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Patient, 91 year old maleThis patient was admitted for lithium toxicity…
Patient, 91 year old maleThis patient was admitted for lithium toxicity and hyponatremia. This patient had a medical history of Atrial Fibrillation, hypercholesterolemia, Bipolar type I, recurrent urinary tract infections, depressive disorder and anxiety. This patient had also been admitted 10 years ago for a stroke.
Venlafaxine, 75mg, OD, PO
Indications: Depressive disorder, Anxiety
Dosage: The typical dose for adults is 75mg daily however doses can be given up to 375mg daily (MIMS, 2016).
Contraindications/Precautions: Bipolar disorder, renal and hepatic impairment, Blood pressure and heart rate sensitive conditions, bradycardia, hypertension, recent MI (MIMS, 2016).
Side effects: Headache, dizziness, chills, hypertension, vasodilation, weight loss, GI upset, insomnia, confusion, suicidal thoughts (MIMS, 2016).
Interactions: Haloperidol, lithium, tramadol, fentanyl, methadone, NSAIDS. (MIMS, 2016).
DRUG INTERACTION
Aspirin, 300mg, OD, PO
Indications: Prophylaxis, treatment of thromboembolic disorder (stroke prevention).
Dosage: The dosage recommended for the indication of stroke prevention is typically 30-325mg tablet, once daily (MIMS, 2016).
Contraindications/ Precautions: Severe hepatic, renal disease, peptic ulcer, gastritis, GI bleeding, bleeding disorders, asthma. (MIMS, 2016).
Side effects: Bronchospasm in asthmatics, GI hemorrhage, inflammation, bleeding, renal damage, metabolic acidosis, syncope, acute renal injury (MIMS, 2016).
Interactions: ACE inhibitors, angiotensin II receptor antagonists, NSAIDS, diuretics (MIMS, 2016).
Haloperidol, 0.5mg OD PO
Indications: Depressive disorder, manic phase
Dosage: For moderate symptom management the recommended oral dose is between 0.5-5mg once daily (MIMS, 2016).
Contraindications/precautions: CNS depression from depressants [alcohol], Parkinsons disease, Significant cardiac disorders [recent MI, heart failure], Hypokalemia, bradycardia, risk factor for stroke, infection, urinary retention (MIMS, 2016).
Side effects: GI upset, weight gain, hallucinations, tiredness, weakness, tachycardia, depression, insomnia, oedema (MIMS, 2016).
Interactions: Anticonvulsants, antihistamines, antihypertensives, anticoagulants, lithium, olanzapine, fluoxetine (MIMS, 2016).
Amiodarone, 200mg, OD, PO
Indications: Atrial fibrillation
Side effects: Corneal deposits, Abnormal thyroid function tests [TFTs], Decreased blood pressure, photosensitivity, bradycardia, pulmonary toxicity (MIMS, 2016).
Interactions: QT prolonging medications, digoxin, Calcium channel blockers, anticoagulants [Dabigatran, lignocaine, midazolam, triazolam], (MIMS, 2016).
Contraindications/Precautions: Hypersensitivity to iodine, bradycardia, thyroid dysfunction, IV erythromycin, Hepatic lung disease, chronic renal failure, asthma, hypotension (MIMS, 2016).
Dosage: Normal range is typically between 160-320mg once daily patients are to be titrated once beginning this medication, starting at 160mg and slowly increasing until the desired therapeutic effect is achieved (Medsafe, 2019).
Paracetamol, 1g QID PO/ 1g/100ml QID IV
Indications: Pain relief, anti-pyrexic
Dosage: The typical dose of paracetamol for a general adult is between 500-1000mg with a maximum dose of 4000mg per 24 hours (MIMS, 2016).
Contraindications/Precautions: Hypersensitivity to paracetamol, hepatic failure or disease, alcoholic liver disease, high alcohol intake (MIMS, 2016).
Side effects: GI upset, elevated LFT’s, pancreatitis (MIMS, 2016).
Interactions: Anti-coagulants, anti-convulsants, augmentin, metoclopramide (MIMS, 2016).
Lithium, 250mg, BD, PO (This medication was stopped on admission to hospital)
Indications: Bipolar, depressive disorder
Dosage: Dosing of lithium tablets are calculated based on a patients weight, a patient weighing approximately 70kg will take an average dose of between 400 – 1,200mg daily, typically broken into two separate doses taken Q12H. Regular blood tests should be conducted to monitor for lithium toxicity, lithium levels should be between 0.7-1mmol/L to ensure therapeutic effect (MIMS, 2016).
Contraindications/Precautions: Renal disease, hyponatremia, hypothyroidism, diabetes, hypertension, previous lithium toxicity, recurrent skin conditions (MIMS, 2016).
Side effects: Nephrogenic diabetes insipidus, renal failure, metabolic effects, polyuria, GI upset, Lithium toxicity – Delirium, confusion, tachycardia (MIMS, 2016).
Interactions: Serotonergic medications, neuroleptics [Haloperidol, carbamazepine], ACE inhibitors, Metronidazole, Co-trimoxazole. (MIMS, 2016).
DRUG INTERACTION
Olanzapine, 2.5mg, OD, PO
Indications: Bipolar, mood stabilizer
Dosage: Daily dose range is typically between 5-20mg, however doses can be lower in less severe cases or when being taken alongside other medications such as lithium. (MIMS, 2016).
Contraindications/Precautions: Risk of glaucoma, dementia related psychosis, increasing age, history of alcohol and substance abuse (MIMS, 2016).
Side effects: Weight gain, hypotension, elevated lipids and elevated blood glucose level, bradycardia (MIMS, 2016).
Interactions: Antihypertensives, carbamazepine, benzodiazepines. (MIMS, 2016).
Quetiapine, 125mg, OD, PO
Indications: Bipolar, mood stabilizer, anti-anxiety
Dosage: Dosing of quetiapine is determined by the therapeutic indication for manic or depressive episodes the recommended dose is between 100-400mg daily (MIMS, 2016).
Contraindications/precautions: Hepatic impairment, dementia, cerebrovascular disease, hypotension, congestive heart failure, stroke risk factor, diabetes. (MIMS, 2016).
Side effects: Dry mouth, withdrawal symptoms, weight gain, decreased hemoglobin, tachycardia, GI upset, irritability, pyrexia (MIMS, 2016).
Interactions: Benzodiazepines, carbamazepine, phenytoin (MIMS, 2016).
Codeine 30mg OD or 30-60mg PRN Q6H, PO Controlled drug
Indications: Pain relief
Dosage: For general adults an average dose of codeine is typically between 15-60mg every 4-6 hours with a maximum daily dose of 300mg (MIMS, 2016).
Contraindications/Precautions: Hypersensitivity to opioids, hepatic failure, obstructive airway disease, head injury, paralytic ileus risk, respiratory impairment, hypothyroidism (MIMS, 2016).
Side effects: GI upset, rash, sweating, respiratory depression, drowsiness, hallucinations, raised intracranial pressure and bradycardia (MIMS, 2016).
Interactions: antipsychotics, metoclopramide, antihypertensives, ciprofloxacin (MIMS, 2016).
Controlled drugs protocol: The administration of controlled medications are to be witnessed and signed by a medication competent person, in this case another registered nurse will need to witness and co-sign the medication chart (NZNO, 2012).
Section 28 of the Misuse of Drugs Regulations, 1977 outline the actions a person administering a controlled medication should take: including locking it away in a safe place i.e. the pyxis or a locked cupboard. All medication rights should be checked by the RN and the witness (NZNO,2018).
DRUG INTERACTION
Ceftriaxone, 2g, BD, IV
Indications: Antibiotic used for urinary tract infection
Dosage: A typical dose of ceftriaxone for the general adult is 1g-2g every 24 hours, administered via infusion over 30-60 minutes, diluted in at least 50mls of compatible fluid ie 0.9% NaCl or 5% dextrose (MIMS, 2016).
Contraindications/precautions: Hypersensitivity to penicillin’s, IV cancer treatments, severe renal impairment, pseudomonas infections, fluid restriction, receiving TPN (MIMS, 2016).
Side effects: GI upset, skin reactions, pancreatitis, secondary infection, elevated LFT’s (MIMS, 2016).
Interactions: IV cancer treatments, TPN, vancomycin (MIMS, 2016).
The medication rights were always ensured when administering medications to this patient.
Right patient: Asking patient to identify themselves, check identity against arm band and NHI on medication chart (HQSC, 2017).
Right medication: Check the name and strength of medication prior to giving, check for any allergies or adverse reactions and expiry date of medication (HQSC, 2017).
Right Dose: Check the dose of the medication in the chart against the dose of the medication you have retrieved from the pyxis (HQSC, 2017).
Right Route: Check suitability for route the medication is being given, ensure this route has been outlined in the medication chart (HQSC, 2017).
Right time: Check frequency charted, confirm when the last dose was given and time it is due (HQSC, 2017).
Right to refuse: Ensure patient has this opportunity (HQSC, 2017).
Right reason: Are the patient circumstances and history give adequate reason to give this medication (HQSC, 2017).
Right documentation: Ensure the medication is signed for by self and checkers if implicated, correct time of administration must be documented (HQSC, 2017).
Social Aspects
Prior to admission the patient was fully independent within the rest home with ADL's and regularly spent time with peers and visited family often (NIDUS, 2018).
On admission the symptoms the patient was displaying included, delirium, confusion, inability to speak, inability to mobilise and difficulty recognising important people (NIDUS, 2018).
This in turn had a negative impact on the supportive people the patient had, family were reluctant to visit the patient as it was emotionally difficult as their family member could no longer recognise them (NIDUS, 2018).
This removed family support from the patient, resulting in a further preventative to the patients healing process (NIDUS, 2018).
References:
Amiodarone. (2016). In MIMS New ethical (Iss 25, pp. 55). Auckland, New Zealand: UBMMedica
Aspirin. (2016). In MIMS New ethical (Iss 25, pp. 79). Auckland, New Zealand: UBMMedica
Ceftriaxone. (2016). In MIMS New ethical (Iss 25, pp. 299). Auckland, New Zealand: UBMMedica
Codeine. (2016). In MIMS New ethical (Iss 25, pp. 180). Auckland, New Zealand: UBMMedica
Haloperidol. (2016). In MIMS New ethical (Iss 25, pp. 121). Auckland, New Zealand: UBMMedica
Health Quality and Safety Commission. (2017). Medication Safety. Retrieved from
https://www.hqsc.govt.nz/assets/Patient-Safety-Week/PR/2017-resources/Community/WhDHB_Rights_-_Back_to_Basics.pdf
Lithium. (2016). In MIMS New ethical (Iss 25, pp. 123). Auckland, New Zealand: UBMMedica
Medsafe. (2019). Cordarone X – amiodarone hydrochloride. Retrieved 21 September, 2019 From
https://www.medsafe.govt.nz/profs/datasheet/c/CordaroneXtabinj.pdf
Network for Investigations of Delirium unifying Science. (2018). Patient family perspective on the delirium experience. Retrieved 18 September, 2019 From
https://deliriumnetwork.org/patient-family-perspective/
New Zealand Nurses Organization. (2018). Guidelines for nurses on the administration of medicines. Retrieved from
https://www.nzno.org.nz/Portals/0/publications/Guideline%20-%20Guidelines%20for%20Nurses%20on%20the%20Administration%20of%20Medicines%20(002).pdf?ver=2019-05-22-101207-447&fbclid=IwAR0pmcFMkLWA6ZbBP0daMjHX1kDO7KTfOYsBLLqxrZqhXGCSCwXlua2BG-U
Olanzapine. (2016). In MIMS New ethical (Iss 25, pp. 124). Auckland, New Zealand: UBMMedica
Paracetamol. (2016). In MIMS New ethical (Iss 25, pp. 191). Auckland, New Zealand: UBMMedica
Quetiapine. (2016). In MIMS New ethical (Iss 25, pp. 127). Auckland, New Zealand: UBMMedica
Venlafaxine. (2016). In MIMS New ethical (Iss 25, pp. 147). Auckland, New Zealand: UBMMedica
The medicines act, 1981 and associated regulations, outline the regulations nurses are to abide by when administering medications to patients (NZNO, 2018).
Prescription medications section 3.1: Medications can only be supplied/administered once an authorised person has prescribed the medication/s to that patient (NZNO, 2018).
The Misuse of Drugs Act 1975, section 3.3 - This act classifies medications into various classes depending on the risk they pose to public if misused. These include the administration of controlled medications. Nurses must ensure they understand and abide by this protocol and legislation (NZNO, 2018).
Dispensing medications, section 4.2.4: Nurses must avoid dispensing medications as this should only be done by authorised personal e.g. Pharmacists (NZNO, 2018).
Administering medications, section 4.3.2: Nurses must use their own clinical knowledge and professional judgement to determine safe administration of prescribed medications
Preparing and checking medications, section 4.3.3: Nurses must ensure any controlled or Intravenous medications are checked by 2 authorised administrators e.g. registered nurses, the second checker must complete their own calculations and professional judgements (NZNO, 2018).
Documentation, section, 4.3.4: All administrations of medications must be documented within the medications chart/records with the correct date and time of administration. All medication charts should contain the patients name, date of birth and NHI number (NZNO, 2018).
The multidisciplinary team: responsibilities and accountabilities: The registered nurse, section 5.4: Nurses must ensure they understand the legal and ethical issues outlined in the guidelines, only delegates administrations of medications to the authorised personal, reports concerns/risks about medication administration, maintains responsibility and accountability throughout the administration process. The student nurse, section 5.7: Understands scope of practice and the role of the registered nurse, Familiar with educational institutes own regulations, Only administered medications under direct supervision of the registered nurse (NZNO, 2018).