Symptom alert: Overdoses and drug interactions
After a young woman felt symptoms of an allergic reaction coming on, she went to the grocery store and bought a bottle of antihistamine, recalls Shelley Cohen, RN, CEN, a consultant and educator with Health Resources Unlimited in Hohenwald, TN.
"She drank the entire bottle in less than a day and presented as an acute anticholinergic toxicity," says Cohen.
In a similar case, a teen-ager came to the ED complaining of abdominal pain, but told nurses that no injury had occurred.
"He finally admitted to buying two bottles of that pink liquid stuff’ for upset stomachs and drank them over two days," says Cohen. "He had so much aspirin in him he had a gastrointestinal bleed. That’s why his stomach hurt."
When you triage patients, do you always consider the possibility of prescription or over-the-counter drug overdoses? "Keeping your antennae up for these suspicions is important, because many patients do not even realize they have overdosed," says Cohen.
In addition, keep a high index of suspicion for symptoms caused by ingestion of herbal agents, urges Stacey Westphal, RN, clinical educator at Cape Canaveral Hospital in Cocoa Beach, FL. "Patients tend to think herbs are safe because they are natural, but there is always a potential for drug interactions," she says.
To improve assessment of patients, do the following:
• Consider risks for diabetics.
Diabetic patients taking warfarin may not realize that certain herbal agents affect blood sugar levels and clotting times, says Cohen. "For example, ginseng affects clotting times when taken in certain doses for patients on warfarin," she says.
• Question patients about medication history.
Ask the following specific questions, recommends Cohen:
— What medications are you taking that your doctor prescribes?
— What vitamins, minerals, herbs, or other medicines do you take that you don’t need a prescription from your doctor to get?
In addition to prescriptions, patients may self-medicate with over-the-counter products or order drugs from the Internet without a prescription, notes Cohen. She suggests the following:
— Keep an appropriate nursing drug reference handbook near the triage phone or at the triage desk.
— Be aware that many of the new medications have names similar to existing drugs, such as Celebrex, which is commonly prescribed for arthritis, and Cerebrex, which is given for seizures.
— Many drugs are prescribed for a variety of medical problems. "Don’t assume the patient is on a particular medicine for seizures when that same medication may also be prescribed for depression," says Cohen.
For example, don’t assume that beta-blockers are being given to treat hypertension or cardiovascular disease, since they also work for migraines or depressive disorders. "Ask the patient what they are taking the medication for," says Cohen.
• Routine medications can mask the signs of shock.
Patients on beta-blockers will have a reduced heart rate, and this is an expected and normal effect, says Cohen. "Looking for tachycardia as an early sign of shock is not helpful in these patients," she says. "The tachycardia will not present as early or as obvious when the patient is on a beta-blocker."
You must be aware of other signs of shock or perfusion changes, such as delayed capillary refill, says Cohen.
If the patient has reduced kidney function, many medications are not metabolized as quickly.
The clinical presentation of the patients will vary based on their ages and other existing medical conditions, but you should identify red flags that may indicate potential perfusion problems, advises Cohen. Red flags include change in mental status; delayed capillary refill; moist, diaphoretic skin; changes in skin color; dizziness or lightheadedness; and nausea with vomiting at times, she says.
"There may also be some vital sign changes, although this may be a late indication," says Cohen.
• Be aware of the potential for drug interactions.
At Cape Canaveral’s ED, a man reported sudden loss of memory. Immediately, ED nurses suspected a possible stroke, intercranial bleeding, or other neurological diagnosis, says Westphal. "In addition, a toxicology screen was done, which had unusual findings," she reports.
At that point, the patient and his wife were asked about herbal medications, and he acknowledged he had been taking a mixture of Chinese herbal remedies. The man was admitted, and it was later determined that the herbal agents apparently were responsible for the memory loss, Westphal says.
If patients identify taking herbal medications, a herbal discharge instruction sheet is given, she adds. In addition, posters are hung throughout the ED on a different herbal drug every week, such as saw palmetto, St. John’s wort, and echinacea.
Give inservices to nurses to bring home the importance of identifying any herbal medications patients are taking, advises Westphal. "If they are aware of possible interactions, it will get them to start asking," she says.
For example, ginseng can elevate blood pressure and cause a patient to present with a hypotensive event, notes Westphal. "This information gives you one more avenue to explore and is also an opportunity for patient education," she says.
Sources
For more information on triage, contact:
- Shelley Cohen, RN, CEN, Health Resources Unlimited, 522 Seiber Ridge Road, Hohenwald, TN 38462. Telephone: (888) 654-3363 or (931) 722-7206. Fax: (931) 722-7495. E-mail: educate @hru.net. Web: www.hru.net.
- Stacey Westphal, RN, MS, CEN, Clinical Educator, Emergency Services, Cape Canaveral Hospital, 701 W. Cocoa Beach Causeway, Cocoa Beach, FL 32931. Telephone: (321) 868-7651. Fax: (321) 868-7249. E-mail: [email protected].
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