Question

Adult Nephrolith ias is with Complications Mary Anne Vincent, PhD, RN, CNE Meet the Client: Mr. Bruce Skene Mr. Bruce Skene is a 55-year-old computer programmer who is originally from an area of Canada that has a population comprised largely of Scottish hertage He has been married for 32 years and has worked for the same company for 28 years While at work, Mr. Skene first experiences sudden left flank pain, which was not due to trauma He tries to 'give it time to let it pass, but his pain does not resolve He does not think it is safe to drive to the hospital, so he calls his wife and she takes him to the emergency department (ED) 1 The HCP cancels the hydrocodone/acetaminophen prescription and prescribes fentanyl 50 mcg intravenously one time now with a 500 ml. normal saline bolus. Prescriptions for abdominal radiography and computed tomography (CT) scan with contrast are also added. The nurse obtains a vial of fentanyl for intravenous administration from the medication cabinet HESI 011118-XXx- Drug Manufacturer FENTANYL CITRATE Injection, USP 100 mcg/2 mL (50 mcg/mL) (0.05 mg/ml) FOR SLOW INTRAVENOUS USE 12:08 AM 11/13/2019

Answer 1

the Nurse should take 1 ml of fentanyl from vial which equal to 50mg and add in 500ml of normal saline and administer

Following intravenous administration of fentanyl, a transient fall in blood pressure may occur, especially in hypovolaemic patients. Appropriate measures to maintain a stable arterial pressure should be taken.

Drug dependence and potential for abuse

Tolerance, physical dependence, and psychological dependence may develop upon repeated administration of opioids. Risks are increased in patients with a personal history of substance abuse (including drug or alcohol abuse or addiction).

Withdrawal syndrome

Repeated administration at short term intervals for prolonged periods may result in the development of withdrawal syndrome after cessation of therapy, which may manifest by the occurrence of the following side effects: nausea, vomiting, diarrhoea, anxiety, chills, tremor, and sweating.

Respiratory Depression

As with all potent opioids, profound analgesia is accompanied by marked respiratory depression, which may persist into or recur in the early postoperative period. Care should be taken after large doses or infusions of fentanyl to ensure that adequate spontaneous breathing has been established and maintained before discharging the patient from the recovery area.

Significant respiratory depression will occur following the administration of fentanyl in doses in excess of 200 micrograms. This, and the other pharmacological effects of fentanyl, can be reversed by specific opioid antagonists, but additional doses may be necessary because the respiratory depression may last longer than the duration of action of the opioid antagonist.

Resuscitation equipment and opioid antagonists should be readily available.

Hyperventilation during anaesthesia may alter the patient's response to CO₂, thus affecting respiration postoperatively.

Administration in labour may cause respiratory depression in the new-born infant.

Risk from concomitant use of sedative medicines such as benzodiazepines or related drugs

Concomitant use of fentanyl and sedative medicines such as benzodiazepines or related drugs may result in sedation, respiratory depression, coma and death. Because of these risks, concomitant prescribing with these sedative medicines should be reserved for patients for whom alternative treatment options are not possible. If a decision is made to prescribe fentanyl concomitantly with sedative medicines, the lowest effective dose should be used, and the duration of treatment should be as short as possible.

The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their caregivers to be aware of these symptoms (see section 4.5).

Cardiac disease

Bradycardia, and possibly cardiac arrest, can occur if the patient has received an insufficient amount of anticholinergic, or when fentanyl is combined with non-vagolytic muscle relaxants. Bradycardia can be antagonised by atropine.

Muscle rigidity

Muscular rigidity (morphine-like effect) may occur.

Rigidity, which may also involve the thoracic muscles, can be avoided by the following measures:

− slow IV injection (usually sufficient for lower doses);

− premedication with benzodiazepines;

− use of muscle relaxants.

Non-epileptic (myo)clonic movements can occur.

Precautions:

Fentanyl should be given only in an environment where the airway can be controlled and by personnel who can control the airway.

Special dosing conditions

The use of rapid bolus injections of opioids should be avoided in patients with compromised intracerebral compliance; in such patients the transient decrease in the mean arterial pressure has occasionally been accompanied by a transient reduction of the cerebral perfusion pressure.

It is recommended to reduce dosage in the elderly and debilitated patients. In uncontrolled hypothyroidism, pulmonary disease, decreased respiratory reserve, alcoholism and hepatic or renal impairment the dosage should be titrated with care and prolonged post-operative monitoring is required.

Patients on chronic opioid therapy or with a history of opioid abuse may require higher doses.

Myasthenia gravis

In patients with myasthenia gravis, careful consideration should be applied in the use of certain anticholinergic agents and neuromuscular-blocking pharmaceutical agents prior to, and during, the administration of a general anaesthetic regimen which includes administering intravenous fentanyl.

Interaction with neuroleptics

If fentanyl is administered with a neuroleptic, the user should be familiar with the special properties of each drug, particularly the difference in duration of action. When such a combination is used, there is a higher incidence of hypotension. Neuroleptics can induce extrapyramidal symptoms that can be controlled with anti-Parkinson agents.

Bile duct

As with other opioids, due to the anticholinergic effects administration of fentanyl may lead to increases of bile duct pressure and in isolated cases spasms of the Sphincter of Oddi might be observed.

Intestinal motility

As with other opioids, fentanyl can have an inhibitory effect on intestinal motility. This should be considered in the pain management of intensive care patients with inflammatory or obstructive intestinal diseases.