Medications to Treat Depression: Recognizing Side Effects of Tricyclic Antidepressants
Mohr---
predominant SE of tricyclic antidepressants are: sedation dry mouth blurred vision urinary retention delayed micturition dizziness fainting Other SE confusion disturbed concentration weight gain constipation ATI----
Side/Adverse Effect Nursing Intervention/Client Education Orthostatic Hypotension Instruct clients about the signs of postural hypotension (lightheadedness, dizziness). If these occur, advise the client to sit or lie down. Orthostatic hypotension can be minimized by getting up slowly
Anticholinergic effects (eg., dry mouth, blurred vision, photophobia, acute urinary retention, constipation, tachycardia)
Instruct the client on ways to minimize anticholinergic effects.
Advise the client to chew sugarless gum, eat foods high in fiber, and increase water intake to at lease 8-10 glasses/day
Teach the client to monitor HR and report noteworthy increases.
Advise the client to notify the primary care provider if sx are intolerable.
Cardiac toxicity usually only at excessive dosing
Obtain the clientʼs baseline ECG and monitor during tx
Sedation Usually diminishes over time
Advise clients to avoid hazardous activities such as driving if sedation is excessive. Advise the client to take med at bedtime to minimize daytime sleepiness and to
promote sleep
Toxicity evidenced by dysrhythmias, mental confusion, and agitation, followed by seizures, and coma
Give Clients who are acutely ill only a 1- week supply of med
Monitor the client for signs of toxicity Notify the PCP if signs of toxicity occur.
Immunosuppressants: Recognizing Risk Factors for Infection Calcineurin inhibitors: cyclosporine
(Sandimmune, Gengraf, Neoral) Glucocorticoids: Prednisone Cytotoxics: azathioprine (Imuran)
increases risk of infection such as fever an/or sore through
advise the client if sx occur to notify the primary care provider immediately
Glucocorticoids are contraindicated in recurring live virus vaccines (increases risk of infection) and systemic fungal infections.
Cyclosporine is contraindicated in recent contact or active infection of chicken pox or herpes zoster
Estrogens: Recognizing Side Effects
endometrial and ovarian CA--occur when prolonged estrogen is the only postmenopausal therapy
give client progestins along with estrogen
instruct client to report persistent vaginal bleeding advise client to have endometrial biopsy q 2 years potential risk for estrogen-dependent breast CA--
rule out prior to starting therapy
encourage regular self-breast exams and mammograms embolic events (ie: MI, pulmonary embolism, DVT, CVA)
discourage client from smoking
monitor the client for pain, swelling, warmth or erythema in lower legs
feminization (gynecomastia, testicular and penile atrophy),, impotence, and decreased libido in males
avoid use of estrogen vaginal creams prior to sexual intercourse sx disappear when med is discontinued
Magnesium Sulfate Therapy: Appropriate Interventions to Counteract Toxicity for a client with Gestational Hypertension
BP at 140/90 or greater
systolic increase of 30 mmHg diastolic increase of 15 mmHg there is no proteinuria or edema
clientʼs BP returns to baseline by 6 weeks postpartum Magnesium Sulfate Toxicity include
absence of patellar DTRs UOP < 30 cc/hr
Resp < 12/min decreased LOC
If Mag toxicity is suspected
immediately discontinue infusion
administer calcium gluconate, (IV admin of 1 g (10ml of 10% soln) at 1 ml/min) Discontinue mag if RR < 12, a low pulse ox (<95%) persists or DTRs are absent
Notify MD
If UOP falls below 20ml/hr the MD is notified so that the drugʼs admin can be adjusted to maintain a therapeutic range
Calcium opposes the effects of mag at the neuromuscular junction
Always have an injectable form of calcium gluconate avail when administering magnesium sulfate by IV
Succinylcholine: Recognizing and Responding to Malignant Hyperthermia
Malignant hyperthermia is a rare metabolic disease characterized by hyperthermia with rigidity of skeletal muscles that can result in death
occurs in affected people exposed to certain anesthetic agents
Succinylcholine (Anectine) especially in conjunction with volatile inhalation agents, appears to be the primary trigger of the disorder
fundamental defect: hypermetabolism resulting in altered control of intracellular calcium leading to muscle contracture, hyperthermia, hypoxemia, lactic acidosis and
hemodynamic and cardiac alterations. hyperthermia not an early sign
definitive treatment is Dantrolene (Dantrium) which slows metabolism along with symptomatic support to correct hemodynamic instability
Blood and Blood Products: Evaluating Client Response to Blood Transfusions NS ok
No dexrose solnʼs or lactated ringers.
no other additives s/b given via the same tubing
During 1st 15 min or 50ml the nurse should remain with the pt
rate s/b no more than 2ml per min
usual rate after the 1st 15 min...1 unit over 2 hrs should not take more than 4 hrs to administer. Steps if acute blood reaction occurs.
e. Stop the transfusion
f. Maintain a patent IV line with saline soln g. notify the blood bank and HCP immediately h. recheck ID tags and numbers
i. monitor VS and UOP j. tx sx per MD order
k. save the blood bag and tubing and send them to blood bank for exam l. complete tranfusion reaction reports
m.collect required blood and urine specimens at intervals stipulated by hospital policy to evaluate for hemolysis
n. document on transfusion reaction.
Acute reactions: 15 min
Acute hemolytic treat shock if present draw blood samples
maintain BP with IV colloid soln give diuretics to maintain urine flow
insert indwelling cath or measure amts of hourly UOP do not transfuse additional RBC
Febrile
give antipyretics as prescribed do not restart transfusion Mild allergic
give antihistamine as directed
if sx are mild and transient, transfusion may be restarted Anaphylactic and severe allergic
initiate CPR if indicated
have epi ready for injection 0.4 ml of 1:1000 soln SQ or 0.1 ml 1:1000 soln diluted to 10ml with saline for IV use
Do not restart transfusion Circulatory overload
place pt upright with feet in dependent position admin prescribed diuretics, 02, morphine phlebotomy may be indicated
Sepsis
obtain culture of ptʼs blood and send bag with remaining blood and tubing to blood bank for further study
treat septicemia as directed---abx, IV, fluids
Vascular Access: Recognizing and Documenting Expected Finding for a Client with a central venous access device.
Insertion: basilic or cephalic vein at least 1 fingerʼs breadth below or above the anticubital fossa. tip is positioned in the lower 1/3 of the superior vena cava Indications:
admin of blood
long term admin of chemo abx
tpn care:
assess q 8 hr. note redness, swelling, drainage, tenderness and condition of dressing change tube and positive pressure cap per protocol (usually q 3 days)
us 10ML or larger syringe to flush the line
clean insertion port with alcohol for 3 sec, let dry
perform flush for intermittent med admin usually 10 Ml of NS before, between and after meds.
use transparent dressing usually change q 7 days and when indicated advise client to avoid excessive physical exercise on affected extremity Tunneled Caths (Hickman)
Insertion: subq tunnel separating point where the cath enters the vein from where it enters the skin with a cuff
indication:
need for vascular access is long term (1 year or more) commonly for chemo
care: to access:
apply local anesthetic, palpate to locate the port clean with alcohol for 3 sec
access with noncoring needle
flush after q use and at least once a month
Basic Pharmacological Principles: Expected Dosage Adjustments Based on Age of Client
Pediatric dosages are based on body wt, body surface area and maturation of body organs.
meds are based on age bec of greater risk for decreased skeletal growth, acute CV failure or hepatic toxicity.
Hematopoietic Growth Factors: Evaluating Client Outcomes
Hematopoietic growth factors act on the bone marrow to increase production of red blood cells
Epoetin used for
anemia of CRF
HIV infected clients taking Retrovir anemia induced by chemo
anemia in clients scheduled for elective surgery SE: hypertension secondary to elevations in HCT increased risk for CV event
Nursing Interventions: Monitor clientʼs iron levels
RBC growth dependent on adequate quantities of iron, folic acid, and vit B12 monitor the clientʼs Hgb and Hct twice a week until target range is reached obtain baseline BP
in CRF, control HTN before tx do not combine with other med
Evaluation of med effectiveness : Hgb level of 10-12 and HCT of 40%
increased reticulocyte count
filgrastin (Neupogen), pegfilgrastin (Neulasta)
stimulate the bone marrow to increase production of neutrophils decreases the risk of infection in clients with neutropenia
SE: bone pain
leukocytosis---decrease dose or stop tx if WBC > 50000 or platelets > 500000 contraindicated in clients sensitive to E. Coli
Evaluation of Medication Effectiveness absence of infection
in chemo for CA tx, an absolute neutrophil count increase to greater than 10,000 after chemo induced nadir.
sargramostim (leukine)
acts on the bone marrow to increase production of WBC (neutrophils, monocytes, macrophages, eosinophils
facilitates recovery of bone marrow after bone marrow transplant used in the tx of failed bone marrow transplant
SE: diarrhea, weakness, rash, bone pain leukocytosis, thrombocytosis
reduce tx if WBC> 50000, neutrophil > 20000 or platelets > 500000 contraindicated in clients allergic to yeast products
use cautiously in clients with heart disease, hypoxia, peripheral edema, pleural and pericardial effusion
Evaluation of Medication Effectiveness absence of infection
WBC and differential within normal ranges
Proton Pump Inhibitors: Client Education omeprazole (Prilosec)
reduce gastric acid secretion by irreversibly inhibiting the enzyme that produces gastric acid
prescribed for gastric and peptic ulcers, GERD, and hypersecretory conditions (Zollinger-Ellison syndrome)
Allow at least a 2 hr interval between this med and: Ampicillin
Iron
ketoconazole
delayed absorption of these meds may occur if taken concurrently with omeprazole. Therapeutic Interventions and Client Education
Do not crush, chew, or break sustained release capsules
may sprinkle contents of the capsule over food to facilitate swallowing take once a day prior to eating
avoid irritating meds (ibuprofen, ETOH) active ulcers should be txʼd for 4-6 weeks
Protonix (pantoprazole) can be admin to client IV. Monitor IV site. may be low incidence of HA and diarrheat
notify PCP for any sign of obvious or occult GI bleeding
Migraine Medications: Evaluating Appropriate Use of Sumatriptan (Imitrex) sumatriptan (Imitrex)
serotonin receptor agonist
prevent the inflammation and dilation of the incranial blood vessels thereby relieving migraine pain
therapeutic uses
to abort acute migraine attack prevent migraine attack
Contraindicated in clients with ischemic heart disease, hx of MI, uncontrolled HTN and other heart diseases
do not give with ergotamine (ergostat)---leads to spastic reaction of blood vessels. don not give triptans within 2 weeks of stopping MAOIs---can lead to MAO toxicity.
Cephalosporins: Evaluating Tx Effectiveness
beta-lactam abx similar to PCNs that destroy bacterial cell walls causing destruction of microorganisms
effective against gram neg organisms and anaerobes more able to reach CSF
broad spectrum bactericidal meds with a high therapeutic index that treat UTIs, post op infections, pelvic infections, and meningitis.
Evaluation of Medication Effectiveness
improvement of infection sx: reduction of fever, pain, and inflammation, clear breath sounds, reduced UTI sx, negative urine CX
Basic Principles of Med Admin: Client Education Regarding Age Related interventions
Promoting Compliance in the older adults
give clear and concise instructions, verbally and in writing
ensure dosage form is appropriate. liquids should be admin to clients who have difficulty swallowing
provide clearly marked containers that are easy to open
assist the client to set up a daily calendar with the use of pill containers suggest that the client obtain assistance from a friend, neighbor, or relative. Medication Admin and Error Prevention: Disposing of Unused Controlled Schedule Medications
If only one part of a premeasured dose of a controlled substance is given, a second nurse witnesses disposal of the unused portion and documents such on the record form Dosage Calculation: Calculating Hourly Infusion Rate for a Large Volume of Fluid A RN is to admin 500 mL of D5W over 4 hr. The IV pump should be set to deliver how many mL per hour
An IV med is to run over 20 min on the pump. The med is mixed in 50 ML of NS. The IV pump should be set to deliver how many mL/hr.
150mL/hr
An IV med is to run over 45 min on the pump. The med is mixed in 100mL of NS. The IV pump should be set to deliver how many mL/ hr?
133 mL/hr.
Intravenous Therapy: Priority Interventions with Initiation of Therapy Unexpected Outcomes and Related Interventions
Fluid volume deficit AMB decreased UOP, dry mucous membranes, hypotension, tachycardia
notify MD, may require adjustment of infusion rate
Fluid Volume excess AMB crackles in lungs, shortness of breath, edema reduce IV flow rate if sx appear and notify MD
Electrolyte imbalances AMB abnormal serum electrolyte levels, changes in mental status and alterations in neuromuscular function, changes in VS and other
manifestations
notify MD. additives in IV or type of IV fluid may be adjusted.
Infiltration as indicated by swelling and possible pitting edema, pallor, coolness, pain at insertion site and possible decrease in flow rate
stop infusion and d/c IV. elevate affected extremity. restart new IV if continued therapy is necessary
phlebitis as indicated by pain, increased skin temp, erythema along path of vein. stop infusion and d/c IV. restart new IV if continued therapy is necessary. place moist warm compress over area of phlebitis
Bleeding occurs at venipuncture site
bleeding from vein is usually slow, continuous seepage. common in clients who have received heparin or have a bleeding disorder or if the IV site is over bend in arm/ hand
if bleeding occurs around venipuncture site and catheter is within vein, gauze dressing may be applied over site. eventually IV may need to be discontinued
blood on the dressing can result when the administration set becomes disconnected from the catheterʼs hub. When blood appears on the dressing, verify that the system is intact and change the dressing
Intravenous Therapy: Documenting Discontinuation of IV Following Signs of Phlebitis
Signs of Phlebitis Edema
Throbbing, burning or pain at the site Warmth
Erythema
May be a red line up the arm with a palpable band at the vein site Slowed infusion
Prevention: rotation of sites
avoiding the lower extremities
proper handwashing and surgical aseptic technique.
Promptly d/c infusion. Notify PCP
elevation
warm/moist compresses
restarting with new tubing and fluid TED hose and/or anticoagulants
culturing the site if drainage is present (P/P)
Unexpected Outcomes and Related Interventions
Phlebitis is present, as evidenced by erythema and tenderness along vein pathway. Stop IV infusion and d/c IV. Restart new IV in other extremity if continued therapy is necessary.
Record appearance of IV site, type of dressing, and status of IV fluid infusion. A special parenteral fluid flow sheet may be used for recording.
Medications Affecting the Respiratory System: Recognizing Ineffectiveness of Beta2-Adrenergic Agonists.
albuterol (Proventil, ventolin)
act by selectively activating the beta2 receptors in the bronchial smooth muscle resulting in bronchodilation. As a result:
bronchodilation is relieved histamine release is inhibited ciliary motility is increased prevention of asthma
tx for ongoing asthma attack long term control of asthma
Effectiveness may be evidenced by long term control of asthma attacks
prevention of exercise induced asthma attack
resolution of asthma attack as evidenced by absence of SOB, clear breath sounds, absence of wheezing, return of RR to baseline.
Oral Hypoglycemics: Client Teaching Regarding Use in Pregnancy Avoid use in pregnancy and lactation (risk for fetal/infant hypoglycemia) Oral hypoglycemic medication contraindicated (causes birth defects).
Medications Used to Treat TB: Recognizing Risk for Phenytoin Toxicity due to Med interactions.
INH (isoniazid)
highly specific for mycobacteria. Isoniazid inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall
indicated for active and latent TB
Latent INH only ---daily for 6 months
Active: multiple med therapy including INH, rifampin, pyrazinamide, and/or pyridoxine daily for 6 months
Med reaction:
Phenytoin--INH interferes with the metabolism of phenytoin with accumulation of phenytoin, resulting in ataxia, and incoordination
monitor levels of phenytoin. dosage of phenytoin may need to be adjusted based on phenytoin levels.
Opioids are used preoperatively for sedation and analgesia, intraoperatively for induction and maintenance of anesthesia and postop for pain management. Opioids alter the perception of pain and the response to painful stimuli. When admin before the end of a surgical procedure the residual analgesia often carries over into the PACU allowing the pt to awaken relatively pain free.
All opioids produce dose-related respiratory depression. Respiratory depression may be difficult to detect in the OR and therefore requires close observation and pulse
oximetry monitoring. Respiratory depression is reversed with naloxone (Narcan). However its use is often associated with a reversal of the analgesic effects of the narcotics as well.
Pain Management: Evaluating Effectiveness of Treatment Pain Management:
The goals of teaching r/t pain management include that the pt and family member understand the following
need to maintain a record of pain level and effectiveness of tx
no need to wait until becomes severe to take drugs or use nondrug therapies for pain relief
med will stop working after it is taken for a period of time, and dosages may need to be adjusted
potential SE and complications associated with therapy. SE: N/V, constipation, itching, sedation and drowsiness, urinary retention, sweating
need to report when pain is not relieved to tolerable levels.
client attained her pain relief goal most of the time client is performing ADLs, walking and ability to sleep
if nurse assess that a client continues to have discomfort after an intervention, it may be necessary to try a different approach. If an analgesic provides only partial relief, the nurse may add relaxation exercises or guided imagery exercises. The nurse may also consult with the physician about increasing the dosage, decreasing the interval between doses, or trying different analgesics.
nurse evaluates the clientʼs perceptions of the effectiveness of the interventions. The client may help decide the best times to attempt a tx. in essence, the client is the best judge of whether an intervention works. The nurse also evaluates tolerance to therapy and the overall relief obtained. a nurse admin an analgesic, SE from the med and the clientʼs reported pain relief must be assessed.
client is the best resource for evaluating the effectiveness of pain relief measures. TPN: Recognizing Appropriate TPN Interventions
TPN: a nutritionally adequate hypertonic soln consisting of glucose and other nutrients and electrolytes given through an indwelling or central IV catheter which may be inserted peripherally or percutaneously, implanted or tunneled.
PN: is a form of specialized nutrition support in which nutrients are provided
intravenously. Safe admin of the form of nutrition depends on appropriate assessment of nutrition needs, meticulous management of the CVC and careful monitoring to
prevent or tx metabolic complications. Parenteral nutrition is admin in a variety of setting including the clientʼs home. Regardless of the setting, the nurse adheres to the same principle of asepsis and infusion management to ensure safe nutrition support.
clients who are unable to digest or absorb enteral nutrition benefit from PN. goal to move toward the use of the GI tract is constant.