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Patient - Coggle Diagram
Patient
Professional responsibilities
7 Medication Rights.
7) Right Documentation
3) Right Time
1) Right Medication
6) Right to refuse/right patient education
5) Right Patient
4) Right Route
2) Right Dose
Allergies
The role of PACU
RN PACU nurses work within a post-anesthesia care unit, where patients are cared for and monitored as they recover from the effects of anaesthesia. PACU nurse responsibilities include all aspects of patient care following surgery.
PACU Nursing Duties
Monitor patient vital signs as they wake from anaesthesia.
Treat pain, nausea, and other patient post-op symptoms and any side effects of anesthesia.
Comfort patients who awaken scared or confused after surgery.
Work with an interdisciplinary medical team.
Document and keep the team informed of the patient’s progress.
Educate the patient and family on post-surgery care.
Handover patient care to alternative HCP.
Medicines Act 1981
State there are 4 classifications of medicines.
Prescription medicine: can only be obtained by a person authorised to prescribe.
Authorised prescribers in NZ include; Registered midwives, Medical Practitioners, Pharmacists, Nurse Practitioners, Dentists, Dieticians, Optometrists and Designated prescribers.
Verbal and telephone medicine orders: write the order as it is being given - read it back to prescriber - colleague to listen to the prescriber's order - write the medication on a medication administration form - write in patient notes that this was required.
Standing orders: A standing order is a written instruction issued by a medical practitioner, dentist, nurse practitioner or optometrist that authorises a specified person or class of people (eg paramedics, RNs) who do not have prescribing rights, to administer and/or supply specified medicines and some controlled drugs
Pharmacy-only medicine
General sale medicines
Restricted medicines
The Medicines Act 1981 regulates medicines, related products and medical devices in New Zealand. The Act ensures that the medicines and products used in New Zealand are safe and effective.
Health Practitioners Competence Assurance Act 2003
Provides a framework for the regulation of health practitioners in order to protect the public where there is a risk of harm from professional practice.
Nursing Council of New Zealand
NCNZ Competencies for a Registered Nurse
The Nursing Council Competencies for Registered Nurses describe the skills and activities of registered nurses. This legal document outline the Scope of Practice of a RN.
NCNZ Code of Conduct
Setting out the standards of behaviour that nurses are expected to uphold in their professional practice
The Misuse of Drugs Act 1975
The Misuse of Drugs Act 1975 is a New Zealand drug control law that classifies drugs into three classes, or schedules, purportedly based on their projected risk of serious harm.
Class B
Second Schedule: Very high risk of harm and on prescription:
Amphetamine
Cannabis
Ephedrine
GHB
Hydromorphone
MDMA
Methadone
Morphine
Opium
Oxycodone
Pethidine
Pseudoephedrine
Class C
Third Schedule: Moderate risk of harm:
Barbiturates
Benzodiazepines
Benzylpiperazine
Cannabis
Codeine
Class A
First Schedule: Very high risk of harm and illegal:
Cocaine
Heroin
Crack
LSD
Mescaline
Methamphetamine
Phencyclidine
Psilocin
TDHB Medication guidelines
TDHB Student Nurse Medication Management Protocol
Used to ensure a safe environment is maintained for patients and nursing students when administering medications.
Student Scope of Practice
TDHB permits all student nurse and midwives to be involved in all medication management processes for all medications under the direct supervision of a RN/RM except for MVAD and CVAD. Additionally, the student nurse is also responsible for ensuring they remain within their local School of Nursing medication policies and procedures and that this is communicated by the student to the preceptor.
This document outlines a Students SOP
Documentation
The student will register their details in the Sample Initials section of the [paper] Medication Chart. In the instance where a single RN/M initial is required, the student will initial as the second person involved in the medication management process.
In the instance where a double RN/M initial is required, the student will initial as the third person involved in the medication management process.
-Students will log in to MedChart as the administrator and utilise the RN/RM who is overseeing the student, to co-sign the administration.
RN Standards for the administration of medicines
Training and education requirements.
The person administering the medicine or delegating responsibility for administration of the medicine must;
Understand their scope of practice as determined by the appropriate regulatory authority or understand their role and responsibilities as per their job description
have had adequate training/orientation for the type of medicine being administered
is familiar with local area policy and guidelines related to medicine administration
-understands the relevant professional and legal issues regarding medicine
administration
Prior to administration
Prior to administration of medication, the regulated nurse or midwife administering the medicine;
Confirms the correctness of the prescription/medication chart, and the information provided on the relevant containers.
Ensures they are aware of the client’s current assessment and planned programme of care of administration and makes a clinical assessment of the suitability of administration at the scheduled time
ensures appropriate protocols regarding the preparation, administration and
documentation of controlled drugs are followed.
Checks the seven medication rights, expiry dates and allergies.
Prepares the medicine as specified by manufacturer/area policy and protocols.
Informs the client of the purpose of the medicine as appropriate.
During administration
During the administration of medication, the regulated nurse administering the medicine;
Monitors the client for adverse effects of the medicine and takes appropriate action as determined by local guidelines, e.g. anaphylaxis management;
Uses the opportunity, if appropriate, to emphasise to the client and significant others; the importance and implications of the prescribed treatment; and to enhance their understanding of its effects and side effects.
After administration
After administration, the regulated nurse administering the medicine;
Makes clear and accurate recordings of the administration of each individual medicine administered or deliberately withheld, or refused, ensuring any written entries and the signature are clear and legible.
Documentation must be timely.
Records the positive and negative effects of the medicine and makes them known to the authorised prescriber.
-Monitors the client for adverse effects of the medicine and takes appropriate action as determined by local guidelines, e.g. anaphylaxis management
Medical History
Age - 68 Gender - Female
Ethnicity - European/Māori
History of; Smoking cigarettes and cannabis, increased BMI and poor lifestyle/diet choices.
Type 2 Diabetic
Hypertension
COPD
Surgical History
Laparoscopic Hysterectomy with Bilateral Salpingo-Oophorectomy
Left and Right Total Knee Joint Replacement
Hiatus hernia repair
Social Aspects
Low Socio-economic status
Retired on the pension, previously on the unemployment/sickness benefit. Currently does voluntary work and is on the Parihaka Marae board. She also watches her 3 youngest mokopuna whilst their parents work on the farm.
Lives in Pari haka with her 2 children and 7 mokopuna.
Volunteers for Hapū Wānanga. A free kaupapa Māori labour, birth and parenting programme designed for young pregnant women and their families/whānau in Taranaki. She also weaves wahakura in her spare time.
Medications
Anaesthetic Medications/ General Anaesthetic + TIVA
Propofol - Continuous infusion
Adverse effects - Apnoea, hypertension, involuntary movements, euphoria, headache, shivering, bradycardia, GI upset, myoclonus and hyperventilation.
Indications - Short acting general anaesthetic used for induction and maintenance of general anaesthesia.
Interactions - CNS depressants incl opioids, alcohol; parasympatholytic agents, drugs causing bradycardia, vasoconstrictors, steroids and inotropes.
Mechanism of Action: The action of propofol involves a positive modulation of the inhibitory function of the neurotransmitter gama-aminobutyric acid (GABA) through GABA-A receptors.
Description: Propofol is an intravenous anaesthetic agent used for induction and maintenance of general anaesthesia. IV administration of propfol is used to induce unconsciousness after which anaesthesia may be maintained using a combination of medications. Recovery from propofol-induced anaesthesia is generally rapid and associated with less frequent side effects.
Fentanyl 100mg - Used as a premedication and for induction - Administered by the anaesthetist.
Indications: Opioid analgesic. Short duration analgesia in anaesthesia (premedication, induction & maintenance) and immediate post-op period. Transdermal patch for the management of chronic cancer pain.
Contraindications: Hypersensitivity, intolerance to opioids, asthma, respiratory depression susceptibility and history of myasthenia gravis.
Precaution: Renal and hepatic impairment, elderly, pulmonary disease, bradyarrthythmia, pregnancy and history of drug abuse.
Mechanism of Action: Fentanyl binds to opioid receptors, especially the mu opioid receptor, which are coupled to G-proteins. Activation of opioid receptors causes GTP to be exchanged for GDP on the G-proteins which in turn down regulates adenylate cyclase, reducing concentrations of cAMP. Reduced cAMP decreases cAMP dependant influx of calcium ions into the cell. The exchange of GTP for GDP results in hyperpolarization of the cell and inhibition of nerve activity.
Alfentenil - 500mcg
Description: A short-acting opioid anesthetic and analgesic derivative of fentanyl. It produces an early peak analgesic effect and fast recovery of consciousness. Alfentanil is effective as an anesthetic during surgery, for supplementation of analgesia during surgical procedures, and as an analgesic for critically ill patients.
Indication: For the management of postoperative pain and the maintenance of general anesthesia.
Used as an intraoperative opioid - Administered by the anaesthetist.
Mechanism of action: Opiate receptors are coupled with G-protein receptors and function as both positive and negative regulators of synaptic transmission via G-proteins that activate effector proteins. Binding of the opiate stimulates the exchange of GTP for GDP on the G-protein complex. As the effector system is adenylate cyclase and cAMP located at the inner surface of the plasma membrane, opioids decrease intracellular cAMP by inhibiting adenylate cyclase. Subsequently, the release of nociceptive neurotransmitters such as substance P, GABA, dopamine, acetylcholine and noradrenaline is inhibited. Opioids also inhibit the release of vasopressin, somatostatin, insulin and glucagon. Alfentanil's analgesic activity is, most likely, due to its conversion to morphine. Opioids close N-type voltage-operated calcium channels (OP2-receptor agonist) and open calcium-dependent inwardly rectifying potassium channels (OP3 and OP1 receptor agonist). This results in hyperpolarization and reduced neuronal excitability.
Pharmacodynamics: Alfentanil is a synthetic opioid analgesic. Alfentanil interacts predominately with the opioid mu-receptor. These mu-binding sites are discretely distributed in the human brain, spinal cord, and other tissues. Its primary actions of therapeutic value are analgesia and sedation. Alfentanil depresses the respiratory centers, depresses the cough reflex, and constricts the pupils.
Contraindications: Opioid intolerance or sensitivity.
Ondansetron - 4mg
Used intraoperatively as a preventative for nausea and vomiting - Administered by the anaesthetist.
Indication: intravenously administered ondansetron injection formulations are indicated for the prevention and treatment of postoperative nausea and vomiting
Mechanism of action: Ondansetron is a selective antagonist of the serotonin receptor subtype, 5-HT3. The role of ondansetron in opiate-induced emesis has not yet been formally established
Pharmacodynamics: Ondansetron is a highly specific and selective serotonin 5-HT3 receptor antagonist. The serotonin 5-HT3 receptors are located on the nerve terminals of the vagus in the periphery, and centrally in the chemoreceptor trigger zone of the area postrema. The temporal relationship between the emetogenic action of emetogenic drugs and the release of serotonin, as well as the efficacy of antiemetic agents, suggest that chemotherapeutic agents release serotonin from the enterochromaffin cells of the small intestine by causing degenerative changes in the GI tract Label, 3,4. The serotonin then stimulates the vagal and splanchnic nerve receptors that project to the medullary vomiting center, as well as the 5-HT3 receptors in the area postrema, thus initiating the vomiting reflex, causing nausea and vomiting
Analgesics - Pain relief
Ketamine
Infusion: Ketamine administered as a continuous IV infusion may improve analgesia and reduce opioid requirements. The doses ordered for pain management are much lower than anaesthetic doses.
Infusion running at 6mg/hr
Indication: Ketamine is indicated as an anesthetic agent for recommended diagnostic and surgical procedures. If skeletal muscle relaxation is needed, it should be combined with a muscle relaxant. If the surgical procedure involves visceral pain, it should be supplemented with an agent that obtunds visceral pain. Ketamine can be used for induction of anesthesia prior other general anesthetic agents and as a supplement of low potency agents
Description: Ketamine is an NMDA receptor antagonist with a potent anesthetic effect.6 It was developed in 1963 as a replacement for phencyclidine (PCP) by Calvin Stevens at Parke Davis Laboratories. It started being used for veterinary purposes in Belgium and in 1964 was proven that compared to PCP, it produced minor hallucinogenic effects and shorter psychotomimetic effects. It was FDA approved in 1970, and from there, it has been used as an anesthetic for children or patients undergoing minor surgeries
Pharmacodynamics: Ketamine is a rapid-acting general anesthetic producing an anesthetic state characterized by profound analgesia, normal pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. The anesthetic state produced by Ketamine has been termed as "dissociative anesthesia" in that it appears to selectively interrupt association pathways of the brain before producing somesthetic sensory blockade. It may selectively depress the thalamoneocortical system before significantly obtunding the more ancient cerebral centers and pathways (reticular-activating and limbic systems).
Ketamine enhances descending inhibiting serotoninergic pathways and can exert antidepressive effects. These effects are seen in concentrations ten times lower than the needed concentration for anesthetic proposes. The effect of ketamine can be described as analgesic by the prevention of central sensitization in dorsal horn neurons as well as by the inhibition on the synthesis of nitric oxide. Ketamine can present cardiovascular changes and bronchodilatation
Mechanism of action: Ketamine interacts with N-methyl-D-aspartate (NMDA) receptors, opioid receptors, monoaminergic receptors, muscarinic receptors and voltage sensitive Ca ion channels. Unlike other general anaesthetic agents, ketamine does not interact with GABA receptors
Half-life: The reported half-life in preclinical studies for ketamine is 186 min
Route of elimination: Pharmacokinetic studies have resulted in the recovery of 85-95% of the administered dose in urine mainly in the form of metabolites. Some other routes of elimination of ketamine are bile and feces. When administered intravenously the resultant recovery is distributed by 91% of the administered dose in urine and 3% in feces.
Contraindications: Severe CV disease, heart failure, severe or poorly controlled hypertension, recent MI, history of stroke, cerebral trauma, intracerebral mass or haemorrhage.
Adverse effects: treatment emergence reactions, GI upset, erythema, rash, hallucinations, abnormal dreams and agitation.
Clonidine
Indications: Centrally acting antihypertensive a2-agonist. Treatment of hypertension + other antihypertensives.
Contraindications: Severe bradyarrhythmia due to sick sinus syndrome, 2nd or 3rd degree A-V block and galactose intolerance.
Precautions: Ineffective in pheochromocytoma associated hypertension, not suitable for renal impairment and heart failure.
Adverse effects: Dizziness, sedation, orthostatic hypotension, dry mouth, sleep disorder, headache, GI upset, erectile dysfunction and fatigue.
Pharmacodynamics: Clonidine functions through agonism of alpha-2 adrenoceptors which have effects such as lowering blood pressure, sedation, and hyperpolarization of nerves.2 It has a long duration of action as it is given twice daily and the therapeutic window is between 0.1mg and 2.4mg daily
Interactions: Other antihypertensives, CNS depressants, haloperidol, methylphenidate, negative chronotropes and dromotropes.
Description: Clonidine is an imidazole derivate that acts as an agonist of alpha-2 adrenoceptors.2 This activity is useful for the treatment of hypertension, severe pain, and ADHD
Mechanism of Action: Clonidine is primarily an alpha-2 adrenoceptor agonist which causes central hypotensive and anti-arrhythmogenic effects. The alpha-2 adrenoceptor is coupled to the G-proteins Go and Gi. Gi inhibits adenylyl cyclase and activates opening of a potassium channel that causes hyperpolarization. Clonidine binding to the alpha-2 adrenoceptor causes structural changes in the alpha subunit of the G-protein, reducing its affinity for GDP. Magnesium catalyzes the replacement of GDP with GTP. The alpha subunit dissociates from the other subunits and associates with an effector.
The stimulation of alpha-2 adrenoceptors in the locus coeruleus may be responsible for the hypnotic effects of clonidine as this region of the brain helps regulate wakefulness. Clonidine can also decrease transmission of pain signals at the spine. Finally clonidine can affect regulators of blood pressure in the ventromedial and rostral-ventrolateral areas of the medulla.
Metabolism: The metabolism of clonidine is poorly understood. The main reaction in clonidine metabolism is the 4-hydroxylation of clonidine by CYP2D6, CYP1A2, CYP3A4, CYP1A1, and CYP3A5
Route of elimination: Approximately 50% of a clonidine dose is excreted in the urine as the unchanged drug and 20% is eliminated in the feces.
Half-life: The elimination half life after epidural administration is 30 minutes but otherwise can range from 6-23h
Dose given - 45mcg
Morphine
Indications: Morphine is used for the management of chronic, moderate to severe pain.2
Opiods, including morphine, are effective for the short term management of pain. Patients taking opioids long term may need to be monitored for the development of physical dependence, addiction disorder, and drug abuse
Contraindications: Hypersensitivity to opioids, following biliary tract surgery, surgical anastomosis, hepatic disease, CNS depression, acute alcoholism, biliary colic, respiratory insufficiency, depression, excessive bronchial sedation, obstructive airways disease, HF and head injury.
Pharmacodynamics: Morphine binding to opioid receptors blocks transmission of nociceptive signals, signals pain-modulating neurons in the spinal cord, and inhibits primary afferent nociceptors to the dorsal horn sensory projection cells.
Morphine has a time to onset of 6-30 minutes. Excess consumption of morphine and other opioids can lead to changes in synaptic neuroplasticity, including changes in neuron density, changes at postsynaptic sites, and changes at dendritic terminals
Mechanism of Action: Morphine acts primarily as a m-opioid receptor agonist, binding to l receptors in the brain, on terminal axons of primary afferents in the spinal cord, and elsewhere. Morphine functions as an indirect N-type cal- cium channel antagonist through G-protein coupling with Ca21 channels, inhibiting neurotransmitter release from peripheral nociceptive neurons to the central nerv- ous system (CNS). Morphine also binds to post- synaptic receptors and hyperpolarizes postsynaptic neurons. Together, these actions reduce the conductance of pain signals to the CNS. Because m- opioid receptors are widely distributed throughout the CNS, including the dorsal horn of the spinal cord, opioids make effective IT therapies
Half Life: Morphine has a half life of 2-3 hours
Route of Elimination: 70-80% of an administered dose is excreted within 48 hours. Morphine is predominantly eliminated in the urine with 2-10% of a dose recovered as the unchanged parent drug. 7-10% of a dose of morphine is eliminated in the feces.
Dose Given: 10mg. Administered by the Registered Nurse as its outside of a Student Nurses SOP
Averse effects: GI upset, abnormal thinking, headache, dizziness, sedation, sweating, rash, flushing, chills, involuntary muscle contraction, bronchospasm, depressed cough, dry mouth, respiratory depression, hypertension, oedema and bradycardia.
Reason for admission
Hine (pseudonym) presented to New Plymouth Emergency Department with severe sudden and rapidly intensifying pain in the abdomen, right shoulder and back. She was nauseous and had a fever. After investigation from the ED team she was diagnosed with gallstones an cholecystitis (inflamed gallbladder). She required a Cholecystectomy and her surgery was scheduled for the following day.
Definition: A cholecystectomy is the surgical removal of the gallbladder. The two basic types of this procedure are open cholecystectomy and the laparoscopic approach.
Description: The laparoscopic cholecystectomy involves the insertion of a long narrow cylindrical tube with a camera on the end, through an approximately 1 cm incision in the abdomen, which allows visualisation of the internal organs and projection of this image onto a video monitor. Three smaller incisions allow for insertion of other instruments to perform the surgical procedure.
Hine had a laparoscopic cholecystectomy with no complications.
