NSG 325 Module 3Case study 2SeizuresA 26-year-old patient who is 8 months pregnant is admitted to the neurologic intensive care unit with the diagnosis of head injury. An automobile accident has left the patient unconscious. On admission an intravenous (IV) line of D51/2 NS at 50ml/hour is started. Within the first 24 hourson the unit, the patient has several tonic-clonic seizures. Standing orders on the unit allow the nurse to administer diazepam (Valium) 5 mg IV push. The prescriber is notified of the seizure and orders an IV loading dose of phenytoin (Dilantin) 800 mg followed by 100 mg every 6 hours, a phenytoin level the next day, and IV cimetidine 300 mg twice a day. 1. What nursing precautions are needed when administering phenytoin and cimetidine IV?- Phenytoin (Dilantin) – Speed=50mg/min. Look for ADRs. Check serum levels=theraputic level is 10-20mcg/mL- Cimetidine – may increase phenytoin blood levels.2. Phenytoin is available for IV infusion in a concentration of 50mg/ml, how much volume will be required to give the proper dose of phenytoin? Does it need to be diluted? How fast can it be given? Can it be given with the current IV fluid?- 16mL- No- 16min or slower if BP starts to drop- No bc of the dextrose. Flush with saline, give drug, flush with saline, continueIV.3. What symptoms should the nurse be alert for during medication administration?- Hypotension4. What symptoms should the nurse be alert for because of the possible interaction of phenytoin and cimetidine? - Hypotension5. The next day, the phenytoin level is 14 mcg/mL. Why is it critical for the nurse to closelymonitor plasma drug levels of phenytoin?- To check theraputic levels- To assess for phenytoin toxicity- To assess for low levels6. One week later the patient goes into labor. Based on initiation of phenytoin near the end of the pregnancy, what fetal effects are most likely to occur? - No particular fetal effects will occur.-7. What precautions might be taken to protect the fetus during drug therapy, during delivery and after delivery? 8. Two weeks later, the patient is stabilized and has been transferred to the neurological progressive care unit. On admission, the nurse notes a fine maculopapular rash on the patient’s trunk. What should the nurse do and why. 9. Phenytoin is discontinued. Carbamazepine (Tegretol) is started to prevent patient’s seizures. The patient is concerned about taking seizure medication because she wants to have more children. She has been advised about possible adverse effects to the fetus. In addition to referring concerns to the prescriber, what information could the nurse provide about seizures, AED’s and pregnancy?- Grapefruit juice increases serum levels or tegretol.- Anemia- Unsteadiness- Avoid breastfeeding and notify health care professional if pregnancy is planned or suspected or if
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