Nursing Exam Review Lecture 6 Drug Toxicities

Lecture 6 Drug Toxicities, Hiatal hernia, Dumping syndrome Drug Toxicities—Know these FIVE medications 1. Lithium (antimania drug) • Used for Bipolar o Specifically, for the manic episodes but not for the depression • Therapeutic level: 0.6 to 1.2 • Toxic level: >2.0 • Notice gray area: 1.3 to 2 2. Lanoxin or Digoxin • Used to treat A-Fib and CHF • Therapeutic level: 1 to 2 • Toxic level: >2 3. Aminophylline—muscle spasm relaxer for the airway • Compound of the bronchodilator theophylline • Therapeutic level: 10 to 20 • Toxic level: >20 • Non-therapeutic level: <10 … if it is not therapeutic, increase dose of medication, and assess for compliance 4. Dilantin (phenytoin) • Seizure medication • Therapeutic level: 10-20 • Toxic level: >20 5. Bilirubin • Breakdown product of Red Blood Cells • Normal level in adults: 0.2 to 1.2 • Always tested in the Newborns on the NCLEX • In Newborns bilirubin is much higher than in adults o Elevated level: 10 to 20 o Toxicity: >20 • When do physicians want to hospitalize these newborns? o When bilirubin level is about 14 to 15 Patterns • 1s and 10s • 2s and 20s o 2s: Low # (Lithium and Lanoxin) o 20s: High # (Aminophylline, Dilantin and Bilirubin) Jaundice—Yellow skin from excess bilirubin in the blood • It appears as yellow skin and sclera Kernicterus—Excess bilirubin in the brain • Occurs when level in the blood gets >20 • In the brain, it may cause aseptic (sterile) meningitis or encephalopathy (don’t need to know) • It can be DEADLY Opisthotonos • Position the newborn assume due to irritation of the meninges from kernicterus • Presentation: hyperextended posture … (Is a medical emergency) Question In what position do you place an opisthotonic newborn? • Put newborn on the side Pathological vs. Physiological Jaundice • If the newborn comes out yellow, something is wrong = Pathologic jaundice • If the newborn turn yellow 2 to 3 days postpartum, that’s ok = Physiologic jaundice Dumping Syndrome vs. Hiatal Hernia • Both gastric emptying problems and are opposites Hiatal Hernia • Regurgitation of gastric acid upward or backward into esophagus • “Like a cow with 2 stomachs,” gastric contents go in wrong direction at the correct rate • S/Sx of hiatal hernia is similar to GERD (Heartburn and indigestion) • S/Sx of hiatal hernia = S/Sx of GERD when lying down after a meal o In other words, Heartburn, Indigestion on lying down after eating • Treatment o Can do 3 things, as shown below 1. Elevate HOB (head of bed) during and 1 hour after meals 2. Increase the amount of fluids with meals 3. Increase the amount of Carb content o These cause the stomach to empty quickly so its content doesn’t back up o High-atal Hernia … Everything high Dumping Syndrome • Gastric contents are dumped too quickly into duodenum o Right direction but at wrong rate • S/Sx of dumping syndrome o Drunk: Staggering gate, impaired judgment, labile—all blood gone to gut o Also get Shock: cold/clammy, tachycardia, pale o Now add Acute abdominal distress: n/v, diarrhea, cramping, guarding, borborygmi, bloating, distention • Dumping syndrome = Drunk, Shock, Acute Abdominal Distress Note • Drunk is what it is • Shock is what it is • Drunk + Shock = Hypoglycemia • Drunk + Shock + Acute abdominal distress = Dumping syndrome Treatment of Dumping Syndrome • Can do 3 things, as shown below 1. Lower HOB (head of bed) during meals and turn pt on the side 2. Decrease the amount of fluids 1 or 2 hours before or after meals 3. Decrease the amount of Carb content o These 3 things prevent the stomach to empty quickly or dump its content into the duodenum • Dumping syndrome … Everything low What is protein is added in the diet? • Protein does the opposite of carbohydrate • Protein bulks gastric content, takes longer to digest, and moves slower through the gut • Therefore, give o Low protein in hiatal hernia o High protein for dumping syndrome Electrolytes • Memorize these 3 sentences 1. Kalemias do the same as the prefix (hypo-, hyper-), except for HR and urine output which go opposite 2. Calcemias do the opposite as the prefix 3. Magnesemias do the opposite as the prefix • Natremias o HypoNatremia = Volume overload … HyperNatremia = Dehydration Kalemia(s) • Go in the same direction as the prefix, except for HR and urine output (UO), which go in the opposite direction • Hypo—Symptoms go low with hypo, except HR and UO • Hyper—Symptoms go high with hyper, except HR and UO Some S/Sx of Hyperkalemia • Brain: seizures, agitation, irritability, loud down • Heart: tented T waves, ST elevated, tachypnea • Bowel: diarrhea, borborygmi • Muscle: spasticity, increase tone, hyperreflexia (3+, 4+) • Heart rate: down (bradycardia) • UO: down (oligouria) Some S/Sx of Hypokalemia • Lethargy, bradypnea, paralytic ileus, constipation, muscle flaccidity, hyporeflexia (0, 1+) • Tachycardia (HR is up) • Polyuria (UO is up) Question Your patient has hyperkalemia, select all that apply a. Adynamic ileus b. Obtunded c. 1+ reflex d. Clonus (irritable) e. U wave f. Depressed ST g. Polyuria h. Bradycardia m Answer • Kalemia goes in the same direction, except HR and urine output … therefore, • Clonus are bradycardia are right ts y. co Calcemia(s) • Go in the opposite direction as the prefix • Hypo—Symptoms go high with hypo • Hyper—Symptoms go low with hyper ng H er o -E Calcemias do the opposite of the prefix—it is a sedative • So Hypercalcemia is bradycardia, bradypnea, flaccid, hypoactive reflexes, lethargy, constipation, etc. • So Hypocalcemia is agitation, irritability, 3+ or 4+ reflexes, spasm, seizure, tachycardia, Chvostek sign (tap the cheek), Trousseau (inflate BP cuff), etc. N ur si Choosing answers for potassium and calcium • For potassium pick answers related to heart problems • For calcium pick answers related to muscle problems Magnesemia(s) • Magnesium goes in the opposite direction of the prefix—it is also a sedative It is possible that S/Sx are from several electrolytes imbalances. In that case, • Choose CALCIUM if nerve or skeletal involvement • Pick POTASSIUM for any other symptom o Generally anything effecting blood pressure Your patient has diarrhea … Which one of the following electrolyte imbalances causes diarrhea? Hyperkalemia, hypokalemia, hypocalcemia, or hypomagnesemia • Tetany? Hypocalcemia Test tip • Common mistake • Tetany = Hyperkalemia—prefix example. Pay attention Natremia(s)—Sodium • HypErnatrema = DEhydration o Hot, flushed, dry skin, thready pulse, rapid HR … Give fluid o Associate “E” in hypernatremia with DEhydration • HypOnatremia = Overload o Crackles, distended neck veins … Fluid restriction, Lasix o Associate “O” in hyponatremia with Overload o Nursing Dx: Fluid Volume Excess Question In addition to a high potassium, what other electrolyte abnormality can be seen in DKA? • Hypernatremia = Dehydration • DKA should make you think of DEhydration, which is also associates with hypErnatremia Question In addition to High Potassium what other electrolyte imbalance is possible in DKA? • Answer: Hypernatremia Review—Think dehydration or Fluid overload • SIADH: Hyponatremia • DI: Hypernatremia • HHNK: Hypernatremia How to spot early signs of electrolyte imbalance? • The earliest sign of any electrolyte disturbance is o Numbness and tingling = Paresthesia o Circumoral paresthesia = Numbness and tingling around the lips • The universal sign of all electrolyte imbalances is o Muscle weakness = Paresis Treatment • Potassium is the only one Boards will test • Never Push Potassium IV • Potassium <40 mEq/L of IV fluid o If >40 mEq/L, clarify dosage with physician How do you lower potassium? • Of all electrolyte imbalance, high potassium is the most problematic • High potassium can stop the heart • The fastest way to lower potassium level is to o Give D5W and regular insulin to decrease potassium o This will drive the potassium into the cell and out of the blood o Temporary solution but quick • Kayexalate is long-term solution o Through enema or ingestion, Kayexalate exchanges potassium for sodium o Potassium is eliminated through feces and pt becomes hypernatremic o Hypernatremia is managed with IV fluid administration o The downside is it takes hours to work • To solve this problem o Give D5W, Regular insulin, and Kayexalate and the same time D5W and Regular insulin work instantly Kayexalate works in a few hours—K Exits Late