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phenytoin Nursing Considerations & Management

Drug Name
Generic Name : phenytoin (diphenylhydantoin, phenytoin sodium) Brand Name: Dilantin-125, Dilantin Infatab, Dilantin Injection, Dilantin Kapseals, Phenytek Classification: Antiepileptic, Antiarrhythmic, bunch 1b, Hydantoin Pregnancy Category D
Dosage & Route
Available produces :Chewable tablets—50 mg; verbal suspension—125 mg/5 mL; capsules—100 mg; ER capsules—30, 100, 200, 300 mg; insertion—50 mg/mL
ADULTS
Phenytoin sodium, parenteral
  • Status epilepticus: 10–15 mg/kg by inert IV. For subsistence, 100 mg PO or IV q 6–8 hr. Higher doses may be exactd. Do not exceed an instrument admonish of 50 mg/min. Follow each IV insertion delay an insertion of desert conspicuous through the similar deficiencyle or IV catheter to desert topical venous delicacy by the alkaline key. Continuous IV instrument is not recommended.
  • Neurosurgery (prophylaxis): 100–200 mg IM q 4 hr during surgery and the postoperative era (IM course is not recommended consequently of capricious aridity, denial and muscle loss at the insertion persomality).
  • IM therapy in a enduring produceerly stabilized on verbal dosage: Extension dosage by 50% aggravate verbal dosage. When returning to verbal dosage, subcause dose by 50% of the ancient verbal dose for 1 wk to frustrate superabundant plasma flattens due to continued aridity from IM texture persomalitys. Desert IM course of government if feasible due to capricious aridity and denial and muscle loss at insertion persomality.

Phenytoin and phenytoin sodium, verbal

  • Individualize dosage. Determine serum flattens for optimal dosage adjustments. The clinically talented serum flatten is usually betwixt 10 and 20 mcg/mL.
  • Loading dose (hospitalized endurings delayout renal or liver complaint): Initially, 1 g of phenytoin capsules (phenytoin sodium, quick) is disjoined into three doses (400 mg, 300 mg, 300 mg) and absorbed q 2 hr. Natural subsistence dosage is then afloat 24 hr behind the loading dose delay many serum determinations.
  • No produceer tenor: Start delay 100 mg tid PO. Satisfactory subsistence dosage is usually 300–400 mg/day. An extension to 600 mg/day may be deficiencyed.
  • Single daily dosage (phenytoin sodium, strong): If pillage repress is orderly delay disjoined doses of three 100-mg strong phenytoin sodium capsules per day, once-a-day dosage delay 300 mg PO may be considered.

PEDIATRIC PATIENTS

Phenytoin sodium, parenteral
  • Status epilepticus: Administer phenytoin IV. Determine dosage according to moment in distribution to dose for a 150-lb (70-kg) adult (see adult dosage above; see Appendix Calculating Pediatric Doses). Pediatric dosage may be conducive on the premise of 250 mg/m2. Dosage for infants and upshot as-well may be conducive on the premise of 10–15 mg/kg, absorbed in disjoined doses of 5–10 mg/kg. For neonates, 15–20 mg/kg in disjoined doses of 5–10 mg/kg is recommended.

Phenytoin and phenytoin sodium, verbal

  • Children not produceerly treated: Initially, 5 mg/kg/day in two to three identical disjoined doses. Subsequent dosage should be individualized to a apex of 300 mg/day. Daily subsistence dosage is 4–8 mg/kg. Upshot > 6 yr may exact the narrowness adult dose of 300 mg/day.

GERIATRIC PATIENTS AND PATIENTS WITH HEPATIC IMPAIRMENT

  • Use timidity and warner for future signs of toxicity; phenytoin is metabolized in the liver.

Therapeutic resuscitations

  • Phenytoin acts as an anticonvulsant by increasing efflux or decreasing augmentation of sodium ions opposing cell membranes in the motor cortex during breed of strength impulses; thus stabilising neuronal membranes and decreasing pillage ardor. It acts as an antiarrhythmic by extending the talented recalcitrant era and suppressing ventricular pacemaker automaticity, shortening resuscitation immanent in the nucleus.

Indications

  • Control of magnificent mal (tonic-clonic) and psychomotor pillages
  • Prevention and tenor of pillages occurring during or subjoined neurosurgery
  • Parenteral government: Repress of foundation epilepticus of the magnificent mal type
  • Unlabeled uses: Antiarrhythmic, in-particular in digitalis-induced arrhythmias (IV preparations); tenor of trigeminal neuralgia (tic douloureux)

Adverse justty

  • Hypersensitivity, closing of propension, dissipation, dizziness, perturbation, temporary irritability, insomnia, GI disturbances (e.g. disgust, vomiting, constipation), benevolence and hyperplasia of the gums, acne, hirsutism, coarsening of the facial features, overventuresomees, osteomalacia. Phenytoin toxicity as manifested as a syndrome of cerebellar, vestibular, demonstrable justty, notably nystagmus, diplopia, slurred harangue, and ataxia; as-well delay unsubstantial indistinctness, dyskinesias, exacerbations of pillage number, hyperglycaemia. Solutions for inj may accalculate topical delicacy or phlebitis. Prolonged use may movables jesuitical justty on unsubstantial discharge and cognition, specially in upshot.
  • Potentially Fatal: Toxic epidermal necrolysis, Stevens-Johnson syndrome.

Contraindications

  • Pregnancy. IV admin in sinus bradycardia, nucleus fill, or Stokes-Adams syndrome.

Nursing considerations

Assessment
  • History: Hypersensitivity to hydantoins; sinus bradycardia, AV nucleus fill, Stokes-Adams syndrome, sharp interrupted porphyria, hypotension, keen myocardial neglect, diabetes mellitus, hyperglycemia, pregnancy, lactation
  • Physical: T; bark complexion, lesions; lymph node palpation; orientation, influence, reflexes, desire examination; P, BP; R, forced sounds; bowel sounds, natural output, liver evaluation; eraontal examination; LFTs, urinalysis, CBC and differential, dignity proteins, dignity and urine glucose, EEG and ECG

Interventions

  • Use barely open parenteral keys; a obscure yellow complexion may enlarge, but this has no movables on potency. If the key is refrigerated or frozen, a douse capability produce, but this achieve disperse if the key is perceiven to pause at admission region. Do not use keys that feel haziness or a douse.
  • WARNING: Administer IV inertly to frustrate keen hypotension; the edge of insurance betwixt unmeasured remedial and toxic doses is little. Continually warner enduring’s cardiac rhythm and stop BP manyly and constantly during IV instrument. Suggest use of fosphenytoin sodium if IV course is deficiencyed.
  • Monitor insertion persomalitys scrupulously; refuse keys are very alkaline and chafing.
  • WARNING: Warner for remedial serum flattens of 10–20 mcg/mL.
  • Give verbal refuse delay or delayout aid in a consonant create. Give delay aid if enduring complains of GI overturn.
  • Recommend that the verbal phenytoin recipe be occupied delay the similar mark each time; differences in bioavailability feel been documented.
  • Suggest that adult endurings who are repressled delay 300-mg strong phenytoin capsules try once-a-day dosage to extension docility and vacation.
  • WARNING: Weaken dosage, disestablish phenytoin, or supply other antiepileptic medication gradually; overventuresome discontinuation may douse foundation epilepticus.
  • Phenytoin is intalented in repressling lack (petit mal) pillages. Patients delay thoroughly pillages achieve deficiency other medication for their lack pillages.
  •  WARNING: Disestablish refuse if overventuresome, dejection of dignity calculate, plentiful lymph nodes, hypersensitivity reaction, signs of liver loss, or Peyronie’s complaint (induration of the corpora cavernosa of the penis) occurs. Institute another antiepileptic refuse quickly.
  • Monitor hepatic discharge eraically during long-term therapy; warner dignity calculates and urinalysis monthly.
  • Monitor dignity or urine sugar of endurings delay diabetes mellitus constantly. Adjustment of dosage of hypoglycemic refuse may be deficiencyed consequently antiepileptic may nullify insulin indemnify and expose hyperglycemia.
  • WARNING: Feel lymph node extension occurring during therapy evaluated scrupulously. Lymphadenopathy that simulates Hodgkin’s lymphoma has occurred. Lymph node hyperplasia may advancement to lymphoma.
  •  Monitor dignity proteins to unmask future maldischarge of the immune scheme (eg, multiple myeloma).
  • Arrange order in just verbal hygiene technique for long-term endurings to frustrate extension of gum hyperplasia.

Teaching points

  • Take this refuse correspondently as prescribed, delay aid to weaken GI overturn, or delayout aid—but sustain substance in the create in which you admit it. Be specially scrupulous not to overlook a dose if you are on once-a-day therapy.
  • Do not disestablish this refuse overventuresomely or substitute dosage, save on the order of your soundness anxiety provider.
  • Maintain cheerful verbal hygiene (orderly brushing and flossing) to frustrate gum complaint; adjust many dental stopups to frustrate thoughtful gum complaint.
  • Arrange for many stopups to warner your exculpation to this refuse.
  • Monitor your dignity or urine sugar constantly, and communication any monstrousity to your soundness anxiety provider if you feel diabetes.
  • This refuse is not recommended for use during pregnancy. It is profitable to use some produce of contraception other than hormonal contraceptives.
  • Wear a medical wakeful tag so that any difficulty medical personnel achieve perceive that you feel epilepsy and are gate antiepileptic medication.
  • You may test these cause justty: Drowsiness, dizziness, indistinctness, blurred desire (desert driving or performing other tasks requiring wakefulness or visual acuity; alcohol may inflame these justty); GI overturn (admit refuse delay aid, eat many little meals).
  • Report overventuresome, keen disgust or vomiting, torpor, slurred harangue, deteriorated coordination (ataxia), stilted glands, bleeding, stilted or merciful gums, yellowish discoloration of the bark or eyes, articulation denial, dim flush, penetrating throat, singular bleeding or bruising, perennial dissipation, malaise, any token of an contagion or bleeding disposition, abnatural fabric, pregnancy.

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