Fundamentals • Proper hand hygiene → wash hands for 20 seconds in warm, soapy water or use hand sanitizer if hands are not visibly soiled • Variance → work not done in the correct way • Incidents & accidents → evens that cause harm to client • Sterile surgical aseptic → keep sterile field above their waist, sterile gauze into placed sterile field, holds hands above their elbows during handwashing • Cane ambulation → gait belt before getting out of bed, nurse is on the client’s affected side slightly behind the client, measure the height of the cane from the wrist crease or greater trochanter, cane held on the unaffected side, elbow flexed 15-30 degrees, cane advanced first in 6-10 secs, advance affected leg to the cane, advance the stronger leg just past the cane, rubber tip should be applied not tennis balls • Crutches ambulation → up with good, down with bad, tripod position formed when the crutches are placed 6 inches in front of and 6 inches to side of each food, elbows flex between 15-30 degrees, crutch tip is entirely on the stair, have client hold handrail for support with one hand & strong leg should be next to the railing • Peritoneal dialysis essential teaching → handwashing to reduce peritonitis (infection of the lining of your belly or abdomen) • Lyme disease → not transmitted human-to-human & standard precautions • HIV → does not require isolation precautions • Standard → wash hands • Contact → wear gloves & gown & disposable equipment ▪ MRS WEE - MRSA • Contact enteric → hand hygiene with soap & water ▪ C.diff, norovirus, rotavirus, shigella • Droplet → surgical mask ▪ SPIDERMAN – N. meningitidis • Airborne → N95 respirator ▪ MTV, SARS, smallpox • Reverse isolation → used to protect immune-compromised clients • Priority tx for PE & acute decompensated HF → diuresis & vasodilators, VTE prophylaxis with ACE inhibitors ▪ Contraindication: CCB b/c of its negative inotropic effects (contract heart with less force), hydrocortisone, albuterol • Device to locate pulse on a darkskin client → transillumination device • Infection measure to implement in TB → remove fans • Extravasation → vesicant drug comes into subcutaneous tissue • Infiltration → non-vesicant drug enters subcutaneous tissue • When to hold BUN & Cr → vancomycin (for MRSA), furosemide, ketorolac (NSAID) – these drugs are nephrotoxic & can cause renal insufficiencies • Asterixis → involuntary flapping of the hands • Peak levels → doesn’t occur before onset but before end of duration • S/S of meningitis → severe HA, fever, stiff neck • • • • • • • • • • • • • • • • • • • Incentive spirometer → prevents atelectasis (collapse of alveoli post-surgery) Short acting insulin → regular insulin & has “R” in the drug name NGT → can be used to administer contrast dye for clients who cannot swallow or is nauseated Digoxin → administered once a day; normal dosage is 0.125 mg to 0.5 mg Physicians order → nurse should not accept a telephone order only in case of emergencies Post-op neuro status → as soon after and at least every hour after Post-op pulse status → every 15 mins for the first hour, every 30 mins for second hour, hourly for next 4 hours Vaccines for adults → do not need Hep A or Hep B if not at risk; should get TDAP every 10 hours, adults over age 60 should receive herpes zoster, flu shots recommended every year OA assistive devices → electric can & jar opener, remote with larger keys, shoes with Velcro or shoes that slip on, changing doorknobs to levers Interventions for transfusion reactions → stop infusion immediately, disconnect blood tubing & connect NS to maintain an open IV line, obtain urine specimen & send to lab to presence of Hgb for red blood cell hemolysis, blood bag & tubing need to be sent to the blood bank & need to be notified Assessment finding after a fall → shortened & externally rotated leg due to muscle spasms Restraints → should be assessed every 2 hours, should be tied using a quick-release knot & never be tied to a fixed portion of the bed frame, should be removed every 2 hours to assess for skin breakdown & to allow the client to eat and or drink, educate client & client’s family before applying restraints & they need to understand why restraints are being used and for how long, prn order is prohibited, HCP must identify why restraint is being used & specific time frame Nursing actions for speaking to an older client who is hearing impaired → maintain normal voice volume, lower voice pitch, turn TV or radio off not down Position for client who is unconscious who needs oral care → side-lying or lateral to facilitate flow of secretions by gravity to prevent aspiration during procedure & keep HOB lowered Nursing action for IV catheter if client’s vein isn’t palpable due to dehydration → dry heat like applying warm pack for 10-20 minutes to promote vasodilation & stroking vein downward Facilitates that provide secondary & tertiary care → ED’s, urgent care, critical care, inpatients Red zone nurse action → indicates 50% or below peak flow and signals emergent situation so the nurse should call HCP Diagnostic test for evaluating acute onset of seizures → electroencephalogram (EEG) Thrombocytopenia nursing actions → takes client with this longer to clot with fewer platelets so during times where they are bleeding even after a bandage is placed over • • • • • • • • • • • • • • • • • the cut, pressure should be applied to the wound for 10 minutes and call back if the bleeding doesn’t stop to receive further instructions like visiting the ED Components that indicate magnet status → transformational leadership, structural empowerment, exemplary professional practice, innovation Component of hospital consumer of assessment of healthcare providers & system survey → willingness to recommend the agency Interventions to decrease risk of developing contractures → applying bilateral SCDs & passive range of motion exercises Payen behavioral pain scale → used for unconscious Pain assessment in advanced dementia scale (PAINTED) → assess pain in patients with dementia Profile of mood states & the pain discomfort scale → used for elderly patients & can be used to assess for anxiety in older adults experiencing pain FACES scale → used with children Advanced directives → EMTs cannot honor unless doctor has signed them, two physicians determine decisions if client is unable, do not expire & can be changed whenever, not all states honor advanced directives Lung sounds ▪ Dullness: below 10th intercoastal ▪ Tympany: heard over stomach ▪ Resonance: normal sound over lung tissue ▪ Hyperresonance: not a normal finding SLE teaching session → sunscreen to prevent rashes & photosensitivity, clothing should be layered to protect against cold weather, calcium-rich foods & adolescents females receiving corticosteroid therapy Five rights of delegation ▪ Right person: person can handle the delegated task ▪ Right circumstance: ensuring client is stable ▪ Right supervision: intervening when task is completed incorrectly by person it was delegated to ▪ Right evaluation: asking person to complete a task & if it was completed ▪ Right communication → reviews how to do a task Nurse best action reporting dizziness when ambulating → assist client to sit back on the bed Subcutaneous injection → injection should be 2 inches away from umbilicus Malignant tumors → poorly differentiated, metastasizes Benign tumors → cause tissue destruction Stage 2 sacral pressure injury → avoid any type of ring cushion b/c it can lead to additional or worsening pressure injuries Preventing constipation → walk, swim, or bike at least three times per week b/c exercise stimulates bowel motility & moves stools through the colon, avoid caffeine beverages b/c it acts as a diuretic, drink 3 quarts of fluids per day (or 8-10 glasses of water or 2L), consume 20-30 g’s of soluble & bulk forming per day • • Ways to improve sleep → limit alcohol in late afternoon & evenings b/c it diuretic effect of alcohol can cause the client to awaken from sleep to void Complications of acute pyelonephritis → upper UTI that can lead to urosepsis & septic shock Cultural Awareness • Hindus → prefer cremations rather than burying the remains of deceased person • Cremations are discouraged → in Islam, Mormonism, Eastern Orthodox • Amish → traditional & alternative health care, funerals are conducted in home, many choose to live without health insurance, health is a gift from God, men hold the authority • Sickle cell high risk groups → Saudi Arabian, AA, Latin Americans, southern Europeans, Mediterranean • Thalassemia high risk group → Mediterranean • Tay Sachs high risk group → Ashkenazi Jewish • Structural functional theory of family → decision making, intrafamily relationships, family structures, patterns of communication in the family • Food items against SDA’s → no pork, no alcohol, no caffeinated beverages • Acculturation → members of another culture adopt the culture of the host predominantly religion • Assimilation → person develops a new cultural identity • Permissive style of parenting → facilitates satisfaction among members of the family ▪ Con: undesirable behaviors in young children because they need more structure and clearer boundaries to develop appropriate behaviors • Laissez-faire style of parenting → appears lazy and caring • Autocratic style of parenting → family is rigid and highly structured • Five concepts of cultural competence → skills, encounters, desire, awareness, knowledge • Culture → shared, learned, and symbolic systems of values, beliefs, and attitudes that shape and influence the way people see and behave within the world, customs, arts, social institutions • Society → people who live in a country or region, their organizations, their way of life • Community → people living in an area or a group or groups of people who share common interests • Spiritually → quality concerned with human spirit or soul as opposed to material or physical things Adult • S/S of cor pulmonale (right-sided HF) → JVD • S/S of left-sided HF → whitish frothy sputum • How does stomach infection cause duodenal ulcer → bacteria enter the lining of the intestines & changes the protective layer • • • • • • • • • • • • • Osteoporosis teaching → exercise must include weight bearing activities & avoid jumping Diabetes foot care → reduce crossing legs, wear shoes or slippers inside or outdoors, dry toes thoroughly between toes after shower & avoid lotion as it retains moisture, inspect inside of shoes before wearing them, inspect feet every day (examine the bottom of feet with mirror if needed) S/S of retinal detachment → floaters in field of visions, partial loss of sight, increasingly blurred images, curtain drawn over eyes, no intense pain in affected eye S/S of hyperkalemia → wide flat P waves, prolonged PR interval, depressed ST segment, tall & peaked T waves, widened QRS interval S/S of hypokalemia → prominent U-weaves & inverted T waves Steatorrhea → symptom of Celiac disease, refers to excretion of abnormal quantities of fecal fat due to reduced fat absorption by the intestines so it produces pale, oily, malodorous stools Hematochezia → passage of fresh blood from anus Melena → condition with dark sticky feces with partly digested blood, sign of upper GI bleeding Questions to ask before a digital rectal exam → asking if there is a change in force of urine when you empty your bladder b/c a change in the force of the urinary stream could indicate a complication associated with BPH Goal of palliative care → terminally ill client will be free of any physical, psychological, or spiritual distress & aims to free the client from pain & distress Homan’s sign → pain & tenderness when forceful dorsiflexion of the foot while keeping the knee extended Sequestration → caused by an enlarged spleen, neonatal, gestational; platelets are sequestered from the circulation (ex: thrombocytopenia from splenomegaly causing platelet sequestration S/S of myxedema coma → ALOC, hyponatremia, hypothermia, hypoventilation, hypoglycemia Children • Circumcision → do not wash penis with soap until the circumcision is healed (5-6 days), glans penis is dark red after circumcision then becomes covered with yellow exudate within 24 hours which is normal and persist for 2-3 days (should not be removed or reported to HCP) ▪ Cleaning → squeeze warm eater from a clean washcloth over the penis to wash it, avoid wipes with alcohol, fasten diaper loosely to prevent rubbing or pressure on the incision site, report redness, bleeding, or drainage • Lead poisoning screening → begins at 12 months for low-risk clients & repeat at 24 months ago; high-risk clients should be screened at 6 months • Best action to ensure fluid intake in children with dehydration not capable of drinking water → offer child popsicle • • • • • • • • Age children should add solid food to diet → at 4 months because the child’s sucking reflex disappears at 4-6 months Static thinking → normal child’s cognitive development where they cannot remember what he or she started to talk about so that at the end of a sentence the child talks about another topic Cleft lip/palate → opening in lip or palate ▪ Concerns: difficulty breastfeeding b/c of being unable to latch onto mother’s breast & suck properly ▪ Causes: rubella virus, exposure to teratogens (radiation), cigarette smoking, folate deficiency, cleft lip is more common in males & cleft palate is more common in females ▪ Interventions: clean suture line with saline, elbow restraints (should be removed every 2 hours), use special squeeze bottles & long nipples, small-bore nipples to prevent choking ▪ Feeding: place child in semi-upright position to reduce nasal regurgitation & monitor for choking & assess the airway ▪ Pre-op position: sleep & feed on sides, palate → lateral or prone ▪ Post-op position: no sucking until incision is healed, cleft lip repair → supine to prevent rubbing of the repaired lip area, cleft palate → abdomen/prone to help facilitate drainage of secretions & prevents airway obstruction ▪ Surgery (palatoplasty): cleft lip → before newborn is discharge and is 6-12 weeks old or weighs about 10 lbs. & is gaining weight steadily, cleft palate → completed by 12-18 months b/c of risk of speech not developing normally & impaired facial growth Alprostadil → keeps ductus arteriosus open or patent; allows for more pulmonary blood flow to the child with low O2 saturations while waiting for surgery Indomethacin → closes PDA Propranolol for PDA → management of tetralogy of Fallot spell Morphine for PDA → decreased pulmonary vascular resistance & calm the child during a tetralogy of Fallot spell Cystic fibrosis diet → high fat diet, high protein, water soluble vitamins (ADEK) Maternity • Urgent assessment → FHR & variation of 20 beats independent of contractions indicates variable fetal decelerations that occur unrelated to the contractions & signification HR due to cord compression & concerning in early stages of labor • Contraction stress test → place client in reclining chair with a slight lateral lift to optimize perfusion & avoid supine hypotension • Primigravida → experiencing first pregnancy Pharmacology • Phenazopyridine → treats UTI pain ▪ • • • • • • • • • • • • • • • Patient teaching: take with food, reddish-orange discoloration of urine is expected Scabicide nursing instruction → should be applied from neck down Varenicline → deterrent for using nicotine Naltrexone → cannot be used during opioid tx but can be given as a maintenance drug of detoxification of long-term opioid Early signs of digitalis toxicity → nausea, loss of appetite (anorexia), vomiting & needs to be reported to HCP Tx of neuropathic pain → adjuvant analgesics including opioid analgesics & addition of tricyclic antidepressants or anti-seizure drugs to help prevent pain transmission; oral opioid analgesics is not enough alone Vaginal suppositories teaching → insert a min of 2 inches, recline on back with hips elevated for 5-10 minutes, wear perineal pad to protect the clothing from drainage or staining, suppository should be cleansed with soap & water prior to reuse Informed consent → nurse witness signature & verifies client is mentally competent, obtained after client has discussed the exact details of the surgery or procedure, acting as a client advocate, the nurse is responsible for ensuring that the client has received adequate information regarding the proposed procedure Tasks before dopamine infusion → check to see if client received volume replacement or adequate fluid volume to reduce further reduction in tissue perfusion without volume Signs of peanut allergy → urticaria (hives), wheezing, dyspnea Adverse response of sumatriptan → angina b/c vasoconstriction may occur & contraindicated in clients with CAD, uncontrolled HTN, previous stroke and this is used to abort migraine HA, administered intranasally & subcutaneously & warm & tingling sensation is normal & temporary with an injection Diet to fight infection & promote wound healing → high calorie & high protein Sulfamethoxazole → treats UTI & should be taken with a full glass of water & dark brown urine is common side effect WHO analgesic ladder ▪ Mild pain: acetaminophen, aspirin, ibuprofen pain 1-3 ▪ Moderate pain: tramadol + mild pain drugs; pain 4-6 ▪ Severe pain: morphine, fentanyl, hydromorphone, oxycodone; pain 7-10 Med for acute mania → valproic acid a mood stabilizer treating bipolar mania b/c of its fast onset ▪ Therapeutic level: 50-125 mcg/mL ▪ Adverse effects: N/V, blood disorders, hair loss, metabolic syndrome ▪ Monitor: hepatotoxic so monitor liver function tests, hgb & platelets for risk of blood dyscrasias (blood disorder) ▪ Teaching: multivitamin may be prescribed to offset the vitamin deficiencies & woman should not conceive & use BC while taking this S/S of fluid volume deficient → tachycardia, decreased UP, tenting of the skin, tachypnea, weight loss, hypotension • • • • • • • • • • • • • • • • • Med for dystonia following administration of fluphenazine → diphenhydramine b/c it’s an anticholinergic for dystonic (involuntary contractions of muscles commonly of the head & neck) reactions associated with antipsychotic use & is an early adverse effect that needs to be reported to HCP Acute steroid use does not cause immediate bruising only long therapy due to thinning of skin Serious adverse effects of TCAs → cardiac arrythmias; cause increase risk of seizures in epileptic clients, worsening of urinary retention & narrow-angle glaucoma, sexual dysfunction Atypical (first generation antipsychotic) → chlorpromazine, fluphenazine, haloperidol ▪ Adverse effects: hyperlipidemia, hyperglycemia, weight gain ▪ Teaching: requires weekly WBC monitoring Typical (second generation antipsychotic) → risperidone, olanzapine, quetiapine, clozapine, lurasidone, ziprasidone, aripiprazole, brexipiprazole ▪ Adverse effects: movement disorders like dystonia or tardive dyskinesia ▪ Teaching: does not require weekly WBC monitoring Meds for panic disorder → amitriptyline (antidepressant), diazepam, phenelzine (MAOI) ▪ Definition: intense feelings of immediate apprehension, fearfulness, terror, impending doom, increase ANS activity, panic attacks last less than 10 minutes Amobarbital → barbiturate used for sedation & to treat insomnia Patient teaching for levothyroxine → take in the morning, don’t take with food, report S/S of hyperthyroidism (tachycardia, weight loss, increased temperature, increased motor activity) ▪ Priority assessment with dosage increase: tachycardia b/c it can cause tachydysrhythmias Patient teaching for sucralfate → used for PUD, taken one hour before meals & at bedtime, not required to sit upright, large pill so should be dissolved in water to help client swallow, most common side effect is constipation Patient teaching for H2 blocks (famotidine) → common side effect is drowsiness Patient teaching for bisphosphonate → sit upright 30 minutes after taking medication Simethicone → treats excessive flatulence (gas) & abdominal cramping ▪ Diet: limit gas forming foods such as legumes (beans) & cruciferous vegetables (cauliflower & broccoli) Omeprazole → PPI indicated for management of GERD & PUD Ferrous sulfate → liquid iron & manages iron deficiency anemia Patient teaching for metformin → most common side effect is GI upset (bloating, diarrhea, N/V), take with meals or prescribed the extended-release form, does not cause hypoglycemia like sulfonylureas & insulin so don’t check glucose levels before, do not take within 48 hours of a contrast procedure b/c of the risk of nephrotoxicity since the metabolites accumulate & cause laic acidosis SSRIs → venlafaxine & duloxetine Modafinil → psychostimulant used in the tx of narcolepsy • • • • • • • • • • • • • • • • Med for treating akathisia → propranolol; most common extrapyramidal side effect associated with antipsychotic medications & helps treat restlessness, individuals feel a compelling urge to move & could be mistaken as an individual being aggressive or agitate, obtain BP & PR before administration & monitor for hypotension & bradycardia Meds that can cause EPS → antipsychotics (haloperidol & fluphenazine) & dopaminemodulating meds like metoclopramide (treats symptoms of slow stomach emptying called gastroparesis in clients with diabetes) Patient teaching for carbamazepine → controls seizure activities, taken with meals, avoid grapefruit, notify HCP if vision changes occur but don’t abruptly stop, notify HCP if excessive drowsiness, weakness, or change in mental status occurs while taking this medication Indications of TPN → GI obstruction, anorexia, burns or trauma Indications of EPN → dysphagia Meds for myxedema coma → IV levothyroxine & liothyronine plus glucocorticoids like hydrocortisone to mitigate hypotension & potential overlook of adrenal dysfunction ▪ Contradiction: methimazole since it’s an antithyroid medication Tolvaptan → treatment of SIADH Vasopressin → treatment of DI Prednisone → can cause weight gain, take in morning with food, b/c it commonly causes insomnia, avoid taking with NSAIDs such as naproxen or ibuprofen b/c of the increased risk for a gastric ulcer Corticosteroids → treats MS, RA, asthma, SLE Patient teaching for PPI → taken one hour before meals with an ample amount of water (take first thing in morning without food or other medications), does not require laboratory testing, don’t take with food or medicine as it decreases its absorption, can cause hypomagnesemia so take supplements ▪ Complications: long term use increases risk of osteoporosis & hypomagnesemia so recommend weight-bearing exercises as well as magnesium & calcium supplements Drug that causes increased risk for lithium toxicity → any medications that can decrease GFR can increase retention of lithium such as NSAIDs, ACEs, diuretics ▪ Range: 0.6-1.2 ▪ Considerations: avoid dehydration & hyponatremia, drug level should be obtained twelve hours after the last dose to avoid a falsely elevated level Carbonic anhydrase inhibitors → ends in “lamide”, treats glaucoma, altitude sickness, CHF, epilepsy Potential complications of dexamethasone → risk of infection (monitor WBCs, increased CRP, febrile), hyperlipidemia (causes development of cholesterol & can increase triglycerides as well as LDS, hyperglycemia Cholinergic drugs → ends in “choline” & “achol), treats angle-closure glaucoma ▪ S/S: Anticholinergic drugs → antipsychotic drugs, treats ▪ S/S: dry mouth, urinary retention, constipation • • • • • • • • • • • • • • • • • • • Complications of blood transfusion → hemolytic reaction & UAP can obtain baseline VS Safe maximum daily dosage for long term use acetaminophen → 3000 mg per day PCA → given loading dose for ordered pain before they can activate their own titrated dosage (ex: client will be given 4mg of morphine before allowing their individual titrated dosage of 1 mg morphine per doc order) Meds allowed for clients with bleeding disorders → codeine phosphate ▪ Contraindications: aspirin, ibuprofen, acetyl salicylic acid Desired outcome for a client on bumetanide → loop diuretics (ethacrynic acid, furosemide, torsemide) that should reduce cardiac preload & wall tension, reduce CVP, BP, resistance, left ventricular end-diastolic pressure, high GFR, reduced right ventricular end-diastolic pressure Patient teaching for metered-dose inhaler → inhale through mouth, shake canister before, continue to inhale when cold propellant is in throat, inhale one spray with one breath, activate device while continuing to inhale Nurse action before administering radioactive iodine (l131) in childbearing clients → hCG pregnancy test Med for graves’ disease → atenolol (to lower BP), PTU, radioactive iodine, methimazole (blocks action of thyroid hormones) Therapeutic effect of tizanidine → decreased muscle spasms, a muscle relaxant (baclofen, carisoprodol, cyclobenzaprine, methocarbamol) for MS & CNS depression so can cause drowsiness, avoid driving & alcohol Adverse effect of quetiapine → fever, stooped posture, shuffling gait (indicates NMS) Meds to avoid for ECT → benzodiazepines & anticonvulsants (alprazolam, phenytoin, valproic acid, topiramate) ▪ Considerations: informed consent, NPO, lab work & EKG completed before, hold anticonvulsants & benzos before b/c of increased risk of seizures Extravasation → pain at incision site, nurse should stop infusion to halt further damage to the vein Serious adverse effect of prednisone → adrenal suppression indicated by decreased ACTH levels, stomach, muscle weakness, muscle pains Meds for Bell’s palsy (facial nerve paralysis) → corticosteroids (prednisone) & antivirals (valacyclovir) b/c it decreases facial nerve inflammation & viral etiology ▪ S/S: abrupt unilateral facial paralysis with eyebrow sagging, diminished taste, decreased eye tearing, drooping of the mouth on the affected side ▪ Management: Artifical tears & ointment, eye patch on affected eye at night Donepezil (acetylcholinesterase inhibitor) → manage symptoms by improving cognition and behavior in dementia in Alzheimer’s disease Side effect of rivastigmine → weight loss; common S/E are flu like symptoms, dizziness, weight loss Pyridostigmine (acetylcholinesterase inhibitor) → improves muscle strength in MG Topiramate → anticonvulsant indicated for tx for epilepsy & migraine HA prevention Severe side effect of theophylline → increased or erratic pulse rate ▪ • • • • • • • • • • • • • • • • • • Considerations: can cause cardiac arrhythmias, given on empty stomach with full glass of water ▪ Side effects: N/V/D, HA, insomnia, restlessness, seizures Time to assess pain after opioids administration → 30 mins after IV route or 1 hour after oral route Quick relief or rescue meds for acute asthma attack → short-acting beta-2 agonists (albuterol & salbutamol) & anticholinergics (ipratropium & tiotropium) Leukotriene → long term control meds used to prevent bronchospasm & inflammatory cell infiltration that are used before a triggering event like exercise Montelukast → as needed before exercise in clients who do not require a daily bronchodilator & is taken at least two hours before imitation of exercise Meds for a-fib → diltiazem, digoxin, amiodarone/dronedarone, anticoagulants (rivaroxaban, apixaban, warfarin) Clonidine → HTN & ADHD Patient teaching for epoetin alfa → may increase BP & is an erythropoietic growth factor indicated to increase RBC for those with chronic kidney disease Considerations for ACEs → nephrotoxic, hyperkalemia (decrease potassium in diet), increased creatinine, don’t need to weigh self-daily Patient teaching for Varenicline → assist in smoking cessation, should be started seven days before planned quit date ▪ S/E: nausea, vivid dreams, depression, suicidal ideating ▪ Contraindications: history of suicidal ideating or unstable psych illness Nicotine replacement therapy (NRT) → forms like patch, lozenge gum, inhaler, nasal spray, first-line choice based on clients’ preferences ▪ S/E: insomnia & vivid dreams Education for bupropion for smoking cessation → promotes weight loss & reduces seizure threshold so it is contraindicated in clients with a seizure disorder Primary action for PPIs → increases stomach pH or decrease amount of acid in stomach; long term use can increase risk of osteoporosis, fractures, hypomagnesemia, Mis S/E for opioids → constipation, ALOC, pupil constriction, urinary retention Relationship between calcium & phosphorous → as one level rises the other decreases; in a client with low calcium, decreasing phosphorus through phosphate secreting medications will inversely increase serum calcium Therapeutic response for mirtazapine → depression is better, sleeping eight hours a night ▪ Teaching: causes sedation & is dosed at night, helpful for those with depressive disorders & who suffer from concomitant insomnia ▪ S/E: increased appetite, weight gain, sedation, dizziness, confusion Long-acting beta-agonist (formoterol) → treatment of chronic respiratory illness, should not be used in acute dyspnea, can cause insomnia (like all beta-blockers) Drip volume → total volume x drop factor divided by minutes Buspirone → non-controlled medication indicated in the treatment of GAD, does not cause dependence or withdrawal symptoms, time of onset may be delayed up to two • • • • • • • • • • • • • • weeks to four weeks, should be taken consistently with or without food, should not be taken during acute anxiety attack, sexual dysfunction is unlikely with this medication Adverse effects of taking SSRIs (fluoxetine) & MAOIs (tranylcypromine) together → serotonin syndrome (hyperthermia, muscle rigidity, tremor, agitation, sweating, dilated pupils, diarrhea S/S of hyperthyroidism → heat intolerance, tachycardia, diarrhea, weight loss, insomnia S/S of hypothyroidism → cold intolerance, bradycardia, constipation, weight gain Education for insulin administration → do not shake vial but gently rotate it to ensure uniform suspension of insulin & store in cool place away from direct sunlight like a fridge Tx of infective endocarditis → antibiotics like vancomycin Important lab to monitor on enoxaparin → platelet count because of risk of HIT which can result in a 50% decrease in the platelet count Nurse action for increase glucose trend on TPN → obtain prescription for sliding scale insulin Patient teaching for doxycycline → wear sunscreen, backup method of BC, glossitis (white coating on tongue) is normal, take medication on an empty stomach, attend follow ups & have labs checked ▪ Considerations: do not need to increase their fluid intake to three liters, GI upset S/E, increase risk for oral & vaginal candidiasis, avoid Ca rich foods, dairy products, or antacids containing Ca, may cause pill-induced esophagitis – take with large glass of water & remain upright 30 mins after taking dose, if ingest dairy products must be separated by 2-3 hours Lab essential prior to initiation of isotretinoin → lipid panel b/c it may raise triglyceride levels, so a baseline lipid panel is necessary along with periodic monitoring ▪ Indication: treats moderate to severe acne vulgaris ▪ Considerations: highly teratogenic so client so get negative pregnancy test prior & have reliable contraception Nurse actions before transfusion platelets → infuse within 30-60 mins, verify informed consent, obtain pre-transfusion VS ▪ Indication: severe thrombocytopenia (platelet count less than 25,000) S/E of niacin → facial flushing when prescribed in high doses ▪ Considerations: can cause liver problems so monitor liver function tests, increase HDL, risk of hypotension Signs to monitor in continuous norepinephrine infusion → BP, IV site, UO, glucose Pregabalin → neuropathic pain (fibromyalgia, herpes zoster, phantom limb pain), certain anxiety disorder, focal seizures, controlled substance is 5x more potent compared to gabapentin ▪ S/E: dizziness, drowsiness, CNS depression ▪ Considerations: fall precautions Systemic effects of topical glucocorticoids → liver toxicity ▪ Indication: dermatitis & eczema to treat symptoms of burning, itching, inflammation ▪ ▪ • • • • • • • • • • • • • • • • • • Long term adverse effects: irritation, redness, thinning of skin Undesirable system effects: adrenal insufficiency, mood changes, bone defects, serum imbalances Possible S/E of oral prednisone → blurred vision, tachycardia Lab drawn before discharge on carbamazepine → CBC b/c drug can cause immunosuppression Patient teaching of phenylephrine → used every 3-4 hours for only 3-5 days to help reduce risk of rebound congestion ▪ Indication: relieves nasal congestion associated allergic rhinitis S/E of short-acting beta-2 agonist → tachycardia, HA, HTN, hyperglycemia, tremors, hypokalemia, increased lactic acid accumulation Med for cough suppressant → dextromethorphan (can cause sedation) Guaifenesin → an expectorant that loosens congestion in a client’s chest & throat making it easier for them to cough out mucus & phlegm Med for acute mountain sickness → acetazolamide, a carbonic anhydrase inhibitor ▪ Considerations: take 24 hours prior to the ascent, causes increased HR, BP, CO Tx for hyperkalemia → kayexalate, glucose & insulin, dialysis Consideration of Sevelamer → take with meals, a phosphate binder that is indicated for CKD, inhibits absorption of phosphorus to allow Ca levels to increase, take stool softeners & laxatives to mitigate constipation Findings to report on metformin → decreased GFR & increased creatinine & increased BUN) Nurse action for infant with pulse of 85 taking digoxin → if pulse is less than 90 the nurse should withhold med then recheck in an hour, if pulse remains low then nurse should inform HCP, digoxin is not administered intramuscularly Med client should take while on ventilation → PPIs Contraindication in salmeterol → labetalol b/c betablockers may cause bronchospasm Med for tx of panic disorders → amitriptyline, diazepam, phenelzine Critical assessment of isotretinoin → mood changes b/c of increased risk of suicide & depression SVT med tx → adenosine 6mg the 1st time followed by 12mg 2nd time & 12mg the 3rd time then a rapid push followed by 20mL of NS Actions that minimize eye drops systemic effects → place finger over inner canthus for 30-60 seconds after instilling eye drops b/c it occludes nasolacrimal duct preventing eye drop solution from reaching the mucous membranes & being absorbed into systemic circulation Med for pernicious anemia → vitamin B12 ▪ Patho: inability of body to utilize vitamin B12 which results in decreasing of Hgb ▪ Diet: increase intake of animal products, strict vegan diet ▪ Causes: diet, gastrectomy, bariatric surgery, Crohn’s disease, celiac disease, pancreatic insufficiency, bacterial overgrowth, fish tapeworm infection, gastric atrophy associated with aging, meds like metformin) • • • • • • • • • • • • • • • • • • • Thiamine → B-vitamin is commonly administered for alcohol withdrawal to prevent encephalopathy Iron dextran → IM or IV indicated for iron deficiency anemia – no PO Folic acid → administered for folic acid deficiency anemia which can be caused by alcoholism or meds like methotrexate Actions to monitor for overdose of aspirin → onset of pulmonary edema & metabolic acidosis ▪ Early S/S of aspirin overdose: tinnitus, hyperventilation (deep & rapid breathing), vomiting, dehydration, fever ▪ Late S/S of aspirin → drowsiness, unsteady gait, bizarre behavior, coma Sequence of mixing two insulins → prep top of vials with an alcohol pad, inject amount of air equal to ordered dosage of NPH insulin, inject amount of air equal to ordered dosage of regular insulin, withdraw ordered dosage of regular insulin, withdraw ordered dosage of NPH insulin; inject air into NPH insulin vial first & then prepare the regular insulin in the same syringe Indication of baclofen → MS, treated by muscle relaxants Tx of acute migraine HA → ketorolac, dexamethasone (corticosteroid), acetaminophencaffeine Herbal supplements follow-up for lorazepam → kava & valerian Serious adverse effect of TCA → cardiac arrhythmias Actions to prevent numbness of the throat & tongue after taking Benzonatate → swallow capsules without chewing Medical history safe to take warfarin → a-fib, thrombotic stroke, mitral valve replacement Expected S/E of hydralazine → vasodilation & decreased afterload Severe form of bone marrow toxicity → aplastic anemia Patient teaching for lactulose → give 30 mL lactulose with juice & monitor blood ammonia ▪ Considerations: average 2-3 loose stools per day, avoid laxatives ▪ S/E: belching, flatulence, abdominal cramping Reason morphine sulfate is contraindicated in lactating women → excreted in the breast milk Med for a-fib → diltiazem & warfarin Diet contraindicated by grapefruit → CCBs, statins, some antibiotics, & some cancer drugs Adverse effects in client taking clozapine → can cause neutropenia & lab work is necessary to ensure client is not experiencing agranulocytosis which enhances risk of infection, WBC of 3,000 requires follow up ▪ Serious effects: agranulocytosis, myocarditis, sialorrhea (excessive drooling), weight gain Patient teaching about isoniazid → B-complex vitamin should be taken to help with neuropathy ▪ Indication: first-line therapy for pulmonary TN ▪ • • • • • • • • • • • • • • Considerations: report signs of hepatotoxicity such as jaundice & clay-colored stools, take for prolonged steroids (at least six months) S/E of rifampin → reddish/orange secretions Oral potassium teaching → sprinkle contents of capsule in apple sauce to increase palatability & do not chew on capsule or tablet, take with food Tonic-clonic seizure tx → benzodiazepine Med nurse should question → hydrocortisone for DI b/c it should be desmopressin, thiazide diuretic, anti-inflammatories Tx of hyperparathyroidism → NS & furosemide b/c of hypercalcemia Tx of hyperthyroidism → antithyroid such as methimazole or propylthiouracil (PTU) Tx of pheochromocytoma → prazosin (alpha-adrenergic blocker) b/c it can cause HTN Onychomycosis → known as tinea unguium which is a fungus infection of the nails (fingernails, toenails) which causes thick, discolored, opaque, crumbling ▪ Causes: dermatophytes 90%, non-dermatophytes (saprophytes & yeast – Candida 10%) ▪ Tx: topical antifungals & systemic antifungals (Terbinafine & Lamisil), taken with food ▪ S/E: abdominal pain, nausea, dyspepsia (indigestion), diarrhea, rash, taste changes ▪ Complications: vision changes need to be reported to HCP, check baseline liver functions must be checked before administration b/c of risk of severe liver toxicity (yellow-colored urine, pale stools, jaundice, persistent nausea) Discharge instructions for digoxin → hold if less than 60 bpm, adequate potassium in daily diet, water pills increase risk of side effects with digoxin, avoid meds that have licorice extract ▪ Range: 0.5-2 ▪ Hold in children if bpm is less than 70 & less than 90-110 in infants ▪ Considerations: hypokalemia, hypercalcemia, hypomagnesemia can increase toxicity Parameter to monitor for terbutaline → breath sounds b/c most common S/E is pulmonary edema so monitor for respiratory crackles & difficulty of breathing Instructions for lisinopril → may decrease ability to taste foods & limit intake of foods high in K (like avocados, apricots, melons, bananas, legumes) b/c it may cause hyperkalemia, instruct client to season food naturally Med for epilepsy → topiramate (anticonvulsant) & lorazepam (benzodiazepine) Hydroxyzine → allergic rhinitis Med to treat & prevent respiratory distress syndrome → colfosceril palmitate a pulmonary surfactant, caused by lack of surfactant in the lungs, administered via endotracheal tube in 2-4 doses 1st 24-48 hours after birth, helps prevent pneumothorax, antenatally – dexamethasone reduces incidence & severity of RDS in the infants for women at risk of pre-term delivery, postnatally – surfactant administration like surfactant (colfosceril palmitate) of treating RDS, may have growth & neurodevelopmental adverse effects, considered in infants who require mechanical • • • • • • • • • ventilation between 7-21 days of age who are receiving supplemental O2 & at high risk of neonatal chronic lung disease HIT nurse action → discontinue heparin infusion & notify HCP Report dizziness for more than a week to HCP Eat small frequent meals when nausea occurs Take food a before meals or 2 hours after meals on amlodipine Med contraindicated in phenytoin → Concern for sumatriptan → can cause HTN so it requires follow-up Route for RhoGAM → IM or IV Application of nitroglycerin ointment → rotate application sites, apply ointment on paper & apply cream to an area of skin, don’t rub cream into the skin until it disappears, don’t cover it with gauze Nursing consideration of phenytoin → avoid taking calcium carbonate & separate times of intake of calcium carbonate & phenytoin by at least 2-3 three hours Critical Care • Causes of respiratory alkalosis → hyperventilating causes you to lose acid (ex: aspirin overdose, anxiety) ▪ Alveolar hyperventilation → low resp rate in ventilator settings, high tidal volume • Causes of respiratory acidosis → hypoventilation – difficulty breathing causing you to retain acid (ex: pneumothorax, COPD, narcotic overdose, drowning) ▪ Alveolar hypoventilation → excessive lung secretions • Causes of metabolic alkalosis → losing acid (ex: vomiting & antacids b/c it has a lot of bases in them, gastric suction, long-term diuretic therapy, potassium loss, cystic fibrosis, ingestion of milk & calcium carbonate, Cushing syndrome) • Causes of metabolic acidosis → retaining acid through overdose (ex: diarrhea, starvation b/c cells starve so body breaks down fat leading to overproduction of ketones, Addison disease) • Safe range for gastric residual volume (GRV) for clients on enteral nutrition → less than or equal to 500 mL ▪ Hold enteral feedings if GRV is less than 500 mL plus signs of intolerance (vomiting, pain, bloating, distention) or if GRV is greater than 500 mL ▪ Hold feeding, notify HCP, administer prokinetic agent such as metoclopramide, recheck GRV after 2 hrs • IV tx for septic shock → norepinephrine (increases vascular tone & MAP) ▪ Initial tx is isotonic fluid and if it doesn’t help then vasopressors such as norepinephrine is used to achieve and maintain MAP at target level ▪ Maintaining a MAP of 65 mm Hg or more is the critical guideline ▪ Establish large-bore IV access, collect CBC, CMP, lactic acid, blood cultures, urine cultures, procalcitonin, administer isotonic IV fluid bolus of 30 mL/kg, infuse empirical antibiotic • • • • • • • • • • • • • Tx for CHF → milrinone Tx for ventricular dysrhythmias → lidocaine & amiodarone Priority action in an infant with low HR, cyanotic, apneic → initiate infant code blue before starting CPR ▪ Use two-finger technique or two-thumb encircling hands technique ▪ Chest depressed 1.5 inches ▪ Head tilt-chin lift maneuver unless there is a cervical spinal cord injury & if suspected then use jaw thrust maneuver Tx of burns → NPO, 12 lead EKG, isotonic fluids (LR), irrigate burns with sterile saline, cover burns with sterile, non-adherent dressing, obtain ABG Parkland formula → 4 mL x kg x TBSA ▪ Half given in 8 hrs ▪ Remaining half given over the next 16 hrs Priority suctions when HR and RR increases during suctioning → stop suctioning & check O2 saturation ▪ If these dependent nursing actions don’t work, then nurse will notify HCP & call rapid response team ▪ Adults: 100-120 mm Hg (suction pressure); 10-15 sec (suction limit) ▪ Children: 80-100 mm Hg; 10 sec (suction limit) ▪ Hyper-oxygenate 100% before suctioning ▪ Avoid catheter large than 2/3rd size of airway ▪ Suction PRN ▪ Continuous: 5 secs ▪ Intermittent: 10 secs S/S seen in burn clients → hyponatremia, hyperkalemia, hypotension, edema in burned areas, reduced UOP ▪ Early post-resuscitation period (day 2-6): hypernatremia, hypokalemia, hypocalcemia, hypomagnesemia, increased UOP, severe hypophosphatemia S/S of Cushing’s triad → irregular respirations, bradycardia, widening pulse pressure S/S of Beck’s triad → hypotension, JVD, muffled heart tones ▪ Indication of cardiac tamponade S/S of Virchow’s triad → stasis, hypercoagulability, vessel injury ▪ Indication of venous thrombosis S/S of Horner’s syndrome → ptosis (droopy eyelid), miosis (constricted pupil), anhidrosis (decreased diaphoresis) ▪ Syndrome that affects nerves in the spinal cord & the lesions causes the above symptoms CVP process → instruct client to relax, not strain or cough, place client supine with HOB elevated to no more than 45 degrees, place the transducer at the fourth intercoastal space, mid-axillary (level of the right atrium aka “Phlebostatic” axis) Normal CO → 4-8L/min (SV x HR) • • • • • • • • • • • • S/S of left-sided HF (decreased blood flow) → decreased pulse, hypotension, decreased kidney perfusion & GFR, decreased urine output, increased ADH, hypernatremia, fluid overload symptoms, ALOC S/S of right-sided HF (back up of blood flow) → fatigue, JVD, ascites, enlarged liver & spleen, increased peripheral venous pressure, anorexia, GI upset, weight gain, dependent edema S/S of abdominal aortic aneurysm (AAA) → N/V, epigastric pain, hypotension, tachycardia, pulsating mass in abdomen ▪ Nursing interventions: LR, prepare abdominal ultrasound, monitor VS ▪ Tx: beta-blockers to reduce size of the aneurysm as well as reduce the risk of rupture ▪ Risk factors: age over 65, CVD, HTN, obesity Priority action for unconscious child with no access to a call button → give 2 mins of CPR at a ratio of 30:2 then look for help and get an AED Trendelenburg position → prevents air embolism during CVP & increases venous blood return when clients are affected with hypotension, hypovolemia, or shock S/S in drowning clients → hypoxia, hypercarbia (increased CO2), respiratory acidosis, possibly hypothermia Methods to rewarm clients suffering from hypothermia → 40-degree bath, warming blanket, warmed IV fluids, radiant lamps ▪ Active core warming: infusing IV fluids ▪ External warming: 40-degree bath, warming blanket, warmed IV fluids, radiant lamps Drugs that can cause malignant hyperthermia → adverse reaction to inhaled or IV anesthesia halothane & succinylcholine b/c they can cause excess calcium buildup in the cells resulting in muscle contractions ▪ S/S: tachycardia, muscle rigidity, fever, rhabdomyolysis ▪ Nursing interventions: cooling blanket & ice to axilla & groin, indwelling catheter, administer Dantrolene (skeletal muscle relaxant), aggressive hydration ▪ Complications: acute kidney injury and metabolic acidosis Psychosocial interventions for clients in ICU → use clocks & calendars to help with orientation & reduces the client’s risk for developing delirium Tx of acute pulmonary edema → morphine & furosemide, HOB 90 degrees, stat chest xray, O2 NRB ▪ Nurse action: stay with client, call for help, notify rapid response team Hypothermia → core body temperature of less than 95 F (35 C) ▪ Mild: 90-95F (32.2-35C), shivering, bradycardia, tachycardia ▪ Moderate: 82-89F (27.8C-32.2C), ALOC, bradycardia, Afib, hypovolemia, cessation of shivering, hyperglycemia ▪ Severe: less than 82F (27.8C), coma, fixed & dilated pupils, bradycardia, apnea, hypotension, Vfib, asystole Frostbite → hypothermia in extremities, may appear red and swollen, pale, clear, or bloody blisters • • • • • • • • • • • • • • • Best position for ARDS → prone Best position for preventing ventilator acquired pneumonia → HOB at least 30 degrees; 30-45 degrees Essential item at bedside for mechanical ventilation → bag valve mask & suction Acute pain → activates SNS ▪ S/S: N/V, diaphoresis, tachycardia, tachypnea, hyperglycemia, HTN, mydriasis (dilated pupils) Subglottic suctioning → reduces risk of VAP Methods to reduce VAP → positioning, oral care, subglottic suctioning, hand hygiene, early mobilization, reduce use of gastric pH (sucralfate is okay) Best indicator for pain → facial expression Second best indicator for pain → muscle tension CPR highest nursing diagnosis priority → ineffective breathing pattern Nursing intervention in severe anemia r/t to PUD → monitoring stools for guaiac (measures loss of blood in stools), assessing VS every 4 hours for tachycardia & hypotension, requires high-iron diet to replace RBC’s Erythropoietin → used for maintenance of Hgb levels in anemia of chronic renal failure Ptosis → drooping of eyelid Pharyngitis → inflamed & sore throat Kernig → positive sign of meningitis Thyroglossal cyst → birth defect mass found on neck
