Microsoft word - m - medication admin - nitroglycerin.doc

EMS SKILL
NITROGLYCERIN
PERFORMANCE OBJECTIVES
Demonstrate proficiency in recognizing the indications, contraindications, criteria, and assist the patient with the administration of the
prescribed medication nitroglycerin.
CONDITION
Establish that a simulated patient complaining of substernal chest discomfort meets the criteria for administration of nitroglycerin and will
assist the patient by administering either the nitroglycerin spray or tablet or two different patients may be selected to demonstrate both
methods of administration. Necessary equipment will be adjacent to the simulated patient.
EQUIPMENT
Simulated patient, oxygen tank with a flow meter, oxygen mask, blood pressure cuff, stethoscope, placebo nitroglycerin spray and tablets,
timing device, clipboard, pen, goggles, masks, gown, gloves.
PERFORMANCE CRITERIA
y
Items designated by a diamond () must be performed successfully to demonstrate skill competency. Items identified by double asterisks (**) indicate actions that are required if indicated. Items identified by (§) should be practiced. PREPARATION
Skill Component
Key Concepts
 Take body substance isolation precautions y Mandatory personal protective equipment - gloves y Situational - long sleeves, goggles, masks, gown  Complete a primary assessment and pertinent vital y Any patient complaining of difficulty breathing should be placed on y If in respiratory distress, patients with a history of COPD should be y Assess mental status/stimulus response (AVPU) placed on 15 Liters/minute via mask. DO NOT withhold oxygen from Any patient complaining of chest pain should be placed on oxygen ** Administer high flow oxygen
Nitroglycerin may cause hypotension due to vasodilation. Always take blood pressure before administration and 5 minutes after ** Obtain blood pressure before administration and 5
minutes after administration.
 Verbalize the criteria for assisting patients with y EMTs may only assist with administration of nitroglycerin as per Reference 802 – Los Angeles County Emergency Medical y EMTs may NOT carry nitroglycerin tablets or spray, but may assist with the patient’s own prescribed medication. y No contraindications are present for administration y In life-threatening situations, an ALS Unit must be enroute or BLS should consider transport if ALS arrival is longer than transport time.  Verbalize the indications for assisting the patient with y Any degree of chest pain/discomfort should be treated with Nitroglycerin regardless how the patient rates the pain.  Verbalize the contraindications for administration of y Patient does not meet indication or criteria for y If last dose of nitroglycerin exceeds 5 minutes, nitroglycerin may be y Patient has taken 3 doses before EMS arrival within y If the patient insists on taking nitroglycerin and it meets the contraindications criteria, EMTs should NOT assist in the administration, but document the patient’s actions. y Administration of Sildenafil citrate (Viagra7) or similar Medication Administration – Nitroglycerin 2002, 2010 PROCEDURE
Skill Component
Key Concepts

 Check medication for:
y Drug name - Trade names for nitroglycerin may include: Nitrolingual Spray7, Nitrobid7, Nitrostat7 y Integrity of container/medication - Make sure container is NOT y Concentration/Dose - dose of nitroglycerin is 0.4mg (grain 1/150) per tablet. (Concentration only refers to liquid form of medications.) y Clarity - not applicable to tablets or unable to see liquid in spray y Expiration date - not to be administered after this date y Make sure that tablet is intact for administration of correct dose. y DO NOT contaminate medication. Pour tablet into lid of container y Remove tablet from container and check that it is intact then into the palm for administration. Gloves should be worn when y One spray delivers 0.4mg of nitroglycerin. DO NOT shake container y Gloves should be worn when administering nitroglycerin spray since medication may be absorbed through the skin. y Ensure that spray opening is pointed toward patient  Remove oxygen mask and instruct patient to open mouth y If patient swallows the tablet it will change the absorption rate and the amount of drug absorbed. Sublingual absorption is faster than y Instruct patient to allow tablet to dissolve and NOT to y If patient inhales the spray it will change the absorption rate and the y Deliver one spray sublingually or transmucosal amount of drug absorbed. Sublingual absorption is faster and more accurate than inhaling medication into lungs. y Use the pain scale of mild, moderate, severe or the 1-10 scale.  Reassess blood pressure and pain response in 5 Nitroglycerin may cause hypotension due to vasodilation. Always take blood pressure before administration and 5 minutes after ** Place patient in shock position - if indicated
y EMTs may administer up to 3 nitroglycerin doses if the patient has not taken the medication and blood pressure remains > 100mm/Hg. y Nitroglycerin administration is for EMERGENCY SUPPORTIVE THERAPY ONLY and is not a substitute for immediate medical care. y In life-threatening situations, an ALS Unit must be enroute or BLS should consider transport if ALS arrival is longer than transport time. REASSESSMENT
(Ongoing Assessment)
Skill Component
Key Concepts

§ Repeat an ongoing assessment every 5 minutes:
Priority patients are patients who have abnormal vital signs, S/S of poor perfusion, if there is a suspicion that the patient’s condition may y Relevant portion of the secondary assessment deteriorate, or when the patient’s condition changes y Patients must be re-evaluated at least every 5 minutes or sooner if any treatment was initiated, medication administered or a change Medication Administration – Nitroglycerin 2002, 2010 in the patient’s condition occurs or is anticipated. Medication Administration – Nitroglycerin 2002, 2010 Skill Component
Key Concepts
 Evaluate results of reassessment and note any changes y Evaluating and comparing results assists in recognizing if the from patient’s previous condition and vital signs patient is improving, responding to treatment or condition is **Manage patient condition as indicated.
PATIENT REPORT AND DOCUMENTATION
Skill Component
Key Concepts

§ Verbalize/Document
y Documentation must be on either the Los Angeles County EMS Report or departmental Patient Care Record form. Assessment findings before and after administration y On the Los Angeles County EMS Report, document administration only in the comment section. Mark the box AEMT Medication Assist@ and write out all pertinent information. y Last reassessment information (before patient care is transferred) should be documented in the section of the EMS form that is called AReassessment after Therapies and/or Condition on Transfer@. • Documenting reassessment information provides a comprehensive picture of patient’s response to treatment. y If the patient insists on taking nitroglycerin and it meets the contraindications criteria, EMTs should NOT assist in the Blood pressure 5 minutes after administration administration, but document the patient’s actions. Medication Administration – Nitroglycerin 2002, 2010 NITROGLYCERIN
Supplemental Information
DEFINITIONS:
• Sublingually - medication administration under the tongue
• Transmucosal - medication route on top of tongue or mucus membrane in the mouth (buccal cavity)
ASSESSMENT: PAIN / DISCOMFORT (non-traumatic):

• Onset - when the pain/discomfort first began (minutes - weeks); what makes it better or worse
• Provokes - causative event or what increases pain/discomfort
• Quality - type of pain, i.e. sharp, ache, squeezing, burning, etc
• Region - area⎟local vs. diffuse pain/discomfort
• Radiation, - pain moves to another area away from its origin;
• Relief - constant vs. intermittent; what makes it better or worse
• Severity - mild, moderate, severe or 0-10 scale used to rate initial event or compare to previous episode or ongoing assessment
• Time - duration
INDICATIONS:

CONTRAINDICATIONS:

• Patient does not meet indication or criteria for administration
• Patient has taken 3 doses before EMS arrival within the last 5 minutes
• Last dose was < 5 minutes ago
• Systolic blood pressure < 100mm/Hg
• Administration of erectile dysfunction medications such as Sildenafil citrate (Viagra7) or similar medication within 24-36 hours
ADVERSE EFFECTS:
• Cardiovascular - hypotension, bradycardia, reflex tachycardia, rebound hypertension
• Neurological - throbbing headache, dizziness/faintness, confusion, blurred vision
• Gastrointestinal - nausea, vomiting, dry mouth
• General - flushed skin, sublingual burning
ADMINISTRATION:
• Adult
-1 tablet or 1 spray of 0.4mg to a maximum of 3 doses, this includes what was taken by the patient. • Pediatric - Not recommended for prehospital care • EMTs may not carry nitroglycerin, they may only assist with administration of a patient=s prescribed nitroglycerin. • In life-threatening situations, an ALS Unit must be enroute or BLS should consider transport if ALS arrival is longer than transport time. • Nitroglycerin may cause hypotension due to vasodilation. Always take blood pressure before administration and 5 minutes after • Instruct patient not to swallow the nitroglycerin tablet, it will change the absorption rate and the amount of drug absorbed. Sublingual absorption is faster than gastrointestinal absorption. • Instruct patient not to inhale nitroglycerin spray, it will change the absorption rate and the amount of drug absorbed. Sublingual absorption is faster and more accurate than inhaling medication into lungs.
• DO NOT shake nitroglycerin spray container or dose delivered will be altered. One spray delivers 0.4mg of nitroglycerin.
REFERENCE:
• Reference 802 – Los Angeles County Emergency Medical Technician Scope of Practice. Medication Administration – Nitroglycerin 2002, 2010

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