Medications in Nursing - Essay Example

?Running head: Medications in Nursing Medications in Nursing Medications in Nursing Question Vecuroniom) Mr. Jian was given Vecuronium bromide as an adjunct to the general anesthesia in order to ensure endotracheal intubation and to relax the skeletal muscles during surgery or during mechanical ventilation (NDH, 2006). In effect, Mr. Jian was given Vecuronium in order to help relax his muscles during the surgery and ensure that his throat is relaxed during the ET intubation. Vecuronium is considered an “intermediate acting nondepolarizing muscle relaxant” (Kovacs and Law, 2008, p. 228). As a nondepolarizing agent, this drug causes skeletal muscle paralysis by blocking the myoneural junction, interfering acetylcholine’s bid for cholinergic receptor sites and then binding with the nicotinic cholinergic receptor at the postjunctional membrane (Stoelting and Miller, 2007). Unlike other depolarizing agents however, vecuronium does not have much agonist activity and has no depolarizing impact at the motor endplate (McEvoy, et.al., 2009). As a muscle relaxant, this drug acts first on the eyelids and the jaw, then acts on the limbs, the abdomen, and then the diaphragm and the intercostals (Bledsoe, Clayden, and Papa, 2005). Adverse reactions of the drug may include skeletal muscle weakness and prolonged respiratory insufficiency or apnea (NDH, 2006). The intubating dose of 0.1mg/kg is sufficient to create intubating conditions within 3 minutes with effects lasting up to 45 minutes (Kovacs and Law, 2008). Co-administration with antibiotics can enhance neuromuscular blockade, thereby also causing increased muscle relaxation and increasing the potency of the drug (NDH, 2006). Using the drug with opioid analgesics can also increase neuromuscular blockade, thereby also causing increased skeletal muscle relaxation. The use of this drug is appropriate for this patient because it causes limited histamine and cardiovascular response (McEvoy, et.al., 2009). Question 2: Digoxin Mr. Jian was prescribed digoxin because of his atrial fibrillation. Digoxin is one of the appropriate choices of drug for Mr. Jian because the drug inhibits the sodium potassium-activated adenosine triphosphate and promotes the movement of calcium from the extracellular to the intracellular cytoplasm as it strengthens myocardial contraction (NDH, 2006). This drug also acts on the CNS to improve the vagal tone, thereby, slowing the conduction through the nodes and thereby ensuring antiarrhythmic effect (NDH, 2006). Digoxin has a significant role in reducing ventricular rate in supraventricular arrhythmias in atrial fibrillations; hence it is the better drug choice for Mr. Jian. It can however cause fatigue, muscle weakness, agitation, headache, anorexia, vomiting, and diarrhea (NDH, 2006). In relation to other drugs, co-administration with verapamil and quinidine can increase the blood digoxin levels and provoke atrioventricular block; administering it with diuretics can cause hypokalemia which can increase the risk of ventricular arrhythmias (Berger, 2010). This drug is not advised for those with hypersensitivity to digoxin, for those with digitalis-induced toxicity, ventricular fibrillation, or ventricular tachycardia (NDH, 2006). For the nurse, there are various nursing precautions which should be considered in the administration of digoxin. After administration of the drug, the nurse needs to monitor Mr. Jian’s pulse rate because extreme slowing of the pulse may indicate digitalis toxicity (NDH, 2006). The nurse also needs to monitor the patient’s potassium levels carefully and take appropriate action before hypokalemia occurs. Before the drug is administered, the nurse needs to take the apical-radial pulse for 1 minute. She then needs to notify the prescriber for any changes (any significant increase or decrease in pulse). If such increase of decrease is seen, the patient’s BP needs to be checked and for an ECG to be performed (NDH, 2006). Question 3: Flecainide and Dofetilide Flecainide is a Class Ic antidysrrhythmic drug (Aronson, 2009). It slows nerve impulses of the heart and therefore makes the heart tissues less sensitive. It is recommended for Mr. Jian because he has a structurally normal heart and has not had a previous heart attack. Since Mr. Jian has had no history of any heart attack or ventricular fibrillation, fleicanide is a possible alternative to digoxin (Aronson, 2009). Even as class Ic drugs can slow down atrial and atrioventricular nodal conduction among patients with atrial fibrillation flutter, they do not however change the refractoriness of the atrial node, allowing a 1:1 AV conduction as the atrial rate decreases (Aronson, 2009). In patients administered fleicanide, there is better and long-term control of recurrence of atrial fibrillation (Aronson, 2009). Since, Mr. Jian is already not in the best state of health, it is important to control and reduce the possibility of the atrial fibrillation manifesting once again. Dofetilide is a class III drug and is one of the recently introduced drugs to address atrial fibrillation. Dofetilide may be preferred for Mr Jian because the drug works just as well as digoxin. It prolongs the action potential nearly twofold in the atria than in the ventricles (Wang, 2005). Studies indicate that compared to digoxin, dofetilide has proven to be more effective with rates of efficacy up to 50% (Wang, 2005). It has no adverse inotropic effects and can sometimes be considered a positive inotropic agent. In a study Cotiga, et.al., (2007) the authors were able to establish that dofetilide has a high pharmacological conversion rate, as seen in the incremental dose response. It was well tolerated among patients with persistent AF. Dofetilide was recommended by the authors as an effective alternative in the conversion of AF in different clinical settings. Since Mr. Jian is suffering from multiple illnesses, the dofetilide can help control his AF and limit the frequency of his hospitalization. Question 4: Furosemide The furosemide was administered to the patient due to the patient’s acute pulmonary edema manifested by the basal lung crepitations (NDH, 2006). The furosemide basically acts as a potent loop diuretic which prevents sodium and chloride reabsorption at the proximal and distal tubes and the ascending loop of Henle (NDH, 2006). The furosemide will help reduce the fluid and the edema in the patient’s lungs and thereby eliminate the crepitations heard on his lungs. It would also assist in safely stabilizing his blood pressure (Aschenbrenner and Venable, 2008). It can also increase blood glucose and triglyceride levels; sometimes it may prevent the excretion of uric acid and increase uric acid levels in the blood (Aschenbrenner and Venable, 2008). Hence, the nurse needs to monitor uric acid levels in the patient’s blood. Furosemide can cause adverse reactions including vertigo, weakness, transient deafness, abdominal discomfort, diarrhea, nausea, vomiting, and frequent urination (NDH, 2006). In some instances, it can also cause muscle spasms and dermatitis. Interactions with other drugs may also manifest. When co-administered with aminoglycoside antibiotics, it can increase ototoxicity; when used with antidiabetics, it can decrease hypoglycemic effects; when used with antihypertensives, it can increase hypotension; when used with NSAIDs, it can inhibit diuretic response; and when used with corticosteroids, it can increase hypokalemia (NDH, 2006). It is therefore important for the nurse to note and monitor the patient’s weight, blood pressure, and pulse rate during rapid diuresis because this drug can cause abrupt fluid and electrolyte loss. In order to prevent nocturia, this drug can be given per orem and IM in the morning with a second dose in the afternoon (NDH, 2006). In instances when the monitoring of the patient reveals increased oliguria, the administration of the drug must be stopped. Signs of hypokalemia must be noted; and these signs include muscle weakness and cramps. Question 5: Patient-controlled analgesia It is appropriate for Mr. Jian to receive PCA because there was a need for him to receive parenteral analgesia for 24 hours or more; hence, instead of constantly administering parenteral analgesia, the PCA would be the more convenient choice for Mr. Jian (Brooker and Nicol). After his surgery, he is being managed for a variety of interventions which would likely cause him pain, anxiety, and disturbance. The PCA would simplify the administration of pain relief for Mr. Jian, making it possible to administer patient care with less pain and less hassle on the patient. Since the patient is also suffering from a variety of illnesses as caused by his cancer, it is considered proper nursing care to make the administration of treatments more pain free and more comfortable. Various studies have considered the use of PCA versus other methods of analgesia administration. One study compared the use of PCA with the transdermal administration. In a randomized, prospective trial, the authors were able to establish that the transdermal administration and the PCA system were comparatively effective and safe methods of delivering analgesia to the patient (Grond, et.al., 2007). The PCA is considered to be one of the major improvements in medicine and pain relief. There is also less strain on nursing resources since the patient administers the medicine to himself. It gives the patient more control over his condition and over the pain he is feeling. As a result, he becomes less anxious about his condition and about the pain he is experiencing (Subramaniam, 2011). PCA is appropriate for Mr. Jian because it potentially delivers various benefits; it is less invasive and inevitably, less costly for him (Viscusi and Pharm, 2006). Since the pain management for the patient is improved through the use of the PCA, he would also be discharged at the soonest possible time with less pain, less anxiety, and less hospital cost. Question 6: Tramadol, Ibuprofen, Celecoxib For the coming week following his surgery, the opioid analgesic Tramadol can be administered to him two times a day for the first 24 hours and as necessary for the rest of the week. His dose cannot include 200 mg a day. Tramadol is a centrally acting synthetic analgesic compound which is thought to bind opioid receptors and prevent reuptake of norepinephrine and serotonin (NDH, 2006). In a study by Ng, et.al., (2006) the authors had occasion to evaluate the compare the use of Tramadol in relation to fentanyl in the post-operative period. The authors were able to establish that both drugs had similar cognitive effects on the first two days of use; however for patients receiving Tramadol, they were able to manage better their cognitively demanding activities as compared to those using fentanyl (Ng, et.al., 2006). Since he is also renally impaired, his dose interval for the drug must be increased and his daily dose be reduced from the usual 300 mg to 200 mg (NDH, 2006). Ketorolac is an NSAID which can also be administered to the patient. Ibuprofen has anti-inflammatory effects and antipyretic effects and this will help prevent fever and reduce inflammation (NDH, 2006). This drug can be administered 7.5 mg every 6 hours; at 30mg maximum daily dose. According to studies, the use of NSAIDS was able to reduce the incidence and the severity of post-operative pain; the pain relief often was effective for up to five days (Smith, 2008). Another NSAID is classified as a Cox 2 inhibitor. Celecoxib can be used to relieve pain (NDH, 2006). It is advisable as a pain reliever because it inhibits prostaglandin synthesis and thereby causes anti-inflammatory and analgesic effects. This can be administered to the patient in case the Tramadol or the Ketorolac would not be able to relieve the pain. Maximum daily dose for this drug must be at 200 mg per day which may be given as a bolus dose (NDH, 2006). Question 7: Warfarin, Ipratropium bromide, and salbutamol puffers In relation to his Warfarin medication, I would advise Mr. Jian to comply strictly with the medicine’s prescribed dose and his follow-up appointments; I would also advise him to carry a card which indicates his risk for bleeding (NDH, 2006). I would also tell him to note signs of bleeding and abnormal bruising especially around the wound site. I would warn him not to take any over-the-counter products with aspirin and other salicylates because these might cause him to bleed. I would also advise him to read the food labels of his food and avoid those which contain Vitamin K because these can impair coagulation (NDH, 2006). I would also advise patient to eat healthy foods. In relation to his Ipratronium bromide, I would teach the patient how to perform inhalation properly by shaking the canister, clearing the nasal passages and the throat, breathing out and expelling as much air from the lungs as possible, to place mouthpiece on mouth, inhale deeply as the dose is released from the inhaler, then to hold breath for a few seconds, remove mouthpiece, and exhale slowly (NDH, 2006). I would also instruct patient to avoid spraying the drug into his eyes. In instances when more than one inhalation is required, I would advise the patient to wait 2 minutes before taking the next dose. I would also instruct patient to remove the canister and wash the inhaler in warm and soapy water atleast once a week (NDH, 2006). As for the salbutamol puffers, the same instruction on proper inhalation shall be given to the patient. I would also instruct him to use the bronchodilator first and then wait five minutes before using the Ipratronium bromide (NDH, 2006). I would also advise him to follow the dosage as prescribed and if he feels any tremors, heartburn, dizziness after administration of the drugs, then he must inform his physician at the soonest time possible. I would also advise him as to the dates of his follow-up check-up. Works Cited Aronson, J. (2009) Meyler's Side Effects of Cardiovascular Drugs. Philadelphia: Elsevier Health Sciences Aschenbrenner, D. & Venable, S. (2008) Drug Therapy in Nursing. Massachusetts: Lippincott Williams & Wilkins Berger, P. (2010) Coronary Care Manual. Philadelphia: Elsevier Health Sciences Bledsoe, B. & Clayden, D. (2005) Prehospital emergency pharmacology. New York: Prentice Hall Brooker, C. & Nicol, M. (2007) Nursing adults: the practice of caring. Philadelphia: Elsevier Health Sciences Cotiga, D., Arshad, A., Aziz, E., Joshi, S., Koneru, J., & Steinberg, J. (2007) Acute Conversion of Persistent Atrial Fibrillation During Dofetilide Initiation. Pacing and Clinical Electrophysiology, volume 30, issue 12, pp. 1527–1530 Grond, S., Hall, J., Spacek, A., Hoppenbrouwers, M., Richarz, U., & Bonnet, F. (2007) Iontophoretic transdermal system using fentanyl compared with patient-controlled intravenous analgesia using morphine for postoperative pain management. Br. J. Anaesthesia, volume 98, number 6: pp. 806-815. Kovacs, G. & Law, A. (2008) Airway Management in Emergencies. New York: McGraw-Hill Publications McEvoy, G., Snow, E., Miller, J., & Kester, L. 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