BSN 4B-Group DCompetency Appraisal 1

Case Analysis # 4

• George Franklin, a 56-year-old dentist, experienced a major myocardial infarction last June. Since that time, he has been using Transderm-Nitro (nitroglycerin) as prescribed by his physician. He applies one Transderm-Nitro 0.2 mg/hr system each morning . When ask about his drug therapy, Dr. Franklin notes that it has been effective in preventing attacks of angina and that he no longer experiences the headaches he once did when using this product.

QUESTIONS and ANSWERS

1. Is it usual to experience headaches when using nitroglycerin products? What advice can the nurse give the patient who experiences headache?

• It is usual to experience headaches when using nitroglycerin products as this is a common side effect which is a result of the peripheral vasodilation. But if pain persists, the client should immediately call for medical assistance. In patients who get these headaches, the headaches may be a marker of the activity of the drug. Patients should resist the temptation to avoid headaches by altering the schedule of their treatment with nitroglycerin, since loss of headache may be associated with simultaneous loss of antianginal efficacy.

• It's important to realize that this usually doesn't represent anything bad, though the side effect can be quite troublesome.

• Nitroglycerin works in the heart arteries by opening up those arteries and allowing more blood to flow through. That's how it can be useful to relieve chest pain.

• As a side effect, though, that same sort of opening up of blood vessels can occur in the head and the brain, and this is what can lead to a headache. In general, this isn't something to worry about, although if the pain is very bad, sometimes dropping down on the dose of nitroglycerin can help, and that's something you could talk to your doctor about. Additionally, especially when starting nitroglycerin, it might be useful to take a little bit of over the counter pain killers such as acetaminophen the first few days; and typically after a few days, the headache goes away on its own. It is also important to instruct the client about avoiding sudden change of position and rise to prevent orthostatic hypotension. But again, if the symptoms persist or get worse, time to talk to your doctor. Headaches may be treated with concomitant administration of mild analgesics. If such headaches are unresponsive to treatment, the nitroglycerin dosage should be reduced or the product discontinued.

2. Describe the procedure for applying Transderm-Nitro or other transdermal therapeutic system.

Procedures for applying Transderm Nitro or other transdermal therapeutic system: • a. Check the order on the chart. Identify patient, and apply gloves.• b. Remove any previously applied Transdermal patch and remove any residual medication

from the skin. If the medication patch is controlled substance, two nurses( one as a witness) must remove the old patch. The nurse one witness will observe the patch , the one nurse will observe the sharps container. Both nurses will sign on the designated area on the chart by the medication order for the controlled substance patch. If the controlled substance patch is not reordered by the MD, the patch removal will be conducted as above and both nurses will sign on the epidural/ IV PCA wastage backing.

• c. Open the package and remove the new patch. Without touching the adhesive surface, remove the plastic backing.

• d. Apply the patch to dry, hairless area of subcutaneous tissue. Do not apply a patch over a bone, tumor, irritated area, or an area where there is emaciated skin tissue. Do not apply a bioclussive, tegaderm, or tape to seal the patch as it can affect the absorption of the medication. (unless patch comes with cover)

• e. Instruct the patient to re-apply daily transdermal medications at the same time to ensure a continuous effect, but alternate the application sites to avoid skin irritation. The patch may be worn while bathing, showering or swimming but should not be rubbed vigorously. Avoid external sources of heat (such as heating pads, prolonged showers in hot waters.)

• If the patch falls off, instruct him to clean and apply a new patch at a different site. • f. Document it on Medication Administration Record.

3. What safety factors does the nurse teach the client about when this type of product is used?

• Safety factors that the nurse teach the client about when this type of products is being used. • Apply gloves when administering Nitrolycerin to prevent vasodilation causing hypotension. Failure to use gloves

may lead to direct skin contact to the medication may lead to dilation of the small vessels which is present in our peripheries.

• Discard unused drug 6 months after bottle is opened (conventional tablets); stabilized tablets (Nitrostat) are less subject to loss of potency.

• Warn the patient not to chew the tablets or capsules; do not crush these preparations.• Rotate sites of application to decrease the chance of inflammation and sensitization; close tube tightly when

finished.• Administer transdermal systems to skin site free of hair and not subject to much movement. Shave areas that

have a lot of hair. Do not apply to distal extremities. • Change sites slightly to decrease the chance of local irritation and sensitization. • Remove transdermal system before attempting defibrillation or cardioversion.• Administer the translingual spray directly onto the oral mucosa; preparation is not to be inhaled.• If signs of drug toxicity occurs, consult to the physician immediately such as Headache, suddenly flushed skin,

orthostatic problems, or reflectory tachycardia. • Instruct the client about avoiding sudden change of position and rise to prevent orthostatic hypotension.• Do not buy large quantities; this drug does not store well. Keep the drug in a dark, dry place, in a dark-colored

glass bottle with a tight lid; do not combine with other drugs.• Do not chew or crush the timed-release preparations; take on an empty stomach.• Do not rub or massage the area. Cover with plastic wrap held in place with adhesive tape. Wash your hands after

application. Keep the tube tightly closed. Rotate the sites frequently to prevent local irritation.• Apply to a slightly different area each day. Remove the old system before you apply a new one. Use care if

changing brands; each system has a different concentration.• Spray translingual spray directly onto oral mucous membranes; do not inhale. Use 5–10 min before activities that

you anticipate will precipitate an attack.• Report blurred vision, persistent or severe headache, rash, more frequent or more severe angina attacks, fainting.

4. Why should transdermal products be removed from a client’s chest before defibrillation or electrocardioversion is attempted?

• Transdermal products or Nitro-Dur must be removed before cardioversion or DC defibrillation is attempted, as well as before applying diathermy treatment, since it may be associated with damage to the paddles and burns to the patient. It can cause potential for altered electrical conductivity which may increase the risk of arcing, a phenomenon associated with the use of defibrillators. Studies also show that defibrillation produced a small explosion in a nitroglycerin patch over which a paddle had been placed. Arcing of the electrical current from the aluminum backing on the patches was the likely cause, but arcing has also occurred with nitroglycerin ointment and electrode gel. All patches and ointments should be removed from the chest of patients about to undergo defibrillation.

Student Nurses:ORIAS, DANNA EUNICA C.

UDDIN, AFNAN MOHAMMED AFSARVALDEZ, MARIELLE FAYE D.

VENTURA, JHADE ROXANNE M.VENTURA, REVELATION O.

VERDADERO, ALVIN O.VIERNES, DARWIN M.

VINOYA, ZYRILLE JOY L.