COLLEGE OF NURSING

Silliman University Dumaguete City

RESOURCE UNIT ON COMMON O.R. DRUGS AND ANESTHESIA

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

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

Mission
y Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where 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 strengthen character, competence and faith. y Instill in all members of the University community an enlightened social consciousness and a deep sense of justice and compassion. y Promote unity among peoples and contribute to national development.

COLLEGE OF NURSING
Silliman University Dumaguete City

O.R. ROTATION RESOURCE UNIT ON COMMON O.R. DRUGS AND ANESTHESIA

Placement: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 the operating room (OR). Given emphasis for each drug and anesthesia is on its classification, mechanism of action, indication, side effects, adverse reactions, and nursing 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 manifest desirable attitudes in the application of the principles, concepts, techniques, and nursing management in the administration of common drugs and anesthesia to clients in the operating room. SPECIFIC OBJECTIVES At the end of 1.5 hours the students shall: CONTENTS T/A T/L ACTIVITIES EVALUATION

I. II.

Prayer Introduction Definition of terms

2mins. 3mins. 2 mins. Socialized discussion Group discussion Oral evaluation Oral evaluation

a. Define the

III.

4 terms correctly.

1. Pharmacokinetics The deals with the process of transforming a drug 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. 2. Pharmacodynamics This 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 loss of reflexes 4. Analgesia means absence of pain sensations IV. 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. Pharmacokinetics 1. 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 as absorption. A drug s absorption rate depends on its routes of administration, its circulation through tissues into which it s administered, and its solubility that is, whether it s more water-soluble (hydrophilic) or fat-soluble (lipophilic). 2. Distribution 5 mins. Lecture discussion Oral evaluation with power point presentation

b. Explain briefly the 4 steps of pharmacoki netics.

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 must permeate all membranes that separate it from its intended site of action. Drug distribution is influenced by blood flow, tissue availability, and protein binding. 3. Metabolism Drug metabolism is the enzymatic conversion of a drug s structure into substrate molecules or polar compounds that are either 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. Excretion The 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 drug s therapeutic effect. Other excretion routes include evaporation through the skin, exhalation from the lungs, and secretion into saliva and breast milk. B. Pharmacodynamics Pharmacodynamics is the study of the biochemical and physiologic effects of drugs and their mechanism of action. A drug s actions may be structurally specific or nonspecific. Structurally specific

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 of action. 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. Strucutrally nonspecific drugs, such as biological response modifiers don t combine with cell receptors; rather, they produce changes within the cell membrane or interior. C. Pharmacotherapeutics Pharmacotherapeutics 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 drug s 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.

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 or overwhelmed 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 that s chemically similar to it. The patient s immune system reacts to the drug as if it were 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 Considerations Although every drug has a usual dosage range, certain factors such as a patient s 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

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 thiazide diuretics 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 patient s 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 Patients Because 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 they re 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. Children Because their bodily functions aren t 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.

4. Pregnancy The many physiologic changes that take place in the body during pregnancy may affect a drug s 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. c. Give one scenario illustrating the incorporati on of the rights of drug administrati on comprehen sively. V. Principles of Drug Administration A. Rights of Drug Administration 1. Right Drug 2. 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 Dose Whether you re 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 you re familiar with the standard abbreviations your institutions uses for writing prescriptions. 4. Right Patient Always compare the name of the patient on the medication record with the name on the patient s identification bracelet. 5. Right Route Each drug prescription should specify the administration route. 3 mins. Lecture discussion Oral evaluation with power point presentation

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 the change. 6. Right Preparation and Administration For 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 you ve reconstituted with the patient s name, the strength 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 Documentation d. Name 2 common benzodiaze pines used in the OR correctly. VI. Common OR drugs and Anesthesia A. Benzodiazepine Benzodiazepines 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 Cabbage Game: The with power point players will pass lump presentation of paper while music is playing, when the music stops, they will get a question from the cabbage and answer it.

sleep. Anxiolytic and amnesia effect occur at doses below those needed to cause sedation, ataxia. Adverse/ side effects CNS: 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; yawning CV: 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 responsibilities Assessment History: Hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication with depression of vital signs;

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: y Before giving midazolam, determine whether patient 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, which may 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) for IV 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 respirations carefully during administration. y Warning Keep resuscitative facilities readily available; have flumazenil available as antidote if

y y y y y

overdose should occur. Keep patient in bed for 3 hours; do not permit ambulatory patients to operate vehicle following an injection. Arrange to monitor liver and renal function and CBC at intervals during long-term therapy. Establish safety precautions if CNS changes occur (Use side rails, accompany ambulating patient). Provide comfort measures and reassurance for patients receiving diazepam for tetanus. Arrange to taper dosage gradually after long-term therapy. Provide patient with written information regarding recovery 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 you go 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 OTC drugs 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.

Report severe dizziness, weakness, drowsiness that persists, rash, or skin lesions; visual or hearing disturbances, difficulty voiding.

2. Diazepam  Classification: Anticonvulsant, anxiolytic, sedativehypnotic, skeletal muscle relaxant  Mechanism of action: Exact mechanism of action not understood; act mainly at the limbic system and reticular formation; may act in spinal 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 effects y 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 paradoxical excitatory reactions during first 2 week of treatment, visual and auditory disturbances, diplopia, nystagmus, depressed hearing, nasal congestion y CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension, palpitations, edema y EENT: Blurred vision, diplopia, dry mouth, increased

y y y y y y y

salivation GI: Anorexia, constipation, diarrhea, elevated liver enzymes, jaundice, nausea, vomiting GU: Libido changes, urinary incontinence, urine retention HEME: Neutropenia MS: Dysarthria, muscle weakness RESP: Respiratory depression SKIN: Dermatitis, urticarial, pruritus, skin rash Other: Phlebitis and thrombosis at the IV injection sites, hiccups, fever, diaphoresis, paresthesias, muscular disturbances, gynecomastia; pain, burning, and redness after MI injection. Nursing responsibilities Assessment 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 patients with history of alcohol or drug abuse because it

can cause physical and psychological dependence, and in patients with hepatic disorders such as hepatic fibrosis and hepatitis because of potentially significant increase in drug s half-life. Use diazepam cautiously in patients with hepatic or renal impairment. Severe hepatitis impairment is a contraindication to use. Expect to give a lower diazepam dose to patient with chronic respiratory insufficiency because of risk of respiratory depression. Mix concentration oral solution (Intensol) with liquid or semisolid food. Use supplied calibrated dropper to measures dose. Protect diazepam injection from light. Don t use solution that s more that slightly yellow or that contains precipitate. Give I.M. injection into deltoid muscle for rapid, complete absorption. Using other sites may cause slow, erratic absorption. Before administering emulsion form, ask if patient is allergic to soybeans because this form contains soybean oil. For an infant or a child, administer I.V. injection slowly over 3 minutes in a dose not to exceed 0.25% mg/kg. Give emulsion form within 6 hours of opening ampule because it contains no preservatives and allow rapid microbial growth. Use polyethylenelined or glass infusion sets and polyethylene or polypropylene plastic syringes for

administration. Don t use a filter with a pore size less than 5 microns because a smaller size may break down the emulsion. Monitor patient for adverse reactions, especially if she has hypoalbuminemia, which increases the risk of sedation. Warning Watch for signs of physical and psychological dependence (strong desire or need to continue taking diazepam, need to increase dose to maintain drug effects, and posttherapy withdrawal symptoms, such as abdominal cramps, insomnia, irritability, nervousness, and tremor). Monitor patient closely for increase in frequency or severity of grand mal seizures when diazepam is used with standard anticonvulsant therapy. Dosage of other anticonvulsants may need to be increased. Avoid abrupt withdrawal of diazepam, as ordered, when used as part of the patient s seizure control regimen because a transient increase in frequency or severity of seizure may occur. Monitor severely depressed patient or one with depression-related anxiety for suicidal tendencies, particularly when therapy starts and dosage changes; depression may worsen temporarily during these times. Watch for psychiatric and paradoxical reactions to diazepam, especially in children and the elderly. If reactions occur, notify prescriber and

y y

expect drug to be discontinued. Monitor patient for decreased drug effectiveness, especially with prolonged use. Check patient s blood counts and liver function periodically, as ordered, because prolonged diazepam therapy rarely causes neutropenia and jaundice.

Patient teaching: y Instruct patient not to take more drug, more often, 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 relieve everyday stress. y Advise patient to avoid hazardous activities until drug s CNS depressants and alcohol during the therapy. y Instruct the patient not to stop taking the drug abruptly without the prescriber s supervision. If the patient has a history of seizures, warn that abrupt withdrawal may trigger them. y Instruct patient to mix Diazepam Intensol with water, soda or similar beverage; applesauce; or pudding just before taking it. Caution her not to save the mixture for later. Tell her to use calibrated dropper that s provided to measure each dose. y Teach patient how to self-administer a rectal form, if prescribed. y Instruct female patient of childbearing age to

notify prescriber immediately if she is or could be pregnant because diazepam therapy will need to be discontinued. 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 collapse y EENT: Blurred vision, diplopia, dry mouth, increased salivation, photophobia y ENDO: Syndrome of inappropriate ADH

y y y y y y

GI: Abdominal pain, constipation, diarrhea, increased liver enzyme levels, jaundice, nausea, thirst, vomiting GU: Libido changes; incontinence, urinary retention, menstrual irregularities HEME:Agranulocytosis, pancytopenia, thrombocytopenia RESP: Apnea, respiratory depression, worsening of sleep apnea or obstructive pulmonary disease SKIN: Diaphoresis Other: Anaphylaxis, injection site pain (I.M.) or phlebitis (I.V.), physical and psychological dependence, withdrawal symptoms. Nursing responsibilities Assessment 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 patient with depression, make sure he already takes an

y y

antidepressant because of increased risk of suicide in patients with untreated depression. Use extreme caution when giving lorazepam to elderly patients, especially those with compromised respiratory function, because drug can cause hypoventilation, sedation, unsteadiness, and respiratory depression. Use drug cautiously in patients with a history of alcohol 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. For I.M. use, inject lorazepam deep into large muscle mass, such as gluteus maximus. For I.V. use, dilute lorazepam with equal amount of sterile water for injection, sodium chloride for injection, or D5W. Give diluted lorazepam slowly, at no more than 2 mg/min. During I.V. use, monitor patient s respirations every 5 to 15 minutes and keep emergency resuscitation equipment readily available. WARNING Monitor patient s respiratory status closely because drug may cause life threatening respiratory depression. Because stopping the drug abruptly increases risk of withdrawal symptoms, expect to taper dosage gradually, especially in epileptic patients.

Patient Teaching

y y

y y

Instruct the patient to take lorazepam exactly as prescribed and not to stop without consulting prescriber because of risk of withdrawal symptoms. Advise patient to avoid hazardous activities until drug s CNS effects are known. Urge patient to avoid alcohol while taking lorazepam because it increases drug s CNS depressant effects. Instruct the patient to report excessive drowsing and nausea. Inform pregnant patient that lorazepam therapy will need to be discontinued early in third trimester to avoid possible withdrawal symptoms in newborn.

e. Explain in their own words the mechanism of actions of the common barbiturate s used in OR.

B. Barbiturates 1. 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

EENT: Laryngospasm GI: Anorexia, constipation, nausea, vomiting, epigastric pain y MS: Arthralgia, muscle weakness y Hypersensitivity: Rashes, angioneurotic edema, serum sickness, morbilliform rash, urticarial; rarely, exfolliative dermatitis, Steven-Johnson s syndrome y RESP: Apnea, bronchospasm, respiratory depression, hypoventilation y SKIN: Jaundice y Other: Tolerance, psychological and physical dependence; anaphylaxis, angioedema, withdrawal syndrome Nursing responsibilities Assessment: 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 y y 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:

y y

Be aware that prolonged use of secobarbiral may lead to tolerance and physical and psychological dependence. Do not use as a bedtime hypnotic for longer than 2 weeks. 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. Assess patient for signs and symptoms of barbiturate toxicity, including dyspnea, severe confusion, and severe drowsiness. Notify prescriber immediately if they appear because barbiturate toxicity may be lifethreatening. Expect prescriber to provide patient with the least 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

y y

y y

y y

as prescribed because of the risk of addiction. Inform patient that taking drug with food may reduce adverse GI effects. Advise patient to avoid alcohol and caffeine and potentially hazardous activities during the therapy. Inform the patient about possible hangover effect. If the patient takes an oral contraceptive, recommend using an additional form of birth control during therapy. Caution patient not to stop taking drug abruptly. 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: hypotension y RESP: respiratory depression, bronchospasm

EENT: laryngospasm GI: constipation, diarrhea, nausea, vomiting. Derm:photosensitivity, rashes, urticaria. phlebitis at IV sitearthralgia, myalgia, neuralgia y Misc: hypersensitivity reactions including angioedema and serum sickness, physical dependence, psychological dependence. Nursing responsibilities Assessment: y Monitor respiratory status, pulse, and blood pressure frequently in patients receiving phenobarbital IV. Equipment for resuscitation and artificial ventilation should be readily available. Respiratory depression is dosedependent. y Prolonged therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient, especially if depressed, suicidal, or with a history of addiction. Geri: Elderly patients may react to phenobarbital with 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 y y y

anxiety when used as a preoperative sedative. Assess postoperative patients for pain with a pain scale. Phenobarbital may increase sensitivity to painful stimuli. Lab Test Considerations: Patients on prolonged therapy should have hepatic and renal function and CBC evaluated periodically. Monitor serum folate concentrations periodically during therapy because of increased folate 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. Toxicity and Overdose: Serum phenobarbital levels 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 with pentobarbital. y Supervise ambulation and transfer of patients following administration. Two side rails should

be raised and call bell within reach at all times. Keep bed in low position. Institute seizure and fall precautions. When changing from phenobarbital 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 15 30 min to reach peak concentrations in the brain. Administer minimal dose and wait for effectiveness before administering 2nd dose to prevent cumulative barbiturate-induced depression Reconstitute 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

precipitate. Discard powder or solution that has been exposed to air for longer than 30 min. 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 doses Advise 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.

Caution patient to avoid driving and other activities requiring alertness until response to medication is known. Do not resume driving until 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 may experience 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

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). f. Discuss 3 nursing responsibili ties for each H2 receptor blocking agent effectively. C. H2 receptor blocking agents H2 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 effects y CNS dizziness, drowsiness, fever, headache, insomnia y CV vasculitis y GI abdominal distress, constipation, diarrhea, nausea and vomiting y GU acute interstitial nephritis, impotence y MS arthralgia, myalgia y RESP bronchospasm y SKIN alopecia, erythema multiforme, rash y Other anaphylaxis, angioedema

Nursing responsibilities y Alert patients with phenylketonuria that effervescent 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 may require 4 to 8 weeks of therapy

2. Cimatidine  Classification: antiulcer, gastric acid secretion inhibitor, H2 receptor antagonists  Mechanism of action: Block histamine s action at H2 receptor sites on stomach s parietal cells. This action reduces gastric fluid volume 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 1 month y GI mild and transient diarrhea y GU impotence, transiently elevated serum creatinine level y SKIN rash y Other pain at IM injection site

Nursing responsibilities y Be aware that rapid administration of cimetidine can increase risk of arrhythmias and hypotension. y Be alert for confusion in elderly or debilitated patients who receive cimetidine. y Advise patient to avoid alcohol while taking cimetidine to prevent interactions. Instruct patient to avoid taking antacids within 1 hour of taking cimetidine. y Warn patient that cigarette smoking increases gastric 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, vasculitis y EENT amblyopia, dry mouth, laryngeal edema, pharyngitis, rhinitis, sinusitis y ENDO gynecomastia

GI abdominal pain, constipation, diarrhea, hepatitis, nausea, vomiting y GU decreased libido, hyperuricemia not associated with gout or nephrolithiasis impotence y HEME anemia, aplastic anemia, eosinophilia, hemolytic anemia, leucopenia, neutropenia, pancytopenia, thrombocytopenia y MS back pain, myalgia y RESP bronchospasm, cough y 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 responsibilities y Monitor CBC, BUN and serum creatinine levels, and liver function test results before and periodically during nizatidine therapy. y Don t 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 to heal. y Smoking increases gastric acid production y 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 immediately about abdominal pain, easy bruising, extreme y

fatigue, yellow skin or sclera, trouble swallowing food, bloody vomitus or bloody or tarry stools. Urge the patient not to take nizatidine with other acid reducers.

g. Comprehen sively explain the significance and use of inhalation gases in the OR.

D. Inhalation gases 1. 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 of oxygen 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 tissue levels 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 action Oxygen is essential for cell metabolism, and in turn, tissue oxygenation is essential for all normal physiological functions.  Adverse/ side effects Oxygen should never be given to a patient who is suffering from paraquat poisoning unless they are

suffering from severe respiratory distress or respiratory arrest, as this can increase the toxicity. (Paraquat poisoning is rare for example 200 deaths globally from 1958 1978). 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, reduces inflammation and post-stroke cerebral edema. Nursing responsibilities y 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 also known 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,

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-Daspartate receptors as well. In general, the effect of nitrous oxide ceases as soon as the inhalation stops, with no residual effect. Adverse/ side effects y 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) is described with nearly all inhaled anesthetics including nitrous oxide. y Inadvertent use of nitrous oxide in pregnancy may 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

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 potentially inhibit 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 with nitrous oxide include gagging, coughing, hypotension, asthma attack, involuntary tracheal closure (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 responsibilities y 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 y

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 During nitrous oxide administration, the flow rate is adjusted based on the patient s overall ventilation. The initial flow rate is set at 5 6 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 becomes hyperinflated, 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 patient s respiratory rate may vary. The patients are told that they will not go to

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 is removed 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, we usually 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. We start the nitrous after the patient has been prepped and draped and immediately before we

scrub in for the case. This has shortened nitrous oxide administration time from 30 40 minutes to 10 20, 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 we place 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 own nose, 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

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, titration allows 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 or just 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

y Coughing y Nausea or vomiting y Dizziness y Headache y Irritated or red eyes y Nervousness and restlessness y Sore throat Nursing responsibilities y 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 or dentist, do not drink alcoholic beverages or take other 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)

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 and raises 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 are hepatotoxicity. 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 tigger off 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

monitoring, correction of arrhythmias and blood pressure, maintenance of fluid and electrolyte balance. Nursing responsibilities The 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, administration should 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, pulse rate 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

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 effects y Coughing, laryngospasm, salivation, etc., during induction. y Increases intracranial pressure. y In susceptible individuals, malignant hyperpyrexia can occur. y Hypotension y Cardiac and respiratory arrest may occur Nursing responsibilities y If side effects occur, discontinuance of triggering agents (e.g., Isoflurane), administration of intravenous dantrolene sodium, and application of supportive therapy. Such therapy includes vigorous efforts to restore body temperature to normal, respiratory and circulatory support as indicated, and management of electrolyte-fluidacid-base derangements.

E. Intravenous anesthesia These are used for induction or maintenance of general anesthesia, induction of amnesia, and as an adjunct to inhalation-type anesthetics. h. Give 5 possible 1. Etomidate  Mechanism of action:

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, hiccup and 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 responsibilities y Resuscitative equipment must be readily available in case or cardiorespiratory distress or arrest. y Status of breath sounds should be assessed by auscultation (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 postanesthesia process, especially if there is a need to turn, cough and deep breathe (which helps to prevent atelectasis and pneumonia.

Encourage ambulation with assistance as needed. This helps to increase circulation and improve ventilation to the alveoli of the lungs; consequently, circulation to the legs will be improved.

i.

Enumerate 3 common antiemetic used in the OR effectively.

F. Antiemetics Used 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 patient s nutritional status. Most of the antiemeticsact 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 partially depresses 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 changes y GI: constipation, dry mouth, increased appetite y GU: urine retention, dark urine, inhibited ejaculation, menstrual irregularities y Hematologic: agranulocytosis, transient leukopenia, y Hepatic: cholestatic jaundice

Metabolic: weight gain 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, especially when giving drug I.V. y For I.M. use, inject deeply into upper outer quadrant of gluteal region. y Do not give by subcutaneous route or mix in syringe with another drug. y To prevent contact dermatitis, avoid getting concentrate or injection solution on hands or clothing. y Monitor CBC and liver function studies during long-term therapy. y Alert: use drug only when vomiting cannot be controlled 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 yellowing does not affect potency; discard extremely discolored solutions. y Teach patient what to use to dilute oral solution. Advise patient to wear protective clothing when exposed to sunlight. y y

2. Droperidol

Mechanism of action: Unknown. Tranquilizes, sedates and 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,tachycardia y Respiratory: laryngospasm, bronchospasm y Skin: chills, shivering Nursing responsibilities y 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 manage hypotension readily available. y Monitor patient for neuroleptic malignant syndrome: altered mental status, autonomic instability, muscle rigidity, and hyperpyrexia y Warn patient to rise slowly to minimize dizziness. y Advise patient to avoid alcohol for 24 hours after receiving 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

has local anesthetic effects. Adverse/ side effects: y CNS: drowsiness, sedation, confusion, sleepiness, dizziness, disorientation, extrapyramidal symptoms y CV: hypotension, hypertension y EENT: dry mouth, blurred vision y GI: nausea, vomiting y GU: urine retention y Hematologic: agranulocytosis, leukopenia, thrombocytopenia y Metabolic: hyperglycemia y Respiratory: respiratory depression, apnea y Skin: photosensitivity, rash Nursing responsibilities y Monitor patient for neuroleptic malignant syndrome: altered mental status, autonomic instability, muscle rigidity, and hyperpyrexia y 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, usually to increase sedation; it has no analgesic activity. y I.M. injection is the preferred parenteral route. Inject deep I.M. into large muscle mass. Rotate injection sites. y Alert: Do not give subcutaneously. y Drug may be mixed with meperidine in same syringe. y In patients scheduled with myelogram, stop drug 48 hours before procedure. Do not resume drug

y y y

y y

until 24 hours after procedure because of the risk of seizures. Look alike- sound alike: do not confuse promethazine with promazine. Tell patient to take oral form with food or milk to reduce GI distress. When treating motion sickness, tell patient to take 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 evening meal. Warn patient to avoid alcohol and hazardous activities that require alertness until CNS effects of drug are known. Inform patient that sugarless gum , hard candy or ice chips may relieve dry mouth. Warn patient about possible photosensitivity reactions. 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, extrapyramidal reactions, parkinsonism-like reactions, akathisia, dystonia, myoclonus, dizziness, anxiety y CV: transient hypertension, bradycardia,

supraventricular tachycardia, hypotension y GI: nausea, diarrhea, bowel disorders y GU: incontinence, urinary frequency y Hematologic: agranulocytosis, neutropenia y Skin: rash, urticarial y Others: loss of libido, prolactin secretion Nursing responsibilities y Monitor BP carefully during IV administration. y Monitor for extrapyramidal reactions, and consult physician if they occur. y Monitor diabetic patients, arrange for alteration in insulin dose or timing if diabetic control is compromised by alterations in timing of food absorption. y WARNING: Keep diphenhydramine injection readily available in case extrapyramidal reactions occur (50 mg IM). y WARNING: Have phentolamine readily available in case of hypertensive crisis (most likely to occur with undiagnosed pheochromocytoma). y Teach patient to take this drug exactly as prescribed. y Do not use alcohol, sleep remedies, sedatives; serious sedation could occur. y Inform patient about possibility of experiencing these 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, and/or severe diarrhea. j. Define briefly an anticoagula nt and its action. G. Anticoagulants These 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 an established 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: fever y EENT: rhinitis y 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 responsibilities y Adjust dose according to coagulation test results

y y y y

y y

y y y

performed just before injection (30 min before each intermittent dose or q 4 6 hr if continuous IV dose). Therapeutic range aPTT: 1.5 2.5 times control. Always check compatibilities with other IV solutions. Use heparin lock needle to avoid repeated injections. Give deep subcutaneous injections; do not give heparin by IM injection. Do not give IM injections to patients on heparin therapy (heparin predisposes to hematoma formation). WARNING: Apply pressure to all injection sites after needle is withdrawn; inspect injection sites for signs of hematoma; do not massage injection sites. Mix well when adding heparin to IV infusion. Do not add heparin to infusion lines of other drugs, and do not piggyback other drugs into heparin line. If this must be done, ensure drug compatibility. Check for signs of bleeding; monitor blood tests. Alert all health care providers of heparin use. 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. This drug must be given by a parenteral route

y y

(cannot be taken orally). Frequent blood tests are necessary to determine blood clotting time is within the correct range. Be careful to avoid injury: Use an electric razor, avoid contact sports and other activities that might lead to injury. Loss of hair may be experienced. Report nosebleed, bleeding of the gums, unusual bruising, black or tarry stools, cloudy or dark urine, abdominal or lower back pain, severe headache.

k. Evaluate effectively the roles and responsibili ties of nurses in administrati on of the common OR drugs and anesthesia

VII.

Open Forum

10 mins. Socialized discussion Interactive discussion

VIII.

Evaluation

Satisfactory 10 mins. Paper and pencil performance in pencil acitivity and paper test @75% level of mastery.

References: Deglin, J. H. &Valler, A. H. (2005).Davis s 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 Nurse s drug handbook (10thed.). USA: Jones and Barlett Learning, LLC. Karch, A. C. (2008). Focus on nursing pharmacology (4thed.). USA: Lippincott Williams & Wilkins. Smeltzer, S. (et al.).(2010). Brunner and suddarth s Medical surgical nursing (12thed.).China: Lippincott Company.