Pharmacological and Parenteral Therapies (24) 1. The side effects of Tricyclic Antidepressants Tricyclic Antidepressants: Amitriptyline (Elavil)---Category C Imipramine (Tofranil) Doxepin (Sinequan) Nortriptyline (Aventyl) Side Effects: Orthostatic hypotension Anticholinergic effects( Dry mouth, Blurred vision, photophobia, Acute urinary retention, constipation and tachycardia) Cardiac toxicity( usually only at excessive dosing) Sedation Toxicity evidenced by dysrhythmias, mental confusion, and agitation, follow by seizure and coma. Use with MAOIs= hypertension 2. Immunosuppressant’s: Recognizing Risk Factors for infection ImmunoSupressants: cyclosporine (sandimmune, Gengraf, Neoral) prednisone (glucocorticoid) azathioprine( imuran) methotrexate and tacrolimus (prograf) Used in transplant people and for autoimmune disorders Increase risk for infection such as fever and/or sore throat should be reported to the primary care provider immediately. 3. Side effects of Estrogens (premarin): Endometrial (vaginal bleeding-persistant= report it) and ovarian cancers occurs when prolong estrogen is the only postmenopausal therapy. *Give progestins too, endometrial biopsy every 2 years Potential risk for estrogen-dependent breast cancer. Embolic events (e.g., MI, Pulmonary embolism, DVT, cerebrovascular accidents). Feminization (gynecomastia, testicular and penile atrophy), Impotence, and decrease libido in males. *Don’t use vaginal creams prior to sex Used of Phenytoin with estrogen can increase the risk of toxicity Estrogen can decrease the effectiveness of Warfarin. 4. Magnesium sulfate Therapy: Appropriate interventions to counteract toxicity for a client with gestational hypertension. If magnesium toxicity is suspected, immediately discontinue infusion Administer Calcium gluconate, the magnesium sulfate antidote Prepare for action to prevent respiratory or cardiac arrest. Signs of toxicity: i. Absence of patellar deep tendon reflexes ii. UOP less then 30ml/hr iii. RR less than 12 per min iv. Decreased LOC Interventions for clients receiving magnesium sulfate are to monitor the client’s… i. Initially they will feel hot faced, flushed, and sedated ii. Blood pressure, pulse, respiratory rate, DTRs, LOC, UOP, visual disturbances, epigastric pain, uterine contractions, and fetal heart rate and activity. iii. Place the client on fluid restriction of 100 to 125ml/hr and maintaining UOP at 30ml/hr or greater. 5. Succinylcholine (Anectine), a depolarizing neuromuscular blocker Recognizing and responding to malignant Hyperthermia. (muscle cramps and inc. temp. when a person has general anesthesia) This med is the preferred agents for seizure control during ECT, endotracheal intubation and endoscopy….cause hypotension and muscle relaxation without Loss of Consc. Or decrease in pain. SE of Succinylcholine is malignant hyperthermia and this can be recognized by muscles rigidity accompanied by increased temp reaching a level as high as 109.4 degree F. To response to malignant hyperthermia, monitor the client’s vital signs, stop Succinylcholine and other anesthetics, Ice or infusion of iced saline can be used to cool the client. Administer dantrolene to decrease metabolic activity of skeletal muscle. 6. Blood and blood products: Evaluating client Response to blood transfusion: Check to see if client’s blood level had Increase in hemoglobin of 1 to 2g/dl per unit of blood administered and Blood pressure above shock parameters. (for Whole and packed RBC) Reduced bleeding and increased platelet count (for platelets) Reduced bleeding and Prothrombin or Aptt time <1.5 times normal (FFP) Monitor for reactions…stop infusion Not at rm. Temp for more than 30 min. 7. Vascular Access: Recognizing and documenting Expected findings for a client with a Central Venous Access Device NO infiltration, no redness and swellings at the site, no leakage at the site Observe site every 2 hrs. for signs on infection or infiltration No backflow of blood into the hub No accidental dislodgement Intact transparent dressing 8. Basic pharmacological principles: Expected Dosage Adjustments Based on Age of Client: Neonate should be given reduced dose because their blood brain barriers have not fully developed. Avoid injury with infants who are not hepatic mature Infants have limited medication metabolizing capacity. The elderly may have prolonged medication effects b/c of decreased liver function since the hepatic metabolism decreases with age. 9. Dosage Calculation: Calculating an oral Dose: Desired/Available X Quanitiy (D/A X Q) IV flow rate i. Volume (ml)/Time (min) X 60 min/1 hr. = IV flow rate (ml/hr) 10. Hematopoietic Growth Factors (Epoetin Alfa (epogen, procrit), darbepoetin alfa (Aranesp) This med acts on the bone marrow to increase production of red blood cells…anemia, HIV clients Evaluating Client Outcomes: Hemoglobin level of 10 to 12g/dl and hematocrit of 40%, Increase reticulucyte count. 11. Proton pump Inhibitor (Omeprazole prilosec), protonix, previcid, nexium…reduce gastric acid secretion…peptic ulcers and GERD: Client Education: Do not crush, chew or break sustained- release capsule. May sprinkle the contain of the capsule over food to facilitate swallowing. Client should take Omeprazole one a day before eating. Avoid taking irritative meds like ibuprofen and alcohol. Active ulcer can be treated for 4 to 6 wks. Protonix can be administered IV and in addition to low incidence of HA and diarrhea, there may be irritation at inj. site leading to thrombophlebitis. Monitor for any signs of inflammation (e.g., redness, swelling, local pain) and change IV site if indicated. Teach the client to notify the doctor for any sign of obvious or occult GI bleeding (e.g., coffee ground emesis). 12. Migraine Meds: Evaluating Appropriate use of sumatriptan (Imitrx): It is use to abort acute migraine attack, and also to prevent migraine attack. S/S: i. Chest symptoms, heavy arms or chest pressure (normal) ii. Angina (no when person is at risk for CAD) iii. No when pregnant Avoid trigger factors: alcohol, fatigue, and tyramine foods (wine and aged cheese) 13. Cephalosporin’s: Evaluating Treatments Effectiveness: Cephalosporins are broad- spectrum bactericidal meds with a high therapeutic index that treat UTI, postoperative infections, pelvic infection, and meningitis. For treatment effectiveness, pt will show improvement of infection symptoms (e.g., reduction in fever, pain and inflammation: clear breath sounds; reduced UTI symptoms, negative urine culture.) No if allergic to Penicillins, with meds that promote bleeding, and not if person has renal impairment. 14. Basic Principles of Med Administration: Client education Regarding AgeRelated interventions: Young kids w/ immature liver and kidney function and older adults may need smaller med doses. Infants have limited medication-metabolizing capacity. Take care to avoid injury prior to hepatic maturation of infants. The aging process can also influence meds metabolism, but varies from individual to individuals. In general, hepatic medication metabolism tends to decline with age. Observe the client for medication effect due to decrease liver function. Give clear instructions, verbal and in writing Dosage form is good…liquids to people who have trouble swallowing Clearly marked containers that are easy to open Daily calendar/pill container Assistance 15. Medication administration and Error Prevention: Disposing of unused Controlled Schedule Medications: 16. Dosage Calculation: Calculating Hourly infusion rate for a Large Volume of Fluid: Volume (ml)/Time (min) X 60 min/1 hr. = IV flow rate (ml/hr) 17. Intravenous therapy: priority interventions with initiation of therapy: Versed injected slowly over 2 or more minutes to decrease side effects. Wait 2 minutes to give another dose Diprivan injected in large vein to decrease pain at injection site…Use IV lidocaine first Need to be driven home after procedure Monitor for therapeutic and/or adverse effects 18. Intravenous therapy: Documenting Discontinuation of IV following signs of Phlebitis: 19. Medications Affecting the Respiratory system: Recognizing Ineffectiveness of Beta2- Adrenergic Agonists (Albuterol, Proventil, ventolin): This med is a bronchodilator Helps to relieve bronchospasm, inhibit histamine release and increase the motility of ciliary body. Used for the prevention of asthma attack (exercise –induced), treat ongoing asthma attack and long term control of asthma. In any case where Albuterol becomes ineffective, the meds will NOT be effective on long term control of asthma Prevent exercise induced asthma attack which will lead to SOB, unclear lungs sounds, wheezing, and prevention of respiratory rate returning to baseline. 20. Oral Hypoglycemic's (sulfonylurea’s, tolbutamide, orinase, glipizide, glucotrol, chloropropamide): Client Teaching Regarding use in pregnancy: This is a pregnancy risk Category C. Avoid use in pregnancy and lactation (risk for fetal/ infant hypoglycemia). Acarbose & Metformin are cat. B 21. Medications Used to treat Tuberculosis: Recognizing Risk for Phenytoin Toxicity due to medication interactions: Isoniazid, streptomycin, ethambulol, pyrazinamide interfere with the metabolism of Phenytoin with the accumulation of Phenytoin, resulting in ataxia (Loss of muscle control, Staggering, Difficulty pronouncing words) and incoordination (Lack of coordination in movement). Monitor the client level of Phenytoin. No if have heart problems Need to be strict with taking it to avoid toxicity Phenytoin decreases the affect of birth control, Warfarin (Coumadin), and glucocorticoids Alcohol, valium, tagament and valporic acid increase phen. Levels 22. Opioids: Monitoring Client for Interactions with Anesthesia: Parenteral fentanyl is used primarily in surgery to induce anesthesia. Approximately 100 times more potent (milligram potency) than morphine. Monitor for client LOC because sedation usually precedes respiratory depression. 23. Pain Management: Evaluating Effectiveness of Treatments: Pain, fear and anxiety will be reduced if pain control is effective. 24. Total Parenteral Nutrition: Recognizing Appropriate TPN Interventions: Never abruptly stop TPN because abrupt rate changes can alter glucose level significantly. Check capillary glucose level every 4 to 6 hr for at least the 1st 24hr. The flow rate is gradually decrease or increase to allow body adjustment 9 usually no more than 10% hourly increase in rate. Clients receiving TPN frequently need supplemental sliding scale regular insulin until the pancreas can increase its endogenous production of insulin. Monitor VS every 4 to 8 hr. Obtain daily lab values including electrolytes. Always use aseptic techniques. Change tubing and solution bag (even if not empty) every 24 hr. Do not use the line for other IV solutions (prevent contamination and flow interruption). Do not add anything to the solution due to risk of contamination and incompatibility. SEE OTHER SHEET TOO Reduction of Risk Potential (24) 1. Rheumatic Fever: Recognizing Expected Laboratory Findings: Throat Culture for GABHS (group A strep) Blood Samples: i. Elevated or rising serum antistreptolysin-O (ASO) titer – most reliable. ii. Elevated C-reactive protein (CRP) or sedimentation rate in response to an inflammatory reaction. Cardiac Function: i. ECG to reveal the presence of conduction disturbances. ii. Echocardiogram to evaluate function of the heart and valves and also to check if the PR interval is prolong. The diagnosis of rheumatic fever is made on the basis of modified Jones criteria. The child should demonstrate the presence of two major criteria or the presence of one major and two minor criteria following an acute infection with GABHS infection. Major criteria: Carditis, Polyarthritis, Chorea, Subcutaneous nodules, Rash (erythema marginatum) Minor criteria: Fever, Arthralgia 2. Seizures: Client Education Regarding Electroencephalogram (EEG): EEG records electrical activity and identifies the origin of seizure activity. Instruct the client to avoid caffeine. Wash hair before the procedure (no oil, spray) and after the procedure remove electrode glue. May be asked to take deep breaths and /or be exposed to flashes of a strobe light during test. Sleep may be withheld prior to test and possibly induced during test. 3. Diabetes Mellitus: Client Teaching Regarding Purpose of self-blood Glucose Monitoring: Teach client that self-blood glucose will help them determine their sugar level for better control. Normal blood sugar is b/n 70 -120. Hypoglycemia: Give 15g of carbohydrate and recheck blood glucose after 15min and if still low, offer another 15 g of carbs. Hyperglycemia: Encourage oral fluid intake. And administer insulin as prescribed Giving insulin: rotate sites, inject at 90 degree angle, RN (when mixing) 4. Acid-Base Imbalances: Identify Expected Laboratory Data: PaO2= 80-100 PaCO2= 35-45 (Less than 35 is respiratory and more than 45 is acidosis) HCO3= 22-26 Ph =7.35-7.45 COMPLEX HANDOUTS 5. Diabetic Ketoacidoses: Recognizing clinical manifestations: Polyuria (excess urine) Polydipsia(excessive thirst) Polyphagia (excessive hunger) Ketone in the urine and the serum Blood glucose greater than 300, affect type 1 diabetes. Change in mental status, signs of dehydration (dry mucous membrane, weight loss, sunken eyeballs resulting from fluid loss such as polyuria) Kussmaul respiration pattern, rapid and deep respirations, not irregular “Fruity” breath ( DKA/METABOLIC ACIDOSIS), nausea, vomiting and /or abdominal pain. Serum osmolarity is high. Na increase due to water loss K initially low due to diuresis and might increase due to acidosis. 6. Fluid Imbalances: Interpret laboratory Values for Dehydration: Hgb and Hct are high Serum osmolarity, urine specific gravity and serum sodium are increased. Normals: i. Hgb level (13-15) ii. Osmolarity (50-300) iii. Hct (35-45%) iv. Specific gravity (1.002-1.030) 7. Diabetes Insipitus: Recognizing Expected Laboratory findings: Deficiency of ADH UOP of about 5 to 20L a day Increase in serum sodium Dilute Urine Blood concentrated Water deprivation test (simplest and most reliable test): inability of urine to concentrate urine 8. Heart Failure: Recognizing Expected lab Findings: BNP elevated (100-300) Increased CVP, PCWP, PAP Decreased CO Left side= lung symptoms (bld. Backs up into lungs) Ride side= edema, and other body symptoms 9. Conscious Sedation: Monitoring Client Physiologic Response Following Conscious Sedation: After completion of the procedure, the monitoring nurse continues to record vital signs and level of consciousness until the clients is fully awake and all assessment criteria return to pre-sedation levels. The typical discharge criteria are LOC as on admission, Vital signs stable for 30 to 90 min, Ability to cough and deep breathe, Ability to take oral fluids, no nausea and vomiting, shortness of breath, or dizziness. 10. Peripheral Venous Disease: Prevent Complications: Encourage bed rest and elevation of the extremity above the level of the heart as ordered Avoid using a knee gatch or pillow under knees Administer intermittent or continues warm moist compresses as order (to prevent thrombus from dislodging and becoming embolus, do not massage the affected limb). Provide thigh- high compression or anti embolism stockings as prescribed to reduce venous stasis and to assist in venous return of blood to the heart. Avoid prolong sitting or standing, constricted clothing, or crossing leg when seated. Administer Anticoagulants as prescribed 11. Sickle Cell Anemia: Preventing Sickle cell Crisis: Give Oxygen Administer analgesia Hydrate the patients Avoid tight or constricted cloths S/S: cyanosis, abdominal pain, leg and back pain, low grade fever, seizures, and stroke manifestations (weakness, paresthesia) 12. Thyroidectomy: Assess for Complications: Respiratory stress, excessive bleeding, thyroid storm Assess for excessive drainage or bleeding during the postoperative period especially at the back of the neck and change dressing as directed. Support the head and the neck with pillows or sandbags if client need to be transfer from stretcher to bed. Monitor for signs of thyrotoxicisis (thyroid storm),(tachycardia, diaphoreses, increased blood pressure, anxiety). Airway Obstruction (because of edema). If client reports that the dressing feels tight, the surgeon needs to be alerted immediately. Put the client in high fowlers in order to decrease edema. Assess for hypocalcaemia and tetany (due to damage of parathyroid glands). Signs of hypocalcaemia are tingling of the fingers and toes, calpopedal spasms, and convulsion. Assess the clients’ voice tone and quality and compare with the preoperative voice. Assess for nerve damage which can lead to vocal cord paralysis and vocal disturbances. 13. Cerebrovascular Accident: Interventions to prevent Aspiration: Assist with safe feeding. Assess swallowing reflexes such as the gag, swallowing and cough before feeding . The client’s liquids may need to be thickened to avoid aspiration. Have the client eat in an upright position and swallow with the head and neck flexed slightly forward. Food in back of mouth on the unaffected side Suction on standby Distraction free environment while feeding 14. Postoperative Nursing: preventing Circulatory Complications: Position the client supine with head flat (prevent hypotension). Do not put pillows under knees or use a knee gatch (decrease venous return). Elevate the legs of the client if shock develops. Prevent and monitor for thromboembolism (especially following abdominal and pelvic surgeries). Apply pneumatic compression stockings and /or elastic stockings. Reposition client every 2hr and ambulate early and regularly. Administer low level anti coagulants as prescribed. Monitor extremities for calf pain, warmth, erythema and edema. 15. Angiography (catheter in femoral artery to see occlusions): Recognizing Complications: Cardiac tamponade can result from fluid accumulation in the pericardial sac. Signs of cardial tamponade includes i. hypotension, jugular venous distention, muffled heart sounds, and paradoxical pulse (variance of 10mm Hg or more in systolic blood pressure b/n expiration and inspiration). ii. Hemodynamic monitoring will reveal intracardia and pulmonary artery pressure similar and elevated (plateau pressure). Retroperitoneal Bleeding- Asses for flank pain and hypotension. Call Doctor…give fluids and blood Restenosis- reoccurring stenosis (of treated vessel), Call Dr. iii. Asses ECG pattern and for occurrence of chest pain. iv. Have to go back to cath lab Hematoma Formation: i. Asses the groin at prescribed intervals and as needed. ii. Hold pressure for uncontrolled oozing/ bleeding. Make sure to notify the provider immediately if the above complication occurs. iii. Monitor peripherial circulation 16. Gastroenteral feedings: Measures to prevent Aspiration: Position client in a fowlers position or at a minimum of 30 degree elevation of head or position client to the side if client aspirated the food. Suction airways 17. Head Injury: Assessing Neurological Status: Assess Change in level of consciousness- the earliest indication of neurological deterioration. Amnesia (loss of memory) before or after injury. Do a GCS assessments. Check for pt response to painful stimuli, Assess for level of consciousness (earliest signs are HA , restlessness, irritability) and length. Check for posturing (decorticate, decelerate, flaccid) and check pupil responses. Asses signs of infection (nuchal rigidity with meningitis) Assess for CSF leakage from nose and ear (“halo” sign –yellow stain surrounded by blood; test positive for glucose.) Check the GCS rating (15 normal; 3= deep coma) Check for Cushing reflex (severe hypertension with a widened pulse pressure and bradycadia) – late sign of ICP 18. Urinary Tract Infection: Recognizing risk factors: Female gender, short urethra predisposes women to UTI, close proximity of the urethra to the rectum increases the risk of infection, Decrease estrogen in aging women, sexual intercourse, The use of feminine hygiene product, pregnancy, poorly fitted diaphragms, wet bathing suit, frequent use of bathtubs or hots tub, Panty hose and synthetic under wear. Indwelling urinary catheters, Stool incontinence, Bladder distention, disease e.g. diabetes mellitus, Urinary condition (anomalies, stasis, calculi, and residual urine) 19. Joint Replacement: Client Teaching Regarding postoperative Nursing Activity Limits: Early Ambulation Transfer out of bed from unaffected side. Weight-bearing status is determined by the orthopedic surgeon and by choice of cemented (usually partial/full weight-bearing as tolerated) versus non-cemented prostheses (usually only partial weight-bearing until after a few weeks of bone growth). Avoid knee gatch (bend). Do not massage legs Client position: Supine with head slightly elevated with affected leg in neutral position and a pillow or abduction device between legs to prevent abduction (movement toward midline), which could cause hip dislocation. Arrange for raised toilet seats, extended handle items (shoehorn, dressing sticks). Avoid flexion of hip > 90º. Do not cross legs. For Knee replacement, Positions of flexion of the knee are limited to avoid flexion contractures. Avoid knee gatch and pillows placed behind the knee. Knee immobilizer may be used while in bed. The goal is for the client to be able to straight leg raise. Kneeling and deep knee bends are limited indefinitely. Use CPM 20. Preoperative Nursing: Recognizing Client Findings Indicative of Readiness for surgical Intervention: Local anes= NPO 3-4 hr Gen. Anes. = NPO 6-8 hrs Need to witness consent Make sure person understands Don’t teach the client, make the dr. come back if needed Don’t pressure the client 21. Postoperative Nursing: Maintain function of Jackson–Pratt Drain: Maintain a dry, intact dressing. Drains should be patent with minimal bleeding or drainage. Monitor amount and character of drainage. Notify physician if it suddenly increase or becomes bright red. Compress drain 22. Pain Management: Management of an Epidural Catheter: Administering a bolus of IV fluids to help offset maternal hypotension as prescribed. The nurse helping to position and steady the client into either a sitting or side-lying modified Sims’ position with the back curved to widen the intervertebral space for insertion of the epidural catheter. Frequent palpation to check for abdominal distension. s/e: sedation, n/v, itching, urinary retention, lower extremity sensory effects, and resp. depression. Sterile dressing over the catheter site Encouraging the client to remain in the side-lying position after insertion of the epidural catheter to avoid supine hypotension syndrome with compression of the vena cava. Do constant check of stomach palpation for stomach distension. 23. Intraoperative Nursing: Circulating Nurse Role Priorities: The circulating nurse performs frequent assessments of client positioning (functional position without pressure), maintenance of sterile technique and a sterile field, and of the client’s intake and output throughout the surgical procedure. She also monitor traffic in the room Assess the amount of urine and blood loss. Report findings to the surgeon and the anesthesia provider, Provide supplies to the surgical team and communicate info about client status to the family members. Notify the PACU of the clients estimated time of arrival. 24. Blood Pressure: Recognizing and Responding to Factors Affecting Blood Pressure: : Principle determinants are CO and systemic vascular resistance If either increase or decrease, the BP does the same Orthostatic hypotension Hypertension Don’t smoke Restrict sodium Weight control and weight control Management of Care (24) 1. Advance Directive: Recognize Purpose: To allow person to make their wishes known when they can’t speak for themselves. Living will signed by 2 witnesses DNR= have to have an order 2. Client Advocacy: Intervening on behalf of the client: Important when people can’t speak for themselves Informed of their rights Assist, don’t direct or control Patient bill of rights is the Patient care partnership 3. Discharge Planning: Intervening to promote Timely Client Discharges: The process begins at the time of admission. Plans are developed with the client and family input, focusing on active participation by client to facilitate a timely discharge. The nurse coordinates the client’s care to provide continuity of care. She facilitate communication b/n the client and the care provider. The nurse clarifies confusing and complex information by the primary care provided which makes it hard for the client to understand proposed therapeutic interventions. Assess client support system, evaluate clients ability to learn and assessment of client psychophysiologic state. Teaching prior to discharge is very important. Provide the client with clear written guidelines on self –care procedure, lifestyle changes, diet, medication administrations etc. 4. Client’s right: Recognizing client rights regarding review of records: The client has the right to review his medical record and request information as necessary for understanding. Clients also have the right to request a copy of their medical record and if the client believes a medical record is not accurate, the client can request that the record be amended. 5. Collaboration with the Interdisciplinary Team: Method for collaboration: Collaboration is used by interdisciplinary teams to make health care decisions about clients with multiple problems. Collaboration, which may take place at the team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone. Nurse- primary care collaboration should be fostered to create a climate of mutual respect and collaborative practice. Collaboration can occur among different levels of nurses with different areas of expertise. 6. COPD: Planning strategies for Fatigue: Determine the client’s physical limitations and structure activity to include periods of rest. Provide rest periods for older adult clients with dyspnea. Design room and walkways with opportunities for relaxation. Incorporate rest into activities of daily living. Position in high fowlers Deep breathing 7. Conflict Resolution: Identify strategies: Compromising: Each party gives up something Competing: One party pursues a desired solution at the expense of others. Cooperating/Accommodating: One party sacrifices something, allowing the other party to get what it wants. This is the opposite of competing Smoothing: One party attempts to “smooth” another party, decreasing the emotional component of the conflict Avoiding: Both parties know there is a conflict, but they refuse to fae it or attempt to resolve it. 8. Genitalia and Rectum: Providing privacy: Cover female waist down during genital exams. 9. Consultation: Referral in response to client concern: Consultants are use when the exact problem remains unclear. Referral is made so the client can access the care identify by the primary care provided or the consultant. These referrals are based on the clients need in relation to actual and potential problem. E.g., A pt with MI being refers to a cardiologist for consultation. 10. Client Education: Document client teaching: Create an environment conducive to learning (e.g., minimize distractions and interruptions, provide for privacy). Use therapeutic communication to develop a trusting relationship that allows the client to express areas of concern (e.g., active listening, empathy). Review previous knowledge and experiences. Explain the therapeutic regimen or procedure. Present steps building to more complex tasks. Demonstrate psychomotor skills. Allow time for return demonstrations. Provide positive reinforcement In order to document client teaching, Evaluation Observe the client demonstrating the learned activity (best for evaluation of psychomotor learning). Ask questions. Listen to the client explain the information learned. Use written tools to measure accuracy of information. Request the client’s self-evaluation of progress. Observe verbal and nonverbal communication. Revise the care plan as needed 11. Delegation: Use of the Five Right of delegation: Professional judgment and critical thinking skills are used when implementing the five rights of delegation. Right task – “a task that is delegable for a specific patient.” A right task is repetitive, requires little supervision, and/or is relatively noninvasive for a certain client. Right Task Wrong Task Right circumstances – the appropriate client setting, available resources, and other relevant factors are considered. If the circumstances have not been assessed or are deemed too complicated, the nurse takes the responsibility and does not delegate a task to AP. Right Circumstance Wrong Circumstance Right person – the right person is delegating the right task to the right person to be performed on the right person. Right Person Wrong Person Right direction/communication – a clear, concise description of the task is conveyed, including its objective, limits, expectations, and when to report concerns/assessment findings. Very specific, clear directions are essential for delegation to work well. Right supervision/evaluation- must be clear, and follw-up 12. Delegation: Monitoring outcomes of delegated tasks: 13. Delegation: Assigning Task to AP based on the role parameters and skills Required: Under their direction, RNs may delegate to LPNs/AP (provided agency policies and state practice guidelines permit) tasks such as: LEADERSHIP BOOK>>>CHART Tasks Delegated to LPNs Tasks Delegated to AP 14. Disaster Planning and Emergency Management: Priority Delivery of Client care: Triage: i. Highest priority: Clients with life threatening injuries but a high probability of survival once stabilized ii. Second: not life threatening, and can wait 45-60 min for tx iii. Lowest: can wait several hours for tx 15. Ethics and values: Appropriate Response to experiencing Negative Feelings about Client: 16. Client Education: Assisting Client to access Current Health information using information technology: Can be used to enhance access to and delivery of knowledge Demonstrate use of Internet in regard to accessing information and support services. Organize learning activities to move from simple to more complex tasks. Incorporate active participation in the learning process. 17. Client Education: Selecting appropriate information technology for Adolescent client education: Provide electronic educational resources as appropriate (e.g., CDs, DVDs, computer/PDA software programs). Demonstrate use of Internet in regard to accessing information and support services. 18. Informed consent: Ensure informed consent: The nurse is responsible for ensure that the provider gave the client the necessary information. The nurse must ensure that the client understood the info and is competent to give informed consent. The nurse is responsible to having the client sign the consent and notifying the provider if the client has more questions or appears not to understand any of the information provided. The provider is then responsible for giving the clarification. 19. Legal responsibility: reporting client abuse: Nurses should follow all laws and facility policies regarding reporting and documenting. Depending on state law, professional nurses are legally bound to report possible criminal behaviors such as child and/or older adult abuse, domestic violence, rape, and certain communicable diseases Middle age group= they have to report it themselves 20. Performance improvement: Utilize references to improve performance and maintain safe practice: STANDARDS JCAHO Do audits 21. Referrals : Assessing need to refer clients for assistance: Clients going home still need nursing care Social services, specialized therapies, home health, hospice Knowledge of community resources 22. Staff Development: Selecting staff education activities based on staff learning style: Assess the need and how they learn 23. Staff Development and performance Improvement: Selecting Education Activities to Ensure staff competencies: Competence- ability to meet the requirement of a particular role Use checklists, peer observation, learning modules, in-services, etc… 24. Supervising client Care: Information source for making Client Assignments: Complexity of care needed Specific care needs (vent., monitoring) Special precautions Skills, experience, and nurse to client ratio Physiological Adaptation (21) 1. Prolapsed Umbilical Cord: Emergency Nursing Response: In an umbilicus cord prolapse, the nurse should relieve the cord compression immediately and increase fetal oxygenation. Call for assistant immediately, notify the care provider about the prolapse cord and position the pt with hip higher than the head. Reposition the pt in a knee chest position, trendelenburg position, or a side lying position with a rolled towel under their right or left hip. Using a sterile gloved hand, insert two finger into the virginal and apply a finger pressure on either side of the cord. Apply a sterile saline-soaked towel to the cord to prevent drying and to maintain blood flow if it is protruding from the vagina. 2. Myocardial Infarction: Evaluating Effectiveness of medication interventions: Vasodilation opposes coronary artery vasospasm and reduces preload and after load, decreasing myocardial oxygen demand. Nitroglycerin med of choice. Morphine the drug of choice for pain to help reduce pain and decrease sympathetic stress leading to preload reduction. Beta- blocker reduces after load. In acute MI, beta- blocker decrease infarct size and improve short and long term survival rate. Thrombolitic agent can be effective in reducing thrombi. 3. Fractures: Discharge Teaching Regarding cast Care: Instruct the client not to stick object into the cast. Teach the client o keep the cast clean and dry. Instruct the pt in isometric exercise to prevent muscle atrophy. Clients are instructed not to place any foreign object under the cast to avoid trauma to the skin. 4. Electrolyte Imbalances: Evaluating effectiveness of Hypokalemia interventions: Body temp will become normal Pulses will move from weak to strong and regular Pt will stop being hypotensive Respiratory distress will be reversed. 5. Fluid Imbalances: Appropriate intervention in response to signs of fluid Volume Excess: Position the pt in the semi fowler position. Administer oxygen as prescribed. Reduce IV flow rates. Administer diuretic as ordered. Limit fluid and Na intake as ordered. Turn and position pt at least every two hr. Support arms and legs to decrease dependent edema and promote venous return as appropriate. 6. Electrolyte Imbalances: Recognizing priority intervention in response to hyponatremia: Restrict water intake as ordered to prevent fluid over load. Administer hypertonic oral and Iv fluids as ordered. Encourage food and fluids high in Na (cheese, milk). Administer isotonic IV solution (0.9% normal saline, ringer’s lactate solution). Encourage pt to change position slowly. 7. Congenital heart Disease: Interventions for Decreased cardiac output: Remain calm when providing care. Keep the child well hydrated. Decrease the work load of the heart by allow bed rest, maintaining body temp, decreasing effort of breathing by encouraging semi fowler position( HOB @ 30; sitting up in infant chair) Possibly sedation for the irritable child. 8. Shock: Recognizing signs and symptoms of hypovolemia: Decrease in Hgb and Hct which might indicate possibly source of bleeding. Blood in the NG tube or in the stool might also be a sign of hypovolemic shock. GI bleeding is also a sign. 9. Acute Gastrointestinal Disorder: Recognizing the signs and symptoms to report: 10. Herpes zoster: Evaluating client teaching: Use an air mattress or bed cradle to prevent pain. Stay at home until vesicles are crusted. Caution should be exercised around infants, pregnant women who have not had chicken pox, and who are immunocompromised. Take meds (Analgesics, NSAIDs, narcotic, Anti viral agents , such as acyclovir, famiclovir as prescribed). Moisten dressing with cool tap water or 5% aluminum and apply to the skin for 30 to 60 min for 4 to 6 times as prescribed. 11. Cystic Fibrosis: Managing illness at home: Ensure that care givers/parents have information regarding access to medical equipment. Instruct parent /caregivers’ ways to provide CPT and breathing exercises. for example, a child can “stand on her head” by using a large, cushioned chair placed against a wall. Administer antibiotics through venous access port. Visit health care provider regularly and stay up to date on immunization with the addition of initial influenza vaccine at 6 months of age and then yearly booster. Do regular physical exercise. Try to participate in support group. 12. HIV/AIDS: Interventions to prevent spread of HIV: Encourage proper use of condom. Frequent hand washing when dealing with blood and other fluids. Encourage pts to notify their sexual partners as soon as possible and also report to the CDC as required. 13. Glomerular Disease: recognizing risk factors: Immunological Reactions e.g . Primary infection with group a beta – hemolytic streptococcal infection (most common). SLE. Vascular injury (Hypertension). Metabolic disease (diabetes mellitus) Nephrotoxic drugs Excessively high protein and high Na diets. 14. Burns: Priority Interventions: Ensure airway patency (intubation, tracheotomy) Provide oxygen as needed (for example, mechanical ventilation). IV fluids Prevent infection Pain management Nutritional support ROM excercises 15. Mechanical Ventilation: Response to Ventilation Alarms and Respiratory Distress: If the nurse can not determine the cause of the alarm, the client is disconnected from the ventilator and manually ventilated with an Ambu bag. Ventilation alarms should never be turned off. Could be kinks, secretions, edema, etc 16. Pulmonary Embolism: Evaluation of Treatment Effectiveness: Pain is reduced. Clots do no get large and more clots are not formed when anticoagulant is taken. 17. COPD: Evaluating ABG’s: Serial ABG’s are monitored to evaluate respiration status. Increase PaCo2 Decreased Pao2 Respiratory acidosis Metallic alkalosis (compensation). 18. Cancer: Preventing Complications of Radiation Treatments: 19. Pain Management: Recognizing and responding to complications of opiods use: Constipation (monitor for bowel movements, fluids, fiber intake, exercise, stool softeners.) Orthostatic hypotension. Urininary retention (monitor pt I/O and wash out for distended stomach, administer bethannechol and catheterized as needed.) N/V (gives antiemetic, tell pt to lie still and move slowly, NPO, avoid odors.) Sedation (monitor LOC and take safety precaution b/c sedation might lead to respiratory depression.) Respiratory depression (monitor clients resp. rate before and following administration with opioids, reduce opioid dose for initial treatments and if necessary administer narcan to reverse the action.) 20. Blood Transfusions: Intervention for complications: Stop infusion… 21. Oxygen Therapy: Assessing for signs of toxicity Signs of toxicity include: i. non productive cough, substenal pain, nasal stuffiness, nausea and vomiting; fatigue, HA, sore throat and hypoventilation. ii. If Sao2 rises significantly, it is a sign of toxicity. Psychosocial Intergrity (14) 1. Family and Community Violence: Evaluating Client outcomes for the client who had been abused: The abused victim stops demonstrating low self esteem and feeling of helplessness, hopelessness, powerlessness, guilt, and shame. They stop protecting the perpetrator and stop accepting responsibility for the abuse. They start accepting the severity of the situation. With the intervention of the nurse, they start making a safety plan for escape when violence occurs. Clients recognize the behaviors and situations that might trigger violence. 2. Non- Substance- Related Dependencies: Providing Care and Support for client with a gambling problem dependency: Be nonjudgmental, provide emotional support for client, and begin to educate client about his addiction and the initial treatment goal of complete abstinence. Teach him how to recognize signs and symptoms of relapse and factors that contribute to relapse and help him develop strategies, such as meditation or exercising to create feeling of pleasure from activities other than gambling. 3. Crisis Management: Identify Interventions: The basis of crisis intervention includes timely interventions, identifying the current problem and directing interventions to its resolution. Establishing a trusting nurse-client relationship. Assist the client to regain a normal level of functioning. Taking an active directive role with client and help client to set realistic goals. Be aware that client is mentally healthy and will often be amenable to outside interventions. 4. Care of Those Who are Dying: Providing Support to the Family Regarding Decision making: End of life issue include decision making in a highly stressful time during which the nurse must consider the desire of the client and the family. Any decisions must be shared with other health care personnel for smooth transition during this time of stress, grief, and bereavement. Always support the client and family’s decision making. 5. Mood Disorders: Recognizing signs and symptoms of Relapse for Bipolar Disorder: Signs and symptoms (Manic) S& S (Depressive phase) Affect: flat, blunted, labile Persistent elevated mood Tearful, crying Agitation and irritability Lack of energy Dislike of interference and intolerance of criticism Anhedonia: losst of pleasure, lack of interest in activities, hobbies Increase in talking and activities. Flight of ideas, rapid, continous speech Physical symptoms of discomfort/pain. with sudden and frequent topic change. Difficulty concentrating, focusing, problem solving Poor judgement Self- distructive behaviour. Decrease sleep Decrease in personal hygiene. Neglect of ADL’s, including nutrition and hydration. Loss or increase in appetite and /or sleep, disturbed sleep Psychomotor retardation or agitation. 6. Cognitive Disorders: Recognizing Signs and symptoms of Impaired Cognition: Impaired memory, judgment, ability to focus, and ability to calculate Impaired LOC, Restlessness and agitation, sun downing. Some perceptual disturbances such as hallucinations and illusions may be presents. Memory loss, confusion. Loss of reasoning ability. Loss of ability to perform ADL’s. Incontinence and more withdrawn. 7. Psychopharmacological Therapies: Evaluating Client Teaching Regarding Lithium, Methylphenidate, Dissulfiram, and Fluoxetine: Lithium: i. Client must maintain adequate sodium and fluid intake while taken lithium so that lithium doesn’t take the place of Na and build up as lithium toxicity (due to vomiting, diarrhea, increased perspiration, or use of diuretics.) ii. Teach client that effects of lithium begin within 5 to 7 days and that it may take 2 to 3 wks to achieve full benefits. iii. Advise client to report signs of toxicity and to take meds as prescribed. iv. Encourage client to comply with laboratory appointment to monitor lithium for effectiveness and adverse effects. v. Encourage compliance of follow up appointment to monitor thyroid and renal function. vi. Methylphenidate (Ritalin): i. Advise the client to swallow sustained–release tablets whole. ii. Teach pt the importance of administering the med in a regular schedule as prescribed. iii. Instruct pt to be alert to signs of mild over dose (restlessness, insomnia, and nervousness.) Signs of severe overdose such as panic, hallucination, circulatory collapse, and seizures. iv. Tell pt to avoid the use of other CNS stimulants, such as coffee, cola, tea, and chocolate and should also avoid alcohol or OTC meds. v. Tell them not to stop abruptly (potential for abstinence syndrome). vi. Instruct pt to take in morning (or daily) after breakfast and the last dose in early afternoon to minimize weight loss and insomnia. vii. The med should be taken at least 6hr before bedtime. Fluoxetine (Prozac): i. Advise pt to take med with meals/food and to take the med on a daily basis to establish therapeutic plasma levels. ii. Tell pt that effect of meds will be realized in 1 to 3 wk and that full benefit may take 2 to 3 months. iii. Instruct pt to continue taking med after improvement b/c sudden discontinuation will lead to relapse. iv. Tell pt that therapy usually continues for 6 months after resolution of symptoms and might take up to a year or longer. v. Adult client taking diuretic should be monitor for Na level. Disulfuram: i. (makes drinking painful). Drinking and taking disulfuram makes one ill (evidence by Sweating, flushing of the face and neck, tachycardia, hypotension, throbbing HA, N/V, Palpitations, dyspnea, weekness, tremor). ii. This med and alcohol can also cause arrhythmias, MI, CHF, seizure, coma and death. 8. Spiritual Care: Evaluating if Needs Have been met: Identify the client’s perception for the existence of a higher power. Facilitate growth in the client’s abilities to connect with a higher power. Assist the client to feel connected or reconnected to a higher power by allowing time and/or resources for the practice of religious rituals. Providing privacy for prayer, meditation, or the reading of religious materials. Establish a caring presence in “being with” the client and family rather than merely performing tasks for them. Identify and provide for the client’s support system (Family,Community,Pastoral). Religious artifacts and rituals Be aware of diet therapies included in spiritual beliefs. Support religious rituals. (Icons, Statues, Prayer rugs, Devotional reads, Music.) Support restorative care. (Prayer, Meditation, Grief work) Evaluation of care is ongoing and continuous, with a need for flexibility as the client and family process the current crisis through their spiritual identity. 9. Sensoriperceptual Alterations: Planning Interventions for the Hearing Impaired Client: Get the client’s attention before speaking. Stand/sit facing the client in a well, quiet room without distractions. Speak clearly and slowly to the client without shouting and hands or other objects covering the mouth. Arrange for communication assistance (sign language interpreter, closedcaption, phone amplifiers, TTY capabilities) as needed. No sharp object should be place in the ear. Ear protection should be kept as low as possible. 10. Stress management: Evaluate Effectiveness of Teaching regarding Stress Management Techniques: Pt starts breathing normally b/c of use of breathing techniques Pt use proper muscle relaxation techniques Pt practices physical exercise during stress. Pt attack stress with active journaling in other to identify stress and plan for future with hope. Pt begins to prioritized to reduce the number of stressor impacting her e.g. a person who may feel stress out due to over work might delegate some work load to the LVN or CAN. A client uses reframing techniques by reframing his sentences to be more positive. The client learns to communicate in a more assertive manner by describing a situation or a situation that causes stress by stating that his feelings about the behavior e.g. When you keep telling me what to do, I feel angry and frustrated. I need to try making some of my own decision. 11. Family Dynamics: Interventions Involving Client Support Systems: Set goals with the family that are realistic. Provide information on support networks. e.g. Child and adult day care and Caregiver support groups. Promote family unity. Encourage conflict resolution when it exists. Minimize family process disruption effects. Remove barriers to health promotion. Increase family members’ abilities to participate. Perform interventions that the family cannot perform. Evaluate goals within the context of the family by checking back to ensure that goals were realistic and achievable. 12. Effective Communication in Mental Health Nursing: Giving Broad Openings: 13. Creating and Maintaining a Therapeutic and Safe Environment: Promote a Therapeutic Milieu for a group of clients: Set up the following provisions to prevent client harm or harm by others: i. No access to sharps or other wise harmful objects. ii. Monitor visitors. iii. Restrictions of alcohol and illegal drug access or use. iv. Restrictions of sexual activities among clients. v. Rapid de-escalation of disruptive and potentially violent behaviors through planned interventions by staff. vi. Plan for safe access to recreational areas, occupational therapy and meeting rooms. vii. Pair client in rooms base on illness and personality. 14. Body Image: Interventions to assist client adaptation: Establish a therapeutic relationship with the client. A caring and nonjudgmental manner puts the client at ease and fosters meaningful communication. Ensure privacy and confidentiality. Many sensitive issues may be discussed, and the client needs to know that these issues are safe to discuss. Identify individuals who may be at risk for body image disturbances. Acknowledge anger, depression, and denial as normal feelings when adjusting to body changes. Encourage the client to participate in the plan of care. Arrange for a visit from a volunteer who has experienced a similar body image change. Safety and Infection Control (17) 1. Newborn Discharge Teaching: Infant Safety Priorities: 2. Never leave the infant unattended with pets, or other small children. Keep small objects (coins) out of the reach of infants (choking hazard). Never leave the infant alone on a bed, couch, or table. Infants move enough to reach the edge and fall off. Never provide an infant a soft surface to sleep on (e.g., pillows and waterbed). The infant’s mattress should be firm. Never put pillows, large floppy toys, or loose plastic sheeting in a crib. The infant can suffocate. Never place the infant on its stomach to sleep during the first few months of life. The back-lying position is the position of choice. When using an infant carrier, always be within arm’s reach when the carrier is on a high place such as a table. If possible, place the carrier on the floor near you. Do not tie anything around the infant’s neck. Check the infant’s crib for safety. Slats should be no more than 2.5 inches apart. The space between the mattress and sides should be less than 2 fingers widths. Keep a crib or playpen away from window blinds and drapery cords. Infants can become strangled in them. The bassinet or crib should be placed on an inner wall, not next to a window, to prevent cold stress by radiation. Eliminate potential fire hazards. Keep a crib and playpen away from heaters, radiators, and heat vents. Linens could catch fire if in contact with heat sources. Smoke detectors should be on every floor of a home and should be checked monthly to assure they are working. Batteries should be changed yearly. (Change batteries when daylight savings time occurs). Provide adequate ventilation. Control the temperature and humidity Disaster Planning: Identify Disaster Preparedness activities: The federal response plan is a government plan that includes the FEMA, US public health CDC, and other Gov’t agencies to guides the coordination of effort in response to a disaster. Planning for the possibility of worldwide pandemic Setting up a community protocol is an important part of disaster planning. The community plan should provide for access to emergency agencies, such as the American Red Cross. The plan may be in house, local, state-wide, or national, depending on the size of the disaster. Mass casualty drills are drills or mock disaster where personnel practice duties in a planned disaster. Identification and assessment of the population at risk. 3. Emergency Management: Decontamination following exposure to bioterrorism: Take measures to protect self and to avoid contact. Try to contain material as much as possible in one place. If individuals are contaminated try decontaminating them as much as possible at the scene or as close as possible to the scene. With few exceptions water is the universal antidote. For biological hazardous materials, use bleach. Wear gloves, gown, mask, and shoe cover to protect self from contamination. Place all contaminated material into plastic bags and seal them. Cleanse skin with gentle soap and water. Donot use an abrasive scrub. 4. Ergonomic Principles: Prevention of Carpal Tunnel Syndrome: Good posture Avoid repetitive movements of hands, wrists, and shoulders. Take a break every 15-20 minutes to flex and stretch joints and muscles. 5. Safe Medication Administration and error Prevention: Selecting appropriate resources for checking prescription accuracy: Right client, right drug, right dose, right time, right route, and right doc. Assess for physical and psychosocial stuff that may affect the med response Drug handbooks Pharmacology textbooks Journals PDR Professional websites 6. Error Prevention: Ensuring client safety when transcribing orders: Don’t use abbreviations Full name should be written out Leave enough space between name and dose Question provider if order isn’t clear Repeat phone orders back Have other nurse listen in 7. Handling Infectious materials: Appropriate disposal: Biohazard bag if any blood Don’t need to double bag unless it touches the outside of the bag Gloves removed and hand hygiene done between all clients Sturdy moisture resistant bag should be used for soiled items, tied at top with a knot Infectious dressings material into a single, nonporous bag without touching outside of bag Rinse in cold water first 8. Client Safety: Removing fire hazards: RACE (rescue, alarm, contain, extinquish) Fire extinguishers: i. Class A: paper wood, upholstery, rags, or other types of trash ii. Class B: flammable liquids and gas iii. Class C: Electrical fires 9. Seizures: Appropriate use of seizure precautions to maintain client safety: Standby oxygen, airway, and suctioning equipment IV access (medication administration during seizure). Side rails in. position and bed in lowest position. Loosen clothing. Do not attempt to restrain the client. Do not attempt to open jaw during seizure activity (may damage teeth, lips, and tongue). Do not use padded tongue blades. Administer oxygen as prescribed. Administer prescribed medications (for example, anticonvulsant and sedative medications to prevent or decrease seizure activity). Document onset and duration of seizure and client findings/observations prior to, during, and following the seizure (level of consciousness, apnea, cyanosis, motor activity, incontinence.) Maintain the client in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions. Reorient and calm the client (may be agitated). 10. Surgical Asepsis: Performing Aseptic Technique: Wash hands. Open plastic covering of package per manufacturer’s directions, slipping the package onto the center of the workspace with the top flap of wrapper opening away from body. Reach around the package to open the top flap of the package, grasp the outside flap between the thumb and the index finger, and unfold the top flap away from body. Next open the side flaps, using the right hand for the right flap and the left hand for the left flap. The last flap should be grasped and turned down toward body. Additional sterile packages: Open next to the sterile field by holding the bottom edge with one hand and pulling back on the top flap with the other hand. Place the packages that are to be used last furthest from the sterile field, and open these first. Add them directly to the sterile field. Lift the package from the dry surface, holding it 15 cm (6 inches) above the sterile field, pulling the two surfaces apart, and dropping it onto the sterile field. Pour sterile solutions by: i. Removing the bottle cap. ii. Placing the bottle cap face up on the surface. iii. Holding the bottle with the label in the palm of the hand so that the solution does not run down the label. iv. First pouring a small amount (1 to 2 ml) of the solution into an available receptacle. v. Pouring the solution onto the dressing or site without touching the bottle to the site. vi. Once the sterile field is set up, it is necessary to don sterile gloves. Sterile gloving includes opening the wrapper and handling only the outside of the wrapper. Don gloves by using the following steps. With the cuff side pointing toward the body, use the left hand and pick up the righthand glove by grasping the folded bottom edge of the cuff and lifting it up and away from the wrapper. While picking up the edge of the cuff, pull the right glove on the hand. With the sterile right-gloved hand, place the fingers of the right hand inside the cuff of the left glove, lifting it off the wrapper, and put the left hand into it. When both hands are gloved, adjustments of the fingers in the gloves may be made if necessary. vii. During that time, only the sterile gloved hand can touch the other sterile gloved hand. viii. At the close of the sterile procedure, or if the gloves tear, the gloves must be removed. Take off the gloves by grasping the outer part of one glove at the wrist, pulling the glove down over the fingers and into the hand that is still gloved. Then, place the ungloved hand inside the soiled glove and pull the glove off so that it is inside out, and only the clean inside part is exposed. Discard into an appropriate receptacle. 11. Infection Control: Identifying and reporting Error in surgical skin preparation: Should cleanse with antimicrobial soap Clip hair in areas that will be involved in surgery 12. Artificial Airway: Instructing family on safe use of equipment: Always keep the following at the client’s bedside: i. Two extra tracheostomy tubes (one the client’s size and one size smaller in case of accidental decannulation), the obturator to the existing tube, oxygen source, suction catheters and suction source, and bag-valve mask. Remove old dressings and excess secretions. Apply the oxygen source loosely if the client desaturates during the procedure. Use cotton-tipped applicators and gauze pads to clean exposed outer cannula surfaces. Begin with hydrogen peroxide followed by normal saline. Clean in circular motion from stoma site outward. Using surgical aseptic technique, remove and clean the inner cannula (use hydrogen peroxide to clean the cannula and sterile saline to rinse it). Use new inner cannula if it is disposable. Clean the stoma site and then the tracheostomy plate with hydrogen peroxide followed by sterile saline. Place split 4 x 4 dressing around tracheostomy. Change tracheostomy ties if they are soiled. Secure new ties in place before removing soiled ones to prevent accidental decannulation. If a knot is needed, tie a square knot that is visible on the side of the neck. One or two fingers should be able to be placed between the tie tape and the neck. 13. Emergency management: Orders of client evacuations in response to fire: Always move pt that are in immediate danger 1st. RACE (rescue, alarm, contain, extinquish) People who can walk and do not need assistance go 1st 14. HIV/Aids: Appropriate environmental precautions: Transmission, infection control measures, safe sex practices. Monitor for skin breakdown. Abstain from unprotected sex by the use of condoms, stick to a single sex partner. Watch out for occupational exposure healthcare workers should always wear glove when dealing with bodily fluid . Advise IV drug users to stay away from contaminated needles. Through blood and body fluids Bleach to clean up blood 15. Meningitis: Client Education regarding prophylactic precautions: Maintain isolation precautions per hospital policy (for example until antibiotics have been administer for 24hr). Implement fever reduction measures such as a cooling blanket, if necessary. Decrease stimuli and exposure to bright light. Maintain bed rest with HOB @ 30 degree. Administer meds as prescribed. (Antibiotics for bacteria infections –such as ceftrixone (Rocephin) or cefotaxine (calforan) until culture and sensitivity results are available. Analgesics- non opioid to avoid masking changes in the level of consciousness. Prophylactic antibiotic to individuals in close contact with client. Avoid overcrowded living conditions There is a vaccine 16. Client Safety: Appropriate use of Restraints: To ensure good circulation to the area and allow for full range of motion to the limb that has been restricted. Pad bony prominences and do neurosensory checks (to include loosening or removing the restraint and testing temperature, mobility, and capillary refill) every 2 hr to identify any neurological or circulatory deficits. Always tie the restraint to the bed frame (loose knots that are easily removed) where it will not tighten when the bed is raised or lowered. Leave the restraint loose enough for range of motion and with enough room to fit two fingers between the device and the client to prevent injury. Always explain the need for the restraint to the client and family so as to help them understand that these actions are for the safety of the client. Regularly assess the need for continued use of the restraints to allow for discontinuation of the restraint or limiting the restraint at the earliest possible time while ensuring the client’s safety. Never leave the client unattended without the restraint. Restraints should never interfere with treatment. Restrict movement as little as is necessary to ensure safety. Fit properly. Be easily changed to decrease the chance of injury and to provide for the greatest level of dignity. 17. Client Safety: Maintain Prescribed Restraint: Have to have an order If applied in an emergency, face to face assessment has to be done in 1 hr. by the doctor Order has to say why and for how long Review instructions Remove and replace them frequently Document: i. Why ii. Interventions done prior to using them iii. Clients LOC iv. Type and location v. Education/explanation to client and family vi. Time of application and removal vii. Behavior while restrained viii. Type and freq. of care ix. Clients response when removed Basic Care and Comfort (13) 1. Hygiene Care: Evaluating appropriate use of assistive devices: Mouth care: i. Remove dentures with gloved hands pulling the down and out at the front and up and out on the bottom. ii. Place dentures in a denture cup or emesis basis and brush them with a soft brush and denture cleaner. iii. Store the dentures or assist client with reinserting them. Foot care: i. Apply moisturizer to the feet but avoid applying it between the toes. ii. Wear clean cotton socks daily. iii. Cut nails straight across and use emery board to file edges. Nail care: i. Use caution and have proper training when cutting nails. Shaving: i. With a blade, the nurse should apply soap or shaving cream to warm, moist skin. ii. The razor should be moved over the skin in the direction of hair growth using short strokes. 2. Complementary and alternative therapies: appropriate use of music therapy for pain management: Type of movement and relaxation therapy that includes distraction from pain. Sessions should last a minimum of 15 min. Use of earphones can increase concentration. 3. Prostate Surgeries: Calculating a clients output when receiving continuous bladder irrigation: Record the amount of irrigating solution instilled (generally large volumes) and the amount of return The difference is the Urine Output 4. Urinary incontinence: Appropriate kegel exercise techniques: Tighten pelvic muscles for a count of 10 Relax slowly for a count of 10 Repeat in sequences of 15 in lying-down, sitting, and standing positions. 5. Bowel Elimination Needs: Client Education Regarding colostomy care: Pouch opening 1/16 to 1/8 inch larger than the stoma. Use skin barrier under all tapes (water, paste, powder). Use skin barrier to protect skin immediately around the stoma. Clean skin gently and pat dry. Do not rub. Apply pouch by pressing adhesive area to skin for 30 secs Change appliance immediately when seal breaks or when1/3 or ¼ full. 6. Burns: Nonpharmacological `comfort interventions for dressing changes: Providing cold/ head applications Controlling the level of noise in the surroundings Proper positioning of the client and the timing of dressing change. Also teach client some relaxation techniques. 7. Applications of heat and cold: Assess need for heat/cold applications: Cold application: i. Sprained ankle ii. Who just had a knee-replacement surgery iii. Toothache iv. Nose bleed. v. Cold application decreases inflammation, prevent swelling, reduce bleeding, reduce fever, diminishes muscle spasms, and decreases pain by decreasing the velocity of nerve conduction. Heat application: i. Helps to increase blood flow to tissues, Increases tissue metabolism, relaxes muscles and is helpful in easing joint stiffness and pain. 8. Crohn’s disease (all layers of bowel; intermittent segments): Selecting a lowfiber, low-residue diet: Avoid foods: i. That are high in residue content, such as whole-grain breads and cereals and raw fruits and vegetables. ii. Alcohol, butter, tea/coffee, fried foods, nuts, gasey foods Can eat: i. Dairy products except yogurt. ii. Enriched refined white bread, buns, bagels, English muffins plain cereals e.g. Cheerios, Cornflakes, Cream of Wheat, Rice Krispies, Special K arrowroot cookies, tea biscuits, soda crackers, plain melba toast white rice, refined pasta and noodles. iii. Fruit juices except prune juice iv. Applesauce, apricots, banana (1/2), cantaloupe, canned fruit cocktail, grapes, honeydew melon, peaches, watermelon vegetable juices v. Potatoes (no skin) vi. Well-cooked and tender vegetables including alfalfa sprouts, beets, green/yellow beans, carrots, celery, cucumber, eggplant, lettuce, mushrooms, green/red peppers, squash, zucchini . vii. Well-cooked, tender meat, fish and eggs viii. Processed food are low in fiber and easy to digest. 9. Dumping syndrome: client education regarding dietary interventions: Eat low carb diet and very little water with each meal. Small, frequent meals Consumption of protein and fat at each meal Avoid concentrated sugars. Restrict lactose intake. Consume liquids 1 hr before or after eating instead of with meals (dry diet) 10. Cholecystitis: dietary restrictions: Encourage low fat diets (reduce dairy; avoid fried foods, chocolate, nuts and gravies). Avoid gas forming foods (beans, cabbage, cauliflower, and broccoli). Smaller more frequent meals may be tolerated better. These foods will trigger cholecystitis (Ice cream, Brownie with nuts, Broccoli with cheese sauce, Biscuits and gravy, Fried eggs and bacon, coffee, Brussels sprouts, onions, legumes, and highly seasoned foods. 11. Palliative Care: Client/family teaching: The nurse should promote physical contact Address feelings of loss and sadness. Provide info to the child/ family about disease, meds, procedures and expected events. The nurse should emphasis open communication among the child, family and health care team. Encourage the child/ family to ask questions. Give reassurance that child is not in pain and that all effort are being make to maintain comfort and support of child’s life. 12. Cognitive Disorders: Promoting Independence in hygiene for a client with Alzheimer’s disease: 13. Rest and Sleep: Recognizing and reporting sleep disorders: There are 3 types of sleep disorders: i. Insomnia: difficulty falling or staying asleep. Affect women more than men and might be due to stress, illness and work related issues. ii. Sleep apnea: Caused by lack of airflow to the nose and month for >10 sec or longer during sleep. Sleep apnea is common in obese individuals and characterize by snoring. iii. Narcolepsy: is a disorder of the sleep and wake mechanism. The person may lose the ability to stay awake. It often happens at inappropriate times and can put the person at risk. Health Promotion and Maintenance (13) 1. Uterine Atony (boggy): Performing Appropriate Assessments: Signs and symptoms: i. Uterus that is larger than normal and boggy with possible lateral displacement on pelvic exam ii. Prolonged lochial discharge, Irregular or excessive bleeding. iii. Assessments for uterine atony include fundal height, consistency, and location. Lochia quantity, color, and consistency. 2. Normal Physiological Changes of pregnancy: Calculating the client’s delivery date: Nagele’s Rule: i. First day of last menstrual cycle ii. Subtract 3 months iii. Add 7 days and 1 year McDonald’s method: i. The gestational age is estimated to be equal to the fundal height 3. Cesarean Birth: Appropraite client position: Position the client in a supine position with a wedge under one hip to laterally tilt her and keep her off of her vena cava and descending aorta. This will help maintain optimal perfusion of oxygenated blood to the fetus during the procedure. 4. Antepartum Diagnostic interventions: Monitoring during a nonstress test: Most widely used technique for antepartum evaluation of fetal well-being Performed during the third trimester. It is a noninvasive procedure that monitors response of the fetal heart rate to fetal movement. A Doppler transducer, used to monitor the FHR, and a tocotransducer, used to monitor uterine contractions, is attached externally to the client’s abdomen to obtain paper tracing strips. The client pushes a button attached to the monitor whenever she feels a fetal movement that is noted on the paper tracing. This allows a nurse to assess the FHR in relationship to the fetal movement. The NST is interpreted as reactive if the FHR accelerates to 15 beats/min for at least 15 sec and occurs two or more times during a 20-min period. This assures that the placenta is adequately perfused and the fetus is welloxygenated. Nonreactive NST indicates that the fetal heartbeat does not accelerate adequately with fetal movement or no fetal movements occur in 40 min. If this is so, a further assessment such as a contraction stress test (CST) or biophysical profile (BPP) is indicated. 5. Newborn hypoglycemia: Identify appropriate interventions: Obtaining blood per heel stick for glucose minitoring. Frequent oral and/or gavage feedings or continues parenteral nutrition is provided early after birth to treat hypoglycemia Untreated hypoglycemia can lead to seizure, brain damage, and death. 6. Labor and Birth Processes: Assess for true labor versus false labor: True Labor Contractions Painful regular frequency Strong, last longer, and are more frequent Felt in lower back, radiating to the abdomen Walking can increase contractions intensity Continues despite comfort measures Cervix (assessed by vaginal exam) Progressive change in dilation and effacement Moves to anterior portion Bloody show Fetus Presenting part engages in pelvis False Labor Contractions Painless, irregular frequency, and intermittent Decrease in frequency, duration and intensity with walking or position changes Felt in lower back or abdomen above the umbilicus Often stop with comfort measures such as oral hydration Cervix No significant change in dilation or effacement Often remain in posterior position No significant bloody show Fetus Presenting part is not engaged in pelvis 7. Bonding: Promoting maternal psychosocial adaptation during the taking-in phase: Begins immediately following birth lasting a few hrs to a few days Relying on others to meet needs for comfort, rest, closeness, and nourishment Focuses on own needs and in concerned with newborn Excited and talkative, reviews labor and birth experience Promote bonding during this phase by delaying nursing/medical procedures during the first hour after birth to allow for unlimited parentinfant contact. Facilitate bonding process by placing the infant skin to skin with the mother soon after birth in an en face position. 8. Toddler: Recognizing expected body-image changes: Appreciates the usefulness of various body parts Develop gender by age 3 The toddler’s anterior fontanel closes by 18 months of age. At 12 month, the toddler’s weight should triple. At 30 months the toddler should weigh 4 times his birth weight. Toddlers grow by 7.5cm (3in) per year. 9. Adolescent (12 to 20 years): planning age-appropriate health promotion education: By 12-20 if not taken by 11-12, adolescence should have taken Tdap, Hep b, HPV series, IPV, MMR, and MVC4. Advise pregnant teens to do early prenatal visits. Encourage them to use condoms, Educate the on alcohol and drugs used. Encourage use of seat belts. Tell them to avoid playing with firearms. Encourage them to do external genotalia exams, pap smears and cervical and urethral culture may be needed. 10. Contraception: Recognizing correct use of condoms: A man should place the condom on his erect penis, leaving an empty space at the tip for a sperm reservoir. Following ejaculation, the man withdraws his penis from the women’s vigina while holding condom rim to prevent any semen spillage to vulva or vaginal area. Condom may be use in conjunction with spermicidal gel or cream to increase effectiveness. Only water soluble lubricants 11. Immunizations: Recognizing complications to report: Normal: soreness at injection site, low grade fever, malaise for 1-2 days) Report any anaphylactic reactions. Monitor for adverse reaction such as dyspnea, stridor, and hypotension. 12. Older Adult (over 65 years): Assessing Risk for Social isolation: Check to see if the adult is staying more in his room than usual. Does he refuse eating out with friends. Does he refuse participating in group activities with peers? If so, then he is at risk. 13. Spinal cord injury: Promoting Independence in self-care: Teach client urinary elimination methods (crede’s methods). Teach client bowels retraining program (consistent time such as 30 mins after meal). Encourage active range of motion for client and have them perform passive ROM. Facilitate the client’s participation in physical therapy and occupational therapy. Standard conversion factors: 1 mg = 1,000 mcg 1 g = 1,000 mg 1 kg = 1,000 g 1 oz = 30 mL 1 L = 1,000 mL 1 tsp = 5 mL 1 tbs = 15 mL 1 tbs = 3 tsp Dosage Calculation: 1 kg = 2.2 lb 1 gr = 60 mg General rounding guidelines are to round to the tenths place. For example, 21.81 = 21.8; 21.86 = 21.9. Normals: PAP: 15-26 PAWP: 4-12 CO: 4-7 CVP: 1-8 Questions 1. A nurse is providing instructions to a client with a prescription for amoxicillin (Amoxil) for a respiratory infection. Which of the following statements by the client indicates to the nurse a need for further teaching? 84998 “My birth control pills are less effective while I am on this medication.” “I must take the medication on an empty stomach.” “The capsules can be opened and mixed with liquids if it is hard for me to swallow them.” “I will keep taking the medication until I have finished the entire bottle.” Rational: Amoxicillin is one of the penicillins that should be taken with food. Answer B 2. A nurse is providing teaching to a client diagnosed with Hodgkin’s lymphoma who is undergoing external radiation treatment. Which of the following should the nurse include in the care plan for the irradiated area? a. b. c. d. Use an antibacterial soap to cleanse the skin use lotion to moisturize irradiated skin avoid patting the skin when drying avoid direct sun exposure to the skin Rational: Sun exposure can be damaging to skin exposed to radiation and should be avoided. Answer D 3. A nurse is providing discharge teaching to a pt who is HIV positive. Which of the following should the nurse include in the teaching: a. b. c. d. Instruct the pt to clean his toothbrush daily in the dishwasher Recommend the pt use separate eating utensils from his family Tell the pt to wear a mask while outside at home Encourage the pt to work in his garden for exercise. Rationale. This action destroys micro-organisms that may be present on the toothbrush. Answer A 4. A nurse is assessing a client who is positive for HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS? Small, purplish-brown raised skin lesions Fever and diarrhea lasting longer than 1 month Persistent, generalized lymphadenopathy CD4+ cells decreased to 750 cells/mm3 Rationale: The presence of small, purplish-brown raised skin lesions, indicating Kaposi’s sarcoma, signifies that the client has developed AIDS. Answer A. 5. For a client diagnosed with HIV, which of the following laboratory findings suggests that medication therapy is effective in controlling disease progression? 85242 WBC 3,500 cells/mm3 Lymphocyte count 1,500 cells/mm3 Decreased viral load Low CD4+/CD8+ ratio Rational: This finding indicates that the viral protein amount is decreasing in the blood, and there is a positive response to treatment. Answer C.