A nurse in the emergency department is assisting in the care of a client.

Click to highlight the findings that require immediate follow-up. To deselect a finding click on the finding again.

Nurses Notes

1630:

Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields, Diffuse, raised rash present on trunk. Abdomen soft, nontender

Vital Signs

1630:

Temperature 38.3°C (101°F)

Heart rate 110/min

Respiratory rate 30/min

Blood pressure 90/55 mmHg

Oxygen saturation 91% on room air

A. Bleeding. Cefotetan, a second-generation cephalosporin, can interfere with vitamin K metabolism, leading to a decreased ability to form blood clots. When combined with NSAIDs, which have an antiplatelet effect, the risk of bleeding increases. Clients taking both medications should be monitored for bruising, prolonged bleeding, or signs of gastrointestinal hemorrhage such as black, tarry stools.

B. Dysrhythmias. Cefotetan and NSAIDs do not have significant cardiac effects that would lead to dysrhythmias. Some antibiotics, such as macrolides and fluoroquinolones, can cause QT prolongation, but cefotetan does not affect cardiac conduction.

C. Dizziness. While NSAIDs can sometimes cause dizziness as a side effect, this is not a significant interaction between cefotetan and NSAIDs. Cefotetan does not commonly cause dizziness unless associated with an allergic reaction or severe hypotension due to an adverse effect.

D. Jaundice. Cefotetan is metabolized by the liver, but it is not highly hepatotoxic and does not commonly cause jaundice. NSAIDs, when used long-term or in high doses, may contribute to liver dysfunction, but this is not a primary concern in the interaction between these two medications.

• Client reports having three to four alcoholic beverages a couple times per week. Phenytoin metabolism is significantly affected by alcohol consumption. Chronic alcohol use increases phenytoin clearance, leading to subtherapeutic drug levels and seizure breakthrough. Conversely, acute alcohol intake inhibits phenytoin metabolism, increasing the risk of toxicity. The client should be counseled to avoid alcohol while on phenytoin therapy.
• Client takes diazepam as needed for anxiety. Diazepam is a CNS depressant that interacts with phenytoin, increasing sedation and the risk of respiratory depression. Both medications can cause drowsiness, dizziness, and impaired coordination, raising the risk of falls and injury. The provider should assess whether diazepam should be discontinued or adjusted when initiating phenytoin therapy.
• Last menstrual period was 3 months ago. Phenytoin is Pregnancy Category D, meaning it poses a significant teratogenic risk, including fetal hydantoin syndrome. The missed menstrual period suggests a possible pregnancy, which must be evaluated before starting phenytoin. A pregnancy test should be performed, and alternative antiseizure medications may need to be considered if pregnancy is confirmed.
• Client is a vegetarian and takes a multivitamin daily. Phenytoin interferes with the absorption of folic acid and vitamin D, both of which are crucial for bone health and red blood cell production. Vegetarians are already at higher risk for folate and vitamin B12 deficiency, making supplementation essential. However, multivitamins containing calcium, magnesium, or iron can decrease phenytoin absorption, reducing its effectiveness. The provider should review the multivitamin’s composition and adjust dosing schedules to prevent interactions.
• Temperature 36.4°C (97.6°F), oral. The client’s temperature is within normal range and does not indicate infection or systemic concerns that would affect phenytoin therapy.
• Heart rate 75/min, Respiratory rate 16/min, Blood pressure 100/74 mm Hg, Oxygen saturation 99% on room air.
  All vital signs are stable and do not indicate hemodynamic instability, respiratory depression, or cardiovascular issues that would contraindicate phenytoin administration.
• Skin color is consistent with genetic background. No rashes or lesions. The client has varicose veins. There are no signs of drug hypersensitivity reactions or dermatologic conditions that would require stopping phenytoin therapy.
• S1 S2 auscultated. No murmurs. All peripheral pulses 2+. Lung sounds clear bilaterally.
  There are no cardiopulmonary concerns that would indicate contraindications to phenytoin.
• Abdomen soft, nontender. Normoactive bowel sounds in all 4 quadrants. Last bowel movement was 3 days ago. Voids four to five times a day. Urine is clear, yellow, and odorless. Mild constipation is noted, but this is not a contraindication for phenytoin. The client should be encouraged to increase fiber and fluid intake to prevent worsening constipation, which can sometimes be a side effect of phenytoin.
• Alert and oriented to person, place, and time. Client has full range of motion and is able to maintain flexion against resistance in all four extremities. There are no neurological deficits requiring immediate intervention, and the client's baseline mental status is intact.