Wednesday, August 10, 2011

Haloperidol

Brand Name: Haldol

Class of Drug: Typical anti-psychotic

Mode of Action: For people with psychotic illnesses like acute psychosis, schizophrenia, there is an overactive / over-secretion of neurotransmitters in their brain. Thus, depending on which areas of nerves are constantly/ excessively triggered, they may see, hear, smell, feel or taste "excessive" things that others do not experience. Haloperidol blocks the receptors for the neurotransmitter, dopamine. Thus, excessive stimulation of the nerves are prevented, resulting in a decrease in the symptoms experienced by the patient.

Used For: Psychotic disorders, Controlling motor and verbal tics of those with Tourette's disorder

Side Effects: Extra-pyramidal side effects (various motor disturbances including inability to initiate movement, inability to stop movements, jerky and sudden movements etc), dizziness, dry mouth, lethargy, muscle stiffness or cramps, tremors, lactation, increased libido, decreased sexual functioning in males, difficulty urinating etc
Serious Side Effects: Neuroleptic Malignant Syndrome (muscle cramps, fever, unstable vital signs, tremors, change in cognition), difficulty breathing or swallowing, seizures, neck cramps etc

If you missed a dosage, just take it as soon as when you remember it. However, if it is almost time for the next dose, take only 1 dose and ignore the missed dose.

http://www.medicinenet.com/haloperidol/article.htm
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682180.html

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Amlodipine

Brand Name: Norvasc

Class of Drug: Calcium channel blocker (CCB)

Mode of Action: A CCB prevents calcium from being transported into smooth muscle cells found along arteries, especially the coronary arteries. Without sufficient calcium, the smooth muscles cannot contract the artery muscles are relaxed. This dilates the arteries and lowers the blood pressure. The heart gets a larger supply of blood and this helps prevent chest pain (angina) which may result if there is insufficient blood flow to the heart and coronary artery spasm.

Used For: Preventing chest pain (angina) and for high blood pressure treatment

Side Effects: Swelling (edema of the lower extremities, headache, feeling faint, fatigue, drowsiness
Serious side effects: Palpitations (rapid, pounding heartbeats) or fainting

If you missed a dosage, just take it as soon as when you remember it. However, if it is almost time for the next dose, take only 1 dose and ignore the missed dose.

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Sunday, August 7, 2011

Rehabilitation Posting II

When I first fed a real patient via a nasogastric tube (NGT), I was feeling a little nervous and I even dropped one of the connecting tubes right at the start! It was quite embarrassing especially with a nurse staring at a clumsy me. Other times during lab practices, I "fed" at most 50ml of plain water. However, this time round, I had to feed 200ml of thicker fluid which flowed much much slower. Thus, the entire process was quite draggy. I lost concentration and as a result, forgot to kink the tube immediately when needed. Luckily, the enrolled nurse (EN) and a fellow nursing student saw it and alerted me! Thankfully, Mr K., my patient, did not cough and appeared fine/ normal. I made a mental note never to lose focus on my task at hand again.

The second time I fed Mr K., I was constantly reminding myself to remember to kink the tube. This time, with the experience of my first NGT feeding, everything was much better and the process was smoother-- I did not drop anything and I kept my eyes constantly on Mr K., his tube and my equipment.

I learnt that besides aspiration of fluid from the NGT to test for its acidity, there are two other methods of testing the placement of the tube. They are auscultation, the pumping of air into the tube and hearing its sound in the stomach and putting the tube into a cup of water to check for presence of any air bubbles, which may mean that the tube is displaced into the lungs. However, the best method to check for tube placement is to send patient for an X-ray. Having said that though, it is not feasible to send patient for an X-ray everytime the patient is about to be fed as there are not only manpower and costs issues, exposing patient to constant radiation, no matter how low, is harmful for the patient too. Thus, the most practical and reliable method is the aspiration method.

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Friday, August 5, 2011

Obstetrics Posting

This is my most awaited posting! I love to interact with pregnant women who are anxiously waiting for the birth of their precious babies, new mothers and families who are basking in the joy of the arrival of the newborns and finally, BABIES!

However, on my first day in the obstetrics ward, what greeted my friends and I was a dismal sight. All the curtains were screened and the different patients were keeping to themselves. They certainly did not look welcoming and friendly, unlike the patients in my other postings. All my anticipation and looking forward towards this posting were dashed.

Over the next few days though, I realized drawn curtains did not mean unfriendly. It just meant that these tired women were exhausted either by their active foetus or by their crying newborns. Another reason was that many women breastfeed their babies and thus, it was more convenient to just leave the curtains drawn rather than screening and unscreening them every 2-3 hours. They were actually quite friendly and happy to share their joy with us; when they delivered, how many children they had, how pretty and handsome their newborn was, how well their child suckled when they breastfed or how much trouble they had when trying to breastfeed etc. Almost all of the mothers were very open too! They allowed us (the students) to be there with them while the breastfeeding nurse taught them breastfeeding. Without their generosity and open minds, we would not have been able to observe breastfeeding live and had to rely on watching videos. Watching the mothers breastfeed their child made me feel that breastfeeding is a natural and beautiful bonding process. THANK YOU to all the mothers who made me realize this!

The posting soon came to an end. Despite what my fellow students said about this obstetrics posting being a boring posting (as we did not have much opportunities to perform obstetrics-related skills), I felt happy and grateful for this posting. This is because I get to observe and learn stuffs too! *happy*

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Subcutaneous Medications (Insulin)

Insulin is basically available in two forms: 1) pen-like structure that stores a certain amount of insulin and can deliver a certain unit (depending on the order) each time its button is pushed or 2) bottled liquid form where you need syringe and needle to deliver the insulin. This post shall focus on the second form of insulin, where preparations are slightly more complicated.

Things Required:
  • IMR
  • Medications (this post shall explain how to serve a short-acting eg. Actrapid and a long-acting insulin simultaneously. If your order requires only one type of medication, just take that medication and ignore the second one)
  • Syringe
  • 3 Needles (2 x 19G, 21G)
  • Gloves
  • Alcohol swabs
  • Kidney dish
Always check the items you take for expiry date and clarity (if applicable).

1. Verify order and patient's need for this procedure. For example, if a patient is on sliding scale (ie. the amount of insulin needed is dependent on his hypocount), he may not need the insulin if his hypocount is of desirable value. Perform hand rub.

2. Get the correct medications out from the fridge (as insulin is usually stored there) and rub the bottles in your palms to warm them. Insulin, when injected cold, may be painful for the patient.

3. Swab the top of the bottles with alcohol swabs. Attach a 19G needle to the syringe and inject air equivalent to the unit of long-acting insulin needed into the long-acting (more cloudy appearance) insulin bottle and then inject air equivalent to the unit of short-acting insulin needed into the short-acting (clearer appearance) insulin bottle. Injecting air first will reduce the resistance when drawing the insulin.

That is, if I need 2 units of long-acting insulin and 3 units of short-acting insulin, I would inject 2 units of air into the bottle containing long-acting insulin first and then inject 3 units of air into the bottle containing short-acting insulin.

4. After injecting air, draw the required units of short-acting insulin. Change to another 19G needle and discard the first needle to avoid cross-contamination of the different insulin. Using the new 19G needle, draw the units of long-acting insulin needed. Discard the needle. Attach the 21G needle to the syringe.

5. Approach and identify patient with 2 patient identifiers again: patient’s name and IC by asking patient and verifying it with his wrist tag. Ensure that patient is not allergic to the medication by checking it with the IMR and by asking patient. Prepare the environment where necessary: adequate lighting, suitable working height, screening of the patient, who would have to expose himself)

6. Perform hand rub and wear gloves (wearing of gloves is dependable on hospital policy).

7. In Singapore, any subcutaneous injections are almost only performed in the abdomen area for adults. Thus, get patient to expose his abdomen and ask where was his last injection site (right or left side of the umbilicus) and avoid it. This is because injecting the same area over and over again with insulin will result in lipodystrophy, where the area would be slightly dented and insulin absorption diminished.

8. If patient's last injection site was to the right side of the umbilicus, measure two finger spacings away from the umbilicus on the left side and clean that area with alcohol swab.

9. Lightly pinch the area with your thumb and forefinger of your non-dominant hand. With your dominant hand holding the syringe like a dart, inject the needle fully, at 90 degrees to the skin and administer the insulin slowly.

10. Release the pinched area and take a piece of alcohol swab. Withdraw the needle and use the alcohol swab to apply pressure to the injection site for around 10 seconds. Do not rub the area as this would increase insulin absorption.

11. Inform patient that the procedure is completed and to inform you if he feels giddy. Remind him to have his meal or some food 30 minutes later. Ensure patient’s safety and comfort levels and that the call bell is within reach before leaving the patient.

12. In the IMR, record that subcutaneous insulin had been given. Check for any adverse reactions/ patient's response to the medications and document in the relevant notes.

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Monday, August 1, 2011

Rehabilitation Posting

In this first ever posting of mine, I met the ever jovial Mr A, who had been hospitalized for quite some time already, due to a fall. As a result of that fall, Mr A had been in ICU (intensive care unit) for about a month and was recently discharged to this community hospital. He suffered a spinal injury and now only has movement neck up and some limited movement with his left finger, as a result of countless physiotherapy. Needless to say, all his ADLs (activities of daily living) had to be taken care of by the nurses and us, student nurses.

Yet, Mr A not only did not despair, he still has a positive outlook on life. One would expect someone in Mr A's condition to be sulking and withdrawn but Mr A was the exact opposite. He was very glad to still be alive and to be with his family. He taught us how to not focus on the small, unhappy details in life but to celebrate the living and be more forgiving. Every time if we had nothing to do, all we had to do was to look for Mr A and he would gladly entertain and cheer us when we should be the ones making his day. Even when I was not there, I would always hear laughter coming from his cubicle as he talked to his new friends (the other patients there) about the day's events. His wife would also come daily with homemade soups and food. Though I know this must be very tiring on her; having to look after their children, work and come visit Mr A everyday without fail, she never once complained or even sighed in front of us but supported her husband through this all. How noble love is..

Anyway, kudos to Mr A. Though it has been more than one year ago, I would never forget Mr A if I ever needed hope (?). I wish him success in his physiotherapy.

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