ch.25-28 case study answers

Neuromuscular junction (NMJ) blockers

:interferes with muscle function. The two groups are nondepolarizing and depolarizing agents. The *nondepolarizing NMJs include those agents that act as antagonists to acetylcholine (ACh) at the NMJ and prevent depolarization of muscle cells* The *depolarizing NMJs act as an ACh agonist at the junction, causing stimulation of the muscle cell and then preventing it from repolarizing.*

gate control theory

_____ ______ _____ states that the transmission of a nerve impulse can be modulated at various points along its path by descending fibers from the brain that close the "gate" and block transmission of pain information and by A fibers that are able to block transmission in the dorsal horn by closing the gate for transmission for the A-delta and C fibers

local

_______ anesthetics block the depolarization of nerve membranes, preventing the transmission of pain sensations and motor stimuli. administered to deliver the drug directly to the desired area and to prevent systemic absorption, which could lead to serious interruption of nerve impulses and response.

general

_______ anesthetics result in analgesia, amnesia, and unconsciousness; they also block muscle reflexes that could interfere with a surgical procedure or put the patient at risk for harm. involves a widespread CNS depression that could be harmful, especially in patients with underlying CNS, cardiovascular, or respiratory diseases.

balanced anesthesia

involves giving a variety of drugs, including anticholinergics, rapid intravenous anesthetics, inhaled anesthetics, NMJ blockers, and narcotics. involves the administration of several drugs rather than a single drug to achieve analgesia, muscle relaxation, unconsciousness, and amnesia.

muscle spasm

often result from injury to the musculoskeletal system—for example, overstretching a muscle, wrenching a joint, or tearing a tendon or ligament. These injuries can cause violent and painful involuntary muscle contractions. thought to be caused by the flood of sensory impulses coming to the spinal cord from the injured area. These impulses can be passed through interneurons to spinal motor nerves, which stimulate an intense muscle contraction. The contraction cuts off blood flow to the muscle fibers in the injured area, causing lactic acid to accumulate and resulting in pain. The new flood of sensory impulses caused by the pain may lead to further muscle contraction, and a vicious cycle may develop.

key adverse effects of neuromuscular junction blockers

prolonged paralysis, inability to breathe, weakness, muscle pain and soreness, and effects of immobility, are related to muscle function blocking.

Muscle spasticity

result of damage to neurons within the CNS rather than injury to peripheral structures. Because the spasticity is caused by nerve damage in the CNS, it is a *permanent condition.* may result from an increase in excitatory influences or a decrease in inhibitory influences within the CNS. The interruption in the balance among all of these higher influences within the CNS may lead to excessive stimulation of muscles, or hypertonia in opposing muscle groups at the same time, a condition that may cause contractures and permanent structural changes. *This control imbalance also results in a loss of coordinated muscle activity.*

key lifespan considerations for an adult when administering antimigraine medication?

• Adults requesting treatment for migraine headaches should be carefully evaluated before one of the antimigraine drugs is used to ensure that the headache being treated is of the type that can benefit from these drugs. • The ergots and the triptans are contraindicated during pregnancy because of the potential for adverse effects in the mother and fetus. • Women of childbearing age should be advised to use contraception while they are taking these drugs. • Women who are nursing should be encouraged to find another method of feeding the baby because of the potential for adverse drug effects on the baby.

nursing assessment considerations with a direct-acting skeletal muscle relaxant

• Assess for contraindications or cautions for the use of the drug, including any known allergies to prevent hypersensitivity reactions; cardiac depression; epilepsy; muscle weakness; respiratory depression, which could be exacerbated by the effects of these drugs; pregnancy and lactation, which require cautious use; renal or hepatic dysfunction, which could alter the metabolism and excretion of the drug; and local infections (if using botulinum toxins) to prevent exacerbation of the infections. • Assess temperature; skin color, and lesions; CNS orientation, affect, reflexes, bilateral grip strength, and spasticity; respiration and adventitious sounds; pulse, electrocardiogram (ECG), and cardiac output; bowel sounds and reported output; and liver and renal function tests to determine baseline status before beginning therapy and for any potential adverse effects.

key nursing considerations including important teaching points for a patient receiving a neuromuscular junction blocker

• Assess for contraindications or cautions: any known allergies to these drugs to avoid hypersensitivity reactions; impaired liver or kidney function, which might interfere with metabolism or excretion of the drug; myasthenia gravis, which may be exacerbated by the use of this drug; impaired cardiac or respiratory function, which may be worsened due to the drug's effect on respiratory muscles and changes in perfusion; personal or family history of malignant hyperthermia, which may increase the patient's risk for this condition; fractures, which might lead to additional trauma with administration of succinylcholine; narrow-angle glaucoma because an increase in intraocular pressure can occur with succinylcholine; paraplegia, which might lead to potassium imbalance with administration of succinylcholine; and current status of pregnancy or lactation. • Perform a physical assessment to establish baseline status before beginning therapy and evaluation for any potential adverse effects. • Assess the patient's neurological status, including level of orientation, affect, reflexes, pupil size and reactivity, and muscle tone and response, to monitor drug effects and recovery. • Monitor respiratory rate and auscultate lung sounds for evidence of adventitious sounds to evaluate effects on respiratory muscles and monitor for adverse reactions. • Monitor vital signs, including temperature, pulse rate, and blood pressure, to identify changes. • Auscultate the abdomen for evidence of bowel sounds to monitor effects on GI muscles and recovery. • Inspect the skin for color and evidence of pressure areas or breakdown, which could result when movement ceases. • Monitor the results of laboratory tests, including liver function tests, to determine the need for possible dose adjustment and serum electrolyte levels to determine potential cautions to the use of the drugs. • Be aware that administration of the drug should be performed by trained personnel (usually an anesthesiologist) because of the potential for serious adverse effects and the need for immediate ventilatory support. • Ensure that emergency supplies and equipment are readily available to maintain airway and provide mechanical ventilation. • Do not mix the drug with any alkaline solutions such as barbiturates because a precipitate may form, making it inappropriate for use. • Test patient response and recovery periodically if the drug is being given over a long period to maintain mechanical ventilation. Discontinue the drug if response does not occur or is greatly delayed. • Monitor patient temperature for prompt detection and treatment of malignant hyperthermia; have dantrolene readily available for treatment of malignant hyperthermia if it should occur. • Arrange for a small dose of a nondepolarizing NMJ blocker before the use of succinylcholine to reduce the adverse effects associated with muscle contraction. • Ensure that a cholinesterase inhibitor is readily available to overcome excessive neuromuscular blockade caused by nondepolarizing NMJ blockers. • Have a peripheral nerve stimulator on standby to assess the degree of neuromuscular blockade, if appropriate. • Provide comfort measures to help the patient tolerate drug effects, such as pain relief as appropriate; reassurance, support, and orientation for conscious patients unable to move or communicate; skin care and turning to prevent skin breakdown; and supportive care for emergencies such as hypotension and bronchospasm. • Monitor patient response closely (blood pressure, temperature, pulse, respiration, reflexes) to determine effectiveness; expect dose adjustment to ensure the greatest therapeutic effect with minimal risk of toxicity. • Provide thorough patient preoperative teaching about this drug because most patients who receive the drug will be receiving teaching about a particular procedure and will be unconscious when the drug is given. Teaching includes the drug to be given, method for administration, effects of the drug (i.e., what to expect), and safety precautions. • Offer support and encouragement to help the patient to cope with drug effects.

key lifespan considerations for an older adult when administering narcotics

• Elderly patients should be specifically asked whether they require pain medication. Many older patients can recall a time when nurses were able to spend more time with patients; they may tend to believe that the nurse will meet their needs. • Older patients are more likely to experience the adverse effects associated with these drugs, including central nervous system, gastrointestinal, and cardiovascular effects. • Many older patients often have renal or hepatic impairment; they are also more likely to have toxic levels of the drug related to changes in metabolism and excretion. • The older patient should have safety measures in effect—side rails, call light, assistance to ambulate—when receiving one of these drugs in the hospital setting.

key nursing implementation considerations for a patient receiving a narcotic antagonist

• Maintain open airway and provide artificial ventilation and cardiac massage as needed to support the patient. Administer vasopressors as needed to manage narcotic overdose. • Administer naloxone challenge before giving naltrexone because of the serious risk of acute withdrawal. • Provide continuous monitoring of the patient, adjusting the dosage as needed, during treatment of acute overdose. • Provide comfort and safety measures to help the patient cope with the withdrawal syndrome. • Ensure that patients receiving naltrexone have been narcotic-free for 7 to 10 days to prevent severe withdrawal syndrome. Check urine opioid levels if there is any question. • If the patient is receiving naltrexone as part of a comprehensive narcotic or alcohol withdrawal program, advise the patient to wear or carry a MedicAlert warning so that medical personnel know how to treat the patient in an emergency. • Institute comfort and safety measures, such as side rails and assistance with ambulation to ensure patient safety; institute a bowel program as needed for treatment of constipation; use environmental controls to decrease stimulation; and provide small frequent meals to relieve GI irritation if GI upset is severe. • Offer support and encouragement to help the patient cope with the effects of drug regimen. • Provide thorough patient teaching, including drug name and prescribed dosage; measures to avoid adverse effects; warning signs to report immediately that may indicate possible problems; safety measures such as avoiding driving, avoiding making important decisions, and having a responsible person available for assistance; and the importance of continued monitoring and evaluation to enhance patient knowledge about drug therapy and to promote compliance.

primary uses for neuromuscular junction blockers across the lifespan

• NMJ blockers are primarily used as adjuncts to general anesthesia, to facilitate endotracheal intubation, to facilitate mechanical ventilation, and to prevent injury during electroconvulsive therapy. • Children: The nondepolarizing NMJs are preferable because of the lack of muscle contraction with its resultant discomfort on recovery. Succinylcholine is usually preferred when a very short-acting, rapid-onset blocker is needed (e.g., for intubation). • Adults: NMJs are used during pregnancy and lactation only if the benefit to the mother outweighs the potential risk to the fetus or neonate.

key general nursing care considerations for patients receiving general and local anesthetic agents?

• Patients receiving general anesthetics must be constantly monitored because the *CNS depression can cause respiratory arrest, cardiovascular reactions including hypotension, and alterations in GI activity that can lead to nausea and vomiting.* • Nursing care of patients receiving general or local anesthetics should include *safety precautions* to prevent injury and skin breakdown, support and reassurance to deal with the loss of sensation and mobility, and patient teaching regarding what to expect to decrease stress and anxiety.

nursing implementation considerations with a centrally acting skeletal muscle relaxant

•Provide additional measures to relieve discomfort—heat, rest for the muscle, NSAIDs, and positioning—to augment the effects of the drug at relieving the musculoskeletal discomfort. •Discontinue the drug at any sign of hypersensitivity reaction or liver dysfunction to prevent severe toxicity. •If using baclofen, taper the drug slowly over 1 to 2 weeks to prevent the development of psychoses and hallucinations. Use baclofen cautiously in patients whose spasticity contributes to mobility, posture, or balance to prevent loss of this function. •Monitor the patient's respiratory status