McKenna's Pharmacology for Nursing, 2e

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P A R T 5  Drugs acting on the autonomic nervous system

CRITICAL THINKING SCENARIO Anticholinergic drugs and heart disease

THE SITUATION E.K., a 64-year-old woman with a long history of heart disease, has suffered from repeated bouts of cystitis. The course of her most current infection was marked by severe pain, frequency, urgency and even nocturnal enuresis. She was treated with an antibiotic deemed appropriate after a urine culture and sensitivity test, and she was given atropine to relax her bladder spasms and alleviate some of the unpleasant side effects that she was experiencing. Within the next few days, she plans to travel to a warm climate for the winter and wants any information that she should have before she goes. CRITICAL THINKING E.K. presents many care problems. What are the implications of giving an anticholinergic drug to a person with a long history of heart disease? Repeated bouts of cystitis are not normal; what potential problems should be addressed in this area? E.K. is about to leave for her winter home in Queensland; what teaching plans will be essential for her if she is taking atropine when she leaves? What are the medical problems that can arise with people who live in different areas at different times of the year? Considering her age, what written information should E.K. take with her as she travels? DISCUSSION E.K. is doing well with her cardiac problems at the moment, but she could develop problems as a result of the anticholinergic drug that has been prescribed. The anticipated adverse effect of tachycardia could tip the balance in a compensated heart, leading to heart failure or oxygen delivery problems. She will need to be carefully evaluated for the status of her heart disease and potential problems. E.K. should be further evaluated for the cause of her repeated bouts with cystitis. Does she have a structural problem, a dietary problem, or a simple hygiene problem? She should receive instruction on ways to avoid bladder infections, such as wiping only from front to back, voiding after sexual intercourse, avoiding baths, avoiding citrus juices and other alkaline ash foods that decrease the acidity of the urine and promote bacterial growth, and pushing fluids as much as possible. E.K. also should be evaluated to establish a baseline for vision, reflexes, the possibility of glaucoma, GI problems, and so on. She should receive thorough teaching about her atropine, especially adverse effects to anticipate, safety

measures to take if vision changes occur, and a bowel program that she can follow to avoid constipation. Because E.K. is leaving a cold climate and travelling to a warm climate, she will need to be warned that atropine decreases sweating. This means that she may be susceptible to heat stroke in the warmer climate. She should be encouraged to take precautions to avoid these problems. It will be difficult to monitor E.K. while she is away. It should be anticipated that people such as E.K. might have two sets of healthcare providers who may not communicate with each other. It is important to give E.K. written information about her current diagnosis, including test results; details about her drugs, including dosages; information about the adverse effects she may experience plus ways to deal with them; and ways to avoid cystitis in the future. It may be useful to include a telephone number that E.K. can use or give to her northern healthcare provider to use if further testing or follow-up is indicated. CARE GUIDE FOR E.K.: HEART DISEASE Assessment: History and examination Assess for a history of allergy to anticholinergic drugs, COPD, narrow-angle glaucoma, myasthenia gravis, bowel or urinary obstruction, tachycardia and recent GI or urinary surgery. Focus the physical examination on the following: CV: blood pressure, pulse rate, peripheral perfusion, ECG CNS: orientation, affect, reflexes, vision Skin: colour, lesions, texture, sweating GU: urinary output, bladder tone GI: abdominal exam Respiratory: respiratory rate, adventitious sounds Implementation Ensure safe and appropriate administration of drug. Provide comfort and safety measures, including assistance/ side rails; temperature control; dark glasses; small, frequent meals; artificial saliva, fluids; sugarless lozenges, mouth care; bowel program. Provide support and reassurance to deal with drug effects, discomfort and GI effects. Provide teaching regarding drug name, dosage, adverse effects, precautions and warnings to report. Monitor blood pressure and pulse rate, and adjust dose as needed. Evaluation Evaluate drug effects: pupil dilation, decrease in signs and symptoms being treated.