ru on common or drugs and anesthesia

8/3/2019 Ru on Common or Drugs and Anesthesia

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RESOURCE UNIT ON COMMON O.R. DRUGS AND ANESTHES

Submitted to:

Asst. Prof. ViennaNicolasa C. Noble

Clinical Instructor

Submitted by:

Darrell Kay B. Macadini

Kent Russel M. Paragas

Jeanne Charlene T. Vilan

Date:

January 11, 2012

COLLEGE OF NURSING

Silliman University

Dumaguete City


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Vision

A leading Christian institution committed to total human development for the well-being of society andenvironment.

Mission

y Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an envwhere Christian fellowship and relationship can be nurtured and promoted.

y Provide opportunities for growth and excellence in every dimension of the University life in order to strengcharacter, competence and faith.

y Instill in all members of the University community an enlightened social consciousness and a deep sense ofand compassion.

y Promote unity among peoples and contribute to national development.

COLLEGE OF NURSING

Silliman University

Dumaguete City


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O.R. ROTATION

RESOURCE UNIT ON COMMON O.R. DRUGS AND ANESTHESIAPlacement:Second Semester, Level IV RLE WARD CLASS

Time Allotment: 1.5 hours ward class

Topic Description:This topic deals with the pharmacologic principle, concepts, and mechanisms involved in common drugs administered to clients in

room (OR). Given emphasis for each drug and anesthesia is on its classification, mechanism of action, indication, side effects, adverse reactions

responsibilities involved.

Central Objective:At the end of one and a half hour of ward class discussion, the learners shall gain knowledge, enhance acquired skills and manif

attitudes in the application of the principles, concepts, techniques, and nursing management in the administration of common drugs and anesthesi

the operating room.

SPECIFIC

OBJECTIVES

CONTENTS T/A T/L ACTIVITIES EVAL

At the end of 1.5

hours the students

shall:

a. Define the

I. PrayerII. IntroductionIII. Definition of terms

2mins.

3mins.

2 mins.

Socialized

discussion

Group discussion

Oral evalu

Oral evalu

COLLEGE OF NURSING

Silliman UniversityDumaguete City


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4 terms

correctly.

b. Explainbriefly the 4

steps of

pharmacoki

netics.

1. PharmacokineticsThe deals with the process of transforming a drug from its

pharmaceutical dosage form to a biologically availablesubstance that can pass throughout the various biological cell

membranes to reach its sites of action.

2. PharmacodynamicsThis is the study of the biochemical and physiologic effects of

drugs and their mechanism of action.

3. Anesthesia a state of narcosis, analgesia, relaxation, and lossof reflexes

4. Analgesia means absence of pain sensationsIV. Overview of Pharmacology

Understanding the basics of pharmacology is an essential nursing

responsibility. Pharmacology is the science that deals with the physical

and chemical properties, and biochemical and physiologic effects, of

drugs. It includes the areas of pharmacokinetics, pharmacodynamics,

pharmacotherapeutics, pharmacognosy, and toxicodynamics.

A. Pharmacokinetics1. Absorption

Before the drug can begin working, it must be transformed

from its pharmaceutical dosage form to a biologically available

substance that can pass throughout the various biological cell

membranes to reach its sites of action. This process is known asabsorption.A drugs absorption rate depends on its routes of

administration, its circulation through tissues into which its

administered, and its solubility that is, whether its more

water-soluble (hydrophilic) or fat-soluble (lipophilic).

2. Distribution

5 mins. Lecture discussion

with power point

presentation

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Distribution is the process by which a drug is transported by the

circulating fluid to various sites, including its sites of action. To

ensure maximum therapeutic effectiveness, the drug mustpermeate all membranes that separate it from its intended site

of action. Drug distribution is influenced by blood flow, tissue

availability, and protein binding.

3. MetabolismDrug metabolism is the enzymatic conversion of a drugs

structure into substrate molecules or polar compounds that areeither less active or inactive and are steadily excreted. Drugs

can also be synthesized to larger molecules. Metabolism may

also convert a drug to a more toxic compound. Because the

primary site of drug metabolism is the liver, children, elderly,

and patients with impaired hepatic function are at risk for

altered therapeutic effects.

4. ExcretionThe body eliminates drugs by both metabolism and excretion.

Drug metabolites and, in some cases, the active drug itself

are eventually excreted from the body, usually through bile,

feces, and urine. The primary organ for drug elimination is the

kidneys. Impaired renal function may alter drug elimination,

thereby altering the drugs therapeutic effect. Other excretion

routes include evaporation through the skin, exhalation fromthe lungs, and secretion into saliva and breast milk.

B. PharmacodynamicsPharmacodynamics is the study of the biochemical and physiologic

effects of drugs and their mechanism of action. A drugs actions

may be structurally specific or nonspecific. Structurally specific


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drugs combine with cell receptors, such as proteins or

glycoproteins, to enhance or inhibit cellular enzyme actions. Drug

receptors are the cellular components affected at the site ofaction. Many drugs form chemical bonds with drug receptors, but a

drug can bond with a receptor only if it has a similar shape much

the same way that a key fits into a lock. When a drug combines

with a receptor, channels are either opened or closed and cellular

biochemical messengers, such as cyclic adenosine monophosphate

or calcium ions, are activated. Once activated, cellular functions

can be turned either on or off by these messengers. Strucutrallynonspecific drugs, such as biological response modifiers dont

combine with cell receptors; rather, they produce changes within

the cell membrane or interior.

C. PharmacotherapeuticsPharmacotherapeutics is the study of how drugs are used to

prevent or treat disease. Understanding why a drug is prescribed

for a certain disease can assist you in prioritizing drug

administration with other patient care activities. Knowing a drugs

desired and unwanted effects may help uncover problems not

readily apparent from the admitting diagnosis. This information

may also help prevent such problems as adverse reactions and

drug interactions.

1. Desired effect is the intended or expected clinical response to

the drug.

2. Adverse reaction is any noxious and unintended response to a

drug that occurs at therapeutic doses used for prophylaxis,

diagnosis, or therapy. Adverse reactions associated with excessive

amounts of a drug are considered drug overdoses.


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3. Idiosyncratic response is genetically determined abnormal or

excessive response to a drug that occurs in a particular patient. The

unusual response may indicate that the drug has saturated oroverwhelmed mechanisms that normally control absorption,

distribution, metabolism, or excretion, thus altering the expected

response.

4. Allergic reaction is an adverse response that results from

previous exposure to the same drug or to one thats chemically

similar to it. The patients immune system reacts to the drug as if itwere a foreign invader and may produce a mild hypersensitivity

reaction, characterized by localized dermatitis, urticaria,

angioedema, or photosensitivity. Allergic reactions should be

reported to the prescriber immediately and drug should be

discontinued.

5. Anaphylactic reactions involves an immediate hypersensitivity

response characterized by urticaria, pruritus, and angioedema. Left

untreated, an anaphylactic reaction can lead to systemic

involvement, resulting in shock.

6. Drug interaction occurs when one drug alters the

pharmacokinetics of another drug.

D. Special ConsiderationsAlthough every drug has a usual dosage range, certain factors

such as a patients age, weight, culture and ethnicity, gender,

pregnancy status, and renal and hepatic function may contribute

to the need of dosage adjustments.

1. Culture and Ethnicity


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Certain drugs are more effective or more likely to produce

adverse effects in particular ethnic groups or races. For

example, black with hypertension respond better to thiazidediuretics that do patients of other races; on the other hand,

blacks also have an increased risk of developing angioedema

with angiotensin-converting enzyme (ACE) inhibitors. A

patients religious or cultural background also may call for

special consideration. For example, a drug made from porcine

products may be unacceptable to a Jewish or Muslim patient.

2. Elderly PatientsBecause aging produce certain changes in body composition

and organ function, elderly patients present unique therapeutic

and dosing problems that require special attention. For

example, the weight of the liver, the number of functioning

hepatic cells, and hepatic blood flow all decrease as a person

ages resulting in slower drug metabolism. Renal function may

also decrease with aging. These processes can lead to the

accumulation of active drug sand metabolites as well as

increased sensitivity to the effects of some drugs in the elderly

patients. Because theyre also more likely to have multiple

chronic illnesses many elderly patients take multiple

prescription drugs each day, thus increasing the risk of drug

interactions.

3. ChildrenBecause their bodily functions arent fully developed, children

particularly those under age 12 may metabolize drugs

differently that adults. In infants, immature renal and hepatic

function delay metabolism and excretion of drugs. As a result,

pediatric drug dosages are very different from adult dosages.


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c.

Give onescenario

illustrating

the

incorporati

on of the

rights of

drug

administrati

on

comprehen

sively.

4. PregnancyThe many physiologic changes that take place in the bodyduring pregnancy may affect a drugs pharmacokinetics and

alter its effectiveness. Additionally, exposure to drugs may pose

risks for the developing fetus. Before administering a drug to a

pregnant patient, be sure to check its assigned FDA pregnancy

risk category and intervene appropriately.

V.

Principles of DrugA

dministrationA. Rights of Drug Administration

1. Right Drug2. Right Time

Various factors can affect the time that a drug is administered,

such as the timing of meals and other drugs, scheduled

diagnostic tests, standardized times used by the institution, and

factors that may alter the consistency of blood levels and drug

absorption.

3. Right DoseWhether youre dispensing an unfamiliar drug or in doubt

about a dosage, check the prescribed dose against the range

specified in a reliable reference. Be sure to consider any

reasons for a dosage adjustment that may apply to you

particular patient. Also, make sure to youre familiar with the

standard abbreviations your institutions uses for writingprescriptions.

4. Right PatientAlways compare the name of the patient on the medication

record with the name on the patients identification bracelet.

5. Right RouteEach drug prescription should specify the administration route.

3 mins. Lecture discussionwith power point

presentation

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d. Name 2common

benzodiaze

pines used

in the OR

correctly.

If the administration route is missing from the prescription,

consult the prescriber before giving the drug. Never substitute

one route for another unless you obtain a prescription for thechange.

6. Right Preparation and AdministrationFor drugs that need to be mixed, poured and measured, be

sure to maintain aseptic technique. Follow any specific

directions included by the manufacturer regarding diluents

type and amount and the use of filters, if needed. Clearly label

any drug that youve reconstituted with the patients name, thestrength or dose, and the date and time that you prepared the

drug, the amount and type of diluent that you used, expiration

date, and your initials.

7. Right DocumentationVI. Common OR drugs and Anesthesia

A. BenzodiazepineBenzodiazepines are anxiolytics, antiepileptics, muscle relaxants,

and sedative-hypnotics. Their exact mechanisms of action are not

understood, but it is known that benzodiazepines potentiate the

effects of GABA, an inhibitory neurotransmitter.

1. Midazolam hydrochloride Classification: Sedative-hypnotics Mechanism of action

Exact mechanisms of action not understood; It acts

mainly at the limbic system and reticular formation;

potentiates the effects of GABA, an inhibitory

neurotransmitter thereby producing a sedating effect.

As a result, midazolam produces a calming effect,

relaxes skeletal muscles, and at high doses induces

60 mins. Lecture discussion

with power point

presentation

Cabbage

players w

of paper w

playing,

music sto

get a ques

cabbage a


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sleep. Anxiolytic and amnesia effect occur at doses

below those needed to cause sedation, ataxia.

Adverse/ side effectsCNS: Agitation, delirium, or dreaming during emergence

from anesthesia; anxiety; ataxia; chills; combativeness;

confusion; dizziness; drowsiness; euphoria; excessive

sedation; headache; insomnia; lethargy; nervousness;

nightmares; paresthesia; prolonged emergence from

anesthesia; sleep disturbance; slurred speech;

weakeness; yawningCV: Cardiac arrest, hypotension, nodal rhythm, PCVs,

tachycardia, vasovagal episodes, palpitations, edema

EENT: Blurred vision, diplopia, or other vision changes;

increased salivation; laryngospasm; miosis; nystagmus;

toothache

GI: Hiccups, nausea, retching, vomiting

RESP: Airway obstruction, bradypnea, bronchospasm,

coughing, decreased tidal volume, dyspnea,

hyperventilation, respiratory arrest, shallow breathing,

tachypnea, wheezing

SKIN: Pruritus, rash, urticaria

GU: Incontinence, urine retention, changes in libido,

menstrual irregularities

Hematologic: Decreased Hct, blood dyscrasias

Other: Injection site burning, edema, induration, pain,redness, and tenderness

Nursing responsibilitiesAssessment

History: Hypersensitivity to benzodiazepines; psychoses,

acute narrow-angle glaucoma, shock, coma, acute

alcoholic intoxication with depression of vital signs;


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elderly or debilitated; impaired liver or renal function;

pregnancy and lactation

Physical: Weight; skin color; lesions; orientation, affect,reflexes, sensory nerve function, ophthalmologic

examination; P, BP; R, adventitious sounds; bowel

sounds; normal output, liver evaluation; normal output;

LFTs, renal function tests, CBC

Interventions:

yBefore giving midazolam, determine whetherpatient consumes alcohol or takes

antihypertensives, antibiotics, or protease inhibitors

because these substances can produce an intense

and prolonged sedative effect when taken with

midazolam.

y Warning Do not administer intraarterially, whichmay produce anteriospasm or gangrene. IV

midazolam is give only in hospital or ambulatory

care settings that allow continuous monitoring of

respiratory and cardiac function. Keep resuscitative

drugs and equipment at hand.

y Do not use small veins (dorsum of hand or wrist) forIV injection.

y Administer IM injections in deep into muscle.y Monitor IV injection site for extravasation.y Monitor LOC before, during, and for at least 2-6

hours after administration of midazolam.

y Carefully monitor pulse, BP, and respirationscarefully during administration.

y Warning Keep resuscitative facilities readilyavailable; have flumazenil available as antidote if


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overdose should occur.

y Keep patient in bed for 3 hours; do not permitambulatory patients to operate vehicle following aninjection.

y Arrange to monitor liver and renal function and CBCat intervals during long-term therapy.

y Establish safety precautions if CNS changes occur(Use side rails, accompany ambulating patient).

y Provide comfort measures and reassurance forpatients receiving diazepam for tetanus.

y Arrange to taper dosage gradually after long-termtherapy.

y Provide patient with written information regardingrecovery and follow-up care. Midazolam is a potent

amnesiac and memory may be altered.

Patient teaching:

y This drug will help you relax and will make yougo to sleep; this drug is a potent amnesia and

you will not remember what has happened to

you.

y Avoid using alcohol or sleep-inducing or OTCdrugs before receiving this drug. If you feel that

you need one of these preparations, consult your

health care provider.

y You may experience these side effects:drowsiness, dizziness (these may become less

pronounced after few days; avoid driving a car or

engaging in other dangerous activities if these

occur); GI upset; dreams; difficulty

concentrating, fatigue, nervousness, crying.


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y Report severe dizziness, weakness, drowsinessthat persists, rash, or skin lesions; visual or

hearing disturbances, difficulty voiding.

2. Diazepam Classification:Anticonvulsant, anxiolytic, sedative-

hypnotic, skeletal muscle relaxant

Mechanism of action:Exact mechanism of action not understood; act mainly

at the limbic system and reticular formation; may act inspinal cord and at supraspinal sites to produce skeletal

muscle relaxation; potentiates the effects of GABA, an

inhibitory neurotransmitter; anxiolytic effects occur at

doses well below those necessary to cause sedation,

ataxia; has little effect on cortical function. Diazepam

suppresses spread of seizure-producing foci in cortex,

thalamus, and limbic structures.

Adverse/ side effectsy CNS: Transient, mild drowsiness initially; sedation,

depression, lethargy, apathy, fatigue, light-headedness,

disorientation, restlessness, confusion, crying delirium,

headache, slurred speech, dysarthria, stupor, rigidity,

tremor, dystonia, vertigo, euphoria, nervousness,

difficulty in concentration, vivid dreams, psychomotor

retardation, extrapyramidal symptoms; mild paradoxicalexcitatory reactions during first 2 week of treatment,

visual and auditory disturbances, diplopia, nystagmus,

depressed hearing, nasal congestion

y CV: Bradycardia, tachycardia, CV collapse, hypertensionand hypotension, palpitations, edema

y EENT: Blurred vision, diplopia, dry mouth, increased


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salivation

y GI: Anorexia, constipation, diarrhea, elevated liverenzymes, jaundice, nausea, vomiting

y GU: Libido changes, urinary incontinence, urineretention

y HEME: Neutropeniay MS: Dysarthria, muscle weaknessy RESP: Respiratory depressiony SKIN: Dermatitis, urticarial, pruritus, skin rashy Other: Phlebitis and thrombosis at the IV injection sites,hiccups, fever, diaphoresis, paresthesias, muscular

disturbances, gynecomastia; pain, burning, and redness

after MI injection.


History: Hypersensitivity to benzodiazepines; psychoses,

acute narrow-angle glaucoma, shock, coma, acute

alcoholic intoxication; elderly or debilitated patients;

impaired liver or renal function; pregnancy, lactation

Physical: Weight; skin color, lesions, orientation, affect,

reflexes, sensory nerve function, ophthalmologic

examination; P, BP, R, adventitious sounds; bowel

sounds, normal output, liver evaluation; normal output,liver evaluation; normal output; LFTs, renal function

tests, CBC.

Intervention:

y Use diazepam with extreme caution in patientswith history of alcohol or drug abuse because it


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can cause physical and psychological

dependence, and in patients with hepatic

disorders such as hepatic fibrosis and hepatitisbecause of potentially significant increase in

drugs half-life.

y Use diazepam cautiously in patients with hepaticor renal impairment. Severe hepatitis

impairment is a contraindication to use.

y Expect to give a lower diazepam dose to patientwith chronic respiratory insufficiency because ofrisk of respiratory depression.

y Mix concentration oral solution (Intensol) withliquid or semisolid food. Use supplied calibrated

dropper to measures dose.

y Protect diazepam injection from light. Dont usesolution thats more that slightly yellow or that

contains precipitate.

y Give I.M. injection into deltoid muscle for rapid,complete absorption. Using other sites may

cause slow, erratic absorption.

y Before administering emulsion form, ask ifpatient is allergic to soybeans because this form

contains soybean oil.

y For an infant or a child, administer I.V. injectionslowly over 3 minutes in a dose not to exceed0.25% mg/kg.

y Give emulsion form within 6 hours of openingampule because it contains no preservatives and

allow rapid microbial growth. Use polyethylene-

lined or glass infusion sets and polyethylene or

polypropylene plastic syringes for


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administration. Dont use a filter with a pore size

less than 5 microns because a smaller size may

break down the emulsion.y Monitor patient for adverse reactions, especially

if she has hypoalbuminemia, which increases the

risk of sedation.

y Warning Watch for signs of physical andpsychological dependence (strong desire or need

to continue taking diazepam, need to increase

dose to maintain drug effects, and posttherapywithdrawal symptoms, such as abdominal

cramps, insomnia, irritability, nervousness, and

tremor).

y Monitor patient closely for increase in frequencyor severity of grand mal seizures when diazepam

is used with standard anticonvulsant therapy.

Dosage of other anticonvulsants may need to be

increased.

y Avoid abrupt withdrawal of diazepam, asordered, when used as part of the patients

seizure control regimen because a transient

increase in frequency or severity of seizure may

occur.

y Monitor severely depressed patient or one withdepression-related anxiety for suicidaltendencies, particularly when therapy starts and

dosage changes; depression may worsen

temporarily during these times.

y Watch for psychiatric and paradoxical reactionsto diazepam, especially in children and the

elderly. If reactions occur, notify prescriber and


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expect drug to be discontinued.

y Monitor patient for decreased drugeffectiveness, especially with prolonged use.

y Check patients blood counts and liver functionperiodically, as ordered, because prolonged

diazepam therapy rarely causes neutropenia and

jaundice.

Patient teaching:

yInstruct patient not to take more drug, moreoften, or for a longer time than prescribed. Warn

her that physical and psychological dependence

can occur, and teach her to recognize the signs.

y Advise patient not to take drug to relieveeveryday stress.

y Advise patient to avoid hazardous activities untildrugs CNS depressants and alcohol during the

therapy.

y Instruct the patient not to stop taking the drugabruptly without the prescribers supervision. If

the patient has a history of seizures, warn that

abrupt withdrawal may trigger them.

y Instruct patient to mix Diazepam Intensol withwater, soda or similar beverage; applesauce; or

pudding just before taking it. Caution her not tosave the mixture for later. Tell her to use

calibrated dropper thats provided to measure

each dose.

y Teach patient how to self-administer a rectalform, if prescribed.

y Instruct female patient of childbearing age to


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notify prescriber immediately if she is or could

be pregnant because diazepam therapy will

need to be discontinued.y Urge family or caregiver to watch patient closely

for suicidal tendencies, especially when therapy

starts or dosage changes.

3. Lorazepam Classification:Amnestic, antianxiety, anticonvulsant,

sedative

Mechanism of action:Exact mechanisms are not understood; acts mainly at

subcortical levels of the CNS, leaving the cortex

relatively unaffected. Main sites of action may be the

limbic system and reticular formation; benzodiazepines

potentiate the effects of GABA, an inhibitory

neurotransmitter; anxiolytic effects occur at doses well

below those needed to cause sedation and ataxia.Lorazepam hyperpolarizes neuronal cells, thereby

interfering with their ability to generate seizures.

Adverse/ side effects:y CNS:Amnesia, anxiety, ataxia, coma, confusion,

delusions, depression, dizziness, drowsiness, euphoria,

extrapyramidal symptoms, fatigue, headache,

hypokinesia, irritability, malaise, nervousness, seizures,slurred speech, suicidal ideation, tremor, unsteadiness,

vertigo.

y CV: Chest pain, palpitations, tachycardia; CV collapsey EENT: Blurred vision, diplopia, dry mouth, increased

salivation, photophobia

y ENDO: Syndrome of inappropriate ADH


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y GI:Abdominal pain, constipation, diarrhea, increasedliver enzyme levels, jaundice, nausea, thirst, vomiting

y GU: Libido changes; incontinence, urinary retention,menstrual irregularitiesy HEME:Agranulocytosis, pancytopenia,

thrombocytopenia

y RESP:Apnea, respiratory depression, worsening ofsleep apnea or obstructive pulmonary disease

y SKIN: Diaphoresisy

Other:A

naphylaxis, injection site pain (I.M.) or phlebitis(I.V.), physical and psychological dependence,

withdrawal symptoms.


History: Hypersensitivity to benzodiazepine, propylene

glycol, polyethylene glycol or benzyl alcohol; psychoses;

acute narrow-angle glaucoma; shock; coma; acute

alcoholic intoxication with depression of vital signs;

pregnancy; lactation; impaired liver or renal function,

debilitation

Physical: Skin color, lesions; Temp; orientation, reflexes,

affect, ophthalmologic examination; pulse, BP;

respiration, adventitious sounds; liver evaluation,abdominal examination, bowel sounds, normal output;

CBC, LFTs, renal function tests

Intervention

y Before starting lorazepam therapy in a patientwith depression, make sure he already takes an


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antidepressant because of increased risk of

suicide in patients with untreated depression.

y Use extreme caution when giving lorazepam toelderly patients, especially those withcompromised respiratory function, because drug

can cause hypoventilation, sedation,

unsteadiness, and respiratory depression.

y Use drug cautiously in patients with a history ofalcohol or drug abuse or a personality disorder

because of an increased risk of physical and

psychological dependence. Also use cautiously in

patients with severe hepatic insufficiency or

encephalopathy because drug may worsen

heptic encephalopathy.

y For I.M. use, inject lorazepam deep into largemuscle mass, such as gluteus maximus.

y For I.V. use, dilute lorazepam with equal amountof sterile water for injection, sodium chloride for

injection, or D5W. Give diluted lorazepam

slowly, at no more than 2 mg/min.

y During I.V. use, monitor patients respirationsevery 5 to 15 minutes and keep emergency

resuscitation equipment readily available.

y WARNING Monitor patients respiratory statusclosely because drug may cause life threateningrespiratory depression.

y Because stopping the drug abruptly increasesrisk of withdrawal symptoms, expect to taper

dosage gradually, especially in epileptic patients.

Patient Teaching


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e. Explain intheir ownwords the

mechanism

of actions

of the

common

barbiturate

s used inOR.

y Instruct the patient to take lorazepam exactly asprescribed and not to stop without consulting

prescriber because of risk of withdrawalsymptoms.

y Advise patient to avoid hazardous activities untildrugs CNS effects are known.

y Urge patient to avoid alcohol while takinglorazepam because it increases drugs CNS

depressant effects.

y Instruct the patient to report excessive drowsingand nausea.

y Inform pregnant patient that lorazepam therapywill need to be discontinued early in third

trimester to avoid possible withdrawal

symptoms in newborn.

B. Barbiturates1. Secobarbital sodium

Classification: Sedative-hypnotic Mechanism of action:

Generalized CNS depressant; It inhibits the upward

conduction of nerve impulses to the reticular formation

of the brain, thereby disrupting impulse transmission to

the cortex. This action depresses the CNS, producing

drowsiness, hypnosis, and sedation. Adverse/ side effects

y CNS: Anxiety, clumsiness, confusion, depression,dizziness, drowsiness, hangover, headache,

insomnia, irritability, lethargy, nervousness,

nightmares, paradoxical stimulation, syncope

y CV: hypotension, bradycardia, syncope


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y EENT: Laryngospasmy GI: Anorexia, constipation, nausea, vomiting,

epigastric painy MS: Arthralgia, muscle weaknessy Hypersensitivity: Rashes, angioneurotic edema,

serum sickness, morbilliform rash, urticarial;

rarely, exfolliative dermatitis, Steven-Johnsons

syndrome

y RESP: Apnea, bronchospasm, respiratorydepression, hypoventilation

y SKIN: Jaundicey Other: Tolerance, psychological and physical

dependence; anaphylaxis, angioedema,

withdrawal syndrome

Nursing responsibilitiesAssessment:

History: Hypersensitivty to barbiturates, manifest or

latent porphyria; nephritis; severe respiratory distress;

previous addiction to sedative-hypnotic drugs,

pregnancy, acute or chronic pain; seizure disorders;

lactation; fever, hyperthyroidism, diabetes mellitus,

severe anemia, pulmonary or cardiac disease, shock,

uremia; impaired liver or renal function, debilitation

Physical: Weight; Temp, skin color, lesions; orientation,affect, reflexes; pulse, BP, orthostatic BP; respiration,

adventitious sounds; bowel sounds, normal output, liver

evaluation, LFTSs, renal function tests, blood and urine

glucose, BUN

Interventions:


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y Be aware that prolonged use of secobarbiralmay lead to tolerance and physical and

psychological dependence.y Do not use as a bedtime hypnotic for longer than

2 weeks.

y WARNING To avoid withdrawal symptoms,expect to taper drugs after long-term therapy.

Withdrawal symptoms usually appear 8 to 12

hours after stopping drug and may include

anxiety, insomnia, muscle twitching, nausea, or

orthostatic hypotension, vomiting, weakness,

and weight loss. Severe symptoms may include

delirium, hallucinations, and seizures.

Generalized tonic-clonic seizures may occur

within 16 hours or up to 5 days after last dose.

y Assess patient for signs and symptoms ofbarbiturate toxicity, including dyspnea, severe

confusion, and severe drowsiness.

y Notify prescriber immediately if they appearbecause barbiturate toxicity may be life-

threatening.

y Expect prescriber to provide patient with theleast possible quantity of secobarbital to

minimize the risk of acute or chronic

overdosage. For patients who are depressed,suicidal, or drug-dependent or who have a

history of drug abuse, institute precautions to

prevent drug hoarding and overdosage.

Patient Teaching

y Instruct the patient to take secobarbital exactly


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as prescribed because of the risk of addiction.

y Inform patient that taking drug with food mayreduce adverse GI effects.

y Advise patient to avoid alcohol and caffeine andpotentially hazardous activities during the

therapy.

y Inform the patient about possible hangovereffect.

y If the patient takes an oral contraceptive,recommend using an additional form of birth

control during therapy.

y Caution patient not to stop taking drug abruptly.y Instruct patient to notify prescriber of bone

pain, muscle weakness, or unexplained weight

loss during the therapy.

2. Pentobarbital Classification:Anticonvulsant, sedative Mechanism of action:

Produces all levels of CNS depression; depresses the

sensory cortex, decreases motor activity, and alters

cerebellar function; Inhibits transmission in the nervous

system and raises the seizure threshold; capable of

inducing (speeding up) enzymes in the liver that

metabolize drugs, bilirubin, and other compounds Adverse/ side effects

y CNS: hangover, delirium, depression,drowsiness, excitation, lethargy, vertigo.

y CV: hypotensiony RESP: respiratory depression, bronchospasm


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y EENT: laryngospasmy GI: constipation, diarrhea, nausea, vomiting.y Derm:photosensitivity, rashes,

urticaria. phlebitis at IV sitearthralgia, myalgia,

neuralgia

y Misc: hypersensitivity reactionsincluding angioedema and serum sickness,

physical dependence, psychological

dependence. Nursing responsibilities

Assessment:

y Monitor respiratory status, pulse, and bloodpressure frequently in patients receiving

phenobarbital IV. Equipment for resuscitation

and artificial ventilation should be readily

available. Respiratory depression is dose-

dependent.

y Prolonged therapy may lead to psychological orphysical dependence. Restrict amount of drug

available to patient, especially if depressed,

suicidal, or with a history of addiction.

Geri: Elderly patients may react to phenobarbitalwith marked excitement, depression, and

confusion. Monitor for these adverse reactions

Seizures - Assess location, duration, and

characteristics of seizure activity.

Sedation - Assess level of consciousness and


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anxiety when used as a preoperative sedative.

y Assess postoperative patients for pain with apain scale. Phenobarbital may increasesensitivity to painful stimuli.

y Lab TestConsiderations: Patients on prolongedtherapy should have hepatic and renal function

and CBC evaluated periodically.

y Monitor serum folate concentrationsperiodically during therapy because of increasedfolate requirements of patients on long-term

anticonvulsant therapy with phenobarbitalMay

cause decrease serum bilirubin concentrations in

neonates, in patients with congenital

nonhemolytic unconjugated hyperbilirubinemia,

and in epileptics.

y ToxicityandOverdose: Serum phenobarbitallevels may be monitored when used as an

anticonvulsant. Therapeutic blood levels are 10

40 mcg/ml. Symptoms of toxicity include

confusion, drowsiness, dyspnea, slurred speech,

and staggering.

Intervention:

y Do not confuse phenobarbital withpentobarbital.

y Supervise ambulation and transfer of patientsfollowing administration. Two side rails should


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be raised and call bell within reach at all times.

Keep bed in low position. Institute seizure and

fall precautions. When changing fromphenobarbital to another anticonvulsant,

gradually decrease phenobarbital dose while

concurrently increasing dose of replacement

medication to maintain anticonvulsant effects.

PO: Tablets may be crushed and mixed with food

or fluids (do not administer dry) for patients with

difficulty swallowing. Oral solution may be taken

undiluted or mixed with water, milk, or fruit

juice. Use calibrated measuring device for

accurate measurement of liquid doses

Injections should be given deep into the gluteal

muscle to minimize tissue irritation. Do not

inject >5 ml into any one site, because of tissue

irritation

Doses may require 1530 min to reach peak

concentrations in the brain. Administer minimal

dose and wait for effectiveness before

administering 2nd dose to prevent cumulative

barbiturate-induced depressionReconstitute sterile powder for IV dose with a

minimum of 3 ml of sterile water for injection.

Dilute further with 10 ml of sterile water. Do not

use solution that is not absolutely clear within 5

min after reconstitution or that contains a


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precipitate. Discard powder or solution that has

been exposed to air for longer than 30 min.

y Solution is highly alkaline; avoid extravasation,which may cause tissue damage and necrosis. If

extravasation occurs, injection of 5% procaine

solution into affected area and application of

moist heat may be ordered130 mg/ml

(undiluted).Do not inject IV faster than 1

mg/kg/min with a maximum of 30 mg over 1 min

in infants and children and 60 mg over 1 min in

adults. Titrate slowly for desired response. Rapid

administration may result in respiratory

depression

doxapramenalaprilatfentanylfosphenytoin levofl

oxacin linezolid meropenem methadonemorphin

epropofolsufentanil amphotericin B cholesteryl

sulfate complexlansoprazole

Patient Teaching

y Advise patient to take medication as directed.Take missed doses as soon as remembered if not

almost time for next dose; do not double dosesAdvise patients on prolonged therapy not to

discontinue medication without consulting

health care professional. Abrupt withdrawal may

precipitate seizures or status epilepticus

Medication may cause daytime drowsiness.


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Caution patient to avoid driving and other

activities requiring alertness until response to

medication is known. Do not resume drivinguntil physician gives clearance based on control

of seizure disorder

Caution patient to avoid taking alcohol or other

CNS depressants concurrently with this

medication

Advise female patients using oral contraceptives

to use an additional nonhormonal contraceptive

during therapy and until next menstrual period.

Instruct patient to contact health care

professional immediately if pregnancy is planned

or suspected

Advise patient to notify health care professional

if fever, sore throat, mouth sores, unusual

bleeding or bruising, nosebleeds, or petechiae

occur

Teach sleep hygiene techniques (dark room,

quiet, bedtime ritual, limit daytime napping,

avoid nicotine and caffeine)

Pedi:Advise parents or caregivers that child mayexperience irritability, hyperactivity and/or sleep

disturbances, which may diminish in a few days

to a few weeks or may persist until drug is

stopped. An alternative medication can be

considered. Instruct parents to monitor for skin


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f. Discuss 3nursing

responsibili

ties for

each H2

receptor

blocking

agent

effectively.

rash occurring 7-20 days after treatment begins

and to contact a health care provider if rash

occurs. Teach family about symptoms of toxicity(staggering, drowsiness, slurred speech).

C. H2 receptor blocking agentsH2 receptor blocking agents or also called as H2 antagonists are

the prototypical acid-secretion antagonists. These drugs reduce but

do not abolish stimulated acid secretion.

1. Ranitidine Classification: antiulcer agent, gastric acid secretion

inhibitor

Mechanism of action:Inhibits basal and nocturnal secretions of gastric acid

and pepsin by competitively inhibiting the action of

histamine at H2 receptors on gastric parietal cells. This

action reduces total volume of gastric juices and thus

irritation of GI mucosa.

Adverse/ side effectsy CNS dizziness, drowsiness, fever, headache,

insomnia

y CV vasculitisy GI abdominal distress, constipation, diarrhea,

nausea and vomiting

y GU acute interstitial nephritis, impotencey MS arthralgia, myalgiay RESP bronchospasmy SKIN alopecia, erythema multiforme, rashy Other anaphylaxis, angioedema


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Nursing responsibilitiesy A

lert patients with phenylketonuria thateffervescent tablets and granules contain

phenylalanine.

y Tell patient that she may take drug with food.y Tell patient to stop taking ranitidine and contact

prescriber if she has trouble swallowing, vomits

blood or passes black or bloody stools.

y Inform patient that healing of an ulcer mayrequire 4 to 8 weeks of therapy

2. Cimatidine Classification: antiulcer, gastric acid secretion inhibitor,

H2 receptor antagonists

Mechanism of action:Block histamines action at H2 receptor sites on

stomachs parietal cells. This action reduces gastric fluidvolume and acidity. Cimetidine also decreases the

amount of gastric acid secreted in response to food,

caffeine, insulin, betazole, or pentagastrin

Adverse/ side effects:y CNS confusion, dizziness, hallucinations,

headache, peripheral neuropathy, somnolence

y ENDO mild gynecomastia if used longer than 1monthy GI mild and transient diarrheay GU impotence, transiently elevated serum

creatinine level

y SKIN rashy Other pain at IM injection site


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Nursing responsibilitiesy Be aware that rapid administration of cimetidine

can increase risk of arrhythmias andhypotension.

y Be alert for confusion in elderly or debilitatedpatients who receive cimetidine.

y Advise patient to avoid alcohol while takingcimetidine to prevent interactions. Instruct

patient to avoid taking antacids within 1 hour of

taking cimetidine.

y Warn patient that cigarette smoking increasesgastric acid secretion and can worsen gastric

disease. Caution patient not to take drug for

more than 14 days, unless prescribed.

3. Nizatidine (Axid) Classification: antiulcer Mechanism of action:

Inhibits basal and nocturnal secretions of gastric acid by

reversibly and competitively blocking H2 receptor

especially those in gastric parietal cells. Nizatidine also

inhibits gastric acid secretion in response to stimuli,

including food and caffeine.

Adverse/ side effects:y CNS agitation, anxiety, confusion, depression,dizziness, fatigue, fever, hallucinations,

headache, insomnia, somnolence

y CV - arrhythmias, chest pain, vasculitisy EENT amblyopia, dry mouth, laryngeal edema,

pharyngitis, rhinitis, sinusitis

y ENDO gynecomastia


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y GI abdominal pain, constipation, diarrhea,hepatitis, nausea, vomiting

yGU decreased libido, hyperuricemia notassociated with gout or nephrolithiasis

impotence

y HEME anemia, aplastic anemia, eosinophilia,hemolytic anemia, leucopenia, neutropenia,

pancytopenia, thrombocytopenia

y MS back pain, myalgiay RESP bronchospasm, coughy SKIN alopecia, diaphoresis, erythema,

multiforme, exfoliative dermatitis, jaundice,

pruritis, rash, Stevens-Johnson syndrome toxic

epidermal necrolysis, urticaria

y Other anaphylaxis, angioedema, serum,sicknesslike reaction

Nursing responsibilitiesy Monitor CBC, BUN and serum creatinine levels,

and liver function test results before and

periodically during nizatidine therapy.

y Dont give within 1 hour of an antacid.y Instruct patient not to take nizatidine within 1

hour of an antacid.

y Inform her that ulcer may take up to 8 weeks toheal.

y Smoking increases gastric acid productiony Teach patient to minimize constipation by

drinking plenty of fluids (if allowed), eating high

fiber foods, and exercising regularly

y Instruct patient to notify prescriber immediatelyabout abdominal pain, easy bruising, extreme


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g. Comprehensively

explain the

significance

and use of

inhalationgases in the

OR.

fatigue, yellow skin or sclera, trouble swallowing

food, bloody vomitus or bloody or tarry stools.

y Urge the patient not to take nizatidine withother acid reducers.

D. Inhalation gases1. Oxygen

Administration of oxygen as a medical intervention,which can be for a variety of purposes in

both chronic and acute patient care. Room air only

contains 21% oxygen, and increasing the fraction ofoxygen in the breathing gas increases the amount of

oxygen in the blood. When 100% oxygen is needed, it

may be delivered via a tight-fitting face mask, or by

supplying 100% oxygen to an incubator in the case of

infants. Oxygen can be administered in other ways,

including specific treatments at raised air pressure, such

as hyperbaric oxygen therapy. High blood and tissuelevels of oxygen can be helpful or damaging, depending

on circumstances and oxygen therapy should be used to

benefit the patient by increasing the supply of oxygen

to the lungs and thereby increasing the availability of

oxygen to the body tissues, especially when the patient

is suffering from hypoxia and/or hypoxaemia.

Mechanism of actionOxygen is essential for cell metabolism, and in turn,

tissue oxygenation is essential for all normal

physiological functions.

Adverse/ side effectsOxygen should never be given to a patient who is

suffering from paraquat poisoning unless they are


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suffering from severe respiratory distress or respiratory

arrest, as this can increase the toxicity. (Paraquat

poisoning is rare for example 200 deaths globally

from 19581978). Oxygen therapy is not recommended

for patients who have suffered pulmonary fibrosis or

other lung damage resulting

from bleomycin treatment.[18]

High levels of oxygen

given to infants causes blindness by promoting

overgrowth of new blood vessels in the eye obstructing

sight. This is retinopathy of prematurity (ROP).Oxygen

has vasoconstrictive effects on the circulatory system,reducing peripheral circulation and was once thought to

potentially increase the effects of stroke. However,

when additional oxygen is given to the patient,

additional oxygen is dissolved in the plasma according

to Henry's Law. This allows a compensating change to

occur and the dissolved oxygen in plasma supports

embarrassed (oxygen-starved) neurons, reducesinflammation and post-stroke cerebral edema.

Nursing responsibilitiesy Monitor the level of oxygen.y Make sure that nobody will smoke near the

oxygen tank.

y Assess for dryness and provide skin care.2. Nitrous oxide

An inorganic inhalation general anesthesia. It is alsoknown as laughing gas is the only inhaled gas

currently used as a general anesthetic. It is the weakest

of the general anesthesia drugs and is primarily for

dental procedures or as a useful supplement to other,


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more potent anesthesia.

Mechanism of action:The mechanism of action of nitrous oxide is trifold and

includes analgesia, anxiolysis, and anesthesia. Its

analgesic mechanism of action is described as opioid in

nature and may involve a number of spinal

neuromodulators. The anxiolytic effect is similar to that

of benzodiazepine and may involve gamma

aminobutyric (GABA) receptors. The anesthesia

mechanism may involve GABA and possibly N-methyl-D-

aspartate receptors as well.In general, the effect ofnitrous oxide ceases as soon as the inhalation stops,

with no residual effect.

Adverse/ side effectsy The side effects of N2O take two main forms:

metabolic inhibition and pressure/volume

problems. Other potential problems relate to

the administration of oxygen.y Nitrous oxide may have neurotoxic effects of

unknown significance on both infantile and

senescent central nervous systems.

y Postoperative nausea and vomiting (PONV) isdescribed with nearly all inhaled anesthetics

including nitrous oxide.

yInadvertent use of nitrous oxide in pregnancymay result in teratogenic and fetal toxic effects.

While decreased fertility, spontaneous abortion,

and congenital abnormalities possibly associated

with nitrous oxide exposure have been reported

in the dental literature, the clinical significance

and causation of these findings remain unknown


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y Short-term impairment in mental performance,manual dexterity, and audiovisual senses has

been described with nitrous oxide use.

y While most adverse effects are reversible,peripheral neuropathies and limb spasms may

become nonreversible manifestations.

Symptoms of nitrous oxide and B12 deficiency

may not appear for days or weeks after known

exposure.

y Nitrous oxide has been shown to potentiallyinhibit methionine synthetase and cause an

increase in homocysteine (Hcy) levels. Elevated

Hcy levels have been correlated with increased

postoperative complications, including possible

cardiovascular morbidity.

y Adverse effects that may be associated withnitrous oxide include gagging, coughing,

hypotension, asthma attack, involuntary trachealclosure (spasm), lung damage,

neuropathy, tinnitus, extremity numbness,

anoxia and general respiratory distress, cardiac

events (including myocardial infarcts), seizures,

misperception of time, and vision-altering

perceptions.Additional adverse effects include

possible exacerbation of vitamin B12 deficiency,anemia, and decreased hematopoiesis.

Nursing responsibilitiesy Before starting the case, plug in the nitrous

oxide machine and turn on the front nitrous

oxide and oxygen tanks. The nitrous pressure

gauge should read approximately 750 psi. The


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nitrous oxide pressure will not fall until the tank

is almost empty. This is because nitrous oxide

inside the tank is in mostly liquid form, and the

partial pressure of the gas does not drop until

the liquid has completely evaporated. The

oxygen pressure gauge will read between 0 and

2,000 psi: the lower the reading, the emptier the

tank. Oxygen in the tank is pressurized gas with

no liquid component.8

y During nitrous oxide administration, the flowrate is adjusted based on the patients overallventilation. The initial flow rate is set at 56

liters per minute. If the reservoir bag becomes

deflated, the patient is either anxious and

breathing too rapidly (encourage them to relax

and slow down), or the flow rate is too low and

should be increased by a liter per minute as

needed. Conversely, if the bag becomeshyperinflated, the most common reason is a kink

in the flow tubing. Ask the patient if they feel

like they are getting enough air. If the answer is

no, look for a kinked hose. If yes, then the

mask may not be snug enough and the patient

may be inhaling room air around the mask. If the

bag deflates normally when the patient is asked

to inhale a deep breath, then the flow rate may

just be too high. The flow rate may have to be

adjusted several times during a more lengthy

procedure, as the patients respiratory rate may

vary.

y The patients are told that they will not go to


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sleep with nitrous oxide, but will feel relaxed.

We instruct the patients that they will only need

the nitrous oxide during the tumescent

anesthesia and that once this is completed, the

nitrous oxide will be turned off, but they should

feel no pain. It is important to reassure them

that touch and pressure sensation will still be

intact. Accordingly, we discontinue the nitrous

oxide and give 100% oxygen as soon as the

tumescent anesthesia is completed. After 5

minutes of 100% oxygen, the nasal hood isremoved from the patient. Thus, the patient is

more or less completely awake and lucid during

the bulk of the procedure itself, only having

been under the influence of the gas during the

painful injections of tumescent anesthetic. In

patients who require endovenous catheter

ablation and concomitant phlebectomy, weusually perform the catheter ablation first, then

finish the tumescent anesthesia for the

phlebectomy, however, it would be just as easy

to perform all the required tumescent

anesthesia at the same time. The sheath and

laser fiber should be inserted into the saphenous

vein before any tumescent anesthesia is begun,

or the epinephrine in the anesthetic and the

trauma of multiple needle punctures will cause

the saphenous vein to spasm, making

percutaneous access more difficult.

y We start the nitrous after the patient has beenprepped and draped and immediately before we


41/57

scrub in for the case. This has shortened nitrous

oxide administration time from 3040 minutes

to 1020, and sometimes even less. The

circulating nurse makes adjustments to the

nitrous oxide administration at the direction of

the physician. We place a pulse oximeter on the

patient, start the recorder and then turn on the

nitrous oxide machine. Our digital flow machine

automatically adjusts flow rates according to the

desired percentage of oxygen and nitrous. The

flow rate is set to 100% oxygen, and then weplace the nasal hood on the patient and adjust

the tubing either behind their head if they are

prone, or if supine, draped around and behind

the head of the surgical table, making sure that

there are no kinks in the hoses and the mask fits

snugly but not uncomfortably tight. The patient

may be allowed to hold the mask over their ownnose, but in practice, this rarely works as well.

The patient is instructed to breathe through the

nose and asked to take one or two deep breaths

to make sure the reservoir bag deflates properly

with each inhalation. Once the nasal hood is in

place and the patient is breathing comfortably,

we start the flow of nitrous oxide at 20% and

start a small electronic timer placed on the top

of the nitrous oxide machine. It is stopped when

the nitrous oxide is stopped at the end of the

tumescent anesthesia. Once the nitrous oxide is

started, the patient is assessed every minute or

two. The desired effects may include any or all


42/57

of the following: a feeling of relaxation,

heaviness or lightness of the limbs, tingling in

the fingertips, circumoral numbness and total

body warmth. If after a minute or two the

appropriate effects are not felt, the nitrous

concentration is increased by 10% and the

patient observed for another minute or two.

This titration procedure is essential in the

success of nitrous oxide administration. Nausea

and vomiting are the most well-known side

effects of nitrous oxide. Properly done, titrationallows administration to each patient of the

minimally effective concentration of nitrous

oxide and greatly decreases the incidence of

nausea and vomiting. If at any time a patient

under nitrous oxide sedation develops

irritability, hallucinations, nausea or vomiting,

confusion, combativeness, uncooperativeness orjust complains of not feeling well, they are

probably overmedicated and the concentration

of nitrous oxide should be reduced immediately.

3. Desflurane(Suprane) Mechanism of action:

Desfluraneis used to cause general anesthesia (loss of

consciousness) before and during surgery. It is breathed

in (inhaled). Although desfluranecan be used by itself,

combinations of anesthetics are often used together.

This helps produce more effective anesthesia in some

patients.

Adverse/ side effects


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y Coughingy Nausea or vomitingy Dizzinessy Headachey Irritated or red eyesy Nervousness and restlessnessy Sore throat

Nursing responsibilitiesy General anesthetics may cause some people to

feel drowsy, tired, or weak for a while after they

have been given. They may also cause problems

with coordination and one's ability to think.

Therefore, for about 24 hours (or longer if

necessary) after receiving a general anesthetic,

do not drive, use machines, or do anything else

that could be dangerous if you are not alert.

y Unless otherwise directed by your doctor ordentist, do not drink alcoholic beverages or takeother CNS depressants (medicines that slow

down the nervous system, possibly causing

drowsiness) for about 24 hours after you have

received a general anesthetic. To do so may add

to the effects of the anesthetic. Some examples

of CNS depressants are antihistamines or

medicine for hay fever, other allergies, or colds;other sedatives, tranquilizers, or sleeping

medicine; prescription pain medicine or

narcotics; barbiturates; medicine for seizures;

and muscle relaxants.

4. Halothane (Fluothane)


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Mechanism of action:Halothane decreases the rate of firing and neuronal

activity in the brain by altering the lipid layer of cell

membranes, causing structural alterations in ion

channels. This results in depression of CNS and

anaesthesia. It depresses the respiratory center and is

also a bronchodilator. It is a cardiac depressant and

causes a decrease in cardiac output and heart rate. Also

causes peripheral vasodilatation and hypotension. It

sensitizes the myocardium to the effects of

catecholamines. It increases cerebral blood flow andraises intracranial and CSF pressures. It causes

considerable cardiac sensitivity to catecholamines and

produces poor muscular relaxation when used alone

and its high halogen content can result in significant

liver toxicity. Because of these limitations and toxicities,

halothane is now less commonly used than newer less

toxic inhalational anesthetics. Adverse/ side effects

y Most significant adverse effects arehepatotoxicity. It can be mild,self limiting

hepatic dysfunction, characterized by elevated

serum SGOT and SGPT or a severe acute

fulminant hepatitis.

y In susceptible individuals halothane may tiggeroff a syndrome of malignant hyperthermia

tachycardia, tachypnoea, pyrexia, acidosis,

arrhythmias, cyanosis, muscular rigidity and

unstable blood pressure. Hyperkalemia may

occur. Treatment consists of external cooling

measures like icepacks, ventilatory support, CVS


45/57

monitoring, correction of arrhythmias and blood

pressure, maintenance of fluid and electrolyte

balance.

Nursing responsibilitiesThe uterine relaxation obtained with Halothane, unless

carefully controlled, may fail to respond to ergot

derivatives and oxytocic posterior pituitary extract

(oxytocin injection).

Halothane increases cerebrospinal fluid pressure.

Therefore, in patients with markedly raised intracranial

pressure, if Halothane is indicated, administrationshould be preceded by measures ordinarily used to

reduce cerebrospinal fluid pressure. Ventilation should

be carefully assessed, and it may be necessary to assist

or control ventilation to insure adequate oxygenation

and carbon dioxide removal.

The patient should be closely observed for signs of

overdosage, i.e., depression of blood pressure, pulserate and ventilation, particularly during assisted or

controlled ventilation.

5. Isoflurane ( Forane) Isoflurane is very similar to euflurane in its chemical

structure. However, the difference in its structure gives

it some favorable characteristics that distinguish it from

its chemical relative. Isoflurane has more rapid onset of

action, causes less cardiovascular depression and

overall has been associated with little or no toxicity

Mechanism of action:General anaesthetics act by fluidizing the cell

membrane and decreasing or altering the stucture of


46/57

h. Give 5possible

ion channels in the membrane, thereby decreasing the

firing rate and potentials. Synaptic transmission is also

decreased. It causes a decrease in arterial pressure and

hypotension, but heart rate is increased. It also does

not sensitize the myocardium to circulating

catecholamines. It causes respiratory depression.

Adverse/ side effectsy Coughing, laryngospasm, salivation, etc., during

induction.

y Increases intracranial pressure.y In susceptible individuals, malignant

hyperpyrexia can occur.

y Hypotensiony Cardiac and respiratory arrest may occur

Nursing responsibilitiesy If side effects occur, discontinuance of triggering

agents (e.g., Isoflurane), administration of

intravenous dantrolene sodium, and applicationof supportive therapy. Such therapy includes

vigorous efforts to restore body temperature to

normal, respiratory and circulatory support as

indicated, and management of electrolyte-fluid-

acid-base derangements.

E. Intravenous anesthesiaThese are used for induction or maintenance of general anesthesia,

induction of amnesia, and as an adjunct to inhalation-type

anesthetics.

1. Etomidate Mechanism of action:


47/57

adverse

reactions of

Etomidate

correctly.

Ultrashort-acting nonbarbiturate hypnotic used for the

induction of anesthesia; chemically, it is a carboxylated

imidazole and has been shown to produce a rapid

induction of anesthesia with minimal cardiovascular and

respiratory effects.

Adverse/ side effects:y Neuromuscular & skeletal: Transient skeletal

movements

y Respiratory: Hyperventilation, hypoventilation,apnea of short duration (5 to 90 seconds with

spontaneous recovery); laryngospasm, hiccupand snoring suggestive of partial upper airway

obstruction

y CV: Hypertension, hypotension, tachycardia,bradycardia and other arrhythmias have

occasionally been observed during induction and

maintenance of anesthesia.

y GI: Postoperative nausea and/or vomiting Nursing responsibilitiesy Resuscitative equipment must be readily

available in case or cardiorespiratory distress or

arrest.

y Status of breath sounds should be assessed byauscultation (hypoventilation may be a

complication) and neurologic changes and status

(no matter how small) and any change in

sensations should be documented and reported.

y Instruct the patient of the postanesthesiaprocess, especially if there is a need to turn,

cough and deep breathe (which helps to prevent

atelectasis and pneumonia.


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i. Enumerate3 common

antiemetic

used in the

OReffectively.

y Encourage ambulation with assistance asneeded. This helps to increase circulation and

improve ventilation to the alveoli of the lungs;

consequently, circulation to the legs will be

improved.

F. AntiemeticsUsed to treat nausea and vomiting in a variety of clinical situations.

The ultimate goals of antiemetic therapy are minimizing or

preventing fluid and electrolyte disturbances and minimizing

deterioration of the patients nutritional status. Most of theantiemeticsact by blocking receptors in the CNS, but some work

directly in the GI tract.

1. Prochloperazine Mechanism of action:

Acts on the chemoreceptor trigger zone to inhibit

nausea and vomiting; in larger doses, it partiallydepresses vomiting center

Adverse/ side effects:y CNS: extrapyramidal reactions, dizziness, EEG

change, pseudoparkinsonism, sedation

y CV: orthostatic hypotension, ECG changes,tachycardia

y EENT: blurred vision, ocular changesy GI: constipation, dry mouth, increased appetitey GU: urine retention, dark urine, inhibited

ejaculation, menstrual irregularities

y Hematologic: agranulocytosis, transientleukopenia,

y Hepatic: cholestatic jaundice


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y Metabolic: weight gainy Skin: mild photosensitivity, allergic reactions,

exfoliative dermatitis

y Other: gynecomastia, hyperprolactinemia Nursing responsibilities:

y Dilute oral solution with tomato juice, fruit juice,milk, coffee, carbonated beverage, tea, water or

soup. Or, mix with pudding.

y Watch for orthostatic hypotension, especiallywhen giving drug I.V.

y For I.M. use, inject deeply into upper outerquadrant of gluteal region.

y Do not give by subcutaneous route or mix insyringe with another drug.

y To prevent contact dermatitis, avoid gettingconcentrate or injection solution on hands or

clothing.

y Monitor CBC and liver function studies duringlong-term therapy.

y Alert: use drug only when vomiting cannot becontrolled by other measures or when only a

few doses are needed. If more than four doses

are needed in 24 hours, notify prescriber.

y Store in light-resistant container. Sight yellowingdoes not affect potency; discard extremelydiscolored solutions.

y Teach patient what to use to dilute oral solution.Advise patient to wear protective clothing when

exposed to sunlight.

2. Droperidol


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Mechanism of action: Unknown. Tranquilizes, sedatesand provides antiemetic effects without affecting reflex

alertness; also causes mild alpha blockade.

Adverse/ side effects:y CNS: drowsiness, neuroleptic malignant

syndrome, restlessness, hyperactivity, anxiety,

hallucinations, dysphoria, dizziness,

extrapyramidal symptoms

y CV: hypotension,tachycardiay Respiratory: laryngospasm, bronchospasmy Skin: chills, shivering

Nursing responsibilitiesy When used for induction of general anesthesia,

give drug with analgesic.

y If used in procedures such as bronchoscopy,topical anesthesia is still needed.

y Keep fluids and other measures to managehypotension readily available.

y Monitor patient for neuroleptic malignantsyndrome: altered mental status, autonomic

instability, muscle rigidity, and hyperpyrexia

y Warn patient to rise slowly to minimizedizziness.

y Advise patient to avoid alcohol for 24 hours afterreceiving drug.

3. Promethazine hydrochloride Mechanism of action: Phenothiazine derivative that

competes with histamine for H1 receptor sites on

effector cells. Prevents, but does not reverse,

histamine- mediated responses. At high doses, drug also

h l l h ff


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has local anesthetic effects.

Adverse/ side effects:y CNS: drowsiness, sedation, confusion,

sleepiness, dizziness, disorientation,

extrapyramidal symptoms

y CV: hypotension, hypertensiony EENT: dry mouth, blurred visiony GI: nausea, vomitingy GU: urine retentiony Hematologic: agranulocytosis, leukopenia,

thrombocytopeniay Metabolic: hyperglycemiay Respiratory: respiratory depression, apneay Skin: photosensitivity, rash

Nursing responsibilitiesy Monitor patient for neuroleptic malignant

syndrome: altered mental status, autonomic

instability, muscle rigidity, and hyperpyrexiay Stop drug 4 days before diagnostic skin testing

because antihistamines can prevent, reduce, or

mask positive skin test response.

y Drug is used as an adjunct to analgesics, usuallyto increase sedation; it has no analgesic activity.

y I.M. injection is the preferred parenteral route.Inject deep I.M. into large muscle mass. Rotateinjection sites.

y Alert: Do not give subcutaneously.y Drug may be mixed with meperidine in same

syringe.

y In patients scheduled with myelogram, stop drug48 hours before procedure. Do not resume drug

til 24 h ft d b f th


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until 24 hours after procedure because of the

risk of seizures.

y Look alike- sound alike: do not confusepromethazine with promazine.

y Tell patient to take oral form with food or milkto reduce GI distress.

y When treating motion sickness, tell patient totake first dose 30 to 60 minutes before travel;

dose may be repeated in 8 to 12 hours if

necessary. On succeeding days of travel, patient

should take dose upon arising and with eveningmeal.

y Warn patient to avoid alcohol and hazardousactivities that require alertness until CNS effects

of drug are known.

y Inform patient that sugarless gum , hard candyor ice chips may relieve dry mouth.

y Warn patient about possible photosensitivityreactions. Advise use of sunblock.4. Metroclopromide

Mechanism of action:Stimulates motility of upper GI tract, increases lower

esophageal sphincter tone, and blocks dopamine

receptors at the chemoreceptor trigger zone

Adverse/ side effects:y CNS: restlessness, drowsiness, fatigue, lassitude,

insomnia, extrapyramidalreactions,

parkinsonism-like reactions, akathisia, dystonia,

myoclonus, dizziness, anxiety

y CV: transient hypertension, bradycardia,

supraventricular tachycardia hypotension


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supraventricular tachycardia, hypotension

y GI: nausea, diarrhea, bowel disordersy GU: incontinence, urinary frequencyy Hematologic: agranulocytosis, neutropeniay Skin: rash, urticarialy Others: loss of libido, prolactin secretion

Nursing responsibilitiesy Monitor BP carefully during IV administration.y Monitor for extrapyramidal reactions, and

consult physician if they occur.

y Monitor diabetic patients, arrange for alterationin insulin dose or timing if diabetic control is

compromised by alterations in timing of food

absorption.

y WARNING: Keep diphenhydramine injectionreadily available in case extrapyramidal

reactions occur (50 mg IM).

y WARNING: Have phentolamine readily availablein case of hypertensive crisis (most likely to

occur with undiagnosed pheochromocytoma).

y Teach patient to take this drug exactly asprescribed.

y Do not use alcohol, sleep remedies, sedatives;serious sedation could occur.

yInform patient about possibility of experiencingthese side effects: Drowsiness, dizziness (do not

drive or perform other tasks that require

alertness); restlessness, anxiety, depression,

headache, insomnia (reversible); nausea,

diarrhea.

y Tell patient to report involuntary movement of

the face eyes or limbs severe depression


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j. Definebriefly an

anticoagula

nt and its

action.

the face, eyes, or limbs, severe depression,

and/or severe diarrhea.

G. AnticoagulantsThese are given to prevent the formation of a clot by inhibiting

certain clotting factors. They are only given prophylactically

because they have no direct effect on a blood clot that has already

formed or an ischemic tissue injured as the result of an inadequate

blood supply caused by the clot. By decreasing blood coagulability,

anticoagulants prevent intravascular thrombosis. Their uses vary

from preventing clot formation to preventing the extension of anestablished clot, or a thrombus.

1. Heparin Mechanism of action:

Accelerates formation of antithrombin III- thrombin

complex and deactivates thrombin, preventing

conversion of fibrinogen to fibrin.

Adverse/ side effects:y CNS: fevery EENT: rhinitisy Hematologic: hemorrhage, overly prolonged

clotting time, thrombocytopenia

y Skin: irritation, mild pain, hematoma, ulceration,cutaneous or subcutaneous necrosis, pruritis,

urticaria

y Other: white clot syndrome,hypersensitivityreactions, including chills,

anaphylactoid reactions

Nursing responsibilitiesy Adjust dose according to coagulation test results

performed just before injection (30 min before


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performed just before injection (30 min before

each intermittent dose or q 46 hr if continuous

IV dose). Therapeutic range aPTT: 1.52.5 times

control.y Always check compatibilities with other IV

solutions.

y Use heparin lock needle to avoid repeatedinjections.

y Give deep subcutaneous injections; do not giveheparin by IM injection.

y Do not give IM injections to patients on heparintherapy (heparin predisposes to hematoma

formation).

y WARNING: Apply pressure to all injection sitesafter needle is withdrawn; inspect injection sites

for signs of hematoma; do not massage injection

sites.

yMix well when adding heparin to IV infusion.

y Do not add heparin to infusion lines of otherdrugs, and do not piggyback other drugs into

heparin line. If this must be done, ensure drug

compatibility.

y Check for signs of bleeding; monitor blood tests.y Alert all health care providers of heparin use.y WARNING: Have protamine sulfate (heparin

antidote) readily available in case of overdose;

each mg neutralizes 100 units of heparin. Give

very slowly IV over 10 min, not to exceed 50 mg.

Establish dose based on blood coagulation

studies.

y This drug must be given by a parenteral route

(cannot be taken orally).


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(cannot be taken orally).

y Frequent blood tests are necessary todetermine blood clotting time is within the

correct range.y Be careful to avoid injury: Use an electric razor,

avoid contact sports and other activities that

might lead to injury.

y Loss of hair may be experienced.y Report nosebleed, bleeding of the gums,

unusual bruising, black or tarry stools, cloudy or

dark urine, abdominal or lower back pain,severe headache.

k. Evaluateeffectively

the roles

and

responsibili

ties of

nurses in

administrati

on of the

common

OR drugs

andanesthesia

VII. Open Forum

VIII. Evaluation

10 mins.

10 mins.

Socialized

discussion

Interactive

discussion

Paper and pencil

acitivity

Satisfacto

performan

and pape

level of m


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References:

Deglin, J. H. &Valler, A. H. (2005).Daviss drug guide for nurses (9thed.). Thailand: Davis Company.

Harrington, S., Liley, L. L. & Snyder, J. S. (2007).Pharmacology and nursing process (5th

ed.). PA, USA: Mosby, Inc.

Jones and Barlett Learning. (2011). 2011 Nurses drug handbook (10th

ed.). USA: Jones and Barlett Learning, LLC.

Karch, A. C. (2008). Focus on nursing pharmacology (4th

ed.). USA: Lippincott Williams & Wilkins.

Smeltzer, S. (et al.).(2010). Brunner and suddarths Medical surgical nursing (12th

ed.).China: Lippincott Company.

ru on common or drugs and anesthesia

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