An emergency department nurse initiates a prescribed sodium nitroprusside continuous intravenous infusion for a patient presenting with acute hypertensive encephalopathy and underlying renal insufficiency. To ensure patient safety during this high-alert parenteral therapy, which interventions must the nurse implement? Select all that apply.
- Shield the medication reservoir with an opaque cover immediately upon preparation to prevent rapid photodegradation.Answer
- Discontinue the infusion immediately if the solution in the intravenous tubing turns dark blue, green, or red.Answer
- Assess the patient for tinnitus, hyperreflexia, and confusion, as these indicate thiocyanate accumulation.Answer
- DMonitor the patient's arterial blood gas for respiratory alkalosis, recognizing it as the hallmark acid-base imbalance of cyanide toxicity.
- EAdminister the continuous infusion through a shared Y-site while concurrently running an intermittent dose of intravenous pantoprazole.
- FElevate the head of the bed to a high-Fowler's position if the patient develops a sudden, severe drop in blood pressure.
Answer
The essential nursing interventions include shielding the medication from light, discontinuing the solution if it changes to a dark blue, green, or red color, and closely monitoring for neurological signs of thiocyanate toxicity due to the patient's renal insufficiency.
Sodium nitroprusside requires specialized handling because of its rapid degradation when exposed to light, which can be identified by the solution turning dark blue, green, or red (normal is faint brown). Furthermore, it is metabolized into thiocyanate, which is renally excreted. Because this patient has renal insufficiency, the nurse must rigorously monitor for thiocyanate toxicity, characterized by central nervous system disturbances such as tinnitus, confusion, and hyperreflexia.
Step-by-Step Solution
Key Concept
Safe administration, compatibility rules, and toxicity monitoring for continuous sodium nitroprusside infusions.