See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/239589269

Nursing Protocol On The Usage Of Ritodrine Hydrochloride (Prepar)

Article · March 2008

CITATIONS READS

0 915

5 authors, including:

Deniz Sayiner Nurdan Demirci

Eskisehir Osmangazi University Marmara University
13 PUBLICATIONS   166 CITATIONS    34 PUBLICATIONS   128 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Antenatal Dönemde Verilen Hipnoz ile Doğum (Hypnobirthing) Eğitiminin Doğum Ağrısı ve Korkusu Üzerine Etkisinin Değerlendirilmesi View project

All content following this page was uploaded by Nurdan Demirci on 14 January 2016.

The user has requested enhancement of the downloaded file.

 *Nursing Protocol On The Usage Of Ritodrine
Hydrochloride (Prepar)

Feride ENGIN YIĞIT**, Deniz SAYINER***, Hediye ARSLAN****,

Nurdan DEMIRCI**, Özlem CAN GÜRKAN**, Zübeyde EKŞI**

ABSTRACT
Objective: Case- controlled, retrospective survey was planned to analyze ongoing applications
in the treatment of preterm labor, which occurs in 7-10 % of all pregnancies, and to test a
certain new protocol to standardize applications in the light of the collected data.
Materials and Methods:
The study was initiated on April, 2001 in the maternity clinic of The Eskişehir Maternity and
Child care center and constituted of five stages. In the first stage of the study, the medical
treatment notebook of the service was screened retrospectively and the numbers of the patients
were determined. In the second stage, the protocol, that is subject of this paper, was formed.
Later, the nurse/midwife took a 2-day course to be introduced to the protocol and to be
informed on how it was going to be used. In the fourth step, the protocol was put in to use. In
the last step the records were evaluated for treatment, care and follow up and the results were
compared with the results collected before the application of the protocol.
Results: It was determined that the groups, which had Prepar treatment before and after the
protocol were similar.
Conclusion: Although the use of the protocol improved the nurse/midwife follow up and care
the desire level was not reached. This might be because of the insufficiency of the number of the
nurse/midwife and the significance of the protocol not being fully understood by the workers.
Keywords: Nursing protocol, nursing care, medication errors
ÖZET
Ritodrine Hydrochloride (Prepar) Kullanimi İçin Hemşirelk Protokolü
Amaç: Çalışma tüm gebelerin yaklaşık % 7-10’unda görülen erken doğumun tedavisindeki
uygulamaları analiz etmek ve toplanan veriler ışığında standart bir protokol geliştirmek
amacıyla retrospektif vaka-kontrolü şeklinde planlanmıştır.
Gereç ve Yöntem: Eskişehir Kadın ve Çocuk Hastalıkları hastanesinin kadındoğum kliniğinde
Nisan 2001 yılında başlanan çalışma 5 aşamadan oluşmuştur. Çalışmanın ilk evresinde
retrospektif olarak servisin hasta dosyaları taranmış ve hasta sayısı belirlenmiştir. İkinci
aşamada protokol geliştirilmiştir. Daha sonra ebe/hemşirelere protokolün nasıl kullanılacağı
konusunda iki günlük bir kurs verilmiştir. Dördüncü aşamada protokol uygulamaya
sokulmuştur. Son aşamada tedavi, bakım ve izlem konusundaki kayıtlar incelenmiş ve toplanan
veiler protokol öncesi uygulamalarla karşılaştırılmıştır.

* IXth Congress of European Society for the Study and Prevention of Infant Death (ESPID). Prenatal Health Care and Postnatal
Development İstanbul/Turkey October 2-6, 2001’de poster olarak sunulmuştur.
** Marmara Üniversitesi Hemşirelik Yüksekokulu Doğum ve Kadın Hastalıkları Hemşireliği Anabilimdalı
*** Osman Gazi Üniveristesi Sağlık Yüksekokulu
**** Maltepe Üniversitesi Hemşirelik Yüksekokulu Müdürü
 Nursing Protocol On The Usage Of… 41
Bulgular: Prepar tedavisi alan grupların protokol öncesi ve sonrası benzer özellikler gösterdiği
belirlenmiştir.
Sonuç: Protokol kullanımı ebe/hemşirelerin izlem ve bakımlarını arttırmasına karşın istendik
düzeye ulaştıramamıştır. Bu ebe/hemşire sayısının yetersizliğinden ve protokolün çalışanlar
tarafından yeterince anlanmadığından kaynaklanabilir.
Anahtar Kelimeler: Hemşirelik protokolü, hemşirelik bakımı, ilaç hataları

INTRODUCTION
Medication errors are among common causes of iatrogenic morbidity and mortality
(Kozer, Scolnic, Macpherson et al 2002). Medical errors are prevalent among
hospitalized patients, with adverse events occurring in an estimated 3.7 % to 16.6-19 %
of hospital admissions (Barker, Flynn, Pepper et al 2002; Freedman, Jesse and Kerber
2002; Weingart, Wilson, Gibberd et al 2000). Medications errors can be made by
anyone involved in the prescribing, transcribing, preparation, dispending, and providing
treatment (Atabek 1994; Ekizler 1991).
Wolf and Smetzer conducted a content analysis of human error and medication error
literature to determine patterns indicating healthcare providers’ responses to making
drug errors (2000).
Nurses are given extensive training on procedures so that they are relatively less likely
to make mistakes. Yet nurses do make errors (Erlen2001). Eight categories of nursing
errors representing a board range of possible errors and contributive or causative factors
were identified: lack of attentiveness; lack of agency/fiduciary concern; inappropriate
judgment; lack of intervention on the patient’s behalf; medication errors; lack of
prevention; missed or mistaken MD/healthcare provider’s orders; and documentation
errors (Benner, Sheets, Uris, Malloch et al 2002.
Correct and complete administration of drugs and reducing mistakes is responsibility of
the institutes as well as that of the personnel. Institutes need do form drug policies;
inform their staff regarding new developments in drugs and to establish mechanisms
that will enable instant spotting and reporting faults. One of these mechanisms is the
development of protocols regarding certain medicine (Kayaalp 2005; Uzun 1991;
Webster and Anderson 2000).
Nursing Interventions &Clinical Skills, defines a protocol as a written and approved
plan specifying the procedures to be fallowed during an assessment or in providing
treatment (Elkin, Perry and Potter2000).
Preterm labor refers to births that occur between 20 and 37 weeks of pregnancy
involving a fetus with an estimated weight between 500 and 2499 g.( Fiscella, Franks,
Kendrick et al 2002; Goldenberg 2002; Landau, Xie, Dishy et al 2002; Simpson and
Careehan 2001). Regular contractions occur at less than 10-min intervals over a 30-to
60-min period that is strong enough to result in 2 cm cervical dilatation and 80 %
effacement. Preterm labor occurs in approximately 5 % to 10 % of all births(Simpson
and Careehan 2001). Despite 15 years of research both preterm birth and low birth
weight rates continue to increase (Moore and Freda 1998).
42 Maltepe Üniversitesi Hemşirelik Bilim ve Sanatı Dergisi, Cilt:1,Sayı:1.2008

The ultimate goal of treating preterm labor is to prolong the pregnancy long enough to
decrease the incidence of neonatal mortality and morbidity associated with prematurely
while minimizing maternal end fetal risk (Witcher 2002).
Treatment options for women with spontaneous preterm birth are limited. A number of
interventions have been found to be ineffective and are not correctly recommended.
They include bed rest, hydration, home uterine monitoring, maintenance tocolysis, and
antibiotics. Tocolysis is widely used to arrest preterm labor (Simpson and Careehan
2001).
Although several agents are commonly used as tocolytics, currently only Ritodrine
Hydrochloride is approved by the U.S. Food and Drug Administration for the treatment
of preterm labor (Kayaalp 2005).
Ritodrine Hydrochloride (Prepar) is one of the agents for use as a tocolytic in Turkey
(Kayaalp 2005; Taşkın 2002). All tocolytic agents place the mother at some risk, and
the risk is increased significantly if dual tocolytic therapy is used, especially when
administered intravenously. Careful, expert-nursing care is essential for all women who
receive tocolytic therapy (Simpson and Careehan 2001).
Aims of the Study
The aim of this study is to develop a protocol regarding Prepar medicine and test the
outcomes of the proposed protocol on preterm labor instances by analyzing ongoing
applications in hospitals for treatment of preterm labor.
Research Hypotheses
The following hypotheses were tested against their respective alternative hypothesis:
Hypothesis 1: If the nurses will use the proposed protocol when the drug is
administered, medical errors can be reduced.
Hypothesis 2: If the nurses will use the proposed protocol when the drug is
administered, side effects can be determinate early.

METHODS
In the first step of the study, which was formed of five steps; the medical treatment
notebook of the service was screened retrospectively and the number of the patients (a
total of 47) which had Prepar treatment between the dates 1 April-31 May 2001 were
determined. The selected patient files were searched files in the archive and 30 files
were inspected, as 17 of the files were not in the archive. The files collected were
evaluated for treatment, care and follow up.
In the second step, a Ritodrine Hydrochloride application protocol proposal was
prepared according to the data collected literature knowledge and the ability and the
politics of the clinic.
 Nursing Protocol On The Usage Of… 43

Afterwards to demonstrate the protocol and to teach the application of it, education was
given to the midwives and nurses working (a total of 15) between the dates 27-28 the
June 2001. Before the education, the decisions of the nurses/midwives were taken.
In the fourth step, the developed protocol was put in to use. For this stage, the records of
a total of 30 pregnant women who had Prepar treatment staying in the clinic between
the dates of July-August 2000 were evaluated for treatment, care and follow up and the
results were compared with the results collected before the application of the protocol.
Before and after protocol group differences for categorical variables were evaluated by
means of chi-square tests, and normally distributed continuous data were evaluated with
percentage, arithmetic means, chi-square, student's t tests. Analyses were performed
with Statistical Package for the Social Sciences (SPSS) software, version 9.0.
FINDINGS
Having inspected the decision of the nurses/midwives working in the clinic where the
study was carried out, it was determined that they have observed the side effects
occurring by the use of the medicine. They declared that there was no Prepar protocol in
the clinics, because of, which they had to call the doctor when they experienced the side
effects, and that the presence of such a protocol was an important necessity. We
examined if the nurses had taken an education on this subject before.
Table 1. The Characteristics Of The Patients

Characteristic Number of Average Standard t p

patients Deviation

Age (Year)
Before The Protocol 30 24.4 5.38 .895 P>0.05
After The Protocol 30 24.6 4.37

When the inspected the characteristics of the patients who had the undergone treatment
of Prepar (Table 1), the age average of the group which had treatment, before the
improvement of the protocol (BP) was 24.4 years and the pregnancy week average was
36.58. The averages of the group who had treatment after the protocol (AP) were
similar. Also the further analyze the differences between two groups, parameters age
and gestational age data were subjected to t test with null hypothesis being the given
parameter’s mean (i.e. age, gestational age) for two groups being equal, while the
alternative hypothesis states otherwise. Alpha level was taken to be 5% for both tests.
The t and p values showed that two groups did not possess significant differences, the
groups were observed to be the same.
The reasons of the patients for the coming to the hospital before the protocol and after
the protocol were similar and most of the patients in the groups (BP 96.7%, AP 80.0 %)
attended to the hospital because of pain (Table 2).
44 Maltepe Üniversitesi Hemşirelik Bilim ve Sanatı Dergisi, Cilt:1,Sayı:1.2008

Table 2. The Reasons For The Coming To The Hospital

Before Protocol After Protocol Total

The Reason Number % Number % Number %

Only Pain 29 96.7 24 80.0 53 88.4

Only Rupture of membranes - - 2 6.7 2 3.3
Only Vaginal Bleeding - - 3 10.0 3 5.0
Pain + Rupture of 1 3.3 1 3.3 2 3.3
membranes

Total 30 100 30 100 60 100

When the distribution of the results of the treatment is investigated in table 3; it can be
seen that the results were similar and the groups went to their houses after passing to the
oral treatment in similar rates (BP 70.0%, AP 63.3 %). BP one patient was sent to her
house without being given any medicine while AP nobody was sent to the house
without beginning to the oral treatment.
Table 3 . The Distribution Of The Results Of Treatment

Before Protocol After Protocol Total

The Result Of Treatment n % n % n %

Discharged after without 1 3.3 - - 1 1.7

being given Prepar
Discharged after passing 21 70.0 19 63.3 40 66.7
oral treatment
Birth
8 26.7 11 36.7 19 31.6

TOTAL 30 100 30 100 60 100

It was determined that most of the patients were treated for Prepar intravenous first and
then they were treated Prepar orally later (BP 70.0%, AP 83.3%), (Table 4.).
 Nursing Protocol On The Usage Of… 45

Table 4 . The Distribution Of The Shape Of Treatment

Treatment Before Protocol After Protocol Total

n % n % n %

Before Intravenous after Oral 21 70.0 25 83.3 46 76.7

Only Intravenous 2 6.7 2 6.7 4 6.6
Only Oral 7 23.3 3 10.0 10 16.7

TOTAL 30 100 30 100 60 100

Before the protocol the proportion of the patients who took only oral treatment was
23.3%, this proportion decreased to 10.0% after the protocol.
When the pulses follow up frequency before and after the protocol was compared. It
was determined that this follow up rouse to three times a day (63.3%) after the protocol
and there were highly significant differences between the two groups was statistically
(Table5).
Table 5 . The Pulse Follow Up Frequency

Pulse Follow Up Before Protocol After Protocol Total

n % n % n %

One times a day 15 50.0 3 10.0 18 30.0

Two times a day 1 3.3 8 26.7 9 15.0
Three times a day 14 46.7 19 63.3 33 55.0

TOTAL 30 100 30 100 60 100

X2=15.69 P=0.000

When the blood Pressure follow up frequency before and after the protocol was
compared (Table 6) it was seen that the frequency of this follow up rouse to three
(66.7%) after the protocol and the difference between the two groups was of highly
significant statistically.
46 Maltepe Üniversitesi Hemşirelik Bilim ve Sanatı Dergisi, Cilt:1,Sayı:1.2008

Table 6 . The Blood Pressure Follow Up Frequency

The Blood Pressure Before Protocol After Protocol Total

Follow Up n % n % n %

One times a day 15 50.0 2 6.6 17 28.3

Two times a day 2 6.6 8 26.7 10 16.7
Three times a day 13 43.4 20 66.7 33 55.0

TOTAL 30 100 30 100 60 100

X2=16.60 P=0.000

DISCUSSION
The averages of the group who had treatment after the protocol were similar and the
differences between the groups were not statistically significant. The groups were
observed to be similar to each other.
The reasons of the patients for the coming to the hospital before the protocol and after
the protocol were similar and most of the patients in the groups attended to the hospital
because of pain. In the literature, the most common symptom in the preterm labor action
is also considered to be pain (Fiscella et al 2002; Goldenberg 2002; Landau R et al
2002; Kee and Hayes 2000).
Ritodrine Hydrochloride, a beta-sympathomimetic drug that is yet controversial about
its efficiency and safety has persisted. In general, beta-sympathomimetics appear to stop
contractions for 24 to 48 hours, with questionable beneficial effects on neonatal
morbidity, ritodrine treatment may result in higher frequency of potentially serious
maternal side effects (Kee and Hayes 2000). Side effects include tremors, malaise,
weakness, dyspnea, tachycardia (maternal and fetal), increased systolic pressure and
decrease diastolic pressure, chest pain, nausea, vomiting, diarrhea, constipation,
erythema, sweating, hyperglycemia, and hypokalemia, More serious adverse reactions
include pulmonary edema, dysrhithmias, ketoacidosis, and anaphylactic shock (Ruiz
1998).
Before the protocol, one patient was sent to her house without being given any medicine
while after the protocol, nobody was sent to the house without beginning to the oral
treatment. Together with the medicine treatment the risk of the beginning of the birth
action is 45-56% and the risk is said to be much higher when the administration of the
medicine is halted (Fiscella et al 2002; Goldenberg 2002; Landau R et al 2002).
It was determined that most of the patients were treated for Prepar intravenous first and
then they were treated Prepar orally later. When the protocols for the use of Ritodrine in
the studies conducted are investigated it is suggested that the beginning treatment
should be intravenous and that the treatment should be passed on to oral treatment
(Taşkın 2002).
 Nursing Protocol On The Usage Of… 47

Nursing care is a critical component of therapy for women experiencing preterm labor
(Jones and Collins 1996). Nurses can use their assessment skills to help identify women
at risk for preterm labor and delivery (Ruiz 1998).
Nursing Interventions,
• Monitor and asses uterine activity and FHR
• Maintain client in left lateral position as much as possible.
• Monitor maternal and fetal vital sing every 15 min when client is receiving IV dose.
• Report systolic blood pressure decreases, diastolic blood pressure decreases, and
pulse increases.
• Report auscultated cardiac dysrhythmias. An electrocardiogram (ECG) may be
ordered.
• Auscultated breath sounds every 4 hours. Notify health care provider if respirations
are > 30/min or there is a change in quality (wheezes, riles, coughing).
• Monitor daily weight to assess fluid overload; monitor strict input and output.
• Provide passive range of motion of legs.
• Report fetal baseline hearth rate >180 beats per min. or any significant contractions
from pretreatment FHR baseline.
• Report persistence of contractions despite tocolytic therapy.
• Report leaking of membranes, any vaginal bleeding, or complaints of rectal
pressure.
• Be alert to presence of hypoglysemia in the newborn delivered within 5 hours of
discontinued beta-sympathomimetic drugs.
• Administer only clear solutions of drugs if using IV route.
Assist clients on bed rest and home tocolytic therapy to plan for assistance with self-
care and family responsibilities (Kee and Hayes 2000; Simpson and Careehan 2001).
Before the protocol the proportion of the patients who took only oral treatment was
23.3%, this proportion decreased to 10.0% after the protocol. This gave the thought that
the doctors were also affected by the protocol in their practices.
It is a significant and positive result that the blood pressure and the pulse follow up
frequencies have rouse after the improvement of the protocol. But the lack of the
recording of the fetal heart rate (FHR), contraction, the liquid taken in and given out
follow ups give the thought that the systematic recording habit has not been acquired. It
was evaluated that before the improvement of the protocol the drop number Per minute
was never followed but after the protocol every IV application was done by controlled
infusion tests (dose-flow) and the number of the drops were controlled. This was
determined to be a useful practice brought by the use of the protocol.
Although the use of the protocol improved the nurse/midwife follow up and care the
desired level was not reached. According to protocol, nurses must follow up every 4-6
hours, but nurse numbers not enough to this follow up limitation three times a day. This
48 Maltepe Üniversitesi Hemşirelik Bilim ve Sanatı Dergisi, Cilt:1,Sayı:1.2008

might associated with insufficiency of the number of the nurse/midwife and the
importance of the protocol not being totally understood by the workers.
For this reason the suggestions are as follows;
The education given to the nurses/midwives might be repeated,
Meetings with the directors of the association could be arranged to raise the number
of the workers,
Knowledge could be provided to the other members of the team,
The evaluation of the protocol could be repeated one year later
The study could be repeated in more populated woman-birth clinics where data
would be abundant.
Limitations Of Study
Study conclusions should be interpreted in light of design limitations. Because the study
was conducted at hospital in a single country, findings may not be representative of
practices elsewhere. Only one hospital was included, therefore these characteristics are
not necessarily typical of all hospitals.
REFERENCES
AtabekT (1994). İlaç hatalarının önlenmesinde hemşirenin sorumlulukları. Hemşirelik
Bülteni,5: 97-105.
Barker KN., Flynn EA., Pepper GA., et al (2002). Medication errors observed in 36
health care facilities. Arch. Inter., 6: 1897-1903.
Benner P., Sheets V., Uris P, Malloch K.,et al (2002). Individual, practice, and system
causes of errors in nursing: a taxonomy. J. Nurs. Adm.,10: 509-523.
Ekizler H (1991). Doğumda ve yenidoğanda sık kullanılan bazı ilaçlarda hemşirelik
girişimi. Marmara Üniversitesi Hemşirelik Dergisi, 1:15-23.
Elkin MK., Perry AG., Potter PA (2000). Nursing Interventions and Clinical Skills. St.
Louise.C.V. Mosby Company, 9-12, 973.
Erlen J (2001). Medications errors: ethical implications. Orthop Nurs., 4: 82-85.
Fiscella K., Franks P., Kendrick JS., et al (2002). Risk of preterm birth that is associated
with vaginal douching. Am J Obstet Gynecol., 6:1345-1350.
Freedman JE., Jesse LR., Kerber R (2002). Medication errors in acute cardiac care.
Circulation, 106: 2623.
Goldenberg RL (2002). The management of preterm labor. Obstet Gynecol., 5:1020-
1037.
Jones DP., Collins BA(1996). The nursing management of women experiencing preterm
labor: clinical guidelines and why they are needed. J. Obstet. Gynecol Neonatal Nurs.,
7:569-592.
Kayaalp SO (2005). Rasyonel Tedavi Yönünden Tıbbi Farmokoloji 2. Cilt. Ankara.
Hacettepetaş Yayınları, 988-989.
 Nursing Protocol On The Usage Of… 49

Kee JLF, Hayes ER (2000). Pharmacology. A Nursing Process Approach. 3rd ed.
Philadelphia: WB Saunders, 213-214.
Kozer E., Scolnic D., Macpherson A., et al (2002). Associated with medication errors in
pediatric emergency medicine. Pediatrics, 4: 737-742.
Landau R., Xie HG., Dishy V.,et al (2002). Beta2- adrenergic receptor genotype and
preterm delivery. Am. J. Obstet. Gynecol., 5:1294-1298.
Moore ML., Freda M (1998). Reducing preterm and low birthweight births: Still a
nursing challenge. MCN, The American Journal of Maternal/Child Nursing, 4: 200-208.
Ruiz RJ (1998). Mechanisms of full-term and preterm labor: factors influencing uterine
activity. J. Obstet. Gynecol. Neonatal Nurs., 6: 652-60.
Simpson KL., Careehan PA (2001). Perinatal Nursing. Philadelphia. Lippincott, 207-
219.
Taşkın L (2002). Doğum ve Kadın Hastalıkları Hemşireliği, Genişletilmiş III. Baskı,
Ankara. Sistem Ofset, 295-297.
Uzun Ö.M (1991). Hemşirelerin ven içi sıvı uygulamalarında yaptıkları hataların ve
sıklıklarının saptanması. Hemşirelik Bülteni, 5: 83-91.
Webster CS., Anderson DJ (2000). A pratical guide to the implementation of an
effective incident reporting scheme to reduce medication error on the hospital ward. Int.
J. Nurs. Pract., 4:176-83.
Weingart SN., Wilson RM., Gibberd RW., et al (2000). Epidemiology of medical error.
BMJ, 320: 774-777.
Witcher PS (2002). Treatment of preterm labor. J. Perinat. Neonatal Nurs., 1: 25-47.
Wolf ZR., Smetzer J (2000). Responses and concerns of healthcare providers to
medication errors clinical nurse specialist. The Journal for Advanced Nursing Practice,
6: 278.

Address for correspondence:

Feride Engin Yiğit
Marmara Üniversitesi Hemşirelik Yüksekokulu
Haydarpaşa/İstanbul –Turkey 34
Phone:0 216 4181606/07-1140 Fax:02164183773
E-Mail: fyigit@marmara.edu.tr

View publication stats