McKenna's Pharmacology for Nursing, 2e

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C H A P T E R 2 8 Neuromuscular junction blocking agents

Care considerations for people receiving NMJ blocking agents

anaesthetist) 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. 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 the person’s 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 non-depolarising NMJ blocker before the use of suxamethonium to reduce the adverse effects associated with muscle contraction. ■ ■ Ensure that a cholinesterase inhibitor is readily available to overcome excessive neuromuscular blockade caused by non-depolarising NMJ blockers. ■ ■ Have a peripheral nerve stimulator on standby to assess the degree of neuromuscular blockade, if appropriate. ■ ■ Provide comfort measures to help the person orientation for conscious individuals unable to move or communicate ; skin care and turning to prevent skin breakdown ; and supportive care for emergencies such as hypotension and bronchospasm. ■ ■ Monitor the person’s 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 preoperative teaching about this drug because most people who receive the drug will be receiving teaching about a particular procedure and will be unconscious when the drug is given. Teaching includes 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 person to cope with drug effects. Evaluation ■ ■ Monitor person’s response to the drug (adequate muscle paralysis). ■ ■ Test the person’s response and recovery tolerate drug effects , such as pain relief as appropriate; reassurance, support and

Assessment: History and examination

■ ■ 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 change in perfusion ; personal or family history of malignant hyperthermia, which may increase the person’s risk for this condition ; fractures, which might lead to additional trauma with administration of suxamethonium ; narrow-angle glaucoma because an increase in intraocular pressure can occur with suxamethonium ; paraplegia, which might lead to potassium imbalance with administration of suxamethonium ; and current status of pregnancy or breastfeeding. ■ ■ Perform a physical assessment to establish baseline status before beginning therapy and evaluation for any potential adverse effects. ■ ■ Assess the person’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 colour 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 . ■ ■ Refer to the Critical thinking scenario for a full discussion of care for an elderly person who is receiving suxamethonium. Implementation with rationale ■ ■ Be aware that administration of the drug should be performed by trained personnel (usually an