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Jul.29.2021

Hydralazine (Maternal-Newborn) - CE

ALERT

Antihypertensives administered with magnesium sulfate increase the risk of hypotension. A precipitous decrease in maternal blood pressure (BP) may lead to shock and placental abruption, which may be life-threatening to the patient and fetus.undefined#ref4">4

Take steps to eliminate interruptions and distractions during medication preparation.

OVERVIEW

Hydralazine is a peripheral vasodilator that relaxes the arteriolar smooth muscle. Increases in heart rate, stroke volume, cardiac output, and left ventricular ejection fraction typically occur with hydralazine use.9 Hydralazine is one of three medications available for first-line management of acute-onset severe hypertension in pregnant and postpartum women.1 The drug crosses the placenta in a clinically insignificant degree.

Hydralazine is indicated for IV administration during hospitalization for severely elevated BP and is contraindicated in patients with documented hypersensitivity, coronary artery disease, or mitral valve rheumatic heart disease.2 Caution should be used when administering hydralazine to patients with severe renal impairment.2

The recommended initial dosage of hydralazine is 5 mg IV or IM, followed by 5 to 10 mg IV every 20 to 40 minutes to a maximum total dose of 20 mg; or a constant infusion of 0.5 to 10 mg per hour.1

Common adverse reactions to hydralazine are headache, palpitations, tachycardia, and drug-induced lupus syndrome.2,10 Other adverse reactions include dizziness, diarrhea, nausea, vomiting, edema, and peripheral neuropathy.10

Nurses should closely and frequently monitor maternal vital signs and the fetal heart rate (FHR) pattern after hydralazine administration because of the potential for hypotension. The patient’s response to antihypertensive medication should be monitored closely if preeclampsia or eclampsia are present because eclampsia causes contracted intravascular volume. Antihypertensive therapy should not decrease arterial pressure too significantly or too rapidly because uteroplacental perfusion may be compromised,4 resulting in an interruption of fetal oxygenation with Categorycategory II (indeterminate) or Categorycategory III (abnormal) FHR characteristics.3

Medications should be diluted or compounded in the pharmacy before dispensing and only when recommended by the manufacturer and approved by the organization’s practice.7 Some organizations will allow medication compounding in a specific area of practice.

If dilution or reconstitution of an IV push medication becomes necessary outside of the pharmacy, the nurse should perform these tasks immediately before medication administration in a clean, uncluttered, and functionally separate location.7 The nurse should use organization-approved, readily available drug information resources and sterile equipment and supplies to dilute or reconstitute IV push medications.7

If the mother and support person express concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Educate the patient and support person regarding the purpose of the medication and the mode of administration.
  • Instruct the mother and support person regarding the potential side effects and adverse effects of the medication.
  • Instruct the patient and support person about the level of maternal and fetal monitoring used to determine reactions to the medication.
  • Instruct the patient to ask for assistance when getting out of bed.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
  2. Introduce yourself to the mother and support person.
  3. Verify the correct patient using two identifiers.
  4. Assess baseline maternal vital signs.
  5. Assess the patient’s medication history, including any drug allergies.
  6. Assess the patient for specific contraindications to receiving hydralazine and advise the practitioner accordingly.
  7. Assess the FHR pattern.
  8. Ensure that the patient has IV access and that a mainline fluid (e.g., lactated Ringer solution or 0.9% sodium chloride solution) is infusing normally.

Preparation

  1. Apply a pulse oximeter to the patient per the organization’s practice.
  2. Obtain the medication, check the practitioner’s order, verify the expiration date, and inspect the medication for particulates, discoloration, or other loss of integrity.
  3. Do not use medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe.
  4. Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate.8 Stated, estimated, or historical weight should not be used.8
  5. Review medication reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, and common side effects and implications.

PROCEDURE

  1. Perform hand hygiene. Don additional appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
  2. Verify the correct patient using two identifiers.
  3. Explain the procedure to the mother and support person and ensure that the mother agrees to treatment.
  4. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation. Use a bar code system or compare the medication administration record (MAR) to the patient’s identification band.
  5. Use commercially available or pharmacy-prepared prefilled syringes to flush and lock vascular access devices (VADs).7
  6. Disinfect vials by cleansing the access diaphragm using friction and a sterile 70% isopropyl alcohol, ethyl alcohol, iodophor, or other approved antiseptic swab and allow to dry at least 10 seconds.7
  7. Draw the prescribed amount of medication into the syringe and prepare the syringe for IV administration; read the medication label for a second check of correct name and dose against the MAR. If the medication is in a glass vial, replace the filter needle with the appropriate-size needle for injection; add an adapter per the organization’s practice.
  8. Remove the ordered dose of medication from the vial using a syringe and needleless attachment immediately before administration. Hydralazine changes color after contact with metal; discard any discolored hydralazine solution.
  9. Remove the needle or needleless administration tip and discard it in the proper sharps receptacle.
  10. Place a new needle or needleless administration tip on the syringe per the organization’s practice.
  11. Label all syringes of IV push medications or solutions unless the syringes are prepared at the patient’s bedside and the medication is administered without any break in the process.7 Use barcode scanning or similar technology immediately before administration.7
  12. Perform hand hygiene and don gloves.
  13. Disinfect the connection surface and sides of the needleless connector using vigorous mechanical scrubbing for a minimum of 5 to 15 seconds, according to the organization’s practice, using a flat swab pad containing 70% isopropyl alcohol or alcohol-based chlorhexidine suitable for use with medical devices.5 Allow the solution to dry.5
  14. The drying time for 70% isopropyl alcohol is 5 seconds; for alcohol-based chlorhexidine, it is 20 seconds.5
    There is moderate quality evidence to support the recommendation to apply mechanical friction for no less than 5 seconds.5
  15. If using a disinfecting port protector or cap, remove the protector or cap from the needleless connector. Discard the protector or cap in the appropriate receptacle.
  16. Rationale: The port protector or cap is never reused.
    The effective length of time for exposure depends on the product. Consult the manufacturer’s instructions for use.
  17. If using a disinfecting port protector or cap, apply a new one.
  18. Confirm patency of the VAD by aspirating for blood return and flushing the VAD using a 10-ml syringe filled with preservative-free 0.9% sodium chloride solution.6 Use a minimum volume of solution that is equal to twice the internal volume of the catheter and add-on devices or a larger volume (e.g., 5 ml) per the organization’s practice.6
    Rationale: A 10-ml syringe generates lower injection pressure. 6
  19. Administer IV push medication using an appropriate-size syringe for the required dose (i.e., a syringe smaller than 10 ml).6,7
  20. Insert the syringe or needleless adapter in the IV push port.
  21. Do not add hydralazine to any IV solution bags. Hydralazine is intended to be used as an IV push medication.
  22. Remove the syringe and discard it in the proper receptacle.
  23. To prevent needlestick injury, do not recap needles.
  24. Flush the VAD using a 10-ml syringe filled with a preservative-free 0.9% sodium chloride solution.6 Use a minimum volume of solution that is equal to twice the internal volume of the catheter and add-on devices or a larger volume (e.g., 10 ml for central VADs; 5 ml for peripheral IV catheters) per the organization’s practice.6
    Rationale: A 10-ml syringe generates lower injection pressure. 6
  25. Lock the catheter or resume the ordered infusion. Lock the catheter port with the appropriate solution per the organization’s practice or the manufacturer’s instructions.
  26. Discard supplies, remove gloves, and perform hand hygiene.
  27. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Monitor the patient for adverse and allergic reactions to hydralazine. Recognize and immediately treat respiratory distress and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.
  2. Monitor the patient during hydralazine therapy until BP stabilizes. Assess vital signs frequently until BP stabilizes at the desired level.
  3. Monitor the FHR pattern.
  4. Institute “Risk to fall” precautions based on the organization’s practice.
  5. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

  • Medication administered per the six rights of medication safety
  • Target BP achieved after medication administration
  • No adverse reactions in the patient or fetus

UNEXPECTED OUTCOMES

  • Medication not administered per the six rights of medication safety
  • Target BP not achieved or BP remains elevated after medication administration
  • Adverse reactions in the patient or fetus

DOCUMENTATION

  • Patient’s response to the medication, including any adverse reactions
  • Verification of the six rights of medication safety (in patient’s record and on patient’s MAR)
  • Maternal vital signs
  • FHR pattern, including changes noted after administration
  • IV injection site
  • IV patency and primary fluid
  • Education
  • Unexpected outcomes and related interventions
  • Patient’s weight in kilograms per the organization’s practice

REFERENCES

  1. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. (2020). Gestational hypertension and preeclampsia: ACOG Practice bulletin number 222. Obstetrics and Gynecology, 135(6), e237-e260. doi:10.1097/AOG.0000000000003891 (Level VII)
  2. American Society of Health-System Pharmacists (ASHP). (2021). Hydralazine. In AHFS DI essentials. Bethesda: ASHP. Retrieved June 15, 2021, from https://www.drugs.com/monograph/hydralazine.html#rb (Level VII)
  3. Cashion, K. (2020). Chapter 18: Fetal assessment during labor. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 358-375). St. Louis: Elsevier.
  4. Dix, D. (2020). Chapter 27: Hypertensive disorders. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 583-597). St. Louis: Elsevier.
  5. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 36: Needleless connectors. Journal of Infusion Nursing, 44(Suppl. 1), S104-S106. (Level I)
  6. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 41: Flushing and locking. Journal of Infusion Nursing, 44(Suppl. 1), S113-S118. (Level I)
  7. Institute for Safe Medication Practices (ISMP). (2015). ISMP safe practice guidelines for adult IV push medications: A compilation of safe practices from the ISMP Adult IV Push Medication Safety Summit. Retrieved June 15, 2021, from https://www.ismp.org/sites/default/files/attachments/2017-11/ISMP97-Guidelines-071415-3.%20FINAL.pdf (classic reference)* (Level VII)
  8. Institute for Safe Medication Practices (ISMP). (2020). 2020-2021 Targeted medication safety best practices for hospitals. Retrieved June 15, 2021, from https://www.ismp.org/sites/default/files/attachments/2020-02/2020-2021%20TMSBP-%20FINAL_1.pdf (Level VII)
  9. Tamargo, J., Cabellero, R., Delp?n, E. (2019). Chapter 8: Cardiovascular drugs – from A to Z. In J.C. Kaski, K.P. Kjeldsen (Eds.), The ESC handbook on cardiovascular pharmacology (2nd ed., pp. 413-812). New York: Oxford.
  10. Vallerand, A.H., Sanoski, C.A. (n.d.). Davis’ drug guide (17th ed.). Philadelphia: F.A. Davis. Retrieved June 15, 2021, from https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51383/all/hydrALAZINE

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports
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