain on a regular basis.

Drug interactions

atcc t (td, bzt, ccd, ddm). Amantaine may exacerbate the sie effects of anticholinergic agents that may also be use to control the symptoms of parkinsonism. Confusion an hallucinations may graually evelop. The osage of amantaine or the anticholinergic agent shoul be reuce. a (ă-pō-MŎR-fēn) Do not confuse apomorphine with morphine. A (ă-PŌ-kĭn) kb (Kin-moby)

A Apomorphine is a nonergot opamine agonist. It is thought to stimulate opamine receptors in the brain, thereby temporarily restoring motor function. It is chemically relate to morphine, but it oes not have any opioi activity. U As Parkinson isease progresses, patients often experience episoes of lower responsiveness to levoopa, which causes perios of hypomobility or off perios (e.g., inability to rise from a chair, speak, or walk). Apomorphine is use to treat the hypomobility associate with the “wearing off” of opamine agonists, either near the en of a osage cycle or at unpreictable times (i.e., the “on-off” phenomenon). tau ou The primary therapeutic outcomes sought from apomorphine for the treatment of parkinsonism are improving motor an ADL scores an ecreasing off time. nu ia  A ta Premedication assessment

1. Perform a baseline assessment of parkinsonism with the use of the UPDRS. 2. Obtain a history of cariovascular symptoms, incluing the baseline vital signs (e.g., bloo pressure, heart rate). 3. Perform a baseline assessment of the patient’s egree of mobility, alertness, an orientation to name, place, an time before initiating therapy. Ask specically whether the patient is taking any other seating meicines. Make regularly scheule subsequent evaluations of bloo pressure, pulse, mental status, an mobility an compare nings. Availability. Subcutaneous: 10 mg/mL in 3-mL cartriges. Sublingual lm: 10 mg, 15 mg, 20 mg, 25 mg, 30 mg. Dosage and administration. Apomorphine is aminis-

tere by a sublingual lm or with the use of a manual,

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

reusable, multiose injector pen that hols a 3-mL cartrige of meicine. To avoi potential confusion with the use of the pen an inavertent overose, it is recommene that the ose of the rug be ientie in milliliters rather than in milligrams. The pen is ajustable in 0.02-mL increments. A training pamphlet that aresses the use of the injector pen is available for patient use.

Medication Safety Alert Do not administer apomorphine intravenously. This drug may crystallize in the vein and form a thrombus or embolism.

adt Use of an antiemetic. One of the pharmacologic actions of apomorphine is emesis. The antiemetic trimethobenzamie shoul be aministere orally at a osage of 300 mg three times aily for at least 3 ays before the initial ose of apomorphine. Trimethobenzamie shoul be continue as necessary to control nausea an vomiting, but generally no longer than 2 months. About 50% of patients are able to iscontinue the antiemetic while continuing therapy with apomorphine. Do not use prochlorperazine or onansetron (Zofran) as antiemetics (see Drug Interactions for apomorphine later in this section). Subcutaneous: Initially, a test ose of 0.2 mL (2 mg) shoul be aministere in the stomach area, upper leg, or upper arm. Both supine an staning bloo pressures shoul be etermine before aministering the ose an again at 20, 40, an 60 minutes after aministration. If signicant orthostatic hypotension evelops, therapy shoul be iscontinue an the patient shoul receive no further oses of apomorphine. If the patient tolerates the 0.2-mL ose an respons, the starting ose shoul be 0.2 mL use on an as-neee basis to treat off times. If neee, the ose can be increase in 0.1-mL (1-mg) increments every few ays on an outpatient basis. The maximum recommene ose is 0.6 mL (6 mg). If a patient iscontinues therapy for longer than 1 week an then wishes to go back to the use of apomorphine, therapy shoul be reinitiate at the starting ose of 0.2 mL, with graual increases in osage to optimal therapy. Sublingual lm: Initial ose is 10 mg aministere sublingually, in a setting where a healthcare provier can monitor bloo pressure an pulse rate. If the patient tolerates the 10 mg ose, an respons aequately, the starting ose shoul be 10 mg, use on an as-neee basis, up to ve times per ay, to treat “off” episoes. The ose may be increase by 5 mg, if the response is insufcient. The maximum single ose is 30 mg. Common adverse effects. Most averse effects ob-

serve with apomorphine are irect extensions of its pharmacologic properties.

215

gttt Nausea, vomiting. These effects can be reuce by premeicating the patient with trimethobenzamie an then slowly increasing the osage. Cdc Orthostatic hypotension. Apomorphine commonly causes orthostatic hypotension, which is manifeste by izziness an weakness, particularly when therapy is initiate. Patients with Parkinson isease are at risk for falling because of the unerlying postural instability associate with the isease; apomorphine may increase the risk of falling by lowering bloo pressure an altering mobility. Anticipate the evelopment of postural hypotension an provie assistance when necessary. Monitor the patient’s bloo pressure before an uring apomorphine therapy in both the supine an staning positions. Teach patients to rise slowly from a supine or sitting position; encourage them to sit or lie own if feeling faint. Serious adverse effects

nc Chewing motions, bobbing, facial grimacing, rocking movements. These involuntary movements (yskinesias) occur in some patients, especially if they are also taking levoopa. A reuction in the osage of the levoopa or apomorphine may be benecial. Sudden sleep events. Sleep episoes have been reporte with the opamine agonists (e.g., apomorphine, pergolie, pramipexole, ropinirole). These episoes are escribe as “sleep attacks” or “sleep episoes,” an they inclue aytime sleep. Some sleep events have been reporte as suen an irresistible; other sleep events have been precee by sufcient warning to prevent accients. Patients who are taking opamine agonists shoul be informe about the possibility of aytime sleepiness an outright sleep attacks with these meicines an allowe to make their own ecisions about riving on the basis of their past experiences with the meicines. The assessment of patients who are at risk for sleep attacks is possible with the Epworth Sleepiness Scale. pcc Nightmares, depression, confusion, hallucinations. Perform a baseline assessment of the patient’s egree of alertness an orientation to name, place, an time before initiating therapy. Make regularly scheule subsequent evaluations of mental status, an compare nings. Report alterations in moo. Provie for patient safety uring these episoes. Reucing the aily meication osage may control these averse effects. Cdc Tachycardia, palpitations. Take the patient’s pulse at regularly scheule intervals. Report any changes for further evaluation. gt Penile erection, priapism. Apomorphine may cause penile erection an, rarely, priapism (i.e., prolonge,

216

UNIT III Drugs Affecting the Autonomic and Central Nervous System

painful erection). Apomorphine has been overuse because of its ability to inuce erection an increase libio. Inications of abuse inclue frequent erections, atypical sexual behavior, heightene libio, yskinesias, agitation, confusion, an epression.

3. Ask specically about any symptoms of hallucinations, nightmares, ementia, or anxiety. Availability. PO: tablets: 0.125, 0.25, 0.5, 0.75, 1, an 1.5 mg; tablets, extene release (24 hours): 0.375, 0.75, 1.5, 2.25, 3, 3.75, an 4.5 mg.

Drug interactions

st tt (dt, dt, t, t, t). The use of serotonin antagonists with apomorphine is contrainicate. Profoun hypotension an loss of consciousness have been reporte. ptz, cd cz, bt (.., d), tt, mtcmd. These meicines are opamine antagonists. They will block the opaminergic effect of apomorphine, thereby aggravating parkinsonian symptoms. et, tt t, dt (.., tt). The use of these agents concurrently with apomorphine signicantly increases the frequency of orthostatic hypotension. Alcohol shoul be avoie when taking apomorphine. Dosage ajustment of the antihypertensive agent is often necessary because of excessive orthostatic hypotension. ax (pră-mĭ-PĔKS-ŏl) max (MĬR-ă-pĕks) max er Do not confuse Mirapex with MiraLAX.

A Pramipexole is a nonergot opamine agonist that stimulates D2 an D3 opamine receptors. U Pramipexole may be use alone to manage the early signs an symptoms of parkinsonism by improving ADLs an motor manifestations such as tremor, rigiity, braykinesia, an postural stability. It may also be use in combination with levoopa for avance parkinsonism to manage similar signs an symptoms of the isease. tau ou The primary therapeutic outcomes sought from pramipexole for the treatment of parkinsonism are as follows: 1. Improve motor an ADL scores 2. Decrease off time 3. Reuce osage of levoopa nu ia  pax ta Premedication assessment

1. Perform a baseline assessment of parkinsonism with the use of the UPDRS. 2. Obtain a history of GI an cariovascular symptoms, incluing baseline vital signs (e.g., bloo pressure, pulse).

Dosage and administration. Adult: PO:

NOTE: Dosage ajustment is require for patients with a serum creatinine clearance of 30 mL/min or lower. See manufacturer’s recommenations. Immeiate-release tablets: Initially, give 0.125 mg three times aily for 1 week. If tolerate, increase the osage to 0.25 mg three times aily the secon week. If tolerate, increase by increments of 0.25 mg three times aily through the seventh week. The usual maintenance osage is 0.5 to 1.5 mg three times aily, with or without levoopa therapy. When pramipexole is use with levoopa, consier reucing the levoopa ose. Extene-release tablets: Initially, 0.375 mg orally once a ay. Increase graually no more than every 5 to 7 ays. The rst ose increase shoul be to 0.75 mg once aily, followe by incremental increases of 0.75 mg; assess therapeutic response an tolerability at a minimum of 5 ays after each ose increase. Aminister meication with foo or milk to reuce gastric irritation. If pramipexole is to be iscontinue, the osage shoul be graually reuce over 1 week. Common adverse effects. Pramipexole causes many

averse effects, but most are ose relate an are reversible. Averse effects vary greatly epening on the stage of the isease an the concurrent use of other meicines. gttt Nausea, vomiting, anorexia. These effects can be reuce by slowly increasing the osage, iviing the total aily ose into three oses, an aministering the meication with foo. Cdc Orthostatic hypotension. Although it is generally mil, pramipexole may cause some egree of orthostatic hypotension; this is manifeste by izziness an weakness, particularly when therapy is being initiate. Tolerance usually evelops after a few weeks of therapy. Monitor the patient’s bloo pressure aily in both the supine an staning positions. Anticipate the evelopment of postural hypotension an take measures to prevent such an occurrence. Teach patients to rise slowly from a supine or sitting position, an encourage them to sit or lie own if feeling faint. Serious adverse effects

nc Chewing motions, bobbing, facial grimacing, rocking movements. These involuntary movements occur in some

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

patients, especially if they are also taking levoopa. A reuction in osage of the levoopa may be benecial. Sudden sleep events. Sleep episoes have been reporte with the opamine agonists (e.g., pramipexole, ropinirole). These episoes are escribe as “sleep attacks” or “sleep episoes,” an they inclue aytime sleep. Some sleep events have been reporte as suen an irresistible; other sleep events have been precee by sufcient warning to prevent accients. Patients who are taking opamine agonists shoul be informe about the possibility of aytime sleepiness an outright sleep attacks with these meicines an be allowe to make their own ecisions about riving on the basis of their past experiences with the meicines. The assessment of patients who are at risk for sleep attacks is possible with the Epworth Sleepiness Scale. pcc Nightmares, depression, confusion, hallucinations. Perform a baseline assessment of the patient’s egree of alertness an orientation to name, place, an time before initiating therapy. Make regularly scheule subsequent evaluations of mental status, an compare nings. Report alterations in moo. Provie for patient safety uring these episoes. Reucing the aily osage may control these averse effects. Impulse control/compulsive behaviors. While taking pramipexole an other opamine agonists, patients can experience an intense urge to gamble, increase sexual urge, an intense urge to spen money uncontrollably, binge eating, an/or other intense urges with the inability to control these urges. Patients may not recognize these behaviors as abnormal. It is important to notify healthcare proviers about the evelopment of impulsive behaviors. Cdc Tachycardia, palpitations. Take the pulse at regularly scheule intervals. Report any changes for further evaluation. Drug interactions

Cmtd, dtzm, m, qd, tmt. These agents inhibit the urinary excretion of pramipexole. A ose reuction of pramipexole is often require to prevent toxic effects. Dm tt. Dopamine antagonists inclue phenothiazines, butyrophenones, thioxanthenes, an metoclopramie. As opamine antagonists, these agents will iminish the effectiveness of pramipexole, which is a opaminergic agonist. att t. A osage ajustment of the antihypertensive agent is often necessary in response to excessive orthostatic hypotension.  (rō-PĬN-ĭ-rŏl) Do not confuse ropinirole with raloxifene or risperidone.

217

A Ropinirole is a nonergot opamine agonist that stimulates D2 an D3 opamine receptors. U Ropinirole may be use alone to manage the early signs an symptoms of parkinsonism by improving ADLs an motor manifestations such as tremor, rigiity, braykinesia, an postural stability. It may also be use in combination with levoopa for avance parkinsonism to manage similar signs an symptoms of the isease an to reuce the egree of “on-off” uctuations that are often associate with the long-term use of levoopa. tau ou The primary therapeutic outcomes sought from ropinirole for the treatment of parkinsonism are as follows: 1. Improve motor an ADL scores 2. Decrease off time 3. Reuce osage of levoopa nu ia  r ta Premedication assessment

1. Perform a baseline assessment of parkinsonism with the use of the UPDRS. 2. Obtain a history of GI an cariovascular symptoms, incluing baseline vital signs (e.g., bloo pressure, pulse). 3. Ask specically about any symptoms of hallucinations, nightmares, ementia, or anxiety. Availability. PO: tablets: 0.25, 0.5, 1, 2, 3, 4, an 5 mg; tablets, extene release (24 hours): 2, 4, 6, 8, an 12 mg. Dosage and administration. Adult: PO: Initially, give 0.25 mg three times aily for 1 week. If tolerate, increase to 0.5 mg three times aily the secon week. If tolerate, increase to 0.75 mg three times aily for the thir week an then to 1 mg three times aily through the fourth week. If necessary, the aily osage may be increase by 1.5 mg/ay on a weekly basis up to a aily osage of 9 mg/ay. Dosages may be further ajuste at weekly intervals up to a total osage of 24 mg/ay. Aminister meication with foo or milk to reuce gastric irritation. Extene-release tablet PO: Initially 2 mg once aily for 1 to 2 weeks, followe by increases of 2 mg/ay at weekly or longer intervals base on therapeutic response an tolerability; there was no aitional benet shown for oses greater than 8 mg/ay in avance Parkinson isease or 12 mg/ay in early Parkinson isease; maximum: 24 mg/ay. When ropinirole is use with levoopa, consier reucing the levoopa osage. If ropinirole is to be iscontinue, the osage shoul be graually reuce over the course of 1 week.

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UNIT III Drugs Affecting the Autonomic and Central Nervous System

Common adverse effects. Ropinirole causes many

averse effects, but most are ose relate an are reversible. Averse effects vary greatly epening on the stage of the isease an the concurrent use of other meicines. gttt Nausea, vomiting, anorexia. These effects can be reuce by slowly increasing the osage, iviing the total aily osage into three oses, an aministering the meication with foo. Cdc Orthostatic hypotension. Ropinirole may cause some egree of orthostatic hypotension, although it is generally mil; this is manifeste by izziness an weakness, particularly when therapy is being initiate. Tolerance usually evelops after a few weeks of therapy. Monitor the patient’s bloo pressure aily in both the supine an staning positions. Anticipate the evelopment of postural hypotension an take measures to prevent such an occurrence. Teach patients to rise slowly from a supine or sitting position, an encourage them to sit or lie own if feeling faint.

Serious adverse effects

nc Chewing motions, bobbing, facial grimacing, rocking movements. These involuntary movements occur in some patients, especially if they are also taking levoopa. Reucing the osage of levoopa may be benecial. Sudden sleep events. Sleep episoes have been reporte with the opamine agonists (e.g., pramipexole, ropinirole). These episoes are escribe as “sleep attacks” or “sleep episoes,” an they inclue aytime sleep. Some sleep events have been reporte as suen an irresistible, whereas other sleep events have been precee by sufcient warning to prevent accients. Patients who are taking opamine agonists shoul be informe about the possibility of aytime sleepiness an outright sleep attacks with these meicines an be allowe to make their own ecisions about riving on the basis of their past experiences with the meicines. The assessment of patients who are at risk for sleep attacks is possible with the Epworth Sleepiness Scale. pcc Nightmares, depression, confusion, hallucinations. Perform a baseline assessment of the patient’s egree of alertness an orientation to name, place, an time before initiating therapy. Make regularly scheule subsequent evaluations of mental status an compare nings. Report alterations in moo. Provie patient safety uring these episoes. Reucing the aily osage may control these averse effects. Impulse control/compulsive behaviors. Patients can experience an intense urge to gamble, increase sexual urge, an intense urge to spen money uncontrollably,

binge eating, an/or other intense urges with the inability to control these urges while taking ropinirole an other opamine agonists. Patients may not recognize these behaviors as abnormal. It is important to notify healthcare proviers about the evelopment of impulsive behaviors. Cdc Tachycardia, palpitations. Take the pulse at regularly scheule intervals. Report any changes for further evaluation. Drug interactions

Cc. This antibiotic inhibits the metabolism of ropinirole. A osage reuction of ropinirole is often require to prevent toxic effects. et (m t td). Estrogen inhibits ropinirole excretion. If estrogen therapy is starte or stoppe uring treatment with ropinirole, it may be necessary to ajust the osage of ropinirole. Dm tt. Dopamine antagonists inclue phenothiazines, butyrophenones, thioxanthenes, an metoclopramie. As opamine antagonists, these agents will iminish the effectiveness of ropinirole, which is a opaminergic agonist. att t. A osage ajustment of the antihypertensive agent is often necessary in response to excessive orthostatic hypotension.  (rō-TĬG-ō-tēen) nu (new-PRO) Do not confuse Neupro with Neupogen.

A Rotigotine is a nonergot opamine agonist with specicity for D3, D2, an D1 opamine receptors. U Rotigotine is use to manage early-stage an late-stage Parkinson isease. tau ou The primary therapeutic outcomes sought from rotigotine for the treatment of parkinsonism are improve motor an ADL scores. nu ia  r ta Premedication assessment

1. Perform a baseline assessment of parkinsonism with the use of the UPDRS. 2. Obtain a history of GI an cariovascular symptoms, incluing baseline vital signs (e.g., bloo pressure, pulse). 3. Ask specically about any symptoms of hallucinations, nightmares, ementia, or anxiety. Availability. Transdermal: 1, 2, 3, 4, 6, an 8 mg/24 hr

patch.

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

and administration. Adult, early-stage: Transdermal: Initial: Apply 2 mg/24 hr patch once aily; may increase by 2 mg/24 hr weekly base on clinical response an tolerability. Lowest effective dose: 4 mg/24 hr (manufacturer recommens a maximum ose of 6 mg/24 hr). Adult, late-stage: Transdermal: Initial: Apply 4 mg/24 hr patch once aily; may increase by 2 mg/24 hr weekly base on clinical response an tolerability. Recommended dose: 8 mg/24 hr; in clinical trials maximum oses up to 16 mg/24 hr were use. When rotigotine is use with levoopa, consier reucing the levoopa osage. If rotigotine is to be iscontinue, the osage shoul be ecrease by less than 2 mg/24 hr preferably every other ay until withrawal is complete. Dosage

Medication Safety Alert The backing layer of rotigotine contains aluminum. To avoid skin burns, the patch should be removed prior to magnetic resonance imaging or cardioversion. Heat application has been shown to increase absorption severalfold with other transdermal products. Patients should be advised to avoid exposing the rotigotine application site to external sources of direct heat, such as heating pads or electric blankets, heat lamps, saunas, hot tubs, heated water beds, and prolonged direct sunlight.

Common adverse effects. Rotigotine causes many averse effects, but most are ose relate an are reversible. Averse effects vary greatly epening on the stage of the isease an the concurrent use of other meicines. gttt Nausea, vomiting, anorexia. These effects can be reuce by slowly increasing the osage. Cdc Orthostatic hypotension. Although it is generally mil, rotigotine may cause some egree of orthostatic hypotension; this is manifeste by izziness an weakness, particularly when therapy is being initiate. Tolerance usually evelops after a few weeks of therapy. Monitor the patient’s bloo pressure aily in both the supine an staning positions. Anticipate the evelopment of postural hypotension an take measures to prevent such an occurrence. Teach patients to rise slowly from a supine or sitting position, an encourage them to sit or lie own if feeling faint. sk. Application site reactions may be seen with rotigotine transermal patches. The signs an symptoms of these reactions generally are erythema, eema, or pruritus limite to the patch area. Daily rotation of rotigotine application sites has been shown to reuce the incience. If the patient reports a persistent application site reaction (of more than a few ays), reports an

219

increase in severity, or reports a skin reaction spreaing outsie the application site, contact the healthcare provier. Serious adverse effects

nc Chewing motions, bobbing, facial grimacing, rocking movements. These involuntary movements occur in some patients, especially if they are also taking levoopa. Reucing the osage of levoopa may be benecial. Sudden sleep events. Sleep episoes have been reporte with the opamine agonists. These episoes are escribe as “sleep attacks” or “sleep episoes,” an they inclue aytime sleep. Some sleep events have been reporte as suen an irresistible, whereas other sleep events have been precee by sufcient warning to prevent accients. Patients who are taking opamine agonists shoul be informe about the possibility of aytime sleepiness an outright sleep attacks with these meicines an be allowe to make their own ecisions about riving on the basis of their past experiences with the meicines. The assessment of patients who are at risk for sleep attacks is possible with the Epworth Sleepiness Scale. pcc Nightmares, depression, confusion, hallucinations. Perform a baseline assessment of the patient’s egree of alertness an orientation to name, place, an time before initiating therapy. Make regularly scheule subsequent evaluations of mental status an compare nings. Report alterations in moo. Provie patient safety uring these episoes. Reucing the aily osage may control these averse effects. Impulse control/compulsive behaviors. Patients can experience an intense urge to gamble, increase sexual urge, an intense urge to spen money uncontrollably, binge eating, an/or other intense urges with the inability to control these urges while taking rotigotine an other opamine agonists. Patients may not recognize these behaviors as abnormal. It is important to notify healthcare proviers about the evelopment of impulsive behaviors. Cdc Tachycardia, palpitations. Take the pulse at regularly scheule intervals. Report any changes for further evaluation. Drug interactions

Dm tt. Dopamine antagonists inclue phenothiazines, butyrophenones, thioxanthenes, an metoclopramie. As opamine antagonists, these agents will iminish the effectiveness of rotigotine, which is a opaminergic agonist. att t. A osage ajustment of the antihypertensive agent is often necessary in response to excessive orthostatic hypotension.

220

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Drug Class: CaTeChol-o-MeThylTransFerase inhiBiTors aa (ĕn-TĂK-ă-pōn) ca (CŎM-tăn) aa/vda/abda sav (stă-LĒ-vō) a (O-pica-pone) o (on-jen-tis)

A Entacapone an opicapone are COMT inhibitors that reuce the estruction of opamine in the peripheral tissues, thereby allowing signicantly more opamine to reach the brain to eliminate the symptoms of parkinsonism. U Carbiopa-levoopa is the current rug combination of choice for the longer-term treatment of Parkinson isease. Unfortunately, these agents lose effectiveness (i.e., the “on-off” phenomenon) an result in the evelopment of more averse effects (i.e., yskinesias) over time. Aing entacapone or opicapone inhibits the metabolism of opamine, which results in more constant opaminergic stimulation in the brain. This stimulation reuces motor uctuations, increases on time, reuces off time, an often results in a reuction in the osage of levoopa. Entacapone an opicapone shoul always be aministere with carbiopa-levoopa. Entacapone an opicapone have no antiparkinsonian effect when it is use alone. Stalevo is a combination prouct that contains levoopa, carbiopa, an entacapone. Unlike entacapone, opicapone is aministere at betime. tau ou The primary therapeutic outcomes sought from entacapone an opicapone for the treatment of parkinsonism are as follows: 1. Reuce motor uctuations 2. Increase on time an reuce off time 3. Reuce total aily osage of carbiopa-levoopa nu ia  comt ib ta Premedication assessment

1. Perform a baseline assessment of parkinsonism with the use of the UPDRS. 2. Obtain a history of bowel patterns an any ongoing GI symptoms. 3. Perform a baseline assessment of the patient’s egree of alertness an orientation to name, place, an time before initiating therapy. 4. Check for any antihypertensive therapy that is currently prescribe. Monitor the patient’s bloo pressure aily in both the supine an staning positions. If antihypertensive meications are being taken,

report this to the healthcare provier for possible osage ajustment. 5. Check the patient’s hepatic function before the initiation of therapy an perioically throughout the course of aministration. Availability. PO: Entacapone (Comtan): 200-mg tablets (o not aminister entacapone without levoopa/carbiopa; it has no pharmacologic effect of its own). Stalevo 50: 12.5 mg carbiopa, 50 mg levoopa, an 200 mg entacapone Stalevo 75: 18.75 mg carbiopa, 75 mg levoopa, an 200 mg entacapone Stalevo 100: 25 mg carbiopa, 100 mg levoopa, an 200 mg entacapone Stalevo 125: 31.25 mg carbiopa, 125 mg levoopa, an 200 mg entacapone Stalevo 150: 37.5 mg carbiopa, 150 mg levoopa, an 200 mg entacapone Stalevo 200: 50 mg carbiopa, 200 mg levoopa, an 200 mg entacapone Opicapone: 25 an 50 mg capsules Dosage and administration. Dosage must be a-

juste in accorance with the patient’s response an tolerance. etc. Adult: PO: Initially, start therapy by aing entacapone to alreay existing levoopa/carbiopa therapy: give one 200-mg tablet of Comtan with each carbiopa-levoopa ose to a maximum of eight times aily (1600 mg of entacapone). The osage of carbiopa-levoopa will nee to be reuce, particularly if the levoopa ose is higher than 600 mg/ ay an if the patient has moerate or severe yskinesias before the entacapone is starte. Once the patient has been stabilize on a new combination of entacapone, levoopa, an carbiopa, the patient may be switche to a Stalevo prouct that most closely matches the osage of levoopa/carbiopa an entacapone being taken. oc. For patients receiving levoopa/carbiopa experiencing “off” episoes: Adult: PO: 50 mg once a ay at betime. Shoul not eat foo for 1 hour before an for at least 1 hour after taking opicapone. Patients with moerate hepatic impairment shoul receive 25 mg once aily at betime; avoi use in patients with severe hepatic impairment.

Common adverse effects. Entacapone an opicapone may increase the averse opaminergic effects of levoopa (e.g., chorea, confusion, hallucinations), but these can be controlle by reucing the osage of levoopa. gttt. Entacapone may cause the evelop of iarrhea 1 to 12 weeks after the initiation of therapy, especially when higher oses are use. These effects may be minimize by a temporary reuction in osage.

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

Constipation is a common sie effect of opicapone. nc Sedative effects. Patients may complain of rowsiness an lethargy, especially uring the initiation of therapy. People shoul not rive or operate complex machinery or perform uties for which they must remain mentally alert until they have gaine enough experience with entacapone to know whether it affects their mental or motor performance. Patients receiving opicapone may complain of insomnia. gt. Urine discoloration. Patients shoul be avise that entacapone may change the color of their urine to a brownish orange but that this is harmless an there is no cause for alarm. Serious adverse effects

nc Neurologic effects. Entacapone an opicapone may increase the averse opaminergic effects of levoopa, such as hallucinations, psychosis, yskinesia, impulse control isorer (e.g., pathologic gambling, hypersexuality, spening money), an suen onset of sleep. A symptom complex resembling neuroleptic malignant synrome (characterize by elevate temperature, muscular rigiity, altere consciousness, an autonomic instability), with no other obvious etiology, has been reporte in association with rapi ose reuctions. Make regularly scheule subsequent evaluations of mental status an compare nings. Report alterations in moo. A reuction of the carbiopa-levoopa osage may be require to alleviate these effects. Provie for patient safety, be emotionally supportive, an assure the patient that these effects usually issipate as tolerance to the rug evelops over the subsequent few weeks. Cdc Orthostatic hypotension. Monitor the patient’s bloo pressure aily in both the supine an staning positions. Anticipate the evelopment of postural hypotension an take measures to prevent such an occurrence. Teach the patient to rise slowly from a supine or sitting position, an encourage the patient to sit or lie own if feeling faint. Drug interactions

ld. Entacapone an opicapone an levoopa have aitive neurologic effects. This interaction may be benecial because it often allows for a reuction in the osage of the levoopa. att t. A osage ajustment of the antihypertensive agent is often necessary in response to excessive orthostatic hypotension. am, t, ,  (t), dm, dbtm. These agents are metabolize by COMTs. The concurrent aministration of entacapone an opicapone with these agents may prolong their uration of activity. Monitor the patient’s bloo pressure an heart rate.

221

Drug Class: anTiCholinergiC agenTs A Parkinsonism is inuce by the imbalance of neurotransmitters in the basal ganglia of the brain. The primary imbalance appears to be a eciency of opamine, which results in a relative excess of the cholinergic neurotransmitter acetylcholine. Anticholinergic agents are thus use to reuce the hyperstimulation that is cause by excessive acetylcholine. U The anticholinergic agents reuce the severity of the tremor an rooling that are associate with parkinsonism. Anticholinergic agents are more useful for patients with minimal symptoms an no cognitive impairment. Combination therapy with levoopa an anticholinergic agents is also successful for controlling symptoms of the isease more completely in about half of patients who are alreay stabilize on levoopa therapy. Anticholinergic agents have little effect on rigiity, braykinesia, or postural abnormalities. If anticholinergic therapy is to be iscontinue, it shoul be one so graually to avoi withrawal effects an the acute exacerbation of parkinsonian symptoms, even for patients in whom there appears to have been no clinical response. tau ou The primary therapeutic outcome sought from anticholinergic agents for the treatment of parkinsonism is a reuction in the severity of the tremor an rooling that are cause by a relative excess of acetylcholine in the basal ganglia. nu ia  A A ta Premedication assessment

1. Perform a baseline assessment of parkinsonism with the use of the UPDRS. 2. Obtain baseline ata relate to patterns of urinary an bowel elimination. 3. Perform a baseline assessment of the patient’s egree of alertness an orientation to name, place, an time before initiating therapy. 4. Take the patient’s bloo pressure in both the supine an staning positions. Recor the pulse rate, rhythm, an regularity. 5. All patients shoul be screene for the presence of close-angle glaucoma before the initiation of therapy. Anticholinergic agents may precipitate an acute attack of close-angle glaucoma. Patients with open-angle glaucoma can safely use anticholinergic agents. Monitor intraocular pressure regularly. Availability, dosage, and administration. Adult: PO (Table 14.3). Aminister meication with foo or milk to reuce gastric irritation.

222

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Table 14.3 Anticholinergic Agents generiC naMe benztropine mesylate Do not confuse benztropine with benzonatate.

BranD naMe Cogentin

Tablets: 25, 50 mg Capsules: 25, 50 mg Do not confuse Benadryl Allergy with Elixir: 12.5 mg/5 mL Syrup: 12.5 mg/5 mL benazepril. Injection : 50 mg/mL in 1-, 10-mL vials; 1-mL cartridges Solution: 6.25 mg/5 mL

diphenhydramine hydrochloride Do not confuse diphenhydramine with dicyclomine or dipyridamole. trihexyphenidyl hydrochloride

availaBiliTy Tablets: 0.5, 1, 2 mg Injection: 1 mg/mL in 2-mL ampules

PMS-trihexyphenidyl

Tablets: 2, 5 mg Elixir: 2 mg/5 mL

iniTial Dosage range (po) 0.5–1 mg at bedtime

MaxiMuM Daily Dosage range 6 mg

25–50 mg three or four times daily

PO: 300 mg IM/IV: 400 mg

1–2 mg daily

12–15 mg

Available in Canada. Do not confuse.

Common adverse effects

gttt Constipation; dryness of the mucosa of the mouth, throat, and nose. These symptoms are the result of the anticholinergic effects that are prouce by these agents. Patients who are taking these meications shoul be monitore for the evelopment of these averse effects. Miler averse effects (e.g., ry mouth) may subsie with continue treatment. Dryness of the mucosa may be relieve by sucking har cany or ice chips or by chewing gum. Give stool softeners as prescribe. Encourage aequate ui intake, foos that provie sufcient bulk, an exercise as tolerate. gt Urinary retention. If patients evelop urinary hesitancy, assess them for blaer istention. Report to the healthcare provier any symptoms of urinary retention for further evaluation. This symptom is a result of the anticholinergic effects prouce by these agents. Patients who are taking these meications shoul be monitore for the evelopment of this averse effect. s Blurred vision. This symptom may subsie with continue treatment. Provie for patient safety. Serious adverse effects

pcc Nightmares, depression, confusion, hallucinations. Make regularly scheule subsequent evaluations of mental status an compare nings. Report the evelopment of alterations in moo. Provie patient safety uring these episoes. Reucing the aily osage may control these averse effects. Cdc Orthostatic hypotension. Although this conition is infrequent an generally mil, all anticholinergic agents

may cause some egree of orthostatic hypotension, which is manifeste by izziness an weakness, particularly when therapy is being initiate. Monitor the patient’s bloo pressure aily in both the supine an staning positions. Anticipate the evelopment of postural hypotension an take measures to prevent such an occurrence. Teach the patient to rise slowly from a supine or sitting position an encourage the patient to sit or lie own if feeling faint. Palpitations, dysrhythmias. Report any changes for further evaluation. Drug interactions

amtd, tccc tdt, tz. These agents may enhance the anticholinergic averse effects. Confusion an hallucinations are characteristic of excessive anticholinergic activity. A osage reuction may be require. ld. Large oses of anticholinergic agents may slow gastric emptying an inhibit the absorption of levoopa. An increase in the osage of levoopa may be require.

alzheimer Disease Alzheimer disease is a progressive neuroegenerative isease that affects oler aults. The probability of being iagnose with Alzheimer isease nearly oubles every 5 years after age 65. Accoring to the Alzheimer’s Association, more than 5 million Americans are living with Alzheimer isease. It is the most common type of ementia. Other types of ementia are ementia with Lewy boies, vascular (multiinfarct) ementia, Parkinson isease ementia, an frontotemporal isorers. Patients with Alzheimer isease will evelop cognitive ysfunction (memory loss), psychiatric an behavioral problems, an ifculty performing ADLs.

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

The neuropathology appears to be an accumulation of amyloi plaques an neurobrillary tangles that cause neuronal injury. Inclue in this neuronal injury are cholinergic neurons that are critical in memory, cognition, an other cortical functions. Disturbances in glutamate neurotransmission have been linke with the pathophysiologic processes unerlying Alzheimer isease. Elevate concentrations of glutamate have been associate with increase sensitivity an/or activity of the glutamatergic system, resulting in neuronal ysfunction an cell eath in Alzheimer isease. Although there is no cure for this isease, meications can ecrease some of the symptoms by increasing acetylcholine an inhibiting glutamate.

Drug TheraPy for alzheimer Disease Drug therapy is focuse on improving cognitive function. Two classes of rugs are currently use to treat Alzheimer isease: acetylcholinesterase inhibitors (onepezil, galantamine, rivastigmine) an an N-methyld-aspartate (NDMA) inhibitor (memantine). To ate, no rugs are available to slow the egenerative process. nUrsing implicAtions for AlZheimer DiseAse therApy Patients start to have ifculty with memory, problem solving, attention, counting, an language. As the isease progresses, behavioral symptoms of Alzheimer isease such as wanering, agitation, anxiety, sleeplessness, an aggression are manifeste. Families an caregivers nee to learn effective management of these behaviors to make patients more comfortable. The focus of patient care is to maintain mental function, manage behavioral symptoms, an slow or elay the symptoms of isease. Be alert for these symptoms of Alzheimer isease: • Impaire memory an jugment; often these patients can no longer rive • Confusion or isorientation; reirecting an calming the patient is an effective intervention • Inability to recognize family or friens; remining an calming the patient is use • Aggressive behavior • Depression; often accompanies anxiety • Psychoses, incluing paranoia an elusions • Anxiety Because this isease is progressive an the patient will continue to have worsening memory an cognitive function changes, this takes its toll on the caregiver of the patient. Developing goo coping skills an a strong support system, as well as utilizing respite care, can help caregivers hanle the stress of caring for a love one with Alzheimer isease. Eventually, patients are care for in a memory care unit, usually a separate section of a nursing home esigne to care for Alzheimer isease patients exclusively.

223

A • Obtain baseline assessments of presenting symptoms. • Recor baseline pulse, respirations, an bloo pressure. • Assess for an recor any GI symptoms present before initiation of therapy. • Assess the patient’s ability to receive an unerstan instructions. Safety and self-care. Caregivers are taught to repeat,

reassure, an reirect the patient with Alzheimer isease as the cognitive ecline progresses. Safety issues shoul always be a concern. Allowing the patient to be as inepenent as long as possible is also consiere.

Stress. The patient with Alzheimer isease can become agitate, anxious, an aggressive as the isease progresses. Recognize the nee for calming reassurance an repeating instructions. The memory loss leas to confusion an frustration. Continue to reassure an reirect behavior that can be stressful. Family resources. Help families connect with pro-

grams esigne to teach them about the various stages of Alzheimer isease an about ways to eal with ifcult behaviors an other caregiving challenges. ia • Implement planne interventions that are consistent with assessment ata, an ientify the iniviual nees of the patient. • Monitor an recor the patient’s vital signs, especially bloo pressure, uring the course of therapy. Report signicant changes in bloo pressure; these are most likely to occur uring perios of osage ajustment. Emphasize measures to prevent orthostatic hypotension. pa edua Eucation is focuse on the caregiver with regar to how to manage the eclining cognitive abilities of the patient. Caregivers shoul remember the three Rs—repeat, reassure, an reirect; these are key concepts to keep in min when ealing with patients with Alzheimer isease. Allow the patient to continue to perform ADLs as long as possible, an supervise all househol ADLs such as cooking an cleaning. Fostering health maintenance

• Throughout the course of treatment, iscuss meication information an how it will benet the patient. • Provie the patient an signicant others with the important information containe in the specic rug monographs for the rugs prescribe. Aitional health teaching an nursing interventions for common an serious averse effects will be foun in each rug monograph.

224

UNIT III Drugs Affecting the Autonomic and Central Nervous System

• Seek cooperation an unerstaning of the following points so that meication compliance is increase: name of meication; osage, routes, an times of aministration; an common an serious averse effects.

2. Recor baseline pulse, respirations, an bloo pressure. 3. Assess for an recor any GI symptoms present before initiation of therapy. Availability

Patient self-assessment. Enlist the patient’s ai in e-

veloping an maintaining a written recor of monitoring parameters (e.g., bloo pressures, weight, exercise; see the Patient Self-Assessment Form for anticholinesterase inhibitors on the Evolve website). Complete the Premeication Data column for use as a baseline to track response to rug therapy. Ensure that the patient unerstans how to use the form, an instruct the patient to bring the complete form to follow-up visits. During follow-up visits, focus on issues that will foster aherence with the therapeutic interventions prescribe.

Drug Class: aCeTylCholinesTerase inhiBiTors dz (dŏn-ĔP-ĭ-zĭl) A (ĀR-ĭ-sĕpt) aaa (ga-lanta-mēn) razad er (raz-ah-dine) va (riva-STIG-men) ex (ex-el-on)

A Donepezil, galantamine, an rivastigmine are acetylcholinesterase inhibitors that allow acetylcholine to accumulate at cholinergic synapses, causing a prolonge an exaggerate cholinergic effect. U Although the causes are unknown, Alzheimer isease is characterize by a loss of cholinergic neurons in the central nervous system, resulting in memory loss an cognitive ecits (ementia). Donepezil an rivastigmine (only the patch) are use in patients with mil to severe ementia to enhance cholinergic function. Galantamine is use in patients with mil to moerate ementia to enhance cholinergic function. Their function iminishes with ongoing loss of cholinergic neurons. Donepezil, galantamine, an rivastigmine o not prevent or slow the neuroegeneration cause by Alzheimer isease. tau ou The primary therapeutic outcome expecte from onepezil, galantamine, an rivastigmine therapy is improve cognitive skills (e.g., wor recall, object naming, language, wor ning, task performance). nu ia  Dz, gaaa, ad rva ta Premedication assessment

1. Obtain baseline assessments of presenting symptoms.

Dz. PO: 5-, 10-, an 23-mg tablets; 5- an 10mg orally isintegrating tablets. gtm. PO: 4-, 8-, 12-mg tablets; 4-mg/mL oral solution; 8-, 16-, 24-mg extene-release 24-hour capsules. rtm. Transdermal: 4.6, 9.5, an 13.3 mg/24 hr patch. Dosage and administration

Dz. PO: Initial osage is 5 mg aily at betime. After 4 to 6 weeks of therapy, osage may be increase to 10 mg aily to assess therapeutic benet. After 3 months, ose may be increase to 23 mg in moerate to severe Alzheimer isease. Donepezil may be taken with or without foo. The orally isintegrating tablets may be helpful for patients who have ifculty swallowing. Allow tablets to issolve on the tongue an follow with a glass of water. gtm. Adult: PO: Immeiate release initial osage 4 mg twice a ay. After a minimum of 4 weeks, osage may be increase to 8 mg twice a ay. Then, after 4 weeks, ose shoul be increase to 12 mg twice a ay. Adult: PO: Extene release initial osage 8 mg once aily. After a minimum of 4 weeks, osage may be increase to 16 mg once a ay. Then after 4 weeks ose shoul be increase to 24 mg once a ay. rtm. Transdermal: Initial: Apply 4.6 mg/24 hr patch once aily; if well tolerate, ose may be titrate (no sooner than every 4 weeks) to 9.5 mg/24 hr (continue as long as therapeutically benecial), an then to 13.3 mg/24 hr patch (maximum ose). Recommended effective dose: Apply 9.5 mg/24 hr or 13.3 mg/24 hr patch once aily; remove ol patch an replace with a new patch every 24 hours. Common adverse effects

gttt Nausea, vomiting, dyspepsia, diarrhea. These are natural extensions of the pharmacologic effects of cholinergic agents. The osage may nee to be reuce if the patient has ifculty with these averse effects. Symptoms are less common with lower oses an ten to subsie after 2 to 3 weeks of therapy. Graually increasing the ose may help avoi these complications. Serious adverse effects

Cdc Bradycardia. Cholinergic agents cause a slowing of the heart. These agents may enhance the braycariac

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

225

effects of beta blockers. Notify the healthcare provier if the heart rate is regularly less than 60 beats/min.

2. Recor baseline pulse, respirations, an bloo pressure.

Drug interactions

Availability. PO: 5- an 10-mg tablets; 7-, 14-, 21-, an 28-mg capsules, extene release (24 hours); 2 mg/mL in 240 an 360-mL oral solution; 10 mg/5 mL in 5 mL cup.

atcc t. As a cholinergic agent, onepezil has the potential to reuce the activity of anticholinergic agents (e.g., benztropine, iphenhyramine, orphenarine, procycliine, trihexypheniyl). sccc-t mc t, cc t. As a cholinesterase inhibitor, onepezil is likely to exaggerate the actions of the epolarizing muscle relaxant (succinylcholine) uring anesthesia an enhance the pharmacologic activity of cholinergic agents such as bethanechol.

Drug Class: nMDa reCepTor inhiBiTor a (MĔM-ăn-tēn) nada Xl (năm-ĔN-dă)

A Memantine is an inhibitor of the NMDA receptor, a type of glutamate receptor. U Although the causes are unknown, one of the neurochemical characteristics of Alzheimer isease is persistent activation of NMDA receptors in the central nervous system. Memantine blocks these receptors an is use alone or in combination with an acetylcholinesterase inhibitor for the treatment of ementia associate with moerate to severe Alzheimer isease. Patients taking memantine show improvement in cognitive function an behavioral symptoms an a slower ecline in ADLs, but memantine oes not prevent or slow the neuroegeneration of Alzheimer isease. tau ou The primary therapeutic outcome expecte from memantine therapy is improve cognitive skills (e.g., wor recall, object naming, language, wor ning, task performance). nu ia  ma ta Premedication assessment

1. Obtain baseline symptoms.

assessments

of

presenting

Dosage and administration. Adult: PO: 5 mg once aily. The ose shoul be increase in 5-mg increments to 10, 15, an 20 mg aily. The minimal interval between ose increases is 1 week. Memantine can be taken with or without foo. The recommene starting ose of extene release memantine is 7 mg once aily. The ose shoul be increase in 7 mg increments to the recommene maintenance ose of 28 mg once aily. The minimum recommene interval between ose increases is 1 week. Conversion: Patients taking 10-mg immeiaterelease tablets twice aily may switch to a 28-mg extene-release capsule once aily the ay after the last ose of a 10-mg immeiate-release tablet. Reduction in dose for renal impairment: A target ose of 10 mg/ay for the immeiate-release form an 14 mg/ay for the extene-release form is recommene in patients with severe renal impairment (creatinine clearance of 5 to 29 mL/min, base on the Cockcroft-Gault equation). Common and serious adverse effects

nc Headache, dizziness, akathisia, insomnia, restlessness, increased motor activity, excitement, agitation. Many of these symptoms ecline with continue therapy an can be reuce with a longer osage titration. Dosage may nee to be reuce if the patient has ifculty with these averse effects. Drug interactions

actzmd, dm bcbt. Meicines that alkalinize the pH of the urine will reuce excretion of memantine. Severe meical conitions such as renal tubular aciosis an severe urinary tract infections also may cause alkalization of the urine, with potential toxicity of memantine.

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UNIT III Drugs Affecting the Autonomic and Central Nervous System

ca Jud ad nx-ga ncleX ® exaa-s Qu K pt • Parkinson disease is a progressive neurologic disorder that is caused by the deterioration of dopamine-producing cells in the portion of the brain that is responsible for the maintenance of posture and muscle tone and the regulation of voluntary smooth muscle. • Normally, a balance exists between dopamine, which is an inhibitory neurotransmitter, and acetylcholine, which is an excitatory neurotransmitter. The symptoms associated with Parkinson disease develop because of a relative excess of acetylcholine in the brain. • The goal of treatment is to restore dopamine neurotransmitter function to as close to normal as possible and to relieve the symptoms that are caused by excessive acetylcholine. • Therapy must be individualized, but selegiline therapy is often started rst to slow the development of symptoms. As selegiline becomes less effective, levodopa is started, with or without selegiline. • Dopamine agonists (e.g., ropinirole, pramipexole) may be added to directly stimulate dopamine receptors. • Entacapone may be added to levodopa therapy to reduce the metabolism of levodopa, thus prolonging its action. • Anticholinergic agents may be added at any time to reduce the effects of the “excessive” acetylcholine. • The nonpharmacologic treatment (e.g., diet, exercise, physical therapy) of Parkinson disease is equally important as medication for maintaining the long-term well-being of the patient. • Although there is no cure for Alzheimer disease, acetylcholinesterase inhibitors (donepezil, rivastigmine) and memantine are used to help improve cognitive skills.

addt l rc

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Clayt on) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types.

sc A patient requested an appointment with their healthcare provider to discuss the possibility that they were developing Parkinson disease, which runs in the family.

1. The nurse suspects that the patient in the scenario is manifesting early Parkinson disease because of the development of which of these symptoms? (Select all that apply.) 1. 2. 3. 4. 5.

Weakness involving one limb Drooling and having difculty chewing and swallowing Gait alterations causing moderate generalized disability Expressionless facial features Tremors on the ngers of one hand

objct: Identify the signs and symptoms of Parkinson disease. nClex tm t: Multiple response Ct k: Application 2. The nurse explained to the patient in the scenario that the symptoms of Parkinson disease are related to the levels of neurotransmitters in the brain and used which statement? 1. “Parkinson disease is related to an excess of serotonin and a deciency of dopamine.” 2. “Parkinson disease is related to an excess of acetylcholine and a deciency of dopamine.” 3. “Parkinson disease is related to an excess of dopamine and a deciency of acetylcholine.” 4. “Parkinson disease is related to an excess of epinephrine and a deciency of acetylcholine.” objct: Identify the neurotransmitter that is found in excess and the neurotransmitter that is decient in people with parkinsonism. nClex tm t: Multiple choice Ct k: Understanding 3. The patient in the scenario was started on selegiline (Zelapar) therapy during the early treatment of Parkinson disease because this drug will have which effect? 1. 2. 3. 4.

Reduce excessive acetylcholine Decrease dopamine in the basal ganglia Reduce the metabolism of dopamine Reduce the metabolism of levodopa, thereby making more available

objct: Explain the action of entacapone, opicapone, and the monoamine oxidase inhibitors (selegiline, sanamide, and rasagiline) as it relates to the treatment of Parkinson disease. nClex tm t: Multiple choice Ct k: Comprehension 4. Choose the most likely option for the information missing from the following sentence by selecting from the list of options provided. The nurse explains to the patient in the scenario that in the future the healthcare provider may start _________1___________ therapy in addition to _______1___________, which is part of the drug class __________2______________ and __________2_____________, respectively. opTion 1

opTion 2

rasagiline

•  monoamine oxidase type B inhibitors •  dopamine agonists •  anticholinergic agents

amantadine hydrochloride carbidopa-levodopa

objct: Discuss the action of carbidopa-levodopa and dopamine agonists in Parkinson disease. nClex tm t: Cloze Ct k: Recognize cues

Drugs Used to Treat Neurodegenerative Disorders CHAPTER 14

5. The patient in the scenario was started on selegiline with carbidopa-levodopa to slow the progression of symptoms of Parkinson disease. The patient was asked to explain the different drugs used for this condition. Using the following grid, place an X reDuCe MoTor FluCTuaTions

227

in the appropriate boxes to identify the therapeutic outcome for these drugs.

reDuCe Dosage oF CarBiDopa-levoDopa

sloW The progression oF The Disease

esTaBlish a BalanCe oF DopaMine anD aCeTylCholine

COMT inhibitors (entacapone, opicapone) Monoamine oxidase inhibitors (selegiline, sanamide, and rasagiline)

objct: Explain the action of entacapone, opicapone, and the monoamine oxidase inhibitors (selegiline, sanamide, and rasagiline) as it relates to the treatment of Parkinson disease. nClex tm t: Matrix Ct k: Evaluate cues 6. The nurse knows that when anticholinergic agents are used, which of the following symptoms will show improvement? (Select all that apply.) 1. 2. 3. 4. 5.

Tremors Drooling Cognition impairment Bradykinesia Rigidity

objct: Discuss the specic symptoms that should show improvement when anticholinergic agents are administered to the patient with Parkinson disease. nClex tm t: Multiple response Ct k: Application

7. The nurse is educating the family of an elderly patient on the mechanism of action for donepezil (Aricept). Which statement by the family indicates that further teaching is needed? 1. “As I understand it, this drug will improve the cognitive skills of my dad.” 2. “So you are saying that this drug is used in patients with mild to moderate dementia caused by Alzheimer disease.” 3. “Are you saying that the enzyme that normally breaks down acetylcholine is inhibited by this medication?” 4. “As I understand it, this medication will slow the progress of the neurodegeneration caused by Alzheimer disease.” objct: Explain the action of the agents used in the treatment of Alzheimer disease. nClex tm t: Multiple choice Ct k: Comprehension

15

Drugs Used for Anxiety Disorders

https://evolve.elsevier.com/Willihnganz

Objectives 1. Compare and contrast the differences between generalized anxiety disorder, panic disorder, phobias, and obsessive-compulsive disorder. 2. Describe the essential components included in a baseline assessment of a patient’s mental status.

3. Discuss the drug therapy used to treat anxiety disorders. 4. Identify adverse effects that may result from drug therapy used to treat anxiety. 5. Discuss psychological and physiologic drug dependence.

Key Terms anxiety (ăng-ZĪ-ĭ-tē) (p. 228) generalized anxiety disorder (JĔNŭr-ăl-īzd ăng-ZĪ-ĭ-tē dĭs-ŌR-dŭr) (p. 228) panic disorder (PĂN-ĭk) (p. 228)

phobias (FŌ-bē-ăz) (p. 229) obsessive-compulsive and related disorders (ŏb-SĔS-ĭv kŏm-PŬL-sĭv) (p. 229) compulsion (kŏm-PŬL-shŭn) (p. 229)

ANXIETY DISORDERS Anxiety is a normal human emotion that is similar to

fear. It is an unpleasant feeling of apprehension or nervousness caused by the perception of potential or actual danger that threatens a person’s security, whereas fear is an emotional response to a real or perceived threat. Mild anxiety is a state of heightened awareness of one’s surroundings and is seen in response to day-to-day circumstances. This type of anxiety can be benecial as a motivator for the individual to take action in a reasonable and adaptive manner. It is sometimes said that people nd the inner strength to meet their challenges or “rise to the occasion.” Patients are considered to have anxiety disorders when their responses to stressful situations are abnormal or irrational and impair normal daily functioning. The National Institute of Mental Health identies anxiety disorders as the most commonly encountered mental health disorders in clinical practice; 16% of the general population will experience anxiety disorders during their lifetime. Anxiety disorders usually begin before the age of 30 years and are more common among women than men. Anxiety is a primary symptom of many psychiatric disorders, including schizophrenia, mania, depression, dementia, and substance abuse. Therefore the evaluation of the anxious patient requires a thorough history and physical and psychiatric examinations to determine whether the anxiety is a primary condition or secondary to another illness. Patients who develop anxiety disorders often have 228

anxiolytics (ăng-zē-ō-LĬ-tĭks) (p. 229) tranquilizers (TRĂN-kwĕ-lī-zŭrz) (p. 229)

more than one. Patients may also have major depression or develop substance abuse problems. The most common disorders are generalized anxiety disorder, panic disorder, social phobia, simple phobia, and obsessivecompulsive disorder (OCD). Generalized anxiety disorder is described as excessive and unrealistic worry about two or more life circumstances (e.g., nances, illness, misfortune) for 6 months or more. Symptoms are both psychological (e.g., tension, fear, difculty concentrating, apprehension) and physical (e.g., tachycardia, palpitations, tremor, sweating, gastrointestinal upset). The disease has a gradual onset, usually among individuals in the 20- to 30-year-old age group, and it has twice the frequency among women as among men. This illness usually follows a chronic uctuating course of exacerbations and remissions that are triggered by stressful events in the person’s life. Persistent irrational anxiety or episodic anxiety generally requires medical and psychiatric treatment. Patients with generalized anxiety disorder often develop other psychiatric disorders (e.g., panic disorder, OCD, social anxiety disorder, major depression) at some time during their lives. Panic disorder is recognized as a separate entity and not as a more severe form of chronic generalized anxiety disorder. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes. During the attack, at least four of the following symptoms arise: palpitations, tachycardia, or pounding heart; sweating; shaking or trembling;

Drugs Used for Anxiety Disorders CHAPTER 15

sensations of shortness of breath or smothering; feelings of choking; chest pain or discomfort; nausea or abdominal distress; feeling dizzy, unsteady, lightheaded, or faint; chills or heat sensation; numbness or tingling sensations; feelings of unreality or depersonalization; fear of losing control; and fear of dying. The average age of onset is during the early 20s; the disorder is often relapsing, and it may require lifetime treatment. Panic disorder is estimated to affect 1% to 2% of Americans at some time during their lives. Women are affected two to three times more frequently than men. Genetic factors appear to play a signicant role in the disease; 15% to 20% of patients will have a close relative with a similar illness. Panic disorder begins as a series of acute or unprovoked anxiety (panic) attacks that involve an intense, terrifying fear. The attacks do not occur as a result of exposure to anxiety-causing situations, as phobias do. Initially the panic attacks are spontaneous, but later during the course of the illness they may be associated with certain actions (e.g., driving a car, being in a crowded place). Patients with panic disorder often develop other psychiatric disorders (e.g., generalized anxiety disorder, personality disorders, substance abuse, OCD, social anxiety disorder, major depression) at some time during their lives. Phobias are irrational fears of specic objects, activities, or situations. Unlike other anxiety disorders, the object or activity that creates the feeling of fear is recognized by the patient, who also realizes that the fear is unreasonable. The fear persists, however, and the patient seeks to avoid the situation. Social phobia is described as a fear of certain social situations in which the person is exposed to scrutiny by others and fears doing something embarrassing. A social phobia involving public speaking is fairly common, and the activity is usually avoided. If public speaking is unavoidable, it is done with intense anxiety. Social phobias are rarely incapacitating, but they do cause some interference with social or occupational functioning. A simple phobia is an irrational fear of a specic object or situation, such as heights (acrophobia), closed spaces (claustrophobia), air travel, or driving. Phobias that involve animals such as spiders, snakes, and mice are particularly common. If the person with the phobia is exposed to the object, there is an immediate feeling of panic, sweating, and tachycardia. People are aware of their phobias, and they simply avoid the feared objects. OCD is not classied under anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The DSM-5 added a new category of disorders called obsessive-compulsive and related disorders (OCRDs). The OCRDs category includes the familiar OCD. Although anxiety remains a key feature in OCRDs, there are enough unique differences between anxiety disorders and OCRDs to justify a separate category. The primary features of

229

OCD are recurrent obsessions or compulsions that cause signicant distress and interfere with normal occupational responsibilities, social activities, and relationships. The average age of onset of the symptoms of OCD is during late adolescence to the early 20s. The condition occurs with twice the frequency in men as in women, and there also appears to be a genetic component to the disease. It is estimated that 2% to 8% of the general population suffers from OCD, making it one of the most common personality disorders. An obsession is an unwanted thought, idea, image, or urge that the patient recognizes as time consuming and senseless but that repeatedly intrudes into that patient’s consciousness, despite their attempts to ignore, prevent, or counteract it. Examples of obsessions are recurrent thoughts of dirt or germ contamination, a fear of losing things, a need to know or remember something, a need to count or check something, blasphemous thoughts, or concerns about something happening to the self or others. An obsession produces a tremendous sense of anxiety in the affected person. A compulsion is a repetitive, intentional, purposeful behavior that must be performed to decrease the anxiety associated with an obsession. The act is done to prevent a vague dreaded event, but the person does not derive pleasure from the act. Common compulsions deal with cleanliness, grooming, and counting. When patients are prevented from performing a compulsion, there is a sense of mounting anxiety. In some individuals the compulsion can become the patient’s lifetime activity. OCD is a complex condition that requires a highly individualized and integrated approach to treatment that includes pharmacologic, behavioral, and psychosocial components.

DRUG THERAPY FOR ANXIETY DISORDERS A great many medications have been used over the decades to treat anxiety. They range from the purely sedative effects of ethanol, bromides, chloral hydrate, and barbiturates to drugs with more specific antianxiety and less sedative activity, such as benzodiazepines, buspirone, hydroxyzine, and propranolol (a beta-adrenergic antagonist). In recent years, tricyclic antidepressants (e.g., imipramine), selective serotonin reuptake inhibitors (SSRIs), and serotoninnorepinephrine reuptake inhibitors (SNRIs) (duloxetine and extended-release venlafaxine) have been studied and are now used for the treatment of anxiety disorders. The treatment of anxiety disorders usually requires a combination of pharmacologic and nonpharmacologic therapies. When it is decided to treat the anxiety in addition to the other medical or psychiatric diagnoses, antianxiety medications— also known as anxiolytics or tranquilizers—are prescribed. See the individual drug monographs later

230

UNIT III Drugs Affecting the Autonomic and Central Nervous System

in this chapter for the mechanisms of action of these agents. USES Generalized anxiety disorder is treated with psychotherapy and the short-term use of antianxiety agents. The US Food and Drug Administration (FDA) has approved four classes of compounds or medications for treatment: (1) specic benzodiazepines (alprazolam, chlordiazepoxide, clonazepam, clorazepate, diazepam, lorazepam, oxazepam); (2) SSRIs (paroxetine and escitalopram); (3) duloxetine and extended-release venlafaxine; and (4) buspirone. To some extent, the beta-adrenergic blocking agents (see Chapter 12) are also used. Although the antihistamine hydroxyzine is infrequently prescribed, it may be an option in patients with a substance abuse disorder. Panic disorders may be treated with a variety of agents in addition to behavioral therapy. Alprazolam and clonazepam (benzodiazepines), as well as sertraline, paroxetine, and uoxetine (SSRIs), are approved by the FDA for the treatment of panic disorder. Other agents that show benet are the tricyclic antidepressants desipramine and clomipramine, as well as mirtazapine (see Chapter 16). Phobias are treated with the use of avoidance, behavior therapy, and benzodiazepines or beta-adrenergic blockers such as propranolol or atenolol. Obsessive-compulsive and related disorders are treated with behavioral and psychosocial therapy in addition to paroxetine, sertraline, uoxetine, or uvoxamine. NURSING IMPLICATIONS FOR ANTIANXIETY THERAPY Assessment History of behavior Obtain a history of the precipitating factors that may have triggered or contributed to the individual’s current anxiety. Has the individual been using alcohol or drugs? Has the patient had a recent adverse event, such as a job or relationship loss, the death of a loved one, or a divorce? Has the individual witnessed or survived a traumatic event? Does the individual have any medical problems (e.g., hyperthyroidism) that could be related to these symptoms? Are there symptoms present that could be attributed to a panic attack, such as a feeling of choking, palpitations, sweating, chest pain or discomfort, nausea, abdominal distress, or fear of losing control, going crazy, or dying? Does the patient have symptoms of obsessions or compulsions? Does the individual have a history of agoraphobia (i.e., situations in which they feel trapped or unable to escape)? Did the attack occur in response to a social or performance situation? Is the patient also depressed? What specic fears does the individual have? Take a detailed history of all medications that the individual is taking. Is there any use of central nervous system (CNS) stimulants (e.g., cocaine,

amphetamines) or CNS depressants (e.g., sedatives, opioids, alcohol)? Adverse effects of medications being taken may be aggravating the patient’s anxiety level. Ask for details regarding how long the individual has been exhibiting anxiety. Has the patient been treated for anxiety previously? When did the symptoms start? Did they begin during intoxication or withdrawal from a substance? Basic mental status Note the patient’s general ap-

pearance and appropriateness of attire. Is the individual clean and neat? Is the posture stooped, erect, or slumped? Is the patient oriented to date, time, place, and person? Determine whether the patient is at risk for harming herself or himself or others. Are they able to participate in self-directed activities of daily living, including eating and providing the self-care that is required to sustain life? These areas are regularly assessed to determine whether acute hospitalization is indicated. Otherwise, the outpatient setting is the most common setting for the treatment of anxiety disorders. What coping mechanisms has the individual been using to deal with the situation? Are these mechanisms adaptive or maladaptive? Identify the individual’s ability to understand new information, follow directions, and provide self-care. Identify events that trigger anxiety in the individual. Discuss the patient’s behavior and thoughts, and foster an understanding of this with their family members. Involve the family and signicant others in the discussion of the anxiety-producing events or circumstances, and explain how these individuals can help the patient to reduce anxiety or cope more adaptively with stressors. Identify support groups. Mood and affect Is the individual tearful, excessively

excited, angry, hostile, or apathetic? Is the facial expression tense, fearful, sad, angry, or blank? Ask the patient to describe their feelings. Is there worry about real-life problems? Are the patient’s responses displayed as an intense fear, detachment, or absence of emotions? If the patient is a child, are there episodes of tantrums or clinging? Patients who are experiencing altered thinking, behavior, or feelings require the careful evaluation of their verbal and nonverbal actions. Often, the thoughts, feelings, and behaviors that are displayed are inconsistent with the so-called normal responses of individuals in similar circumstances. Identify management techniques for handling anxiety-producing situations effectively. Assess whether the mood being described is consistent with or appropriate for the circumstances being described. For example, is the patient speaking of death while smiling?

Drugs Used for Anxiety Disorders CHAPTER 15

Clarity of thought Evaluate the coherency, relevancy,

and organization of the patient’s thoughts. Ask specic questions about the individual’s ability to make judgments and decisions. Is there any memory impairment? Identify areas in which the patient is capable of having input into setting goals and making decisions. (This will help the patient to overcome a sense of powerlessness over certain life situations.) When the patient is unable to make decisions, set goals to involve the patient to the degree of their capability because abilities change with treatment. Psychomotor functions Ask specic questions regard-

ing the activity level that the patient has maintained. Is the patient able to work or go to school? Is the patient able to fulll responsibilities at work, socially, or within the family? How have the patient’s normal responses to daily activities been altered? Is the individual irritable, angry, easily startled, or hypervigilant? Observe the patient for unusual gestures, hand tremors, voice quivering, and actions such as pacing or the inability to sit still. Obsessions or compulsions Does the individual ex-

perience persistent thoughts, images, or ideas that are inappropriate and cause increased anxiety? Are there repetitive physical or mental behaviors, such as handwashing, needing to arrange things in perfect symmetric order, praying, or silently repeating words? If obsessions or compulsions are present, how often do these occur? Do the obsessions or compulsions impair the patient’s social or occupational functioning? Sleep pattern What is the patient’s normal sleep pat-

tern, and how has it varied since the onset of the symptoms? Ask specically whether insomnia is present. Ask the individual to describe the amount and quality of the sleep. What is the degree of fatigue that is present? Is the individual having recurrent stressful dreams (e.g., after a traumatic event)? Is there difculty falling or staying asleep? Dietary history Ask questions about the individual’s

appetite and note weight gains or losses not associated with intentional dieting. Implementation • Deal with problems as they occur; practice reality orientation. • Identify signs of escalating anxiety; decrease the escalation of anxiety. • Provide a safe, structured environment for the release of energy; set limits on aggressive or destructive behaviors. • Establish a trusting relationship with the patient by providing support and reassurance. • Reduce stimulation by having interactions with the patient in a quiet, calm environment. Provide a

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nonstimulating environment for patients who are having sleeping difculties (e.g., dim lighting, quiet area) that will encourage drowsiness and sleep. • Provide an opportunity for the individual to express their feelings. Use active listening and therapeutic communication techniques. Be especially aware of cues that would indicate that the patient may be considering self-harm. (If suicidal ideation is suspected, ask the patient directly if suicide is being considered. If necessary, intervene to provide for safety.) Allow the patient to make decisions of which they are capable, make decisions when the patient is not capable, and provide a reward for progress when decisions are initiated appropriately. Involve the patient in self-care activities. During periods of severe anxiety or during escalating anxiety, the individual may be unable to have insight or to make decisions appropriately. Encourage the individual to develop coping skills with the use of various techniques, such as rehearsing or role-playing responses to threatening stressors. Have the individual practice problem solving, and discuss the possible consequences of the solutions that are offered by the patient. Assist individuals with nonpharmacologic measures, such as music therapy, relaxation techniques, or massage therapy. Patient Education For those patients who are attending an outpatient clinic or hospitalized, orient the individual to the unit and the rules of the unit. Explain the process of privileges and how they are obtained or lost. (The extent of the orientation and explanations given will depend on the individual’s orientation to date, time, place, and abilities.) Explain activity groups and resources that are available within the community. A variety of group process activities (e.g., social skills groups, selfesteem groups, work-related groups, physical exercise groups) exist in particular therapeutic settings. Meditation, biofeedback, and relaxation therapy may also be benecial. Involve the patient and their family in goal setting, and integrate them into the available group processes to develop positive experiences for the individual to enhance their coping skills. Patient education should be individualized and based on assessment data to provide the individual with a structured environment in which to grow and enhance self-esteem. Initially, the individual may not be capable of understanding lengthy explanations; therefore the approaches used should be based on the patient’s capabilities. Explore the coping mechanisms that the patient uses in response to stressors, and identify methods of channeling these toward positive realistic goals as an alternative to the use of medication.

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UNIT III Drugs Affecting the Autonomic and Central Nervous System

Fostering health maintenance Throughout the course

of treatment, discuss medication information and how the medication will benet the patient. Stress the importance of the nonpharmacologic interventions and the long-term effects that compliance with the treatment regimen can provide. Additional health teaching and nursing interventions for adverse effects are described in the drug monographs later in this chapter. Seek cooperation and understanding regarding the following points so that medication compliance is increased: the name of the medication; its dosage, route, and times of administration; and its adverse effects. Instruct the patient not to suddenly discontinue prescribed medications after having been on longterm therapy. Withdrawal should be undertaken with instructions from a healthcare provider, and it usually requires 4 weeks of gradual reduction in dosage and widening the intervals of administration. Patient self-assessment Enlist the patient’s help with

developing and maintaining a written record of monitoring parameters (see the Patient Self-Assessment Form for Antianxiety Medication on the Evolve website). Complete the Premedication Data column for use as a baseline to track patient response to drug therapy. Ensure that the patient understands how to use the form, and instruct the patient to bring the completed form to follow-up visits. During follow-up visits, focus on issues that will foster adherence with the therapeutic interventions that have been prescribed.

DRUG CLASS: BENZODIAZEPINES Benzodiazepines are most commonly used because they are more consistently effective, are less likely to interact with other drugs, are less likely to cause overdose, and have less potential for abuse than other antianxiety agents. They account for perhaps 75% of the 100 million prescriptions that are written annually for anxiety. Six benzodiazepine derivatives are used as antianxiety agents (Table 15.1). Actions It is thought that the benzodiazepines have mechanisms of action similar to CNS depressants, but individual drugs in the benzodiazepine family act more selectively at specic sites, which allows for a variety of uses (e.g., sedative-hypnotic, muscle relaxant, antianxiety agent, anticonvulsant). The benzodiazepines reduce anxiety by binding to alpha-2 sites of the GABA-A receptor to stimulate the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). (See Chapter 13 for more discussion of the actions of benzodiazepines.) In patients with reduced hepatic function or in older adults, lorazepam and oxazepam may be most appropriate because they have a relatively short duration of action and no active metabolites. The other

benzodiazepines all have active metabolites that signicantly prolong the duration of action and that may accumulate to the point of excessive adverse effects with chronic administration. Uses Patients with anxiety reactions to recent events and those with treatable medical illnesses that induce anxiety respond most readily to benzodiazepine therapy. In general, benzodiazepines are equally effective for the treatment of anxiety. Patients generally respond to therapy within 1 week. Because all benzodiazepines have similar mechanisms of action, the selection of the appropriate derivative depends on how the benzodiazepine is metabolized (see Actions previously). Oxazepam, lorazepam, chlordiazepoxide, diazepam, and clorazepate are used for the treatment of anxiety associated with alcohol withdrawal. Oxazepam and lorazepam are the drugs of choice in patients with severe liver impairment because they have no active metabolites. Sometimes a long-acting benzodiazepine with active metabolites (e.g., diazepam or chlordiazepoxide) is preferred because they seem to result in a smoother clinical course with lower chance of recurrent withdrawal or seizures. However, their use is somewhat limited for patients who cannot tolerate oral administration as a result of nausea and vomiting. Diazepam or lorazepam may be administered intramuscularly in this case (see Chapter 48). Use of benzodiazepines during pregnancy, whether for anxiety (see Table 15.1) or for sedation (see Table 13.1), should be avoided. Benzodiazepines are pregnancy category D and X. Animal studies indicate the possibility of increased risk of congenital malformations if prescribed in the rst trimester of pregnancy. Benzodiazepines are also not recommended for breastfeeding mothers. The benzodiazepines transfer to breast milk and can accumulate in breast-fed infants, acting as a sedative. Therapeutic Outcome The primary therapeutic outcome expected from the benzodiazepine antianxiety agents is a decrease in the level of anxiety to a manageable level (i.e., coping is improved; physical signs of anxiety such as a look of anxiety, tremor, and pacing are reduced). Nursing Implications for Benzodiazepines Premedication assessment

1. Record baseline data regarding the level of anxiety that is present. 2. Record the patient’s baseline vital signs, particularly blood pressure in both the sitting and supine positions. 3. Check for a history of blood dyscrasias or hepatic disease. 4. Determine whether the individual is pregnant or breastfeeding.

Drugs Used for Anxiety Disorders CHAPTER 15

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Table 15.1 Benzodiazepines Used to Treat Anxiety GENERIC NAME alprazolam

INITIAL DOSAGE RANGE (PO) 0.25–0.5 mg three times daily

MAXIMUM DAILY DOSAGE RANGE 4 mg for anxiety management 10 mg for panic disorder

Tablets, extended release, 24 hr: 0.5, 1, 2, 3 mg

0.5–1 mg daily

10 mg maximum for extended-release tablets; usual range is 3–6 mg daily

Capsules: 5, 10, 25 mg

5–10 mg three or four times daily

100 mg

BRAND NAME Xanax Apo-Alpraz Do not confuse Xanax with Zantac or Zyrtec.

AVAILABILITY Tablets: 0.25, 0.5, 1, 2 mg Tablets, orally disintegrating: 0.25, 0.5, 1, 2 mg Solution: 1 mg/mL

Xanax XR

chlordiazepoxide Do not confuse chlordiazepoxide with chlorpromazine. clorazepate

Tranxene T

Tablets: 3.75, 7.5, 15 mg

10 mg once to three times daily

60 mg

diazepam Do not confuse diazepam with Ditropan.

Valium BIO-Diazepam Do not confuse Valium with valerian.

Tablets: 2, 5, 10 mg Liquid: 5 mg/5 mL Concentrate: 5 mg/mL Injection: 5 mg/mL in 2-mL prelled syringe Rectal gel: 2.5, 10, 20 mg/ rectal delivery system

2–10 mg two to four times daily

—

lorazepam Do not confuse lorazepam with loperamide.

Ativan Apo-Lorazepam Do not confuse Ativan with Ambien or Atarax.

Tablets: 0.5, 1, 2 mg Liquid: 2 mg/mL Injection: 2, 4 mg/mL in 1-, 10-mL vials

2–3 mg divided two or three times daily

10 mg

oxazepam

— Apo-oxazepam

Capsules: 10, 15, 30 mg

10–15 mg three or four times daily

120 mg

Available in Canada. Do not confuse. High-alert medication.

Availability, dosage, and administration. See Table 15.1.

Use of benzodiazepines may result in physical and psychological dependence when taken steadily for several days to weeks, even when taken in recommended dosages. Abuse and misuse can result in overdose or death, especially when benzodiazepines are combined with other medicines, such as opioid pain relievers, alcohol or illicit drugs, and CNS depressants (e.g., sedatives, hypnotics, muscle relaxants). The rapid discontinuance of benzodiazepines after long-term use may result in symptoms that are similar to those of alcohol withdrawal, such as weakness, anxiety, delirium, and tonic-conic (grand mal) seizures. These symptoms may not appear for several days after discontinuation. Discontinuation of benzodiazepines consists of gradual withdrawal over 2 to 4 weeks. Pregnancy and lactation. It is recommended that benzodiazepines not be administered during at least the rst trimester of pregnancy. There may be an increased incidence of birth defects because these agents readily cross the placenta and enter the fetal circulation. If benzodiazepines are taken regularly during pregnancy, the

infant should be monitored closely after delivery for signs of withdrawal, including sedation and hypotonia. Mothers who are breastfeeding should not receive benzodiazepines regularly. The benzodiazepines readily cross into the breast milk and exert a pharmacologic effect on the infant. Common adverse effects

Neurologic Drowsiness, hangover, sedation, lethargy. Patients may complain of morning hangover, blurred vision, and transient hypotension on arising. Explain to the patient the need for rising rst to a sitting position for several moments until any dizziness or lightheadedness passes and then standing slowly. Assist the individual with ambulation, if necessary. If hangover becomes troublesome, the dosage should be reduced, the medication changed, or both. People who work around machinery, drive, administer medication, or perform other duties for which they must remain mentally alert should not take these medications while working.

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UNIT III Drugs Affecting the Autonomic and Central Nervous System

Serious adverse effects

Psychological Excessive use or abuse. Habitual benzodiazepine use may result in physical dependence. Discuss the case with the healthcare provider and make plans to cooperatively approach the gradual withdrawal of the medications that are being abused. Assist the patient with recognizing the abuse problem. Identify underlying needs and plan for the more appropriate management of those needs. Provide emotional support of the individual, display an accepting attitude, and be kind but rm. Hematologic Blood dyscrasias. Routine laboratory studies (e.g., red blood cell and white blood cell counts, differential counts) should be scheduled. Stress the patient’s need to return for these tests. Monitor the patient for sore throat, fever, purpura, jaundice, or excessive and progressive weakness. Gastrointestinal Hepatotoxicity. The symptoms of hepatotoxicity are anorexia, nausea, vomiting, jaundice, hepatomegaly, splenomegaly, and abnormal liver function tests (e.g., elevated bilirubin, aspartate aminotransferase [AST], alanine aminotransferase [ALT], gamma-glutamyltransferase [GGT], and alkaline phosphatase [ALP] levels; increased prothrombin time [PT]). Drug interactions

Antihistamines, alcohol, analgesics, anesthetics, probenecid, tranquilizers, opioids, cimetidine, other sedativehypnotics. All these agents increase the toxic effects of benzodiazepines and may cause excessive sedation and impaired psychomotor function. Oral contraceptives, cimetidine, uoxetine, metoprolol, propranolol, isoniazid, ketoconazole, valproic acid. These agents inhibit the metabolism of alprazolam, chlordiazepoxide, clonazepam, and diazepam. Pharmacologic effects of the benzodiazepines may be increased, and excessive sedation and impaired psychomotor function may result. Smoking, rifampin. Smoking and rifampin enhance the metabolism of benzodiazepines. Larger doses may be necessary to maintain anxiolytic effects in patients who smoke.

DRUG CLASS: AZASPIRONES buspirone (byū-SPĪ-rōn) Do not confuse buspirone with bupropion.

Actions Buspirone is an antianxiety agent that comes from the chemical class known as the azaspirones, which are chemically unrelated to benzodiazepines or other anxiolytic agents. The mechanism of action of buspirone is not fully understood. It is a partial serotonin and dopamine agonist, and it interacts in several ways with nerve systems in the midbrain; therefore it is

sometimes called a midbrain modulator. It does not affect GABA receptors. Its advantages over other antianxiety agents are that it has lower sedative properties and it does not alter psychomotor functioning. It requires 7 to 10 days of treatment before initial signs of improvement are evident, and it takes 3 to 4 weeks of therapy for optimal effects to occur. Uses Buspirone is approved for use in the treatment of generalized anxiety disorders and for the short-term relief of the symptoms of anxiety. Buspirone has no antipsychotic activity, and it should not be used in place of appropriate psychiatric treatment. Because there is minimal potential for abuse with buspirone, it is not a controlled substance. Therapeutic Outcome The primary therapeutic outcome expected from buspirone is a decrease in the level of anxiety to a manageable level (i.e., coping is improved; physical signs of anxiety such as a look of anxiety, tremor, and pacing are reduced). Nursing Implications for Buspirone Therapy Premedication assessment. Record baseline data regarding the level of anxiety present. Availability. PO: Tablets: 5, 7.5, 10, 15, and 30 mg.

Schedule assessments periodically throughout therapy for the development of slurred speech or dizziness, which are signs of excessive dosing. Dosage and administration. Adult: PO: Initially, 5 mg

two to three times daily. Doses may be increased by 5 mg every 2 to 3 days. Maintenance therapy often requires 30 mg daily in divided doses. Do not exceed 60 mg daily. Common adverse effects

Neurologic Sedation, lethargy. The most common adverse effects of buspirone therapy are CNS disturbances (3.4%), which include dizziness, insomnia, nervousness, drowsiness, and lightheadedness. People who work around machinery or who perform other duties for which they must remain mentally alert should not take this medication while working. Slurred speech and dizziness are signs of excessive dosing. Report to the healthcare provider for further evaluation. Provide patient safety during these episodes. Drug interactions

Itraconazole, erythromycin, clarithromycin, diltiazem, verapamil, uvoxamine, grapefruit juice. These substances potentiate the toxicity of buspirone by inhibiting its metabolism. If any of these are used together, the dose of buspirone should be reduced by half for a few weeks and then adjusted as needed.

Drugs Used for Anxiety Disorders CHAPTER 15

Rifampin, phenytoin, phenobarbital, carbamazepine. These drugs enhance the metabolism of buspirone. An increase in the dose of buspirone may be needed. Alcohol. Buspirone and alcohol generally do not have additive CNS depressant effects, but individual patients may be susceptible to impairment. Tell patients to use alcohol with extreme caution.

DRUG CLASS: SELECTIVE SEROTONIN REUPTAKE INHIBITORS uvoxamine (ū-VŎKS-ă-mēn) Do not confuse uvoxamine with uoxetine. Luvox Do not confuse Luvox with Lasix, Levoxyl, or Lovenox.

Actions Fluvoxamine inhibits the reuptake of serotonin at nerve endings, thus prolonging serotonin activity. Uses Fluvoxamine is used for the treatment of OCRDs when obsessions or compulsions cause marked distress, are time consuming, or interfere substantially with social or occupational responsibilities. Fluvoxamine reduces the symptoms of these disorders but does not prevent obsessions and compulsions. However, patients indicate that the obsessions are less intrusive and that they have more control over them. Therapeutic Outcome The primary therapeutic outcome expected from uvoxamine is a decrease in the level of anxiety to a manageable level (i.e., coping with obsession is improved; frequency of compulsive activity is reduced). Nursing Implications for Fluvoxamine Therapy See Serotonin-Norepinephrine Reuptake Inhibitors section in Chapter 16

DRUG CLASS: MISCELLANEOUS ANTIANXIETY AGENTS hydroxyzine (hī-DRŎKS-ĭ-zēn) Do not confuse hydroxyzine with hydroxyurea. Vistaril (VĬS-tă-rĭl) Do not confuse Vistaril with Restoril or Zestril.

Actions When dened strictly by chemical structure, hydroxyzine is considered an antihistamine. It acts within the CNS to produce sedation and antiemetic, anticholinergic, antihistaminic, antianxiety, and antispasmodic activity, thus making it a somewhat multipurpose agent.

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Uses Hydroxyzine is used as a mild tranquilizer for psychiatric conditions that are characterized by anxiety, tension, and agitation. It is also occasionally used as a preoperative or postoperative sedative to control vomiting, diminish anxiety, and reduce the amount of opioids that are needed for analgesia. Hydroxyzine may also be used as an antipruritic agent to relieve the itching that is associated with allergic reactions. Therapeutic Outcomes The primary therapeutic outcomes expected from hydroxyzine are as follows: 1. A decrease in the level of anxiety to a manageable level (i.e., coping is improved; physical signs of anxiety such as a look of anxiety, tremor, and pacing are reduced) 2. Sedation, relaxation, and reduction in analgesics before and after surgery 3. Absence of vomiting when used as an antiemetic 4. Itching controlled during allergic reactions Nursing Implications for Hydroxyzine Therapy Premedication assessment

1. Perform a baseline assessment of anxiety symptoms. 2. Determine the patient’s level of anxiety present before and after surgical intervention; record and intervene appropriately. 3. For nausea and vomiting, administer when nausea rst starts and determine the effectiveness of control before giving subsequent doses. 4. For allergic reactions, perform a baseline assessment of physical symptoms before administering the dose; repeat this assessment before the administration of subsequent doses to determine the medication’s effectiveness. 5. Monitor the patient for the level of sedation present, slurred speech, or dizziness; report to the healthcare provider if these symptoms are excessive before administering repeat doses. Availability. PO: 10-, 25-, and 50-mg tablets; 25-, 50-,

and 100-mg capsules; 10 mg/5 mL syrup. IM: 25 and 50 mg/mL. Dosage and administration. Adult:

• Antianxiety: PO: 25 to 100 mg three or four times daily; IM: 50 to 100 mg every 4 to 6 hours • Preoperatively and postoperatively: IM: 25 to 100 mg • Antiemetic: IM: 25 to 100 mg Common adverse effects. These symptoms are the anti-

cholinergic effects that are produced by hydroxyzine. Patients who are taking these medications should be monitored for the development of these adverse effects.

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UNIT III Drugs Affecting the Autonomic and Central Nervous System

Sensory Blurred vision. Caution the patient that blurred vision may occur and make appropriate suggestions for personal safety. Gastrointestinal Constipation; dryness of the mucosa of the mouth, throat, and nose. Mucosal dryness may be relieved by sucking hard candy or ice chips or by chewing gum. The use of stool softeners (e.g., docusate) may be required for constipation. Neurologic Sedation, slurred speech, dizziness. People who work around machinery, drive, administer medication, or

perform other duties for which they must remain mentally alert should not take these medications while working. Slurred speech and dizziness are signs of excessive dosing. Report to the healthcare provider for further evaluation. Provide patient safety during these episodes. Drug interactions

Antihistamines, alcohol, analgesics, anesthetics, tranquilizers, opioids, other sedative-hypnotics. These all are agents that can increase toxic effects. Monitor the patient for excessive sedation, and reduce the dosage of hydroxyzine if necessary.

Clinical Judgment and Next-Generation NCLEX ® Examination-Style Questions Key Points • Anxiety is an unpleasant feeling of apprehension or nervousness that is caused by the perception of danger threatening the patient’s security. In most cases, it is a normal human emotion. • When a patient’s response to anxiety is irrational and impairs their daily functioning, they are said to have an anxiety disorder. Some 16% of the general population will experience an anxiety disorder during their lifetime. • The most common types of anxiety disorders are generalized anxiety disorder, panic disorder, social phobia, simple phobia, and obsessive-compulsive disorder. • Anxiety is a component of many medical illnesses that involve the cardiovascular, pulmonary, digestive, and endocrine systems. It is also a primary symptom of many psychiatric disorders. Therefore the evaluation of the anxious patient requires a thorough history and physical and psychiatric examination to determine whether the anxiety is the primary condition or secondary to another illness. Persistent irrational anxiety or episodic anxiety usually requires medical and psychiatric treatment. • The treatment of anxiety disorders usually requires a combination of pharmacologic and nonpharmacologic therapies. • It is the responsibility of the nurse to educate patients about their therapy, to monitor for therapeutic benets and common and serious adverse effects, and to intervene whenever possible to optimize therapeutic outcomes.

Additional Learning Resources

SG

Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/ Willihnganz) for additional online resources.

Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types.

Scenario A patient admitted to the mental health unit following a panic attack that lasted longer than 15 minutes was advised to come in for medication adjustment. 1. Identify the type of behavior the patient may be exhibiting with each cue. Indicate with an X in the box that gives an example of the behavior.

Counts the number of steps that it takes to walk to the car Phobic disorder Generalized anxiety disorder Obsessivecompulsive and related disorder Panic disorder

Excessive and unrealistic worry about grades as a student

Declines getting into the MRI machine, feeling too conned

Suddenly feeling lightheaded and seeing spots, then fainting during a course examination

Drugs Used for Anxiety Disorders CHAPTER 15

Objective: Compare and contrast the differences between generalized anxiety disorder, panic disorder, phobias, and obsessive-compulsive disorder. NGN test item: Matrix Cognitive skill: Analysis cues 2. A nurse performing a baseline mental status assessment on the patient in the scenario will include which of the following details? (Select all that apply.) 1. 2. 3. 4. 5.

General appearance and appropriateness of attire Clarity of thought Mood and affect Obsessions or compulsions Job history

Objective: Describe the essential components included in a baseline assessment of a patient’s mental status. NCLEX item type: Multiple response Cognitive skill: Application 3. The nurse caring for the patient in the scenario with an anxiety disorder knows that certain drugs can be used for treatment of anxiety disorders. Using an arrow, match the drug class used in the treatment of the specic anxiety disorder.

DRUG CLASS USED FOR ANXIETY • Azaspirones • Selective serotonin reuptake inhibitors • Benzodiazepines

ANXIETY DISORDERS • GAD • Panic disorders • OCD • Phobias

Objective: Discuss the drug therapy used to treat anxiety disorders. NCLEX item type: Drop and drag Cognitive skill: Comprehension 4. The nurse will monitor which of these laboratory values to determine whether there are any adverse effects for the patient in the scenario who is receiving a benzodiazepine for anxiety? 1. 2. 3. 4. 5. 6. 7. 8.

Complete blood cell count with differential Thyroid function Lipid panel Blood glucose Liver function Renal function Biochemical prole Electrolytes

237

Objective: Identify adverse effects that may result from drug therapy used to treat anxiety. NCLEX item type: Extended multiple response Cognitive skill: Analyze cues 5. The patient in the scenario was prescribed Ativan and is now exhibiting possible adverse effects. The nurse evaluates these symptoms. For each symptom mark an X to indicate whether the nding is signicant for an adverse effect associated with Ativan or is an unrelated nding.

SYMPTOMS

SIGNIFICANT FINDING

UNRELATED FINDING

Lightheadedness Morning hangover Blurred vision Excessive thirst Urinary retention Tired during the day

Objective: Identify adverse effects that may result from drug therapy used to treat anxiety. NCLEX item type: Matrix Cognitive skill: Evaluate outcomes 6. After discussing with the patient and the family the drug management of lorazepam (Ativan) for anxiety, the nurse knows further teaching is needed after the patient makes which statement? 1. “I know that I need to avoid drinking any alcohol while taking this Ativan.” 2. “I understand that this drug may make me drowsy during the day and I should not work around machinery while taking it.” 3. “I understand that I can stop the drug at any time that I feel I do not need it anymore.” 4. “I know that Ativan will start to work within a week.” Objective: Discuss psychological and physiologic drug dependence. NCLEX item type: Multiple choice Cognitive skill: Comprehension

16

Drugs Used for Depressive and Bipolar Disorders

https://evolve.elsevier.com/Willihnganz

Objectives 1. Describe the essential components of the baseline assessment of a patient with depression or bipolar disorder. 2. Identify the premedication assessments that are necessary before the administration of monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and antimanic agents.

3. Describe the common adverse effects that may develop for patients who are taking MAOIs. 4. Describe the common adverse effects that may develop for patients who are taking SSRIs and SNRIs. 5. Describe the common adverse effects that may develop for patients who are taking TCAs. 6. Describe the common adverse effects that may develop for patients who are taking lithium.

Key Terms mood (MŪD) (p. 238) mood disorder (MŪD dĭs-ŌR-dŭr) (p. 238) neurotransmitters (nū-rō-TRĂNZ-mĭtŭrz) (p. 239) dysthymia (dĭs-THĬ-mē-ă) (p. 239) depression (dē-PRĔSH-ŭn) (p. 239)

cognitive symptoms (KŎG-nĭ-tĭv) (p. 239) psychomotor symptoms (sī-kō-MŌtŭr) (p. 239) bipolar disorder (bī-PŌ-lăr) (p. 239) mania (MĀ-nē-ă) (p. 239) euphoria (yū-FŎR-ē-ă) (p. 240) labile mood (LĀ-bīl) (p. 240)

DEPRESSIVE AND BIPOLAR DISORDERS The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), recognizes ajor sychiatric isorers on a continuu, with eressive isorers an sychotic sectru at the ens of the continuu an with biolar isorers serving as a brige between the two iagnostic classes in ters of sytoatology, faily history, an genetics. The coon feature aong eressive an biolar isorers is the resence of sa, ety, or irritable oo, accoanie by changes that signicantly affect the iniviual’s caacity to function. Duration, tiing, an assue etiology are what iffer between the isorers (DSM-5). Mood is a sustaine eotional feeling erceive along a noral continuu of sa to hay that affects our ercetion of our surrounings. A mood dis order (or affective isorer) is resent when certain sytos iair a erson’s ability to function for a tie. Moo isorers are characterize by abnoral feelings of eression or euhoria. They involve the rolonge an inaroriate exression of eotion that goes beyon brief eotional uset fro negative life exeriences. In severe cases, other sychotic features ay also be resent. About 15% to 20% of the 238

grandiose delusions (GRĂN-dē-ōs dĕ-LŪ-zhŭnz) (p. 240) cyclothymia (sī-klō-THĬ-mē-ă) (p. 240) suicidal ideation (sū-ĭ-SĪ-dĕl ī-dē-Āshĕn) (p. 240) antidepressants (ăn-tī-dē-PRĔS-ăntz) (p. 241)

US oulation will have a iagnosable oo isorer uring their lifetie. In Mental Health: A Report of the Surgeon General (U.S. Deartent of Health an Huan Services, 1999) it was recognize that the effect of ental illness on health an rouctivity has been rofounly unerestiate. Major eression currently ranks as the secon leaing cause of isease buren (i.e., years live with the isability) in the Unite States; the leaing cause is ischeic heart isease. Unfortunately, the ajority of eole with eression receive no treatent. Unertreatent of oo isorers stes fro any factors, incluing social stiga, nancial barriers, unerrecognition by healthcare roviers, an unerareciation by the general ublic of the otential benets of treatent. The sytos of eression, such as feelings of worthlessness, excessive guilt, an lack of otivation, eter eole fro seeking treatent. Mebers of racial an ethnic inority grous often encounter aitional barriers. The unerlying causes of oo isorers are still unknown. They are too colex to be coletely exlaine by a single social, eveloental, or biologic theory. A variety of factors aear to work together to

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

cause eressive isorers. It is known that atients with eression have changes in the brain neuro transmitters noreinehrine, serotonin, oaine, acetylcholine, an gaa-ainobutyric aci, but other unexecte negative life events (e.g., the suen eath of a love one, uneloyent, eical illness, other stressful events) also lay a role. Enocrine abnoralities, such as excessive secretion of cortisol an abnoral thyroi-stiulating horone, have been foun in 45% to 60% of atients with eression. Genetic factors also reisose atients to eveloing eression. Deressive isorers an suicie ten to cluster in failies, an relatives of atients with eression are two to three ties ore likely to evelo eression. Meicines being taken for other iseases ay also contribute to eression, incluing antihyertensives (e.g., ethyloa, cloniine, betaarenergic blocking agents), antiarkinsonian eicines (e.g., levooa), an horones (e.g., estrogens, rogestins, corticosterois).

DEPRESSIVE DISORDER Major eressive isorer (MDD) an ysthyia are known as unipolar disorders, anifeste by varying egrees of eression. Patients with MDD exerience one or ore secic eisoes of eression, whereas atients with dysthymia suffer fro ore chronic, ongoing sytos of eression that last for at least 2 years. The onset of a eressive isorer tens to occur uring the late 20s, although it can occur at any age. The lifetie frequency of eressive sytos aears to be as high as 26% for woen an 12% for en. Risk factors for eression inclue a ersonal or faily history of eression, rior suicie attets, feale gener, lack of social suort, stressful life events, substance abuse, an eical illness. The Aerican Psychiatric Association classies eisoes of eression as il, oerate, an severe. Mil eression causes only inor functional iairent. Moerate eression involves an intereiate egree of iairent an affects both sytoatology an functionality. Patients with severe eression have several sytos that excee the iniu iagnostic criteria an aily functioning is signicantly iaire; hositalization ay be require. It is beyon the scoe of this text to iscuss oo isorers in etail, but this iscussion escribes general tyes of sytos associate with oo isorers. Patients exeriencing depression islay varying egrees of eotional, hysical, cognitive, an sychootor sytos. Eotionally, the eression is characterize by a ersistent, reuce ability to exerience leasure in life’s usual activities, such as hobbies, faily, an work. Patients frequently aear sa, an a ersonality change is coon. They ay escribe their oo as sa, hoeless, or blue. Patients often feel

239

that they have let others own, although these feelings of guilt are unrealistic. Anxiety sytos (see Chater 15) are resent in alost 90% of eresse atients. Physical sytos often otivate the erson to seek eical attention. Coon hysical sytos seen in atients with eression inclue chronic fatigue, slee isturbances such as frequent early orning awakening (terinal insonia), aetite isturbances (weight loss or gain), an other sytos such as stoach colaints or heart alitations. Cognitive symptoms, such as the inability to concentrate, slowe thinking, confusion, an oor eory of recent events, are articularly coon in oler atients with eression. Psychomotor symptoms of eression inclue slowe or retare oveents, thought rocesses, an seech or, conversely, agitation anifesting as uroseless, restless otion (e.g., acing, han wringing, outbursts of shouting). Coorbi conitions such as substancerelate isorers, anic isorer, obsessive-coulsive an relate isorers, an anorexia nervosa are coonly resent in atients with MDD.

Life Span Considerations Depression The patient and caregivers must understand the importance of continuing to take the prescribed antidepressant medication despite a minimal initial response. The lag time of 1 to 4 weeks between the initiation of therapy and the therapeutic response must be emphasized. In most cases, the symptoms of depression may improve within a few days (e.g., improved appetite, sleep, psychomotor activity). However, the depression still exists, and monitoring should be continued for negative thoughts, feelings, and behaviors. Suicide precautions should be maintained until assessment indicates that suicidal ideation is no longer present. Suicide statistics are varied and not well documented. Adolescents and older adults with depression are more likely to have suicidal ideation, and older adults commit suicide more frequently than depressed people of other age groups. It appears that older adults are quite serious when attempting suicide because one in two attempts is successful. Suicide is the third leading cause of death in adolescents; the incidence may be even higher because of underreporting. Suicide is a call for help; however, it is permanent when successfully completed. All comments about suicide or suicide gestures should be taken seriously. Bipolar disorder (forerly known as manic depression) is characterize by istinct eisoes of mania (elation, euhoria) an eression searate by intervals without oo isturbances. The atient islays extree changes in oo, cognition, behavior, ercetion, an sensory exeriences. At any one tie, a atient with biolar isorer ay be anic or eresse, exhibit sytos of both ania an eression (ixe), or be between eisoes. Sytos of acute ania usually begin abrutly an escalate over several ays. These sytos

240

UNIT III Drugs Affecting the Autonomic and Central Nervous System

inclue a heightene oo (euphoria), quicker thoughts (ight of ieas), ore an faster seech (ressure seech), increase energy, increase hysical an ental activities (sychootor exciteent), ecrease nee for slee, irritability, heightene ercetual acuity, aranoia, increase sexual activity, an iulsivity. There is often a labile mood, with rai shifts towar anger an irritability. The attention san is short, resulting in an inability to concentrate. Anything in the environent ay change the toic of iscussion, leaing to ight of ieas. Social inhibitions are lost, an the atient ay becoe isrutive an lou, earting suenly fro the social interaction an leaving everything in isarray. As the anic hase rogresses, aroxiately two-thirs of atients with biolar isorer evelo sychotic sytos (see Chater 17), riarily aranoi or grandiose delu sions (the elusion that one has great talents or secial owers), if treatent interventions have not been initiate. Unfortunately, ost anic atients o not recognize the sytos of illness in theselves an ay resist treatent. Cyclothymia is a iler for of biolar illness characterize by eisoes of eression an hyoania that are not severe enough to eet the full criteria for biolar isorer, but the sytos of which last at least 2 years. Biolar isorer occurs equally in en an woen, with a revalence rate of 0.4% to 1.6% in the ault oulation of the Unite States. The onset of biolar isorer is usually uring late aolescence or the early 20s. It is rare before aolescence, an it ay occur as late as age 50. Aroxiately 60% to 80% of atients with biolar isease will begin with a anic eisoe. Without treatent, eisoes last fro 6 onths to a year for eression an for aroxiately 4 onths for ania. Patients with biolar isorer coonly have co-occurring conitions such as anxiety isorers (anic attacks, hobias, social anxiety), attention-ecit/ hyeractivity isorer, an substance use isorer (e.g., alcohol). Peole with eressive an biolar isorers have a high incience of atteting suicie. The frequency of successful suicie is 15%, which is 30 ties higher than that of the general oulation. All atients with eressive sytos shoul be assesse for suicial thoughts or suicidal ideation. Factors that increase the risk of suicie inclue increasing age, being wiowe, being unarrie, uneloyent, living alone, substance abuse, revious sychiatric aission, an feelings of hoelessness. The resence of a etaile lan with the intention an ability to carry it out inicate strong intent an a high risk for suicie. Other hints of otential suicial intent inclue changes in ersonality, a suen ecision to ake a will or give away ossessions, an the recent urchase of a gun or hoaring a large suly of eications, incluing antieressants, tranquilizers, or other toxic substances.

The rognosis for eressive an biolar isorers is highly variable. Of atients with ajor eression, 20% to 30% recover fully an o not exerience another bout of eression. Another 50% have recurring eisoes, often with a year or ore searating the events. The reaining 20% have a chronic course with ersistent sytos an social iairent. Most treate eisoes of eression last aroxiately 3 onths; untreate ones last 6 to 12 onths. Patients with biolar illness are ore likely to have ultile subsequent eisoes of sytos.

TREATMENT OF DEPRESSIVE AND BIPOLAR DISORDERS Moo isorers are treate with nonharacologic an haracologic theray. Cognitive behavior theray, sychoynaic theray, an interersonal theray with haracologic treatent have been ore successful than any one treatent alone. Psychotheray iroves sychosocial function, interersonal relationshis, an ay-to-ay coing. Patients an faily ebers shoul be taught to recognize the signs an sytos of ania, as well as those of eression, an the iortance of treatent coliance to iniize the recurrence of the illness shoul be stresse. Patients shoul be encourage to target sytos that hel the recognize oo changes an to seek treatent as soon as ossible. Most atients ass through three hases—acute, continuation, an aintenance—before full function is restore. The acute hase is the erio fro iagnosis to initial treatent resonse. The initial resonse occurs when the sytos becoe so signicantly reuce that the erson no longer ts the criteria for the illness. Meication resonse in the acute hase tyically takes 10 to 12 weeks, uring which tie the atient is seen by the healthcare rovier weekly or biweekly to onitor sytos an averse effects, to ake osage ajustents, an to rovie suort. Psychotheraies are initiate at the sae tie. Treatent of the acute hase is often rolonge because about half of atients becoe noncoliant with the eication an the sychotheray or abanon the rogra. The goals of the continuation hase of theray are to revent relase an to consoliate the initial resonse into a colete recovery (ene as being syto free for 6 onths). The continuation hase involves 4 to 9 onths of cobine haracotheray an sychotheray for atients with a rst eisoe of MDD. Maintenance-hase theray is recoene for iniviuals with a history of three or ore eressive eisoes, chronic eression, or biolar isorer. The goal of aintenance-hase theray is to revent recurrences of the oo isorer; atients ay receive haracologic an nonharacologic theray for this conition for a year or ore.

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

Nonharacologic treatent for eression an biolar illness is electroconvulsive theray (ECT). When erfore uner the guielines rovie by the Aerican Psychiatric Association, ECT is safe an effective for all subtyes of ajor eression an biolar isorers. It is ore effective, ore rai in onset of effect, an safer for atients with cariovascular isease than any rug theraies. A course of ECT usually consists of 6 to 12 treatents, but the nuber is iniviualize to the nees of the atient. Patients are now reeicate with anesthetics an neurouscular blocking agents to revent any of the averse effects reviously associate with ECT. Although it has been isuse, ECT shoul be viewe as a treatent otion that can be lifesaving for atients who otherwise woul not recover fro eressive illness. It is usually followe by rug theray to iniize the rate of relase.

DRUG THERAPY FOR DEPRESSIVE AND BIPOLAR DISORDERS ACTIONS Pharacologic treatent of eression is recoene for atients with sytos of oerate to severe eression, an it shoul be consiere for atients who o not reson well to sychotheray. Several classes of rugs, collectively known as antidepressants, are use for treatent. Patients iagnose with biolar isorer showing sytos of ania ay be treate haracologically with an antianic agent, lithiu (see Drug Class: Antianic Agent), valroate, or an atyical antisychotic agent (see Uses later). Antieressants can be subivie into four categories: 1. First-generation antieressants: onoaine oxiase inhibitors (MAOIs) an tricyclic antieressants (TCAs) 2. Secon-generation antieressants: selective serotonin reutake inhibitors (SSRIs) an serotoninnoreinehrine reutake inhibitors (SNRIs) 3. Miscellaneous agents: buroion, irtazaine, trazoone, vilazoone, an vortioxetine 4. N-ethyl-d-asartate (NMDA) antagonist (esketaine): for use in treatent of resistant eression an aults with MDD with suicial thoughts or actions The secon-generation antieressants have efcacy siilar to an lower toxicity with overose than the rst-generation antieressants, so they are recoene as rst-line agents. All antieressants excet esketaine have varying egrees of effects on noreinehrine, oaine, an serotonin by blocking reutake an reucing estruction of these neurotransitters, thereby rolonging their action. The eveloent of a clinical antieressant resonse requires at least 2 to 4 weeks of theray at

241

aequate osages. In general, the antieressant use for theray shoul be change if there is no clear effect within 4 to 6 weeks. Patients not resoning after two or ore trials of antieressant rugs are consiere to have treatent-resistant eression. Esketaine (Sravato), a raily acting rug, is arove for treatent-resistant eression in conjunction with an oral antieressant. It is also inicate for eressive sytos in aults with MDD with suicial thoughts or actions in conjunction with oral antieressants. Esketaine is an NMDA recetor antagonist. It is ainistere intranasally uner the suervision of a healthcare rovier. It ay increase bloo ressure an ay iair attention, jugent, an thinking. Because of the averse effects it ust be ainistere uner the suervision of a healthcare rovier, an it is only available through a restricte rogra. Although uch is known about the haracologic actions of antieressants, the exact echanis of action of these agents for treating eressive an biolar isorers is still unknown. However, it is now unerstoo that these isorers are not sily a eciency of neurotransitters, but very colex isorers associate with genetics, life stressors, an altere hysiologic athways in the brain. USES Two factors are iortant when selecting an antieressant rug: the atient’s history of resonse to reviously rescribe antieressants an the otential for averse effects associate with ifferent classes of antieressants. Contrary to arketing clais, there are no ifferences aong antieressant rugs (with the excetion of the MAOIs) in relative overall theraeutic efcacy an onset cause by full theraeutic osages. However, there are substantial ifferences in the averse effects cause by ifferent agents. It is not ossible to reict which rug will be the ost effective for an iniviual atient, but atients o show a better resonse to a secic rug, even within the sae class of rugs. About 30% of atients o not show areciable theraeutic benet with the rst agent use, but they ay have a high egree of success with a change in eication. The history of revious treatent is helful uring the selection of new treatent if illness returns. Aroxiately 65% to 70% of atients reson to antieressant theray, an 30% to 40% achieve reission. Theray is base on a atient’s history of revious resonse or the successful resonse of a rst-egree relative who resone to antieressant theray. Concurrent eical conitions such as obesity, seizure history, otential for ysrhythias, resence of anxiety, an otential for rug interactions ust also be consiere in theray selection. Certain tyes of oo isorers reson to eication ore reaily than others. Theraeutic success with TCAs an lithiu can be irove by onitoring an aintaining theraeutic seru levels

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UNIT III Drugs Affecting the Autonomic and Central Nervous System

an ajusting osages as neee. Seru levels of other classes of antieressants generally o not correlate well with success in theray, but they ay be helful to eterine whether the atient is ahering to the osage regien or suffering fro toxicities associate with higher seru levels. Recent changes in ractice guielines ehasize the nee for continuing rug theray for all atients; lifelong aintenance theray will be require for soe atients. The osages of continuance an aintenance theray ust also be the sae as the acute ose effective for eliinating eressive sytos. When atients are given lower aintenance osages, the risk of relase is signicantly greater than when oses are aintaine at acute ose levels. Antieressants increase the risk of suicial thinking an behavior (suiciality) in short-ter stuies of chilren an aolescents with MDD an other sychiatric isorers. Anyone consiering the use of an antieressant for a chil or an aolescent ust balance the risk with the clinical nee. When theray is starte, atients ust be closely observe for clinical worsening, suiciality, or unusual changes in behavior. Failies an caregivers nee to be avise about the nee for close observation an counication with the rescriber. Poole analyses of shortter (4 to 16 weeks) lacebo-controlle trials of nine antieressant rugs (SSRIs an others) in chilren an aolescents with MDD, obsessive-coulsive relate isorers, or other sychiatric isorers—a total of 24 trials involving ore than 4400 atients— have reveale a greater risk for averse reactions reresenting suicial thinking or behavior uring the rst few onths of treatent in those receiving antieressants. The average risk of such reactions in atients receiving antieressants was 4%, which was twice the lacebo risk of 2%. No suicies occurre uring these trials. Patients ust be counsele about execte theraeutic benets an averse effects to be tolerate because of antieressant theray. The hysiologic anifestations of eression (e.g., slee isturbance, change in aetite, loss of energy, fatigue, alitations) begin to be alleviate within the rst week of theray. The sychological sytos (e.g., eresse oo, lack of interest, social withrawal) will irove after 2 to 4 weeks of theray at an effective osage. Therefore it ay take 4 to 6 weeks to ajust the osage to otiize theray an to iniize averse effects. Unfortunately, soe averse effects evelo early in theray, an atients who are alreay essiistic because of their illness have a tenency to becoe noncoliant. The haracologic treatent of biolar isorer ust be iniviualize because the clinical resentation, severity, an frequency of eisoes vary wiely aong atients. Acute ania is initially treate with lithiu, valroate, or an atyical antisychotic

agent (e.g., olanzaine, riserione) as onotheray. Otions with the best evience to suort use as aintenance treatents inclue antisychotics, lithiu, an valroate; ossible alternatives inclue laotrigine, carbaazeine, or oxcarbazeine. NURSING IMPLICATIONS FOR MOOD DISORDER THERAPY Assessment History of mood disorder

• Obtain a history of the atient’s oo isorer. Is it eressive only, or are there both anic an eressive hases interserse with erios of noralcy? What reciitating factors contribute to the changes in oo? Is it associate with a articular season? How often o the eressive, noral, an anic oos ersist? Are there better or worse ties of ay? Has the atient been treate reviously for a oo isorer? What is the atient’s current status? Has the iniviual been using alcohol or rugs? Has there been a recent loss (e.g., job loss, en of a relationshi, eath of a love one)? • Obtain a etaile history of all eications that the iniviual is currently taking an those taken within the ast 2 onths to evaluate the atient’s aherence to the treatent regien. How coliant has the atient been with the treatent regien? Basic mental status

• Note the atient’s general aearance an aroriateness of attire. Is the iniviual clean an neat? Is the osture erect, stooe, or slue? Is the iniviual oriente to ate, tie, lace, an erson? • What coing echaniss have been use to eal with the oo isorer? How aative are these coing echaniss? If these coing echaniss are alaative, initiate changes by guiing the iniviual in the use of ore aative coing strategies. • Review stanarize instruents or tools colete by the atient, such as the Beck Deression Inventory II (Beck, Steer, an Brown, 1996), a wiely use assessent tool when screening for eression. Interpersonal relationships

• Assess the atient’s interersonal relationshis. Ientify eole in the atient’s life who are suortive. • Ientify whether interersonal relationshis have ecline between the atient an faily ebers, at work, or in social settings. Mood and affect

• Is the iniviual elate, overjoye, angry, irritable, crying, tearful, or sa? Is the facial exression tense, worrie, sa, angry, or blank? Ask the erson to

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

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escribe their feelings. Be alert for exressions of loneliness, aathy, worthlessness, or hoelessness. Moos ay change suenly. • Be brief, irect, an to the oint with atients exeriencing the anic hase who have becoe arguentative an aggressive. Setting liits will be necessary. Plan to aroach the iniviual in a quiet, safe environent with other staff available in case the atient is aggressive or threatens har to self or others. • Patients with altere thinking, behavior, or feelings ust be carefully evaluate for verbal an nonverbal actions. Often the thoughts, feelings, an behaviors islaye by these atients are inconsistent with the so-calle noral resonses of ersons in siilar circustances. • Assess whether the oo being escribe is consistent with the circustances being escribe. For exale, is the erson seaking of eath while siling?

secically whether insonia is resent an whether it is initial (falling aslee) or terinal (staying aslee) in nature. Ask the iniviual to escribe the ercetion of the aount an quality of slee nightly. Are nas taken regularly?

Clarity of thought. Evaluate the coherency, relevancy,

Implementation • Nursing interventions ust be iniviualize an base on atient assessent ata. • Provie an environent of accetance that focuses on the iniviual’s strengths while iniizing weaknesses. Soeties it is necessary to rovie a new environent for the atient uring a erio of eression. The iniviual ay not be able to work an ay nee a new eer grou. The atient ay also nee to be away fro the faily while restructuring an regrouing ersonal resources, ientifying strengths, an achieving a theraeutic rug level. • Provie an oortunity for the atient to exress feelings. Use active listening an theraeutic counication techniques. Allow the atient to exress feelings in nonverbal ways, such as involveent in hysical activities or occuational theray. Recognize that atients are hyeractive an talkative uring the anic hase; it ay be necessary to interrut talking an give concise, sile irections. • Reain cal, irect, an r when roviing care. Because atients in the anic hase ten to be arguentative, avoi getting involve in an arguent. State the unit rules in a atter-of-fact anner an enforce the. • Allow the atient to ake ecisions, if caable; ake those ecisions that the atient is not caable of aking. Provie a rewar for rogress when ecisions are initiate aroriately. Involve the atient in self-care activities. • If the atient is suicial, ask for etails about the lan being forulate. Follow u on etails obtaine with aroriate faily ebers or signicant others (e.g., have guns reove fro the hoe if this is art of the suicie lan). Provie for atient safety an suervision, an recor observations at secie intervals consistent with the severity of

an organization of the atient’s thoughts; observe for ight of ieas, hallucinations, elusions, aranoia, or graniose ieation. Ask secic questions about the iniviual’s ability to ake jugents an ecisions. Is there evience of eory iairent? Ientify areas in which the atient is caable of roviing inut to set goals an ake ecisions. (This will hel the iniviual overcoe a sense of owerlessness regaring life situations.) When the atient is unable to ake ecisions, lan to ake the. Set goals to involve the atient because abilities change with treatent. Provie an oortunity to lan for self-care. Suicidal ideation. If the iniviual is susecte of be-

ing suicial, ask the atient whether they have ever ha thoughts about suicie. If the resonse is “yes,” get ore etails. Has a secic lan been forulate? How often o these thoughts occur? Does the atient ake irect or inirect stateents regaring eath (e.g., “things woul be better” if eath occurre)? Psychomotor function. Ask secic questions about

the activity level the atient has aintaine. Is the erson able to work or go to school? Is the erson able to fulll resonsibilities at work, socially, an within the faily? How have the erson’s noral resonses to aily activities been altere? Is the iniviual withrawn an isolate or still involve in social interactions? Check gestures, gait, acing, resence or absence of treors, an ability to erfor gross or ne otor oveents. Is the atient hyeractive or iulsive? Note the seech attern. Are there rolonge auses before answers are given or altere levels of volue an inection? Sleep pattern. What is the atient’s noral slee at-

tern, an how oes it vary with oo swings? Ask

Dietary history. Ask questions about the atient’s a-

etite, an note weight gains or losses not associate with intentional ieting. During the anic hase, the iniviual ay becoe anorexic. Is the erson able to sit own to eat a eal, or o they only eat sall aounts while acing? Nonadherence. Nonaherence is usually exresse

by the enial of the severity of the isease. In aition, listen for excuses that the atient ay ake for not taking rescribe eicine (e.g., cannot affor it, asytoatic, “I on’t like the way it changes e. I want to be yself!”).

244

• • • •

•

•

•

•

UNIT III Drugs Affecting the Autonomic and Central Nervous System

the suicie threat an the olicies of the ractice site. This is the highest riority for those with severe oo isorers. Manic atients ay har others; it ay be necessary to liit their interactions with other atients. Patients in the anic hase ay require a quiet roo. Stay with atients who are highly agitate. Ainister as-neee rugs as orere for hyeractivity. Make necessary observations about atient resonses to the eications ainistere. ECT ay be orere to treat severe eression. Check the healthcare rovier’s orers secic to the retreatent an osttreatent care of the atient receiving ECT. Use hysical restraints within the guielines of the clinical setting as aroriate to the behaviors being exhibite. Use the least restrictive alternative ossible for the circustances. Have sufcient staff available to assist with violent behavior to eonstrate the ability to control the situation while roviing for the safety an well-being of the atient an fellow staff ebers. Provie for nutritional nees by having highrotein, high-calorie foos aroriate for the iniviual to eat while acing or highly active. Have nutritious snacks that the atient is known to like available on the unit, an offer the throughout the ay. Give vitains an liqui suleental feeings as orere. Maniulative behavior ust be hanle in a consistent anner by all staff ebers. Set liits an use consequences that are agree to by all staff ebers. When the atient attets to blae others, refocus on the atient’s resonsibilities. Give ositive reinforceent for nonaniulative behaviors when they occur. Slee erivation (i.e., issing one or ore night’s slee) is a ossibility with anic atients an can be life threatening. Provie a quiet, nonstiulating environent for the atient to slee. For atients with eression, o not allow the iniviual to slee continually. Design activities uring the ay that will stiulate the iniviual an roote slee at night. Scheule secic rouns to evaluate the iniviual’s slee an safety.

Patient Education • Orient the iniviual to the unit. Exlain the rules an the rocess of rivileges an how they are obtaine or lost. (The extent of the orientation an exlanations given will een on the atient’s orientation to ate, tie, an lace, as well as their abilities.) • Describe the variety of grou activities (e.g., social skills, self-estee, hysical exercise) available within articular theraeutic settings. • Involve the atient an the faily in goal setting, an integrate the atient into the aroriate grou

rocesses to evelo ositive exeriences an enhance coing skills. • Base atient eucation on the assessent ata an iniviualize teaching to rovie the atient with a structure environent in which to grow an enhance their self-estee. • Before ischarge, ake sure the atient an the faily unerstan the esire treatent outcoes an the entire follow-u lan (e.g., frequency of theray sessions, rescribe eications, riary healthcare rovier visits, return-to-work goals). Fostering health maintenance

• Throughout the course of treatent, iscuss eication inforation an how it will benet the atient. Drug theray is not ieiately effective in treating eression; therefore the atient an signicant others ust unerstan the iortance of continuing to take the rescribe eications esite inial initial resonse. The lag tie of 2 to 4 weeks between the initiation of rug theray an the theraeutic resonse ust be stresse. • Encourage the atient, faily, an caregivers to be alert to the eergence of anxiety, agitation, anic attacks, insonia, irritability, hostility, aggressiveness, iulsivity, akathisia (sychootor restlessness), hyoania, ania, unusual changes in behavior, worsening of eression, an suiciality, esecially at the start of antieressant treatent an when the osage is ajuste u or own. Avise the faily an caregivers to observe for the eergence of such sytos on a aily basis because changes ay be abrut. Such sytos shoul be reorte to the atient’s rescriber, esecially if they are severe, are abrut in onset, or were not art of the atient’s resenting sytos. Sytos such as these ay be associate with an increase risk of suicial thinking an behavior an ay inicate the nee for very close onitoring an ossible changes in the eication regien. • Ehasize the nee for the lithiu bloo level to be easure at secie intervals. Give the atient etails regaring the ate, tie, an lace for the test to be erfore. • Stress the iortance of aequate hyration (i.e., six to eight 8-ounce glasses of water er ay) an soiu intake when receiving lithiu theray. • Instruct the atient to weigh hiself or herself aily. • Provie the atient or signicant others with iortant inforation containe in the secic rug onograhs for the eicines rescribe. The onograhs also contain health teaching an nursing interventions for coon an serious averse effects. • Seek cooeration an unerstaning of the following oints so that eication aherence is increase: nae of the eication; its osage, route, an tie of ainistration; an its coon an serious averse effects. Encourage the atient not to

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

iscontinue or ajust the rug osage without consulting the healthcare rovier. • Chilren an aolescent atients ust be closely observe for clinical worsening, suiciality, or unusual changes in behavior. Failies an caregivers nee to be avise of the nee for close observation an counication with the rescriber. • Provie atients an failies with inforation about available counity resources, incluing the National Alliance on Mental Illness. Patient self-assessment. Enlist the atient’s hel with

eveloing an aintaining a written recor of onitoring araeters. See the Patient Self-Assessent For for Antieressants on the Evolve website, an colete the Preeication Data colun for use as a baseline to track the atient’s resonse to rug theray. Ensure that the atient unerstans how to use the for, an instruct the atient to bring the colete for to follow-u visits. During follow-u visits, focus on issues that will foster aherence with the theraeutic interventions rescribe.

Clinical Pitfall Antidepressants may increase the risk of suicidal thinking and behavior (suicidality) in patients of all ages who are experiencing MDD. Patients who are started on antidepressants should be monitored daily by family members and caregivers for the emergence of agitation, irritability, unusual changes in behavior, and suicidality. These symptoms should be immediately reported to healthcare providers.

DRUG THERAPY FOR DEPRESSIVE DISORDERS

DRUG CLASS: MONOAMINE OXIDASE INHIBITORS Actions MAOIs block the etabolic estruction of einehrine, noreinehrine, oaine, an serotonin neurotransitters by the enzye onoaine oxiase (MAO) in the resynatic neurons of the brain. As a result, the concentration of these central nervous syste (CNS) neurotransitters becoes increase. Although MAO inhibition starts within a few ays after initiating theray, the antieressant effects require 2 to 4 weeks to becoe evient. Aroxiately 60% of the clinical iroveent of sytos of eression occurs after 2 weeks, an axiu iroveent is usually attaine within 4 weeks. Uses The MAOIs use toay are henelzine, tranylcyroine, isocarboxazi, an selegiline (Table 16.1). They are equally effective an have siilar averse effects. They are ost effective for atyical eression, anic isorer, obsessive-coulsive relate isorers, an

245

soe hobic isorers. Selegiline is arove for treatent of MDD. They are also use when TCA theray is unsatisfactory an when ECT is inaroriate or refuse. Selegiline is available as a transeral atch that shoul be change once every 24 hours. Patients using the lowest strength available (6 g) o not have ietary restrictions. However, ietary restrictions are require for those using the 9- an 12-g atches. Therapeutic Outcomes The riary theraeutic outcoes execte fro MAOIs are elevate oo an the reuction of sytos of eression. Nursing Implications for Monoamine Oxidase Inhibitors Premedication assessment

1. Obtain the atient’s bloo ressure an ulse rate before an at regular intervals after initiating theray. 2. If the atient has iabetes, onitor the bloo glucose level to establish baseline values an assess this erioically uring theray. Because MAOIs cause hyoglyceia, a osage ajustent in insulin or oral hyerglyceic theray ay be require. If the atient has a history of severe renal isease, liver isease, cerebrovascular isease, or congestive heart failure, o not give the eication an consult with the rescriber. 3. Colete a iet history to ensure that the atient has not ingeste eals with a high tyraine content uring the ast few ays. 4. Colete a eication history to ensure that the atient has not taken any of the following eicines uring the ast few ays: SSRIs, SNRIs, TCAs, extroethorhan, eherine, ahetaines, ethylheniate, levooa, traaol, St. John’s wort, cyclobenzarine, carbaazeine, or eeriine. Availability. See Table 16.1

Medication Safety Alert Monoamine Oxidase Inhibitors and Hypertension Monoamine oxidase inhibitors, when used in conjunction with certain foods and beverages that contain tyramine and other medicines, may result in severe hypertension potentially leading to stroke, other organ damage, and death.

Foos containing signicant quantities of tyraine inclue well-riene cheeses (e.g., Caebert, Ea, Roquefort, Paresan, ozzarella, chear); yeast extract; re wines; ickle herring; sauerkraut; overrie bananas, gs, an avocaos; chicken liver; an beer. Foos containing other cheicals that ay raise bloo ressure inclue fava beans, chocolate, coffee, tea, an colas.

246

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Table 16.1 Antidepressants DAILY MAINTENANCE DOSAGE RANGE (MG)

MAXIMUM DAILY DOSAGE RANGE (MG)

GENERIC NAME BRAND NAME MONOAMINE OXIDASE INHIBITORS

AVAILABILITY

INITIAL DOSAGE RANGE (ORAL UNLESS OTHERWISE NOTED)

isocarboxazid

Marplan

Tablets: 10 mg

10 mg twice daily

40

60

phenelzine

Nardil

Tablets: 15 mg

15 mg three times daily

15–60

90

selegiline Do not confuse selegiline with sertraline or Salagen.

Emsam

Patch, transdermal: 6, 9, 12 mg/24 hr

6-mg patch daily

6

12

tranylcypromine

Parnate

Tablets: 10 mg

30 mg daily divided

30

60

Tablets: 10, 20, 40 mg Liquid: 10 mg/5 mL

20 mg daily

20–40

40

SELECTIVE SEROTONIN REUPTAKE INHIBITORS citalopram Celexa Do not confuse Celexa with Zyprexa or Celebrex. Ran-Citalo escitalopram

Lexapro Do not confuse Lexapro with loxapine. Cipralex

Tablets: 5, 10, 20 mg Liquid: 1 mg/mL

10 mg daily

10–20

20

uoxetine Do not confuse uoxetine with uphenazine, uvoxamine, famotidine, uvastatin, or paroxetine.

Prozac Do not confuse Prozac with Prilosec or Proscar. APO-Fluoxetine

Capsules: 10, 20, 40 mg Tablets: 10, 20, 60 mg Solution: 20 mg/5 mL Capsules, delayed release, weekly: 90 mg

20 mg in the morning 20–60

80

uvoxamine Do not confuse uvoxamine with uoxetine.

— Riva-Fluvox

Tablets: 25, 50, 50 mg at bedtime 100 mg Capsules, 24 hr sustained release: 100, 150 mg

50–300

300

paroxetine Do not confuse paroxetine with uoxetine, paclitaxel, or pyridoxine.

Paxil Do not confuse Paxil with paclitaxel, Plavix, or Taxol.

Capsules: 7.5, mg Tablets: 10, 20, 30, 40 mg Suspension: 10 mg/5 mL

20 mg daily

20–50

50–75

Paxil CR

Tablets, extended release (24 hr): 12.5, 25, 37.5 mg

sertraline Do not confuse sertraline with selegiline, Seroquel, or Singulair.

Zoloft

Tablets: 25, 50, 100 mg Oral concentrate: 20 mg/mL

50 mg daily

50–200

200

Do not confuse Zoloft with Zocor or Zyloprim.

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

247

Table 16.1 Antidepressants—cont’d INITIAL DOSAGE RANGE (ORAL UNLESS OTHERWISE NOTED)

GENERIC NAME BRAND NAME AVAILABILITY SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS desvenlafaxine Pristiq Tablets, 24 hr 50 mg daily at the sustained release: same time 25, 50, 100 mg

DAILY MAINTENANCE DOSAGE RANGE (MG)

MAXIMUM DAILY DOSAGE RANGE (MG)

50–400

400

duloxetine

Cymbalta Do not confuse Cymbalta with Zyprexa or Celebrex. Drizalma Sprinkle

Capsules, sustained 40 mg daily release: 20, 30, 40, 60 mg

60

120

levomilnacipran

Fetzima

Capsules, extended release: 20, 40, 80, 120 mg

40–120

120

venlafaxine

Effexor XR

Tablets: 25, 37.5, 75 mg in two or three 75–225 50, 75, 100 mg doses daily, taken Capsules, tablets, with food sustained release: 37.5, 75, 150, 225 mg

TRICYCLIC ANTIDEPRESSANTS amitriptyline — Do not confuse amitriptyline with aminophylline.

20 mg once daily for 2 days; then 40 mg once daily

Tablets: 10, 25, 50, 75, 100, 150 mg

25–75 mg daily, divided as needed

75–200

225 (outpatients) 375 (inpatients)

300 (inpatients)

amoxapine

—

Tablets: 25, 50, 100, 150 mg

50 mg two or three times daily

200–300

400 (outpatients) 600 (inpatients)

clomipramine

Anafranil

Capsules: 25, 50, 75 mg

25 mg once daily

100–150

250

desipramine

Norpramin

Tablets: 10, 25, 50, 75, 100, 150 mg

50–75 mg daily, divided in one to four doses

100–200

300

doxepin Do not confuse doxepin with digoxin.

Silenor NOVO-Doxepin

Capsules: 10, 25, 50, 75, 100, 150 mg Tablets: 3, 6mg Oral concentrate: 10 mg/mL

25 mg three times daily

75–150

300 (inpatients)

imipramine hydrochloride

—

Tablets: 10, 25, 50 mg

30–75 mg daily in 50–150 one to four divided doses

200 (outpatients) 300 (inpatients)

imipramine pamoate —

Capsules: 75, 100, 125, 150 mg

75–150 mg daily at bedtime

75–150

200 (outpatients) 300 (inpatients)

nortriptyline

Pamelor Norventyl

Capsules: 10, 25, 50, 75 mg Solution: 10 mg/5 mL

25–50 mg in one to four divided doses

50–75

150

protriptyline

—

Tablets: 5, 10 mg

5–10 mg three times daily

20–40

60

trimipramine

— Apo-Trimiprapine

Capsules: 25, 50, 100 mg

25 mg three times daily

50–150

200 (outpatients) 300 (inpatients)

Available in Canada. Do not confuse.

248

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Meications (incluing over-the-counter eicines) containing syathoietic aines whose etabolis is blocke by MAOIs ay result in excessive accuulation of neurotransitters siilar to noreinehrine. Exales are extroethorhan, carbaazeine, cyclobenzarine, ethylheniate, trytohan, ahetaines, eherine, ethyloa, levooa, linezoli, an einehrine. MAO inhibition of the etabolis of these neurotransitters that originate fro foo, beverages, an eicine ay result in a suen increase in bloo ressure with systolic ressures in the range of 160 to 230  Hg an iastolic ressures of 100 to 130  Hg, a hyertensive crisis an a eical eergency. Acute sytos inclue severe heaache, stiff neck, heart alitations, sweating, nausea, an voiting. Patients ust be transorte to a eical facility for eergency treatent to reuce bloo ressure before signicant organ aage occurs. It is recoene that at least 14 ays lase between the change in iet avoiing tyraine-containing roucts an iscontinuation of other aine-containing eicines before initiating MAOI theray. Dosage and administration

1. Instruct the atient how to liit tyraine-containing foos, which coul cause a life-threatening hyertensive crisis if they are ingeste concurrently with MAOIs. 2. The osage shoul be taken in ivie oses, with the last ose ainistere no later than 6 pm to revent rug-inuce insonia. Caution the atient not to iscontinue the eicine abrutly. If a ose is isse, take it ieiately when this is realize an then sace the reainer of the aily osage throughout the rest of the ay. 3. Make certain that the atient is not receiving any of the eications liste in the reeication assessent shown reviously. Common adverse effects

Cardiovascular Orthostatic hypotension. The ost coon averse effect of MAOIs is hyotension; it is ore signicant with henelzine than with tranylcyroine. Orthostatic hyotension, anifeste by izziness an weakness, is generally il an is ore coon when theray is starte. Daily ivie oses hel iniize the hyotension, an tolerance usually evelos after a few weeks of theray. Monitor the atient’s bloo ressure aily in both the suine an staning ositions. Anticiate the eveloent of ostural hyotension an take easures to revent its occurrence. Teach the atient to rise slowly fro a suine or sitting osition, an encourage sitting or lying own if feeling faint. Neurologic Drowsiness, sedation. Phenelzine has il to oerate seating effects. These sytos ten to isaear

with continue theray an with the ossible reajustent of the osage. Infor the atient of ossible seative effects. The atient shoul use caution while riving or erforing other tasks that require alertness. Consult with the healthcare rovier to consier oving the aily ose to betie if seation continues to be a roble. Restlessness, agitation, insomnia. These effects are ore coon with tranylcyroine an are transient as the osage is being ajuste. Have the atient take the last ose before 6 pm to iniize insonia. Sensory Blurred vision. Caution the atient that blurre vision ay occur an ake aroriate suggestions for the atient’s ersonal safety. Gastrointestinal Constipation; dryness of mucosa of the mouth, throat, nose. Mucosal ryness ay be relieve by sucking har cany or ice chis or by chewing gu. Give the atient stool softeners as rescribe. Encourage aequate ui intake an foos that will rovie sufcient bulk. Genitourinary Urinary retention. If the atient evelos urinary hesitancy, assess for blaer istention. Reort this to the healthcare rovier for further evaluation. Serious adverse effects

Cardiovascular Hypertension. Hyertensive crisis is a ajor otential colication with MAOI theray, articularly with tranylcyroine. Drug interactions

Drugs that increase toxic effects. See the Meication Safety Alert: Monoaine Oxiase Inhibitors an Hyertension. Tricyclic antidepressants. MAOIs an TCAs, esecially iiraine an esiraine, shoul not be ainistere concurrently. It is recoene that at least 14 ays lase between the iscontinuation of MAOIs an the initiation of another antieressant. Selective serotonin reuptake inhibitors, serotoninnorepinephrine reuptake inhibitors. Severe reactions— such as convulsions, hyeryrexia, an eath—have been reorte with concurrent use of these rugs. It is recoene that at least 14 ays lase between iscontinuing an MAOI an starting SSRI or SNRI theray. A 5-week interval is recoene between iscontinuing uoxetine an starting MAOIs. General anesthesia, diuretics, antihypertensive agents. MAOIs ay otentiate the hyotensive effects of general anesthesia, iuretics, an antihyertensive agents. Insulin, oral hypoglycemic agents. MAOIs have an aitive hyoglyceic effect when cobine with insulin an oral sulfonylureas. Monitor the atient’s bloo glucose level an lower the hyoglyceic osage, if necessary.

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

Meperidine, tramadol. When MAOIs are use concurrently with eeriine or traaol, atients ay suffer fro hyeryrexia, restlessness, hyertension, hyotension, convulsions, an coa. The effects of this interaction ay occur for several weeks after iscontinuing an MAOI. Morhine ight be an alternative at lower oses, but onitoring is neee.

DRUG CLASS: SELECTIVE SEROTONIN REUPTAKE INHIBITORS Actions SSRIs (see Table 16.1) are a class of antieressants cheically unrelate to other antieressants. They inhibit the reutake of serotonin fro the synatic cleft, thereby increasing the serotonin concentration that enhances neurotransission. Uses SSRIs have becoe the ost wiely use class of antieressants an have been shown to be as effective in treating eression as TCAs. A articular avantage of the SSRIs is that they o not have the anticholinergic an cariovascular averse effects that often liit the use of TCAs. As with other antieressants, it takes 2 to 4 weeks of theray to obtain the full theraeutic benet when treating eression. Fluoxetine is the only SSRI that has been arove for use in treating eression in chilren an aolescents. The US Foo an Drug Ainistration has recoene that aroxetine not be given to atients younger than 18 years. SSRIs are also being stuie for treatent of obsessive-coulsive relate isorers, obesity, eating isorers (e.g., anorexia nervosa, buliia nervosa), biolar isorer, anic isorer, autis, an several other isorers. Fluvoxaine, aroxetine, sertraline, an uoxetine are arove for use in atients with obsessive-coulsive relate isorers. Fluoxetine is arkete uner the bran nae Sarafe for treatent of reenstrual yshoric isorer. Therapeutic Outcomes The riary theraeutic outcoes execte fro the SSRIs are elevate oo an reuction of the sytos of eression. Nursing Implications for Selective Serotonin Reuptake Inhibitor Therapy

249

4. Monitor any CNS sytos resent, such as insonia or nervousness. 5. Check the atient’s heatic stuies before initiating the eication an erioically throughout the course of ainistration. Availability, dosage, and administration. See Table 16.1

Medication Safety Alert Serotonin Syndrome Serotonin syndrome may develop as a result of excessive accumulation of serotonin in nerve synapses. It is an uncommon event, but may be potentially fatal. The syndrome occurs if two or more drugs block the metabolism of serotonin, leaving excessive serotonin in nerve synapses. Most case reports have arisen from the combined use of SSRIs and MAOIs, or not allowing a recommended 14-day washout period before stopping one class of medicine and starting the other class of medicine. Less frequently reported cases have been noted with SSRIs, TCAs, SNRIs, buspirone, vortioxetine, vilazodone, linezolid, fentanyl, triptans, and meperidine. Monitor for symptoms of serotonin syndrome, including irritability, hallucinations, delirium, reduced consciousness, increased muscle tone, myoclonus, diaphoresis, shivering, tremor, hyperthermia, and increased or decreased blood pressure and heart rate. Notify the healthcare provider immediately.

Observation. Sytos of eression ay irove

(e.g., increase aetite, slee, an sychootor activity) within a few ays. However, the eression still exists, an it usually takes several weeks of the atient receiving theraeutic osing before iroveent is note. Suicie recautions shoul be aintaine uring this tie. syndrome. Abrut iscontinuation or interrution of antieressant theray ay result in a iscontinuation synroe. Sytos ay vary with the antieressant but coonly inclue nausea, voiting, iarrhea, heaaches, light-heaeness, izziness, iinishe aetite, sweating, chills, treors, aresthesia, fatigue, sonolence, an slee isturbances (e.g., vivi reas, insonia). Greater risks for eveloing a iscontinuation synroe have been associate with antieressants with shorter half-lives, longer urations of treatent, an abrut iscontinuation. Discontinuation

Premedication assessment

Common adverse effects

1. Obtain the atient’s baseline bloo ressures in the suine, an staning ositions; recor an reort signicant lowering to the healthcare rovier before ainistering the rug. 2. Obtain the atient’s baseline weight an scheule weekly weight easureents. 3. Note any gastrointestinal (GI) sytos resent before the start of theray.

Neurologic Restlessness, agitation, anxiety, insomnia. These effects usually occur early in theray an ay require short-ter treatent with seative-hynotic agents. Avoiing betie oses ay also hel ecrease the incience of insonia. Sedative effect. Tell the atient about ossible seative effects. The atient shoul use caution while

250

UNIT III Drugs Affecting the Autonomic and Central Nervous System

riving or erforing other tasks that require alertness. Consult with the healthcare rovier to consier oving the aily ose to betie if seation continues to be a roble. Gastrointestinal Nausea, anorexia. Most of these effects ay be iniize by teorarily reucing the osage an taking the ose with foo. Encourage the atient not to iscontinue theray without consulting the healthcare rovier rst. Serious adverse effects

Psychological Suicidal ideation. Monitor the atient for changes in thoughts, feelings, an behaviors uring the initial stages of theray. Drug interactions

Tricyclic antidepressants. The interaction between SSRIs an TCAs is very colex. An increase toxicity results fro TCAs. Observe the atient for signs of toxicity, such as ysrhythias, seizure activity, an CNS stiulation. Lithium. Lithiu ay enhance the serotonergic effect of SSRIs, thereby increasing the risk of serotonin toxicity (serotonin synroe). Use the cobination of SSRIs an lithiu very cautiously, onitoring closely for signs of serotonin toxicity such as irritability, hallucinations, eliriu, increase uscle tone, shivering, yoclonus, an reuce consciousness. Monoamine oxidase inhibitors. Severe reactions— incluing exciteent, iahoresis, rigiity, convulsions, hyeryrexia, an eath—have been reorte with the concurrent use of MAOIs an SSRIs. It is recoene that at least 14 ays lase between iscontinuing an MAOI an starting SSRI theray. A 5-week sto interval is recoene between iscontinuing uoxetine an starting MAOIs. Haloperidol. Fluoxetine an uvoxaine increase haloeriol levels an the frequency of extrayraial sytos (EPSs). If use concurrently, the osage of haloeriol ay nee to be ecrease. Phenytoin, phenobarbital. Colex interactions occur when henobarbital an henytoin enhance the etabolis of aroxetine, thereby requiring a osage increase in aroxetine for theraeutic effect. In a siilar fashion, aroxetine increases the etabolis of henytoin, thus requiring an increase in the osage of henytoin to aintain the theraeutic effect. Conversely, uoxetine ay iinish the etabolis of henytoin, thereby resulting in otential henytoin toxicity. Carbamazepine. Fluoxetine an uvoxaine can increase carbaazeine concentrations, which can result in signs of toxicity such as vertigo, treor, heaache, rowsiness, nausea, an voiting. The osage of carbaazeine ay nee to be reuce. Carbaazeine ay enhance the excretion of citalora, thereby

leaing to a ecrease theraeutic effect. The osage of citalora ay nee to be increase. Alprazolam. Fluoxetine, uvoxaine, an sertraline rolong the activity of alrazola, which results in excessive seation an iaire otor skills. Propranolol, metoprolol. Fluvoxaine an citalora signicantly inhibit the etabolis of these beta-arenergic blocking agents. Monitor the atient closely for braycaria an hyotension. Reuce the osage of the beta blocker as neee. Cimetidine. Cietiine inhibits the etabolis of aroxetine an sertraline. Patients shoul be closely onitore when cietiine is ae to aroxetine or sertraline theray. Warfarin. Fluoxetine, aroxetine, sertraline, citalora, an uvoxaine ay enhance the anticoagulant effects of warfarin. Observe the atient for etechiae, ecchyoses, noseblees, bleeing gus, ark tarry stools, an bright re or coffee-groun eesis. Monitor the international noralize ratio (INR) of warfarin; reuce the osage of warfarin if necessary. Smoking. Cigarette soking enhances the etabolis of uvoxaine. Dosages of uvoxaine ay nee to be increase to achieve full theraeutic resonse. Amphetamines, tryptophan, dextromethorphan, linezolid, ephedrine, pseudoephedrine, epinephrine. All of these agents increase serotonin levels, otentially causing serotonin synroe when taken by a erson receiving SSRIs.

DRUG CLASS: SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS Actions SNRI (see Table 16.1) are a class of antieressants that act by inhibiting the reutake of serotonin an noreinehrine—an, to a lesser extent, oaine—fro the synatic cleft, thereby rolonging the action of the neurotransitters. Uses SNRIs have becoe a wiely use class of antieressants. As with other antieressants, it takes 2 to 4 weeks of theray to obtain the full theraeutic benet in treating eression. Venlafaxine is arove for treatent of eression, generalize anxiety isorer, social anxiety isorer, an anic isorer. Duloxetine is arove for treatent of MDD, generalize anxiety isorer, broyalgia, chronic usculoskeletal ain, an iabetic eriheral neuroathic ain. Desvenlafaxine an levoilnaciran are arove for treatent of MDD. Therapeutic Outcomes The riary theraeutic outcoes execte fro the SNRIs are elevate oo an reuction of sytos of eression.

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

Nursing Implications for SerotoninNorepinephrine Reuptake Inhibitor Therapy Premedication assessment

1. Obtain the atient’s baseline weight an bloo ressure. 2. Note any GI sytos before starting theray. 3. Monitor any CNS sytos resent, such as insonia or nervousness. 4. Reort any history of hyertension, substance abuse, or renal or heatic isease to the healthcare rovier. Availability, dosage, and administration. See Table 16.1

Discontinuation of therapy. If the atient has taken the eicine for ore than 1 week before iscontinuation, the osage shoul be taere over the next few ays. If venlafaxine has been taken for ore than 6 weeks, the osage shoul graually be taere over the next 2 weeks. Observation. Sytos of eression ay irove (e.g., increase aetite, slee, an sychootor activity) within a few ays. However, the eression still exists, an it usually takes several weeks of the atient receiving theraeutic osing before iroveent is note. Suicie recautions shoul be aintaine uring this tie.

251

onitore for excessive effects of these two rugs when cietiine is ae to the theraeutic regien. Trazodone. Serotonin synroe ay evelo when trazoone is use in conjunction with venlafaxine. Use trazoone cautiously; initiate theray at a lower osage an closely onitor for the averse effects liste. Haloperidol. Venlafaxine increases haloeriol levels an increases the frequency of EPSs, such as akathisia, ystonia, seuoarkinsonis, an yskinesia (see Chater 17 for ore inforation). If these rugs are use concurrently, the osage of haloeriol ay nee to be ecrease.

DRUG CLASS: TRICYCLIC ANTIDEPRESSANTS Actions Until recently, TCAs (see Table 16.1) were the ost wiely use eications for the treatent of eression. SRRIs now have that istinction, but their longter effects are yet to be coletely eterine. TCAs rolong the action of noreinehrine, oaine, an serotonin to varying egrees by blocking the reutake of these neurotransitters in the synatic cleft between neurons. The exact echanis of action when these rugs are use as antieressants is unknown.

Common adverse effects

Neurologic Dizziness, drowsiness. The atient shoul be warne to not work with achinery, oerate a otor vehicle, ainister eication, or erfor other uties that require ental alertness until it is known whether this averse effect iairs jugent. Restlessness, agitation, anxiety, insomnia. These effects usually occur early in theray, an the atient ay require short-ter treatent with seative-hynotic agents. Avoiing betie oses ay hel ecrease the incience of insonia. Gastrointestinal Nausea, anorexia. Most of these effects ay be iniize by teorarily reucing the osage an taking the oses with foo. Serious adverse effects

Psychological Suicidal ideation. Monitor the atient for changes in thoughts, feelings, an behaviors uring the initial stages of theray. Drug interactions

Monoamine oxidase inhibitors. Severe reactions— incluing exciteent, iahoresis, rigiity, convulsions, hyeryrexia, an eath—have been reorte with the concurrent use of MAOIs an SNRIs. It is recoene that at least 14 ays lase between iscontinuing an MAOI an starting SNRI theray (an vice versa). Cimetidine. Cietiine inhibits the etabolis of venlafaxine an uloxetine. Patients shoul be closely

Uses TCAs rouce antieressant an il tranquilizing effects. After 2 to 4 weeks of theray, these rugs elevate oo, irove aetite, an increase alertness in aroxiately 80% of atients with enogenous eression. Cobination theray with henothiazine erivatives ay be beneficial for treating eression associate with schizohrenia or oerate to severe anxiety an eression observe with sychosis. All TCAs are equally effective for treating eression, assuing that aroriate osages are use for an aequate erio. Consequently the selection of an antieressant is base riarily on the characteristics of each agent. Seation is ore notable with aitrityline, oxein, an triiraine. Protrityline has no seative roerties, an it ay actually rouce il stiulation in soe atients. All tricyclic coouns islay anticholinergic activity, with aitrityline islaying the ost an esiraine the least. This factor shoul be consiere in atients with cariac isease, rostatic hyerlasia, or glaucoa. Other factors to consier are that en ten to reson better to iiraine than woen an oler aults ten to reson better to aitrityline than younger atients. Doxein is also arove for treating anxiety, an iiraine is arove for treating enuresis in chilren who are 6 years ol an oler. Cloiraine is not use to treat eression, but is arove for treating obsessive-coulsive relate isorers.

252

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Selecte TCAs are also use to treat hanto lib ain, chronic ain, cancer ain, eriheral neuroathy with ain, ostheretic neuralgia, arthritic ain, eating isorers, reenstrual sytos, an obstructive slee anea. Therapeutic Outcomes The riary theraeutic outcoes execte fro TCAs are elevate oo an reuction of sytos of eression. Nursing Implications for Tricyclic Antidepressants

Sensory Blurred vision. Caution the atient that blurre vision ay occur an ake aroriate suggestions to ensure the atient’s ersonal safety. Gastrointestinal Constipation; dryness of mucosa of the mouth, throat, nose. Mucosal ryness ay be relieve by sucking har cany or ice chis or by chewing gu. The use of stool softeners such as ocusate or the occasional use of a stiulant laxative such as bisacoyl ay be require for constiation.

Premedication assessment

1. Note the consistency of the atient’s bowel oveents; constiation is coon when taking TCAs. 2. Obtain the atient’s baseline bloo ressure in suine an staning ositions; recor an reort signicant hyotension to the healthcare rovier before ainistering the rug. 3. Check the atient’s history for sytos of ysrhythias, tachycaria, or congestive heart failure; if resent, consult the healthcare rovier before starting theray (the atient ay require electrocariograhy before theray is starte). 4. If the atient has a history of seizures, check with the healthcare rovier to see if the osage of anticonvulsant theray eications nees to be ajuste.

Serious adverse effects

See Table 16.1. The eication shoul be initiate at a low osage level an increase graually, articularly for oler or ebilitate atients. Dosage increases shoul be ae in the evening because increase seation often occurs.

Neurologic Tremor. Aroxiately 10% of atients evelo this averse effect. Treor can be controlle with sall oses of roranolol. Numbness, tingling. Reort these sytos to the healthcare rovier for further evaluation. Parkinsonian symptoms. If these sytos evelo, the TCA osage ust be reuce or iscontinue. Antiarkinsonian eications will not control sytos inuce by TCAs. Seizure activity. High oses of antieressants lower the seizure threshol. Ajustent of anticonvulsant theray ay be require, esecially for seizure-rone atients. Cardiovascular Dysrhythmias, tachycardia, heart failure. Reort these sytos to the healthcare rovier for further evaluation. Psychological Suicidal ideation. Monitor the atient for changes in thoughts, feelings, an behaviors uring the initial stages of theray.

Observation. Sytos of eression ay irove

Drug interactions

Availability, dosage, and administration. Adult: PO:

(e.g., increase aetite, slee, an sychootor activity) within a few ays. However, the eression still exists, an it usually takes several weeks of the atient receiving theraeutic osing before iroveent is note. Suicie recautions shoul be aintaine uring this tie. Common adverse effects

Cardiovascular Orthostatic hypotension. All TCAs ay cause soe egree of orthostatic hyotension, anifeste by izziness an weakness, articularly when theray is rst begun. Monitor the atient’s bloo ressure aily in both the suine an staning ositions. Anticiate the eveloent of ostural hyotension an take easures to revent such an occurrence. Teach the atient to rise slowly fro a suine or sitting osition an encourage the atient to sit or lie own if feeling faint. Neurologic Sedative effects. Tell the atient about ossible seative effects. These effects usually occur early in theray. Taking a single ose at betie ay iinish or relieve the seative effects.

Enhanced anticholinergic activity. Antihistaines, henothiazines, trihexyheniyl, an benztroine enhance the anticholinergic activity associate with TCA theray. The averse effects are usually not severe enough to warrant iscontinuing theray, but stool softeners ay be require. Enhanced sedative activity. Ethanol, barbiturates, narcotics, tranquilizers, antihistaines, anesthetics, an seative-hynotics enhance the seative activity associate with TCA theray. Concurrent theray is not recoene. Phenobarbital. Phenobarbital ay stiulate the etabolis of TCAs. Dosage ajustents of the antieressant ay be necessary. Bupropion. Buroion ay increase seru levels of TCAs. Dosages ay nee to be reuce. Carbamazepine. TCAs can increase carbaazeine concentrations, resulting in signs of toxicity such as vertigo, treor, heaache, rowsiness, nausea, an voiting. The osage of carbaazeine ay nee to be reuce. Carbaazeine ay also reuce seru levels of TCAs. Dosages of the TCA ay nee to be increase.

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

253

Valproic acid, methylphenidate. These eications ay increase the seru levels of the TCAs. This reaction has been avantageous in attets to gain a faster onset of antieressant activity, but an increase incience of ysrhythias also has been reorte. Clonidine. TCAs inhibit the antihyertensive effects of cloniine an ay enhance the hyertension seen with the abrut iscontinuation of cloniine. Concurrent theray shoul be avoie. Monoamine oxidase inhibitors. Severe reactions— incluing convulsions, hyeryrexia, an eath— have been reorte with concurrent use. It is recoene that 2 weeks lase between iscontinuing an MAOI an starting TCAs. Selective serotonin reuptake inhibitors. The interaction between SSRIs an TCAs is colex. The net result is that there is an increase toxicity fro the TCAs. Observe atients for signs of toxicity, such as ysrhythias, seizure activity, an CNS stiulation. Amphetamines, tryptophan, dextromethorphan, linezolid, ephedrine, pseudoephedrine, epinephrine. All of these agents increase serotonin levels, otentially causing serotonin synroe when taken by a erson receiving TCAs. These eications shoul be use together only uner the suervision of a healthcare rovier. Cimetidine. Cietiine inhibits the etabolis of TCAs. Patients shoul be closely onitore for aitional anticholinergic sytos. In general, cietiine theray shoul be avoie in atients taking TCAs. Ranitiine an faotiine ay be use without rug interactions. Smoking. Cigarette soking enhances the etabolis of TCAs. Dosages of the TCA ay nee to be increase to achieve a full theraeutic resonse.

the averse effects of TCAs. Disavantages inclue seizure activity an the requireent of ultile oses aily. It ust not be use in atients with sychotic isorers because its oaine agonist activity causes increase sychotic sytos. Buroion is also arove as a 12-hour extenerelease tablet to suort soeone who is trying to quit soking. Treatent shoul be initiate while the atient is still soking because aroxiately 1 week of treatent is require to achieve steay-state bloo levels of buroion. Patients shoul set a target quit ate uring the rst 2 weeks of treatent with buroion, generally in the secon week. Treatent shoul be continue for 7 to 12 weeks; longer treatent shoul be guie by the relative benets an risks for iniviual atients. Buroion 24-hour extene-release tablets (Alenzin, Wellbutrin XL) are arove for use in atients with a iagnosis of seasonal affective isorer.

DRUG CLASS: MISCELLANEOUS AGENTS

200-g 12-hour extene-release tablets; 150, 174, 300, 348, 450, 522-g 24-hour extene-release tablets.

BUPROPION HYDROCHLORIDE

Therapeutic Outcomes The riary theraeutic outcoes execte fro buroion theray when use for eression are elevate oo an reuction of sytos of eression. When it is use for soking cessation, the execte outcoe is the terination of soking. Nursing Implications for Bupropion Therapy Premedication assessment

1. Obtain the atient’s baseline weight. 2. Use the Dyskinesia Ientication Syste: Conense User Scale (DISCUS) or the Abnoral Involuntary Moveent Scale (AIMS) (see Evolve website) at secie intervals to etect or check u on EPSs; recor an reort in accorance with institutional olicy. Availability. PO: 75- an 100-g tablets; 100-, 150-, an

Dosage and administration for depression. Adult: PO: bupropion hydrochloride (byū-PRŌ-pē ŏn) Do not confuse bupropion with buspirone. Aplenzin (ah-plen-zin) Forvo XL (for-ve-oh) Wellbutrin SR and XL (wĕl-BYŪ-trĭn)

Actions Buroion is a onocyclic antieressant. Its echanis of action is not fully known. Coare with TCAs, it is believe to be a weak inhibitor of the reutake of the neurotransitters noreinehrine an oaine. It has no onoaine oxiase inhibition or serotonin reutake inhibition effect. Uses Buroion is arove for use in atients with MDD who are unresonsive to TCAs or who cannot tolerate

Ieiate release; initially, 100 g twice aily. This ay be increase to 100 g three ties aily after 3 ays of theray. No single ose of buroion shoul excee 150 g; o not excee 450 g aily. Avoi taking a ose shortly before betie. 12-hour ER (sustaine release): 150 g once aily in the orning. This ay be increase to 150 g twice a ay after 3 ays. No single ose shoul excee 200 g or 200 g twice aily. 24-hour ER: 150 g once aily in the orning. This ay increase by ay 4 of osing to 300 g once aily. Maxiu ose is 450 g once aily. Dosage and administration for smoking cessation. Adult: PO: Dosing shoul begin at 150 g/

ay given every ay for the rst 3 ays, followe by a osage increase for ost atients to the recoene usual osage of 300 g/ay. There shoul

254

UNIT III Drugs Affecting the Autonomic and Central Nervous System

be an interval of at least 8 hours between successive oses. Dosages above 300 g/ay shoul not be use. Buroion shoul be swallowe whole, not crushe, ivie, or chewe. Treatent shoul continue for 7 to 12 weeks; longer treatent shoul be guie by the relative benets an risks for iniviual atients. If a atient has not ae signicant rogress towar abstinence by the seventh week of theray with buroion, it is unlikely that they will quit uring that attet an treatent shoul robably be iscontinue. Conversely, a atient who successfully quits after 7 to 12 weeks of treatent shoul be consiere for ongoing theray with buroion. Dosage taering of buroion is not require when iscontinuing treatent. The atient shoul continue to receive counseling an suort throughout treatent with buroion an for a erio of tie thereafter. Individualization of therapy. The soking cessation atient is ore likely to quit soking an reain abstinent if seen frequently an receiving suort fro the healthcare rovier. Ensure that the atient reas the instructions rovie an has any questions answere. The atient’s healthcare rovier shoul review the overall soking cessation rogra, incluing treatent with buroion. The atient shoul be avise about the iortance of articiating in the behavioral interventions, counseling, an suort services to be use in conjunction with buroion. Observation. In the atient with eression, sytos of eression ay irove within a few ays (e.g., irove aetite, slee, an sychootor activity). However, the eression still exists, an it usually takes several weeks of the atient receiving theraeutic osing before iroveent is note. Suicie recautions shoul be aintaine uring this tie. Common adverse effects

Gastrointestinal Anorexia, constipation, diarrhea, nausea, vomiting. Most GI effects ay be iniize by teorarily reucing the osage, giving with foo, an using stool softeners for constiation. Neurologic Restlessness, agitation, anxiety, insomnia. These effects usually occur early in theray, an the atient ay require short-ter treatent with seative-hynotic agents. Avoiing betie oses ay hel ecrease the incience of insonia.

Drug interactions

Cimetidine. Cietiine inhibits the etabolis of buroion an increases buroion bloo levels. A ecrease in the buroion osage ay be necessary. Carbamazepine, phenobarbital, phenytoin. Carbaazeine, henobarbital, an henytoin ay ecrease buroion seru levels, leaing to ecrease haracologic effect. It ay be necessary to ajust the osage of buroion. Nicotine replacement. Although buroion is use in cobination with nicotine relaceent roucts to hel with soking cessation, coainistration of nicotine relaceent roucts with buroion ay cause hyertension. Monitor the atient’s bloo ressure when roucts such as nicotine atches or nicotine gu are being use. Ritonavir. Ritonavir ay stiulate the etabolis of buroion, causing a reuction in seru concentrations of buroion. An increase in the buroion osage ay be necessary. Levodopa. Buroion has soe il oainergic activity an ay result in an increase in the averse effects cause by levooa. If buroion is to be ae to levooa theray, it shoul be initiate at a lower osage with sall increases in the osage of buroion.

mirtazapine (mĭr-TĂZ-ĕ-pĕn) Remeron (RĔ-mĕr-ŏn) Do not confuse Remeron with Restoril.

Actions Mirtazaine is a tetracyclic antieressant that is a central resynatic alha-2 antagonist, which results in increase release of noreinehrine an serotonin. It oes not inhibit the reutake of noreinehrine or serotonin. The echanis of action is unknown, but the haracologic resonse is siilar to that of TCAs. Uses Mirtazaine is use to treat MDD. Therapeutic Outcomes The riary theraeutic outcoes execte fro irtazaine theray are elevate oo an reuction of sytos of eression. Nursing Implications for Mirtazapine Therapy Premedication assessment

Serious adverse effects

Neurologic Seizures. See Assessent: History of Seizure Activity in the Antieiletic Theray section of Chater 18 Psychological Suicidal ideation. Monitor the atient for changes in thoughts, feelings, an behaviors uring the initial stages of theray.

1. Obtain the atient’s baseline bloo ressures in the suine, an staning ositions; recor an reort signicant hyotension to the healthcare rovier before ainistering the rug. 2. Obtain the atient’s baseline weight an scheule weekly weight easureents. 3. Check for a history of seizures. If resent, notify the healthcare rovier before starting theray.

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

4. Check the atient’s heatic stuies before initiating theray an erioically throughout the course of ainistration. 5. Use the DISCUS or the AIMS (see Evolve website) at secie intervals to etect or check u on EPSs; recor an reort in accorance with institutional olicy. 6. Obtain the atient’s white bloo cell count before an at regular intervals after initiating theray because agranulocytosis has been reorte. Availability. PO: 7.5-, 15-, 30-, an 45-g tablets; 15-,

30-, an 45-g orally isintegrating tablets (Reeron SolTab). Dosage and administration. Adult: PO: Initially, 15 g aily. Every 1 to 2 weeks the osage ay be increase u to a axiu of 45 g aily. Increases in osage shoul be ae in the evening because increase seation is often resent. Observation. See Tricyclic Antieressants section. Sytos of eression ay irove (e.g., increase aetite, slee, an sychootor activity) within a few ays. However, the eression still exists, an it usually takes several weeks of the atient receiving theraeutic osing before iroveent is note. Suicie recautions shoul be aintaine uring this tie.

Herbal Interactions St. John’s Wort St. John’s wort may increase the toxic effects of antidepressant medications. The use of St. John’s wort with other antidepressants should be done only with close supervision by a healthcare provider.

trazodone hydrochloride (TRĂ-zō-dōn) Do not confuse trazodone with amiodarone or tramadol.

Actions Trazoone was the rst of the triazoloyriine antieressants to be release for clinical use. The triazoloyriines are cheically unrelate to the other classes of antieressants. The exact echaniss of action of trazoone are unknown, but it otentiates serotonin activity by inhibiting reutake an estruction of serotonin. The actions are colex an in soe ways reseble those of the TCAs, benzoiazeines, an henothiazines; however, the overall activity of trazoone is haracologically ifferent fro that of each of these classes of rugs. Uses Trazoone has been shown to be as effective as TCAs in treating eression; eression associate with schizohrenia; an eression, treor, an anxiety associate with alcohol eenence. Coare with other antieressants, trazoone has a low incience

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of anticholinergic averse effects, which akes it articularly useful in atients whose antieressant osages are liite by anticholinergic averse effects an in atients with severe close-angle glaucoa, rostatic hyerlasia, organic ental isorers, or cariac ysrhythias. Trazoone is coonly use to treat insonia in atients with substance abuse because it is seating, iroves slee continuity, an has inial otential for tolerance an aiction. Therapeutic Outcomes The riary theraeutic outcoes execte fro trazoone theray are elevate oo an reuction of sytos of MDD. Nursing Implications for Trazodone Therapy Premedication assessment

1. Obtain the atient’s baseline bloo ressures in the suine, an staning ositions. 2. Recor an reort signicant hyotension to the healthcare rovier before ainistering the rug. Availability. PO: 50-, 100-, 150-, an 300-g tablets. Dosage and administration. Adult: PO: Initially, 150

g in three ivie oses. Increase the osage in increents of 50 g aily every 3 to 4 ays while onitoring the clinical resonse. Do not excee 400 g aily in outatients or 600 g aily in hositalize atients. Trazoone theray shoul be initiate at a low osage an increase graually, articularly in oler aults or ebilitate atients. Dosage increases shoul be ae in the evening because increase seation often occurs. Ainister the eication shortly after a eal or with a light snack to reuce averse effects. Observation. Sytos of eression ay irove (e.g., increase aetite, slee, an sychootor activity) within a few ays. However, the eression still exists, an it usually takes several weeks of the atient receiving theraeutic osing before iroveent is note. Suicie recautions shoul be aintaine uring this tie. Common adverse effects

Cardiovascular Orthostatic hypotension. Although eisoes are infrequent an generally il, trazoone ay cause soe egree of orthostatic hyotension, anifeste by izziness an weakness, articularly when theray is initiate. Monitor the atient’s bloo ressure aily in both the suine an staning ositions. Anticiate the eveloent of ostural hyotension an take easures to revent an occurrence. Teach the atient to rise slowly fro a suine or sitting osition, an encourage the atient to sit or lie own if feeling faint. Neurologic Drowsiness. The atient shoul be warne to not work with achinery, oerate a otor vehicle,

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UNIT III Drugs Affecting the Autonomic and Central Nervous System

ainister eication, or erfor other uties that require ental alertness until it is known whether this averse effect iairs jugent. Serious adverse effects

Cardiovascular Dysrhythmias, tachycardia. Reort these sytos to a healthcare rovier for further evaluation. Neurologic Confusion. Before initiating theray, erfor a baseline assessent of the atient’s egree of alertness an orientation to nae, lace, an tie. Make regularly scheule subsequent evaluations of the atient’s ental status an coare nings. Reort any signicant alterations to the rescriber. Dizziness, lightheadedness. Provie for atient safety uring eisoes of izziness an reort these sytos to the rescriber for further evaluation. Drug interactions

Enhanced sedative activity. Ethanol, narcotics, tranquilizers, antihistaines, anesthetics, henothiazines, an seative-hynotics enhance the seative effects associate with trazoone theray. Concurrent theray is not recoene. MAOIs, SSRIs, SNRIs. Serotonin synroe ay evelo when trazoone is use in conjunction with any of these agents. Use trazoone cautiously; initiate theray at a lower osage an closely onitor for the averse effects liste. vilazodone (vĭl-ĂZ-zō-dōn) Do not confuse vilazodone with trazodone or nefazodone. Viibryd (vī-brĭd)

Actions Vilazoone is a eication that acts as an SSRI an a artial agonist of serotonin (5-hyroxytrytaine) 5-HT1A recetors, thereby enhancing serotonin activity. Uses Vilazoone is arove to treat MDD in aults. Therapeutic Outcomes The riary theraeutic outcoes execte fro vilazoone theray are elevate oo an reuction of sytos of eression. Nursing Implications for Vilazodone Therapy Premedication assessment

1. Note any GI sytos resent before the start of theray. 2. Monitor any CNS sytos resent (e.g., insonia, restlessness). Availability. PO: 10-, 20-, an 40-g tablets.

Dosage and administration. Adult: PO: Initially, 10

g once aily with foo for 7 ays, followe by 20 g once aily with foo for the next 7 ays, an then increase to the recoene osage of 40 g once aily. Vilazoone shoul be taken with foo for otial absortion. Observation. Sytos of eression ay irove (e.g., increase aetite, slee, an sychootor activity) within a few ays. However, the eression still exists, an it usually takes several weeks of the atient receiving theraeutic osing before iroveent is note. Suicie recautions shoul be aintaine uring this tie. Common adverse effects

Gastrointestinal Diarrhea, nausea, vomiting. These averse effects shoul be il, articularly if the ose is ainistere with foo. They shoul also resolve with continue theray. Patients with ersistent voiting shoul be evaluate for other causes, as well as for the eveloent of electrolyte ibalance. Neurologic Dizziness, drowsiness. Provie for atient safety uring eisoes of izziness an reort these sytos to the healthcare rovier for further evaluation. The atient shoul not take these eications while working with achinery, oerating a otor vehicle, ainistering eication, or erforing other uties that require ental alertness. Serious adverse effects

Neurologic Confusion. Before initiating theray, erfor a baseline assessent of the atient’s egree of alertness an orientation to nae, lace, an tie. Make regularly scheule subsequent evaluations of the atient’s ental status an coare nings. Reort any signicant alterations to the rescriber. Dizziness, lightheadedness. Provie for atient safety uring eisoes of izziness an reort these sytos to the healthcare rovier for further evaluation. Psychological Suicidal ideation. Monitor the atient for changes in thoughts, feelings, an behaviors, esecially uring the initial stages of theray. Drug interactions

Enhanced sedative activity. Ethanol, narcotics, tranquilizers, antihistaines, anesthetics, henothiazines, an seative-hynotics enhance the seative effects that are associate with vilazoone theray. Concurrent theray is not recoene. Trazodone, MAOIs, SSRIs, SNRIs, tramadol, triptans. Serotonin synroe ay evelo when vilazoone is use in conjunction with any of these agents. See the Meication Safety Alert: Serotonin Synroe earlier in this chater.

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

Aspirin, nonsteroidal antiinammatory drugs, warfarin. Serotonin release by latelets lays an iortant role in heostasis. SRRIs ay enhance the anticoagulant effects of warfarin an enhance the otential for GI bleeing cause by nonsteroial antiinaatory rugs (NSAIDs) or asirin. Observe the atient for etechiae, ecchyoses, noseblees, bleeing gus, ark tarry stools, an bright re or coffee-groun eesis. Monitor rothrobin tie an the INR of warfarin, an reuce the osage of warfarin if necessary. Phenytoin, phenobarbital, carbamazepine. These agents ay enhance the etabolis of vilazoone, reucing seru levels an leaing to ecrease haracologic effect. Erythromycin, clarithromycin, uoxetine, grapefruit juice. These rugs inhibit the etabolis of vilazoone, causing an increase in seru levels an the otential for toxicity. Dosages of the antieressant ay nee to be reuce by u to 50% to avoi toxicities. vortioxetine (vōr-tē ŎX-ĕt-ēn) Do not confuse vortioxetine with atomoxetine. Trintellix (trĭn-TĔL-ĭx)

Actions Vortioxetine is a eication that acts as an SSRI, an agonist of the serotonin 5-HT1A recetors that enhances serotonin activity an antagonizes the serotonin 5-HT3 recetors. Uses Vortioxetine is arove to treat MDD in aults. Therapeutic Outcomes The riary theraeutic outcoes execte fro vortioxetine theray are elevate oo an reuction of sytos of eression. Nursing Implications for Vortioxetine Therapy Premedication assessment

1. Note any GI sytos resent before the start of theray. 2. Monitor any CNS sytos resent (e.g., insonia, restlessness). Availability. PO: 5-, 10-, an 20-g tablets. Dosage and administration. Adult: PO: Initially, 10 g

once aily, followe by 20 g once aily as tolerate. For those not tolerating 10 g aily, theray ay be reuce to 5 g aily. Maxiu aily ose is 20 g. If the rug is well tolerate, atients shoul reain on theray for several onths. When iscontinuation is lanne, the ose shoul be taere to onitor closely for eveloent of withrawal sytos an to etect the eveloent of eressive sytos. The anufacturer recoens

257

that oses of 15 g aily or higher shoul be reuce to 10 g aily for 1 week before full iscontinuation to revent withrawal sytos. Common adverse effects

Gastrointestinal Diarrhea, nausea, vomiting, dry mouth. These averse effects shoul be il an shoul resolve with continue theray. Patients with ersistent voiting shoul be evaluate for other causes, as well as for the eveloent of electrolyte ibalance (synroe of inaroriate secretion of antiiuretic horone or serotonin synroe). Neurologic Dizziness, abnormal dreams. Provie for atient safety uring eisoes of izziness. Provie cofort an atient safety in those reorting abnoral reas. Reort these sytos to the healthcare rovier for further evaluation. The atient shoul not take these eications while working with achinery, oerating a otor vehicle, ainistering eication, or erforing other uties that require ental alertness. Serious adverse effects

Psychological Suicidal actions, hypomania, mania, serotonin syndrome. Monitor the atient for changes in thoughts, feelings, an behaviors, esecially uring the initial stages of theray. Sytos of eression ay irove (e.g., increase aetite, slee, an sychootor activity) within a few ays. However, the eression still exists, an it usually takes several weeks of the atient receiving theraeutic osing before iroveent is note. Suicie recautions shoul be aintaine uring this tie. Review atient history for a ersonal or faily history of biolar isorer because vortioxetine ay inuce latent biolar isorer. Vortioxetine is not arove for treatent of biolar eression. Drug interactions

Trazodone, MAOIs, SSRIs, SNRIs, tramadol, triptans, buspirone, St. John’s wort, linezolid, fentanyl. Serotonin synroe ay evelo when vortioxetine is use in conjunction with any of these agents. Use these rugs cautiously; initiate theray at a lower osage an closely onitor for the averse effects liste. Aspirin, nonsteroidal antiinammatory drugs, warfarin. Serotonin release by latelets lays an iortant role in heostasis. Selective serotonin reutake inhibitors ay enhance the anticoagulant effects of warfarin an enhance the otential for GI bleeing cause by NSAIDs or asirin. Observe the atient for etechiae, ecchyoses, noseblees, bleeing gus, ark tarry stools, an bright re or coffee-groun eesis. Monitor rothrobin tie an the INR of warfarin an reuce the osage of warfarin if necessary.

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UNIT III Drugs Affecting the Autonomic and Central Nervous System

Buspirone. Busirone inhibits the etabolis of vortioxetine, causing an increase in seru levels an the otential for toxicity. Dosages of vortioxetine shoul be reuce by u to 50% to avoi toxicities.

DRUG CLASS: ANTIMANIC AGENT LITHIUM CARBONATE lithium carbonate (LĬTH-ē-um)

Actions Lithiu is a onovalent cation that coetes with other onovalent an ivalent cations (i.e., otassiu, soiu, calciu, agnesiu) at cellular bining sites that are sensitive to changes in cation concentration. Lithiu relaces intracellular an intraneuronal soiu, stabilizing the neuronal ebrane. It also reuces the release of noreinehrine an increases the utake of trytohan, the recursor to serotonin. It also interacts with secon-essenger cellular rocesses to inhibit intracellular concentrations of cyclic aenosine onohoshate. Because of the colexity of the CNS, the exact echaniss of action of lithiu for treating oo isorers are unknown. It has no seative, eressant, or euhoric roerties, which ifferentiates it fro all other sychotroic agents. Uses Lithiu is use to treat acute ania an for rohylactic treatent of recurrent anic an eressive eisoes in atients with biolar isorer. In atients with biolar isorer, it is ore effective in reventing signs an sytos of ania than those of eression. It is also effective in soe atients for reucing the recurrence of the eressive eisoes associate with uniolar isorer. Therapeutic Outcome The riary theraeutic outcoe execte fro lithiu theray is aintaining the iniviual at an otial level of functioning, with inial exacerbations of oo swings. Nursing Implications for Lithium Therapy Premedication assessment

1. Before initiating lithiu theray, the following laboratory tests shoul be colete for baseline inforation: electrolytes, fasting bloo glucose, bloo urea nitrogen (BUN), seru creatinine, creatinine clearance, urinalysis, an thyroi function. 2. Obtain baseline bloo ressures with the atient in the suine, an staning ositions; recor an reort signicant hyotension to the healthcare rovier before ainistering the rug. 3. Weigh the atient aily, check the hyration status (e.g., oistness of ucous ebranes, skin turgor,

rness of eyeball), an onitor urine secic gravity. 4. Lithiu ay enhance soiu eletion, which increases lithiu toxicity. Assess for early signs of lithiu toxicity before giving the eication, incluing nausea, voiting, aboinal ain, iarrhea, lethargy, seech ifculty, il izziness, uscle twitching, an treor. Availability. PO: Lithium carbonate: 150-, 300-, an 600-

g casules; 300-g tablets; 300- an 450-g slowrelease tablets. Lithium citrate: 8 Eq/5 L solution in 500-L bottles. Dosage and administration. Adult: PO: 300 to 600 g

three or four ties aily. Ainister with foo or ilk. An aequate iet is iortant to aintain noral seru soiu levels an to revent toxicity. The onset of the acute antianic effect of lithiu usually occurs within 5 to 7 ays; the full theraeutic effect often requires 10 to 21 ays. Serum lithium levels. Lithiu levels are onitore once or twice weekly uring the initiation of theray an onthly while the atient is receiving a aintenance osage. Bloo shoul be rawn aroxiately 12 hours after the last ose was ainistere. The noral seru level is 0.4 to 1.2 Eq/L. Protly reort seru levels higher than these values to the healthcare rovier. Good nutrition. Lithiu ay enhance soiu eletion, which increases lithiu toxicity. The atient shoul aintain a noral ietary intake of soiu an aequate aintenance uis (i.e., 10 to 12 eightounce glasses of water aily), esecially when initiating theray, to revent toxicity. Common adverse effects

Gastrointestinal Nausea, vomiting, anorexia, abdominal cramps. These averse effects are usually il an ten to resolve with continue theray. Encourage the atient not to iscontinue theray without rst consulting the healthcare rovier. If gastric irritation occurs, ainister the eication with foo or ilk. If sytos ersist or increase in severity, reort the to the healthcare rovier for evaluation. These also ay be early signs of toxicity. Excessive thirst. This averse effect is usually il an tens to resolve within a week with continue theray. Encourage the atient not to iscontinue theray without rst consulting the healthcare rovier. If excessive thirst ersists or becoes severe, the atient shoul consult the healthcare rovier. Neurologic Fine hand tremor. If ne han treor ersists or becoes severe, the atient shoul consult the healthcare rovier. Genitourinary Excessive urination. This averse effect is usually il an tens to resolve within a week with continue

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

theray. Encourage the atient not to iscontinue theray without rst consulting the healthcare rovier. If excessive urination ersists or becoes severe, the atient shoul consult the healthcare rovier. Serious adverse effects

Gastrointestinal Persistent vomiting, profuse diarrhea. These are sytos of iening serious toxicity. Reort the ieiately an o not give the next ose of eication until ainistration has been reconre by the healthcare rovier. Neurologic Hyperreexia, lethargy, weakness. These are signs of iening serious toxicity. Reort the ieiately an o not give the next ose of eication until ainistration has been reconre by the healthcare rovier. Endocrine, metabolic Progressive fatigue, weight gain. These ay be early signs of hyothyroiis. Reort these sytos to the healthcare rovier for further evaluation. Hyperglycemia. Reort this syto to the healthcare rovier for further evaluation. Genitourinary Nephrotoxicity. Monitor urinalysis an kiney function tests for abnoral results. Reort an increasing BUN or creatinine level, increasing or ecreasing urine outut or ecreasing secic gravity (esite aequate ui intake), an casts or rotein in the urine. Rare adverse effects from lithium therapy

Pruritus, ankle edema, metallic taste. Reort these sytos for further evaluation by the healthcare rovier. Drug interactions

Reduced serum sodium levels. The theraeutic activity an toxicity of lithiu are highly eenent on soiu concentrations. Decrease soiu levels signicantly

259

enhance the toxicity of lithiu an high soiu levels result in low lithiu levels. Patients who are to begin iuretic theray, a low-soiu iet, or activities that rouce excessive an rolonge sweating shoul be observe articularly closely. Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor blockers. Angiotensin-converting enzye inhibitors (ACEIs) an angiotensin recetor blockers (ARBs) (see Chater 22) ay increase the seru concentration of lithiu. Monitor atients receiving concurrent theray. Monitoring lithiu seru levels ay be necessary. Diuretics. Diuretics ay reuce the eliination of lithiu, resulting in lithiu toxicity. Monitor the atient’s lithiu seru levels closely. Monitor atients receiving concurrent long-ter theray for signs of the eveloent of lithiu toxicity (e.g., nausea, voiting, aboinal ain, iarrhea, lethargy, seech ifculty, il izziness, treor). A lithiu level ay be necessary. Methyldopa. Monitor atients receiving concurrent long-ter theray for signs of the eveloent of lithiu toxicity (e.g., nausea, voiting, aboinal ain, iarrhea, lethargy, seech ifculty, il izziness, treor). A lithiu level ay be necessary. Nonsteroidal Antiinammatory Drugs. NSAIDs (e.g., iburofen, naroxen; see Chater 19) ay increase the seru concentration of lithiu. Monitor for signs of lithiu toxicity (e.g., nausea, voiting, aboinal ain, iarrhea, lethargy, seech ifculty, il izziness, treor). A lithiu level ay be necessary. Selective Serotonin Reuptake Inhibitors. Lithiu ay enhance the serotonergic effect of SSRIs, thereby increasing the risk of serotonin toxicity (serotonin synroe). Use the cobination of SSRIs an lithiu very cautiously, onitoring closely for signs of serotonin toxicity such as irritability, hallucinations, eliriu, increase uscle tone, shivering, yoclonus, an reuce consciousness.

260

UNIT III Drugs Affecting the Autonomic and Central Nervous System

Clinical Judgment and Next-Generation NCLEX ® Examination-Style Questions Key Points • The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), recognizes major psychiatric disorders on a continuum, with depressive disorders and psychotic spectrum at the ends of the continuum and bipolar disorders serving as a bridge between the two diagnostic classes in terms of symptomatology, family history, and genetics. The common feature among depressive and bipolar disorders is the presence of sad, empty, or irritable mood, accompanied by changes that signicantly affect the individual’s capacity to function. • Treatment of mood disorders requires both nonpharmacologic and pharmacologic therapy. Simultaneous psychotherapy and pharmacologic treatment are more successful than either treatment alone. • Antidepressant medications act on a variety of receptors in the CNS, as well as peripheral tissues, and are associated with many adverse effects and drug interactions. It is the responsibility of the nurse to educate patients about therapy and to monitor for therapeutic benet and common and serious adverse effects, as well as to intervene whenever possible to optimize therapeutic outcomes. • Be alert for serotonin syndrome with combined use of SSRIs and MAOIs, which may develop as a result of excessive accumulation of serotonin in nerve synapses. It is an uncommon event, but may be potentially fatal. Symptoms include irritability, hallucinations, delirium, reduced consciousness, increased muscle tone, myoclonus, diaphoresis, shivering, tremor, hyperthermia, and increased or decreased blood pressure and heart rate.

Additional Learning Resources

SG

Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content. Go to your Evolve website (https://evolve.elsevier.com/Clayt on) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types.

Scenario A patient with known bipolar disorder was admitted to the mental health unit for medication adjustment. 1. The nurse was assessing the patient in the scenario who came in with increasing episodes of depression. Which components are part of the baseline assessment? (Select all that apply.) 1. 2. 3. 4.

Dietary history History of previous depression episodes and treatments Sleep pattern Suicidal ideation

5. Tattoos present 6. Oral hygiene and number of dental cavities 7. Clarity of thought Objective: Describe the essential components of the baseline assessment of a patient with depression or bipolar disorder. NCLEX item type: Extended multiple response Cognitive skill: Analyze cues 2. The patient in the scenario was being treated for depression and the nurse will monitor for thoughts of suicide. Indicate with an X which behavior may indicate suicidal ideation and which is unrelated.

SYMPTOMS

SIGNIFICANT FINDING

UNRELATED FINDING

Patient remarking that the patient had a plan and was intent on carrying it out Poor hygiene Comments from the patient such as, “Things will get better after I’m gone.” Pacing in the room Excessive appetite Sleeping throughout the day Patient’s relative indicated that the patient has recently given away a collection of expensive dishes

Objective: Describe the essential components of the baseline assessment of a patient with depression or bipolar disorder. NCLEX item type: Matrix Cognitive skill: Evaluate outcomes 3. The nurse knows to assess for a severe drug interaction that can occur between SSRIs and several drug classes. Indicate with an X the drug class associated with the drug interaction (more than one interaction will apply). EXCITE- HALLUCIMENT NATIONS

DIAPHOCONVULRESIS RIGIDITY SIONS

MAOIs Lithium TCAs

Objective: Describe the common adverse effects that may develop for patients who are taking SSRIs and SNRIs. NCLEX item type: Matrix Cognitive skill: Analyze cues

Drugs Used for Depressive and Bipolar Disorders CHAPTER 16

4. The nurse is explaining to the patient taking an MAOI of the need to be aware of which condition developing? (Select all that apply.) 1. 2. 3. 4. 5.

Hyperpyrexia Constipation Hypotension Blurred vision Hypertension

Objective: Describe the common adverse effects that may develop for patients who are taking MAOIs. NCLEX item type: Multiple response Cognitive skill: Application 5. The nurse was instructing a patient staring on duloxetine (Cymbalta) on the adverse effects to expect and which ones to report. Indicate with an X the common and serious effects from SNRIs. SYMPTOMS

COMMON EFFECT

SERIOUS EFFECT

Anorexia

7. The nurse is discussing ways to prevent lithium toxicity with the patient in the scenario who currently is taking lithium. Which of the following indicate correct instructions? (Select all that apply.) 1. 2. 3. 4. 5. 6. 7.

Report symptoms of persistent vomiting Drink 10 glasses of water (8 ounces each) daily Check lithium blood levels monthly Diuretic therapy prevents lithium toxicity Report symptoms of lethargy and weakness Report symptoms of perfuse diarrhea Monitor thyroid function

Objective: Describe the common adverse effects that may develop for patients who are taking lithium. NCLEX item type: Extended multiple response Cognitive skill: Analyze cues 8. The nurse reviewed the preassessment expectations for the typical medications used for patients with depression and bipolar disorders and found that the assessment overlapped. Indicate with an X which ones are associated with each drug class.

Drowsiness MAOIS

Anxiety Agitation

Blood pressure

Suicidal ideation

Pulse

Insomnia

Glucose

Irritability and delirium

Hepatic laboratory tests

Objective: Describe the common adverse effects that may develop for patients who are taking SSRIs and SNRIs. NCLEX item type: Matrix Cognitive skill: Evaluate cues 6. Patients taking doxepin should be aware of which of the following adverse effects common to TCAs? (Select all that apply.) 1. 2. 3. 4. 5.

Orthostatic hypotension Diarrhea Dry mouth and throat Hyperglycemia Blurred vision

Objective: Describe the common adverse effects that may develop for patients who are taking TCAs. NCLEX item type: Multiple response Cognitive skill: Application

261

TCAS

SSRIS

SNRIS

ANTIMANIC AGENTS

Medication history Thyroid laboratory tests Weight History of seizures

Objective: Identify the premedication assessments that are necessary before the administration of monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and antimanic agents. NCLEX item type: Matrix Cognitive skill: Take action

17

Drugs Used for Psychoses

https://evolve.elsevier.com/Willihnganz

Objectives 1. Identify the signs and symptoms of psychotic behavior. 2. Describe the major indications for the use of antipsychotic agents.

3. Discuss the antipsychotic medications that are used for the treatment of psychoses. 4. Identify the common adverse effects that are observed with the use of antipsychotic medications.

Key Terms psychosis (sī-KŌ-sĭs) (p. 262) delusion (dĕ-LŪ-zhŭn) (p. 262) hallucinations (hă-lū-sĭ-NĀ-shŭnz) (p. 263) disorganized thinking (dĭs-ŌR-gănīzd THĬN-kĭng) (p. 263) loosening of associations (LŪ-sĕnĭng ŭv ăs-sō-sē-Ā-shŭnz) (p. 263) disorganized behavior (dĭs-ŌR-gănīzd bē-HĀV-yŭr) (p. 263) negative symptoms (NĔG-ĕ-tiv SĬMPtĕmz) (p. 263) target symptoms (TĂR-gĕt SĬMPtĕmz) (p. 263) typical (rst-generation) antipsychotic agents (TĬP-ĭ-kŭl ăn-tī-sī-KŎT-ĭk) (p. 264)

atypical (second-generation) antipsychotic agents (ā-TĬP-ĭ-kŭl ăn-tī-sī-KŎT-ĭk) (p. 264) equipotent doses (ĕk-wē-PŌ-tĕnt DŌS-ĕz) (p. 264) extrapyramidal symptoms (EPSs) (ĕks-tră-pĭ-RĂM-ĭ-dăl) (p. 264) dystonias (dĭs-TŌN-ē-ăz) (p. 268) pseudoparkinsonian symptoms (SŪ-dō-păr-kĭn-SŌ-nēĭn) (p. 268) akathisia (ă-kĕ-THĬ-zhă) (p. 268) tardive dyskinesia (TĂR-dīv dĭs-kĭ-NĒzē-ă) (p. 268)

PSYCHOSIS Psychosis does not have a single denition but is a clinical

descriptor applied to someone who is out of touch with reality. Psychotic symptoms can be associated with many illnesses, including dementias and delirium, that may have metabolic, infectious, or endocrinologic causes. The underlying illness must be treated, not just the psychosis. Psychotic symptoms are also common in patients with mood disorders such as major depression and bipolar disorder and schizophrenia spectrum. Psychosis can also be caused by many drugs (e.g., phencyclidine, opiates, amphetamines, cocaine, hallucinogens, anticholinergic agents, alcohol). Psychotic disorders are characterized by loss of reality, perceptual decits such as hallucinations and delusions, and deterioration of social functioning. Schizophrenia is the most common of the several psychotic disorders dened by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 262

Abnormal Involuntary Movement Scale (AIMS) (ăb-NŌR-mŭl ĭn-VŎLĕn-tār-ē MŌV-mĕnt SKĀL) (p. 269) Dyskinesia Identication System; Condensed User Scale (DISCUS) (dĭs-kĭ-NĒ-zē-a ī-dĕn-tĭ-fĭKĀ-shŭn SĬS-tĕm: kŏn-DĔNST YŪ-zŭr SKĀL) (p. 269) neuroleptic malignant syndrome (NMS) (nyū-rō-LĔP-tĭk mă-LĬG-nănt SĬN-drōm) (p. 269) depot antipsychotic medicine (DĔ-pō ăn-tē-sī-KŎT-ĭk) (p. 269)

Psychotic disorders are extremely complex illnesses that are inuenced by biologic, psychosocial, and environmental circumstances. Some of the disorders require several months of observation and testing before a nal diagnosis can be determined. It is beyond the scope of this text to discuss psychotic disorders in detail, but general types of symptoms associated with psychotic disorders will be described. A delusion is a false or irrational belief that is rmly held despite obvious evidence to the contrary. Delusions may be persecutory, grandiose, religious, sexual, or hypochondriacal. Delusions of reference—in which the patient attributes a special, irrational, and usually negative signicance to other people, objects, or events, such as song lyrics or newspaper articles, in relation to self—are common. Delusions may be dened as “bizarre” if they are clearly irrational and do not derive from ordinary life experiences. A common bizarre delusion is the patient’s belief that their

Drugs Used for Psychoses CHAPTER 17

thinking process, body parts, or actions or impulses are controlled or dictated by some external force. Hallucinations are false sensory perceptions that are experienced without an external stimulus and seem real to the patient. Auditory hallucinations experienced as voices that are characteristically heard commenting negatively about the patient in the third person are prominent among patients with schizophrenia. Hallucinations of touch, sight, taste, smell, and bodily sensation also occur. Disorganized thinking is commonly associated with psychoses. These thought disorders may consist of a loosening of associations or a ight of ideas so that the speaker jumps from one idea or topic to another unrelated one (derailment) in an illogical, inappropriate, or disorganized way. Answers to questions may be obliquely related or completely unrelated (tangentiality). At its most serious, this incoherence of thought extends into pronunciation itself and the speaker’s words become garbled or unrecognizable. Speech may also be overly concrete (loss of ability to think in abstract terms) and inexpressive; it may be repetitive and may convey little or no real information. Disorganized behavior is another common characteristic of psychosis. Problems may be noted with any form of goal-directed behavior, leading to difculties with performing activities of daily living such as organizing meals or maintaining hygiene. The patient may appear markedly disheveled, may dress in an unusual manner (e.g., wearing several layers of clothing, scarves, and gloves on a hot day), or may display clearly inappropriate sexual behavior (e.g., public masturbation) or unpredictable, nontriggered agitation (e.g., shouting, swearing). Negative symptoms, or changes in affect, may also be symptoms of psychosis. Emotional expressiveness is diminished; there is poor eye contact and reduced spontaneous movement. The patient appears to be withdrawn from others, and the face appears to be immobile and unresponsive. Speech is often minimal (alogia), with only brief, slow, monotone replies given in response to questions. There is a withdrawal from areas of functioning that affect interpersonal relationships, work, education, and self-care (asociality), and anhedonia, the decreased ability to experience pleasure from positive stimuli or reduced pleasure from previously positive stimuli.

TREATMENT OF PSYCHOSIS The importance of the initial assessment for an accurate diagnosis cannot be overestimated for a patient with acute psychosis. A thorough physical and neurologic examination, a mental status examination, a complete family and social history, and a laboratory workup must be performed to exclude other causes of psychoses, including substance abuse. Both drug and nondrug therapies are critical to the treatment of most psychoses. Long-term outcome is improved for patients with an integrated drug and nondrug treatment regimen.

263

Nonpharmacologic interventions benecial to patients include (1) individual psychotherapy to improve insight into the illness and help the patient cope with stress; (2) group therapy to enhance socialization skills; (3) behavioral or cognitive therapy; and (4) vocational training. Referral to community resources such as the National Alliance on Mental Illness (NAMI) may provide additional support for the patient and family. Before initiating therapy, the treatment goals and baseline level of functioning must be established and documented. Target symptoms must also be identied and documented. Target symptoms are critical monitoring parameters used to assess changes in an individual’s clinical status and response to medications. Examples of target symptoms include frequency and type of agitation, degree of suspiciousness, delusions, hallucinations, loose associations, grooming habits and hygiene, sleep patterns, speech patterns, social skills, and judgment. The ultimate goal is to restore behavioral, cognitive, and psychosocial processes and skills to as close to baseline levels as possible so that the patient can be reintegrated into the community. Realistically, unless the psychosis is part of another medical diagnosis such as substance abuse, most patients will have recurring symptoms of the mental disorder for most of their lives. Therefore treatment is focused on decreasing the severity of the target symptoms that most interfere with functioning. A variety of scales have been developed to assist with the objective measurement of change in target symptoms in response to psychotherapy and pharmacotherapy. These include the Brief Psychiatric Rating Scale (BPRS), the Positive and Negative Syndrome Scale for Schizophrenia (PANSS), the Clinical Global Impression (CGI) scale, and the Rating of Aggression Against People and/or Property (RAAPP) scale.

DRUG THERAPY FOR PSYCHOSIS Pharmacologic treatment of psychosis includes several classes of drugs. The most specic are the rst- and second-generation antipsychotic agents, but benzodiazepines (see Chapter 15) are often used to control acute psychotic symptoms. Beta-adrenergic blocking agents (beta blockers; e.g., propranolol) (see Chapter 12), lithium (see Chapter 16), anticonvulsants (e.g., valproic acid) (see Chapter 18), carbamazepine (see Chapter 18), antiparkinsonian agents (see Chapter 14), and anticholinergic agents (see Chapters 12 and 14) occasionally play a role in controlling the adverse effects of medications used in antipsychotic therapy. Antipsychotic (also known as neuroleptic) medications can be classied in several ways. Traditionally, they have been divided into phenothiazines and nonphenothiazines. Antipsychotic medications can also be classied as low-potency or high-potency drugs. The terms low potency and high potency refer only to the milligram doses used for these medicines and not to any difference in effectiveness (e.g., 100 mg of chlorpromazine, a low-potency drug, is equivalent in

264

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

antipsychotic activity to 2 mg of haloperidol, a highpotency drug). Chlorpromazine and thioridazine are low-potency drugs, whereas triuoperazine, uphenazine, thiothixene, haloperidol, and loxapine are highpotency drugs. Since 1990, antipsychotic medications have also been classied as typical (rst-generation) antipsychotic agents or atypical (second-generation) antipsychotic agents on the basis of their mechanism of action (see Table 17.1 later in this chapter). The atypical antipsychotic agents are aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, pimavanserin, quetiapine, risperidone, and ziprasidone. All of the remaining antipsychotic agents listed in Table 17.1 are typical antipsychotic agents. ACTIONS The typical antipsychotic medications block the neurotransmitter dopamine in the central nervous system (CNS). The atypical antipsychotic agents block dopamine receptors, but they also block serotonin receptors to varying degrees. However, the exact mechanisms whereby these actions prevent psychotic symptoms are unknown. There is substantially more to the development of psychotic symptoms than elevated dopamine levels. There are at least ve known types of dopamine receptors and several more types of serotonin receptors in various areas of the CNS. Antipsychotic medications also stimulate or block cholinergic, histaminic, nicotinic, alpha-adrenergic, and beta-adrenergic neurotransmitter receptors to varying degrees, accounting for many of the adverse effects of therapy. Pimavanserin differs from other atypical antipsychotics in that it selectively blocks a serotonin (5-hydroxytryptamine) receptor (5-HT2A) and lacks activity at dopamine receptors. It is effective in treating psychosis related to Parkinson disease dementia. Using atypical antipsychotics for treatment of Parkinson disease dementia-related psychosis can worsen Parkinson disease motor symptoms. Because of pimavanserin’s lack of activity at dopamine receptors, it does not aggravate Parkinson disease’s motor symptoms.

Medication Safety Alert Increased Mortality in Elderly Patients With Dementia-Related Psychosis Antipsychotic drugs increase the all-cause risk of death in elderly patients with dementia-related psychosis.

USES All antipsychotic medications are equal in efcacy when used in equipotent doses. There is some unpredictable variation among patients, however, and individual patients sometimes show a better response to particular drugs. In general, medication should be selected on the basis of the need to avoid certain adverse effects when dealing with concurrent medical or psychiatric disorders. Despite practice trends, no proof

exists that agitation responds best to sedating drugs or that withdrawn patients respond best to nonsedating drugs. There are several reasons that a patient may become agitated, such as pain, fear, and confusion. Nonpharmacologic methods may be helpful initially to manage agitated patients by seeking the source of agitation and meeting their needs. This is especially true for patients who have difculty communicating (e.g., dementia, aphasia, or other cognitive impairment). If medications are needed, a medication history should be a major factor in drug selection. The nal important factors in drug selection are the clinically important differences in the frequency of adverse effects. No single drug is least likely to cause all adverse effects; thus individual response should be the best determinant of which drug is to be used. The atypical antipsychotic agents tend to be more effective in relieving the negative and cognitive symptoms associated with schizophrenia and treating refractory schizophrenia, and they have a much lower incidence of extrapyramidal symptoms (EPSs) and hyperprolactinemia. The initial goals of antipsychotic therapy are calming the agitated patient, who may be a physical threat to himself or herself or to others, and beginning the treatment of the psychosis and thought disorder. Combined therapy with benzodiazepines (often lorazepam) and antipsychotic medications allows lower dosages of the antipsychotic medication to be used, reducing the risk of serious adverse effects more commonly seen with higher-dose therapy. Some therapeutic effects, such as reduced psychomotor agitation and insomnia, are observed within 1 week of therapy, but reductions in hallucinations, delusions, and thought disorder often require 6 to 8 weeks of treatment to achieve the full therapeutic effect. Rapid increases in the dosing of antipsychotic medications will not reduce the antipsychotic response time. Patients, families, and the healthcare team must be informed about giving antipsychotic agents an adequate chance to work before unnecessarily escalating the dosage and increasing the risk of adverse effects.

Clinical Pitfall During episodes of acute psychosis, the patient is out of touch with reality and often does not understand the need to take medicines that will help stabilize their condition. The nurse must ensure that the patient has actually swallowed the medication when it is administered and not just “mouthed” or “cheeked” it. Outpatients often require that medication administration be supervised to ensure adherence to the medication regimen. In some cases, it is necessary to inject long-acting medicines to overcome a patient’s nonadherence problem. After an acute psychotic episode has resolved and the patient is free from overt psychotic symptoms, a decision must be made as to whether maintenance therapy is necessary. This will depend on the diagnosed psychotic disorder and the patient’s tolerance of the adverse effects of the medication. However, most psychotic disorders are treated with lower maintenance dosages to minimize the risk of recurrence of the disorder’s psychotic episodes (Box 17.1).

Table 17.1 Antipsychotic Agents GENERIC NAME BRAND NAME TYPICAL (FIRST-GENERATION) ANTIPSYCHOTIC AGENTS Phenothiazines chlorpromazine Do not confuse chlorpromazine with chlordiazepoxide, chlorhexidine, chlorpropamide, or chlorthalidone.

Teva-Chlorpromazine

ADULT DOSAGE RANGE (MG)

SEDATION

MAJOR ADVERSE EFFECTS EXTRAPYRAMIDAL ANTICHOLINERGIC SYMPTOMS HYPOTENSION EFFECTS

Tablets: 10, 25, 50, 100, 200 mg Injection: 25 mg/mL

25–2000

+++

++

+++

++

Tablets: 1, 2.5, 5, 10 mg Elixir: 2.5 mg/5 mL Concentrate: 5 mg/mL Injection: 2.5 mg/mL; 25 mg/mL

0.5–40

+

++++

+

+

AVAILABILITY

– PMS—Fluphenazine

perphenazine

—

Tablets: 2, 4, 8, 16 mg

12–64

+

+++

+

++

prochlorperazine

– Prochlorazine

Tablets: 5, 10 mg Injection: 5 mg/mL Suppository: 25 mg

15–150

+

+++

+

+

thioridazine

–

Tablets: 10, 25, 50, 100 mg

200–800

+++

+

+++

+++

triuoperazine

–

Tablets: 1, 2, 5, 10 mg

2–40

+

+++

+

+

Thioxanthenes thiothixene

—

Capsules: 1, 2, 5, 10 mg

6–60

+

+++

+

+

Haldol Teva-Haloperidol

Tablets: 0.5, 1, 2, 5, 10, 20 mg Concentrate: 2 mg/mL Injection: 5 mg/mL Injection, sustained release: 50 mg/ml and 100 mg/mL

1–100

+

+++

+

+

Capsules: 5, 10, 25, 50 mg

20–250

++

+++

++

+

Nonphenothiazines haloperidol

loxapine Do not confuse loxapine with Lexapro.

Xylac

Drugs Used for Psychoses CHAPTER 17

uphenazine

265

10–30

+

+

+

0

Saphris Secuado

Tablets, sublingual: 2.5, 5, 10 mg Transdermal patch (24 hr): 3.8, 5.7, 7.6 mg

5–20

++

++

++

+

brexpiprazole

Rexulti

Tablets: 0.25, 0.5, 1, 2, 3, 4 mg

2–4

+

+

0/+

0/+

cariprazine

Vraylar

Capsules: 1.5, 3, 4.5, 6 mg

1.5–6

+

++

0/+

0/+

clozapine

Clozaril Do not confuse Clozaril with Colazal. Versacloz

Tablets: 25, 50, 100, 200 mg Tablets, orally disintegrating: 12.5, 25, 100, 150, 200 mg Oral suspension: 50 mg/mL in 100 mL bottle

300–900

+++

+

+++

++

iloperidone

Fanapt

Tablets: 1, 2, 4, 6, 8, 10, 12 mg

2–24

++

+

++

++

lumateperone

Caplyta

Capsules: 42 mg

42

++

+

++

++

lurasidone

Latuda

Tablets: 20, 40, 60, 80, 120 mg

20–160

++

++

++

++

olanzapine Do not confuse olanzapine with oxcarbazepine.

Zyprexa Do not confuse Zyprexa with Celexa, Zaroxolyn, or Zyrtec. Zyprexa Zydis Relprevv Zyprexa

Tablets: 2.5, 5, 7.5, 10, 15, 20 mg

PO: 5–20 IM short acting: 30 mg IM sustained release: 300 mg q 2 weeks

++

+

++

+++

paliperidone

Invega

Tablets, extended release: 1.5, 3, 6, 9 mg IM injection, suspension: 39, 78, 117, 156, 234 mg IM injection, suspension: 273, 410, 546, 819 mg

3–12

+

+++

++

0

Tablets: 10 mg Capsules: 34 mg

34

+

0/+

++

+

Invega Sustenna Invega Trinza pimavanserin

Nuplazid

Tablets, orally disintegrating: 5, 10, 15, 20 mg Injection: 10 mg Injection, sustained release: 210, 300, 405 mg

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

asenapine

266

ATYPICAL (SECOND-GENERATION) ANTIPSYCHOTIC AGENTS aripiprazole Abilify Tablets: 2, 5, 10, 15, 20, 30 mg Abilify Maintena Tablets, orally disintegrating: 10, 15 mg Oral solution: 1 mg/mL Injection, intramuscular suspension: 300, 400 mg Prelled syringes: 300, 400 mg

Continued

Table 17.1 Antipsychotic Agents—cont’d SEDATION ++

MAJOR ADVERSE EFFECTS EXTRAPYRAMIDAL ANTICHOLINERGIC SYMPTOMS HYPOTENSION EFFECTS 0 ++ 0

Tablets: 0.25, 0.5, 1, 2, 3, 4 mg 2–16 Tablets, orally disintegrating: 0.25, 0.5, 1, 2, 3, 4 mg PO solution: 1 mg/mL IM injection, suspension: 12.5, 25, 37.5, 50 mg Prelled syringe: 90, 120 mg

+

++

++

+

Capsules: 20, 40, 60, 80 mg IM injection: 20 mg

+

++

+

++

GENERIC NAME quetiapine

BRAND NAME Seroquel Do not confuse Seroquel with or Sertraline. Seroquel XR

AVAILABILITY Tablets: 25, 50, 100, 200, 300, 400 mg Tablets, 24-hr extended release: 50, 150, 200, 300, 400 mg

risperidone

Risperdal Do not confuse Risperdal with estradiol, reserpine, Restoril, risedronate, or ropinirole. Risperdal Consta Perseris

ziprasidone Do not confuse ziprasidone with zidovudine.

Geodon

ADULT DOSAGE RANGE (MG) 50–800

40–160

Available in Canada. Do not confuse.

Drugs Used for Psychoses CHAPTER 17 267

268

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

Box 17.1

Antipsychotic Medicines: Response Times and Adverse Effects

Patients who begin antipsychotic drug therapy can expect some therapeutic effects, such as reduced psychomotor agitation and insomnia, within 1 week of starting treatment. However, reduction in hallucinations, delusions, and thought disorders often requires 6 to 8 weeks for a full therapeutic response to be achieved. Rapid increases in dosages of antipsychotic medications will not reduce the antipsychotic response time but will increase the frequency of adverse effects. Antipsychotic medicines may produce extrapyramidal effects. Tardive dyskinesia may be reversible during its early stages, but it becomes irreversible with continued use of the antipsychotic medication. Regular assessment for tardive dyskinesia should be performed for all patients receiving antipsychotic drugs. Older adult patients should be observed for hypotension and tardive dyskinesia.

ADVERSE EFFECTS OF ANTIPSYCHOTIC DRUG THERAPY EXTRAPYRAMIDAL SYMPTOMS Many of the serious adverse effects of antipsychotic medications can be attributed to the pharmacologic effect of blocking dopaminergic, cholinergic, histaminic, serotonergic, and adrenergic neurotransmitter receptors. Although these agents block D2 dopamine receptors in the mesolimbic area of the brain to stop psychotic symptoms, blockade of D2 receptors in other areas of the brain explains the occurrence of EPSs. EPSs are the most troublesome adverse effects and the most common cause of nonadherence associated with antipsychotic therapy. There are four categories of EPSs: dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia. Acute dystonia has the earliest onset of all the EPSs. Dystonias are spasmodic movements (prolonged tonic contractions) of muscle groups such as tongue protrusion, rolling back of the eyes (oculogyric crisis), jaw spasm (trismus), and neck torsion (torticollis). These symptoms are often frightening and painful for the patient. Approximately 90% of all dystonic reactions occur during the rst 72 hours of therapy. Dystonic reactions are most frequent in male patients, younger patients, and patients receiving high-potency medications such as haloperidol. Dystonic reactions are generally brief and are the EPSs most responsive to treatment. Acute dystonic reactions may be controlled by intramuscular injections of diphenhydramine, benztropine, diazepam, or lorazepam. Rating scales for assessing patients with different forms of dystonias include the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), the Global Dystonia Scale (GDS), the Unied Dystonia Rating Scale (UDRS), and the Fahn-Marsden Scale.

Pseudoparkinsonian symptoms of tremor, muscular rigidity, mask-like expression, shufing gait, and loss or weakness of motor function typically begin after 2 to 3 weeks of antipsychotic drug therapy but may occur up to 3 months after starting therapy. They are more commonly seen in older adults. These symptoms result from a relative deciency of dopamine, with cholinergic excess, caused by antipsychotic medications and are well controlled by anticholinergic antiparkinsonian drugs (e.g., benztropine, diphenhydramine, trihexyphenidyl). Akathisia is a syndrome consisting of subjective feelings of anxiety and restlessness and objective signs of pacing, rocking, and inability to sit or stand in one place for extended periods. Akathisia can increase aggression and is a frequent cause of noncompliance. It occurs more commonly when high-potency antipsychotic medications are used. The mechanism of action is unknown. Reducing the dosage of the antipsychotic medication or switching to a lower-potency drug should be considered. Treatment with anticholinergic agents, benzodiazepines (e.g., diazepam, lorazepam), beta blockers (e.g., propranolol), and clonidine has shown varying degrees of success. Tardive dyskinesia is a syndrome of persistent and involuntary hyperkinetic abnormal movements. It develops in about 20% to 25% of patients receiving typical antipsychotic medications on a long-term basis (e.g., months to years). There appears to be a lower incidence in patients receiving atypical antipsychotic agents, but these agents are newer, and it sometimes takes years for tardive dyskinesia to develop. This drug-induced, late-appearing neurologic disorder is noted for such symptoms as buccolingual masticatory syndrome or orofacial movements. The buccolingual masticatory movements begin with mild forward, backward, or lateral tongue movement. As the disorder progresses, more obvious movements appear, including tongue thrusting, rolling, or “y-catching” movements, as well as chewing or lateral jaw movements that produce smacking noises. Symptoms may interfere with the patient’s ability to chew, speak, or swallow. Facial movements include frequent blinking, brow arching, grimacing, and upward deviation of the eyes. The severity of symptoms of tardive dyskinesia can uctuate daily and symptoms often will remit during sleep. The clinical manifestations of tardive dyskinesia are similar to those of dystonias, but there are some signicant differences. Tardive dyskinesia typically appears after antipsychotic dosage reduction or discontinuation, it improves when the antipsychotic dosage is increased, it worsens with the administration of anticholinergic agents, and it may persist for months or years after antipsychotic medicines are discontinued. The exact cause of tardive dyskinesia is unknown. Early signs may be reversible but, over time, they may become irreversible, even with discontinuation of the antipsychotic medicine.

Drugs Used for Psychoses CHAPTER 17

The best treatment approach to tardive dyskinesia is prevention. Patients who receive maintenance antipsychotic drug therapy should be assessed for early signs of tardive dyskinesia at least semiannually and preferably quarterly. Findings should be documented in patient records to ensure continuity of care and medicolegal protection. Because of the variability in severity and presentation, rating scales have been developed to standardize assessments and diagnoses. The Abnormal Involuntary Movement Scale (AIMS) rates dyskinetic movements, but it is not exclusively diagnostic for tardive dyskinesia (see Evolve website). The Dyskinesia Identication System: Condensed User Scale (DISCUS)

rates the presence and severity of abnormal movements and considers other variables when formulating a conclusion. The DISCUS evaluation specically describes the type of tardive dyskinesia and allows diagnoses to change over time (see Evolve website). Treatment of tardive dyskinesia is not particularly successful. When feasible, immediate tapering and discontinuation of the offending antipsychotic drug is recommended when signs of tardive dyskinesia become apparent. Antipsychotic drug cessation (or dose reduction) must be carefully considered because of the potential for relapse or worsening of psychotic symptoms. If a patient receiving a typical antipsychotic medicine develops signs of tardive dyskinesia, switching to an atypical antipsychotic may alleviate the adverse effects. If the patient is receiving an anticholinergic for tardive dyskinesia the dose should be reduced, gradually discontinued, or switched to amantadine. Other options to treat tardive dyskinesia are the vesicular monoamine transporter 2 (VMAT2) inhibitors, valbenazine (Ingrezza) and deutetrabenazine (Austedo). These agents act centrally by depleting dopamine storage in presynaptic vesicles. Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse effect of antipsychotic therapy in which the patient displays EPSs as part of the symptoms of the disorder. It occurs in 0.5% to 1.4% of patients receiving antipsychotic therapy and is reported most often with high-potency antipsychotic agents given intramuscularly. It typically occurs after 3 to 9 days of treatment with antipsychotic medications, and it is not related to dosage or previous drug exposure. Once NMS begins, symptoms rapidly progress over 24 to 72 hours. Symptoms usually last for 5 to 10 days after discontinuation of oral medications and 13 to 30 days with depot antipsychotic medicine (depot: injectable, slow-release dose form). Most cases of NMS occur in patients younger than 40 years old, and it occurs twice as often in men. The syndrome is characterized by the following: fever, severe EPSs (e.g., lead-pipe rigidity, trismus, choreiform movements, opisthotonos), autonomic instability (e.g., tachycardia, labile hypertension, diaphoresis, incontinence), and alterations in consciousness (e.g., stupor, mutism, coma). Mortality rates have been as high as 30%, but prompt recognition

269

of the symptoms has reduced the mortality rate to 4% in recent years. It is hypothesized that the cause of the symptoms is excessive dopamine depletion. Treatment includes bromocriptine or amantadine as dopamine agonists and dantrolene as a muscle relaxant. Fever is treated with cooling blankets, adequate hydration, and antipyretics. After the patient’s condition has stabilized, a thorough evaluation of the medications being prescribed must be made. Resumption of the antipsychotic medication may result in a recurrence of NMS; therefore the lowest dose possible of an antipsychotic agent is prescribed, and close observation of the patient’s response is required. SEIZURES Antipsychotic agents may lower the seizure threshold in patients with seizure disorders and even in those with no previous history of seizures. The low-potency typical agents and clozapine, an atypical agent, have a higher incidence of inducing seizures. WEIGHT GAIN Antipsychotic drug therapy often causes substantial weight gain. There is a higher prevalence of obesity associated with schizophrenia, and the weight gain often contributes to nonadherence to therapy. Obesity leads to an increased risk of type 2 diabetes mellitus, dyslipidemia, hypertension, coronary heart disease, and stroke (see Chapter 20). The frequency and amount of weight gain are generally greater with atypical agents than with typical medications, although individual atypical agents vary in the extent to which they cause weight gain. Of the atypical agents, clozapine and olanzapine cause the most weight gain, moderate weight gain is reported with risperidone and quetiapine, and aripiprazole and ziprasidone cause the least weight gain. HYPERGLYCEMIA Hyperglycemia and the development of diabetes is reported particularly with atypical antipsychotic agents. The mechanism whereby this occurs is unknown, and research in this area is more difcult because patients with schizophrenia also have a twofold to threefold higher incidence of diabetes mellitus than the general population. Hyperglycemia occurs more frequently with clozapine, olanzapine, and quetiapine, but development of hyperglycemia with the other atypical agents can occur. DYSLIPIDEMIA Dyslipidemia has been reported with atypical antipsychotic agents. The risk prole may differ between agents. DYSRHYTHMIAS Thioridazine, ziprasidone, haloperidol, quetiapine, olanzapine, asenapine, iloperidone, lurasidone, and risperidone have rarely been associated with torsades

270

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

de pointes—a ventricular dysrhythmia associated with prolongation of the QTc interval on the electrocardiogram, syncope, and sudden death. Bradycardia, electrolyte imbalance (hypokalemia, hypomagnesemia), presence of congenital prolongation of the QTc interval, and concomitant use of other medications that may signicantly prolong the QTc interval (e.g., quinidine, sotalol, moxioxacin, dofetilide) can increase the risk of torsades de pointes and sudden death in patients receiving antipsychotic agents.

OTHER ADVERSE EFFECTS Other adverse effects of antipsychotic therapy can also be predicted on the basis of the receptor-blocking activity of the agents: • Blocking the cholinergic (acetylcholine) receptors explains the anticholinergic effects (e.g., dry mouth, constipation, sinus tachycardia, blurred vision, inhibition or impairment of ejaculation, urinary retention) associated with antipsychotic agents. • Blocking histamine-1 receptors causes sedation, drowsiness, and appetite stimulation and contributes to the hypotensive effects and potentiation of CNS depressant drugs. Antipsychotic agents also block alpha-1 and alpha-2 adrenergic receptors, causing postural hypotension, sexual dysfunction, reex tachycardia, and potentiation of antihypertensive agents. The most potent alpha-1 blockers are chlorpromazine and thioridazine, whereas haloperidol has almost no effect on alpha-1 receptors. Antipsychotic agents may produce many adverse effects other than those already listed, including hepatotoxicity, blood dyscrasias, allergic reactions, endocrine disorders, skin pigmentation, and reversible effects in the eyes. Patients receiving clozapine are particularly susceptible to developing agranulocytosis. Regularly scheduled white blood cell (WBC) counts are mandatory.

Clinical Pitfall Antipsychotic medicines may have adverse effects such as seizure activity, pseudoparkinsonian symptoms, tardive dyskinesia, and hepatotoxicity that require management by the prescribing healthcare provider. The patient and those providing supervision need to understand the importance of reporting any of these symptoms promptly for appropriate interventions.

NURSING IMPLICATIONS FOR ANTIPSYCHOTIC THERAPY Assessment History of behavior

• Gather information from the patient and other individuals relating to the onset, duration, and progression of the patient’s symptoms. Has the patient previously been treated for this or other mental

disorders? Does the patient have any coexisting health conditions? • Take a detailed history of all medications that the patient is taking or has taken during the past 3 months. • Inquire about the use of illegal substances. Basic mental status

• Note the patient’s general appearance and appropriateness of attire. Is the patient clean and neat? Is the posture erect, stooped, or slumped? Is the patient oriented to date, time, place, and person? • What coping mechanisms has the patient been using to deal with the situation? How adaptive are the coping mechanisms? Initiate changes in maladaptive coping mechanisms by guiding the patient toward the use of more adaptive coping strategies. • Has the patient been able to carry out self-care activities and social and work obligations? • Are symptoms of depression present? Symptoms may not be evident during the acute phase of schizophrenia. Interpersonal relationships. Assess the quality of the

relationships in which the patient is involved. Identify people in the patient’s life who are supportive. Ask the family and signicant others to describe the relationship they have with the patient. Has there been deterioration in their closeness and their ability to interrelate effectively? Mood and affect. Patients experiencing altered think-

ing, behavior, or feelings require careful evaluation of their verbal and nonverbal actions. Often the thoughts, feelings, and behaviors displayed are inconsistent with the so-called normal responses of individuals in similar circumstances. • Is the facial expression worried, sad, angry, or blank? • Is the patient displaying behaviors that are inappropriate or blunted? Does the patient have a at affect? • Is the patient apathetic to normal situations? • Is there consistency when the patient is expressing feelings verbally and nonverbally? • Does the patient overreact to situations at times? Clarity of thoughts and perception

• Does the patient suffer from delusions, disorganized speech pattern, ight of ideas, autism, grandiose ideas, or mutism? Ask about the presence of hallucinations (auditory, visual, tactile). • Does the patient talk about unrelated topics (loose association) as though they are connected and related? • Is the patient self-absorbed and not in contact with reality? • Does the patient display an interruption of thoughts? • Does the patient display paranoid behavior?

Drugs Used for Psychoses CHAPTER 17

Suicidal ideation. Ask the patient whether they have

ever had thoughts about suicide. If the response is “yes,” get more details. Has a specic plan been formulated? How often do these thoughts occur? Does the patient make direct or indirect statements regarding death (e.g., “things would be better” if death occurred)? Psychomotor function. What is the patient’s activity

level? Is the individual unable to sit still and instead paces continually? Is the patient catatonic (i.e., immobile as a result of psychological dysfunction)?

•

•

•

Sleep pattern. What is the patient’s normal sleep pat-

tern, and how has it varied since the onset of the psychotic symptoms? Ask specically whether insomnia is present. Ask the patient to describe their perception of the amount and quality of sleep nightly. What is the level of fatigue? Are naps taken regularly? Dietary history. Ask questions about the patient’s ap-

petite and note weight gains or losses not associated with intentional dieting. Implementation • Nursing interventions must be individualized and based on patient assessment data. • Provide the individual with a structured environment that is safe and that decreases external stimuli. • Provide an environment of acceptance that focuses on the individual’s strengths while minimizing weaknesses. • Provide an opportunity for the patient to express feelings. Use active listening and therapeutic communication techniques. Allow the patient to express feelings in nonverbal ways, such as involvement in physical activities or occupational therapy. • Allow the patient to make decisions, if capable; make those decisions that the patient is not capable of making. Provide a reward for progress when decisions are initiated appropriately. • Involve the patient in self-care activities. Assist with personal grooming as needed. Ensure that the patient is dressed appropriately. • Set limits for the patient to handle inappropriate behaviors and enforce them in a kind, rm manner. • Once the content is known, do not reinforce the patient’s hallucinations or delusions. • When the patient has altered perceptions, provide diversionary activities and minimize interactions, such as viewing television programs that may reinforce the distorted perceptions. • Be open and direct when handling a patient who is highly suspicious. Speak distinctly to be heard; do not whisper or laugh in circumstances that the patient could misconstrue. • If the patient is suicidal, ask for details about the plan being formulated. Follow up on details

•

271

obtained with appropriate family members or signicant others. Provide for patient safety and supervision as appropriate. Use physical restraints within the guidelines of the clinical setting as appropriate to the behaviors being exhibited. Use the least restrictive alternative possible for the circumstances. Provide for nutritional needs by having high-protein, high-calorie foods appropriate for the individual to eat while pacing or highly active. Give vitamins and liquid supplemental feedings as ordered. Provide an opportunity for the individual to be involved in selecting foods appropriate to needs (to lose or gain weight). If the person is paranoid and suspects being poisoned, allow the individual to self-serve food, open canned food, and perform other activities, as appropriate within the setting. Manipulative behavior must be handled in a consistent manner by all staff members. Set limits and use consequences that are agreed to in advance by all staff members. When the patient attempts to blame others, refocus on the patient’s responsibilities. Give positive reinforcement for nonmanipulative behaviors when they occur.

Patient Education • Orient the individual to the unit. Explain the rules and the process of privileges and how they are obtained or lost. (The extent of the orientation and explanations given will depend on the patient’s orientation to date, time, and place, as well as their abilities.) • Base patient education on assessment data and individualize instruction to provide the patient with a structured environment. • Explain the activity groups available and how and when the individual will participate in them. • Involve the patient and family in establishing outcomes and integrate the patient into the appropriate group processes to develop positive experiences to enhance coping skills. • Before discharge, make sure the patient and the family understand the desired treatment outcomes and the entire follow-up plan (e.g., frequency of therapy sessions, prescribed medications, primary healthcare provider visits, return-to-work goals). Fostering health maintenance

• Throughout the course of treatment, discuss medication information and how it will benet the patient’s symptoms and circumstances. Drug therapy is a major portion of antipsychotic therapy. Although symptoms may improve, they may not be totally eliminated. The onset of a drug’s effectiveness varies widely, depending on the drug and the route of administration. • Nonadherence is a major problem in this group of patients; therefore tracking the medications being

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UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

taken requires careful scrutiny. On an outpatient basis, many of these patients need their medications administered by another responsible individual. Nonadherence is thought to be a major cause of repeat hospitalization in these patients. Long-acting injections may be used for some patients in an attempt to overcome this problem. On an inpatient basis, the nurse must always check to be sure that the patient is actually swallowing the medication because there is a high incidence of “cheeking” (i.e., hiding drugs between the teeth and gums). • Use baseline clinical evaluation rating scales (e.g., BPRS, CGI, PANSS) and adverse effect scales (e.g., GDS, TWSTRS for dystonias, DISCUS or AIMS for EPSs) at specied intervals; record and report ndings in accordance with agency policy. • Seek cooperation and understanding of the following points so that medication adherence is increased: name of the medication; its dosage, route, and time of administration; and its common and serious adverse effects. Encourage the patient not to discontinue or adjust the drug dosage without consulting the healthcare provider. Provide the patient and family with information about available community resources, including the NAMI. Patient self-assessment. Enlist the patient’s help with

developing and maintaining a written record of monitoring parameters. See the Template for Developing a Written Record for Patients to Monitor Their Own Therapy on the Evolve website, and complete the Premedication Data column for an assessment of the patient’s physical and mental capabilities as a baseline to track the patient’s response to drug therapy. Ensure that the patient understands how to use the form, and instruct the patient to bring the completed form to follow-up visits. Because there are a number of debilitating adverse effects and others that are life threatening if they are not acted on correctly, it is important to maintain open communication with healthcare providers, nurses, therapists, and pharmacists throughout the course of therapy.

DRUG CLASS: ANTIPSYCHOTIC AGENTS Actions Although the antipsychotic medications are from distinctly different chemical classes, all are similar in that they act by blocking the action of dopamine in the brain. The exception is pimavanserin, which selectively blocks the 5-HT2A serotonin receptor and lacks activity at dopamine receptors. The atypical antipsychotic agents block serotonin receptors in addition to dopamine receptors. Because all the antipsychotic agents work at different sites in the brain, adverse effects are observed in different body systems. Atypical antipsychotic agents tend to be more effective and have fewer adverse effects than typical agents.

Uses Antipsychotic agents are used to treat psychoses associated with mental illnesses such as schizophrenia, mania, and psychotic depression. Medications used to treat these disorders are grouped into two broad categories (Table 17.1): rst-generation antipsychotic drugs, also known as typical antipsychotic drugs, including the phenothiazines and nonphenothiazines (e.g., thioxanthenes, haloperidol, loxapine); and secondgeneration antipsychotic drugs, also known as atypical antipsychotic drugs (e.g., aripiprazole, olanzapine, quetiapine, risperidone). The atypical antipsychotics (except pimavanserin) are usually used rst line to provide signicant relief of active psychotic symptoms such as hallucinations, delusions, and thought disorganization for approximately 70% of patients with schizophrenia. In addition, several of the atypical antipsychotics are used for treatment of bipolar disorder (e.g., lurasidone) and as adjunctive treatment to major depressive disorders (e.g., aripiprazole). Risperidone is used to treat irritability associated with autistic disorder in children and adolescents. Clozapine is reserved for more resistant cases that do not respond adequately to the other atypical agents. All these antipsychotic medications also signicantly reduce the risk of recurrence. Pimavanserin is used for the treatment of hallucinations and delusions associated with Parkinson disease dementia-related psychosis. As clinical experience is being gained with the second-generation antipsychotic drugs, dramatic weight gain, diabetes mellitus, electrocardiographic changes (e.g., QT interval prolongation), and dyslipidemia have been reported. The risk of these potentially serious adverse effects is not the same with all drugs, but the US Food and Drug Administration has issued precautionary statements to encourage close monitoring of body weight, blood glucose, and serum lipid levels in all patients receiving these antipsychotic agents. Therapeutic Outcome The primary therapeutic outcome expected from antipsychotic therapy is maintaining the individual at an optimal level of functioning, with minimal exacerbations of psychotic symptoms and minimal adverse effects from medicines. Nursing Implications for Antipsychotic Agent Therapy Premedication assessment

1. Obtain baseline blood pressures with the patient supine and standing; record and report signicant lowering to the healthcare provider before administering the medicine. Monitor on a yearly basis thereafter. 2. Check the patient’s electrolyte levels, body weight, waist circumference, height, blood glucose level, lipid prole, hepatic function, cardiac function, and thyroid function before initiating therapy and

Drugs Used for Psychoses CHAPTER 17

periodically throughout the course of treatment. Weight should be monitored every 4 weeks until 12 weeks after initiating therapy and then every 3 months. Monitor waist circumference and fasting plasma glucose level annually and fasting lipid levels every 5 years. 3. Use baseline clinical evaluation rating scales (e.g., BPRS, CGI, PANSS) and adverse effect scales (e.g., GDS, TWSTRS for dystonias, DISCUS or AIMS for EPSs) at specied intervals; record and report ndings in accordance with agency policy. 4. Use of clozapine requires a baseline WBC count and weekly WBC counts for the rst 6 months of treatment because of the high incidence of agranulocytosis. Thereafter, if WBC counts are acceptable (i.e., ≥3500/mm3) and if the absolute neutrophil count is more than 2000/mm3, WBC counts can be monitored every other week. WBC counts must be monitored weekly for at least 4 weeks after the discontinuation of clozapine. Availability, dosage, and administration. See Table 17.1.

The dosage must be individualized according to the patient’s degree of mental and emotional disturbance. It will often take several weeks for a patient to show optimal improvement and become stabilized on an adequate maintenance dosage. As a result of the cumulative effects of antipsychotic agents, the patient must be reevaluated periodically to determine the lowest effective dosage necessary to control psychiatric symptoms. Common adverse effects

Neurologic Chronic fatigue, drowsiness. Chronic fatigue and drowsiness are common problems associated with medications used to treat psychoses. Sedative effects associated with antipsychotic therapy can be minimized by giving the dose of medication at bedtime. The patient should not take these medications while working with machinery, operating a motor vehicle, administering medication, or performing other duties that require mental alertness. Cardiovascular Orthostatic hypotension. All antipsychotic agents may cause some degree of orthostatic hypotension manifested by dizziness and weakness, particularly when therapy is initiated. Monitor the patient’s blood pressure daily in the supine and standing positions. Anticipate the development of postural hypotension and take measures to prevent an occurrence. Teach the patient to rise slowly from a supine or sitting position and encourage the patient to sit or lie down if feeling faint. Sensory Blurred vision. Caution the patient that blurred vision may occur and make appropriate suggestions to ensure the patient’s personal safety.

273

Genitourinary Urinary retention. Urinary retention may occur after the administration of antipsychotic agents. Gastrointestinal Constipation; dryness of mucosa of the mouth, throat, nose. Mucosal dryness may be relieved by sucking hard candy or ice chips or by chewing gum. A highber diet, stool softeners (e.g., docusate), or the occasional use of a stimulant laxative (e.g., bisacodyl) may be required to treat constipation. Serious adverse effects

Neurologic Seizure activity. Provide for patient safety during episodes of seizures; report this symptom to the healthcare provider for further evaluation. An adjustment of anticonvulsant therapy may be required, especially for seizure-prone patients. Pseudoparkinsonian symptoms. Report the development of drooling, cogwheel rigidity, shufing gait, mask-like expression, or tremors. Anticholinergic agents may be used to help control these symptoms. Tardive dyskinesia. Tardive dyskinesia occurs much more commonly with the rst-generation antipsychotic drugs. Report the development of ne tremors of the tongue, “y-catching” tongue movements, and lip smacking. This is particularly important for patients who have been receiving antipsychotic drugs and anticholinergic medications for several years. Gastrointestinal Hepatotoxicity. The symptoms of hepatotoxicity are anorexia, nausea, vomiting, jaundice, hepatomegaly, splenomegaly, and abnormal liver function test results (e.g., elevated bilirubin, aspartate aminotransferase [AST], alanine aminotransferase [ALT], gammaglutamyltransferase [GGT], and alkaline phosphatase levels [ALP]; increased prothrombin time [PT]). Hematologic Blood dyscrasias. Routine laboratory studies (e.g., red blood cell, WBC, and differential counts) should be scheduled. This is particularly important for patients receiving clozapine. Monitor for sore throat, fever, purpura, jaundice, or excessive and progressive weakness. Hypersensitivity Hives, pruritus, rash. Report these symptoms to the healthcare provider for further evaluation. Other Photosensitivity. The patient should be cautioned to avoid prolonged exposure to sunlight and ultraviolet light. Suggest that the patient wear long-sleeved clothing, a hat, and sunglasses when exposed to sunlight. Advise against using articial tanning lamps. Drug interactions

Drugs that increase adverse effects. Antihistamines, alcohol, analgesics, anesthetics, tranquilizers, opiates, St. John’s wort, and sedative-hypnotics increase the

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UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

toxic effects of antipsychotic drugs. Monitor the patient for excessive sedation and reduce the dosage of the previously mentioned drugs if necessary. Drugs that decrease therapeutic effects Dopamine agonists. Dopamine agonists (i.e., levodopa, ropinirole, pramipexole) block the dopamine antagonist effects of the antipsychotic agents. Avoid concurrent use. Carbamazepine, phenytoin, rifampin, St. John’s wort. Carbamazepine, phenytoin, rifampin, and St. John’s wort stimulates the metabolism of haloperidol, brexpiprazole, cariprazine, clozapine, aripiprazole, iloperidone, lurasidone, lumateperone, olanzapine, quetiapine, paliperidone, risperidone, and ziprasidone. Adjustment of the dosage of the antipsychotic medicine may be required. Divalproex sodium. Divalproex sodium increases the serum level of paliperidone. Dosage adjustments may be needed to avoid toxicities. Erythromycin, cimetidine, clarithromycin, uoxetine, grapefruit juice, ketoconazole. All of these agents inhibit the metabolism of aripiprazole, asenapine, clozapine, haloperidol, iloperidone, lurasidone, quetiapine, risperidone (only uoxetine) and ziprasidone, causing an increase in serum levels and potential toxicity from the antipsychotic drug. Dosages of the antipsychotic drug may need to be reduced to avoid toxicities.

Fluvoxamine, ciprooxacin. Fluvoxamine and ciprooxacin inhibit the metabolism of asenapine, clozapine, and olanzapine. Dosage adjustments may be needed to avoid toxicities. Paroxetine. Paroxetine inhibits the metabolism of brexpiprazole, haloperidol, iloperidone, risperidone, and thioridazine. Dosage adjustments may be needed to avoid toxicities. Smoking. Cigarette smoking enhances the metabolism of clozapine and olanzapine. Increased dosages may be necessary to maintain effects in patients who smoke. Antihypertensive agents. Antihypertensive agents (see Chapter 22) (e.g., beta blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers) signicantly enhance the hypotensive effects of antipsychotic agents. Concurrent therapy is not recommended unless it is used to treat the adverse effects of antipsychotic agents. Insulin, oral hypoglycemic agents. Patients with prediabetes or diabetes must be monitored for the development of hyperglycemia, particularly during the early weeks of therapy. Assess patients regularly for glycosuria and report it to the healthcare provider if it occurs with any frequency. Patients receiving oral hypoglycemic agents or insulin may require a dosage adjustment.

Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions Key Points • Psychoses are symptoms of psychotic disorders—that is, illnesses in which the patient has lost touch with reality. The underlying illness must be treated, not just the psychosis. • A combination of nonpharmacologic and pharmacologic therapies provides the most successful therapeutic outcomes. • The emphasis on community treatment has ensured that almost all healthcare settings treat patients with psychotic symptoms. Community hospitals and health maintenance organizations now provide care to many psychiatric patients, and nurses increasingly serve residential care facilities. Many patients require years of antipsychotic drug treatment to prevent exacerbations of their illness. • Although antipsychotic medications cause many adverse effects, most can be minimized by patient education, manipulation of dosage and administration, and sometimes adjunctive drug treatments. These patients require careful monitoring of target symptoms to maximize response and minimize adverse effects.

Additional Learning Resources

SG Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content.

Go to your Evolve website (https://evolve.elsevier.com/Willihng anz) for additional online resources.

Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types.

Scenario A patient with a known diagnosis of schizophrenia was admitted to the psychiatric area of the hospital after an episode of psychotic behavior. 1. A nurse is assessing the patient in the scenario who has been admitted to the psychiatric unit and who has been hearing voices that told them to lock all the doors and not answer any phone calls. The nurse recognizes which of the signs and symptoms of psychotic behavior that may be exhibited? Indicate with an X the signicant factors and the unrelated factors associated with psychotic behavior.

Drugs Used for Psychoses CHAPTER 17

SIGNIFICANT FACTORS

UNRELATED FACTORS

Auditory hallucinations Grandiose delusions Wringing hands Flight of ideas Garbled speech

Objective: Identify the signs and symptoms of psychotic behavior. NCLEX item type: Matrix Cognitive skill: Analyze cues 2. A patient who is taking an antipsychotic agent develops extrapyramidal symptoms. Which of these symptoms, if observed by the nurse, would indicate the presence of extrapyramidal effects? (Select all that apply.) 1. 2. 3. 4. 5. 6. 7. 8. 9.

Tongue protrusion Pressured speech Neck torsions Seizures Shufing gait Pacing or rocking Frequent blinking Jaw spasms Mask-like expression

Objective: Identify the common adverse effects that are observed with the use of antipsychotic medications. NCLEX item type: Extended multiple response Cognitive skill: Prioritize hypothesis 3. The nurse knows that extrapyramidal effects may be seen with antipsychotic medications; what other adverse effects should be monitored for? (Select all that apply.) 1. 2. 3. 4. 5.

Seizures Weight loss Chronic fatigue Dyslipidemia Hyperglycemia

Objective: Identify the common adverse effects that are observed with the use of antipsychotic medications. NCLEX item type: Multiple response Cognitive skill: Application

275

4. The nurse is discussing with the patient in the scenario being treated for psychoses with antipsychotic medications what to expect. Which statement by the nurse needs to be revised? 1. “While you take these medications they should work within the week to reduce auditory hallucinations or those voices you hear.” 2. “These medications will be effective in reducing your feelings of agitation.” 3. “While you take these medications you may nd that you start to gain weight.” 4. “These medications will allow you to get a good night’s sleep.” Objective: Discuss the antipsychotic medications that are used for the treatment of psychoses. NCLEX item type: Multiple choice Cognitive skill: Comprehension 5. The nurse reviewing a patient’s medication list recognized which one as the antipsychotic? 1. 2. 3. 4.

Lithium carbonate Sertraline (Zoloft) Olanzapine (Zyprexa) Amitriptyline (Elavil)

Objective: Discuss the antipsychotic medications that are used for the treatment of psychoses. NCLEX item type: Multiple choice Cognitive skill: Knowledge 6. The nurse knows that the patient in the scenario who has schizophrenia will need to have their medication dose adjusted if they develop which of the following? 1. Signicant weight gain 2. Delusions that they are perceived as being controlled by radio waves 3. Loss of their sense of taste and smell 4. The sense that the medications do not work anymore Objective: Describe the major indications for the use of antipsychotic agents. NCLEX item type: Multiple choice Cognitive skill: Understanding

18

Drugs Used for Seizure Disorders

https://evolve.elsevier.com/Willihnganz

Objectives 1. Identify the different types of seizure disorders. 2. Identify nursing interventions during the management of seizure activity. 3. Discuss the desired therapeutic outcomes from antiepileptic agents used for seizure disorders.

4. Identify the drug classes used to treat seizure disorders. 5. Describe the neurologic assessment performed on patients taking antiepileptic agents to monitor for common and serious adverse effects.

Key Terms seizures (SĒ-zhŭrz) (p. 276) epilepsy (ĔP-ĭ-lĕp-sē) (p. 276) generalized seizures (JĔN-ŭr-ăl-īzd) (p. 276) focal seizures (FŌ-kĕl) (p. 276) antiepileptic drugs (ăn-tī-ĕp-ĭ-LĔPtĭk) (p. 276) tonic phase (TŎN-ĭk) (p. 277) clonic phase (KLŎN-ĭk) (p. 277)

postictal state (PŌST-ĭk-tĕl) (p. 277) status epilepticus (STĂ-tŭs ĕp-ĭ-LĔP-tĭk-ŭs) (p. 277) atonic seizure (ĕ-TŎN-ĭk) (p. 277) myoclonic seizures (mī-ō-KLŎN-ĭk) (p. 277) seizure threshold (THRĔSH-hōld) (p. 278)

SEIZURE DISORDERS Seizures ar a sympm f an abnrmaliy in h

nrv clls f h brain. A sizur is a brif prid f abnrmal lcrical aciviy in hs nrv cn rs. Sizurs may b cnvulsiv (i.., accmpanid by viln, invlunary muscl cnracins) r nn cnvulsiv. During a sizur, hr is fn a chang in h prsn’s cnsciusnss, snsry and mr sysms, subjciv wllbing, and bjciv bhav ir. Sizurs may rsul frm fvr, had injury, brain umr, mningiis, hypglycmia, a drug vrds r wihdrawal, r pisning. I is simad ha 8%  10% f all ppl will hav a sizur during hir lifims. If h sizurs ar chrnic and rcurrn, h pain is diagnsd as having epilepsy. Epilpsy is h ms cmmn f all nurlgic disrdrs. I is n a singl disas bu rahr svral diffrn disr drs ha hav n cmmn characrisic: a suddn discharg f xcssiv lcrical nrgy frm nrv clls in h brain. An simad 2.3 millin Amricans hav hs disrdrs, and apprximaly 125,000 nw cass ar diagnsd annually. Th caus f pilpsy may b unknwn (i.., idipahic), r i may b h rsul f a had injury, a brain umr, mningiis, r a srk. 276

treatment responsive (TRĒT-mĕnt rē-SPŎN-sĭv) (p. 278) treatment resistant (TRĒT-mĕnt rē-ZĬS-tĕnt) (p. 278) gingival hyperplasia (JĬN-jĭ-văl hīpŭr-PLĀ-zhă) (p. 281) nystagmus (nĭs-TĂG-mŭs) (p. 284)

In 2017 h Inrnainal Lagu Agains Epilpsy, a wrldwid rganizain f pilpsy prfssinals, mad rvisins  h classicain sysm f sizur yps. Sizurs ar classid in focal (parial) ns, generalized ns, and unknwn ns. Fcal sizurs bgin in a lcalizd ara in n hmisphr f h brain and ar subdividd in fcal ns awar sizurs and fcal ns impaird awarnss sizurs. Focal onset aware seizures (frmrly knwn as simpl parial si zurs) ar characrizd by a prsn bing awak and awar during sizurs. Focal onset impaired awareness seizures (frmrly knwn as cmplx parial sizurs) ar characrizd by a prsn bing cnfusd r hir awarnss is affcd in sm way during a sizur. Bh yps f fcal sizurs can vlv in gnral izd sizurs, which is a prcss rfrrd  as secondary generalization. Generalized seizures rfr  hs ha affc bh hmisphrs f h brain, ar accmpanid by a lss f cnsciusnss, and may b subdividd in cnvulsiv and nncnvulsiv yps. Gnralizd pilpsis hav a rang f sizur subyps, including absnc, my clnic, anic, nic, and nicclnic sizurs. Epilpsy is rad alms xclusivly wih mdicains knwn as anticonvulsants r as antiepileptic drugs, a rm gain ing mr widsprad us.

Drugs Used for Seizure Disorders CHAPTER 18

DESCRIPTIONS OF SEIZURES GENERALIZED CONVULSIVE SEIZURES Th ms cmmn gnralizd cnvulsiv sizurs ar h nicclnic, anic, and myclnic sizurs. TONIC-CLONIC SEIZURES Tnicclnic sizurs ar h ms cmmn yp f sizur. During h tonic phase, pains suddnly d vlp inns muscular cnracins ha caus hm  fall  h grund, ls cnsciusnss, and li rigid. Th back may arch, h arms may x, h lgs may xnd, and h h may clnch. Air is frcd up h larynx, xruding saliva as fam and prducing an au dibl sund lik a cry. Rspirains sp and h pain may bcm cyanic. Th nic phas usually lass 20  60 scnds bfr diffus rmbling ss in. Thn h clonic phase bgins, which is manifsd by bilarally symmric jrks alrnaing wih h rlaxain f h xrmiis. Th clnic phas sars slighly and gradu ally bcms mr viln, and i invlvs h whl bdy. Pains fn bi hir ngus and bcm in cninn f urin r fcs. Usually wihin 60 scnds, his phas prcds  a rsing, recovery phas f ac cid paralysis and slp ha lass 2  3 hurs, rfrrd  as h postictal state. Th pain has n rcllcin f h aack n awakning. Th svriy, frquncy, and durain f aacks ar highly variabl; hy may las frm 1  30 minus and may ccur as frqunly as daily r as infrqunly as vry fw yars. Status epilepticus is a rapidly rcurring gnralizd sizur ha ds n allw h individual  rgain nrmal funcin bwn sizurs. I is a mdical mrgncy ha rquirs prmp ramn  minimiz prma nn nrv damag and prvn dah. Atonic or Akinetic Seizures A suddn lss f muscl n is knwn as an atonic seizure r a drop attack. This may b dscribd as a had drp, h drpping f a limb, r h slumping f h bdy  h grund. A suddn lss f muscl n r suls in a dramaic fall. Sad pains may slump fr ward vilnly. Pains usually rmain cnscius. Th aacks ar shr, bu injury frqunly ccurs frm h uncnrlld falls. Ths pains fn war prciv hadgar  minimiz rauma. Myoclonic Seizures Myoclonic seizures invlv lighninglik rpiiv cn racins f h vlunary muscls f h fac, runk, and xrmiis. Th jrks may b islad vns, r hy may b rapidly rpiiv. I is n uncmmn fr pains  ls hir balanc and fall  h r. Ths aacks c cur ms fn a nigh as h pain nrs slp. Thr is n lss f cnsciusnss wih myclnic sizurs. GENERALIZED NONCONVULSIVE SEIZURES By far h ms cmmn gnralizd nncnvulsiv sizur disrdr is absence sizurs. Ths sizurs

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ccur primarily in childrn, and hy usually disap par a pubry; hwvr, h pain may dvlp a scnd yp f sizur aciviy. Aacks cnsis f par xysmal pisds f alrd cnsciusnss lasing 5  20 scnds. Thr ar n prdrmal r psical phas s. Pains appar  b saring in spac, and hy may xhibi a fw rhyhmic mvmns f h ys r had, lip smacking, mumbling, chwing, r swallw ing mvmns. Falling ds n ccur, pains d n cnvuls, and hy will hav n mmry f h vns ha ccur during h sizurs. Focal (Localized) Seizures Classicain f fcal sizurs (als knwn as parial sizurs) is subdividd in fcal ns awar sizurs (simpl mr sizurs) and fcal ns impaird un awarnss (cmplx sizurs). Simple motor seizures invlv lcalizd cnvulsins f vlunary muscls. A singl bdy par such as a ngr r an xrmiy may sar jrking. Turning h had, smacking h lips, muh mvmns, drling, abnrmal numbnss, in gling, and crawling snsains ar hr indicains f fcal simpl mr sizurs. Th muscl spasm may nd spnanusly, r i may sprad vr h whl bdy. Th pain ds n ls cnsciusnss unlss h sizur dvlps in a gnralizd cnvulsin. Complex seizures ar manifsd by a vas array f ps sibl sympms. Th pain’s uward apparanc may b nrmal, r hr may b aimlss wandring, lip smacking, unusual and rpad chwing, r swal lwing mvmns. Th prsn is cnscius bu may b in a cnfusd, dramlik sa. Th aacks, which may ccur svral ims daily and las fr svral min us, cmmnly nd during slp r wih a cludd snsrium, and h pain usually has n rcllcin f h vns f h aack.

ANTIEPILEPTIC THERAPY Idnifying h caus f sizur aciviy is impran fr drmining h yp f hrapy rquird. Cnribuing facrs (.g., had injury, fvr, hypglycmia, drug vrds) mus b spcically rad  crrc h undrlying caus bfr chrnic anipilpic hrapy is sard. Afr h undrlying caus is rad, i is rar ha chrnic anipilpic hrapy is ndd. Whn sizur aciviy cninus, drug hrapy is h primary frm f ramn. Th gals f hrapy ar  imprv h pain’s qualiy f lif, rduc h frquncy f si zur aciviy, and minimiz h advrs ffcs f h mdicain. Thrapuic ucms mus b individu alizd fr ach pain. Th slcin f h mdicain dpnds n h yp f sizur, h ag and gndr f h pain, any hr mdical cndiins prsn, and h pnial advrs ffcs f h individual mdica ins. On pnial lngrm advrs ffc f sm anipilpic dugs is sprsis. Carbamazpin, phnbarbial, phnyin, and primidn can rduc bn dnsiy lading  sprsis and fracurs.

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UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

ACTIONS Unfrunaly, h mchanisms f sizur aciviy ar xrmly cmplx and n wll undrsd. In gnral, anipilpic mdicins ac by incrasing h seizure threshold and rgulaing nurnal ring by in hibiing xciary prcsss r nhancing inhibiry prcsss. Th mdicains can als prvn h si zur frm sprading  adjacn nurns. Dpnding n h anipilpic mdicains, hy can shar mul ipl mchanisms f acin (pirama, valpra, and hrs) r xr jus n mchanism (lacsamid, vigabarin). Anipilpic mdicain may mdula h sdium (ms cmmn mchanism), passium, r calcium channls, nhanc gammaaminbuyric acid (GABA), inhibi h gluama rcpr, r bind  h synapic vsicl prin (SV2A) (Tabl 18.1). Phnyin, carbamazpin, lamrigin, znisamid, and valpric acid ac n sdium and calcium chan nls  sabiliz h nurnal mmbran and may dcras h rlas f xciary nurransmirs. Bnzdiazpins, phnbarbial, iagabin, gabapn in, and prgabalin nhanc h inhibiry ffc f GABA, an inhibiry nurransmir ha cunr balancs h ffc f xciary nurransmirs. GABA pns chlrid channls, rsuling in a hypr plarizd cll mmbran ha prvns xciain f h cll, spping furhr prpagain f h sizur. Sizur cnrl mdicains ar smims subdivid d in bradspcrum and narrwspcrum agns in rlain  hir fcacy agains diffrn yps f sizurs. Exampls f bradspcrum agns ar l viracam, pirama, valpric acid, znisamid, and lamrigin. Ths drugs ar fn usd fr h iniial ramn f a pain wih a nwly diagnsd sizur disrdr. Exampls f narrwspcrum agns ar phnyin, carbamazpin, and xcarbazpin (Frnch & Pdly, 2008).

In gnral, anipilpic hrapy shuld sar wih h us f a singl drug slcd frm a grup f agns basd n h yp f sizur. In chsing an iniial hr apy, clinicians mus wigh rlaiv fcacy, pharmac kinics, and pnial fr advrs ffcs f ach drug, bu hr painspcic facrs nd  b cnsidrd, including ag, sx, childbaring pnial, cmrbidiis, and cncmian mdicains. Cmparaiv fcacy and lrabiliy daa ar limid, hwvr, and rials ha hav bn prfrmd hav n shwn signican diffrncs amng varius drugs in rms f fcacy. Wih mr han 20 anipilpic drugs and implanabl anisizur dvics availabl  ra pilpsy in aduls, ppruniis  ailr drug hrapy hav nvr bn grar, bu h muliud f ramn pins fr si zurs is a challng. In gnral, if ramn is n succssful wih h rs agn chsn, ha agn is discninud and an hr agn is sard. If ramn fails wih h scnd agn, h halhcar prvidr may dcid  discnin u h scnd agn and sar a hird agn, r cmbi nain hrapy may b sard by adding an alrnaiv mdicain  n f h iniial agns. Occasinally sm pains will rquir mulipldrug hrapy wih a cmbinain f agns and will sill n b cmplly fr f sizurs. Ths pains wih nwly diagnsd pilpsy wh rspnd  ramn ar rfrrd  as “treatment responsive,” and hs wh d n rspnd  iniial agns ar rfrrd  as “treatment resistant.” Abu half f pains wih nwly diagnsd pilpsy bcm fr f sizurs whil using h rs prscribd anipilpic drug. Alms whirds f pains b cm fr f sizurs afr rciving h scnd r hird agn. Nnpharmaclgic ramn f rfracry sizurs includs surgical inrvnin, h us f an implan abl vagus nrv simular fr childrn wh ar 12

Table 18.1 Common Mechanisms of Antiepileptic Drugs ANTIEPILEPTIC DRUGS

MECHANISM OF ACTION

Phenytoin, fosphenytoin carbamazepine, oxcarbazepine, eslicarbazepine, lamotrigine, cenobamate, lacosamide runamide, topiramate, zonisamide

Voltage-gated ion channels Voltage-gated sodium channels

Ethosuximide, levetiracetam, pregabalin, topiramate, zonisamide

Voltage-gated calcium channels

Levetiracetam

Voltage-gated potassium channels

Phenobarbital, primidone, benzodiazepines including diazepam, lorazepam, and clonazepam; possibly topiramate

GABA inhibition GABA-A receptors

Tiagabine, vigabatrin

Increases availability of neurotransmitter GABA

Levetiracetam, brivaracetam

SV2A

Perampanel

Ionotropic glutamate receptors AMPA receptor

Valproic acid, topiramate, zonisamide

Mixed/unknown

AMPA, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid; GABA, gamma-aminobutyric acid; SV2A, synaptic vesicle protein. Adapted from Rogawski MA, Löscher W, Rho JM. Mechanisms of action of antiseizure drugs and the ketogenic diet. Cold Spring Harb Perspect Med. 2016;6(5):a022780; Miziak B, Konarzewska A, Ułamek-Kozioł M, Dudra-Jastrz ębska M, Pluta R, Czuczwar SJ. Anti-epileptogenic effects of antiepileptic drugs. Int J Mol Sci. 2020;21(7):2340; Stefanovic S, Jankovic M, Milosavljevic M, etal. Pharmacodynamics and common drug-drug interactions of the third-generation antiepileptic drugs. Expert Opin Drug Metab Toxicol. 2018;14(2):153-159.

Drugs Used for Seizure Disorders CHAPTER 18

yars ld and ldr, and a kgnic di. Th kgnic di is usd fr childrn, and i includs h rsricin f carbhydra and prin inak; fa is h primary ful ha prducs acidsis and ksis. Alhugh h di has bn shwn  rduc rfracry sizurs in childrn wh hav n achivd ffciv cnrl wih drug hrapy, h advrs ffcs f his di includ high bld lipid lvls wih lngrm ffcs ha ar n knwn.

Medication Safety Alert Antiepileptic drugs may increase the risk of suicidal thoughts and behavior. This applies to all antiepileptic drugs, including those used to treat psychiatric disorders, migraines, and other conditions, as well as epilepsy.

Accrding  a rpr by h US Fd and Drug Adminisrain (2008), pains wh wr rciving anipilpic drugs had apprximaly wic h risk f suicidal bhavir r idain (0.43%) cmpard wih pains rciving placb (0.22%). Th incrasd risk f suicidal bhavir and suicidal idain was b srvd as arly as 1 wk afr saring h anipilpic drug, and i cninud hrugh 24 wks f us f h mdicain. Halhcar prfssinals shuld clsly mnir all pains currnly rciving anipilpic drugs fr nabl changs in bhavir ha culd indi ca h mrgnc r wrsning f suicidal hughs r bhavir r dprssin. Th drugs includd in h analysis wr carbamazpin, flbama, gabapnin, lamrigin, lviracam, xcarbazpin, prgabalin, iagabin, pirama, valpra, and znisamid.

Life Span Considerations Antiepileptic Therapy In children, antiepileptic therapy may cause a change in personality and possible indifference to both school and family activities. Behavioral differences must be discussed with the healthcare provider, family or caregivers, and teachers. The school nurse must be informed about the medications that have been prescribed. Liquid dosage forms of antiepileptic medicines must be measured accurately to help maintain seizure control. It is extremely important to shake the liquid rst to disperse the medication uniformly in the suspension. The dosage should then be measured with an oral syringe to ensure accuracy before administration. Medications should be taken at the same time daily to maintain a consistent blood level. Dosages should not be selfadjusted, and drugs should not be discontinued suddenly. Monitoring the patient’s response to antiepileptic therapy is essential. Dosages may need to be adjusted weekly, especially during the initiation of therapy.

USES Anipilpic mdicins ar usd  rduc h fr quncy f sizurs.

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NURSING IMPLICATIONS FOR ANTIEPILEPTIC THERAPY Nurss may play an impran rl in h crrc diag nsis f sizur disrdrs. Accura sizur diagnsis is crucial  h slcin f h ms apprpria mdi cains fr ach pain. Bcaus halhcar prvidrs ar n always abl  bsrv pain sizurs dircly, nurss shuld larn  bsrv and rcrd hs vns bjcivly. Assessment History of seizure activity

• Wha aciviis was h pain ngagd in immdi aly bfr h las sizur? • Has h pain bn ill rcnly? • Is hr a hisry f fvr, unusual rash, r ick infsain? • Has h pain nicd any paricular aciviy ha usually prcds h aacks? • Whn was h las sizur bfr h currn n? • Did h pain hav any changs in bhavir bfr h ns f h sizur (.g., incrasing anxiy r dprssin)? • Is h pain awar f a prsizur “aura” (i.., a paric ular fling r dr ha ccurs bfr a sizur ns)? • Was hr an “pilpic cry”? Seizure description

• Rcrd h xac im f sizur ns and h du rain f ach phas, a dscripin f h spcic bdy pars invlvd, and any prgrssin f sizur acin in h affcd bdy pars. • Did h pain ls cnsciusnss? • Wr siffning and/r jrking mvmns prsn? • Dscrib h aunmic rspnss usually sn during h clnic phas: alrd, jrky rspirains; frhy salivain; dilad pupils; any y mv mns; cyansis; diaphrsis; incninnc. Postictal behavior

• Rcrd h lvl f cnsciusnss (i.., rinain  im, plac, and prsn). • Assss h dgr f alrnss, faigu, r hadach prsn. • Evalua h dgr f waknss, any alrains in spch, and mmry lss. • Pains fn hav muscl srnss and an xrm nd fr slp. Rcrd h durain f slp. • Evalua any bdily harm ha ccurrd during h sizur (.g., bruiss, cus, lacrains). Implementation Management of seizure activity. Assis h pain dur

ing a sizur by ding h fllwing: • D n lav h pain. • Hav drugs availabl  ra saus pilpicus r knw h prcdur fr baining hm as quickly as pssibl.

280

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

• Prc h pain frm furhr injury. Plac pad ding arund r undr h pain’s had; d n ry  rsrain h pain and lsn any igh clhing. If h pain is in a sanding psiin iniially, lwr  a hriznal psiin. • Whn h pain sars  rlax afr a sizur, urn slighly n h sid  allw scrins  drain u f h muh. • Rmain calm and qui, and giv rassuranc  h pain whn h sizur is vr. • Hav xygn availabl, as wll as mrgncy quipmn fr sucining and/r vnilaing h pain. • Sucin h pain as ndd and iniia vn ilary assisanc if brahing ds n rurn spnanusly. • Prvid a plac fr h pain  rs immdialy afr a sizur. Summn apprpria assisanc af r h sizur. • Iniia nursing inrvnins apprpria  h undrlying caus f h sizurs (.g., high fvr, mablic disrdr, had rauma, drug r alchl wihdrawal). • If h pain has anhr sizur r if a sizur lass fr mr han 4 minus, immdialy summn assis anc; h pain may b ging in saus pilpicus. • Obsrv all aspcs f h sizur fr daild r crding: aura (if prsn), im sard and ndd, bdy pars affcd, rdr f prgrssin f sizur acin, aunmic signs (.g., alrd brahing, dia phrsis, incninnc, salivain, ushing, pupil dilain), psical prid bsrvains (.g., vial signs; lvl f cnsciusnss; spch parn/disr dr; muscl srnss, waknss, r paralysis), and hw lng ach phas lasd. Psychological implications

Lifestyle. Encurag h pain  mainain a nr mal lifsyl. Prvid fr apprpria limiains (.g., limis n praing pwr quipmn r m r vhicls; swimming)  nsur pain safy. Mak h pain awar f h Rhabiliain Ac f 1973, which was iniiad  nsur ha individuals wih disabiliis d n xprinc discriminain in mplymn. Cnac h Epilpsy Fundain f Amrica and sa vcainal rhabiliain agncis fr infrmain abu vcainal rhabiliain and mplymn. Expressing feelings. Allw h pain  vnila hir flings. Sizurs may ccur in public, and hy may b accmpanid by incninnc. Pains ar usually mbarrassd abu having a sizur in frn f hrs. Prvid fr h xprssin f flings abu any discriminain ha h pain fls a h wrk plac. Encurag h pn discussin f slfcncp issus rlad  h disas and is ffc n daily ac iviis, wrk, and h rspnss f hrs ward h pain.

School-age children. Accpanc by prs can prsn a prblm  a pain in his ag grup. Th schl nurs can hlp achrs and hr childrn  undr sand h pain’s sizurs. Denial. B alr fr signs f dnial f h disas, which ar indicad by incrasd sizur aciviy in a prviusly wllcnrlld pain. Qusin h pa in’s adhrnc  h drug rgimn. Adherence. Drmin h pain’s currn mdi cain schdul, including h nam f h mdica in, h dsag, and h im f h las ds. Hav any dss bn skippd? If s, hw many? If adhr nc appars  b a prblm, ry  drmin h rasns why s ha apprpria inrvnins can b implmnd. Status epilepticus

1. Prvid fr pain prcin and summn assis anc  ranspr h pain  an mrgncy faciliy. 2. Adminisr xygn. Hav sucin and rsusciain quipmn availabl and aach cardiac and xygn saurain mnirs. 3. Esablish an inravnus (IV) lin and hav drugs availabl fr ramn (.g., lrazpam, diazpam, fsphnyin, phnyin, phnbarbial, valpric acid, and lviracam). Whn adminisring IV drugs, mnir h pain fr bradycardia, hyp nsin, and rspirary dprssin. 4. Mnir h pain’s vial signs and nurlgic saus. 5. Insr a nasgasric ub if h pain is vmiing. Patient Education Exercise and activity. Discuss wha aciviis r acins

riggr sizurs and hw  avid hm. Encurag h pain  mainain a rgular lifsyl wih mdra aciviy. Avid xcssiv xrcis ha culd lad  x cssiv faigu. Nutrition. Avid xcssiv us f simulans (.g.,

caffincnaining prducs). Sizurs ar als knwn  fllw h signican inak f alchlic bvrags; hrfr such ingsin shuld b avidd r limid. Ask h halhcar prvidr whhr viamin suppl mns ar ndd, bcaus sm anicnvulsans inr fr wih viamin and minral absrpin. Safety. Tach h pain  avid praing pwr

quipmn r machinry. Driving may b minimizd r prhibid. Chck sa laws rgarding hw r if an individual wih a hisry f sizur aciviy may qual ify fr a drivr’s licns. B spcially alr  signs f cnfusin and impaird crdinain in ldr pains. Prvid fr h pain’s safy. Stress. Th rducin f nsin and srss wihin h

individual’s nvirnmn may rduc sizur aciviy in sm pains.

Drugs Used for Seizure Disorders CHAPTER 18

Oral hygiene. Encurag daily ral hygin prac

ics and schduling f rgular dnal xaminains. Gingival hyperplasia, which is gum vrgrwh as sciad wih hydanins (.g., phnyin, hin), can b rducd wih gd ral hygin, frqun gum massag, rgular brushing, and prpr dnal car. Medication considerations in pregnancy

• If prgnancy is suspcd, cnsul an bsrician as sn as pssibl. • Infrm h halhcar prvidr f sizur mdicains. • D n discninu mdicains unlss ld  d s by h halhcar prvidr. • Th pain shuld carry an idnicain card r bracl. health maintenance. Thrughu h curs f ramn, discuss mdicain infrmain and hw i will bn h pain. Rcgniz ha nnadhrnc may b a mans f dnial. Explr un drlying prblms rgarding h pain’s accpanc f h disas and h nd fr sric adhrnc fr maximum sizur cnrl. Prvid h pain and signican hrs wih impran infrmain cn aind in h spcic drug mngraphs fr h mdi cains prscribd. Addiinal halh aching and nursing inrvnins rgarding h advrs ffcs ar dscribd in h drug mngraphs ha fllw. Sk cprain and undrsanding f h fllw ing pins s ha mdicain adhrnc is incrasd: h nam f h mdicain, is dsag, is ru and ims f adminisrain, and is cmmn and srius advrs ffcs. Fostering

Patient self-assessment. Enlis h pain’s hlp

wih dvlping and mainaining a wrin rcrd r sizur diary f mniring paramrs (.g., dgr f lhargy; sdain; ral hygin fr gum disrdrs; dgr f sizur rlif; any nausa, vmiing, r an rxia prsn). S h Pain SlfAssssmn Frm fr Anicnvulsans n h Evlv wbsi. Cmpl h Prmdicain Daa clumn fr us as a bas lin  rack h pain’s rspns  drug hrapy. Ensur ha h pain and signican hrs undr sand hw  us h frm. Hav hrs rcrd h da, im, durain, and frquncy f any sizur pisds. In addiin, rcrd h pain’s bhavir immdialy bfr and afr sizurs. Emphasiz aking mdicains a h sam im daily  hlp mainain a cnsisn hrapuic drug lvl. Th pa in shuld cnsul wih a pharmacis bfr aking vrhcunr mdicains  prvn drug inr acins. Hav h pain bring h cmpld frm  fllwup visis.

281

DRUG THERAPY FOR SEIZURE DISORDERS

DRUG CLASS: BENZODIAZEPINES Actions Th mchanisms f acin fr bnzdiazpins ar n fully undrsd, bu i is hugh ha bnzdiazpins simula BDZ2 rcprs  inhibi nurransmissin by nhancing h ffcs f GABA in h pssynapic clfs bwn nrv clls. Incrasd lvls f GABA pn h chlrid channl, rsuling in a hypr plarizd cll mmbran ha prvns furhr xci ain f h cll, hus prvning prpagain f h sizur aciviy. (S Chapr 13 fr mr dails n bnzdiazpin aciviy.) Uses Th fur bnzdiazpins apprvd fr us as ani pilpic hrapy ar diazpam, lrazpam, clnaz pam, and clrazpa. Clnazpam is usful fr h ral ramn f absnc, akinic, and myclnic sizurs in childrn. Diazpam and lrazpam mus b adminisrd inravnusly  cnrl sizurs; hy ar h drugs f chic fr raing saus pi lpicus. Clrazpa is usd wih hr anipilpic agns  cnrl parial sizurs. Diazpam can b adminisrd as a rcal gl  ra sizur clusrs (acu rpiiv sizurs) ha can b usd a hm. Diazpam (Valc) and midazlam (Nayzilam) can als b adminisrd as a nasal spray a hm  ra sizur clusrs. Sizur clusrs ar prids f in crasd sizur aciviy, which is having w r mr sizurs in a 24hur prid. Sizur clusrs ar dif frn frm saus pilpicus. Saus pilpicus is sizurs lasing lngr han 5 minus and rquirs hspializain. Therapeutic Outcomes Th primary hrapuic ucms xpcd frm h bnzdiazpins ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Minimal advrs ffcs frm hrapy Nursing Implications for Benzodiazepines Premedication assessment

1. Rviw ruin bld sudis  dc bld dys crasias and hpaxiciy. 2. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rina in  nam, plac, and im bfr iniiaing hr apy. Mnir h pain’s bhaviral rspnss  hrapy. 3. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy.

282

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

Table 18.2 Antiepileptic Medicines GENERIC NAME BENZODIAZEPINES

BRAND NAME

AVAILABILITY

ADULT DOSAGE RANGE USE FOR SEIZURES

clobazam

On Sympazan PMS-Clobazam

Tablets: 10, 20 mg Oral suspension: 2.5 mg/mL (120 mL) Film: 5, 10, 20 mg

Up to 40 mg/day

Adjunct treatment of partial seizures in adolescents older than 16, and adults

clonazepam

Klonopin Do not confuse Rivitrol Klonopin with clonidine.

Tablets: 0.5, 1, 2 mg Tablets, orally disintegrating: 0.125, 0.25, 0.5, 1, 2 mg

Up to 20 mg/day

Absence and myoclonic seizures

clorazepate

Tranxene-T

Tablets: 3.75, 7.5, 15 mg

Up to 90 mg/day

Focal seizures

diazepam Do not confuse diazepam with Ditropan.

Valium Do not confuse Valium with valerian. Diastat

Tablets: 2, 5, 10 mg Nasal liquid: 5, 10 mg/0.1 mL Intramuscular, intravenous: 5 mg/mL Oral concentrate: 5 mg/mL Gel, rectal: 2.5, 10, 20 mg

Initially 5–10 mg/day; up to 30 mg/day

All forms of epilepsy; used in conjunction with other agents

lorazepam Do not confuse lorazepam with loperamide.

Ativan Do not confuse Ativan with Ambien. Apo-Lorazepam

Tablets: 0.5, 1, 2 mg Oral solution: 2 mg/mL Intramuscular, intravenous: 2, 4 mg/mL

Intravenous: 4–8 mg, repeated at 10- to 15-min intervals, if seizing

Status epilepticus

Cerebyx Do not confuse Cerebyx with Avelox, Celebrex, or Celexa.

Intravenous: 100 mg phenytoin in 2-mL vials; 500 mg phenytoin in 10mL vials (75 mg/mL of fosphenytoin is equivalent to 50 mg/mL of phenytoin)

Same dosage as for phenytoin

Status epilepticus; see also phenytoin

Dilantin Tablets, chewable: 50 mg Do not confuse Capsules: 30, 100, 200, 300 Dilantin with Diucan. mg

300–600 mg/day

Generalized tonicclonic seizures; psychomotor seizures

SUCCINIMIDES ethosuximide

Zarontin

Capsules: 250 mg Syrup: 250 mg/5 mL

1000–1500 mg/day

Absence seizures

methsuximide

Celontin

Capsules: 300 mg

900–1200 mg/day

Absence seizures

HYDANTOINS fosphenytoin

phenytoin Do not confuse phenytoin with phenylephrine.

Available in Canada. Do not confuse.

Availability, dosage, and administration. S Tabl

18.2. Us f bnzdiazpins may rsul in physical and psychlgical dpndnc whn akn sadily fr svral days  wks, vn whn akn in rcm mndd dsags. Abus and misus can rsul in vr ds r dah, spcially whn bnzdiazpins ar cmbind wih hr mdicins, such as piid pain rlivrs, alchl r illici drugs and cnral nrvus sysm dprssans (.g., sdaivs, hypnics, mus cl rlaxans). Th rapid discninuanc f bnzdi azpins afr lngrm us may rsul in sympms ha ar similar  hs f alchl wihdrawal, such as waknss, anxiy, dlirium, and nicclnic (grand

mal) sizurs. Ths sympms may n appar fr svral days afr discninuain. Discninuain f bnzdiazpins cnsiss f gradual wihdrawal vr 2  4 wks.

Medication Safety Alert Rapidly discontinuing benzodiazepines after long-term use may result in symptoms similar to those of alcohol withdrawal. These may vary from weakness and anxiety to delirium and generalized tonic-clonic seizures. The symptoms may not appear for several days after discontinuation. Treatment consists of the gradual withdrawal of benzodiazepines over the course of 2 to 4 weeks.

Drugs Used for Seizure Disorders CHAPTER 18

Intravenous administration. D n mix parnral diazpam r lrazpam in h sam syring wih hr mdicains; d n add hs  hr IV s luins bcaus f prcipia frmain. Adminisr diazpam slwly a a ra f n mr han 5 mg/min r lrazpam a a ra f n mr han 2 mg/min. If a all pssibl, giv hs drugs wih h pain undr lcrcardigram (ECG) mniring and b srv clsly fr bradycardia. Whn bradycardia ccurs, sp bluss unil h har ra rurns  nrmal. Common adverse effects

Neurologic Sedation, drowsiness, dizziness, fatigue, lethargy. Th mr cmmn advrs ffcs f bnzdiazpins ar xnsins f hir pharmaclgic prpris. Ths sympms nd  disappar wih cninud hrapy and pssibl dsag radjusmn. Encurag h pain n  discninu hrapy wihu rs cn suling h halhcar prvidr. Th pain shuld b warnd n  wrk wih machinry, pra a mr vhicl, adminisr mdicain, r prfrm hr du is ha rquir mnal alrnss. Prvid fr pain safy during pisds f dizzinss and aaxia; rpr hs changs  h halhcar prvidr fr furhr valuain.

Clinical Pitfall Do not mix parenteral diazepam, lorazepam, or phenytoin with other medications in the same syringe, and do not add either medication to other IV solutions because of precipitate formation. Always check for IV incompatibility before administering either medication through an established IV line, and use the SAS (Saline ush rst, Administer the prescribed drug, Saline ush after the drug) technique. Administer diazepam slowly at a rate of 5 mg/min and lorazepam at a rate of 2 mg/min. Administer phenytoin slowly at a rate of 25 to 50 mg/min, preferably through a large vein or as an IV piggyback. Phenytoin can be quite irritating to small veins. During the administration of either medication, it is recommended that an ECG monitor be used to closely observe for bradycardia. If bradycardia occurs, stop the bolus infusion until the heart rate returns to normal. Observe the patient during administration for respiratory depression and hypotension.

Sensory Blurred vision. Cauin h pain ha blurrd visin may ccur and mak apprpria suggsins fr h pain’s prsnal safy. Serious adverse effects

Psychological Behavioral disturbances. Bhaviral disurbancs such as aggrssivnss and agiain hav bn r prd, spcially in pains wh ar mnally handicappd r wh hav psychiaric disurbancs. Prvid suppriv physical car and safy during

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hs rspnss. Assss h lvl f h pain’s x cimn, and dal calmly wih h individual. During prids f xcimn, prc h pain frm harm and prvid fr h physical channling f nrgy (.g., walk wih hm). Sk a chang in h mdica in rdr. Hematologic Blood dyscrasias. Ruin labrary sudis (i.., rd bld cll [RBC], whi bld cll [WBC], diffr nial, and plal cuns) may b schduld. Mnir h pain fr sr hra, fvr, purpura, jaundic, r xcssiv and prgrssiv waknss. Bld dyscrasias ar a rar bu srius advrs ffc. Gastrointestinal Hepatotoxicity. Th sympms f hpaxiciy in clud anrxia, nausa, vmiing, jaundic, hpa mgaly, splnmgaly, and abnrmal livr funcin s rsuls (.g., lvad bilirubin, aspara amin ransfras [AST], alanin aminransfras [ALT], gammagluamylransfras [GGT], and alkalin phs phaas lvls [ALP]; incrasd prhrmbin im [PT]). Drug interactions

Drugs that increase toxic effects. Anihisamins, al chl, analgsics, anshics, ranquilizrs, narcics, cimidin, sdaivhypnics, and hr cncurrn anipilpic drugs incras h xic ffcs f bnz diazpins. Mnir h pain fr xcssiv sdain and limina hr mdicins n ndd fr ani pilpic hrapy, if pssibl. Smoking. Cigar smking nhancs h mab lism f bnzdiazpins. Incrasd dsags may b ncssary  mainain ffcs in pains wh smk.

DRUG CLASS: HYDANTOINS Actions Th primary si f acin f h hydanins is h m r crx, whr hy inhibi h sprad f sizur ac iviy. Th hydanins sabiliz h hrshld f nu rnal cll mmbrans agains hyprxciabiliy causd by blcking h vlaggad sdium channls. This rsuls in a rducin in susaind highfrquncy nu rnal dischargs. Phnyin als rducs h maximal aciviy f brainsm cnrs rspnsibl fr h nic phas f nicclnic sizurs. Uses Th hydanins (.g., phnyin, fsphnyin) ar anicnvulsans usd  cnrl fcal sizurs and gnralizd nicclnic sizurs. Phnyin is h ms cmmnly usd anipilpic f h hydanins. Fsphnyin is a prdrug ha is cnvrd  ph nyin afr adminisrain. Fsphnyin is paricu larly usful whn lading dss f phnyin mus b adminisrd. Phnyin causs lss sdain han phnbarbial. In xic cncnrains, phnyin can induc sizurs.

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UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

Therapeutic Outcomes Th primary hrapuic ucms xpcd frm h hydanins ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Minimal advrs ffcs frm hrapy Nursing Implications for Phenytoin Premedication assessment

1. Rviw ruin bld sudis  dc bld dys crasias and hpaxiciy. 2. Drmin baslin bld sugar lvls in pains wih diabs. Mnir hs pains pridically a spcid inrvals bcaus hyprglycmia may b causd by hydanin hrapy. 3. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rina in  nam, plac, and im bfr iniiaing hr apy. Mnir h pain’s bhaviral rspnss  hrapy. 4. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy. Availability, dosage, and administration. S Tabl 18.2.

Adminisr mdicain wih fd r milk  rduc gasric irriain. If an ral suspnsin is usd, shak i wll rs. Encurag h us f an ral syring fr accura masurmn. Intramuscular (IM): If a all pssibl, avid IM ad minisrain. Absrpin is slw and painful. IV: D n mix parnral phnyin in h sam syring wih hr mdicains; bcaus f prcipia frmain, d n add  hr IV sluins. Adminisr phnyin slwly a a ra f 25  50 mg/min. Fsphnyin may b adminisrd a a ra f 150 mg/min. If a all pssibl, giv hs drugs un dr ECG mniring and bsrv h pain clsly fr bradycardia. If bradycardia ccurs, sp bluss unil h har ra rurns  nrmal. Thrapuic bld lvls fr phnyin ar bwn 10 and 20 mg/L. Common adverse effects

Gastrointestinal Nausea, vomiting, indigestion. Ths ffcs ar cm mn during h iniiain f hrapy. Gradual incrass in dsag and adminisrain wih fd r milk will rduc gasric irriain. Neurologic Sedation, drowsiness, dizziness, fatigue, lethargy. Ths sympms nd  disappar wih cninud hrapy and pssibl dsag adjusmn. Encurag h pain n  discninu hrapy wihu rs cnsuling h halhcar prvidr. Th pain shuld b warnd n  wrk wih machinry, pra a mr vhicl, adminisr mdicain, r prfrm hr duis ha rquir mnal alrnss. Prvid fr pain safy during pisds f dizzinss; rpr hs changs  h halhcar prvidr fr furhr valuain.

Confusion. Prfrm a baslin assssmn f h pa in’s dgr f alrnss and rinain  nam, plac, and im bfr iniiaing hrapy. Mak rgu larly schduld subsqun valuains f h pa in’s mnal saus and cmpar ndings. Rpr signican alrains in mnal saus  h halh car prvidr. Sensory Blurred vision. Cauin h pain ha blurrd visin may ccur and mak apprpria suggsins fr h pain’s prsnal safy. Nystagmus. Nystagmus is a backandfrh mv mn f h yballs n h hriznal plain, paricu larly whn lking larally (u f h crnrs f h ys). Pains may dvlp nysagmus as highr ds ag lvls ar rquird  cnrl sizurs r as h drug accumulas in h bdy. Nysagmus may b usd as an indicar f pssibl vrds. Mnir h pain clsly fr hr signs f xiciy such as s dain, lhargy, nausa and vmiing, and aaxia. If nysagmus and hr signs f xiciy bcm mr prminn, bring his  h anin f h halhcar prvidr. Srum lvls may b rdrd and h dsag rducd. Dental hygiene Gingival hyperplasia. Th frquncy f gum vr grwh may b rducd by using gd ral hygin, including gum massag, frqun brushing, and prp r dnal car. Serious adverse effects

Metabolic Hyperglycemia. Hydanins may lva bld glu cs lvls, spcially if highr dsags ar usd; pa ins wih diabs mllius ar mr suscpibl  hyprglycmia. Paricularly during h arly wks f hrapy, pains wh ar diabic r prdiabic mus b mnird fr h dvlpmn f hypr glycmia. Assss h pain rgularly fr glycsuria and rpr i  h halhcar prvidr if i ccurs wih any frquncy. Pains wh ar rciving ral hypglycmic agns r insulin may rquir a dsag adjusmn. Hematologic Blood dyscrasias. Ruin labrary sudis (i.., RBC, WBC, and diffrnial cuns) shuld b schd uld. Mnir h pain fr sr hra, fvr, pur pura, jaundic, r xcssiv and prgrssiv waknss. Gastrointestinal Hepatotoxicity. Th sympms f hpaxiciy in clud anrxia, nausa, vmiing, jaundic, hpa mgaly, splnmgaly, and abnrmal livr funcin ss (.g., lvad bilirubin, AST, ALT, GGT, and ALP; incrasd PT). Integumentary Dermatologic reactions. Rpr a rash r prurius immdialy and wihhld addiinal dss pnding apprval by h halhcar prvidr.

Drugs Used for Seizure Disorders CHAPTER 18

Drug interactions

Drugs that enhance therapeutic and toxic effects. Warfarin, carbamazpin, xcarbazpin (>1200 mg/day), pirama, mrnidazl, azl anifungal agns (.g., iracnazl, vricnazl, ucnazl), mprazl, phnhiazins, disulram, amidarn, isniazid, chlramphnicl, cimidin, and sulfna mids nhanc h hrapuic and xic ffcs f ph nyin. Mnir pains wih cncurrn hrapy fr signs f phnyin xiciy, such as nysagmus, sda in, r lhargy. Srum lvls may b rdrd; a r ducd dsag f phnyin may b rquird. Drugs that decrease therapeutic effects. Lxapin, phnbarbial, nirfuranin, hphyllin, hanl (chrnic ingsin), rifampin, sucralfa, flic acid, and anacids dcras h hrapuic ffcs f ph nyin. Mnir pains wih cncurrn hrapy fr incrasd sizur aciviy. Mniring changs in h pain’s srum lvls shuld hlp prdic pssibl in crasd sizur aciviy. Disopyramide, quinidine, mexiletine. Phnyin d crass h srum lvls f hs agns. Mnir pa ins fr h rdvlpmn f dysrhyhmias. Prednisolone, dexamethasone. Phnyin dcrass h srum lvls f hs agns. Mnir pains fr rducd aniinammary aciviy. Estrogen-containing contraceptives. Phnyin n hancs h mablism f srgns. Sping r bld ing may b an indicain f rducd srgn lvls and rducd cnracpiv aciviy wih srgn cnaining cnracpivs. Using alrnaiv frms f birh cnrl is rcmmndd. Theophylline. Phnyin dcrass h srum lv ls f hphyllin drivaivs. Mnir pains fr a highr frquncy f rspirary difculy. Th h phyllin dsag may nd  b incrasd by 50%  100%  mainain h sam hrapuic rspns. Valproic acid. This agn may incras r dcras h aciviy f phnyin. Mnir h pain fr an incrasd frquncy f sizur aciviy. Mniring changs in srum lvls shuld hlp prdic pssibl incrasd sizur aciviy. Mnir pains wih cn currn hrapy fr signs f phnyin xiciy, includ ing nysagmus, sdain, and lhargy. Srum lvls may b rdrd, and a rducd dsag f phnyin may b rquird. Ketoconazole. Th cncurrn adminisrain wih kcnazl may alr h mablism f n r bh drugs. Mniring h lvls f bh drugs is rcmmndd.

Medication Safety Alert Phenytoin is associated with many drug interactions. Those listed earlier are the most common drug interactions recognized, but it is only a representative list. Consult a resource such as Drug Interaction Facts for a more complete description.

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DRUG CLASS: SUCCINIMIDES Actions Th succinimids lva h sizur hrshld by d prssin f nrv ransmissin in h crx by rduc ing h currn in h Typ calcium channls fund in primary affrn nurns. Th hrapuic plasma lvl fr hsuximid is 40  100 mcg/mL. Uses Succinimids (.g., hsuximid, mhsuximid) ar usd  cnrl absnc sizurs. Therapeutic Outcomes Th primary hrapuic ucms xpcd frm h succinimids ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Minimal advrs ffcs frm hrapy Nursing Implications for Succinimides Premedication assessment

1. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rin ain  nam, plac, and im bfr iniiaing hrapy. 2. Mnir h pain’s bhaviral rspnss  hrapy. 3. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy. Availability, dosage, and administration. S Tabl 18.2. Common adverse effects

Gastrointestinal Nausea, vomiting, indigestion. Ths ffcs ar cm mn during h iniiain f hrapy. Gradual incrass in dsag and adminisrain wih fd r milk will rduc gasric irriain. Neurologic Sedation, drowsiness, dizziness, fatigue, lethargy. Ths sympms nd  disappar wih cninud hrapy and pssibl dsag adjusmn. Encurag h pa in n  discninu hrapy wihu rs cnsul ing h halhcar prvidr. Th pain shuld b warnd n  wrk wih machinry, pra a m r vhicl, adminisr mdicain, r prfrm h r duis ha rquir mnal alrnss. Prvid fr pain safy during pisds f dizzinss; rpr hs changs  h halhcar prvidr fr furhr valuain. Drug interactions

Drugs that enhance toxic effects. Anihisamins, al chl, analgsics, anshics, ranquilizrs, hr ani pilpic drugs, and sdaivhypnics nhanc h xic ffcs f succinimids.

286

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

DRUG CLASS: MISCELLANEOUS ANTIEPILEPTIC MEDICINES

2. Minimal advrs ffcs frm hrapy Nursing Implications for Carbamazepine Premedication assessment

carbamazepine (kăr-bă-MĀZ-ă-pēn) Tegretol (TĔG-rĕ-tŏl) Do not confuse Tegretol with Toradol or Trileptal.

Actions Carbamazpin blcks h vlaggad sdium channls in brain clls, which rsuls in a rducin in susaind highfrquncy nurnal dischargs. I als blcks h rupak f nrpinphrin and dcrass h rlas f nrpinphrin and h ra f dpamin and GABA urnvr. Dspi knwldg f hs phar maclgic ffcs, h mchanisms f acin as an ani pilpic, slciv analgsic, and animanic agn ar n fully knwn. Carbamazpin is srucurally rlad  h ricyclic anidprssans. Uses Carbamazpin is an anipilpic fn usd in cm binain wih hr anipilpic agns  cnrl gnralizd nicclnic and fcal sizurs. I is n f fciv fr cnrlling myclnic r absnc sizurs. Carbamazpin has als bn usd succssfully  ra h pain assciad wih rigminal nuralgia (ic du lurux). I may als b usd  ra manicdprssiv disrdrs whn lihium hrapy has n bn pimal. Th US Fd and Drug Adminisrain issud an alr  halhcar prfssinals abu dangrus and pssibly faal skin racins ha may ccur wih car bamazpin in crain pain ppulains. Ths skin racins ar signicanly mr cmmn amng pains wih a paricular human lukcy anign (HLA): h HLAB*1502 alll. This alll ccurs alms xclusivly in prsns f Asian ancsry. Pains wih his ancsry shuld b scrnd wih availabl gnic ss fr h alll bfr saring ramn wih carba mazpin. If s rsuls ar psiiv, h drug shuld n b sard unlss h xpcd bn clarly u wighs h risk f srius skin racins. Pains wh s psiiv fr h alll may als b a incrasd risk frm hr anipilpic drugs ha hav causd srius skin racins. Mr han 90% f all srius skin rac ins ccur wihin h rs fw mnhs f ramn. This mans ha pains wh hav bn n h drug fr lngr prids wihu dvlping skin racins hav a lw risk f racin in h fuur, vn if hy hav sd psiiv fr h alll. Therapeutic Outcomes Th primary hrapuic ucms xpcd frm car bamazpin ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy

1. As a rsul f srius advrs racins, h manu facurr rcmmnds ha h fllwing baslin sudis b rpad a rgular inrvals: cmpl bld cun, srum irn, livr funcin ss, urinal ysis, bld ura nirgn (BUN), srum crainin, srum sdium, and phhalmlgic xaminain. 2. Rviw h pain’s hisry  xclud Asian an csry, including Suh Asian Indian ancsry. If h pain ds hav his ancsry, bring i  h prscribr’s anin s ha gnic sing may b cmpld. 3. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im bfr iniiaing hrapy. Mnir h pain’s bhaviral rspnss  hrapy. 4. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy. Availability. PO: 200mg abls; 100mg chwabl ab

ls; 100, 200, and 400mg abls, xndd rlas (12 hurs); 100, 200, and 300mg capsuls, xndd rlas (12 hurs); 100 mg/5 mL ral suspnsin. Dosage and administration. Adult: PO: Iniial dsag

is 200 mg wic daily n h rs day. Dsag may b in crasd by 200 mg/day a wkly inrvals. Maximum dsag 1000 mg/day in adlscns 12  15 yars and 1200 mg/day in hs ldr han 15 yars. Common adverse effects. Ths ffcs can b rducd

by slwly incrasing h dsag. Thy ar usually mild and nd  rslv wih cninud hrapy. Encurag h pain n  discninu hrapy wihu rs cnsuling h halhcar prvidr. Gastrointestinal. Gasrinsinal ffcs includ nau sa and vmiing. Neurologic Drowsiness, dizziness. Prvid fr pain safy dur ing pisds f drwsinss r dizzinss. Pains mus b warnd n  wrk arund machinry, pra m r vhicls, r prfrm hr duis ha rquir cn san mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. Serious adverse effects

Cardiovascular Orthostatic hypotension, hypertension. Mnir h pa in’s bld prssur daily in h supin and sanding psiins. Anicipa h dvlpmn f psural hyp nsin and ak masurs  prvn an ccurrnc. Tach h pain  ris slwly frm a supin r siing psiin, and ncurag h pain  si r li dwn if fling fain.

Drugs Used for Seizure Disorders CHAPTER 18

Dyspnea, edema. If carbamazpin is usd by a pa in wih a hisry f har failur, mnir daily wighs, lung sunds, and accumulain f dma. Neurologic Slurred speech, sedation, confusion. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im b fr iniiaing hrapy. Mak rgularly schduld sub squn valuains f h pain’s mnal saus and cmpar ndings. Rpr any signican alrains  h halhcar prvidr. Genitourinary Nephrotoxicity. Mnir h pain’s urinalysis and kidny funcin ss fr abnrmal rsuls. Rpr in crasing BUN and crainin lvls, dcrasing urin upu r spcic graviy dspi h amun f uid inak, cass r prin in h urin, frank bld r smkyclrd urin, r RBCs in xcss f 0  3 n h urinalysis rpr. Gastrointestinal Hepatotoxicity. Th sympms f hpaxiciy in clud anrxia, nausa, vmiing, jaundic, hpa mgaly, splnmgaly, and abnrmal livr funcin ss (i.., lvad bilirubin, AST, ALT, GGT, and ALP; incrasd PT). Hematologic Blood dyscrasias. Ruin labrary sudis (i.., RBC, WBC, and diffrnial cuns) shuld b schd uld. Mnir h pain fr sr hra, fvr, pur pura, jaundic, r xcssiv and prgrssiv waknss. Integumentary Dermatologic reactions. Rpr a rash r prurius im mdialy and wihhld addiinal dss pnding ap prval by h halhcar prvidr. Drug interactions

Drugs that enhance therapeutic and toxic effects. Isniazid, cimidin, uxin, uvxamin, kcnazl, and macrlid anibiics (.g., ryh rmycin, clarihrmycin) inhibi h mablism f carbamazpin. Mnir h pain fr signs f xic iy, such as disrinain, aaxia, lhargy, hadach, drwsinss, nausa, and vmiing. Dsag rducins in carbamazpin may b ncssary. Verapamil, diltiazem, lamotrigine. Ths drugs incras srum lvls f carbamazpin. Mnir h pain fr signs f xiciy (.g., disrinain, aaxia, lhargy, hadach, drwsinss, nausa, vmiing). A 40%  50% dcras in h carbamazpin dsag may b ncssary. Warfarin. Carbamazpin may diminish h ani cagulan ffcs f warfarin. Mnir h inrnainal nrmalizd rai [INR] and incras h dsag f warfarin, if ncssary. Phenobarbital, phenytoin, valproic acid. Carbamazpin nhancs h mablism f hs agns. Mnir h pain fr an incrasd frquncy f sizur aciviy. Mniring changs in srum lvls shuld hlp pr dic pssibl incrasd sizur aciviy.

287

Doxycycline. Carbamazpin nhancs h mab lism f his anibiic. Mnir h pain fr signs f cninud infcin. Estrogen-containing contraceptives. Carbamazpin nhancs h mablism f srgns. Sping r blding may b an indicain f rducd srgn lv ls and rducd cnracpiv aciviy. Th us f hr frms f birh cnrl is rcmmndd. gabapentin (găb-ă-PĔN-tĭn) Neurontin (nyŭr-ŎN-tĭn) Do not confuse Neurontin with Neoral.

Actions Th mchanism f acin f gabapnin is unknwn. I ds n appar  nhanc GABA. Uses Gabapnin is usually usd in cmbinain wih hr anipilpic drugs  cnrl fcal sizurs. Gabapnin is als apprvd fr pshrpic nural gia. Off labl, gabapnin is usd in hr disrdrs, such as brmyalgia, diabic nurpahy, and vas mr sympms assciad wih mnpaus. Therapeutic Outcomes Th primary hrapuic ucms xpcd frm ga bapnin ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Sympmaic rlif frm rslss lgs syndrm and pshrpic nuralgia 3. Minimal advrs ffcs frm hrapy Nursing Implications for Gabapentin Premedication assessment

1. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im bfr iniiaing hrapy. Mnir h pain’s bhaviral rspnss  hrapy. 2. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy. 3. Whn gabapnin is usd as an analgsic, prfrm a pain assssmn bfr adminisring i and a appr pria inrvals during hrapy. Rpr pr pain cn rl, and bain a mdicain in h pain’s rdrs. Availability. PO: 100, 300, and 400mg capsuls;

300, 600, and 800mg abls; 250 mg/5 mL ral sluin.

Medication Safety Alert Serious breathing difculties may occur in patients using gabapentinoids (gabapentin or pregabalin) who have respiratory risk factors. These include the use of opioid pain medicines and other drugs that depress the central nervous system, and conditions such as chronic obstructive pulmonary disease that reduce lung function. The elderly are also at higher risk.

288

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

Dosage and administration. Adult: PO: 900  1800

mg daily. Iniially adminisr 300 mg a bdim n day 1, 300 mg w ims n day 2, and hn 300 mg hr ims n day 3. May incras using 300, 400, 600, r 800mg dsag frms givn hr ims pr day. Effciv ds is 900  1800 mg/day, bu up  2400 mg/day has bn usd lng rm. Dsags f 3600 mg/day hav bn givn  limid pains fr a rlaivly shr durain. Th maximum im b wn dss fr h hrimsdaily schdul shuld n xcd 12 hurs. Note: Dsag adjusmn may b ncssary in pains whs simad crainin clar anc is lss han 50 mL/min. Thrapuic bld lvls fr gabapnin ar 2  20 mg/L. If h pain als uss anacids, adminisr gaba pnin a las 2 hurs afr h las ds f anacid, bcaus anacids rduc h absrpin f gabapnin. Common adverse effects

Neurologic Sedation, drowsiness, dizziness. Ths sympms nd  disappar wih cninud hrapy and pssibl ds ag adjusmn. Encurag h pain n  discn inu hrapy wihu rs cnsuling h halhcar prvidr. Prvid fr pain safy during pisds f drwsinss r dizzinss. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. Sensory Blurred vision. Cauin h pain ha blurrd visin may ccur and mak apprpria suggsins fr h pain’s prsnal safy. Serious adverse effects

Neurologic Slurred speech, lethargy, confusion. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im b fr iniiaing hrapy. Mak rgularly schduld sub squn valuains f h pain’s mnal saus and cmpar ndings. Rpr any signican alrains. Drug interactions

Enhanced sedation. Cnral nrvus sysm dprs sans—including slp aids, analgsics, ranquilizrs, and alchl—nhanc h sdaiv ffcs f gabap nin. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. Prvid fr pain safy during pisds f drwsi nss r dizzinss. Urine protein. Falspsiiv radings fr prin in h urin hav bn rprd by pains wh ar ak ing gabapnin wh us h Mulisix 10SG Ragn dipsick s (Simns Halhcar, Erlangn, Grmany). Th manufacurr rcmmnds ha h mr spcic

sulfsalicylic acid prcipiain prcdur b usd  drmin h prsnc f urin prin. lamotrigine (lă-MŎ-trĭ-gēn) Do not confuse lamotrigine with lamivudine. Lamictal (lă-MĬK-tăl) Do not confuse Lamictal with labetalol, Lamisil, or Lomotil.

Actions Lamrigin is a nwr anipilpic f h phnyl riazin class ha is unrlad  hr anipilpic mdicains currnly availabl. I is hugh  ac primarily by blcking vlagsnsiiv sdium. I may als ac n h calcium channls in h nurnal mm brans. This sabilizs h nurnal mmbrans and in hibis h rlas f xciary nurransmirs (.g., gluama), which may induc sizur aciviy. Uses Lamrigin is usd in cmbinain wih hr ani pilpic hrapy  ra fcal sizurs and h gnralizd sizurs f LnnxGasau syndrm in pdiaric and adul pains. Lamrigin is als apprvd fr us in cmbinain wih hr sandard hrapis  ra bi plar disrdr  dlay h im  h ns f md pisds (i.., dprssin, mania, mixd pisds). Therapeutic Outcomes Th primary hrapuic ucms xpcd frm la mrigin ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Tramn f biplar disrdr 3. Minimal advrs ffcs frm hrapy Nursing Implications for Lamotrigine Premedication assessment

1. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rina in  nam, plac, and im bfr iniiaing hr apy. Mnir h pain’s bhaviral rspnss  hrapy. 2. Rviw h pain’s mdicain hisry  dr min whhr h pain is alrady aking valpric acid fr sizur cnrl. 3. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy. Availability. PO: abls: 25, 100, 150 and 200 mg; chw

abl abls: 5 and 25 mg; rally disingraing abls: 25, 50, 100, and 200 mg; abls, 24hur xndd r las: 25, 50, 100, 200, 250, and 300 mg. Dosage and administration

Seizure disorder. Adult: PO: If h pain is alrady aking valpric acid fr sizur cnrl, iniia lam rigin hrapy a 25 mg vry hr day fr 2 wks,

Drugs Used for Seizure Disorders CHAPTER 18

fllwd by 25 mg daily fr 3  4 wks; hn h ds may b incrasd by 25  50 mg PO daily vry 1  2 wks unil h mainnanc dsag is achivd. Th usual mainnanc ds is 100  400 mg/day PO, giv n in n  w dividd dss. Th usual mainnanc ds fr pains wh add lamrigin  valpric acid aln rangs frm 100  200 mg/day. If h pain is n alrady aking mablism inducing mdicains (.g., valpric acid, carbamaz pin, phnyin, phnbarbial, rifampin) fr sizur cnrl, iniia lamrigin hrapy a 25 mg PO v ry day fr 2 wks, hn 50 mg/day PO fr wks 3  4; hn h ds may b incrasd by 50 mg/day PO vry 1  2 wks unil h mainnanc dsag is achivd. Th usual mainnanc ds is 225  375 mg/day PO, givn in w dividd dss. If h pain is alrady rciving mablisminducing mdicains fr sizur cnrl, h dsag f lamrigin shuld b apprximaly w ims hs dsags up  400 mg daily in dividd dss; s h manufacurr’s rcm mndains. Thrapuic bld lvls fr lamrigin ar 3  15 mg/L. Bipolar disorder. Adult: PO: Iniial dsag d pnds n hr mdicains ha ar bing akn. Targ dsag is 200 mg/daily f immdiarlas mdicain. Common adverse effects

Gastrointestinal Nausea, vomiting, indigestion. Ths ffcs ar cm mn during h iniiain f hrapy. Gradual incrass in dsag and adminisrain wih fd r milk will rduc gasric irriain. Neurologic Sedation, drowsiness, dizziness. Ths sympms nd  disappar wih cninud hrapy and pssibl ds ag adjusmn. Encurag h pain n  discn inu hrapy wihu rs cnsuling h halhcar prvidr. Prvid fr pain safy during pisds f drwsinss r dizzinss. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. Sensory Blurred vision. Cauin h pain ha blurrd visin may ccur, and mak apprpria suggsins fr h pain’s prsnal safy. Serious adverse effects

Integumentary Dermatologic reactions. Apprximaly 10% f pa ins wh rciv lamrigin dvlp a skin rash and uricaria during h rs 4  6 wks f hra py. Slwr incrass in ach dsag adjusmn ar hugh  dcras h incidnc f rash. In ms cas s, h rash rslvs wih cninud hrapy; hwvr, h halhcar prvidr shuld b prmply infrmd

289

bcaus h rash culd als b an arly indicar f a mr srius cndiin. Cmbinain hrapy wih valpric acid appars  b mr likly  prcipia a srius rash. Encurag h pain n  discninu h la mrigin unil alrnaiv anipilpic hrapy can b cnsidrd  prvn rnwd sizur aciviy. Neurologic Aseptic meningitis. Lamrigin may caus asp ic mningiis. Pains shuld b advisd  cnac hir halhcar prvidr immdialy if hy xp rinc signs and sympms f mningiis, such as hadach, fvr, siff nck, nausa, vmiing, rash, and snsiiviy  ligh. Pains shuld b valuad fr hr causs f mningiis; if n hr causs ar fund, h discninuain f lamrigin shuld b cnsidrd. Drug interactions

Drugs that enhance therapeutic and toxic effects. Valpric acid rducs h mablism f lam rigin by as much as 50%. Signican lamrigin ds ag rducin may b rquird. Drugs that decrease therapeutic effects. Phnbarbial, phnyin, primidn, carbamazpin, xcarbazpin, hsuximid, rifampin, acaminphn, srgn cn aining ral cnracpivs, and prgsin ral cn racpivs nhanc h mablism f lamrigin. Mnir h pain fr h incrasd frquncy f sizur aciviy. Mniring changs in srum lvls shuld hlp prdic pssibl incrasd sizur aciviy. Th wicdaily adminisrain f lamrigin may b ncssary. Enhanced sedation. Cnral nrvus sysm dprs sans—including slp aids, analgsics, ranquilizrs, and alchl—nhanc h sdaiv ffcs f lam rigin. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. Prvid fr pain safy during pisds f drwsi nss r dizzinss. levetiracetam (lĕ-vĕ-tĭr-ă-SĒ-tĕm) Keppra (KĔP-ră) Do not confuse Keppra with Kaletra.

Actions Lviracam is classid as a pyrrlidin drivaiv chmically unrlad  hr anipilpic drugs avail abl. Is mchanism f acin is unknwn, bu i ap pars  acs n vlaggad passiumchannls and bind  h SV2A. Uses Lviracam is apprvd fr us in cmbinain wih hr anipilpic hrapy  ra fcal sizurs,

290

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

myclnic sizurs, and primary gnralizd nic clnic sizurs in aduls. Therapeutic Outcomes Th primary hrapuic ucms sugh frm lvi racam ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Minimal advrs ffcs frm hrapy Nursing Implications for Levetiracetam Premedication assessment

1. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy. 2. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im bfr iniiaing hrapy. 3. Rviw h pain’s labrary rprs and rpr any abnrmal rnal funcin (.g., BUN, crainin, crainin claranc). Availability. PO: 250, 500, 750, and 1000mg abls;

250, 500, 750, 1000mg disingraing abls; 500 and 750, 1000, and 1500mg abls, xndd rlas (24 hurs); 100 mg/mL ral sluin. Injection: 100 mg/mL in 5mL vials; 500 mg/5 mL; 500 mg/100 mL; 1000 mg/100 mL; 1500 mg/100 mL. Dosage and administration. Adult: PO: Iniial ds is

500 mg wic daily. Dsag may b incrasd vry 2 wks by 500 mg wic daily unil a maximum ds f 3000 mg/day is aaind. Note: Dsag adjusmn is ncssary in pains whs simad crainin claranc is lss han 80 mL/min. S h packag insr fr addiinal insruc ins. Th hrapuic bld lvls fr lviracam ar 12  46 mg/L. Common adverse effects

Neurologic Weakness, drowsiness, dizziness. Ths ffcs can b rducd by slwly incrasing h dsag. Thy ar usually mild, and hy nd  rslv wih cninud hrapy. Encurag h pain n  discninu hr apy wihu rs cnsuling h halhcar prvidr. Prvid fr pain safy during pisds f waknss and dizzinss. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss un il i is knwn hw hy ar affcd by his mdicain. Serious adverse effects

Neurologic Confusion, disorientation. Mak rgularly schduld assssmns f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im, and cmpar ndings. Rpr any signican alra ins  h halhcar prvidr.

Drug interactions

Enhanced sedation. Cnral nrvus sysm dprs sans—including slp aids, analgsics, ranquilizrs, and alchl—nhanc h sdaiv ffcs f lvi racam. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. oxcarbazepine (ŏks-kăr-BĂZ-ĕ-pēn) Do not confuse oxcarbazepine with olanzapine. Trileptal (trī-LĔP-tŏl) Do not confuse Trileptal with Tegretol.

Actions Oxcarbazpin is a prdrug ha mablizs in sm f h aciv mablis f carbamazpin. Oxcarbazpin blcks h vlaggad sdium chan nls, rsuling in sabilizain f hyprxcid nural mmbrans. In addiin, i may mdula h vlag gad passium and calcium channls, which may cnribu  h anicnvulsan ffcs f h drug. Uses Oxcarbazpin is usd as mnhrapy r cmbi nain hrapy fr h ramn f fcal sizurs in aduls and as cmbinain hrapy fr h ramn f fcal sizurs in childrn wh ar 4  16 yars ld. Bcaus f h srucural similariy  carbamazpin, bfr saring hrapy cnsidr scrning pains f Asian dscn fr h varian HLAB*1502 alll. Therapeutic Outcomes Th primary hrapuic ucms xpcd frm x carbazpin ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Minimal advrs ffcs frm hrapy Nursing Implications for Oxcarbazepine Premedication assessment

1. Bcaus f his drug’s pnial  caus srius ad vrs racins, h manufacurr rcmmnds ha srum lcrly baslin lvls b drmind and hn rpad pridically whil h pain is r civing xcarbazpin hrapy. 2. Rviw h pain’s mdicain hisry  nsur ha h pain ds n hav an allrgy  carbam azpin. If hr is an allrgy, infrm h charg nurs and h halhcar prvidr immdialy. D n ad minisr h mdicain wihu spcic apprval. 3. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im bfr iniiaing hrapy. Mnir h pain’s bhaviral rspnss  hrapy. 4. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy.

Drugs Used for Seizure Disorders CHAPTER 18

Availability. PO: 150, 300, and 600mg abls; 150,

300, 600mg abls, xndd rlas (24 hurs); 300 mg/5 mL suspnsin. Dosage and administration. Adult: PO: Iniial dsag

is 300 mg wic daily fr h rs 3 days. Th ds ag may b incrasd by 300 mg/day vry 3 days  1200 mg/day. Dsags f 2400 mg/day hav bn fund  b ffciv fr pains cnvrd frm hr anicnvulsan hrapy  mnhrapy wih xcarbazpin. Pediatric (4 to 16 years old): PO: Iniial dsag is 4  5 mg/kg wic daily, n  xcd 600 mg/day. Th dsag shuld b gradually incrasd vr h nx 2 wks  a arg mainnanc lvl basd n h pa in’s bdy wigh: 20–24.9 kg 25–34.9 kg 35–44.9 kg 45–49.9 kg 50–59.9 kg 60–69.9 kg >70 kg

600–900 mg/day in two divided doses 900–1200 mg/day in two divided doses 900–1500 mg/day in two divided doses 1200–1500 mg/day in two divided doses 1200–1800 mg/day in two divided doses 1200–2100 mg/day in two divided doses 1500–2100 mg/day in two divided doses

Th hrapuic bld lvls fr xcarbazpin ar 3  35 mg/L. Common adverse effects

Neurologic Confusion, poor coordination, drowsiness, dizziness. Ths ffcs can b rducd by slwly incras ing h dsag; hy ar usually mild and nd  r slv wih cninud hrapy. Encurag h pain n  discninu hrapy wihu rs cnsuling h halhcar prvidr. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im bfr iniiaing hrapy. Mak rgularly schduld subsqun valu ains f h pain’s mnal saus, and cmpar ndings; rpr any signican alrains. Prvid fr pain safy during pisds f drwsinss, cn fusin, r dizzinss. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. Serious adverse effects

Hematologic Blood dyscrasias. Ruin labrary sudis (i.., RBC, WBC, and diffrnial cuns) shuld b

291

schduld. Mnir h pain fr sr hra, f vr, purpura, jaundic, r xcssiv and prgrssiv waknss. Nausea, headache, lethargy, confusion, obtundation, malaise. Ths ar sympms f hypnarmia. I is x rmly impran  nify h halhcar prvidr if h pain is xhibiing any f hs cndiins. Wihhld addiinal dss f h drug unil spcic r drs  adminisr h mdicain hav bn rcivd. Drug interactions

Drugs that decrease therapeutic effects. Phnbarbial, primidn, phnyin, valpric acid, carbamazpin, and vrapamil may nhanc h mablism f x carbazpin. Mnir h pain fr an incrasd fr quncy f sizur aciviy. Dsags f xcarbazpin may nd  b incrasd. Estrogenand progestin-containing contraceptives. Oxcarbazpin nhancs h mablism f srgns and prgsins. Sping r blding may b an indicain f rducd cnracpiv aciviy. Rcmmnd ha h pain us hr frms f birh cnrl whil aking xcarbazpin. phenobarbital (fē-nō-BĂR-bĭ-tŏl)

Actions Phnbarbial, a lngacing barbiura, lvas h sizur hrshld and prvns h sprad f lcrical sizur aciviy by nhancing h inhibiry ffc f GABA. Th xac mchanism is unknwn. Uses Phnbarbial is an ffciv anipilpic agn. Bcaus f is sdaiv ffcs, hwvr, i is nw usd primarily as an alrnaiv whn singl nnsdaing anipilpic drugs ar unsuccssful fr h cnrl f sizurs. Phnbarbial is ms usful fr raing fcal and gnralizd nicclnic sizurs and gnralizd myclnic sizurs, usually in cmbinain wih hr anipilpic drugs. Th hrapuic bld lvls fr phnbarbial ar 15  45 mg/L. Therapeutic Outcomes Th primary hrapuic ucms xpcd frm ph nbarbial ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Minimal advrs ffcs frm hrapy Nursing Implications for Phenobarbital Premedication assessment

1. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rina in  nam, plac, and im bfr iniiaing hr apy. Mnir h pain’s bhaviral rspnss  hrapy.

292

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

2. Obain h pain’s vial signs (.g., bld prssur, puls, rspirains). Availability. PO: abls: 15, 16.2, 30, 32.4, 60, 64.8, 97.2,

and 100 mg; lixir and sluin: 20 mg/5 mL. IV: 65 and 130 mg/mL. Dosage and administration

Seizure control. Adult: PO: 60  200 mg/day r 50  100 mg w  hr ims daily. Status epilepticus. IV: 15 mg/kg as a singl ds. Note: Rapidly discninuing phnbarbial afr h lngrm us f high dsags may rsul in sympms ha ar similar  hs f alchl wihdrawal. Ths may vary frm waknss and anxiy  dlirium and gnralizd sizurs. Discninuain f phnbarbial cnsiss f cauius and gradual wihdrawal vr 2  4 wks. adverse effects. Gnral advrs f fcs f phnbarbial includ drwsinss, lh argy, hadach, muscl r jin pain, and mnal dprssin. Neurologic Hangover, sedation, lethargy, diminished alertness. Pains may cmplain f “mrning hangvr,” blurrd visin, and ransin hypnsin n arising. Explain  h pain h nd  rs ris  a siing psiin, say siing fr svral mmns unil any dizzinss r lighhaddnss passs, and hn sand slwly. Assisanc wih ambulain may b rquird. If h hangvr ffc bcms rublsm, hr shuld b a rducin in h dsag, a chang in h mdicain, r bh. Ppl wh wrk arund machinry, driv, admin isr mdicains, r prfrm hr duis fr which hy mus rmain mnally alr shuld n ak his mdicain whil wrking. Common

Serious adverse effects

Psychological Excessive use or abuse. Th habiual us f phn barbial may rsul in physical dpndnc. Discuss h issu wih h halhcar prvidr and mak plans  cpraivly apprach h gradual wihdrawal f h mdicains bing abusd if sizur cnrl is mainaind. Paradoxical response. Oldr pains may rspnd paradxically  phnbarbial by dmnsraing xcimn, uphria, rslssnss, and cnfusin. Prvid suppriv physical car and safy during hs rspnss. Integumentary Hypersensitivity. Racins  phnbarbial ar infr qun bu may b srius. Rpr sympms f hivs, prurius, rash, high fvr, r h inammain f h mucus mmbrans fr valuain by a halhcar prvidr.

Hematologic Blood dyscrasias. Bld dyscrasias ar rar; hwvr, labrary sudis (.g., RBC, WBC, diffrnial, and plal cuns) shuld b schduld whn sympms warran. Srss h impranc f h pain rurning fr his labrary wrk. Mnir h pain fr h dvlpmn f sr hra, fvr, purpura, jaundic, r xcssiv and prgrssiv waknss. Drug interactions

Drugs that increase toxic effects. Anihisamins, alc hl, analgsics, anshics, ranquilizrs, valpric acid, mnamin xidas inhibirs, and hr sdaiv hypnics incras h xic ffcs f phnbarbial. Mnir h pain fr xcssiv sdain, and rduc h dsag f phnbarbial r anhr mdicin if ncssary. Phenytoin. Th ffcs f phnbarbial n ph nyin ar variabl. Srum lvls may b rdrd, and a chang in phnyin dsag may b rquird. Obsrv pains fr incrasd sizur aciviy and fr signs f phnyin xiciy (.g., nysagmus, sdain, lhargy). Reduced therapeutic effects. Phnbarbial rducs h ffcs f h fllwing mdicins: • Warfarin: Mnir h pain’s inrnainal nr malizd rai (INR) and incras h dsag f war farin, if ncssary. • Estrogens: This drug inracin may b criical in pains wh ar rciving cnracpivs ha cnain srgn. If pains dvlp sping and brakhrugh blding, a chang in cnracpivs and h us f alrnaiv frms f cnracpin shuld b cnsidrd. • Corticosteroids, beta-adrenergic blockers, metronidazole, doxycycline, antidepressants, quinidine, and chlorpromazine: Th pain shuld b mnird fr signs f incrasd aciviy f h illnss fr which h mdicain was prscribd. Dsag incrass may b ncssary, r phnbarbial may hav  b discninud. pregabalin (prĕ-GĂB-ă-lĭn) Lyrica (LĬR-ĭ-kă)

Actions Prgabalin wrks by blcking h vlaggad cal cium channls. I is chmically rlad  gabapnin. I ds n appar  nhanc GABA. Uses Prgabalin is an anipilpic usd in cmbinain wih hr anipilpic agns  cnrl fcal sizurs. Prgabalin is als apprvd fr h ramn f pain as sciad wih brmyalgia, diabic nurpahy, nu rpahic pain assciad wih spinal crd injury, and pshrpic nuralgia (a cmplicain f acu hrps

Drugs Used for Seizure Disorders CHAPTER 18

293

zsr acivain, which is fn dscribd as unbar abl iching, lcric shck–lik pain, r burning). Prgabalin has h pnial fr abus and dpn dnc, and i has bn dsignad as a Schdul V cn rlld subsanc. Sympms suggsiv f physical dpndnc (insmnia, nausa, hadach, diarrha) hav bn bsrvd in sm pains in clinical sudis afr h drug’s abrup discninuain.

450 mg daily. Th hrapuic bld lvls fr prgaba lin hav n bn sablishd.

Therapeutic Outcomes Th primary hrapuic ucms xpcd frm pr gabalin ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Sympmaic rlif frm pain assciad wih  brmyalgia, diabic nurpahy, and pshrpic nuralgia 3. Minimal advrs ffcs frm hrapy

Spinal cord injury-associated neuropathic pain. Adult:

Nursing Implications for Pregabalin Premedication assessment

1. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rina in  nam, plac, and im bfr iniiaing hr apy. Mnir h pain’s bhaviral rspnss  hrapy. 2. Obain a baslin masurmn f h pain’s cr ainin claranc fr pnial dsag adjusmn. 3. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy. 4. Rviw h pain’s mdical rcrd fr indicains f a hisry f subsanc abus. 5. Whn prgabalin is usd as an analgsic, prfrm a pain assssmn wih h pain bfr adminisr ing i and a apprpria inrvals during hrapy. Rpr pr pain cnrl and bain a mdicain in h pain’s rdrs.

Neuropathic pain associated with diabetic peripheral neuropathy. Adult: PO: Up  300 mg daily. Iniially

adminisr 50 mg hr ims daily and incras  100 mg hr ims daily wihin 1 wk n h basis f h pain’s lranc. PO: Up  600 mg daily. Iniially adminisr 75 mg wic daily and incras  150 mg wic daily wihin 1 wk basd n rspns and lrabiliy. Postherpetic neuralgia. Adult: PO: 150  600 mg dai

ly. Iniially adminisr 50 mg hr ims daily r 75 mg wic daily. Fr pains wh d n xprinc suf cin pain rlif afr 2  4 wks f ramn wih 300 mg daily and wh can lra advrs ffcs, h daily dsag can b incrasd  a maximum f 600 mg daily (i.., 200 mg hr ims daily r 300 mg wic daily).

Medication Safety Alerts Patients should be monitored for signs of pregabalin abuse, including dosage escalation, tolerance, and drug-seeking behavior. When discontinuing therapy, taper over at least 1 week to minimize the potential for withdrawal symptoms. Serious breathing difculties may occur in patients using gabapentinoids (gabapentin or pregabalin) who have respiratory risk factors. These include the use of opioid pain medicines and other drugs that depress the central nervous system, and conditions such as chronic obstructive pulmonary disease that reduce lung function. The elderly are also at higher risk.

Common adverse effects

Iniially adminisr 50 mg hr ims daily r 75 mg wic daily. Th daily dsag can b incrasd  a maximum f 600 mg daily in dividd dss, dpnd ing n h pain’s rspns and h dvlpmn f any advrs ffcs.

Neurologic Sedation, drowsiness, dizziness. Ths sympms nd  disappar wih cninud hrapy and pssibl dsag adjusmn. Encurag h pain n  discninu hrapy wihu rs cnsuling h halhcar prvid r. Prvid fr pain safy during pisds f drwsi nss r dizzinss. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. Sensory Blurred vision. Cauin h pain ha blurrd visin may ccur, and mak apprpria suggsins fr h pain’s prsnal safy.

Fibromyalgia. Adult: PO: 300  450 mg daily. Iniially

Serious adverse effects

Availability. PO: capsuls: 25, 50, 75, 100, 150, 200, 225,

and 300 mg; abls, 24hur xndd rlas: 82.5, 165, 330 mg; ral sluin: 20 mg/mL. Dosage and administration. Dsags shuld b ad

jusd fr pains wih a crainin claranc blw 60 mL/min. Seizure control. Adult: PO: 150  600 mg daily.

adminisr 75 mg wic daily and incras  150 mg wic daily wihin 1 wk. If hr is a hrapuic bn  and h advrs ffcs ar accpabl, h dsag may b incrasd  225 mg wic daily fr a al f

Neurologic Confusion, disorientation. Mak rgularly schduld assssmns f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im,

294

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

and cmpar ndings. Rpr any signican alra ins  h halhcar prvidr. Psychological Excessive use or abuse. Evalua h pain’s r spns  prgabalin as an analgsic. Idnify hir undrlying nds and plan fr h mr apprpria managmn f hs nds. Discuss h pain’s cas wih h halhcar prvidr and mak plans  c praivly apprach h gradual wihdrawal f h mdicains ha ar bing abusd. Suggs a chang  a mildr analgsic whn indicad. Pains d n hav  undrg h sympms f wih drawal  b rad fr addicin. Thy may b rad wih h gradual rducin f daily pia agnis dss. If wihdrawal sympms bcm svr, h pain may rciv mhadn. Th mprary adminisrain f ranquilizrs and sdaivs may hlp rduc bh pain anxiy and h craving fr h pia agnis. Drug interactions

Enhanced sedation. Cnral nrvus sysm dprs sans—including slp aids, analgsics, ranquilizrs, bnzdiazpins, xycdn, and alchl—nhanc h sdaiv ffcs f prgabalin. Pains mus b warnd n  wrk arund machinry, pra m r vhicls, r prfrm hr duis ha rquir cn san mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. Prvid fr pain safy during pisds f drwsinss r dizzinss. topiramate (tō-PĬR-ă-māt) Do not confuse topiramate with torsemide. Topamax (TŌ-pă-măks)

Actions Th mchanism f acin f pirama as an ani pilpic agn is unknwn. Thr pnial mchanisms may suppr anipilpic aciviy: (1) h prlngd blckad f sdium channls in h nurnal mm bran, (2) h pniain f h aciviy f h inhibi ry nurransmir GABA, and (3) h anagnism f crain rcprs f h xciary nurransmir. Uses Tpirama is an anipilpic usd in cmbinain wih hr anipilpic agns  cnrl fcal and gnralizd nicclnic sizurs. I is als usd fr pa ins 2 yars ld and ldr wh hav sizurs assci ad wih LnnxGasau syndrm. Tpirama has als bn apprvd fr aduls fr h prvnin (bu n ramn) f migrain hadachs. Therapeutic Outcomes Th primary hrapuic ucms xpcd frm pi rama ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy

2. Prvnin f migrains 3. Minimal advrs ffcs frm hrapy Nursing Implications for Topiramate Premedication assessment

1. Prfrm a baslin assssmn f h pain’s spch parns and dgr f alrnss, as wll as rinain  nam, plac, and im, bfr inii aing hrapy. Mnir h pain’s bhaviral r spnss  hrapy. 2. Obain h pain’s baslin wigh fr fuur rfr nc. Wigh lss may b an advrs ffc f pira ma hrapy. 3. Assss h pain’s baslin sa f hydrain. Rar cass f lighidrsis (dcrasd swaing) and hyprhrmia hav bn rprd, paricularly in childrn and in hs pains wh ar aking hr mdicains wih anichlinrgic aciviy. Prpr hy drain bfr and during aciviis such as xrcis r xpsur  warm mpraurs is rcmmndd. 4. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy. 5. If his drug is usd fr migrain prvnin, rviw h pain’s mdical rcrd  dcumn h fr quncy f migrain hadachs. 6. Ask fmal pains if hr is a pssibiliy f prg nancy a his im. If s, nify h halhcar pr vidr f his pssibiliy bfr saring hrapy. Availability. PO: 25, 50, 100, and 200mg abls; 25,

50, 100, 200mg capsuls, xndd rlas (24 hurs); 15 and 25mg sprinkl capsuls; 25, 50, 100, 150, and 200mg sprinkl capsuls, xndd rlas (24 hurs). Dosage and administration

Antiepileptic. Adult: PO: Iniially 25 mg wic daily. Incras h daily dsag by 50 mg a wkly inrvals un il a clinical rspns is achivd. Th usual rcmmndd daily dsag is 400 mg in w dividd dss. Tpirama may b akn wih r wihu fd. Th abls shuld n b brkn bcaus hy as bir. Th sprinkl capsuls may b swallwd whl r adminisrd by carfully pning h capsul and sprinkling h nir cnns n a small amun (.g., 1aspn) f sf fd. Swallw his drugfd mixur immdialy; d n chw. Th hra puic bld lvls fr pirama ar 5  25 mg/L. Migraine prevention. Adult: PO: Us h abls r sprinkl capsuls. Dsag incras is as fllws: wk 1, 25 mg daily in h vning; wk 2, 25 mg in h mrning and 25 mg in h vning; wk 3, 25 mg in h mrning and 50 mg in h vning; wk 4 and hraf r, 50 mg in h mrning and 50 mg in h vning. D n us pirama  ra migrain hadachs. Common adverse effects

Neurologic Sedation, drowsiness, dizziness. Ths sympms nd  disappar wih cninud hrapy and pssibl

Drugs Used for Seizure Disorders CHAPTER 18

dsag adjusmn. Encurag h pain n  dis cninu hrapy wihu rs cnsuling h halh car prvidr. Ppl wh wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss shuld b paricu larly cauius unil hy knw hw h mdicain af fcs hm. Prvid fr pain safy during pisds f dizzinss and rpr hs pains  h halhcar prvidr fr furhr valuain. Serious adverse effects

Neurologic Confusion, disorientation. Mak rgularly schduld assssmns f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im, and cmpar ndings. Rpr any signican alra ins  h halhcar prvidr. Cleft palate in newborns. Tpirama incrass h risk f dvlpmn f clf lip r clf pala in infans brn  wmn bing rad wih pirama. Thr is psiiv vidnc f human fal risk basd n human daa, bu h pnial bns frm h us f h drug in prgnan wmn may b accpabl in crain siua ins dspi is risks. Wmn aking pirama shuld ll hir halh car prvidrs immdialy if hy ar planning  r hav bcm prgnan. Pains shuld n sp ak ing pirama unlss ld  d s by hir halhcar prvidr. Metabolic Hydration status. Dcrasd swaing and vr haing hav bn rprd wih h us f pirama, primarily in childrn. Ms cass ccur in assciain wih xpsur  lvad nvirnmnal mpra urs, vigrus aciviy, r bh. Prpr hydrain b fr and during aciviis such as xrcis r xpsur  warm mpraurs is rcmmndd.

295

valproic acid (văl-PRŌ-ĭk Ă-sĭd) Depakene (DĔP-ă-kēn)

Actions Valpric acid is an anipilpic agn srucurally un rlad  any hr agn currnly usd  ra si zur disrdrs. Is mchanism f acin is unknwn; hwvr, i appars  suppr GABA aciviy as an inhibiry nurransmir. Uses Valpric acid has brad aciviy agains fcal sizurs and gnralizd nicclnic sizurs. I is h nly availabl agn ha can b usd as singldrug hrapy fr raing pains wih a cmbinain f gnralizd nicclnic, absnc, r myclnic sizurs. Valpric acid is als bing sd fr us ihr aln r in cm binain wih lihium r carbamazpin fr raing acu mania assciad wih biplar disrdr in pa ins wh d n rspnd  lihium hrapy aln. I is als apprvd fr h prvnin f migrain had achs; i is n ffciv fr h ramn f migrain hadachs. Therapeutic Outcomes Th primary hrapuic ucms xpcd frm val pric acid ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Tramn f acu mania in biplar disrdr 3. Prvnin f migrains 4. Minimal advrs ffcs frm hrapy Nursing Implications for Valproic Acid Premedication assessment

Drug interactions

Drugs that decrease therapeutic effects. Phnbarbial, primidn, phnyin, valpric acid, and carbamazpin may nhanc h mablism f pirama. Mnir h pain fr incrasd frquncy f sizur aciviy. Enhanced sedation. Cnral nrvus sysm dprs sans—including slp aids, analgsics, ranquilizrs, and alchl—nhanc h sdaiv ffcs f pira ma. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. Prvid fr pain safy during pisds f drwsi nss r dizzinss. Estrogen-containing contraceptives. Tpirama n hancs h mablism f srgns. Sping r bld ing may b an indicain f rducd srgn lvls and rducd cnracpiv aciviy. Rcmmnd ha h pain us alrnaiv frms f birh cnrl whil aking his mdicain.

1. Th manufacurr rcmmnds ha h fllwing baslin sudis b cmpld bfr hrapy is inii ad and a rgular inrvals hrafr: livr funcin ss, srum ammnia lvls in pains xprincing sympms f lhargy r chang in mnal saus, blding im drminain, and plal cun. 2. Rviw h pain’s ruin bld sudis  dc bld dyscrasias and hpaxiciy. 3. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im bfr saring hrapy. Mnir h pain’s bhaviral rspnss  hrapy. 4. Ask fmal pains abu h pssibiliy f prgnancy. Availability. PO: 250mg capsuls; 125mg capsuls

cnaining cad paricls (sprinkls); 250, and 500 mg abls, susaind rlas (24 hurs); 250 mg/5 mL sluin. Injection: 100 mg/mL in 5mL vials.

296

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

Dosage and administration. Adult: PO: 10  15 mg/

kg daily, dividd in w  hr dss. Adminisr mdicain wih fd r milk  rduc gasric irria in. Incras by 5  10 mg/kg/day a wkly inr vals. Th maximum daily dsag is 60 mg/kg. Th hrapuic bld lvls ar 50  100 mg/L. A capsul cnaining nriccad paricls is availabl fr pa ins wh hav prsisn nausa and vmiing. Common adverse effects

Gastrointestinal Nausea, vomiting, indigestion. Ths ffcs ar cm mn during iniiain f hrapy. Gradual incrass in dsag and adminisrain wih fd r milk rduc gasric irriain. Neurologic Sedation, drowsiness, dizziness. Ths sympms nd  disappar wih cninud hrapy and pssibl ds ag adjusmn. Encurag h pain n  discn inu hrapy wihu rs cnsuling h halhcar prvidr. Ppl wh wrk arund machinry, pr a mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss shuld n ak hs mdi cains whil wrking. Prvid fr pain safy dur ing pisds f dizzinss and rpr hs pains  h halhcar prvidr fr furhr valuain. Sensory Blurred vision. Cauin h pain ha blurrd visin may ccur, and mak apprpria suggsins fr h pain’s prsnal safy. Serious adverse effects

Hematologic Blood dyscrasias. Ruin labrary ss (.g., RBC, WBC, diffrnial, and plal cuns) shuld b schd uld. Mnir h pain fr sr hra, fvr, purpu ra, jaundic, r xcssiv and prgrssiv waknss. Neurologic Birth defects. Thr is an incrasd risk f nural ub dfcs, cranifacial dfcs, and cardivascular mal frmains in infans xpsd  valpric acid during gsain. Wmn f childbaring ag shuld us val pric acid nly if i is ssnial  manag hir mdical cndiins. Wmn wh ar n planning a prgnancy shuld us ffciv cnracpin. Wmn wh b cm prgnan whil aking valpric acid shuld n discninu hrapy wihu discussing i rs wih hir halhcar prvidrs. Gastrointestinal Hepatotoxicity. Th sympms f hpaxiciy ar anrxia, nausa, vmiing, jaundic, hpamgaly, splnmgaly, and abnrmal livr funcin s rsuls (.g., lvad bilirubin, AST, ALT, GGT, and ALP; in crasd PT). Pancreatitis. Th sympms f pancraiis ar ab dminal pain, nausa, vmiing, and anrxia. Rpr sympms  h halhcar prvidr bcaus f h pnial fr lifhraning cmplicains.

Drug interactions

Drugs that decrease therapeutic effects. Phnbarbial, primidn, phnyin, pirama, and carbamazpin may nhanc h mablism f valpric acid and hus dcras is hrapuic ffc. Mnir h pain fr h incrasd frquncy f sizur aciviy. Mniring changs in srum lvls shuld hlp prdic h pn ial fr incrasd sizur aciviy. Enhanced sedation. Cnral nrvus sysm dprs sans—including slp aids, analgsics, ranquilizrs, and alchl—nhanc h sdaiv ffcs f valpric acid. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss unil i is knwn hw hy ar affcd by his mdicain. Prvid fr pain safy during pisds f drwsi nss r dizzinss. zonisamide (zō-NĬS-ă-mīd) Zonegran (Zō-nĕ-grăn)

Actions Znisamid is classid as a sulfnamid, and i is chmically unrlad  hr anipilpic agns. I acs by blcking sdium and calcium channls  sa biliz h nurnal mmbrans, prvning prpaga in f a sizur simulus. I ds n affc GABA aciviy. Uses Znisamid is apprvd fr us in cnjuncin wih hr anipilpic hrapy fr h ramn f fcal sizurs in aduls. Therapeutic Outcomes Th primary hrapuic ucms sugh frm znisamid ar as fllws: 1. Rducd frquncy f sizurs and rducd injury frm sizur aciviy 2. Minimal advrs ffcs frm hrapy Nursing Implications for Zonisamide Premedication assessment

1. Rviw h pain’s mdicain hisry  nsur ha h pain ds n hav an allrgy  sulfn amid mdicains (.g., Bacrim, Spra). If h pa in ds hav such an allrgy, infrm h charg nurs and h halhcar prvidr immdialy. D n adminisr h mdicain wihu spcic apprval. 2. Rviw h pain’s mdical rcrd fr a hisry f skin rashs. If h pain dvlps a rash, infrm h charg nurs and h halhcar prvidr imm dialy. D n adminisr h mdicain wihu spcic apprval. 3. Rviw h pain’s mdical rcrd  dcumn h frquncy f sizur aciviy.

Drugs Used for Seizure Disorders CHAPTER 18

4. As a rsul f h pnial fr srius advrs rac ins, h fllwing baslin sudis shuld b r pad a rgular inrvals: cmpl bld cun, livr funcin ss, BUN, and srum crainin. 5. Prfrm a baslin assssmn f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im bfr saring hrapy. 6. Obain h pain’s baslin vial signs. Availability. PO: 25, 50, and 100mg capsuls. Dosage and administration. Adult: PO: Iniial dsag

is 100 mg daily, akn wih r wihu fd. Bcaus f sdaiv ffcs, h drug may b akn a bdim. Afr 2 wks, h dsag may b incrasd  200 mg/ day fr a las 2 wks. Bh capsuls may b akn a h sam im. Th dsag can b incrasd up  600 mg/day, wih a las 2 wks bwn dsag chang s  assss h hrapuic ffcs f hrapy and  mnir fr advrs ffcs. Encurag h pain  drink six  igh 8unc glasss f war daily whil aking his mdicain. Th hrapuic bld lvls fr znisamid ar 10  40 mg/L.

297

Serious adverse effects

Neurologic Confusion, disorientation. Mak rgularly schduld assssmns f h pain’s spch parns, dgr f alrnss, and rinain  nam, plac, and im, and cmpar ndings. Rpr any signican alra ins  h halhcar prvidr. Genitourinary Nephrotoxicity. Mnir h pain’s kidny func in s rsuls fr abnrmal ndings. Rpr in crasing BUN and crainin lvls; frank bld r smkyclrd urin; RBCs in xcss f 0  3 n h urinalysis rpr; r back pain, abdminal pain, r pain n urinain. Hematologic Blood dyscrasias. Ruin labrary sudis (.g., RBC, WBC, and diffrnial cuns) shuld b schd uld. Mnir h pain fr sr hra, fvr, pur pura, jaundic, r xcssiv and prgrssiv waknss. Integumentary Dermatologic reactions. Rpr a pain’s rash r pru rius, wih r wihu fvr, immdialy and wihhld addiinal dss f h mdicain unil apprvd by h halhcar prvidr.

Common adverse effects

Neurologic Drowsiness, dizziness. Ths ffcs ar usually mild and nd  rslv wih cninud hrapy; hy can b rducd by slwly incrasing h dsag. Encurag h pain n  discninu hrapy wihu rs cnsuling h halhcar prvidr. Prvid fr pain safy during pisds f dizzinss. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r prfrm hr duis ha rquir cnsan mnal alrnss unil i is knwn hw hy ar affc d by his mdicain.

Drug interactions

Enhanced sedation. Cnral nrvus sysm dprs sans—including slp aids, analgsics, ranquiliz rs, and alchl—nhanc h sdaiv ffcs f znisamid. Pains mus b warnd n  wrk arund machinry, pra mr vhicls, r pr frm hr duis ha rquir cnsan mnal alr nss unil i is knwn hw hy ar affcd by his mdicain. S Tabl 18.3 fr a lising f hr anipilpic mdicains.

Table 18.3 Other Antiepileptic Drugs GENERIC NAME brivaracetam

BRAND NAME Briviact Brivlera

AVAILABILITY Intravenous: 50 mg/5 mL Oral solution: 10 mg/mL (300 mL) Tablets: 10, 25, 50, 75, 100 mg

ADULT DOSAGE RANGE 50–200 mg/day

USE FOR SEIZURE Focal-onset seizures (adjunct)

cannabidiol

Epidiolex

Oral liquid: 100 mg/mL in 100-mL bottles

2.5–10 mg/kg/day twice daily

Lennox-Gastaut syndrome; Dravet syndrome

cenobamate

Xcopri

Tablets: 50, 100, 150, 200 mg

Up to 400 mg/day

Focal-onset seizures

eslicarbazepine

Aptiom

Tablets: 200, 400, 600, 800 mg

Up to 1600 mg/day

Focal-onset seizures (adjunct)

lacosamide

Vimpat

Intravenous: 200 mg/20 mL Oral solution: 10 mg/mL (200, 465 mL) Tablets: 50, 100, 150, 200 mg

200–400 mg/day

Simple or complex focal seizures

298

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

Table 18.3 Other Antiepileptic Drugs—cont’d GENERIC NAME perampanel

BRAND NAME Fycompa

AVAILABILITY Oral suspension: 0.5 mg/ mL (340 mL) Tablets: 2, 4, 6, 8, 10, 12 mg

ADULT DOSAGE RANGE 2–12 mg/day

USE FOR SEIZURE Focal onset seizures with or without secondary generalization (adjunct); primary generalized tonicclonic seizures (adjunct)

primidone

Mysoline

Tablets: 50, 250 mg

750–1500 mg; do not exceed 2000 mg/day

Focalized seizures; generalized tonicclonic seizures

runamide

Banzel

Oral suspension: 40 mg/ mL (460 mL) Tablets: 200, 400 mg

400–3200 mg/day

Lennox-Gastaut syndrome (adjunct)

tiagabine Do not confuse tiagabine with tizanidine

Gabitril Do not confuse Gabitril with gabapentin

Tablets: 2, 4, 12 16 mg

32–56 mg in 2–4 divided doses

Focal seizures (adjunct)

vigabatrin

Sabril, Vigadrone

Tablets: 500 mg Powder packets: 500 mg

1.5 g two times daily

Refractory focal onset impaired awareness seizures

Available in Canada. Do not confuse.

Clinical Judgment and Next-Generation NCLEX ® Examination-Style Questions Key Points • Seizures are the result of the sudden excessive ring of a small number of neurons and the spread of electrical activity to adjacent neurons. • There are several types and many causes of seizures. If the seizures are chronic and recurrent, the patient is diagnosed as having epilepsy. • Epilepsy is treated almost exclusively with antiepileptic medications. • The effective treatment of epilepsy requires the cooperation of the patient and the healthcare provider. • The desired therapeutic outcome of seizure treatment is to reduce the frequency of seizures while minimizing the adverse effects of drug therapy. To attain this, therapy must be individualized to consider the type of seizure activity and the age, gender, and concurrent medical conditions of the patient. • Patients, as well as their families and caregivers, require education and support regarding their responsibilities with respect to the management of epilepsy.

Additional Learning Resources

SG

Go to your Study Guide for additional Review Questions for the NCLEX® Examination, Critical Thinking Clinical Situations, and other learning activities to help you master this chapter content.

Go to your Evolve website (https://evolve.elsevier.com/Willihng anz) for additional online resources. Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions The following questions are typical of the NCLEX examination and include both NGN (Next Generation) and traditional questions. See Chapter 1 for further information regarding question types.

Scenario A patient was recently diagnosed with epilepsy by a healthcare provider after having experienced multiple episodes of convulsions accompanied by loss of consciousness. 1. The nurse witnesses the patient from the scenario with epilepsy as the patient suddenly had spasms of his arms and legs, falling to the oor. The patient initially lost consciousness and was quite groggy when he woke up. Which type of seizure will be documented by the nurse? 1. 2. 3. 4.

Tonic-clonic seizure Atonic seizure Focal simple motor seizure Absence seizure

Objective: Identify the different types of seizure disorders. NCLEX item type: Multiple choice Cognitive skill: Understanding

Drugs Used for Seizure Disorders CHAPTER 18

2. An infant is brought to the emergency department with observable twitching of the extremities and a temperature of 104.2°F as reported by his parents. The nurse will need to attend the infant. Use an X for the appropriate (necessary) action to take, or the not appropriate action (could be harmful). NURSING ACTION

APPROPRIATE

NOT APPROPRIATE

Take the infant’s vital signs. Administer antiepileptic drugs as ordered. Leave the infant and mother for a brief time to allow privacy. Assess the infant’s airway. Monitor the response to antiepileptic therapy. Restrain the infant and swaddle in blankets. Protect the infant from injury. Ensure emergency equipment is available.

299

NCLEX item type: Multiple response Cognitive skill: Application 4. The patient in the scenario asked the nurse what to expect when taking the antiepileptic valproic acid (Depakene), which was recently initiated. What are appropriate responses by the nurse? (Select all that apply.) 1. “You should notice a decrease in the frequency of your seizures.” 2. “You will not need any laboratory tests to check for the drug level.” 3. “Common side effects from this drug are nausea and gastrointestinal upset; this will decrease if you take the drug with food and as your body gets used to it.” 4. “You may feel drowsy or dizzy at rst; these symptoms tend to disappear with continued therapy.” 5. “The drug dosage will need to be increased over several weeks before we get to the maintenance dose.” Objective: Discuss the desired therapeutic outcomes from antiepileptic agents used for seizure disorders. NCLEX item type: Multiple response Cognitive skill: Application 5. From the following medications ordered by the healthcare provider for patients with known seizure disorders, the nurse knows which medications are for the seizures? (Select all that apply.) 1. 2. 3. 4. 5.

Levetiracetam (Keppra) 500 mg PO Carbamazepine (Tegretol) 200 mg PO Terbinane (Lamisil) 250 mg PO Gabapentin (Neurontin) 300 mg PO Phenytoin (Dilantin) 100 mg PO

Objective: Identify the drug classes used to treat seizure disorders. NCLEX item type: Multiple response Cognitive skill: Comprehension

Objective: Identify nursing interventions during the management of seizure activity. NCLEX item type: Matrix Cognitive skill: Taking action

6. The nurse monitoring a patient recently started on pregabalin (Lyrica) for peripheral neuropathy for any adverse effects. The nurse knows that the healthcare provider needs to be notied after the patient makes which statements? (Select all that apply.)

3. When caring for a patient with epilepsy who is hospitalized and is recovering from a seizure, what are the expected assessments/ interventions by the nurse during the postictal time? (Select all that apply.)

1. “I keep having blurred vision, especially in the morning.” 2. “I seem to be slurring my words and I am having trouble concentrating.” 3. “I nd myself needing to take a nap after breakfast, I’m so sleepy.” 4. “I have a better appetite now since I have been started on this drug.” 5. “I feel like my pain has not really improved at all with this med.”

1. Place oxygen and suction equipment at the bedside. 2. Determine whether any bodily harm occurred during the seizure. 3. Evaluate the degree of weakness, speech pattern changes, and memory loss. 4. Encourage oral hygiene and ask the patient to brush their teeth. 5. Turn the patient on their side to allow secretions to drain out of the mouth. Objective: Identify nursing interventions during the management of seizure activity.

Objective: Describe the neurologic assessment performed on patients taking antiepileptic agents to monitor for common and serious adverse effects. NCLEX item type: Multiple response Cognitive skill: Application

19

Drugs Used for Pain Management

https://evolve.elsevier.com/Willihnganz

Objectives 1. Describe the pain assessment used for patients receiving opiate agonists. 2. Differentiate among the properties of opiate agonists, opiate partial agonists, and opiate antagonists. 3. Discuss the common adverse effects of opiate agonists.

4. Identify opiate antagonists and expected therapeutic outcomes to monitor. 5. Describe the three pharmacologic effects of salicylates. 6. Compare the common and serious adverse effects and drug interactions associated with salicylates.

Key Terms pain experience (PĀN ĕks-PĒR-ē-ĕns) (p. 300) pain perception (pŭr-SĔP-shŭn) (p. 300) pain threshold (THRĔSH-hōld) (p. 300) pain tolerance (TŎL-ŭr-ĕns) (p. 300) nociception (nō-sē-SĔP-shŭn) (p. 300) acute pain (ă-KYŪT) (p. 300) chronic pain (KRŎN-ĭk) (p. 301) nociceptive pain (nō-sē-SĔP-tĭv) (p. 301) somatic pain (sō-MĂ-tĭk) (p. 301) visceral pain (VĬS-ŭr-ăl) (p. 301)

neuropathic pain (nyŭr-ō-PĂTH-ĭk) (p. 301) idiopathic pain (ĭd-ē-ō-PĂTH-ĭk) (p. 301) analgesics (ăn-ăl-JĒ-zĭks) (p. 301) opiate agonists (Ō-pē-ăt ĂG-ŏ-nĭsts) (p. 301) opiate partial agonists (Ō-pē-ăt PĂRshŭl ĂG-ŏ-nĭsts) (p. 301) opiate antagonists (Ō-pē-ăt ăn-TĂGŏ-nĭsts) (p. 301) prostaglandin inhibitors (prŏs-tăGLĂN-dĭn ĭn-HĬ-bĭ-tŭrz) (p. 301)

PAIN The International Association for the Study of Pain denes pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” An unpleasant sensation that is part of a larger situation is called a pain experience The pain experience is highly subjective and inuenced by behavioral, physiologic, sensory, emotional (e.g., attention, anxiety, fatigue, suggestion, prior conditioning), and cultural factors for a particular person under a certain set of circumstances. This accounts for the wide variation in individual responses to the sensation of pain. The three terms used in relationship to the pain experience are pain perception, pain threshold, and pain tolerance. Pain perception (also known as nociception) is an individual’s awareness of the feeling or sensation of pain. Pain threshold is the point at which an individual rst acknowledges or interprets a sensation as being painful. Pain tolerance is the individual’s ability to endure pain. 300

salicylates (săl-ĭ-SĬL-āts) (p. 301) nonsteroidal antiinammatory drugs (nŏn-stĕ-RŌY-dăl ĂN-tī-ĭnFLĂ-mă-tō-rē) (p. 301) nociceptors (nō-sē-SĔP-tŭrz) (p. 301) opiate receptors (Ō-pē-ăt rē-SĔPtŭrz) (p. 301) range orders (RĀNJ ŌR-dŭrz) (p. 309) drug tolerance (DRŬG TŎL-ŭr-ĕns) (p. 310) ceiling effect (SĒ-lĭng ĕ-FĔKT) (p. 316)

Pain has physical and emotional components. Factors that decrease an individual’s tolerance to pain include prolonged pain that is insufciently relieved, fatigue accompanied by the inability to sleep, an increase in anxiety or fear, unresolved anger, depression, and isolation. Patients with severe intractable pain fear that the pain cannot be relieved, and patients with cancer fear that new or increasing pain means that the cancer is spreading or recurring. Pain is usually described as acute or short term and as chronic or long term. Acute pain arises from sudden injury to the structures of the body (e.g., skin, muscles, viscera). The intensity of pain is usually proportional to the extent of tissue damage. The sympathetic nervous system is activated, resulting in an increase in the heart rate, pulse, respirations, and blood pressure. This sympathetic nervous system stimulation also causes nausea, diaphoresis, dilated pupils, and an elevated glucose level. Continuing or persistent pain results from ongoing tissue damage or from chemicals released by the surrounding cells during the initial trauma (e.g., a crushing injury). The intensity diminishes

Drugs Used for Pain Management CHAPTER 19

as the stimulus is removed or tissue repair and healing take place. Acute pain serves an important protective physiologic purpose that warns of potential or actual tissue damage. Chronic pain has a slower onset and lasts longer than 3 months beyond the healing process. Chronic pain does not relate to an injury or provide physiologic value. Depending on the underlying cause, it is often subdivided into chronic cancer or noncancer pain (persistent noncancer pain). It may arise from visceral organs, muscular and connective tissue, or neurologic factors such as diabetic neuropathy, trigeminal neuralgia, or amputation. As chronic pain progresses, especially poorly treated pain, other physical and emotional factors come into play, affecting almost every aspect of a patient’s life—physical, mental, social, nancial, and spiritual—and causing additional stress, anger, chronic fatigue, and depression. Although pain has always been viewed as a symptom of a disease or a condition, chronic pain and its harmful physiologic effects are now regarded as a disease itself. Pain may also be classied by pathophysiology. Nociceptive pain is the result of a stimulus (e.g., chemical, thermal, mechanical) to pain receptors. Nociceptive pain is usually described by patients as dull and aching. It is called somatic pain if it originates from the skin, bones, joints, muscles, or connective tissue (e.g., arthritis pain) and visceral pain if it originates from the abdominal and thoracic organs. Nociception is the process whereby a person becomes aware of the presence of pain. There are four steps in nociception: (1) transduction, (2) transmission, (3) perception, and (4) modulation (Fig. 19.1). Neuropathic pain results from injury to the peripheral or central nervous system (CNS) (e.g., trigeminal neuralgia). Patients describe neuropathic pain as stabbing and burning. Phantom limb pain is a neuropathic pain experienced by amputees in a body part that is no longer there. Idiopathic pain is a nonspecic pain of unknown origin. Anxiety, depression, and stress are often associated with this type of pain. Common areas associated with idiopathic pain are the pelvis, neck, shoulders, abdomen, and head.

PAIN MANAGEMENT Analgesics are drugs that relieve pain without pro-

ducing loss of consciousness or loss of reexes. The search for an ideal analgesic continues. It is difcult to nd one that meets this denition: it should be potent enough to provide maximum relief of pain; it should not cause dependence; it should cause a minimum of adverse effects (e.g., constipation, hallucinations, respiratory depression, nausea, vomiting); it should not cause tolerance; it should act promptly and over a long period with a minimum amount of sedation so that the patient is able to remain conscious and responsive; and it should be relatively inexpensive.

301

At present, no completely satisfactory classication of analgesics is available. Historically they have been categorized based on potency (mild, moderate, strong), origin (opium, synthetic, coal-tar derivative), or addictive properties (narcotic, nonnarcotic). Research into the control of pain has recently given new insight into pathways of pain within the nervous system and a better understanding of precise mechanisms of action of analgesic agents. The current nomenclature for analgesics stems from these recent discoveries. In this chapter the medications have been divided into opiate (opioid) agonists, opiate (opioid) partial agonists, opiate (opioid) antagonists, and prostaglandin inhibitors (acetaminophen, salicylates, and nonsteroidal antiinammatory drugs [NSAIDs]). The commonly used term “opioid” refers broadly to all substances that bind to opiate (opioid) receptors in the brain, including opiate agonists, opiate partial agonists, and opiate antagonists. Opioids, in general, are drugs from a variety of origins, opium (heroin, morphine, codeine) or synthetic (meperidine, fentanyl), with varying degrees of analgesic potency, euphoric effect, and addictive properties. ACTIONS The pathways of the pain transmission signal from the site of injury to the brain for processing and reexive action have not been fully identied. The rst step leading to the sensation of pain is the stimulation of receptors known as nociceptors (see Fig. 19.1). These nerve endings are found in skin, blood vessels, joints, subcutaneous tissues, periosteum, viscera, and other tissues. The nociceptors are classied as thermal, chemical, and mechanical-thermal, based on the types of sensations that they transmit. The exact mechanism that causes stimulation of nociceptors is not fully understood; however, bradykinins, prostaglandins, leukotrienes, histamine, and serotonin sensitize these receptors. Receptor activation leads to action potentials that are transmitted along afferent nerve bers to the spinal cord. A series of neurotransmitters (somatostatin, cholecystokinin, substance P) play roles in the transmission of nerve impulses from the site of damage to the spinal cord. Within the CNS, there may be at least four pain-transmitting pathways up the spinal cord to various areas of the brain for response. The CNS contains a series of receptors that control pain. These are known as opiate receptors because stimulation of these receptors by the opiates blocks the pain sensation. These receptors are subdivided into four types: mu (μ), delta (δ), kappa (κ), and epsilon (ε) receptors. Sigma (σ) receptors are another type that react to opioid agonists and partial agonists. The receptors are located in different areas of the CNS. The κ receptors are found in greatest concentration in the cerebral cortex and in the substantia gelatinosa of the dorsal horn of the spinal cord. They are responsible

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

302 1

Transduction 1. Noxious stimuli causes cell damage with the release of sensitizing chemicals • Prostaglandins • Bradykinin • Serotonin • Substance P • Histamine 2. These substances activate nociceptors and lead to generation of action potential

3

Perception Conscious experience of pain

Mod

Site of pain

ulati

1

3

on

2 Transmission

4 2

2

Transmission Action potential continues from • Site of injury to spinal cord • Spinal cord to brainstem and thalamus • Thalamus to cortex for processing

4

Modulation • Neurons originating in the brainstem descend to the spinal cord and release substances (e.g., endogenous opioids) that inhibit nociceptive impulses

Fig. 19.1 Nociceptive pain originates when the tissue is injured. 1, Transduction occurs when there is release of chemical mediators. 2, Transmission involves the conduction of the action potential from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex. 3, Perception is the conscious awareness of pain. 4, Modulation involves signals from the brain going back down the spinal cord to modify incoming impulses. (Developed by M. McCaffery, C. Pasero, and J. A. Paice. From McCaffery M, Pasero C. Pain: Clinical Manual. 2nd ed. St. Louis: Mosby; 1999.)

for analgesia at the levels of the spinal cord and brain. Stimulation of κ receptors also produces sedation and dysphoria. The μ receptors are located in the painmodulating centers of the CNS and induce central analgesia, euphoria, physical dependence, miosis, and respiratory depression. The σ receptors are located in the limbic area of the brain and in the spinal cord and may play a role in the euphoria produced by selected opiates. The σ receptors are thought to produce the autonomic stimulation and psychotomimetic (e.g., hallucinations) and dysphoric effects of some opiate agonists and partial agonists. The functions of the σ receptors are under investigation. Research is focusing on developing synthetic chemicals that target specic receptors to maximize analgesia but minimize the potential for adverse effects, such as addiction. As described, other chemicals—histamine, prostaglandins, serotonin, leukotrienes, substance P, and bradykinins—released during trauma also contribute to pain. Developing pharmaceuticals that block these chemicals is another effective way of stopping pain. Antihistamines (e.g., diphenhydramine), prostaglandin inhibitors (e.g., NSAIDs), substance P antagonists (e.g., capsaicin), and antidepressants that prolong norepinephrine and serotonin activity (e.g., tricyclic antidepressants, selective serotonin reuptake inhibitors) have analgesic properties. Other pharmacologic agents can suppress pain by a variety of mechanisms. Adrenergic agents, such as

norepinephrine and clonidine, and gamma-aminobutyric acid receptor stimulants (e.g., baclofen, gabapentin) produce signicant analgesia by blocking nociceptor activity. Gabapentin, pregabalin, and carbamazepine act as analgesics by suppressing spontaneous neuronal ring, as occurs in trigeminal neuralgia. Tricyclic antidepressants inhibit the reuptake of serotonin and norepinephrine, causing the onset of analgesia to be more rapid, as well as improving the outlook of the person with chronic pain and depression. Some antidepressants (e.g., amitriptyline) also block pain by antihistaminic and anticholinergic activity. Bisphosphonates (e.g., zoledronic acid) may be effective in treating cancer pain associated with bony metastases. USES The World Health Organization recommends a stepwise approach to pain management in relation to cancer pain (Fig. 19.2). Mild acute pain is effectively treated with analgesics such as aspirin, NSAIDs, or acetaminophen. Pain associated with inammation responds well to NSAIDs. Unrelieved or moderate pain is generally treated with a moderate-potency opiate such as codeine or oxycodone, which is often used in combination with acetaminophen or aspirin (Tylenol with Codeine No. 3 and Percodan, respectively). Severe acute pain is treated with opiate agonists (e.g., morphine, hydromorphone). Morphine sulfate is

Drugs Used for Pain Management CHAPTER 19 Freedom from cancer pain Opioid for moderate to severe pain Nonopioid  Adjuvant Pain persisting or increasing

3

2

Opioid for mild to moderate pain  Nonopioid  Adjuvant Pain persisting or increasing

1

Nonopioid  Adjuvant

Fig. 19.2 World Health Organization’s Pain Relief Ladder. (Adapted from World Health Organization, 2005. Retrieved from http://www.who .int/cancer/palliative/painladder/en.)

usually the drug of choice for the treatment of severe chronic pain. Other agents such as antidepressants or anticonvulsants may be used as adjunctive therapy with analgesics, depending on the causes of pain. The healthcare delivery system in the United States has an unfortunate, long-standing history of inadequate pain management. The Joint Commission’s current standards for pain management therapy include the following primary therapeutic outcomes: 1. Relief of pain intensity and duration of pain complaint 2. Prevention of the conversion of persistent pain to chronic pain 3. Prevention of suffering and disability associated with pain 4. Prevention of psychological and socioeconomic consequences associated with inadequate pain management 5. Control of adverse effects associated with pain management 6. Optimization of the ability to perform activities of daily living (ADLs) Although considered acceptable at one time, placebo therapy should never be used with pain management. One premise of pain management is that the patient should be believed when describing the presence of pain. The use of placebos implies a lack of belief in the patient’s description and can seriously damage the patient-provider relationship. The American Pain Society has declared that the use of placebos is unethical and should be avoided. A Note About Opioid Abuse Opioids are commonly prescribed for pain. Evidence supports short-term efcacy (12 weeks or less) of opioid treatment for pain management. However, few studies have been conducted to assess the long-term

303

benets of opioids for chronic pain (pain lasting greater than 12 weeks) with outcomes examined at least 1 year later. Opioid pain medications present serious risks to health and wellness through debilitation and the potential for death from overdose. The Centers for Disease Control and Prevention (CDC) reported that opioids were involved in 46,802 overdose deaths in 2018 (69.5% of all drug overdose deaths). Two out of three (67.0%) opioid-involved overdose deaths involve synthetic opioids (fentanyl or fentanyl analogs). The CDC (Dowell etal, 2016) and Canada health authorities (Busse et al, 2017) have published guidelines for prescribing opioids for chronic noncancer pain. Both recommend nonpharmacologic therapy and nonopioid pharmacologic therapy for chronic pain. Opioids should only be considered if expected benets for pain management and function are anticipated to outweigh risks to the health of the patient. If opioids are prescribed, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy (see Chapter 48). NURSING IMPLICATIONS FOR PAIN MANAGEMENT The management of all types of pain is a major healthcare concern. Rating pain as the fth vital sign means that the patient’s pain should be assessed every time vital signs are taken and recorded. Taking the pain rating only when doing vital signs, however, is not sufcient. The nurse should also evaluate the pain level immediately before and after pain medications are given; at 1-, 2-, and 3-hour intervals for oral medications; and at 15to 30-minute intervals after parenteral administration. Most assessment data sheets have a section on pain management that contains the following elements: rating before and after medication, nonpharmacologic measures initiated, patient teaching performed, and breakthrough pain measures implemented. The pain ow sheet provides the healthcare team members with a quick visual reference to evaluate the overall effectiveness of the pain management prescribed. The American Pain Foundation (now defunct) developed the Pain Care Bill of Rights, which explains to the patient exactly what to expect and/or demand in the way of pain management (Box 19.1). Nurses must assist the patient in managing pain. The rst important step in this process is to believe the patient’s description of the pain. Pain brings with it a variety of feelings, such as anxiety, anger, loneliness, frustration, and depression. Part of the patient’s response is tied to past experiences, sociocultural factors, current emotional state, and beliefs regarding pain. Psychological, physical, and environmental factors all must be considered in managing pain. Never overlook the value of general comfort measures such as a back rub, repositioning, and the use of hot or cold applications. A variety of relaxation techniques and diversional activities may prove psychologically

304

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

Box 19.1

Pain Care Bill of Rights

As a person with pain, you have the right to: • Have your pain taken seriously and to be treated with dignity and respect by doctors, nurses, pharmacists, and other healthcare professionals. • Have your pain thoroughly assessed and promptly treated. • Be informed by your healthcare provider about the possible causes of your pain, and possible treatments, including the benets, risks, and costs of each. • Participate actively in decisions about how to manage your pain. • Have your pain reassessed regularly and your treatment adjusted if your pain has not been eased. • Be referred to a pain specialist if your pain persists. • Get clear and prompt answers to your questions, take time to make decisions, and refuse a particular type of treatment if you choose. Created by the American Pain Foundation (now defunct). Retrieved from https://masspaininitiative.org/

benecial. Decreasing environmental stimuli to ensure the patient gets successful periods of rest is essential. The patient’s pain must be evaluated in a consistent manner. A wide variety of assessment tools have been developed to enable healthcare providers to gain some degree of uniformity in interpreting and recording the patient’s description of pain. Some of the pain assessment tools for use with infants and young children include the following: • Riley Infant Pain Scale (RIPS) Assessment Tool • Face, Legs, Activity, Cry, Consolability (FLACC) Scale, for use in nonverbal patients • Pain Observation Scale for Young Children (POCIS), intended for children 1 to 4 years of age • Modied Objective Pain Score (MOPS), intended for children 1 to 4 years of age after ear, nose, and throat surgery • Toddler-Preschooler Postoperative Pain Scale (TPPPS), for use in evaluating pain in smaller children during and after medical or surgical procedures • Postoperative Pain Score (POPS), for infants having surgical procedures • Neonatal Infant Pain Scale (NIPS), for pain in preterm and full-term neonates; used to monitor pain before, during, and after a painful procedure The list of tools available is extensive, and the preceding is only a partial listing. For further information on pain scales and details of each, search the Internet to nd the data needed. The Wong-Baker FACES pain rating scale (Fig. 19.3) has widespread use for patients 3 years of age and older and is particularly useful for adults who have language barriers or who do not read because they can select the face that best describes their pain. The McGill-Melzack Pain Questionnaire provides descriptive words and phrases that may be used to help the patient communicate the subjective pain

experience (Fig. 19.4). It is especially useful for individuals who have chronic pain. When possible, chart the description in the patient’s exact words. It may be necessary to seek additional data from signicant others. Scales such as the ones shown in Fig. 19.5 are often used to assess acute pain. The most common scale used asks the patient to rate the pain being experienced on a scale of 0 (no pain) to 10 (intense or excruciating). The degree of relief for the pain after an analgesic is given is again rated using the same 0-to-10 scale. When different potencies of analgesic agents are ordered for the same patient, the nurse can use these numerical rating data in combination with the other data gathered to determine whether a more or less potent analgesic agent should be administered. The color scale is similar to a slide rule. The patient selects the hue or depth of color that corresponds with the pain being experienced. The nurse turns the slide rule scale over, and a numerical value is identied that can be used to consistently record the patient’s response. Effective pain control depends on the degree of pain experienced. The previously described 0-to-10 scale is a useful way to determine the patient’s level of pain. For a patient with mild to moderate acute pain, a nonnarcotic agent may be successful, but a patient with severe chronic pain may need a potent analgesic such as morphine. The route of administration is chosen on the basis of several factors. One major consideration is how soon the action of the drug is needed. The oral and rectal routes have a longer onset of action than the parenteral route. It is sometimes erroneously believed that oral medications are inadequate to treat pain, but they can provide excellent pain relief if appropriate doses are provided. Generally the oral route is used initially to treat pain if no nausea and vomiting are present. The patient may initially be treated effectively with oral medications; however, the rectal, transdermal, subcutaneous, intramuscular, intraspinal, epidural, and intravenous (IV) routes may be required, depending on the patient and the course of the underlying disease.

Clinical Pitfall All patients have a right to adequate management of pain. To help ensure appropriate analgesia, the rating of pain has been designated “the fth vital sign.” From a nursing standpoint, this means that pain should be assessed every time the vital signs are taken and recorded. Nurses should also evaluate the pain level immediately before administering a pain medication and afterward at 1-, 2-, and 3-hour intervals for oral medications and at 15- to 30-minute intervals after parenteral administration. Although pain assessment forms vary, the elements contained in each collect similar information about pain: rating before and after medication, nonpharmacologic measures initiated, patient teaching performed, and breakthrough pain measures implemented. The pain ow sheet provides the healthcare team members with a quick visual reference to evaluate the overall effectiveness of the pain management prescribed.

Drugs Used for Pain Management CHAPTER 19

0 No hurt

1 Hurts little bit

2 Hurts little more

3 Hurts even more

4 Hurts whole lot

305

5 Hurts worst

Fig. 19.3 Wong-Baker FACES pain rating scale. (From Hockenberry MJ, Wilson D. Wong’s Nursing Care of Infants and Children. 10th ed. St. Louis: Mosby; 2015.)

Life Span Considerations Analgesics Maintaining a relatively steady blood level of analgesic is the best way to control pain. However, drug absorption, metabolism, and excretion are affected by the patient’s age. Dosages and frequency of administration of analgesics may have to be increased in children, especially teenagers, because many medicines are more rapidly metabolized and excreted by patients in this age group. Conversely, an older adult may need a somewhat smaller dose of an analgesic given less frequently because of slower metabolism and excretion. In either situation, it is imperative that the nurse regularly assess the patient’s pain level and contact the healthcare provider for adjustments in dosages and frequency based on the response to the analgesic.

Before initiating a pain assessment, assess the patient for hearing and visual impairment. If the person is unable to hear the questions or see the visual aids used to assess pain, any data collected may be invalid. Nurses must evaluate and document the effectiveness of the pain medications given in the patient’s medical record. Record and report all complaints of pain for analysis by the healthcare provider. The pattern of pain, particularly an increase in frequency or severity, may indicate new causes of pain. The main reasons for increased frequency or intensity of pain are pain from long-term immobility; pain from the treatment modalities used (e.g., surgery, chemotherapy, or radiation therapy); pain from direct extension of a tumor or metastasis into bone, nerve, or viscera; and pain unrelated to the original cause or the therapeutic treatments used. Assessment History of pain experience

• Medication history: What medications are being prescribed, and how effective have they been? What dosage has been required to achieve adequate comfort? Has the patient had any adverse effects to the medications? If yes, get details of the adverse effects and the measures taken for management. What is the patient’s attitude toward the use of pain medications (e.g., opioids, anxiolytics)? What are the family’s or signicant other’s attitudes toward the use of medications to control the pain? Does the patient have any history of substance abuse?

• Patient’s perception of pain: To identify the causes of the pain, have the patient describe their perception of it. What does the patient feel is the cause of the pain? In the older adult, multiple chronic and acute pain problems may be present, making it difcult to determine which problem is the most urgent or causing the most pain. Multiple pain complaints, combined with impaired hearing, vision, memory, and cognition, must be taken into consideration during the pain assessment. Evaluate the pain according to location, depth, quality, duration, and severity. • Obtain baseline vital signs at least every shift or more often as dictated by the patient’s condition and type of medications administered. • Listen to the patient and believe the pain experience being described, regardless of whether the physical data substantiate the degree of discomfort described. Do not let personal biases or values interfere with establishing interventions that provide maximum pain relief for the individual. The myths that pain decreases with aging and that pain is expected with aging are incorrect! • Onset: When was the pain rst noticed? When was the most recent attack? Is the onset slow or abrupt? Is there any particular activity that starts the pain? Does the pain occur in response to eating certain foods? • Location: What is the exact location of the pain? It may help to have the patient mark on a drawing of a human gure the areas where the pain is felt; this may be especially useful with pediatric patients, who can be given crayons to help identify different intensities in addition to the location. With acute pain, the site of the pain can be more easily identied; however, with chronic pain, this may be more difcult because the normal physiologic responses of the sympathetic nervous system are no longer present. • Depth: What is the depth of the pain? Does it radiate, having the sensation of spreading out or diffusing over an area, or is it localized in a specic site? The lack of physical symptoms comparable with the pain described does not mean that the patient’s complaints should be ignored. • Quality: What is the actual sensation felt when the pain is present: stabbing, dull, cramping, sore, burning, or other? Is the pain always in the same place and of the same intensity?

UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

306

McGill-Melzack Pain Questionnaire Patient’s name __________________ Age ___________________ File No. ________________________ Date __________________ Clinical category (e.g., cardiac, neurologic) Diagnosis: ______________ ________________ ________________ Analgesic (if already administered): 1. Type _____________________________________________ 2. Dosage __________________________________________ 3. Time given in relation to this test ___________________ Patient’s intelligence: circle number that represents best estimate. 1 (low)

2

3

4

5 (high)

This questionnaire has been designed to tell us more about your pain. Four major questions we ask are: 1. 2. 3. 4.

Where is your pain? What does it feel like? How does it change with time? How strong is it?

It is important that you tell us how your pain feels now. Please follow the instructions at the beginning of each part.

Part 1. Where Is Your Pain? Please mark on the drawing below the areas where you feel pain. Put E if external, or I if internal, near the areas you mark. Put EI if both external and internal.

Part 2. What Does Your Pain Feel Like? Some of the words below describe your present pain. Circle ONLY those words that best describe it. Leave out any category that is not suitable. Use only a single word in each appropriate category—the one that best applies. 1 Flickering Quivering Pulsing Throbbing Beating Pounding 2 Jumping Flashing Shooting 3 Pricking Boring Drilling Stabbing Lancinating 4 Sharp Cutting Lacerating 5 Pinching Pressing Gnawing Cramping Crushing

6 Tugging Pulling Wrenching 7 Hot Burning Scalding Searing 8 Tingling Itchy Smarting Stinging 9 Dull Sore Hurting Aching Heavy 10 Tender Taut Rasping Splitting

11 Tiring Exhausting 12 Sickening Suffocating 13 Fearful Frightful Terrifying 14 Punishing Grueling Cruel Vicious Killing 15 Wretched Blinding

16 Annoying Troublesome Miserable Intense Unbearable 17 Spreading Radiating Penetrating Piercing 18 Tight Numb Drawing Squeezing Tearing 19 Cool Cold Freezing 20 Nagging Nauseating Agonizing Dreadful Torturing

Part 3. How Does Your Pain Change with Time? 1. Which word or words would you use to describe the pattern of your pain? 1 Continuous Steady Constant

2 Rhythmic Periodic Intermittent

3 Brief Momentary Transient

2. What kind of things relieve your pain? 3. What kind of things increase your pain?

Part 4. How Strong Is Your Pain? People agree that the following 5 words represent pain of increasing intensity. They are: 1 Mild

2 Discomforting

3 Distressing

4 Horrible

5 Excruciating

To answer each question below, write the number of the most appropriate word in the space beside the question. 1. 2. 3. 4.

Which word describes your pain right now? Which word describes it at its worst? Which word describes it when it is least? Which word describes the worst toothache you ever had? 5. Which word describes the worst headache you ever had? 6. Which word describes the worst stomachache you ever had?

Fig. 19.4 McGill-Melzack Pain Questionnaire. (Copyright R. Melzack, 1970, 1975. Reprinted with permission from Dr. Melzack and Mapi Trust.)

______ ______ ______ ______ ______ ______

Drugs Used for Pain Management CHAPTER 19

A

307

PAIN INTENSITY SCALES Simple Descriptive Pain Distress Scale1 None

Annoying

No pain 0

1

2

Uncomfortable

Dreadful

0-10 Numeric Pain Distress Scale1 Distressing pain 3 4 5 6 7

Horrible

Agonizing

8

Unbearable pain 9 10

Visual Analog Scale (VAS)2 No distress

B

Unbearable distress

PAIN RELIEF SCALES Pain Relief Visual Analog Scale

No relief

Complete relief

C

Percent Relief Scale

0% No relief

10%

20%

30%

40%

50%

60%

70%

80%

1If

used as a graphic rating scale, a 10-cm baseline is recommended.

2A

10-cm baseline is recommended for VAS scales.

90%

100% Complete relief

Fig. 19.5 Pain rating scales. (A) Pain intensity scales. (B and C) Pain relief scales. (From Ignatavicius DD. Pain: the fth vital sign. In Ignatavicius DD, Workman ML. Medical-Surgical Nursing: Patient-Centered Collaborative Care. 7th ed. St. Louis: Saunders; 2013:48. A, Redrawn from Agency for Health Care Policy and Research. Acute Pain Management: Operative or Medical Procedures and Trauma. AHCPR Publ. No. 92-0032. Rockville, MD: US Department of Health and Human Services; 1992. B, Redrawn from Fishman B etal. The Memorial Pain Assessment Card: A valid instrument for the evaluation of cancer pain. Cancer. 1987;60(5):1151–1158. C, Redrawn from the Pain Research Group. Brief Pain Inventory. Madison, WI: Department of Neurology, University of Wisconsin–Madison.)

• Duration: Is the pain continuous or intermittent? How often does it occur and, once felt, how long does it persist? Is there a cyclic pattern to the pain? • Severity: Have the patient rate the pain using the pain scale methodology that is standard for the clinical setting. Self-reporting pain assessment tools are used for most children 3 years and older. After age 8, children understand numerical values, so one of the visual analog scales or word-graphic rating scales can be used. Nonverbal observations . Note the patient’s general

body position during an episode of pain. Look for

subtle clues such as facial grimaces, immobility of a particular part, and holding or resisting movement of an extremity. With pediatric patients, facial expressions, squinting, grimacing, and crying may also be used as indicators of pain level and pain relief. Developmental differences inuence the pain experience and how children in different age groups express pain. Infants may express pain through continual inconsolable crying, irritability, poor oral intake, and alterations in sleep pattern. Preschool children may verbalize pain; exhibit lack of cooperation; be “clingy” to parents, nurses, or signicant others; and not want the site of the pain touched—they may actually push

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UNIT III Drugs Affecting the Autonomic and Central Nervous Systems

you away as you approach the painful area. Older children may deny pain in the presence of peers and display regressive behaviors in the presence of support personnel. Pain relief. What specic measures relieve the pain?

What has already been tried for pain relief, and what, if anything, has been benecial? Physical data. In the presence of pain, always exam-

ine the affected part for any alterations in appearance, change in sensation, or limitation in mobility or range of motion. In older adults, it is particularly important to evaluate the musculoskeletal and neurologic systems during the physical examination. Behavioral responses. What coping mechanisms does

the patient use to manage the pain experience: crying, anger, withdrawal, depression, anxiety, fear, or hopelessness? Is the individual introspective and selffocusing? Does the individual continue to perform ADLs despite the pain? Does the individual alter lifestyle patterns appropriately to enhance pain relief measures prescribed? Is the individual able to continue to work? Is the individual socially withdrawn? Is the person seeing more than one healthcare provider to try to obtain an answer about the origin of the pain or to obtain more pain medication from a different healthcare provider?

Life Span Considerations Pain in the Older Adult Patient Pain assessment in the older adult patient must include more than a simple rating of pain using a pain scale. Many older adults suffer from more than one chronic illness, so obtain a nursing history and perform a physical and functional assessment to understand the effect of pain on the patient’s ability to meet self-care needs.

Implementation Comfort measures

• Provide for the patient’s basic hygiene and comfort. Use techniques such as back rubs, massage, or hot and cold applications as ordered. • Ask the patient what measures have been successful in the past in providing pain relief. • Relieve pain by doing any or all of the following, as appropriate: (1) support an affected part during movement, provide appropriate assistance during movement or activities, or apply binders or splint an incisional area before initiating activities such as deep breathing and coughing; (2) give analgesics before starting painful activities and plan for the activity to take place during the medication’s peak action; and/ or (3) use hot or cold applications, massage, pressure, and vibration as interventions for pain relief.

Exercise and activity. Unless contraindicated, moder-

ate exercise should be encouraged. Often, pain causes the individual not to move the affected part or to position it in a manner that provides relief. Stress the need to prevent complications by using passive range of motion. Regularly scheduled exercise is important to prevent further deterioration of the musculoskeletal system, especially in older patients who may also have diminished capacity. Nonpharmacologic approaches . To enhance the ef-

fects of the medication therapy, use nonpharmacologic strategies such as relaxation techniques, visualization, meditation, biofeedback, and transcutaneous electrical nerve stimulation (TENS) units. (The patient will require instruction for using each of these prescribed techniques.) Assist with referral to a pain clinic for management of pain, especially chronic pain. Goals should be established when initiating a treatment regimen. Prevention, reduction, or elimination of pain is an important therapeutic goal. The patient and caregiver(s) should be involved in the establishment of these goals so that outcomes important to the patient are incorporated into the treatment goals and so that they have realistic expectations. Pain, especially chronic pain, may not be completely eliminated but must be managed. Additional important goals include improving the patient’s quality of life, functional capacity, and ability to retain independence. Specic therapeutic goals established may include the following: • Pain at rest: 40 >35

High-density lipoprotein cholesterol (mg/dL)

150

Blood pressure (mm Hg)

>130/85

>130/85

Fasting glucose (mg/dL)

>100

>100

aPeople

with central obesity and at least two of the remaining four factors are considered to have metabolic syndrome. bThere are specic circumferences for different ethnicities in the International Diabetes Federation document cited below. cThis also applies to those individuals with previously diagnosed type 2 diabetes. Data from Alberti KG, Eckel RH, Grundy SM, etal; International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; International Association for the Study of Obesity. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation. 2009;120(16):1640-1645; and from International Diabetes Federation. The IDF Consensus Worldwide Denition of the Metabolic Syndrome. Brussels, Belgium: International Diabetes Federation; 2006. Available at https://www.idf.org/e-library/consensusstatements.html.

disease. Historically, the hypothesis of insulin resistance has been studied in great depth, and the syndrome has been renamed to be more descriptive of the underlying causes. Other terms include diabesity, insulin resistance syndrome, and, more recently, cardiometabolic syndrome. Metabolic syndrome is still the most commonly used term worldwide. The key characteristics of metabolic syndrome are the presence of type 2 diabetes mellitus, abdominal obesity, hypertriglyceridemia, low levels of high-density lipoproteins (HDLs), and hypertension. Although metabolic syndrome occurs worldwide, an estimated 34.7% of adults (i.e., one in three) in the United States have metabolic syndrome. Hispanics have the highest rate (35.4%), followed by whites (33.4%) and blacks (32.7%). It is estimated that about 4.5% of adolescents between the ages of 12 and 17 years also have metabolic syndrome. Table 20.1 gives the denition of metabolic syndrome provided in a consensus statement by several international organizations that study atherosclerosis, obesity, cardiovascular disease, and diabetes (Alberti, 2009). People with central obesity and any two of the four other criteria are dened as having metabolic syndrome. RESULTING CONDITIONS People with metabolic syndrome are three times more likely to have (and twice as likely to die of) a heart attack or stroke than people without the

331

syndrome. People with metabolic syndrome have a vefold greater risk of developing type 2 diabetes. On a global scale, up to 80% of the 200 million people with diabetes will die as a result of cardiovascular disease. This puts the prevalence of metabolic syndrome and diabetes substantially ahead of HIV/AIDS in terms of morbidity and mortality, yet the problem is not as well recognized. In addition to type 2 diabetes and heart disease, other factors associated with metabolic syndrome include renal disease, obstructive sleep apnea, polycystic ovary syndrome, cognitive decline in older adults, and dementia in older adults. RISK FACTORS Obesity and Sedentary Lifestyle Risk factors for the development of metabolic syndrome include poor diet, sedentary lifestyle (lack of exercise), and genetic predisposition. The dietary habits of most Americans have changed signicantly over the past 20 years, causing a dramatic increase in weight gain in the United States. Simply put, weight gain occurs when energy intake (food calories) exceeds energy expenditure (burning calories). Categories of obesity are determined by using the body mass index (BMI). BMI is described as weight in proportion to height. BMI is calculated the same way for both adults and children. The calculation is based on the following formulas: Kilograms and Meters (or Centimeters) Weight in kilograms (kg) BMI = (Height in meters [m])2 With the metric system, the formula for BMI is weight in kilograms divided by height in meters squared. Because height is commonly measured in centimeters, divide the height in centimeters by 100 to obtain the height in meters. Example: Weight = 68 kg, height = 165 cm (1.65 m) Calculation: 68 ÷ (1.65)2 = 24.98 Pounds and Inches Weight in pounds (Ib) BMI = 703 (Height in inches [in])2 Calculate the BMI by dividing the weight in pounds (lb) by the height in inches (in) squared and multiplying by a conversion factor of 703. Example: Weight = 150 lb, height = 5 5″ (65″) Calculation: (150 ÷ 652) × 703 = 24.96

The National Heart, Blood and Lung Institute guidelines also describe overweight and obesity in terms of the BMI. Table 20.2 shows the relationship between BMI and weight (healthy weight, overweight, or obesity). According to comparison data from the Centers for Disease Control and Prevention (CDC, 2019), in all states more than 20% of adults were obese. One state had a prevalence of 20% to less than 25%; 25 states had a prevalence of 25% to 30%; 23 states had a prevalence

332

UNIT IV Drugs Affecting the Cardiovascular System

Table 20.2 Relationship Between Body Mass Index and Categories of Obesity BODY MASS INDEX (KG/M2) 40

Obesity, class III (extreme obesity)

of 30% to less than 35%; and 12 states had a prevalence of 35% or higher. Fig. 20.1 presents a comparison of obesity rates by race/ethnicity and state. A sedentary lifestyle contributes to overweight and obesity. New technologies such as labor-saving devices and remote-control devices, as well as the availability of entertainment through television and computers, have signicantly reduced daily caloric expenditure. Today, despite common knowledge that regular exercise promotes health, the CDC reports that all states had more than 15% of adults who were physically inactive (engaging in no leisure-time physical activity) and ranged from 17.3% to 47.7%. Inactivity levels vary among adults by race/ethnicity and location. Longer working hours that lead to less time to prepare food at home and larger portions of commercially prepared food aggravate the problem. The ease and convenience of food preparation (e.g., fast-food restaurants, drive-through windows, the use of a microwave versus a convection oven) and increases in portion sizes have placed too many easily consumed calories on the table. Consequently, reduced physical activity and increased caloric intake have resulted in a national epidemic of obesity. Alcohol, Smoking, and Stress Other negative lifestyle choices, such as excessive consumption of alcohol and cigarette smoking, aggravate metabolic syndrome. Excessive alcohol consumption causes fat accumulation in the liver, which is also associated with metabolic syndrome. Cigarette smoking is a major contributor to pulmonary disease (see Chapter 30) and hypertension (see Chapter 22). One study showed that employees with chronic work stress were more than twice as likely to have metabolic syndrome as those without work-related stress. Another study demonstrated that patients with jobrelated stress had a twofold increase in the risk of recurrent unstable angina and myocardial infarction. Genetic Factors Genetic factors inuence each component of the syndrome, as well as the syndrome itself. A family history

of rst-degree relatives (e.g., parents, siblings) that includes type 2 diabetes, hypertension, and early heart disease (e.g., angina, heart attack) greatly increases the likelihood that an individual will develop metabolic syndrome (Fig. 20.2). TREATMENT The variety of factors associated with the presence of metabolic syndrome requires an individualized approach to treatment that is based on a person’s specic risk factors and diseases present. Lifestyle management is critical to prevent and treat the comorbidities that make up the metabolic syndrome. Research indicates that lifestyle changes alone may delay the onset of type 2 diabetes mellitus by more than 50%. The overall treatment goals for metabolic syndrome are listed in Table 20.3 Weight loss and increased physical activity are usually the rst steps of treatment. Reducing the number of calories consumed—while burning more calories— can have very positive effects in treating metabolic syndrome. Even a 10- to 15-pound weight loss can improve hypertension and hyperglycemia. Initial therapeutic goals are a 7% to 10% weight reduction during the rst year of treatment, with an ongoing goal of a BMI less than 25 kg/m2. Several dietary approaches can be used to lose weight. Adopting the DASH (Dietary Approaches to Stop Hypertension) diet may help patients who also have hypertension (see Chapter 22). The Mediterranean diet—one rich in “good” fats (e.g., olive oil), containing a reasonable amount of carbohydrates, and with protein from sh and chicken— is frequently recommended. The diet should include reduced intake of saturated fat ( and