Polypharmacy (REASON FOR ADMISSION & MEDICAL HISTORY (This patient…
REASON FOR ADMISSION & MEDICAL HISTORY
This patient Mike (pseudonym) presented to Hawera Emergency Department (ED) with blurred vision, nausea and dizziness. He was tachycardiac at 200-250 BPM with an elevated BP.
This gentleman was 32 years old, he had a cardiac history with a type 2 NSTEMI 5 years previously after having a chest infection and he had had an infection for a week prior to admission.
He was a smoker, overweight and identified as a Eurpoean New Zealander.
- class III antiarrhythmic.
Mechanism of action:
Also blocks potassium channels
and slow the outward movement of potassium.
Potassium is an essential mineral that has many roles in your body. It helps
regulate muscle contractions, maintain healthy nerve function and regulate fluid balance.
plays crucial role in electric signal functioning of the heart's middle thick muscle layer, known as the myocardium.
Acts directly on
heart muscle cells
to prolong repolarisation and the refractory period, increasing the
threshold for ventricular fibrillation
Also acts on peripheral smooth muscle to
IV - Immediate onset - Peak 20 minutes.
Metabolised in the liver
Excreted in the urine
Contraindications & Cautions
When amiodarone is used to treat life-threatening arrhythmia, there are no contraindications.
Caution should be used in the presence of shock, hypotension, or respiratory depression.
Common adverse effects
Nausea, vomiting, GI distress, weakness, dizziness, hypotenstion, HF, liver toxicity.
Can cause serious toxic effects if combined with
digoxin or quindine
sold under the brand name lanoxin is used for the treatment of **chronic heart failure and/or atrial fibrillation and flutter.
acts as a class I anti-arrhythmic agent
life threatening ventricular arrhythmias
- Beta-adrenergic blocker - specifically beta 1.
treatment of stable angina, also used for treatment of hypertensions, prevention of reinfarction in people with MI, and treatment of stable, symptomatic HF. In Mike's situation, the primary indication of metoprolol use was to
slow down his HR
Mechanism of action:
inhibit beta receptors, alpha receptors, or both
Beta 1 receptors:
located in the heart
to mimic the actions of the sympathetic nervous system…fight or flight (increased HR and BP)
Beta 2 receptors:
located in the heart but primarily located in vascular smooth muscle
…also mimics that sympathetic nervous system response and causes vasoconstriction of the smooth muscle of the vessel wall
vascular smooth muscle
via muscle contraction
Blocking these receptors means the sympathetic nervous system is inhibited therefore the fight or flight response of increased HR & BP as well as blocking vasoconstriction of the vessels = blocked hypertension.
in the GI tract after oral administration and undergo hepatic metabolism, it has an
of 15minutes, reaching
in 60-90 minutes with a varying
of 15-19 hours.
is immediate with a
being 60-90 minutes and a
of 15-19 hours.
Contraindications and cautions
Contraindicated in individuals with bradycardia, heart block, and cardiogenic shock as blocking the sympathetic response could exacerbate these diseases.
Caution should be used in individuals with diabetes, peropheral vascular disease, astham, COPD or thyrotoxicosis due to blocking the sympathetic response blocks normal reflexes necessary for maintaining homeostasis in people with these conditions.
There are many adverse effects associated with the blockage of SNS.
Beta blockers are primarily used to treat hypertension and angina
. However, they can also be preferred when
treating tachycardia as bradycardia is a predominant adverse reaction.
gastric pain, nausea & vomiting.
HF, reduced CO, arrhythmias, bradycardia.
bronchospasm, dyspnoea, cough.
Clinically important drug-drug interactions
Hypertension occurs when
(an antihypertensive medication) is given with beta-blockers - it is best to
avoid this combination.
Decreased antihypertensive effect occurs when beta-blockers are given with non-steroidal anti-inflammatory drugs - if this combination is used, the person should be
and dose adjustment made as required.
Potential for a change in BGL if these drugs are given with
and the individual will not present the usual signs & symptoms of hypoglycaemia or hyperglycaemia therefore if this combination is used
monitor BGL closely
: The major therapeutic use of adenosine is as an antiarrhythmic drug for the
rapid treatment of supraventricular tachycardias.
Mechanism of action:
Adenosine is another
antiarrhythnic agent used to convert Supraventricular Tachycardia (SVT)
to sinus rhythm.
Often the drug of choice for terminating SVT, including those associated with the use of alternative conduction pathways around the AV node.
Suppresses AV node conduction.
decreases automaticity in the AV node.
: resets the SA node by stopping the heart for around 7 seconds.
dilates coronary arteries via smooth muscle relaxation.
In patients with high degree AV block or sinus node dysfunction due to its MOA.
Converts out of SVT into NSR
May develop a 2nd or 3rd degree heart block
Asystole can occur for no more than 1 minute
Feelings of doom
Flushing due to vasodilation
Short half life of 5-20 seconds therefore it needs to be given
via rapid IV bolus using 3-way stopcock
Give proximal to central circulation and elevate site of administration to give the medication the best chance of reaching central circulation & heart.
: Phosphodiesterase inhibitor (Inotrope)
Mechanism of action:
Block the enzyme
which is an important enzyme involved with cardiac muscle contraction.
This blockage leads to the increase in myocardial cell cyclic adenosine monophosphate (cAMP), which then leads to increases in calcium levels in the cell,
thus increasing myocardial contractility.
Increased cellular calcium
causes a stronger contraction and prolongs the effects of the
sympathetic stimulation, which can lead to vasodilation, increased oxygen consumption and arrhythmias.
short-term treatment of HF that has not responded to digoxin or diuretics or vasodilators alone.
Available for IV use only. Widely
in liver, and
primarily in the urine.
produces a prompt
increase in CO and decreases pulmonary capillary pressure and vascular resistance
without causing a significant increase in HR or myocardial oxygen consumption.
Contradictions & Cautions:
Contraindicated in the following conditions: severe aortic or pulmonic vascular disease which could be exacerbated by increased contraction. Acute MI, which could be exacerbated by increased O2 consumption & increased force of contraction.
Most common: ventricular arrhythmias, hypotension, chest pain and burning at the IV site following injection.
: opioid agonist
General over view of opioids:
(The four types of opioid receptors).
1 "mu" (u)
are the primarily pain-blocking receptors. Besides analgesia,
mu-receptors also account for a feeling of euphoria, respiratory depression, decreased GI activity, development of dependence, and pupil constriction.
2 Kappa (K)
receptors are assocaited with some analegia and pupillary constriction, dysphoria, and sedation.
3 Beta (B)
receptors react with enkephalins in the periphery to modulate pain transmission.
4 sigma receptors
primarily cause pupillary dilation, are also thought to be responsible for hallucinations, dysphoria, and psychoses occurring with opioid use.
For analgesia before, during, and after surgery or the management of acute or chronic breakthrough pain.
IV administration is the most reliable way to achieve therapeutic levels of opioids. Onset of action is almost immediate when given IV, however maximal analgesic & respiratory depressant effect may not be noted for several minutes.
Duration of action
is 30 - 60 minutes after single IV dose of up to 100mg.
While IM and SC administration can be offered, the onset and therapeutic level is not as effective.
Fentanyl is primarily
in the liver, with approx 75% of an IV dose
in the urine and the remaining in the faeces.
should be individualised according to factors such as
age, bodyweight, physical status, use of other medications, and pathological condition.
Contraindications & Cautions
Known hypersensitivity or intolerance to fentanyl or other opioid analgesics.
Children 2 years of age or younger as safe limits have not been established.
Caution in hypotensive patients as well as bradycardia as fentanyl may produce bradycardia and possibly asystole.
Drug dependance to avoid drug abuse
Caution should be used in impaired respiration and respiratory depression as this is a dangerous side effect of fentanyl, patients should be closely monitored for this possibility.
Respiratory depression with apnoea, if prolonged cardiac arrest and shock may result from opioid-induced respiratory centre depression.
Orthostatic hypotension, nausea, vomiting, constipation, impaired mental processes, hallucinations, pupil constriction, anxiety, sweating and dependance.
Clinically important drug-drug interactions:
When opioid agonists are given with barbiturate general anaesthetics, or with MAO inhibitors, or some phenothiazines the likelihood of
respiratory depression, hypotension, sedation, and coma is increased
. If these drug interactions cannot be avoided, individuals should be monitored even more closely with appropriate measures taken.
Tetracyclines work by
inhibiting protein synthesis in a wide range of bacteria, preventing cell replication.
caused by susceptible strands of bacteria.
, but not completely in the GI Tract - Factors that
affect the absorption are:
food, iron, calcium & other drugs in the stomach.
Concentrated in the
in the urine.
ranges from 12 - 25 hours.
Contraindications & Cautions
Fungal, myobacterial, or viral ocular infection as this medication kills
the undesired bacteria, and also the normal flora
which increases the risk of exacerbation
Tetracyclines should NOT be used in children younger than 8 years of age due to the
potentially damage of developing bones and teeth
People with hepatic or renal failure due to these being concentrated in the bile and excreted in urine.
Irritation of the GI tract - nausea, vomiting, diarrhoea, abdominal pain, dysphagia, and glossitis (inflammation of the tongue).
Skeletal effects involves - damage to the teeth and bones, due to tetracyclines affinity for teeth and bones, they accumulate there weakening the structure and causing
staining and pitting of teeth and bones.
Superinfections, such as yeast infections, as they also destroy normal flora.
penicillin and tetracyclines
are taken together, the effectiveness of
decreases and the penicillin dose should be increased when used together.
The effectiveness of
decreases when taking tetracyclilnes and women should be advised to use an additional form of birth control.
Additional patient education
Because oral tetracyclines are not effectively absorbed if taken with food or diary products, they should be administered on an
empty stomach 1 hour before or 2-3 hours after any meal or any other medication.
DIAGNOSIS AND TREATMENT
When things went from bad to worse for Mike...
When my nurse and I came on in the morning shift, Mike had experienced majority of is SVT overnight, the doctors came in and were quite happy with Mike's turnaround, although he wasn't yet out of the woods, his condition had definitely improved.
Mike mentioned to the Dr's that his feet had become numb and he couldn't move them, they were cool to touch and white pallor but they didn't think this was concerning yet.
It wasn't until about 2 hours after the Dr's had been and we got the doppler to check his peripheral pulses which is when we discovered he had
no popliteal, dorasilis pedial or posterior tibal pulse.
An urgent CT revealed that Mike had
bilateral blood clots from hips down
This meant Mike had to be urgently taken to theatre to attempts to remove these, he came back ventilated and eventually passed away 24 hours later.
It is likely that his clots had developed as a result of his heart failure due to his heart not supplying his demand due to his weakened heart which
slowed down his blood flow causing clots to form.
PRIMARY DIAGONISIS: SVT
Mike was diagnosed with Supraventricular Tachycardia (SVT) also known as paroxysmal supraventricular tachycardia, defined as
an abnormally fast heartbeat
occurring above the ventricles in the atira or AV node.
The gold standard of treating SVT is adenosine which 'resets' the SA node by causing asystole, if this doesn't work then a synchronised cardioversion will be the next option.
Causes: Heart failure, pericarditis, pneumonia, heavy tobacco, alcohol or cannibas use.
The medications used in attempt to
Mikes heart is discussed in this concept map, However, these were unsuccessful and Mike ended up requiring a
which uses a low-voltage shock that is synced with the cardiac cycle, so that is lands on the R wave in the QRS complex. If it were to land on any other waves, such as the T wave this could lead to additional arrhythmias such as V-Fib.
SECONDARY DIAGNOSIS: Cardiogenic shock
Essentially, due to
Mike's SVT his cardiovascular system failed to perfuse his tissues adequately
, resulting in widespread impairment of cellular metabolism. This is further explained in an additional concept map along with cardiogenic shock treatment.
When cells aren't receiving an adequate amount of oxygen, the cell shifts from
decreases ATP stores and affects the pH of the cell.
ACTS & LAWS RELEVANT TO MEDICATION ADMINISTRATION
Need to relate to patient
The nursing discipline has had close association with the
storage and administration of medicines
. This includes knowledge of
medicines and appropriate dosage, their administration, side effects, suitability for the patient, adherence, nurses' clinical judgment and legal and ethical responsibilities.
In New Zealand, there are statutory laws regarding the control of medicines.
The medicines act 1981
State there are
classifications of medicines:
Prescription medicine: can only be obtained by a person authorised to prescribe.
Authorised prescribers in NZ include:
when there is poor prescribing practice, for instance ineligible, the NZNO recommends the nurse documents the poor prescribing and reports this to the manager.
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.
Restricted medicines AND
Medication which can only be sold or supplied by a pharmacist from pharmacy or hospital, or in accordance with a standing order.
General sale medicines
Are not scheduled or classified and can be supplied from any retail outlet.
The misuse of drugs act 1975
The medication process requires therapeutic, diagnostic, or preventive purposes, which involves prescribing, dispensing, administering, receiving, and recording medication storage and handling.
includes assessment, planning, and implementation.
TDHB IV OPIOD PROTOCOL
The IV opioid protocol is a great flowchart identifying the assessments, planning, and implementation of administering opioids.
For instance, IF the patient is over the age of 13 with a pain greater than 3/10 and not using regular opioids with IV protocol prescribed in the drug chart, with a respiratory rate >8, sedation score 2 or less, BP and HR within normal range, IV opioid can be injected according to age and weight, the nurse then
waits 3 minutes
to access whether the loop may need to be repeated.
As a nurse, it is vital to be familiar with local workplace policies as they may differ between institutions.
Responsibilities of the Registered Nurse
Gaining informed consent prior to administration, this includes ensuring the patient is aware of what medication they are being given, what it is for, and any possible adverse effects of taking the medication.
Health and Disabilities Services Consumer rights
states each health consumer has the
right to make an informed choice and give informed consent
supported with elements such as:
1) "Services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent, except where any enactment, or the common law, or any other provision of this Code provides otherwise."
2) "Every consumer must be presumed competent to make an informed choice and give informed consent, unless there are reasonable grounds for believing that the consumer is not competent."
3) "Where a consumer has diminished competence, that consumer retains the right to make informed choices and give informed consent, to the extent appropriate to his or her level of competence."
Every consumer has the right to refuse services and to withdraw consent to services.
Is aware of, and complies with, agency policies regarding the preparation and checking of medicines.
Reporting any adverse events, including errors. The RN must take every action to prevent any potential harm to the patient and report any error as soon as possible. A life-threatening reaction that can happen following administration of medication is
- an acute, life-threatening hypersensitivity to an allergen. This reaction quickly causes
, release of vasoactive mediators and an increase in capillary permeability. This
increase in capillary permeability
fluid to leak from the vascular space into the interstitial space
ANY NURSE ADMINISTERING MEDICATION SHOULD BE COMPETENT IN RECOGNISING AND TREATING ANAPHYLATIC SHOCK
The patient will have a
onset of symptoms, including dizziness, chest pain, incontinence, decreased HR, decreased B/P, swelling of the lips or tongue, wheezing and stridor.
A patient can have a severe allergic reaction, possibly leading to anaphylactic shock following contact, inhalation, ingestion, or injection with an antigen.
Management of anaphylactic shock:
1) recognition of signs and symptoms of anaphylactic reaction
2) maintenance of a patent airway
3) prevention of spread of the allergen by using a tourniquet and stopping treatment if applicable.
4) Administration of drugs
is the drug of choice
For the treatment of acute allergic reactions, life-threatening angioneurotic oedema, and anaphylactic shock resulting from reactions to drugs, animal serums, insect stings and other allergens.
use only. In emergency situations, adrenaline may be injected
very slowly intravenously
but only as a dilute solution of
as opposed to 1: 1,000.
0.3 - 0.5 mL administered slowly, the dose may be repeated every
and if the reaction is severe the dose may be
to 1mL .
can counteract the effects of adrenaline.
The patients BP and HR needs to be stable prior to administration due to adrenalines powerful cardiac stimulant with
with one of its main therapeutic actions being
increasing systolic B/P, decreasing diastolic B/P, and increasing HR
Onset of action: rapid and the half-life is approx 5-10 minutes.
Adrenaline is rapidly distributed to the
heart, spleen, several glandular tissues, and adrenergic nerves.
Adrenaline is a direct-acting sympathomimetic agent exerting effect of alpha and beta adrenoreceptors.
Mike's chest infection giving rise to his cardiac risk
Approximately 37% of heart disease patients experience some type of infection within the previous 3 months. Among stroke patients, this is almost at 30%. Both with the period most at risk being the
first two weeks following the infection.
When the body acquires an infection, the white cell production is increased to help eliminate the infection. This process also
increased the platelets in the blood
thus, encouraging the
formation of clots.
New research has found a
link between infections such as chest infections, pneumonia, or urinary tract infections to an increased risk of having a coronary event
such as a heart attack or stroke within the following 3 months.
Education may not have been given or understood in regards to aspects such as completing the course of antibiotics and the importance of taking the doxycycline on an empty stomach to optimise absorption
If education or understanding lacked, this then would have decreased Mike's compliance. If his chest infection could have even been prevented, or thereby, treated correctly, perhaps his cardiac event would not have been so severe, or not occur at all.