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Kristen O'Brien, BSN, RN

freelance health writer | nurse educator

/ Awareness

March 30th – Celebrating Doctors Around the World

March 30th is National Doctor’s Day in the healthcare field and we want to celebrate all the doctors out there. If you are a doctor, know that you are appreciated, you are making a difference, and you’re doing amazing work. Thank you for your care!

/ Medication Monday, Pharmacology

Medication Monday: Naloxone

Generic Drug Name: naloxone

Brand Names: Narcan, Evzio

Classification: 

Therapeutic: antidotes (for opioids)

Pharmacologic: opioid antagonists

Indications:

  • Reversal of CNS and respiratory depression due to opioid overdose

Mechanism of Action: 

Competitively blocks the effects of opioids, primarily CNS and respiratory depression, without producing any effects of the opioids

Expected Response: reverse signs of excess opioids

Common Adult Doses: (ALWAYS CHECK YOUR ORDERS)

For post-op opioid-induced respiratory depression:

IV (Adults): 0.02-0.2 mg every 2-3 minutes until response obtained. Repeat every 1-2 hours if needed.

IV (Children): 0.01 mg/kg every 2-3 minutes until response obtained. Repeat every 1-2 hours if needed.

IM, IV, SubQ (Neonates): 0.01 mg/kg every 2-3 minutes until response obtained. Repeat every 1-2 hours if needed.

For opioid-induced respiratory depression during chronic use (>1 week):

IV, IM, SubQ (Adults >40kg): 20-40 mcg (0.02-0.04 mg) given every minute boluses or as infusion to titrate and improve respiratory function without reversing analgesia.

IV, IM, SubQ (Adults and children <40kg): 0.005-0.02 mg/dose given every minute boluses or as infusion to titrate and improve respiratory function without reversing analgesia.

Overdose of opioids:

IV, IM, SubQ (Adults): (if not opioid dependent) 0.4 mg (10 mcg/kg) every 2-3 minutes until resolved. (if opioid dependent) 0.1-0.2 mg every 2-3 minutes.

IM, SubQ (Adults and children): Evzio – 0.4 mg every 2-3 minutes until emergency medical assistance arrives

IV, IM, SubQ (Children >5 years or >20kg): 2 mg/dose every 2-3 minutes

IV, IM, SubQ (Infants up to 5 years or 20kg): 0.1 mg/kg every 2-3 minutes

Intranasal (Adults and children): 1 spray (2 mg or 4 mg) in one nostril every 2-3 minutes, alternating nostrils

Contraindications:

  • Hypersensitivity to naloxone

Use cautiously in:

  • Cardiovascular disease
  • Patient’s physically dependent on opioids (may cause withdrawal)
  • In pregnant patients dependent on opioids as fetus can be affected as well
  • Lactating mothers
  • Pediatrics – may cause withdrawal syndrome in neonates of dependent mothers

Side Effects:

Common

  • Nausea
  • Vomiting
  • Hypertension
  • Hypotension

Life-Threatening

  • Ventricular arrhythmias

Nursing Considerations:

Assessment

  • Monitor respiratory rate, rhythm, and depth; pulse and ECG; BP; level of consciousness frequently for 3-4 hours after peak of naloxone.
  • Patients taking opioids >1 week are extremely sensitive to naloxone. Dilute and administer slowly.
  • Assess patients for level of pain after administration as analgesia is reversed.
  • Assess patients for signs and symptoms of acute opioid withdrawal (vomiting, restlessness, abdominal cramps, increased BP and temperature). Severity is different for each person but can start within minutes to 2 hours.
  • Lack of improvement could indicate other issues that need to be explored.

Nursing Diagnoses

  • Ineffective breathing pattern (Indications)
  • Ineffective coping (Indications)
  • Acute pain

Implementation

  • Do not confuse naloxone with Lanoxin (Digoxin). Do not confuse Narcan (naloxone) with Norcuron (vecuronium).
  • Have resuscitation equipment nearby: oxygen, vasopressors, and mechanical ventilator.
  • Doses should be titrated carefully in post-op patients to avoid interference with pain control.
  • Evzio: a take-home naloxone auto-injector that patients, family members, and others can have closely in case an overdose occurs. Has visual and voice instructions. Inject in to upper outer thigh.
  • Intranasal: If being used, inform family or others to call 911 for emergency support.
  • IV doses: Administer undiluted for suspected overdoses. Administer diluted with sterile water if respiratory depression noted.
  • Educate patient to
    • As medication becomes effective, explain why the naloxone was given and the effects it is having.
    • Intranasal dose: instruction family or caregivers on correct administration technique.
    • Evzio: explain purpose and instructions. Inform to call 911 for emergency support.

Expected Outcomes

  • Adequate ventilation following excess opioids
  • Alertness without significant pain or withdrawal symptoms.

Reference

Vallerand, A. H. & Sanoski, C. A. (2019). Davis’s drug guide for nurses. (16th ed., pp. 890-893). F.A. Davis Company.

/ Medication Monday, Pharmacology

Medication Monday: Adenosine

Generic Drug Name: adenosine

Brand Names: Adenocard, Adenoscan

Classification: 

Therapeutic: antiarrythmics

Pharmacologic: n/a

Indications:

  • Conversion of paroxysmal supraventricular tachycardia (PSVT) to normal sinus rhythm (NSR) after failed vagal maneuvers.
  • Diagnostic tool to assess myocardial perfusion defects from coronary artery disease

Mechanism of Action: 

Interrupts the re-entrant pathways of the AV node in the heart to restore sinus rhythm. Slows AV conduction time. Vasodilates the coronary arteries.

Expected Response: normal sinus rhythm restored

Common Adult Doses: (ALWAYS CHECK YOUR ORDERS)

For PSVT:

IV (Adults and children >50kg): Adenocard – 6 mg by rapid IV bolus, if no response, repeat 1-2 minutes later as 12 mg rapid IV bolus. Adenoscan – 140 mcg/kg/min for 6 minutes

IV (children <50kg): 0.05-0.1 mg/kg as rapid bolus, may repeat in 1-2 minutes if ineffective with increased dose of 0.05-0.1 mg/kg with maximum dose of 0.3 mg/kg

Contraindications:

  • Hypersensitivity to adenosine
  • 2nd or 3rd degree AV block or sick sinus syndrome, unless functioning artificial pacemaker is present
  • Myocardial ischemia/infarction (only Adenoscan)

Side Effects:

Common

  • Shortness of breath
  • Facial flushing
  • Transient arrhythmias

Life-Threatening

  • Seizures (only with Adenoscan)
  • Stroke (only with Adenoscan)
  • Myocardial infarction
  • Ventricular tachycardia
  • Hypersensitivity reactions

Nursing Considerations:

Assessment

  • Monitor heart rate every 15-30 seconds and EKG during drug administration. Short, transient period of 1st, 2nd, or 3rd degree heart block or systole can occur after the injection which resolves quickly due to adenosine’s short duration. Ectopic beats are also common after the return to normal sinus rhythm but should only last a few seconds.
  • Monitor blood pressure during drug administration.
  • Assess respiratory status (rate and sounds) after administration. Patients with asthma history may experience bronchospasms.

Nursing Diagnoses

  • Decreased cardiac output (Indications)

Implementation

  • IV Push: Administer medication undiluted (3 mg/ml concentration) over 1-2 seconds via peripheral IV. Follow each dose with a rapid 20 ml saline flush to ensure dose reaches systemic circulation.
  • Intermittent Infusion (diagnostic test): Administer 30 ml vial undiluted (3 mg/ml concentration) at a rate of 140 mcg/kg/min over 6 minutes for a total dose of 0.84 mg/kg. Thallium-201 should be injected halfway through the Adenoscan dose (3 minutes in to procedure) as close to the IV site as possible
  • Educate patient to
    • caution patient to change positions slowly to minimize orthostatic hypotension
    • instruct patient to report facial flushing, shortness of breath, or dizziness
    • Have patient avoid products with methylxanthines (caffeinated coffee, tea, carbonated drinks, or drugs aminophylline or theophylline) prior to myocardial perfusion imaging study

Expected Outcomes

  • Conversion to NSR from PSVT
  • Diagnosis of myocardial perfusion defects

Reference

Vallerand, A. H. & Sanoski, C. A. (2019). Davis’s drug guide for nurses. (16th ed., pp. 113-114). F.A. Davis Company.

/ Medical-Surgical

October: Breast Cancer Awareness Month

Many of us have heard of the word cancer and breast cancer is talked about often. But did you know that it affects 1 in 8 women? That’s 12.5% of all women will get breast cancer. That number seems crazy high to me for an incidence rate! It is also the second leading cause of cancer-related deaths (American Cancer Society, 2021).

What to watch for:

  • New lump or mass in your breast or armpit area
  • Breast swelling
  • Skin dimpling on breast
  • Breast or nipple pain
  • Inward turning of nipple
  • Nipple or breast skin that’s red, flaky, dry, or beginning to thicken
  • Abnormal nipple discharge
  • Swollen lymph nodes around chest or in armpit region

What can you do to decrease your chances of getting breast cancer?

  • Limit your alcohol intake (20% higher chance with 2-3 drinks a day)
  • Lower your BMI, especially before menopause
  • Move your body 150-300 minutes of moderate activity or 75-150 minutes of vigorous activity a week
  • Have children before age 30 (over 30 has higher hormone levels)
  • Try to breastfeed if possible (fed is best! But breastfeeding does help lower your chances)
  • Certain birth controls increase your risk so ask your doctor about which one is best for you
  • After menopause, hormone replacement therapy increases your risks and should be weighed against the benefits
  • Breast implants have been linked to a rare type of non-Hodgkin lymphoma

Perform monthly self breast exams while in the shower and report any unusual findings to your doctor.

References

American Cancer Society. (2021). Breast cancer. https://www.cancer.org/cancer/breast-cancer.html

/ Medication Monday, Pharmacology

Medication Monday: Quetiapine

Generic Drug Name: Quetiapine

Brand Names: Seroquel, Seroquel XR

Classification: 

Therapeutic: Antipsychotics, mood stabilizers

Pharmacologic: n/a

Indications:

  • Schizophrenia
  • Bipolar depression
  • Acute manic episodes with bipolar I disorder
  • Depression

Mechanism of Action: 

Dopamine and serotonin antagonist. Also antagonizes Histamine H1 receptors and alpha1-adrenergic receptors.

Expected Response: decreased episodes of psychoses, depression, or acute mania.

Common Adult Doses: (ALWAYS CHECK YOUR ORDERS)

For schizophrenia:

Oral max dose 800 mg/day

Immediate release: 25 mg twice daily on Day 1, 50 mg two to three times a day on Day 2 and 3, up to 300-400 mg/day in two or three divided doses by day 4.

Extended release: 300 mg once daily. Increase by 300 mg/day.

For acute manic disorder in bipolar I:

Oral max dose 800 mg/day

Immediate release: 50 mg twice a day on Day 1, 100 mg twice a day on Day 2, 150 mg twice a day on Day 3, 200 mg twice a day on Day 4, and may increase to 400 mg twice a day on Day 6 if needed.

Extended release: 300 mg once a day on Day 1, 600 mg once a day on Day 2, then 400-800 mg once a day on Day 3.

Depression:

Oral max dose 300 mg/day

Extended release: 50 mg once daily on Days 1 and 2, then 150 mg once daily starting Day 3

Contraindications:

  • Hypersensitivity to Quetiapine
  • Lactating mothers
  • With agents that also prolong QT interval
  • Hx arrhythmias
  • Congenital long QT syndrome

Side Effects:

Common

  • Dizziness
  • Weight gain
  • Drowsiness

Life-Threatening

  • Neuroleptic malignant syndrome
  • Seizures
  • Pancreatitis
  • Drug reaction with eosinophilia and systemic symptoms (DRESS)
  • Stevens-Johnson syndrome

Nursing Considerations:

Assessment

  • Monitor mental status (mood, orientation, behavior) before and during therapy
  • Assess for suicidal tendencies, especially during early therapy
  • Monitor orthostatic blood pressures during dosage changes
  • Monitor for extrapyramidal side effects (restlessness, muscle spasms, mask-like face, drooling, gait changes, etc.)
  • Monitor for tardive dyskinesia (involuntary rhythmic mouth movements)
  • Monitor for signs of neuroleptic malignant syndrome: fever, respiratory distress, tachycardia, seizures, diaphoresis, hypo or hypertension, pallor, or tiredness.
  • Assess for rash which could indicate Stevens-Johnson syndrome
  • Monitor for signs of pancreatitis: nausea, vomiting, anorexia, and persistent severe abdominal pain which can radiate to back.
  • Monitor for signs of DRESS: fever, rash, lymphadenopathy, other organ involvement (liver, kidneys), or facial swelling.
  • Trend lab work: liver enzymes, lipid panel, complete blood count, blood sugar, prolactin,

Nursing Diagnoses

  • Risk for self-directed violence (indications)
  • Disturbed thought process (indications)
  • Imbalanced nutrition: risk for more than body requirements (side effects)

Implementation

  • May be given with or without food
  • Do not crush or chew extended release tablets
  • Educate patient to 
    • take at the same time every day, do not double up doses if one is forgotten
    • do not give to patients with dementia-related psychosis
    • watch for extrapyramidal side effects
    • change positions slowly as their blood pressure may drop more easily
    • notify their provider immediately if they develop – thoughts of harm to self or others, worsening depression, trouble sleeping, extreme increase in activity and talking
    • if female, let provider know if they plan to become pregnant or are pregnant or if they are breastfeeding or plan to

Expected Outcomes

  • Decrease in excited, manic behavior
  • Decrease in signs of depression with bipolar disorder
  • Decrease in manic episodes in patients with bipolar I disorder
  • Decrease in positive symptoms of schizophrenia (hallucinations, delusions)
  • Decrease in negative symptoms of schizophrenia (social withdrawal, flat or blunt affect)

Reference

Vallerand, A. H. & Sanoski, C. A. (2019). Davis’s drug guide for nurses. (16th ed., pp. 1071-1073). F.A. Davis Company.