# NCLEX: Physiological Integrity; Pharmacological and Parenteral Therapies

## Physiological Integrity; Pharmacological and Parenteral Therapies: CONVERSIONS AND CALCULATIONS IN MEDICATION ADMINISTRATION

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

COMMON METRIC CONVERSION

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Weight:

1 gram (gm) = 1,000,000 micrograms (mcg)
1 milligram (mg) = 1,000 micrograms (mcg)
1,000 milligrams (mg) = 1 gram (gm)
1 kilogram (kg) = 1,000 grams (gm)

B. Volume:

1 liter (L) = 1,000 milliliters (mL)
1 kiloliter (kL) = 1,000 liters (L)
1 milliliter (mL) = 1 cubic centimeter (cc)

APOTHECARY SYSTEM (Note: metric is preferred for medication administration.)

A. Weight:

60 grains (gr) = 1 dram (dr)
8 drams (dr) = 1 ounce (oz)

B. Liquid:

60 minims = 1 fluidram (fl dr)
8 fluidrams (fl dr) = 1 fluidounce (fl oz)
16 fluidounces (fl oz) = 1 pint (pt)
2 pints (pt) = 1 quart (qt)
4 quarts (qt) = 1 gallon (gal)

EQUIVALENT HOUSEHOLD CONVERSIONS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

20 drops (gtt) = 1 milliliter (mL)
1 teaspoon (tsp) = 5 milliliters (mL)
1 ounce (oz) = 30 milliliters (mL)
1 cup (C) = 240 milliliters (mL)
1 liter (L) = 1,000 milliliters (mL)

DETERMINING EQUIVALENCY FROM ONE SYSTEM TO ANOTHER

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

Use a proportion. On the left side of the proportion is what you know to be an equivalent (e.g., 30 milliliters equals 1 ounce). On the right side of the proportion is what you need to determine (e.g., you want to give 1.5 ounces and your medicine cup is in milliliters—you would write “x“ milliliters equals 1.5 ounces). Rewrite the proportion without using the symbols.

Example:

1 oz : 30 mL :: x mL : 1.5 oz
Solve for x:
1x = 30 × 1.5
x = 45
1.5 ounces equals 45 milliliters (mL)

ALTERNATE FORMULA FOR CALCULATION WITH LIKE UNITS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

[latex] \frac D {(Desired Amount)} {A (Available Amount)} [\latex] × Q (Quantity Available) = x

Example: the order is for 50 mg of phenobarbital, which comes in 20 mg per 5 mL.

DIMENSIONAL ANALYSIS FOR CONVERSION AND CALCULATION

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

Another format for dosage calculation that uses only one equation even when conversion to like units is needed.

Example with like units: penicillin 500 mg comes in 250-mg capsules. You would give _______ capsules. On the left side of the equation is the drug form you are solving for:
x capsules =
On the right side, place the known information in a common fraction with the numerator matching the x quantity (capsules). The amount in each capsule that is known is the denominator (250 mg):

Example with different units: Keflin 400 mg IM q10h. The drug is available in 0.5 gm per 2 mL.

### Physiological Integrity; Pharmacological and Parenteral Therapies: MEDICATION ADMINISTRATION: INFANTS AND CHILDREN

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

DEVELOPMENTAL CONSIDERATIONS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Be honest. Do not bribe or threaten child to obtain cooperation.

B. When administering medication, do so in the least traumatic manner possible.

C. Describe any sensations child may expect to experience (e.g., “pinch” of needle during IM).

D. Explain how child can “help” nurse (e.g., “Lie as still as you can”).

E. Tell child that it is OK to cry; provide privacy.

F. Offer support, praise, and encouragement during and after giving medication.

G. Allow child opportunity for age-appropriate therapeutic play to work through feelings and experiences, to clarify any misconceptions, and to teach child more effective coping strategies.

SAFETY CONSIDERATIONS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Be absolutely sure dose you are giving is both safe (check recommended mg/kg) and accurate (have another nurse check your calculations). Remember: dose should generally be smaller than adult dose.

B. Check identification band or ask parent or another nurse for child’s first and last name.

C. Restrain child to avoid injury while giving medication; a second person is often required to help hold child.

ORAL MEDICATIONS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Use syringe without needle to draw up medication.

B. Position: upright or semireclining.

C. Place tip of syringe along the side of infant’s tongue, and give medication slowly, in small amounts, allowing infant to swallow. Medicine cups can be used for older infants and children. Never pinch infant or child’s nostrils to force the child to open mouth.

D. When giving tablets or capsules (that are not enteric coated), crush and mix into smallest possible amount of food or liquid to ensure that child takes entire dose. Do not mix with essential food or liquid (e.g., milk); select an “optional” food, such as applesauce.

OPHTHALMIC INSTILLATIONS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Position: supine or sitting with head extended.

B. For eyedrops: hold dropper 1 to 2 cm above middle of conjunctival sac.

C. For eye ointment: squeeze 2 cm of ointment from tube onto conjunctival sac.

D. After giving drops or ointment, encourage child to keep eyes closed briefly, to maximize contact with eyes. Child should be asked to look in all directions (with eyes closed) to enhance even distribution of medication.

E. Whenever possible, administer eye ointments at nap time or bedtime, due to possible blurred vision. Administer eyedrops prior to ointment (if both are ordered for the same time). Eyedrops may “roll off ” the slick surface of the eye ointment.

OTIC INSTILLATIONS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Position: head to side so that affected ear is uppermost.

B. For child under 3 years of age: pull pinna gently down and back.

C. For child 3 years of age and over: pull pinna gently up and back.

D. After administering eardrops, encourage child to remain with head to side with affected ear uppermost, to maximize contact with entire external canal to reach eardrum. Gentle massage of area in front of ear will facilitate entry of eardrops into canal.

E. If eardrops are kept in refrigerator, allow to warm to room temperature before instilling.

DERMATOLOGICAL INSTILLATIONS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Remember: young child’s skin is more permeable; therefore, there is increased risk for medication absorption and resultant systemic effects. Monitor for systemic effects.

B. Apply thin layer of cream or ointment, and confine it to portions of skin where it is essential.

RECTAL MEDICATIONS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Prepare child emotionally and physically; rectal route is invasive and embarrassing, particularly for children.

B. Position: side-lying with upper leg flexed.

C. Lubricate rounded end of suppository and insert past anal sphincter with gloved fingertip (wear double gloves when inserting rectal medication).

D. Remove fingertip but hold child’s buttocks gently together until child no longer strains or indicates urge to expel medication.

INTRAMUSCULAR MEDICATIONS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Because the infant or child is much smaller physically than an adult, the nurse should select a shorter needle, generally 5/8 inch (infant) to 1 inch (child).

B. Preferred injection sites in infants and young children include the vastus lateralis and ventrogluteal muscles. The deltoid muscle, though small, provides easy access and can be used in children over 12 months of age with adequate muscle mass.

C. Usually 1 mL is the maximum volume that should be administered in a single site to infants and children.

D. Because of vast differences in size, muscle mass, and subcutaneous tissue, it is especially important to note bony prominences as landmarks for intramuscular injections.

E. Have a second adult present to help restrain the child.

F. Once the nurse has told the child he or she is to receive an injection, the procedure should be carried out as quickly and skillfully as possible.

### Physiological Integrity; Pharmacological and Parenteral Therapies: INTRAVENOUS THERAPY/BLOOD ADMINISTRATION

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

INFUSION SYSTEMS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Plastic bag:

1. Contains no vacuum—needs no air to replace fluid as it flows from container.

2. Medication can be added with syringe through a resealable latex port.

a. During infusion, administration set should be completely clamped before medications are added.

b. Prevents undiluted, and perhaps toxic, dose from entering administration set.

B. Closed system:

1. Requires partial vacuum—however, only filtered air enters container.

2. Medication may be added during infusion through air vent in administration set.

1. Standard sets—deliver 10 to 15 drops (gtt)/mL.

2. Pediatric or minidrop sets—deliver 60 drops (gtt)/mL.

3. Controlled-volume sets—permit accurate infusion of measured volumes of fluids.

a. Particularly valuable when piggybacked into primary infusion.

b. Solutions containing drugs can then be administered intermittently.

4. Y-type administration sets—allow for simultaneous or alternate infusion of two fluids.

a. May contain filter and pressure unit for blood transfusions.

b. Air embolism significant hazard with this type of administration set.

5. Positive-pressure sets—designed for rapid infusion of replacement fluids.

a. In emergency, built-in pressure chamber increases rate of blood administration.

b. Pump chamber must be filled at all times to avoid air embolism.

c. Application of positive pressure to infusion fluids is responsibility of physician.

6. Infusion pumps—used to deliver small volumes of fluid or doses of high-potency drugs.

a. Used primarily in neonatal, pediatric, and adult intensive care units.

b. Have increased the safety of parenteral therapy and reduced nursing time.

D. Long-term delivery systems—centrally placed venous access catheters and ports for the administration of drugs (e.g., chemotherapy), blood and blood products, antibiotics, analgesics, antiemetics, and total parenteral nutrition (TPN). Types: Hickman/Broviac, Groshong, venous access port (VAP).

1. Inserted under strict aseptic conditions using local or general anesthesia.

2. Major concern: prevention of infection.

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Factors influencing rate:

1. Client’s size.

2. Client’s physical condition.

3. Age of client.

4. Type of fluid.

5. Client’s tolerance to fluid.

6. Client’s position.

B. Flow rates for parenteral infusions can be computed using the following formula:

C. Generally the type of fluid administration set determines its rate of flow.

1. Fluid administration sets—approximately 15 gtt/min.

2. Blood administration sets—approximately 10 gtt/min.

3. Pediatric administration sets—approximately 60 gtt/min.

4. Always check information on the administration set box to determine the number of gtt/mL before calculating; varies with manufacturer.

D. Factors influencing flow rates:

1. Gravity—a change in the height of the infusion bottle will increase or decrease the rate of flow; for example, raising the bottle higher will increase the rate of flow, and vice versa.

2. Blood clot in needle—stopping the infusion for any reason or an increase in venous pressure may result in partial or total obstruction of needle by clot due to:

a. Delay in changing infusion bottle.

b. Blood pressure cuff on, or restraints on or above infusion needle.

c. Client lying on arm in which infusion is being made.

3. Change in needle position—against or away from vein wall.

4. Venous spasm—due to cold blood or irritating solution.

5. Plugged vent—causes infusion to stop.

FLUID AND ELECTROLYTE THERAPY

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Types of therapy:

1. Maintenance therapy—provides water, electrolytes, glucose, vitamins, and in some instances protein to meet daily requirements.

2. Restoration of deficits—in addition to maintenance therapy, fluid and electrolytes are added to replace previous losses.

3. Replacement therapy—infusions to replace current losses in fluid and electrolytes.

B. Types of intravenous fluids (Commonly Used Intravenous Fluids):

1. Isotonic solutions—fluids that approximate the osmolarity (280 to 300 mOsm/L) of normal blood plasma.

a. Sodium chloride (0.9%)—normal saline.

• Indications:

(a) Extracellular fluid replacement when Cl– loss is equal to or greater than Na+ loss.
(b) Treatment of metabolic alkalosis.
(c) Na+ depletion.
(d) Initiating and terminating blood transfusions.

• Possible side effects:

(a) Hypernatremia.
(b) Acidosis.
(c) Hypokalemia.

b. Five percent dextrose in water (D5W).

• Provides calories for energy, sparing body protein and preventing ketosis resulting from fat breakdown.

(a) 3.75 calories are provided per gram of glucose.
(b) United States Pharmacopeia (USP) standards require use of monohydrated glucose, so only 91% is actually glucose.
(c) D5W yields 170.6 calories; D5W means 5 grams glucose/100 mL water.
50 × 3.75 = 187.5 calories/L
0.91 × 187.5 = 170.6 calories/L

• Indications:

(a) Dehydration.
(b) Hypernatremia.

• Possible side effects:

(a) Hypokalemia.
(b) Osmotic diuresis—dehydration.
(c) Transient hyperinsulinism.
(d) Water intoxication.

c. Five percent dextrose in normal saline (D5NS).

• Prevents ketone formation and loss of potassium and intracellular water.
• Indications:

(a) Hypovolemic shock—temporary measure.
(b) Burns.

• Same side effects as normal saline.

d. Isotonic multiple-electrolyte fluids—used for replacement therapy; ionic composition approximates blood plasma.

• Types—Plasmanate, Polysol, and lactated Ringer’s.
• Indicated in: vomiting, diarrhea, excessive diuresis, and burns.
• Lactated Ringer’s is contraindicated in severe metabolic acidosis and/or alkalosis and liver disease.
• Same side effects as normal saline.

2. Hypertonic solutions—fluids with an osmolarity much higher than 310 mOsm (+50 mOsm); increase osmotic pressure of blood plasma, thereby drawing fluid from the cells.

a. Ten percent dextrose in normal saline (D10NS).

• Administered in large vein to dilute and prevent venous trauma.
• Used for: nutrition and to replenish Na+ and Cl–.
• Possible side effects:

(a) Hypernatremia (excess Na+).
(b) Acidosis (excess Cl–).

b. Sodium chloride solutions, 3% and 5%.

• Indicated in water intoxication and severe sodium depletion.

3. Hypotonic solutions—fluids whose osmolarity is significantly less than that of blood plasma (–50 mOsm); these fluids lower plasma osmotic pressures, causing fluid to enter cells.

a. 0.45% sodium chloride—used for replacement when requirement for Na+ use is questionable.

b. 2.5% dextrose (D) in 0.45% saline, also 5% D in 0.2% NaCl—common rehydrating solution.

• Indications:

(a) Fluid replacement when some Na+ replacement is also necessary.

(b) Encourage diuresis in clients who are dehydrated.

(c) Evaluate kidney status before instituting electrolyte infusions.

• Possible side effects:

(a) Hypernatremia.
(c) Use with caution in clients who are edematous with cardiac, renal, or hepatic disease.
(d) After adequate renal function is established, appropriate electrolytes should be given to avoid hypokalemia.

4. Alkalizing agents—fluids used in the treatment of metabolic acidosis:

a. Ringer’s:

• Administration—rate usually not more than 300 mL/hr.
• Side effects—observe carefully for signs of alkalosis.

b. Sodium bicarbonate:

• Indications:

(a) Replace excessive loss of bicarbonate ion.
(b) Emergency treatment of life-threatening acidosis.

(a) Depends on client’s weight, condition, and carbon dioxide level.
(b) Usual dose is 500 mL of a 1.5% solution (89 mEq).

• Side effects:

(a) Alkalosis.
(b) Hypocalcemic tetany.
(c) Rapid infusion may induce cellular acidity and death.

5. Acidifying solutions—fluids used in treatment of metabolic alkalosis.

a. Types:

• Normal saline.
• Ammonium chloride.

b. Administration—dosage depends on client’s condition and serum laboratory values.

c. Side effects:

• Hepatic encephalopathy in presence of decreased liver function because ammonia is metabolized by liver.
• Toxic effects: irregular respirations, twitching, and bradycardia.
• Contraindicated with renal failure.

6. Blood and blood products (Transfusion with Blood or Blood Products).

a. Indications:

• Maintenance of blood volume.
• Supply red blood cells to maintain oxygen-carrying capacity.
• Supply clotting factors to maintain coagulation properties.
• Exchange transfusion.

INTRAVENOUS CANCER CHEMOTHERAPY

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Usual sites: forearm, dorsum of hand, wrist, antecubital fossa.

B. Procedure:

1. Normal saline infusion usually started first, to verify vein patency, position of needle. Chemotherapy “piggybacked” into IV line that is running.

2. Rate: usually 1 mL/min. Running slowly decreases nausea, vomiting, and the degree of vein damage.

3. Check vein patency every 3 to 5 minutes.

4. If more than one drug is to be infused, normal saline should be infused between drugs.

5. Never infuse against resistance.

6. Stop treatment if client reports pain at needle site. Extravasation (infiltration of toxic drugs into tissue surrounding vessel) may be present

7. If extravasation present, begin protocol appropriate to drug administered (e.g., flushing of line with saline, applying ice or heat, local injection of site with antidote drugs, topical application of steroid creams).

8. Once treatment is completed, remove needle, apply Band-Aid, exert pressure to prevent hematoma formation.

COMPLICATIONS OF IV THERAPY (Complications of IV Therapy).

TOTAL PARENTERAL NUTRITION (TPN): nutrition through a central venous line to clients who are in a catabolic state; are malnourished and cannot tolerate food by mouth or enteral nutrition; are in negative nitrogen balance; or have conditions that interfere with protein ingestion, digestion, and absorption (e.g., Crohn’s disease, major burns, and side effects of radiation therapy of abdomen). Least desirable route for nutrition.

A. Types of solutions:

1. Hydrolyzed proteins (Hyprotein, Amigen).

2. Synthetic amino acids (Freamine).

3. Usual components:

a. 3% to 8% amino acid.

b. 10% to 25% glucose.

c. Multivitamins.

d. Electrolytes.

4. Supplements that can be added:

a. Fructose.

b. Alcohol.

c. Minerals: iron, copper, calcium.

d. Trace elements: iodine, zinc, magnesium.

e. Vitamins: A, B, C.

f. Androgen hormone therapy.

g. Insulin.

h. Heparin.

i. Fats (lipid or fat emulsions) with prolonged use. Lipid emulsions are contraindicated if client has allergy to eggs or is on ↑ lipid-containing medications such as propofol (Diprivan).

1. Dosage varies with clinical condition; 1 to 2 L over 24 hours at a constant IV drip rate. If TPN is discontinued, the rate must be tapered over 4 to 8 hours to avoid fluid, electrolyte abnormalities.

2. Solution prepared under laminar flow hood (usually in pharmacy); solution must be refrigerated; when refrigerated, expires in 24 hours; once removed from refrigerator, expires in 12 hours.

3. Incompatible with most medications; check with pharmacy. Give in a dedicated TPN line. Do not inject IV push medications into TPN line.

4. Route: Must be given via central line catheter—double- or triple-lumen catheter or infusion port of pulmonary artery (PA) catheter inserted by physician into internal jugular or subclavian vein. More commonly given via peripherally inserted central catheter (PICC line), inserted by specially trained IV nurses into brachial or cephalic veins. Placement must be confirmed by x-ray before beginning infusion. Catheter tip in superior vena cava or right atrium.

5. Management of PICC line:

a. Always wash hands before handling.

b. Do not take BP in PICC arm.

c. No needle sticks near or above PICC. If possible draw blood from opposite arm.

d. Avoid excessive shoulder use; if sent home with PICC, cautious use of backpacks, playing basketball, shoveling, weight lifting.

e. Cover PICC arm before bathing/showering.

f. If dressing becomes wet, soiled, or loose, change as soon as possible.

g. If catheter breaks, secure with tape and call care provider.

h. If sudden chest pain, shortness of breath (SOB), or gurgling sensation heard near ear with catheter breakage, clamp or pinch catheter, have client lie on left side with head down. Call physician.

6. Side effects:

a. Hyperosmolar coma.

b. Hyperglycemia greater than 130 mg/dL.

c. Septicemia.

d. Thrombosis/sclerosis of vein.

e. Air embolus.

f. Pneumothorax.

C. Analysis/nursing diagnosis:

1. Fluid volume excess, potential, related to inability to tolerate amount and consistency of solution.

2. Fluid volume deficit related to state of malnutrition.

3. Risk for injury related to possible complications.

4. Altered nutrition, more or less than body requirements, related to ability to tolerate parenteral nutrition.

D. Nursing care plan/implementation:

1. Goal: prevent infection.

a. Dressing change:

• Strict aseptic technique.
• Nurse and client wear mask during dressing change.
• Cleanse skin with solution as ordered:

(a) Acetone to defat the skin, destroy the bacterial wall.
(b) Iodine 1% solution as antiseptic agent.

• Dressing changed q48–72h; transparent polyurethane dressings may be changed weekly.
• Mark with nurse’s initials, date and time of change.
• Air-occlusive dressing.

b. Attach final filter on tubing setup, to prevent air embolism.

c. Solution: change q24h to prevent infection.

d. Culture wound and catheter tip if signs of infection appear.

e. Monitor temperature q4h.

f. Use lumen line for feeding only (not for CVP or medications).

2. Goal: prevent fluid and electrolyte imbalance.

a. Daily weights.

b. I&O.

c. Blood glucose q6h for 24 hours using glucometer; may need insulin coverage. If normal range, change to daily.

d. Monitor Chem 20 electrolytes biweekly initially.

e. Infusion pump to maintain constant infusion rate.

3. Goal: prevent complications.

a. Warm TPN solution to room temperature to prevent chills.

b. Monitor for signs of complications (Complications Associated with Total Parenteral Nutrition).

• Infiltration.
• Thrombophlebitis.
• Fever.
• Hyperglycemia.
• Fluid and electrolyte imbalance.

c. Have client perform Valsalva maneuver or apply a plastic-coated clamp when changing tubing to prevent air embolism.

d. Tape tubings together to prevent accidental separation.

E. Evaluation/outcome criteria:

1. No signs of infection.

2. Blood sugar less than 130 mg/dL.

3. Electrolytes within normal limits.

4. Wounds begin to heal.

5. Weight: no further loss, begins to gain.

## Physiological Integrity; Pharmacological and Parenteral Therapies; PSYCHOTROPIC MEDICATIONS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

ANTIPSYCHOTICS (also called neuroleptics, major tranquilizers)

A. Typical antipsychotics:

1. Phenothiazines (prochlorperazine [Compazine], promazine HCl [Sparine], chlorpromazine HCl [Thorazine], thioridazine [Mellaril], trifluoperazine HCl [Stelazine], perphenazine [Trilafon], triflupromazine HCl [Vesprin], fluphenazine enanthate [Prolixin]).

2. Butyrophenones (haloperidol [Haldol, Serenace], droperidol fentanyl citrate [Innovar]).

3. Thiothixenes (chlorprothixene [Taractan], thiothixene [Navane])—chemically related to phenothiazines, with similar therapeutic effects.

4. Dibenzoxazepines—loxapine succinate [Loxitane])

B. Atypical antipsychotics:

1. Risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon).

a. Use—incremental increases for first 3 days to manage psychotic symptoms. Effective for both positive and negative symptoms of schizophrenia. Risperidone also available as longacting injection (Risperdal Consta): IM q 2 wk in alternate gluteal muscle site; delayed onset of action. Benefit: lower incidence of extrapyramidal symptoms.

b. Assessmentside effects: same as for typical antipsychotics but with higher incidence of weight gain.

2. Clozapine (Clozaril).

a. Use—those who do not respond to other neuroleptic antipsychotic drugs; offers relief from schizophrenic symptoms: hallucinations, delusions, flat affect, apathy.

b. Assessmentside effects:

• Most serious is agranulocytosis (potentially fatal; reversible if diagnosed within 1 to 2 weeks of onset).

(a) Symptoms of agranulocytosis: infection, high fever, chills, sore throat, malaise, ulceration of mucous membranes.
(b) Laboratory value: Discontinue drug with white blood cell (WBC) count less than 2,000 mcg/L or granulocyte count less than 1,000 mcg/L.

• Other side effects: seizures, tachycardia, orthostatic hypotension.
• Caution: must have weekly blood tests for WBC count; do not resume clozapine once it is discontinued, due to side effects.

C. General use of antipsychotic medications—acute and chronic psychoses; most useful in cases of disorganization of thought or behavior; to decrease panic, fear, hostility, restlessness, aggression, and withdrawal.

D. General assessmentside effects:

1. Hypersensitivity effects:

a. Blood dyscrasia—agranulocytosis, leukopenia, granulocytopenia.

b. Skin reactions—solar sensitivity, allergic dermatitis, flushing, blue-gray skin.

c. Obstructive jaundice.

2. Extrapyramidal symptoms (EPS) affecting voluntary movement and skeletal muscles

a. Parkinsonism (also called pseudoparkinsonism)—tremors, cogwheel rigidity, shuffling gait, pill-rolling, masklike facies, salivation, and difficulty starting muscular movement (dyskinesia).

b. Dystonia—limb and neck spasms (torticollis), extensive rigidity of back muscles (opisthotonos), oculogyric crisis, speech and swallowing difficulties, and protrusion of tongue.

c. Akathisia—motor restlessness, pacing, foot tapping, inner tremulousness, and agitation.

d. Tardive dyskinesia (TD)—excessive blinking; vermiform tongue movement; stereotyped, abnormal, involuntary sucking, chewing, licking, and pursing movements of tongue and mouth; grimacing, frowning, rocking.

• Cause—long-term use of high doses of antipsychotic drugs.
•  Predisposing factors—age, women, organic brain syndrome (OBS); history of electro-convulsive therapy (ECT) or use of tricyclic antidepressants or anti-Parkinson drugs.

3. Potentiates central nervous system depressants.

4. Orthostatic hypotension (less with butyrophenones).

5. Anticholinergic effects (atropine-like)—dry mouth, stuffy nose, blurred vision, urinary retention, and constipation.

6. Pigmentary retinopathy—ocular changes (lens and corneal opacity).

7. Photosensitivity.

8. Weight gain (especially true of the atypical antipsychotic medications).

9. Neuroleptic malignant syndrome (NMS):

a. Description: a rare complication of antipsychotic drugs, with a rapid progression (1 to 3 days) and a 20% mortality rate. It is a serious medical emergency for which early recognition of symptoms is critical. Onset: at start, after change, or dose increase, when used with combination of medications.

b. Assessment:

• ↑Vital signs: extreme temperature of 107°F (leading to seizures, diaphoresis, confusion, → stupor, coma), fluctuating BP, pulse: irregular, tachycardia.
• Laboratory values: increased creatine phosphokinase (CPK), increased potassium, leukocytosis (↑ WBC).
• Renal failure.
• Muscular: parkinsonian rigidity (lead-pipe skeletal muscle rigidity) that leads to dyspnea and dysphagia, tremors, dyskinesia.
• At risk: clients with organic brain disorders and severe dehydration.

c. Medical treatment:

• Discontinue all drugs STAT.
• Institute supportive care.
• Administer bromocriptine (Parlodel) or dantrolene (Dantrium), dopamine function–enhancing substances (e.g., levodopa, carbidopa, bromocriptine, amantadine).

d. Health teaching: avoid overheating or dehydration; diet: ↑ fluids, ↑ fiber, hard candy.

E. Antipsychotic agents—comparison of side effects (Antipsychotic Agents—Comparison of Side Effects).

F. General nursing care plan/implementation:

1. Goal: anticipate and check for side effects.

a. Protect the person’s skin from sunburn when outside.

b. For hypotension: take BP and have person lie down for 30 minutes, especially after an injection.

c. Watch for signs of blood dyscrasia: sore throat, fever, malaise.

d. Observe for symptoms of hypothermic or hyperthermic reaction due to effect on heat-regulating mechanism.

e. Observe for, withhold drug for, and report early symptoms of: jaundice and bile tract obstruction; high fever; upper abdominal pain, nausea, diarrhea; rash; monitor liver function.

f. Relieve excessive mouth dryness: mouth rinse, increase fluid intake, gum or hard candy.

g. Relieve gastric irritation, constipation: take with and increase fluids and roughage in diet.

h. Observe for and report changes in carbohydrate metabolism (glycosuria, weight gain, polyphagia); change diet.

i. Check blood sugar levels periodically.

2. Goal: health teaching.

a. Dangers of drug potentiation with alcohol or sleeping pills.

b. Advise about driving or occupations where blurred vision may be a problem.

c. Caution against abrupt cessation at high doses.

d. Warn regarding dark urine (sign of jaundice, urinary retention).

e. Have client with respiratory disorder breathe deeply and cough (drug is a cough depressant).

f. Need for continuous use of drug and follow-up care.

g. Prompt reporting of hypersensitivity symptoms: fever, laryngeal edema; abdominal distention (constipation, urinary retention); jaundice; blood dyscrasia.

G. General evaluation/outcome criteria:

1. Behavior is less agitated.

2. Knows side effects to observe for, lessen, and/or prevent.

3. Continues to use drug.

ANTIDEPRESSANTS

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

A. Tricyclic antidepressants (TCAs) (imipramine HCl [Tofranil], desipramine HCl [Norpramine, Pertofrane], nortriptyline HCl [Pamelor, Aventyl], trimipramine [Surmontil], clomipramine [Anafranil], amitriptyline HCl [Elavil, Endep], amitriptyline HCl/perphenazine [Triavil], protriptyline HCl [Vivactil], doxepin HCl [Sinequan, Adapin]), bupropion (Wellbutrin), trazodone (Desyrel), amoxapine (Asendin)—effective in 2 to 4 weeks.

1. Use—elevate mood in depression, increase physical activity and mental alertness; may bring relief of symptoms of depression so that client can attend individual or group therapy; bipolar disorder, depressed; dysthymic disorder; sleep disturbance; agitation.

2. Assessmentside effects:

a. Behavioral—activation of latent schizophrenia (hallucinations); hypomania; suicide attempts; mental confusion. Withhold drug if observed.

b. Central nervous system (CNS)—tremors, seizures, ataxia, jitteriness, irritability.

c. Autonomic nervous system (ANS)—dry mouth, nasal congestion, aggravation of glaucoma (blurred vision), constipation, urinary retention, edema, paralysis, ECG changes (flattened T waves; arrhythmia severe in overdose).

3. Nursing care plan/implementation:

a. Goal: assess risk of suicide during initial improvement—careful, close observation.

b. Goal: prevent risk of tachycardia and cardiac arrhythmias and orthostatic hypotension—use caution with client with cardiovascular disease, hyperthyroidism, having ECT or surgery (gradually discontinue 2 to 3 days before surgery). Monitor BP, pulse twice a day; ECGs, 2 to 3/wk until dose adjusted.

• Avoid long hot showers or baths.

c. Goal: observe for signs of urinary retention, constipation: monitor I&O and weight gain (encourage exercise).

• Fiber diet.
• Reduced calories.

d. Goal: cautious drug use with glaucoma or history of seizures. Observe seizure precautions due to lowered seizure threshold.

e. Goal: health teaching.

• Advise against driving car or participating in activities requiring mental alertness, due to sedative effects.
• Encourage increased fluid intake and frequent mouth rinsing to combat dry mouth; use candy, ice; take with food.
• Avoid smoking, which decreases drug effects.
• Avoid use of alcohol and other drugs, due to adverse interactions, especially over-the-counter (OTC) drugs (e.g., antihistamines).
• Advise of delay in desired effect (2 to 4 weeks).
• Instruct gradual discontinuance to avoid withdrawal symptoms.

4. Evaluation/outcome criteria: diminished symptoms of agitated depression and anxiety.

B. Monoamine oxidase inhibitors (MAOIs) (phenelzine sulfate [Nardil], isocarboxazid [Marplan], tranylcypromine sulfate [Parnate], iproniazid [Marsilid], pargiline HCl [Eutonyl], nialamide [Niamid]).

1. Assessmentside effects:

a. Behavioral—may activate latent schizophrenia, mania, excitement.

b. CNS—tremors; hypertensive crisis (avoid: cheese, colas, caffeine, red wine, beer, yeast, chocolate, chicken liver, and other substances high in tyramine or pressor amines [e.g., amphetamines and cold and hay fever medication]); intracerebral hemorrhage; hyperpyrexia.

c. ANS—dry mouth, aggravation of glaucoma, bowel and bladder control problems; edema, paralysis, ECG changes (severe arrhythmia in overdose).

d. Allergic hepatocellular jaundice.

2. Nursing care plan/implementation:

a. Goal: reduce risk of hypertensive crisis—diet restrictions of foods high in tyramine content.

b. Goal: observe for urinary retention—measure I&O.

c. Goal: health teaching.

• Therapeutic response takes 2 to 3 weeks.
• Food and alcohol restrictions: avocados, bananas, raisins, licorice, chocolate, aged cheese, yogurt, sour cream, papaya, figs, overripe fruit, sausages, salami, bologna, liver, herring, soy sauce, meat tenderizers, red wine, beer, caffeine, cola, yeast, chocolate.
• Change position gradually to prevent postural hypotension.
• Report any stiff neck, palpitations, chest pain, headaches because of possible hypertensive crises (can be fatal).
• Take no nonprescribed drugs.

3. Evaluation/outcome criteria:

a. Improvement in sleep, appetite, activity, interest in self and surroundings.

b. Lessening of anxiety and complaints.

C. Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine [Prozac], paroxetine [Paxil], sertraline [Zoloft], fluvoxamine [Luvox], citalopram hydrobromide [Celexa])—SSRIs are generally the first-line choice because they have fewer side effects, do not require blood monitoring, and are safe in overdose.

1. Assessmentside effects: CNS stimulation—insomnia, agitation, headache (especially with Prozac); weight loss; sexual dysfunction (men: impotence; women: loss of orgasm, decreased libido). Other side effects are similar to TCAs (dry mouth, sedation, nausea).

2. Nursing care plan/implementation:

a. Goal: reduce insomnia, agitation—take early in day; avoid alcohol, caffeine; teach relaxation before sleep time.

c. Goal: prevent weight loss—weigh every day or every other day, same time and scale; do not use with clients who are anorexic.

3. Evaluation/outcome criteria:

a. Improvement in mood and hygiene, thought and communication patterns.

b. Has not harmed self.

c. No significant anticholinergic and cardiovascular side effects.

ANTIANXIETY AGENTS (also called anxiolytics, minor tranquilizers) (Antianxiety Agents: Comparison)

A. Benzodiazepines, beta-adrenergic blockers, buspirone HCl, diphenylmethane antihistamines

Focus topic: Physiological Integrity; Pharmacological and Parenteral Therapies

1. Use—acute alcohol withdrawal, tension, and irrational fears; anxiety disorders, preoperative sedation; have muscle relaxant and anticonvulsant properties.

2. Assessment—side effects: hypotension, drowsiness, motor uncoordination, confusion, skin eruptions, edema, menstrual irregularities, constipation, extrapyramidal symptoms, blurred vision, lethargy; increased or decreased libido.

3. Nursing care plan/implementation:

a. Goal: administer cautiously, because drug may:

• Be habituating (causing withdrawal convulsions; therefore, gradual withdrawal necessary).
• Potentiate CNS depressants.
• Have adverse effect on pregnancy.
• Be dangerous for those: with suicidal tendencies or severe psychoses, narrow-angle glaucoma, elderly or debilitated.

b. Goal: reduce GI effects—crush tablet or take with meals or milk; give antacids 1 hour before.

c. Goal: monitor effects on liver function: Periodic liver function tests and blood counts, especially with upper respiratory infection, hepatic or renal dysfunction.

d. Goal: reduce risk of—hypotension, respiratory depression, phlebitis, venous thrombosis.

e. Goal: health teaching.

• Advise against suddenly stopping drug (withdrawal symptoms begin in 5 to 7 days).
• Talk with physician if plans to be or is pregnant or lactating.
• Urge to drink fluids.
• Avoid: alcohol, OTC drugs (due to potentiation of other CNS depressants), and heavy smoking and caffeine.
• Problem with habituation.

4. Evaluation/outcome criteria: decreased alcohol withdrawal symptoms or preoperative anxiety; no seizures or confusion; relief of tension, anxiety, skeletal muscle spasm.

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Resources:

• # NCLEX: Cardiovascular disorders

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