C H A P T E R 2 8
Neuromuscular junction blocking agents
439
Care considerations for
people receiving NMJ blocking agents
Assessment: History and examination
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■
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.
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■
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
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.
■
■
Test the person’s response and recovery
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
tolerate drug effects
, such as pain relief
as appropriate; reassurance, support and
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).
