Lecture Note
Nursing Concepts Note
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University:
West Coast University -
Course:
NURS 493 | Integration of Nursing Concepts Academic year:
2025
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286
Pages:
88
Author:
customer-8218013
WCU 493 EXIT NOTES
FUNDAMENTALS
Normal Lab Values: (Blue Book pg. 81)
• Maintaining Major Electrolytes; Imbalance/IntervenDons.
• Sodium: 135-45
• Potassium 3.5-5
• Albumin: 3.5-5
• ESR: less than 20 mm/hr. > indicates inflammaDon
• Acid Base Balance
TherapeuDc MedicaDon Monitoring (Blue book pg. 170)
• Digoxin level: 0.8-2.0
• Lithium level: 0.4-1.4
• Phenytoin: 10-20
• Magnesium Sulfate: 4-8
Vital Signs:
• HR: 60-100
• O2: 95%-100%
Skin ElasDcity (Funds p. 163)
• Checking skin elasDcity for hydraDon levels.
o Older adults: sternum
o Infants: stomach
Privacy Records (Funds p. 22)
• Maintaining paDent privacy when using computer records.
PosiDons: (Funds pg. 74)
• Trendelenburg: increases blood flow to the heart
o Facilitates postural drainage and venous return
o Contraindicated for:
§ PaDent shows signs of HYPOVOLEMIA
§ Infants with cysDc fibrosis
§ Children with head injuries
• Semi-Fowler’s (30 degrees)
o Prevents regurgitaDon of enteral feedings
o Prevents aspiraDon by paDent s who have difficulty swallowing
• Fowler’s posiDon (45-60 degrees)
o NG tube inserDon / sucDoning
o Chest expansion
o Drainage aeer abdominal surgeries
• High Fowler’s (60-90 degrees)
o Lung expansion – helps relieve dyspnea
o Prevents aspiraDon during meals
• Orthopneic
o paDent sits at the bed/chair with arms resDng on the overbed table (tri-pod posiDoning)
o chest expansion for COPD paDent s
Bladder-retraining Program (Funds p. 255):
• Restoring Control: EducaDonal Methods for Bladder Retraining
• Urinate at scheduled intervals
• Gradually increase urinaDon intervals aeer no inconDnence episodes for 3 days
• Assist the paDent to the bathroom every 1-3hr during waking hours and every 4-6hr during sleeping hours
1 • Encourage the paDent to take deep, slow breaths to help diminish the urge to urinate
Bowel-training program
• Post foley catheter removal expect urinary retenDon unDl the bladder retains its full tone.
• A nursing is planning care for a paDent who has a prescripDon for a bowel-training
Dehiscence & EvisceraDon (Funds p. 343):
• Dehiscence: parDal/total rupture (separaDon) of a sutured wound
• EvisceraDon: protrusion of visceral organs through a wound opening
• S/S:
o PaDent reports “popping” or “giving away”
• PrevenDon:
o Thin, folded blanket or small pillow over surgical wounds when paDent coughs
• IntervenDons:
o Priority ® call for help
o Stay with paDent
o Cover wound and any organs with sterile towels and dressings soaked with sterile normal saline
o PosiDon supine with hips and knees bent
o NPO preparaDon to return for surgery
Seizures (Funds p. 60, MS p. 35):
• Seizure Emergency Response: Treatment Approaches for Status Epilep:cus
• Priority ® protect the paDent s head
• During a seizure:
o Protect paDent s privacy and paDent from injury
o Turn paDent to side
o Remove clumer from the bed
o Padded side rails
o Losen clothing
o Dim lighDng
• Status epilepDcus:
o Repeated seizure acDvity within a 30-min Dme frame or a seizure lasDng more than 5 min
§ Decreased O2 levels
§ Inability of the brain to return to normal funcDoning
§ Nursing AcDons
• Maintain airway
• Provide O2
• Establish IV
• Perform ECG monitoring
• Diazepam or Lorazepam IV push followed by IV phenytoin
• Care for a paDent with Hx of seizures
o Provide sucDon at bedside
o Padded side rails
o Losen clothing
o Elevate the side rails near the head when the paDent is in bed
o Place the bed in the lowest posiDon
o Keep O2 setup at the bedside
Jaundice (Funds p. 164):
• Skin and Vascular Health: Assessing Jaundice in Pa:ent s with Dark Skin Tone
• Light skin tones: skin-palm hands, sclera, mucous membranes
• Darker skin tone: oral mucous membranes or hard palate
Cyanosis (Funds p. 164):
• Darker skin tones: palms and soles, Black pigmented skin turns grayish
• Brown skin: change to yellow-brown
• Light skin: blue
2 Interprofessional (Funds p. 7):
• OccupaDonal therapist: plan for ADLS (ex. Difficulty eaDng with a utensil)
• Speech language therapist: injuries on speech, language, and swallowing
Leadership Styles (Leadership p. 3):
• AutocraDc/authoritarian:
o Makes decisions for group
• DemocraDc:
o Includes the group when decisions are made
• Laissez-faire:
o Makes very few decisions, does limle planning
Advance DirecDves (Funds p. 18):
• Teaching pa:ent s about planning ahead for medical decisions.
• Communicate a paDent wishes regarding end-of-life care when the paDent becomes unable to do so
• Two Components:
o Living will:
§ Expresses the paDent s wishes regarding medical treatment in the event the paDent becomes incapacitated
o Durable power of amorney:
§ Designates a health care surrogate who makes health care decisions for a paDent who is unable to do so
§ Can be any competent adult
§ Does not go into effect unDl the paDent is uncapable of making decisions
Pressure Injuries (Funds p. 344):
• PrevenDon:
o Provide a firm, wrinkle-free foundaDon
o ReposiDon: 2 hours > bed; 1 hour > chair
o Keep HOB at or below 30 degrees
o Lie rather than pull
Sterile Field (Funds p. 50):
• SeEng up sterile environments for medical procedures.
• Hold items to add to a sterile field at a minimum of 6 inches above the field
• Keep all surfaces dry
• Procedure:
o PERFORM HAND HYGEINE FIRST
o Setup field:
§ Away
§ Side
§ Towards
o Pouring sterile soluDons:
§ Place bomle cap face up on a clean (non-sterile surface)
§ Hold bomle with label in the palm of the hand
§ Pour 1-2 mL into receptacle
§ Sterile soluDons expire 24 hours aeer opening
Falls (Funds p. 59):
• Preven:ng pa:ent falls in healthcare seEngs.
• PrevenDon:
o Sit on side of bed for few seconds
o Stand at side of bed for few seconds prior to walking
o Answer call lights
o Provide hourly rounding
o Bedside tables, overbed tables, and other frequent use items are within reach
o PaDent s who are sedated, unconscious, compromised > keep siderails up
§ AVOID FULL side rails who amempt to get out of bed without assistance
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Nonskid footwear or nonskid bath mats in tubs and showers
Handrails in showers and shower chairs
Know proper use crutches and canes
Restraints (Funds p. 60):
• Educa:ng on the appropriate use of restraints.
• Only used if other less restricDve means were tried
• Provider must prescribe seclusion or restraint in wriDng
• Time limits:
o 18+ : 4 hour
o 9-17: 2 hours
o 8 years and younger: 1 hour
• PaDent s should never be lee alone, unsupervised, lee in a prone or supine posiDon
• ConDnuous in-person or remote supervision is necessary
• Documents every 15-30 minutes
• DisconDnue when paDent is exhibiDng behavior that is safer and quieter
NG Tube (Funds p. 333):
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Tube Feeding Maintenance: Ensuring Patency in Nasogastric Tubes
Pharmacological Routes: Administering Medica causes hypoglycemia or acidosis when receiving iodine media
§ 3 days before
o Educate:
§ SensaDons of warmth or flushing might be felt when dye is injected
• Post procedure:
o Nursing acDons:
§ Maintain bedrest in supine posiDon with extremity straight
§ Assess VS and affected extremity
• Every 15min for the first hour
• Every 30min for the second hour
• Every hour
• Every 4hr
§ Conduct conDnuous cardiac monitoring for dysrhythmias
§ Withhold Meuormin for 48 hours aeer
§ Apply pressure dressing
o PaDent educaDon:
§ Leave dressing in place for first 24 hours
§ Avoid strenuous exercise
§ Restrict lieing to less than 10lb
§ If vessel in the arm ® restrict lieing to 5 lb. or less
• ComplicaDons:
o Slurred speech and extremity weakness > stroke
o Chest pain
§ Embolism
§ Restenosis of treated vessel
• clot reformaDon can occur immediately or several weeks aeer the procedure
Kidney Labs (MS p. 375):
• Kidney Disease Lab Results: Expected Laboratory Findings in Renal CondiDons
• Blood creaDne
• BUN
• GFR ¯
• K+
• Dietary restricDons
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Limit protein
§ Helps preserve some kidney funcDon in paDent s who have predialysis
Give pt: Carbohydrates, calcium, vitamin D and iron are
TURP (MS p. 440): CAUSED BY ENLARGED PROSTATE
• PostoperaDve:
o Includes placement of indwelling three way catheter:
§ ConDnuous bladder irrigaDon of NS
§ Rate is adjusted to keep irrigaDon to return pink or lighter
§ If bright-red or ketchup appearing with clots ® increase CBI
§ If obstructed ® turn off CBI and irrigate with 50 mL irrigaDon
o Catheter is removed ® iniDal voiding is uncomfortable, red in color, and contains clot
§ color progresses towards amber in 2-3 days
• Educate:
o Avoid heavy lieing, strenuous exercise, sexual intercourse (usually 2-6 weeks)
o NTP of urine output that is bright red with clots or urine the resembles ketchup à arterial bleeding
Fluid Volume Overload/Deficit OR Hyper/Hypovolemia (MS p. 277):
• Fluid Balance: Iden:fying Cri:cal Findings in Fluid Imbalances
• Hypovolemia:
o S/S:
§ Tachycardia
§ Thready pulse
§ Hypotension
o Labs:
§ HEMOCONCENTRATION
• Elevated H/H and platelets
• Hypervolemia:
o S/S:
§ Tachycardia
§ Bounding pulses
o Nursing acDons:
§ Weight paDent daily
§ NoDfy provider if 1 to 2 lb. gain in 24 hr or 3lb gain in one week
DVT/VTE (MS p. 227):
• S/S:
o Warmth, edema
o Tenderness, calf, or groin pain
o Shortness of breath and chest pain > PE
• Nursing care:
o Encourage ambulaDon following iniDaDon of anDcoagulant therapy
§ Dorsiflexion/planter flexion exercises of the foot when in bed
§ Elevate above level of heart
o Warm moist compress
o Never massage
o Thigh-high compression/anD-embolism stockings
Lupus Erythematosus (MS p. 577):
• Autoimmune Disorders: Recognizing Signs of Systemic Lupus Erythematosus
• Chronic CondiDons Monitoring: Observing Lupus, Gout, and Fibromyalgia Signs
• ConnecDve Tissue / AUTOIMMUNE
• S/S:
o Bumerfly rash (erythematous)
o Raynaud’s phenomenon
o PericardiDs
o Anemia
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Fever
Lab:
o Elevated ANA and ESR
PaDent educaDon:
o Use mild protein shampoo and avoid harsh hair treatments
o Wear hat, long-sleeve shirt, and long pants when outdoors
o Avoid UV and prolonged sun exposure
MedicaDons
o NSAIDs
o CorDcosteroids (Prednisone)
§ Used for immunosuppression and to reduce inflammaDon
o Immunosuppressant agents (Methotrexate)
§ Monitor liver enzymes and indicaDons of infecDon
§ Avoid live vaccine administraDon for 30 days before beginning therapy
§ Given during remission to prevent exacerbaDon
Fibromyalgia (MS p. 581):
• Chronic Condi:ons Monitoring: Observing Lupus, Gout, and Fibromyalgia Signs
• Chronic pain syndrome that involves muscle sDffness, sleep disturbance, generalized muscle weakness, and chronic faDgue
• S/S:
o Mild to severe faDgue
o Sleep disturbances
o Jaw pain
o Depression
o ConcentraDon and memory difficulDes
o Visual changes
o GU: Abdominal pain, heart burn, consDpaDon, diarrhea
o GI: frequency, urgency, dysuria, pelvic pain
o Numbness/ Dngling of extremiDes
• MedicaDons:
o Pregabalin / DuloxeDne (SNRI)
§ Increase the release of serotonin and norepinephrine, resulDng in decreased nerve pain
o NSAIDs
§ Used to decrease pain and inflammaDon
o Amitriptyline (TCAs)
§ Help to induce sleep and decrease pain
§ CauDon
• OrthostaDc hypotension
• PaDent educaDon
o Limit intake of caffeine, alcohol, and other substances that interfere with sleep
o Develop a rouDne for sleep
o Engage in regular, low-impact exercise
o AlternaDve therapies
§ Acupuncture, stress management, tai chi, hypnosis)
MulDple Sclerosis (MS p. 59, Blue p. 153):
• Educa:ng Empowerment: Providing Guidance for Recently Diagnosed Mul:ple Sclerosis Pa:ents
• Planning care for mul:ple sclerosis pa:ents.
• Neurologic disease resulDng in impaired and worsening funcDon of voluntary muscles
• AUTOIMMUNE disorder affecDng nerve cells in brain and spinal cord
o MYELIN SHEATH
• Expected findings:
o MUSCLE SPASMS & STIFFNESS
o FaDgue
o Pain or paresthesia
o Diplopia
o Uhthoff’s sign (temporary worsening of vision)
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o Tinnitus
o VerDgo (sensaDon or moDon of spinning)
o Dysphagia
o Dysarthria
o Nystagmus
o Bowel and bladder dysfuncDon
Nursing care:
o Encourage fluid intake
o Establish voiding Dme (every 1.5-2 hours)
§ Self-catheterize
o Monitor cogniDve changes (reorient paDent )
o Use communicaDon board
o Apply eye patches for diplopia:
§ Alternate every few hours
o Rest before a meal
o PaDent teaching:
§ Balance exercise & rest throughout the day
§ AVOID 4 S’s = trigger flare ups
• Stress
• Sickness
• Smoking
• Sun/ extreme heat
Referrals:
o Speech pathologist
MedicaDons:
o Interferon beta-1a and beta-1b
§ Injectable agent that should be started early in the course
§ Flu like manifestaDons are an A/E
o Immunosuppressant/DMARD (Cyclosporin)
§ Risk for infecDon à NTP of flu-like symptoms
§ Hepatotoxic
§ Nephrotoxic
§ Gingival hyperplasia
o CorDcosteroids (Prednisone)
§ Do not stop abruptly
§ Reduce inflammaDon
o AnD-spasmodic (Dantrolene, Baclofen)
§ Treat muscle spasDcity
§ Observe for increased weakness
§ Monitor for liver damage with dantrolene
§ Do not stop abruptly (baclofen)
§ Dantrolene à can cause photosensiDvity
• Wear sunglasses
§ Baclofen à avoid taking with anDhistamines
• AnDhistamines will intensify the depressant effects of baclofen
o AnDconvulsant (Carbamazepine)
§ Used for paresthesia
§ Interferes with effecDveness of oral contracepDves
o Stool soeeners (Docusate sodium)
o AnDcholinergics (Propantheline)
§ Bladder dysfuncDon
Myasthenia gravis
• AUTOIMMUNE disease – body amacks itself, amacking and destroying acetylcholine receptors à low acetylcholine à LOW
SECRETIONS
o PaDent will present with weak muscle and dry body from low acetylcholine
o Body becomes very DRY
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Risk factors: geneDcs, smoking, obesity
AVOID 4 S’s = triggers
o Stress
o Smoking
o Sickness
o Sun / excessive heat
Findings
o Ptosis (droopy eyes)
o Diplopia
o Dysphagia
o Dyspnea
o FaDgue
Treatment
o Give Cholinergic medicaDons (NeosDgmine / pyridosDgmine)
§ Increases secreDons
§ Give before meals à encourage semi-solid foods
o Cholinergic crisis
§ AIRWAY PROTECTION
• Have intubaDon tray at bedside
§ Administer Atropine to reverse cholinergic toxicity
Parkinson’s Disease
• ¯ dopamine, acetylcholine
• Findings
o Shuffling gait
o Pin rolling (looks like they’re rolling a booger between their fingers lol)
o Tremors at rest
• Levodopa / Carbidopa
o Levodopa: allows dopamine to stay in the body
§ NO protein: blocks absorpDon of medicaDon
o Carbidopa: conserves dopamine
• Community Health Strategies: TerDary PrevenDon for Parkinson's Disease
o Provide paDent supervision
§ Because the paDent ’s voluntary motor control is affected by the disease, the nurse should recommend that
the family provide paDent supervision to create a safe and respecuul environment. HIGH RISK FALLS
o Recommend an exercise program, alternated with periods of rest, to improve the paDent ’s mobility
o Decrease excess environmental sDmuli to increase the paDent ’s ability to concentrate on listening
Gout (MS p. 579):
• Chronic Condi:ons Monitoring: Observing Lupus, Gout, and Fibromyalgia Signs
• S/S:
o Severe joint pain (great toe)
o Painful, swollen when touched or moved
• Labs:
o ESR:
o Serum uric acid: 6.5 mg/dL
o Urinary uric acid:
o BUN & CreaDne:
• Meds:
o Acute: Colchicine, NSAIDs, Can cause diarrhea
o Chronic: Allopurinol
§ 2-3L of fluid /day
• Educate:
o Low-purine diet (no organ meats or shellfish
Central Venous Catheters (MS p. 175):
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Cardiovascular Procedures: U:lizing Peripherally Inserted Central Catheters
o InserDon:
§ Basilic or cephalic at least one fingerbreadth below or above the antecubital fossa
• Nursing care:
o Clean inserDon port with alcohol for 15 sec and allow to dry prior to accessing
o Advise not to immerse the arm with water
o Shower > cover dressing site to avoid water exposure
o No BP or venipuncture taken with PICC
o Use 10mL syringe to flush
PICC line: Measure the arm circumference above the inserDon site daily.
Chest Tube Systems (MS p. 111):
• 3 chambers
o SucDon
o Water seal:
§ NO CONTINUOUS/CONSTANT
§ FluctuaDng/Ddaling is fine
o CollecDng:
§ No more than 70 mL of blood
Chest Tube InserDon (MS p. 111):
• Thoracic Care: Preven:ng and Managing Chest Tube Complica:ons
• Pneumothorax:
o ParDal to complete collapse of the lung due to accumulaDon of air in the pleural space
• Hemothorax:
o ParDal to complete collapse of the lung due to accumulaDon of blood in the pleural space
• ConsideraDons:
o Drainage below paDent s chest level including during ambulaDon
o Never clamp, strip, or milk tubing
o Ensure a rubber-Dpped hemostat is at bedside; the nurse should clamp the chest tube if there is an interrupDon in
the sealed drainage system to prevent air entering the paDent ’s chest
• ComplicaDons:
o Tension pneumothorax:
§ Tracheal deviaDon absent breath on one side
• Removal
o Cover the inserDon site with an occlusive dressing to prevent air entry into the pleural space
o Instruct the paDent to perform the Valsalva maneuver during removal to maintain the appropriate amount of
negaDve pressure in the chest to prevent air entry
• HAVE AVAILABLE
o Montgomery straps (occlusive dressing)
o Padded clamps (to find the leak) Only for a few secondso Sterile saline (to put the end of the tubing)
VenDlators
• Alarms
o Low: leak
§ Monitor the water seal chamber for conDnuous bubbling. Locate the source of the air leak, and intervene
accordingly (Dghten connecDon, replace drainage system)
§ Check all connecDons
§ NTP
o High: kink, blockage
§ SucDon as needed
§ Check for kinks
§ Give bag valve mask (if unable to find the cause of the high alarm)
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Nurse may have to disconnect the machine and manually venDlate the paDent if the venDlator
fails or the paDent experiences respiratory distress, but this is not the first acDon the nurse should
take
Apnea:
§ VenDlator does not detect spontaneous respiraDon in a preset Dme period
Inflammatory Bowel Diseases (MS p. 347):
• Key assessments for pa:ents with gastrointes:nal issues and weight loss.
• Findings to report for a pa/ent with an Acute Infec/ous GI Disorder
o Sunken fontanels, dry mucus membranes
• Crohn’s:
o InflammaDon and ulceraDon of GI tract
o Involves anywhere in the GI tract
o S/S:
§ Pain RLQ
§ Diarrhea: 5 loose stools/day with mucus or pus
§ Abdominal distenDon, tenderness, and/or firmness
§ Steatorrhea
§ Fever
§ Risk for colostomy. (p.106) Stoma=beefy red. Colostomyformed stool. ileostomy -liquid stool. Measure stoma a 1/3” to
½”. Use skin barrier change q 3 days
o Nursing care
§ Monitor colonoscopy due to the increased risk of colon cancer
§ Monitor electrolyte imbalance, especially potassium
§ Monitor I/O and assess for dehydraDon
§ High protein, high calorie, low fiber foods, low fat
§ Avoid caffeine and alcohol
§ Small, frequent meals
§ Weight 1-2 Dmes weekly
• UlceraDve ColiDs:
o Edema and inflammaDon in rectum and rectosigmoid
o S/S:
§ Pain LLQ
§ Diarrhea: up to 15-20 liquid stools/day containing mucus, blood, pus
§ Abdominal distenDon, tenderness, and/or firmness
§ Fever
o Sucralfate
o Nursing Care (same as Crohn’s Disease)
§ Monitor colonoscopy due to the increased risk of colon cancer
§ Monitor electrolyte imbalance, especially potassium
§ Monitor I/O and assess for dehydraDon
§ Low-residue, High protein, high calorie, low fiber foods, low fat
§ 2,000-3,000mL fluid/day
§ Avoid caffeine and alcohol
§ Small, frequent meals
§ Weight 1-2 Dmes weekly
• DiverDculiDs:
o InflammaDon and infecDon of bowel mucosa
§ Caused by bacteria, food, or fecal mamer trapped in the diverDcula (pouch herniaDons in the intesDne)
o S/S:
§ Pain LLQ
§ Fever
§ Chills
§ Tachycardia
§ Abd distenDon
o Nursing Care
§ Consume a clear liquid diet unDl manifestaDons subside
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Avoid seeds or indigesDble material (nuts, popcorn, seeds) – can block the diverDculum
Avoid alcohol
Limit fat to 30% of daily intake
CURRENT: LOW FIBER
PREVENTS ACUTE: HIGH FIBER
PancreaDDs
Elevated amylase
Cullen’s sign
o Bluish discoloraDon around the umbilicus
§ Reflects pancreaDc necrosis or intraabdominal bleeding à NTP
Arthroplasty (MS p. 453):
• Knee:
o Nursing acDons:
§ Avoid anything behind the knee
§ Place one pillow under the lower calf
§ Small blanket or pillow slightly above ankle to keep heels off the bed
§ Apply ice or cold therapy to incisional area
§ Clean incision daily with soap and water
• Hip:
o Nursing acDons:
§ Supine posiDon with head slightly elevated
§ Affected leg in neutral posiDon
§ Pillow or abducDon device between legs
o PaDent educaDon:
§ Raised toilet seats and assisDve items (avoid low chairs)
§ Straight chairs with arms
§ Avoid flexion greater than 90 degrees
§ Externally rotate the toes (NOT internally)
Mastectomy (MS p. 635):
• Drains are usually lee in for 1 to 3 weeks
• Remove when there is a 25 mL of output or less in a 24 hr period
• Avoid dependent posiDon, flexing the affected arm, avoid b/p and lab draws in the affected arm
• Perform early arm and hand exercises
• AcDve ROM 1 week aeer
• Numbness can occur
• Wear loose fisng clothes
Scoliosis (MS p. 178):
• Recognizing signs of scoliosis.
• Complex deformity of the spine that also affects ribs
• Lateral curvature of the spine and spinal rotaDon that causes rib asymmetry
• Expected findings:
o Asymmetry in scapula, ribs, flanks, shoulders, and hips
o Improperly fisng clothing (one leg shorter than the other)
HIV (MS p. 571):
• Preven:ve measures for those living with HIV. Transferred via blood and body fluids. “SEX and NEEDLES”
• S/S:
o Chills
o Rash
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o Sore throat and headache
o Night sweats
o Weakness and faDgue
o FLU LIKE SYMPTOMS
Decreased CD4+ cells (below 180 > severely immunocompromised)
Increased CD8 cells
DiagnosDcs:
o “+” from HIV anDbody screening test (ELISA) confirmed with “+” HIV anDbody test (Western blot or indirect
immunofluorescence assay IFA)
PaDent educaDon:
o PracDce good hygiene
o Clean and disinfect surfaces. Bleach 10% or Chlorhexidine
o PPE think droplet risk for coughing and or splash
o Avoid crowded areas or traveling with poor sanitaDon
o Avoid cleaning pet limer boxes
o Wash dishes in hot water
o Bathe with anDmicrobial soap
o Avoid stop and start with medicaDons
o No sharing razors or nail clippers
MedicaDon – AnDvirals. “vir” names
o Ganciclovir
§ Used for HIV
§ ComplicaDon
• Suppresses bone marrow (leukocytes and thrombocytes)
o Administer granulocyte colony-sDmulaDng factors
• Monitor WBC, absolute neutrophil, and platelet counts frequently during treatment
o NTP of infecDon, bleeding
o Avoid crowds
• Can cause N/V
o Administer with food
• Use with cauDon in paDent s who have renal impairment or dehydraDon, and paDent s taking
nephrotoxic medicaDons
o Zidovudine
§ Can cause decreased Hgb, severe anemia, and neutropenia from bone marrow suppression, resulDng in
hematologic toxicity
Tuberculosis (MS p. 143):
• Tuberculosis Management: Evalua:ng Pa:ent Presenta:ons
• Tuberculosis Care: An:cipa:ng Pa:ent Needs for TB Management
• Tuberculosis Control: Implemen:ng Transmission Precau:ons
• Tuberculosis Care: An:cipa:ng Prescribed Medica:ons
• Tuberculosis Management: Monitoring Medica:on Reac:ons
• Tuberculosis Discharge Instruc:on: Assessing Teaching Effec:veness
• Caused by Mycobacterium tuberculosis; typically affects the lungs but can spread to any organ
• AIRBORNE PRECAUTION
• S/S:
o Weight loss and anorexia
o Low grade nighsmefever
o DiaphoreDc
o Blood in sputum/purulent
o Persistent cough lasDng long than 3 weeks
o Report of breathing
o InduraDon of 10 mm or greater in diameter indicate a posiDve skin test
§ Immunocompromised paDents: 5mm
• Nursing Care:
o NegaDve pressure room (a room with air exhaust directly to the outdoor environment)
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o PPE for nurse: N95 mask
o PaDent should wear a surgical mask if transportaDon to another department is necessary
EducaDon:
o Exposed family members should be tested
o Sputum samples needed every 2-4 weeks to monitor therapy effecDveness
o No longer considered infecDous aeer 3 consecuDve negaDve sputum cultures
o Foods rich in protein, iron and vitamins C and B – adequate caloric intake
• TesDng
o Nucleic acid amplificaDon tesDng
§ Detects the presence of M.TB in respiratory secreDons and can check for Rifampin resistance.
• Results: <2hr
§ The most rapid and accurate screening
o QuanDFERON-TB Gold (blood test)
§ DiagnosDc for infecDon, whether acDve or latent
§ Results: w/in 24hr
o Acid-fast bacilli smear and culture
§ + acid-fast: acDve infecDon
§ + culture: confirmaDon of diagnosis for M.TB
• Obtain three early-morning sputum samples
• Wear personal protecDve equipment when obtaining specimens
• Samples should also be obtained in a negaDve-airflow room
• Needed every 2-4 weeks to monitor therapy effecDveness
o PaDent s are no longer considered infecDous aeer 3 consecuDve negaDve sputum cultures
and can resume work and social interacDons.
o Mantoux test
§ + intradermal TB test w/in 2-10 weeks of exposure to the infecDon
§ Should be read in 48-72hr
§ + test result: induraDon (palpable, raised, hardened area) of 10mm or greater in diameter
§ + Test result for immunocompromised: induraDon of 5mm
§ A + test can indicate that the paDent has developed an immune response to TB.
• Does not confirm that acDve disease is present
§ PaDent s who have had a + Mantoux test or have received a Bacillus Calmeme-Guerin vaccine within the
past 10y can have a false-posiDve Mantoux test.
• These paDent s need a CXR or QuanDFERON-TB Gold test to evaluate the presence of acDve TB
infecDon.
§ PaDent experiencing immunocompromise can demonstrate lack of response to Mantoux tesDng, even if
M.TB is present in the body.
• Other diagnosDc tesDng is indicated to rule out infecDon.
§ PaDent s who have latent TB can have a posiDve Mantoux test and can receive treatment to prevent
development of an acDve form of the disease
o CXR
§ Can be prescribed to detect acDve lesions in the lungs
Nursing Care
o Humidified O2 therapy
o Prevent infecDon transmission
§ N95 HEPA filter when caring for paDent
§ NegaDve airflow room, implement airborne precauDons
§ Use barrier protecDon when the risk of hand or clothing contaminaDon exists
§ Have the paDent wear a surgical mask if transportaDon to another department is necessary
• PaDent should be transported using the shortest and least busy route
§ Teach the paDent to cough and expectorate sputum into Dssues that are disposed of by the paDent into
provided plasDc bags or no-touch receptacles
o Administer prescribed medicaDons and compliance for several months. No skipping doses.
o Promote adequate nutriDon
§ Encourage fluid intake and a well-balanced diet for adequate caloric intake
§ Encourage foods that are rich in protein, iron and vitamins C and B
o Provide emoDonal support
15 •
•
•
MedicaDons (RIPE):
ALL HEPATOTOXIC à liver funcDon tesDng should be completed prior to treatment and monthly
o Rifampin
§ urine and other secreDons will be orange
§ interfere with efficacy of oral contracepDves
o Isoniazid
§ Usually prescribes with Pyridoxine (Vitamin B6)
§ Take on an EMPTY stomach
§ Monitor hepatotoxicity
• Do not drink alcohol
§ Monitor neurotoxicity
• Tingling of the hands and feet
• Vit B6 will prevent this
o Pyrazinamide
§ Observe hepatotoxicity
• Liver enzymes should be completed baseline and checked every 2 weeks aeer starDng
§ Assess for history of GOUT
• Can be contraindicated and will cause adverse effect of non-gouty polyarthralgia’s (pain in mulDple
joints)
• Drink a glass of water with each does and increase fluid during the day to help prevent gout and
kidney issues
o Ethambutol
§ NO children 8y/o or younger
§ Educate on visual acuity
• Obtain baseline visual acuity tests, and complete monthly aeer starDng treatment
• Determine color discriminaDon ability before starDng treatment and periodically
How long should you give these medicaDons?
o 6-12 months
o Even up to 2 years for mulDdrug-resistant TB
o Failure will lead to resistant strain of TB
Monitor hepatotoxicity/Monitor liver enzymes (ALT/AST)
o Jaundice, Anorexia, Malaise, FaDgue, Nausea
o Bruising
o Dark oliguria
Stroke (MS p. 87):
• Post-stroke pa:ent care coordina:on.
• Lee cerebral hemisphere: responsible for language, mathemaDcal skills, and analyDc thinking
• Right cerebral hemisphere: responsible for visual and spaDal awareness and propriocepDon
o Poor impulse control
o Hemianopsia (visual changes)
• Nursing Care:
o Monitor VS every 1-2 hours
o Elevate HOB to reduce ICP – avoid flexion or extension of the neck
o If communicaDon impaired:
§ Use picture board of commonly requested items/needs
o Place food in the back of mouth on unaffected side
o Have sucDon standby
o DistracDon-free environment
o Ambulate ASAP
o ROM every 2 hr:
§ AcDve ROM > unaffected
§ Passive ROM > affected
o Dress affected side first
o Provide frequent rest periods from sisng in the wheelchair
• If new onset à FINGERSTICK GLUCOSE
o Hypoglycemia must be ruled out, as it can cause stroke-like symptoms
16 Carpal Tunnel Syndrome (MS p. 476):
• Carpal tunnel surgery. Raise hand above head post op.
• Take frequent breaks from repeDDve moDons
• Expected findings:
o Phalen’s Maneuver:
§ PaDent s place the back of their hands together and bend both wrist at the same Dme (90-degree flexion) >
numbness, Dngling, or weakness
o Tinel’s sign:
§ Tap lightly over the median nerve > pain shoot from the wrist to the hand
• Post op care:
o Check neurovascular status of fingers every hour
o Encourage to move them frequently
• Educate:
o Hand movements and heavy lieing might be restricted 4-6 weeks
o Report increasing pain to surgeon
TPN (MS p. 310):
• Nutri:onal Support: Providing Total Parenteral Nutri:on Appropriately
• Change tube every 24 hours
• Keep the TPN refrigerated when not in use
• Keep dextrose 10% in water at bedside
• Given in a central line or PICC line
• NEVER stop abruptly
o At risk for Hypoglycemia
• Cannot speed up or slow down rate
• Q4 blood glucose checks
• Assess VS every 4-8hr and daily weights
• If precipitate is present à white crystals
o Cannot be used, needs to be returned to the pharmacy
• Sterile procedure
o Preparing the TPN
o Changing tubing and soluDon bag every 24hr
o Do not use the line for other IV bolus soluDons
o Do not add anything to the soluDon due to risks of contaminaDon and incompaDbility
o Use a mask when changing the central line dressing
• May need supplemental regular insulin
• If TPN is infusing too rapidly à sit the paDent upright to prevent or treat dyspnea
o The nurse should also administer O2 if needed
Paracentesis (MS p. 311): ComplicaDon HYPOVOLEMIC SHOCK
• Abdominal Procedure: Performing Paracentesis for Symptom Relief
• Used for abdominal ascites
• Preprocedural:
o Consent
o Have the paDent void before the procedure or insert an indwelling urinary catheter
o PosiDon the paDent UPRIGHT
§ Edge of the bed with feet supported or
§ HIGH-Fowler’s in bed
o Baseline
§ VS
§ Weight
§ Abdominal girth
• Post-procedural R/O HYPOVOLEMIC SHOCK
o Maintain pressure at the inserDon site for several min, apply dressing to the site
o Check VS, record weight, and measure abdominal girth. Document and compare to preprocedural measurements
17 o
o
o
o
o
o
Monitor temperature every 4hr for a minimum of 48hr
Assess I/O every 4hr
Administer medicaDon
§ DiureDcs (spironolactone and furosemide) can be prescribed to control fluid volume
Administer IV bolus fluids or albumin
ConDnue monitoring of blood albumin, protein, glucose, amylase, electrolytes, BUN, and creaDnine levels
PaDent educaDon
§ Avoid alcohol, maintain a low-sodium diet, and monitor the puncture site for bleeding or leakage of fluid
§ Change posiDons slowly to decrease the risk of falls, which can be related to hypovolemia from the removal
of ascites fluid
Electroencephalography (MS p. 18):
• Seizure Awareness: EducaDng PaDent s on Electroencephalogram Procedures
• EEG assessing the electrical acDvity of the brain and determines abnormaliDes in brain wave pamerns
• Ability of brain to funcDon and highlights areas of abnormality
• PaDent educaDon:
o Wash hair
o Stay awake prior to test
o Might be exposed to bright flashing lights
o Do not have any caffeine the day of the test
Ostomies (MS p. 314):
o Post procedure:
§ Stoma should be pink and moist
§ Apply skin barriers and creams (adhesive paste) and dry
§ Empty when bag is 1/3 to one ½
§ Foods that cause an odor:
• Fish
• Eggs
• Asparagus
• Garlic beans
• Dark green leafy vegetables
§ Decrease odor:
• Bumermilk
• Cranberry juice
• Parsley
• Yogurt
Colostomy Care:
• Clean skin at stoma site with washcloth and warm water
• Dry the skin using pasng moDon and apply skin barrier
• AcDvate adhesive in a skin barrier holding for 30 sec
• Cut 0.3 cm larger than stoma
Sigmoid colon resecDon with colostomy
• Colostomy is placed at the descending or sigmoid colon à stools will sDll be fairly solid
• Stoma will appear large at first, will shrink within 6-8 weeks aeer surgery as the edema decreases
• Will take 2-6 days for peristalsis to return
• Aeer surgery, paDent ’s diet quickly returns to a regular diet, there are not any food restricDons, unless the paDent chooses to
decrease intake of foods that increase gas or odor
Neutropenia (MS p. 561):
• Neutrophil count less than 2,000/mm3
• Occurs in paDent s who have viral infecDons
• PaDent s have an increased risk for an infecDon
• PrecauDons:
o Restrict visitors
o Prohibit visits with people who have an infecDon
18 •
o Restrict exposure to live plants
o Restrict ingesDon of fresh fruits and vegetables
Administer FilgrasDm to sDmulate WBC producDon
Leukopenia (MS p. 561):
• Total WBC less than 4,000/mm3
• Indicates: drug toxicity, autoimmune disease, bone marrow failure, infecDons
Thrombocytopenia (low platelets) (MS p.616)
• Cancer Treatment Knowledge: Assessing Thrombocytopenia Understanding
• Secondary to disease and/or treatment; greatly increases the paDent ’s risk for bleeding
• Greatest risk: platelet count <50,000/mm and spontaneous bleeding can occur at <20,000/mm
• Nursing AcDons
o Monitor for petechiae, ecchymosis, bleeding of the gums, nosebleeds, and occult of frank blood in stool, urine, or
vomit
o Bleeding precauDons
§ Avoid IVs and injecDons
§ Apply pressure for approx. 10min and aeer blood is obtained
§ If needlesDcks ® smallest gauge possible
§ Handle paDent gently and avoid trauma
o Administer blood products (platelets) if count is <10,000/mm
o Administer Oprelvekin to sDmulate platelet producDon
o Educate:
§ Prevent bleeding by:
• Using electric razor
• Soe-bristled toothbrush
• Avoid blowing nose vigorously
• Avoid contact sports
Pancytopenia (MS p.616)
• Decrease in WBC, RBC, and platelets
• The risk of serious infecDon increases as the ANC falls.
o An ANC <1,000/mm indicated a weak immune system
o Implement neutropenic precauDons
§ Private room
• Nursing acDons
o Monitor for infecDon
§ NTP of temperature >100F
o Administer anDmicrobial, anDviral, and anDfungal medicaDons
o Administer blood products (granulocytes)
Diabetes (MS p. 547):
• Diabetes Management: Teaching PaDent s about Glycosylated Hemoglobin Blood Tests
• School-age educaDon:
o Eat a snack half an hour between physical acDvity
o Monitor levels frequently on sick days
o Store bomles in room temperature or in a refrigerator
• Type 1:
o Contraindicated to use cold pack
• Glycosylated hemoglobin (HbA1c):
o Expected 4%-6%
o With diabetes 6.5%-8% with a target goal of less than 7%
o Best indicator for average blood glucose level for 120 days
DKA (MS p.555)- Warm and Dry = Sugar High and KETONES
• Related to T1DM
19 •
•
•
•
•
•
•
•
•
•
InfecDon is the most common cause
Blood glucose >300mg/dL
Findings
o 3 P’s: polyuria, polydipsia, polyphagia
o Dehydrated: increase OSM-thick blood
o Wt. LOSS
o GI: N/V, abdominal pain
o Blurred vision, headache, weakness
o OrthostaDc hypotension
o PosiDve KETONES
o FRUITY BREATH
o KUSSMAUL RespiraDons (deep, rapid)
o METABOLIC ACIDOSIS
o Mental status changes
Labs
o Kidney funcDon: increased secondary to dehydraDon
o Blood osmolarity: high
Nursing care
o Check V/S every 15 min unDl stable, then every 4hr
o Treat underlying cause
o Start with rapid infusion of 0.9%NS for the first 1-3hr (paDent s who have elevated blood sodium levels might
require 0.45% sodium chloride)
o When blood glucose levels decrease to 250mg/dL, change the IV soluDon to one containing D5 in 0.45% to
prevent hypoglycemia
o Administer regular insulin as an IV bolus, follow with conDnuous IV infusion of Regular insulin
o Monitor K+
§ Potassium levels might iniDally be increased
HHS ( p. 122) GLUCOSE OVER 600 AND NO KETONES
Related to T2DM and not as abrupt as T1DM because they are sDll making insulin. Usually found by accident or pt. keeps
coming back in for UTI, vaginiDs. Etc.
InfecDon is the most common cause
Blood glucose >600mg/dL
Findings
o 3 P’s: polyuria, polydipsia, polyphagia
o Dehydrated: increase OSM-thick blood
o Wt. LOSS
o GI: N/V, abdominal pain
o Blurred vision, headache, weakness
o NO KETONES
o Reversable Paralysis with controlled.
o Labs and Nursing care see T1DM. Educate paDents sxs hyperglycemia and hypoglycemia-cold and candy needs candy.
o Chronic DX DM= Neuropathy-amputaDons, Nephropathy-CKD and ReDnopathy-Blind
Intracranial Pressure (ICP):
• Head Injury Care: Posi:oning Pa:ent s to Alleviate Increased Intracranial Pressure
• Log-roll the paDent when reposiDng
o Keep head in a neutral posiDon and avoiding flexion of the neck and hips
• Educate:
o Avoid flexing the neck
o Spread out nursing acDviDes throughout the day
o Limit sucDoning the paDent ’s airway to 15 seconds
o Place the paDent in a quiet environment
o Decrease ICP – High-Fowler’s
• MedicaDon:
o Mannitol-Monitor for bilateral crackles
20 Blood Transfusion (MS p. 259):
• Blood AdministraDon: Procedure for Delivering Packed Red Blood Cells and Fresh Frozen Plasma
• Hematological Support: Addressing Adverse ReacDons to Blood Transfusions
• Blood type and crossmatch informaDon is complete and in the medical record
• Compare the blood product label against the medical record and the paDent ’s idenDficaDon number with another nurse to
ensure correct blood product is administered
• Consent
• Baseline Labs: CBC and Lytes.
• Infuse blood within 30min of the blood arriving to the unit
• Y-tubing with a filter
• Baseline VS and remain with the paDent for the first 15-30 minutes. Now LVN and UAP can monitor paDent.
• Use 0.9% sodium chloride
• Transfusion is within 4 hours
• 18-20 gauge needle to infuse
• Consent form
• Document the paDent ’s refusal in the medical record
Blood transfusion reacDons
- Acute hemolyDc transfusion reacDon
o Immediate or can manifest during subsequent transfusions
§ Blood products that are incompaDble with the paDent ’s blood type or Rh factor
§ Can be mild or life-threatening
• DIC (disseminated intravascular coagulaDon
• Circulatory overload
§ Chills, fever, low-back pain, tachycardia, flushing, hypotension, chest Dghtening or pain, tachypnea, nausea,
anxiety, hemoglobinuria, and impending sense of doom, sudden oliguria
o Nursing acDons
§ STOP TRANSFUSION
§ Remove blood product from IV tubing
§ IniDate infusion of 0.9% sodium chloride using new tubing
§ Monitor V/S and fluid status
§ Send the blood bag and administraDon set to the lab for tesDng
§ Document the reacDon in the medical record
- Febrile transfusion reacDon
o Commonly occurs within 2hr of starDng the transfusion
§ Results from development of anD-WBC anDbodies
§ Can be seen when the paDent has received mulDple transfusion
§ Chills, increase of 1C (2F) or greater from the pretransfusion temperature, flushing, hypotension, and
tachycardia
o Nursing acDons
§ Use WBC filter for administraDon to catch the WBCs and prevent the reacDon from occurring
§ STOP THE TRANSFUSION
§ Administer anDpyreDcs
§ IniDate an infusion of 0.9% sodium chloride using new tubing
§ Document the reacDon in the medical record
-
Allergic transfusion reacDon
o During or up to 24hr aeer transfusion
§ SensiDvity reacDon to a component of the transfused blood products
§ Itching, urDcaria, and flushing
§ The paDent can develop an anaphylacDc transfusion reacDon resulDng in bronchospasm, laryngeal edema,
hypotension, and shock
o Nursing acDons
§ Mild reacDon
• STOP THE INFUSION
• IniDate 0.9% sodium chloride using new tubing
21 §
-
• Administer an anDhistamine, such as diphenhydramine
• If provider prescribes to restart the transfusion, do so slowly
• Document
AnaphylacDc reacDon
• STOP THE INFUSION
• Administer epinephrine, corDcosteroids, vasopressors, O2 or CPR if indicated
• Remove the blood tubing from the paDent ’s IV access
• IniDate an infusion of 0.9% sodium chloride using new tubing
• Document
Circulatory overload
o Can occur any Dme during the transfusion
§ Transfusion rate that is too rapid for the paDent
• Older adult paDent s
• PreexisDng increased circulatory volume
§ Crackles, dyspnea, cough, anxiety, JVAD, tachycardia
• Can progress to pulmonary edema
o Nursing acDons
§ SLOW OR STOP THE INFUSION
• Depending on the severity
§ PosiDon the paDent upright with feet lower than the level of the heart
§ Administer O2, diureDcs, and morphine as prescribed
OsteoarthriDs and Low-Back Pain (MS p. 479): UNILATERAL JOINT PAIN
• HolisDc Pain Management: Non-Drug Approaches for OsteoarthriDs and Low-Back Pain
• Encourage the paDent to take slow, deep breaths to relieve pain. PAIN WORSENS AFTER ACTIVITY
• OsteoarthriDs:
o Non-pharmacological:
§ Use large joints rather than small ones
§ Using 2 hands to hold objects
§ Bend at knees
§ Heat ® joint tenderness and muscle sDffness
§ Hot baths and showers, hot packs, and moist heat pad to promote comfort
• Avoid high temperatures to prevent burns
§ Cold ® inflammaDon
• Limit 20 minutes and wrap them in cloth before placing in skin
§ Use small pillow under head
§ Exercise but avoid repeDDons and resistance
o Risk factors
§ Aging: as the joints bear the load of the body’s weight over Dme
§ Obesity: increases the load
§ Smoking: loss of carDlage in the knees
o Pharmacological à glucosamine
§ Can increase risk for bleeding
§ Increases BP, should not be used for hypertensive paDents
§ Can cause hyperglycemia
§ Used for reducing pain sores and improving joint mobility
§ PaDent s who have shellfish allergies might experience reacDons
Rheumatoid ArthriDs: (MS p.585)
• Rheumatoid Arthri/s Assessment: Analyzing Joint Disease Signs
• Findings
o Pain at rest and with movement
o Morning sDffness
o PleuriDc pain (pain upon inspiraDon)
o Xerostomia (dry mouth)
22 •
•
•
•
•
•
•
•
o Anorexia/ weight loss
o FaDgue
o Paresthesia’s
o Recent illness/ stressor
o Joint pain
o Lack of funcDon
o Joint swelling and deformity
o Low-grade fever
o Elevated ESR
o Muscle weakness/ atrophy
o Reddened sclera and/or abnormal shape of pupils
o Lymph node enlargement
Take hot showers to help relieve morning sDffness rather than sponge baths or tub baths
NSAIDs to relieve pain and inflammaDon
Methotrexate
Diet:
o High in protein
o Vitamins
o Iron to promote Dssue repair
Perform their own ADLs to promote joint mobility
Frequent rest periods
ICE to reduce inflammaDon
HEAT to alleviate joint discomfort
Enteral Feedings (MS p. 309, Funds p. 335):
• NutriDonal Support: Managing Diarrhea in PaDent s Receiving Intermiment Enteral Feeding
• Nursing acDons:
o Formula at room temperature
o Flush tubing at least 30 mL of water
o G-tube à elevate the HOB 30-45 degrees to decrease risk of aspiraDon
• ComplicaDons:
o Diarrhea ® slow the rate, evaluate for C. diff if diarrhea conDnues and has a foul odor
Vision Loss (MS p. 261):
• Nurturing Comfort: SupporDng PaDent s Dealing with Vision Impairment
• Contact lens:
o Remove contact lenses to prevent corneal abrasions and ocular infecDon
o Use fresh soluDon
• Eyeglasses care:
o Use soe cloth for drying
o Store eyeglasses in a labeled container inside a drawer in the paDent s bedside table
• Amblyopia
o Unilateral central blindness occurs as a result of strabismus
o This will result in central blindness if the child does not receive treatment by 6 years of old
o Patch the unaffected eye to strengthen the weak eye muscles
• Presbyopia
o Unable to focus on objects up close
o Develops with aging, beginning in middle age, and results from the decreased elasDcity of the lens
Electrolyte Imbalance: (Blue book p.81)
Hypokalemia (less than 3.5): SAME AS PREFEX
o Decreased DTR
o Muscle weakness, cramping
o HypoacDve bowel sounds
o Dysrhythmias
o Flat and/or inverted T waves
Hyperkalemia (more than 5) SAME AS PREFEX
o Peaked T-waves
o Muscle twitching
o HyperacDve bowel sounds
23 Hyponatremia (less than 135)
o Weakness
o Lethargy
o Confusion
o Seizures
o Headache
o Muscle cramps, twitching
o Hypotension
o Tachycardia
o Weight GAIN, edema
Hypocalcemia (less than 9.0) OPPOSITE AS PREFEX
o Tetany, tremors, cramps
o Trousseau’s sign
o Chvostek’s sign
o Seizures
o Hyperreflexia
o Impaired closng Dme
o Numbness and Dngling of the extremiDes
ECG à prolonged Q-T intervals
Disorders of the Eye (MS p.67)
Cataract (MS p. 67, Blue p. 156):
• Avoid aspirin
• Itching is expected and use
cool compress to ease
discomfort
• Bend at knees (avoid bending
waist) when picking up objects
on the floor
• Avoid lieing anything that
weighs more than 10lbs
• S/S:
o Double vision
(diplopia)
o Bluish/white
o Blurry
Hypernatremia (more than 145)
o Swollen, dry tongue
o SDcky mucus membranes
o HallucinaDons
o Lethargy, restlessness, irritability
o Seizures
o Hypertension
o Tachycardia
o Hyperreflexia, twitching
o Pulmonary edema
Hypercalcemia (more than 10.5) OPPOSITE AS PREFEX
o Muscle weakness
o Kidney stone
o Lethargy/ coma
o Hyporeflexia
o Pathologic fractures
o Flank pain
o Deep done pain
o Polyuria, polydipsia, dehydraDon
o HTN
o N/V
ECG à shortened Q-T intervals
Glaucoma (MS p. 69):
• Decreased fluid drainage or increased
fluid secreDon increases intraocular
pressure
• Open-angle glaucoma
o Headache
o Mild eye pain
o Loss of peripheral vision
o Decreased accommodaDon
o Halos seen around lights
o MedicaDon: Acetazolamide
§ A/E: paresthesia
(Dngling of the
fingers)
• Angle-closure glaucoma
o Decreased or blurred vision
o Colored halos around lights
o Pupils nonreacDve to light
o Severe pain and nausea
o Photophobia
MedicaDons
• Every 12hr – one drop in each eye
twice daily
• Wait 5-10min between eye drops if
more than one
• Once eye drop insDlled, apply
pressure using the punctual occlusion
technique (placing pressure on the
inner corner of the eye) – 1-2min
o Timolol (beta-blocker)
Macular degeneraDon (MS p. 67):
• Central loss of vision that
affects the macula of the eye
• Expected findings:
o Lack of depth
percepDon
o Objects appear
distorted
o Blurred vision
o Loss of central vision
o Blindness
24 §
§
§
Decrease IOP by
reducing aqueous
humor producDon
Monitor for
bronchoconstricDon
and hypoglycemia
Life-long
medicaDon
ReDnal Detachment
• Dark floaters
• Curtain
• Common cause of cataracts
Chronic Pain IntervenDons (MS p. 28):
• Chronic Pain Care: Strategies for Long-Term Pain Relief
• Administer long-acDng or controlled-release opioid analgesics
• Administer analgesics around the lock rather than PRN
• Refer pain management center
• Refer to palliaDve or hospice treatment center
Chemotherapy (MS p. 603):
• PaDent educaDon:
o Clean toothbrushes in a dishwasher daily or rinse in bleach soluDon
o Take temperature daily
o Prevent StomaDDs rinsing with room temperature soluDon
o Ambulate throughout the day
o Discard beverages sisng at room temperature for longer than an hour
o Eat small meals a day
o BOTTLED WATER
o Neutropenic precauDons
o Select COLD foods
o Flush the toilet twice
• Nursing acDons:
o AnDemeDcs given before
Respiratory Distress Syndrome (MS p.161)
• Respiratory Crisis Interven:on: Managing Pa:ent s in Respiratory Distress
• Tachypnea
• Tachycardia
• Hypoxia
• Cyanosis
• Dyspnea
• Use of accessory muscles
o Mechanical venDlaDon (PEEP) or CPAP to prevent alveolar collapse during expiraDon
§ Monitor for pneumothorax (PEEP can cause lungs to collapse)
o SucDon paDent PRN
o ABGs
o ConDnuous ECG
o PosiDon paDent to facilitate venDlaDon and perfusion
§ Benzodiazepines (Lorazepam)
• reduce anxiety and decrease O2 consumpDon
§ Propofol (General anesthesia)
• Sedates paDent for mechanical venDlaDon
§ CorDcosteroids
25 • Decreased inflammaDon
Opioids
• Pain management
§ Neuromuscular blocking agents (Verconium)
• Facilitates venDlaDon and decreased O2 consumpDon
Severe respiratory syndrome (MS p.162)
o SOB
o Dyspnea
o Orthopnea (difficulty breathing lying flat)
o Rapid, shallowing breathing
o CyanoDc, momled, dusky skin or mucus membranes
o Tachycardia
o SUBSTERNAL retracDons
o Decreased O2 (<90%)
o AdvenDDous breath sounds (wheezing, rales)
o Cardiac arrhythmias
o Confusion
o Lethargy
Oxygen toxicity (MS p.118)
o Results from high concentraDon of O2 or long duraDons of therapy
§ NonproducDve cough
§ Substernal pain
§ Nasal sDffness
§ N/V
§ FaDgue
§ Headache
§ Sore throat
§ HypovenDlaDon
o Nursing acDons
§ Use the lowest level of O2 to maintain prescribed SaO2
§ Monitor ABGs
§ Use an O2 mask with conDnuous CPAP or BiPAP if prescribed to help decrease the amount of O2 needed
§ Use PEEP as prescribed while the paDent is receiving mechanical venDlaDon to help decrease the amount
of needed O2
§
•
•
Compartment Syndrome: (MS p. 225)
• Tingling, numbness, worsening pain, edema, pain on passive movement, and unequal pulses
• Pain with passive movement and unrelieved by analgesics
• Nursing care
o Loosen dressing
o Prepare for fasciotomy
o Monitor for comfort, impaired mobility, and decreased sensory percepDon of the affected extremity by following the
6 Ps
§ Pain
§ Pressure
§ Paralysis
§ Paresthesia
§ Pallor
§ Pulselessness
Below-the-knee amputaDon
• Assist the paDent to a PRONE posiDon for 20-30min every 3-4hr following an amputaDon à reduces the risk of flexion
contractures
CholecysDDs: (MS p.355)
• InflammaDon of the gallbladder wall
o Caused by gallstones obstrucDng the bile duct causing bile to back up and the gall bladder to become inflamed
• Sharp pain in the RUQ, radiaDng to the right shoulder
26 •
•
•
•
•
o Murphy’s sign
Intense pain (increased HR, pallor, diaphoresis with NV aeer indigesDon of high-fat food)
Rebound tenderness
Dyspepsia, belching, flatulence
Fever
Administer analgesics as needed
Cholelithiasis (MS p. 355):
• Pain Management: MedicaDon Approach for PaDent s with Cholelithiasis
• MedicaDons:
o Analgesics: Morphine Sulfate or Hydromorphone ® acute biliary pain
o NSAID: Ketorolac ® mild to moderate pain
o Bile acid
Anemia Decreased RBC CharacterisDcs. Indicator of underlying disease or disorder. Anemia results in decreased oxygenaDoncarrying capacity and delivery to the Dssues and organs. Could be R/T decreased RBC and or HXH or both. The goal of the
treatment is to restore and maintain adequate Dssue oxygenaDon. Reminder Blood Carries all the messages to the body. The
Spleen is the quality control area for the blood and the bone marrow is the map. Many factors can impact and influence blood
loss.
Pernicious Anemia: (MS p.293)
• Lack of Intrinsic Factor
• Bariatric surgery
• Vitamin B12 deficiency(MS p.293)
o GlossiDs
o Smooth, beefy-red tongue
• Instruct the paDent the need for monthly vitamin B12 injecDons
• Schilling test: measures vitamin B12 absorpDon
• ETOH
Iron deficiency anemia – Hypochromic(MS p.293)
• Iron or vitamin deficiency: Lacks iron,B-12, folic acid, and intrinsic factors.
• Blood Loss
• Fissures at the corner of the mouth
AplasDc: MalfuncDon bone marrow(MS p.293)
• Chemotherapy
• RadiaDon exposure
• Toxins
Erythroblastosis Fetalis: DestrucDon by anDbodies(MS p.293)
• Rh incompaDbility and ABO incompaDbility. Both causes are associated with blood type.
Secondary: Due to lack of erythropoieDn(MS p.293)
• Renal disease
• Leukemia
• CA
Sickle cell anemia-GeneDc Factors recessive trait(MS p.293)
• Most common form of SCD
• ManifestaDons and complicaDons of SCA are the result of the RBC sickling, which leads to increased blood viscosity,
obstrucDon of blood flow, and Dssue hypoxia.
• Tissue hypoxia causes Dssue ischemia, which results in pain
• Increased destrucDon of RBCs occurs
• Jaundice of the sclera due to RBC destrucDon and release of bilirubin into the vascular system
27 •
•
•
IntervenDons: IV fluids over oral ( decrease for Dssues and decreased 02 demand) and nutriDon support with TPN.
ACCRONYM: HOP ( Hydrate, Oxygenate and Pain)
Thalassemia inherited body makes abn amt of Hgb
Hemophilia inherited trait from mom to son. Bleeding disorder. Other bleeding disorders are caused from Chemo and
Cirrhosis.
Bacterial MeningiDs: (MS p.31)
• Isolate as soon as suspected (droplet > private room)
• Droplet unDl anDbioDcs have been administered for 24 hours and oral and nasal secreDons no longer infecDous
• Decreased environment sDmuli
• S/S:
o Fever
o Photophobia
o Nuchal rigidity
o Petechial rash
o Impaired consciousness
EncephaliDs:
• Can be caused by mumps, rubeola, and varicella
• S/S:
o Fever
o Nuchal rigidity (discomfort/pain when trying to turn/move > sDff)
o Altered mental status
• Nursing Care
o Standard precauDons
o Monitor V/S every 2hr for changes consistent with IICP
o Assess neurological status every 4hr
o Maintain HOB 30-45 degrees
o Provide with a low-sDmulaDon environment to promote comfort and decrease agitaDon
Fresh Frozen Plasma: (MS p. 259)
• Transfuse within 30mins aeer obtaining it from the blood bank NEED TO BRING TO ROOM TEMP
• Administer over 30-60 minutes
HepaDDs A: (MS p. 365)
• Fecal-oral transmission
o Contaminated food or water
o Contact with infected stool
• Encourage safe food handling and hand hygiene
• Clean surfaces with hydrogen peroxide to kill virus
Hep B
• Blood transmission
o Unprotected sex with infected individual
o Infants born to infected mothers
o Contact with infected blood
• Can develop within 25-180 days of infecDon
o Anorexia, fever, faDgue, and pain in the joints and in the RUQ
• Nursing care
o Limit physical acDvity
o Avoid alcohol
o Eat small, frequent meals
Hep C
• Blood transmission
o Blood, blood products or organ transplants
o Contaminated needles, unsanitary tamoo equipment
o Sexual contact
28 Labs
• AST/ALT: elevated
• Bilirubin: elevated
Nursing care
• High- carb, high-calorie, moderate fat, moderate protein
• Small frequent meals to promote nutriDon and healing
Cardiac CatheterizaDon (MS p. 172):
• Pain site is an expected finding following cardiac catheterizaDon
• ComplicaDons:
o Slurred speech and extremity weakness > stroke
o Chest pain
§ Embolism
§ Restenosis of treated vessel
• clot reformaDon can occur immediately or several weeks aeer the procedure
Cancer ( p. 158)-Healthy cells transform into mx cells upon exposure to certain eDologic agents, viruses, chemicals, and physiological
agents.
• Risk Factors: Age, Races, GeneDcs, Exposure to Chemicals, viruses, sun exposure, diet high in red meat, high in fat and low in
fiber.
• Most common types : Br, Bladder, Kidney, Liver, Lung, see pg. 677
• TNM: Staging CA Tumor; Node and Metastasis. Grading is needed because some CA cells are more mx than others.
• Chemotherapy (MS p. 689): SE: pantothenic, hematopoieDc, neutropenic, faDgue, nausea, pain, and bleeding precauDons.
• RadiaDon Therapy (MS p. 605):
• Cancer Treatment Knowledge: EducaDng on RadiaDon Therapy OpDons
Brachytherapy (MS p. 605):
• Internal radiaDon that is placed close to the target of the Dssue
• Nursing acDons:
o Private room and door closed
o Place a sign on the door warning radiaDon source
o Wear a dosimeter film badge that records personal amount of radiaDon exposure
o Limit visitors to 30 min visits
o Maintain 6 feet from the source
o Individuals trying to conceive, who are pregnant, or under 16 should not enter room
o Wear lead apron when providing care, keeping the front of the apron facing the source of radiaDon
o Keep a lead container in the paDent ’s room with tongs – (if rod falls out or in bed linens do not touch with your
hand)
o RadiaDon sign on the door
o Xerostomia-dry mouth
• PaDent EducaDon
o Remain the posiDon prescribed by the provider to prevent dislodgement of the radiaDon implant
o Call nurse for assistance with eliminaDon
External Beam RadiaDon therapy (MS p. 606):
• Delivery is in small doses for several weeks aimed at the body from an external source.
• PaDent is NOT radioacDve and is not hazardous to others
• PaDent educaDon:
o Do not wash off markings
o Well-balanced diet that does not contain red meat.
§ RadiaDon can cause altered taste
o Manage faDgue by providing rest periods
o If MucosiDs occurs:
§ Avoid spicy, salty, acidic foods
§ Cold foods rather than hot foods
§ May experience altered taste sensaDons.
§ Use soe Dssue toothbrush
o Gently wash the skin over irradiated area with mild soap and water
29 •
o Dry with pasng moDons
o Use HAND to clean; NOT washcloth
o Do not expose skin to sun or heat source
ComplicaDons
o Treatment of head and neck cancer
§ Jaw sDffness, nausea, and lymphedema, dry mouth, difficulty swallowing, mouth sores, and dental caries
StomaDDs (MS p. 604):
• Cancer Symptom Management: Pa:ent Educa:on on Stoma::s Preven:on
• InflammaDon of Dssues in the oral cavity
• Nursing acDons:
o Avoid glycerin-based mouthwashes or mouth swabs for paDent
o Nonalcoholic, anestheDc mouthwashes are recommended
o Assess oral mucosa every 8 hours.
• Educate:
o Rinse with soluDon of 0.9% of sodium chloride, room-temperature water, salt, and soda water
o Rinse before and aeer meals
o Choose soe, bland foods high in calories:
§ Mashed potatoes, scrambled eggs, milk shakes, bananas
o AVOID SPICY, SALTY, ROUGH, HARD FOOD
o Drink at least 2L of fluid/day
• MedicaDons
o NystaDn suspension, acyclovir (anDviral)
Triage (MS p. 69):
• Priori:zing care during emergencies.
• Red: emergent
o Unconscious, thready pulse
• Yellow: urgent or delayed (30 min-1 hour)
o Open fracture
• Green: green
• Black: expectant
o Agonal respiraDons
GERD (MS p. 319):
• Gastric content and enzyme backflow into esophagus
• Primary treatment is diet and lifestyle
• Risk factors:
o Obesity
o Older age
o Sleep apnea
• S/S:
o VomiDng
o Weight loss
o Wheezing
• MedicaDons
o PPIs (pantoprazole, omeprazole) RISK FOR ASPIRATION PNA
§ Monitor for electrolyte imbalance and hypoglycemia in paDent s who have DM
§ Monitor for abd. Cramping, fever, and diarrhea
• Indicated C. diff
§ Long-term use of PPIs
• increases the risk for fractures, especially in older adults
• Hypomagnesemia
o Antacids (aluminum hydroxide, magnesium hydroxide, calcium carbonate and sodium bicarbonate)
§ Ensure the pt is not taking levothyroxine (contraindicated)
§ Evaluate kidney funcDon in paDent s taking mag hydroxide
30 Histamine 2 receptor blockers (famoDdine)
§ Reduces acid
§ CauDon with paDent s who have kidney disease
§ Take with meals at bedDme
§ Separate doses from antacids (1hr before or aeer)
o Metoclopramide
§ ProkineDc
• Increases the moDlity of the esophagus and stomach
• Monitor for EPS
o Report abnormal, involuntary movement
EducaDon:
o Avoid large meals
o Consume 4-6 small meals throughout the day
o Avoid Dght-fisng clothing around the abdomen
o Weight loss, if applicable
o Elevate HOB 6-8in
o Avoid lieing heavy objects
o
•
PepDc Ulcer Disease (MS p. 327):
• Non-Opioid Pain Relief: Administering Headache Medica:ons for Pa:ent s with Pep:c Ulcers
• Erosion of mucosal lining of the stomach, esophagus, duodenum
• Usually caused by H. Pylori
• Nursing care:
o Avoid caffeine (coffee and tea) and carbonated drinks
o Suppress acid producDon
o H2 receptor blockers and PPIs
o Noninvasive test for H. Pylori
§ C13 urea breath test, stool exam, and serologic anDbody tesDng
Burns (MS p. 499):
• Burns Management: Priori:zing Care for Burn Vic:ms
• Nursing Care:
o Stop the burning process
o Apply cool water soaks or run cool water over injury
§ DO NOT USE ICE
o Cover burn with a clean cloth
o Provide warmth
• Minor burns:
o Cleanse with mild soap and water
o Apply dressing (hydrocolloid, nonadherent)
• Major burns:
o Respiratory
§ Provide humidified O2
§ Support the airway and venDlaDon
§ Perform CPT and have the paDent cough, breathe deeply, and use incenDve spirometer
o Fluid replacement:
§ IniDate large bore needle
§ Administer half of the total 24hr IV fluid volume within 8hr from the Dme the burn occurred and the
remaining volume over the next 6hr
§ Infuse isotonic crystalloid soluDons (0.9% NS or LR)
§ Infuse colloid soluDons (albumin or syntheDc plasma expanders) aeer the first 24hr of burn recovery
• Assess for fluid overload: edema, engorged neck veins, rapid and thready pulse, lung crackles,
wheezes
§ Prepare to administer blood products
• Monitor for manifestaDons of SHOCK
o Confusion
31 •
•
o Increased capillary refill Dme
o Urine output <30ml/hr
o Rapid elevaDons of temp
o Decreased bowel sounds
InfecDon prevenDon
o ProtecDve environment
o Limit visitors
o Administer tetanus
o Administer anDbioDcs
o Strict asepsis with wound care
NutriDon support
o Increase protein
o High carbohydrates
Spinal Cord Injury: (MS p.95)
• Injuries in the cervical region > quadriplegia
• Injuries below T1 > paraplegia
Autonomic dysreflexia: (MS p.99)
• SCI injury above T6 + severe HTN
• S/S:
o Severe HTN
o Headache
o Bradycardia
o Flushing
o Diaphoresis
o PiloerecDon (goosebumps)
o Nasal sDffness
• Nursing acDons:
o Sit up paDent to reduce BP
o NoDfy provider
o Assess for kinks, irrigate
o Insert catheter if bladder is distended
o Remove Dght clothing
Angina/MI (p.130)
• Chest pain, Dghtness, radiates to the LEFT shoulder
• At risk: elderly, diabeDc, CHF
• Nonmodifiable risk factors
• Modifiable risk factors- EDUCATE…
• SXS MI: elevated ST, Elevated Troponin level, “crushing C/P”, dyspnea, faDgue, pallor, palpitaDons, and nausea
• Stable A: pain stops with NTG
• Unstable A : pre infarcDon
• Prinzmals A : caused spasm artery
• IntervenDons: start with 02 > NTG>ASA>MS. Order 12 lead EKG. Add thrombolyDcs.
Lethal Arrythmias (p.138) IdenDfy the EKG Rhythms, medicaDons, and treatments.
• Shockable Rhythms:
• Defibrillate because paDent is dead): V-Fib, V-Tach no pulse
• Cardiovert because paDent is alive: V-Tach with a pulse and A-fibrillaDon
• Non Shockable Rhythms ( no electricity to tun on the pump) : Asystole and PEA=CPR then Epinephrine.
32 Heart Failure (MS ch.32)
o
Pathophysiology:
-HF is a complication that can result from problems such as cardiomyopathy, valvular heart
disease, endocarditis, acute MI, and hypertension
o
Types:
Left-sided failure(pulmonary edema)
Right-sided failure (corpulmonale)
3. S/S:
-pulmonary congestion
-crackles
-dyspnea
-cough
-blood-tinged, frothy sputum
-restlessness
-tachycardia
-S-3
-orthopnea
-nocturnal dyspnea
S/S:
-enlarged organs
-edema
-weight gain
-distended neck veins
-ascites
New Terminology: Systolic heart failure: heart can’t contract and eject
Diastolic heart failure: ventricles can’t relax and fill
•
•
•
•
Fluid Balance and Heart Health: Recognizing Heart Failure Symptoms
Heart Failure Indicators: IdenDfying Signs of Pulmonary CongesDon
Heart muscle is unable to pump effecDvely
o Risk factor: MI (lack of oxygenated blood to the heart muscle)
§ Heart muscle injury/death in MI
Leading to inadequate cardiac output (lack of maintenance of fluid/blood)
o Tachycardia, HTN, Tachypnea
o Lee: perfuses oxygenated blood to the body
§ Backflow of oxygenated blood
• Pink Frothy sputum (Pulmonary Edema)
33 •
•
•
• Crackles
• Pulmonary congesDon (dyspnea, cough, bibasilar crackles)
o Right: RECEIVES de-oxygenated blood (Right side of the heart RECIEVES deoxygenated blood)
§ Pooling of deoxygenated blood into peripheral extremiDes
• JVD
• Peripheral edema
• Hepatomegaly (liver enlargement)
Labs/ DiagnosDcs
o Human B-type natriureDc pepDdes (BNP)
§ Confirms a diagnosis of HF
• <100: no HF
• 100-300: HF is present
• >300: mild HF
• >600: moderate HF
• >900: severe HF
o Hemodynamic monitoring
§ Central venous pressure: increased
§ Pulmonary wedge pressure: increased
§ Cardiac output: decreased
Nursing Care/ EducaDon
o Fluid RestricDon: Weigh paDent daily / STRICT I&Os
o SXS SOB sit the paDent in high fowlers posiDon
o Take prescribed medicaDons (even if there are no manifestaDons of HTN) DiureDcs, ACE Inhibitors and Digoxin
o Schedule regular provider appointments to monitor HTN and cardiovascular status
o Exercise at least 3/week in a manner that provides aerobic benefits
o Explore smoking cessaDon opDons such as nicoDne replacement therapy, medicaDons such as bupropion, and
support groups.
o NutriDon
§ If taking K+ sparing medicaDon = avoid K+ rich foods
§ If taking K+ wasDng medicaDon = increase K+ rich foods
§ Limit oral intake of fluid 1500/day
§ Limit Na for no more than 2g/day
§ Diet low in fat, saturated fat, and cholesterol
§ Limit alcohol intake to 2 servings for men, 1 serving for women
§ DASH diet
• High in fruits, vegetables, and low-fat foods
§ Consume foods rich in calcium and magnesium
Treatments
o DiureDcs : Pump needs to parks and PEE
• K+ SPARING
- Spironolactone
• S/E:
o Hyperkalemia
o GynecomasDa
• N/C:
o Avoid eaDng foods high in potassium! (green leafy veggies, bananas, avocados)
o Avoid salt subsDtutes and K supplements
o Monitor K levels (3.5-5.0)
• K+ WASTING
- Loop DiureDcs (Furosemide)
• S/E:
o Hypokalemia
o Hyperglycemia
o Hyponatremia
• N/C:
o Administer Furosemide SLOWLY (can cause ototoxicity)
34 -
•
•
o
o
Thiazides
• S/E:
o
Replace if K+ is <3.5
Take with food or milk to reduce gastric irritaDon
Hypokalemia
§ If given with Digoxin, can lead to Digoxin TOXICITY
Hyponatremia
Hyperglycemia
PhotosensiDvity
o
o
o
• N/C:
o Give with meals to decrease GI upset in the AM
o Replace K+ if <3.5
o Monitor renal funcDon
o PaDent s with SULFA allergy should avoid thiazide diureDcs
A/E: OrthostaDc Hypotension à Fall risk
Monitor for:
• Increase U/O
• Decrease edema/ crackles / pulmonary congesDon
•
ANTIHYPERTENSIVES
- Ace-Inhibitors “-pril” (Captopril/enalapril/lisinopril): Need to park the pump
- 1st line medicaDon for HF
- AcDon:
- Dilates blood vessels, lowers BP (Does not directly act on HR)
- S/E:
- Angioedema
- Dry cough
- Elevated K+
- N/C:
- Monitor for Hypotension
- Assess BP + Pulse
- Monitor K+ levels
o Normal 3.5-5.0
- Educate to avoid foods high in K+ and avoid salt subsDtutes
- Assess for angioedema
o CAUTION: swelling of the face & mouth
- Educate pt. to not stop abruptly; can cause Rebound HTN à tapper off medicaDon
- Contraindicated: 1st trimester pregnancy
- High dose = hepatotoxic
- Low dose = used for DM; protects kidneys
- Captopril
o NSAIDs decrease effecDveness
o Give 1hr before meals, or 2hr aeer meals
- Beta-Blockers “-LOL” (metoprolol/propranolol/acebutolol)
- AcDon:
- Blocks beta receptors
- Decreases workload of the heart à decrease cardiac output
- Decreases BP / HR
- S/E:
- Hypotension
- Bradycardia
- Bronchi- constricDon
- Masks S/S of Hypoglycemia
- N/C:
- Monitor for Hypotension
- Change posiDons slowly
- Contraindicated with asthma and COPD paDents
35 -
-
-
- Taper off medicaDon
- Weigh daily
Calcium Channel Blockers (Verapamil/ Nifedipine/ DilDazem/ Amlodipine)
- Used for:
- Lower HR & BP
- HTN
- Angina
- Dysrhythmias
- AcDon:
- Blocks movement of Ca
o Relaxes blood vessels
o Decreases BP
o Increases supply of O2 to the heart muscles
o Decreases heart’s workload
- S/E:
- OrthostaDc Hypotension
- Dizziness
- Flushing
- Headache
- Peripheral edema
- ConsDpaDon
- N/C:
- Change posiDon slowly
- Do not stop medicaDon abruptly
o Rebound HTN
o Tapper off medicaDon
- NO grapefruit juice!!!
o Causes severe Hypotension
- Prevent consDpaDon
o Fluids, fiber, fruits
Angiotensin-II Receptor Antagonists (ARBs)
- Valsartan/ Losartan
- Good opDon for paDent s taking ACE inhibitors who report cough or have Hyperkalemia
- AcDon:
- Blocks the effects of angiotensin II at the receptor and decrease peripheral resistance
- S/E:
- OrthostaDc hypotension
o Change posiDon slowly
- Angioedema
o Monitor for swelling on lips/face
- Hyperkalemia
o Avoid foods high in K+
Alpha-Adrenergic Antagonist
- Doxazosin/Prazosin
- AcDon:
- Reduce BP by causing vasodilaDon
- S/E:
- OrthostaDc hypotension
o Change posiDon slowly
- N/C:
- Start treatment with a low dose
- Given usually at night Dme
- Monitor BP for 2hr aeer iniDaDon of treatment
INOTROPIC AGENTS
- Digoxin / Dopamine / Dobutamine
36 -
Class: Cardiac Glycosides
Used for:
- HF
- Cardiogenic shock
- AnDarrhythmic (A-fib)
AcDon:
- (+) Inotropic acDvity
- Increases contracDon of the heart = improves cardiac output
Digoxin Toxicity
- TherapeuDc Range: 0.8-2.0 mg/ml
- >2 = TOXIC
- Causes:
- Decreased K+ (<3.5)
- Decreased/impaired kidney funcDon
- S/S à NTP
- N/V, diarrhea (early sign)
- Blurred vision, yellow/green halo
- Headache, drowsiness, confusion
- AnDdote à Digibind
- Spironolactone and Digoxin are oeen given together to reduce the risk of Digoxin Toxicity
N/C:
- Assess apical pulse for 1min
- Hold medicaDon
o Adult: <60bpm
o Children: <70 bpm
o Infants: <80bpm
- Monitor K+ & magnesium
-
-
Implantable Cardioverter Defibrillator (ICD) (MS p. 186):
• Cardiac Device EducaDon: Assessing Teaching for PaDent s with Implantable Cardioverter Defibrillators
• PaDent educaDon:
o Wear sling when out of bed
o Do not raise arm
o The paDent should keep his cell-phone on the opposite side of the ICD, as close proximity could interfere with the
ICD’s funcDon
o Presence of the ICD may trigger the metal detectors at airport à noDfy security personnel
PAD VS PVD (p. 133)
Venous Disorders:
•
Pathophysiology:
-interferes with adequate
return of blood flow from the
legs. Includes venous insuff &
VTE & VV.- sxs warm legs, thick
skin, and painless ulcers
- NI: Elevate legs, compression stockings, wound care, and weight loss.
Arterial Disorders:
•
Pathophysiology:
-If you have atherosclerosis in one place you have it everywhere.
-It is a medical emergency if you have an acute arterial occlusion (numb, cold, pain, no pulse)
37 -More symptomatic in lower extremities: cold, pale, shiny legs, no hair, and pain.
- NI: Avoid dependent edema leg positions, avoid cold, stop TOB,
-Arterial blood isn't getting to the tissue→ coldness, numbness, decreased peripheral pulses,
atrophy, bruit, skin/nail changes, and ulceraDons
-If the patient has pain while resting this means they have an ARTERIAL obstruction
-Since arterial blood is having difficulty getting to the tissue, if you elevated the affected
extremity the pain would increase or decrease?
We ELEVATE veins
We DANGLE arteries
-Arterial disorders of the lower extremities are usually treated with either angioplasty,
endarterectomy, or bypasss surgery.
Delayed Wound Healing:
• Encourage intake of 2,500 mL/day
• Educate on good sources of protein
• Albumin levels less than 3.5 is risk for delay wound healing
Cardioversion
• V-tach with a pulse
DefibrillaDon (pulseless)
• V-fib
• V-tach (no pulse)
Fecal ImpacDon:
• Place paDent in side-lying posiDon with knees flexed
• Contraindicated to administer bisacodyl
o Can administer an oil retenDon enema prior to procedure
• Insert a lubricated gloved finger and advance it along the rectal wall when digitally evacuaDng stool
Osteoporosis:
• Risk factors:
o Sedentary lifestyle
• Older adult paDent s:
o Engage in weight-bearing exercises > promote bone health by increasing calcium and phosphorus levels
OsteomyeliDs
• InfecDon of the bone, bone marrow, and the surrounding soe Dssue
• Drainage, swelling, tenderness, and warmth at the infected site
Phantom limb pain
• MedicaDons
o Opioids
o Amitriptyline (TCA)
o GabapenDn (anDepilepDc)
o Propranolol (beta blocker) à can reduce the persistent pain, burning sensaDons
38 Transient Ischemia amack (TIA)
• A temporary disturbance of the blood supply to the brain, brief alteraDons in neurologic funcDon
• Causes
o AtheroscleroDc plaque in the caroDd arteries
o HTN
• Nursing care
o Limit sodium intake to help control HTN and prevent future TIAs
Total hip arthroplasty – postop
• Instruct the paDent to perform leg exercises to help prevent venous thromboembolism
• Prevent hip flexion of the affected extremity beyond 90 degrees due to the risk of dislocaDon
o Raised toilet seats and reclining chairs help prevent hyper-flexion
• Use an abducDon pillow
• Elevate the paDent ’s heels off the bed to prevent skin breakdown
Catheter Care
• Sterile technique
• Change the dressing every 2 days
o Change the semipermeable dressing every 7 days
• Clean the access port on the CVAD line with povidone-iodine or 70% alcohol prior to use
• Use fricDon when cleaning the access port
Psoriasis
• Autoimmune disease, causing rapid turnover of cells; no cure
• Silver plaques on reddened skin
o Avoid triggers (stress, trauma, infecDon)
o Topical corDcosteroids
o Phototherapy
o Methotrexate
o Avoid alcohol
Dumping Syndrome (MS p. 336)
• Rapid release of metabolic pepDdes following the
ingesDon of a food bolus
• ManifestaDons
o Feeling of fullness, weakness, dizziness,
palpitaDons, sweaDng, abdominal cramping,
and diarrhea
o ManifestaDons resolve aeer having a bowel
movement. However, late, or residual
vasomotor manifestaDons can occur 10min –
3hr aeer eaDng
• Nursing acDons
o Instruct the paDent to lay down following
meals to slow movement of food through the
intesDne and prevent injury
o Eat high-protein, high-fat, low to moderate
carbohydrate diet
o Instruct the paDent to eat small meals and
limiDng taking liquids with meals
Refeeding syndrome (MS p. 309)
• PotenDally life-threatening condiDon that occurs when
enteral feeding is started in a paDent who is in a
starvaDon state and whose body has begun to
catabolize protein and fat for energy
• Nursing acDons
o Monitor for new onset of confusion or
seizures
o Assess for shallow respiraDons
o Monitor for increased muscular weakness
o NTP and obtain blood electrolytes
- Anorexia nervosa / bulimia
Concussion
• Early findings
39 •
o Headache
o Nausea
o Increased sleeping
Late findings
• Decreased motor response
• Bradycardia
SIADH vs. DI (MS p. 520/522)
SIADH “SOAKED INSIDE”
• Excessive release of ADH (aka. vasopressin)
• Expected findings
o Cheyne-Stokes respiraDons
o Confusion
o Seizures
o NO URINE
o Fluid volume excess
§ Tachycardia
§ SOB
§ Bounding pulses
§ HTN
§ Crackles in lungs
§ Distended neck veins
§ Weight GAIN (w/out edema)
§ Intake > output
• Labs
o Urine tesDng – think CONCENTRATED
§ Urine osmolarity
o Blood tesDng – think DILUTE
§ ¯ Na
§ ¯ blood osmolarity
• Nursing Care
o Restrict oral fluids to 500-1000mL/day
§ Can provide comfort methods for
thirst (mouth care, ice chips)
o Use 0.9% NA, instead of water, to flush enteral
tubes, and to mix medicaDons or dilute
feedings administered enterally
o Monitor I&O
o Monitor for pulmonary edema (MEDICAL
EMERGENCY)
o Daily weights (wt. gain of 1kg = 1L of fluidà
NTP)
o Report altered mental status (headache,
confusion, lethargy, seizures, coma)
o Reduce environmental sDmuli
o Seizure precauDons
o Monitor for indicaDon of HF (can occur from
fluid overload) à administer loop diureDc
• Treatment
o Vasopressin antagonist (Tolvaptan)
§ Promotes water excreDon w/out
causing Na loss
DI “DRY INSIDE”
• Deficiency of ADH
• Expected Findings
o Polyuria (failure of the renal tubules to collect
and reabsorb water)
o Polydipsia
o Tachycardia
o Hypotension
o Dry mucus membranes
o Weak, poor peripheral pulses
o Decreased cogniDon
o Ataxia
• Labs
o Urine tesDng – think DILUTE
§ ¯ urine specific gravity (< 1.005)
§ ¯ urine osmolarity
§ ¯ urine pH / Na/ K+
• As urine volume increases,
urine osmolality decreases
o Blood tesDng – think CONCENTRATION
§ blood osmolality
§ blood Na / K+
• As blood volume decreases,
the blood osmolality
increases
• Nursing Care
o Daily weight
o Diet: regular diet with restricDon of foods that
exert a diureDc effect [caffeine])
o IV therapy: hydraDon and electrolyte
replacement
o Treat consDpaDon with bulk foods, fruit juices
or laxaDves
o Provide skin and mouth care using a soe
toothbrush and mild mouthwash to avoid
trauma to the oral mucosa. Use alcohol-free
skin care products, and apply emollient loDon
aeer baths
• Treatment
o ADH replacement agents
§ Desmopressin (syntheDc ADH)
§ Vasopressin (intranasally, orally, or
parenterally)
40 Monitor glucose, blood Na, I&O,
bowel pamerns
§ Perform frequent oral care
Loop diureDc (furosemide)
§ Use with cauDon: can cause Na
excreDon and worsen hyponatremia
Hypertonic sodium chloride IV fluid
§ Elevate the Na level to alleviate
neurological compromise
§ Severe hyponatremia = administer
200-300mL hypertonic IV fluid (3%
sodium chloride)
•
§
o
o
•
•
•
•
PaDent
o
o
o
Dose can be adjusted
depending on urine output
CauDon with CAD paDents,
can cause vasoconstricDon
(Vasopressin)
Lifelong Vasopressin therapy
(neurogenic DI)
Monitor wt. (NTP of wt. gain
>2lb in 24hr)
educaDon
Daily weight / I&O
Diet: high-fiber
Wear a medical alert bracelet
Urine specific gravity : think URINE CONCENTRATION
Hypervolemia à USG <1.010
Hypovolemia à USG >1.025
Adrenal Disorders (MS p.541)
Addison’s Disease
Cushing’s Disease
• Results from long term use of glucocorDcoids
• A decreased in aldosterone and corDsol
(asthma/arthriDs)
• Findings
• Findings
o Weakness, faDgue, sleep disturbances
o Wt. LOSS
o Irritability / depression
o Salt craving
o decreased immune funcDon
o HyperpigmentaDon of the skin
o HTN / tachycardia
o Weakness / FaDgue
o Wt. GAIN
o N/V and anorexia
o Buffalo hump
o Abdominal pain
o Moon face
o OrthostaDc hypotension
o Truncal obesity
o DehydraDon
o Osteoporosis
o Hyponatremia
o HirsuDsm
o Hyperkalemia
o Purple striae
o Hypoglycemia
o Thinning, balding hair
o Hypercalcemia
o Hyperglycemia
• Nursing care
• Nursing care
o Prevent circulatory shock
o Monitor I&O
o Monitor fluid and electrolyte imbalance
o Prevent infecDon
o Administer saline infusions to restore fluid
o Monitor and protect against skin breakdown
volume
o Monitor WBC
o Administer HydrocorDsone IV bolus and a
o Daily weights
conDnuous infusion or intermiment IV bolus
o Foods high in calcium and vitamin D
o Monitor and treat hyperkalemia
• MedicaDons
§ ECG
o Ketoconazole (adrenal corDcosteroid inhibitor)
§ Sodium polystyrene sulfonate
§ Monitor liver enzymes
§ Insulin
§ A/E: N/V, dizziness, skin changes
o Monitor and treat hypoglycemia
§ Take medicaDon with food
• MedicaDons
o HydrocorDsone, prednisone, and corDsone
§ Monitor weight, BP, and electrolytes
§ Tapper off dose to avoid acute
adrenal insufficiency
§ Take with food
ComplicaDons à Acute adrenal insufficiency
• Sudden drop in adrenocorDcoids due to sudden disconDnuaDon of medicaDon
• Rapid infusion of 0.9%NS
41 •
•
•
•
•
•
PaDent
•
•
.
HydrocorDsone as IV bolus
Insulin and dextrose to move K+ into cells
Loop or thiazide diureDcs to manage hyperkalemia
H2 antagonist (famoDdine) IV for ulcer prevenDon
Place paDent in recumbent posiDon with legs elevated
Vasopressors to increase BP
EducaDon
Taper off medicaDon
During Dmes of stress, addiDonal glucocorDcoids might be needed to prevent adrenal crisis
Thyroid ComplicaDons
• Thyroid Crisis Management: Immediate AcDons for Hyperthyroid PaDents Experiencing Thyroid Storm
• Thyroid Health: Recognizing Hypothyroidism Symptoms
Hypothyroidism (MS p.531)
Hyperthyroidism (MS p.525)
Findings:
Findings:
• T3/T4: DECREASED
• T3/T4: INCREASED
• TSH: INCREASED
• TSH: DECREASED
• Low B/P
• Irritability and emoDonal
• Bradycardia
• HyperacDvity, decreased amenDon span
Lethargy and FaDgue
• Insomnia
• COLD intolerance
• Weakness, exercise intolerable
• Poor Wound Healing
• Muscle weakness
• ConsDpaDon
• HEAT intolerance
• Weight GAIN
• Weight LOSS
• Depression and Withdrawal
• Diarrhea
• Bradycardia, Hypotension, Dysrhythmias
• Menstrual irregulariDes
• HypovenDlaDon
• Increased libido
• Coarse Hair
• Warm, sweaty, flushed skin
• Hair LOSS
• Tremors
• Abnormal menstrual periods
• Exophthalmos (Grave’s disease only)
• Decreased libido
• Photophobia
Nursing Care
• Goiter
o Monitor cardiac changes
• Elevated SBP and widened pulse pressure
o Monitor weight
• Tachycardia, palpitaDons, and dysthymias
o AnD-embolism stockings and elevate the paDent ’s legs
• Dyspnea
to assist venous return
Nursing Care
o Monitor respiratory status
o Minimize paDent ’s acDviDes
o Encourage to cough and breathe deeply to
o Promote calm environment
prevent pulmonary complicaDons
o High-calorie, protein
o Low-calorie, high-bulk diet
o Provide eye protectant (Exophthalmos)
o Administer stool soeeners as needed
o Reduce room temp/ cool showers
o Avoid fiber laxaDves, which interfere with
o NTP of temp increase of 1F
absorpDon of levothyroxine
o ECG
o CauDon the use of electric blankets or other heaDng
o Avoid palpaDng the thyroid gland
devices
MedicaDons
o Can result in unrecognized burns due to
Methimazole and Propylthiouracil (PTU)
decreased sensaDon
o inhibits the producDon of the thyroid hormone
MedicaDons
o Hepatotoxic
Levothyroxine (Synthroid)
o NTP of jaundice
o Take the dose prescribed
o Leukopenia / thrombocytopenia
§ Do not stop taking the medicaDon or
o NTP of fever, sore throat, and bruising
change the dose or brand name
o Take with meals
o Take in the AM, 30-60min before breakfast
o Methimazole should be stopped if pregnant
o Follow intake of iodine
42 Monitor for manifestaDons of hyperthyroidism
(irritability, tremors, tachycardia, heat
intolerance, rapid weight loss)
o LIFELONG treatment
o Can increase the effects of warfarin and
increase the need for insulin and digoxin
o Doses start small, increases every 2-3w. TSH is
monitored to ensure correct dosage
o Calcium interferes with the metabolism of
Levothyroxine
§ Avoid taking calcium within 4hr of
Levothyroxine
ComplicaDons: Myxedema Coma
§ EMERGENCY
ManifestaDons
§ Respiratory failure
§ Hypotension
§ Hypothermia
§ Bradycardia, dysrhythmias
§ Hyponatremia
§ Hypoglycemia
§ Coma
Nursing Care
§ Airway patency with vent support if needed
§ ConDnuous ECG monitoring
§ ABGs
§ Warm blankets
§ Monitor temp and BP unDl stable
§ Replace fluid with 0.9%NS
§ Levothyroxine IV bolus
§ AdministraDon of T3 IV unDl the paDent is stable
§ Treat hypoglycemia with glucose
§ CorDcosteroids
§ Treat any underlying illnesses
o
Beta-Blockers (Propranolol)
o Monitor HR, BP, ECG
o Monitor for hypoglycemia (DM pts)
o Monitor for orthostaDc hypotension
o Hold if HR is <60/min
Iodine soluDons (Lugol’s soluDon)
o Inhibits the release of thyroid hormone
o Short-term (10 days following surgery)
o Take 1hr aeer anDthyroid medicaDon
o Contraindicated for pregnant/breasueeding
o Mix with juice to mask taste
o Use straw to avoid staining
Treatments/ Procedures
RadioacDve iodine therapy
o Contraindicated with pregnant pts
o ConDnue to take anDthyroid meds
o Stay 1m away from pregnant individuals, infants, or
small children for the first week following treatment.
o Limit contact to no more than 1hr daily
o RadiaDon precauDon
o Do not use the same toilet as others for 2w
o Flush toilet 3 Dmes
o Take a laxaDve 2-3days aeer treatment to help
rid of the radiaDon
o Wash clothes separate from others
§ Run a full cycle aeer washing
contaminated clothing
o Avoid contaminaDon from saliva (no sharing
drinks)
Thyroidectomy
o Take PTU 4-6w before surgery
o Take iodine for 10-14 days before surgery
o Reduces gland size and prevents further
bleeding
o Post-op
o Support neck
§ Semi-Fowler’s
§ Avoid neck extension
o Deep breathing and coughing every 30-60min
o Hoarseness and sore throat are expected
o Monitor VS/15min unDl stable, then every
30min
o Assess for laryngeal nerve damage by asking
pt to speak as soon as awake from anesthesia
and every 2hr
o Administer pain meds
o Check for indicaDons of hypocalcemia
§ Parathyroid damage
§ PosiDve Chvostek’s and Trousseau’s
sign
§ Have IV Calcium gluconate readily
available
ComplicaDon: Thyroid Storm/Crisis
§ EMERGENCY
ManifestaDons
§ Hyperthermia
§ HTN
43 § Delirium
§ VomiDng
§ Abdominal pain
§ Tachydysrhythmias
§ Chest pain
§ Dyspnea
§ PalpitaDons
Nursing AcDons
§ ConDnuous ECG
§ Acetaminophen to decrease temp
o Salicylate (aspirin) is contraindicated
§ Provide cool sponge baths/ ice packs
§ Methimazole or PTU
§ Beta-blockers
§ GlucocorDcoids
o If adrenal insufficiency is suspected
o Treats shock
§ IV fluids
§ Supplemental O2
§ Increase caloric intake with meals
Cirrhosis (MS p. 365)
• Scarring of the liver caused by necroDc injury or a chronic inflammaDon over a prolonged period of Dme.
• Bile ducts are blocked à jaundice (sclera, palm or hand and oral mucosa)
• Risk factors
o Alcohol use disorder
o Chronic viral hepaDDs (hep B,C, or D)
o SteatohepaDDs (famy liver disease causing chronic inflammaDon)
• Findings
o FaDgue
o Weight loss, abdominal pain, distension
o Pruritus (itching of the skin)
o Confusion (due to the buildup of waste products in the blood and brain that the liver is unable to get rid of)
o Esophageal varices
o Splenomegaly
o Ascites
o Petechiae
o Spider angiomas
o Dependent peripheral edema
o Asterixis (flapping of the hands)
o Fruity odor of the breath
• Treatment
o DiureDcs
o Beta-blocking agent
o Lactulose (decreases ammonia levels)
o Paracentesis (relieve ascites
___________________________________________________________________
NURSING CARE OF CHILDREN
Varicella:
• Transmission:
o Airborne
o Indirect contact
44 Direct
Droplet
§ Communicable unDl lesions form crusts
AnDpyreDc: Tylenol, never aspirin
AnDpruriDc: diphenhydramine
Fluids and nutriDon
NoDfy health department
Keep fingernails short, skin clean and dry; bathe in tepid water
Not contagious when skin lesions are crusted over
o
o
•
•
•
•
•
•
EpiglosDs (Peds p.96)
• Pediatric Respiratory Illness: Planning for EpigloE:s Care in Toddlers
• Medical emergency
• Findings
o No cough
o Drooling
o Tripod posiDon
o Dysphonia (croaking sound)
o Dysphagia
o Inspiratory stridor
o Use of accessory muscles
o Sore throat, high fever
• Nursing care
o Protect the airway
o NO throat culture or tongue blade
o Prepare for intubaDon
o Administer corDcosteroids, and IV fluids
o Administer anDbioDc starDng with IV, then transiDon to oral to complete a 10-day course
o INITIATE DROPLET precauDons and maintain for first 24hr aeer IV anDbioDcs iniDated
Bacterial Pneumonia (Peds p.95)
• Bacterial Pneumonia: IdenDfying Typical ManifestaDons
• Findings
o HIGH fever
o Cough
o Tachypnea
o RetracDons and nasal flaring
o Chest pain
o Dullness with percussion
o Rhonchi, fine crackles
o Pale color that progresses to cyanosis
o Irritability, restless, lethargic
o Abdominal pain, diarrhea, lack of appeDte, and vomiDng
• Nursing Care
o Rest
o IV anDbioDcs
o Increased oral intake
o Monitor I&O
o AnDpyreDcs for fever
o CPT for postural drainage
o IV fluids
o Administer O2
o ConDnuous oximetry
45 AppendiciDs (Peds p. 145):
• S/S:
o Pain in RLQ
o Fever
Kawasaki Disease (Peds p. 120):
• Pediatric Cardiovascular Care: Planning for Kawasaki Disease Management
• S/S:
o Onset of fever lasDng 5 days-2 weeks (unresponsive to anDpyreDcs)
• Nursing care:
o Maintain cardiac monitoring
o Offer clear liquids and soe, non-acidic foods
Acute GlomerulonephriDs (Peds p. 159):
• Risk factors:
o Recent upper respiratory infecDon or
streptococcal infecDon
• S/S:
o Cloudy, tea-colored urine
o Decreased urine output
o Facial edema ® worse in the morning ®
spreads to extremiDes and abdomen during
the day
o Hematuria
o MASSIVE proteinuria
• Nursing care:
o Weigh child on the same scale with same
amount of clothing daily
NephroDc Syndrome (Peds p. 160):
• AlteraDons in glomerular membrane allow to pass into
urine ® proteinuria, hyperlipidemia, edema
• S/S:
o Weight gain
o Facial and periorbital edema ® decreased
throughout the day
o Decreased urine – FROTHY
o Anorexia
• Labs
o Hypoalbuminemia
o Elevated H/H and platelets
o ESR increased
• Nursing care:
o Monitor edema and abdominal girth
RheumaDc Fever (Peds p. 118):
• Risk factors:
o Occurs within 2-6 weeks following an untreated or parDally treat upper respiratory infecDon
• S/S:
o Large joints with swelling
o Pink, nonpruriDc macular rash on trunk and inner surfaces of extremiDes
o Elevated ESR
• MedicaDons
o Methotrexate
Maltreatment of Infants and Children (Peds p. 295):
• Iden:fying infant abuse risk factors.
• Risk factors:
o Caregiver characterisDcs:
§ Having a partner unrelated to child
§ Low income
§ Substance use
§ History of being abused
§ Lack of support
o CharacterisDc of child:
§ Child 1 year old or younger
§ Physical or mental disability
§ Premature
o Environmental:
§ Chronic stress
§ Divorce, alcohol, or substance disorder, poverty
§ Unemployment
46 §
§
Crowded living condiDons
SubsDtute caregivers
Car Seat Safety (Peds p. 17)
• Educa:ng pa:ents on car seat safety before discharge.
• 45-degree angle
• Rear facing, middle seat, away from windows
• Shoulder harnesses are placed in the slots or below the level of the infants shoulders
• Rear facing unDl the age of 2
• Retainer clip at the level of the newborn’s axillae
• Make sure 2 fingers between baby chest and harness
•
Sickle Cell Crisis (Vaso-occlusive): (PED p.126)
• S/S:
o Painful swelling of the hands and feet
o Hematuria
o Visual disturbances
• Nursing care:
o IniDate IV fluids
§ HYDRATION IS PRIORITY à decreases the rate of cell sickling and can reduce pain
§ Hypotonic fluids are typically infused at 250ml/he for 4hr
o Keep extremiDes extended
o RBC transfusion
o Humidified O2
o NO automated BP cuff à can cause venous occlusion and increased pain.
o Assess peripheral circulaDon hourly
o Assess the paDent ’s mouth every 8hr à presence of sores or lesions and any other signs of infecDon
CysDc Fibrosis: (PED p. 105)
• Cys:c Fibrosis Management: Pre-Postural Drainage Protocol
• Contact precauDon
• Perform chest physiotherapy using percussion and postural drainage > reduce mucus obstrucDon
o Done before meals to avoid vomiDng or regurgitaDon
§ Or at least 1hr aeer meals
o Mechanical or manual percussion (will be prescribed by provider)
o Administer bronchodilator prior
o Have the child remain in each postural drainage posiDon for 20-30min to allow tome for percussion, vibraDon, and
postural drainage. Older children can tolerate longer periods
• High calorie, high protein diet
• Include daily acDvity
• High-dose anDbioDc treatment
• Hemoptysis: greater than 250mL/24hr is risk for hemorrhage
• Pancrelipase (PancreaDc enzymes):
o Treat paDent with pancreaDc impairment due to cysDc fibrosis
o Enhances digesDon of protein, fats, carbs in GI tract
o Take with meals to help with digesDon (prior to ingesDng, not following)
o Can sprinkle contents on food
• S/S:
o Steatorrhea
o Deficiency
• ContraindicaDons:
o Hot climates
• Sweat chloride test:
o Confirm the diagnosis > increase sodium and chloride
47 Juvenile Idiopathic ArthriDs (PED p. 187)
• Managing Juvenile Arthri:s: Teaching Methods for Chronic Neuromusculoskeletal Disorders
• Chronic autoimmune inflammatory disease affecDng joints and other Dssues
o Leads to wearing down and damage to the arDcular carDlage
o ExacerbaDon worsens with illnesses
• Expected Findings
o Joint swelling, sDffness, redness, warmth that is worse in the AM or aeer inacDvity : have child take warm bath AM
o Mobility limitaDons
o Fever
o Rash
o Limp in the AM
o Delayed growth
• Labs
o Elevated C-reacDve protein
o Elevated erythrocyte sedimentaDon rate (ESR)
• Nursing Care / PaDent EducaDon
o Administer analgesics
o ParDcipate in physical therapy to increase mobility and prevent deformiDes
o Full ROM exercise (swimming)
o Apply WARM moist packs prior to exercise
o Warm baths
• Treatment
o NSAIDs
o Methotrexate (DMARD)
§ Use when NSAIDs doesn’t work
§ Take at bedDme to prevent nausea
§ Teratogenic effects on fetus
o CorDcosteroids (Prednisone)
Toddlers (Peds p. 21)
• Expected physical findings in toddlers. Protruding Abdomen
• Age-appropriate acDviDes for toddlers.
Varicella (Peds p. 235):
• Understanding how chickenpox spreads.
• Transmission:
o Airborne
o Indirect contact
o Direct
o Droplet
• Varicella zoster is the causaDve agent of both chickenpox and herpes zoster.
o The virus is contagious to people who have not had chickenpox or have not received vaccinaDon for varicella
Reye Syndrome: (PEDS p. 61)
• Primarily affects the liver and brain, causing liver dysfuncDon and cerebral edema
• Risk factor
o Aspirin
o Follows illness (flu, gastroenteriDs, varicella)
• S/S:
o Altered mental status
o Impaired hepaDc funcDon
o Confusion
o Delirium
o Profuse vomiDng
o Seizures
o Loss of consciousness
• Nursing care
48 Maintain hydraDon (IV)
PosiDon the paDent
§ Avoid extreme flexion, extension, or rotaDon
§ Maintain the head midline
§ Keep the HOB elevated 30 degrees
§ Monitor coagulaDon and prevent hemorrhage
§ Implement seizure precauDons
MedicaDons
o Mannitol
§ Decrease cerebral swelling
o
o
•
Diabetes: (PED p. 215)
• School-age educaDon:
o Eat a snack half an hour between physical acDvity
o Monitor levels frequently on sick days
o Store bomles in room temperature or in a refrigerator
• Type 1:
o Contraindicated to use cold pack
Asthma:
• Albuterol metered-dose inhaler:
o Clean mouthpiece everyday with warm water and soap, drying it before placing it back
o Wait at least 1 minute between inhalaDons
o Take long, slow inhalaDon
o Take medicaDon 5 to 20 minutes prior to exercise to promote bronchodilaDon
Myelomeningocele
• A serious complicaDon of spinal bifida is a NTD in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at
birth.
• At risk for latex allergy
Anterior fontanel
• Closes at 12-18 months
Posterior fontanel
• Closes at 2-3 months
____________________________________________________________________________________________________________
MATERNAL NEWBORN
Cesarean Birth (MNB p. 105)
• PosiDoning for cesarean birth.
• Place a wedge under one of the client’ hips.
Basal body temperature (MNB p. 4):
• Teaching basal body temperature method for contracep:on.
• BBT is the temperature of the body at rest
• PaDent educaDon:
o Take temperature immediately aeer waking up and before gesng out of bed
o Working at night > take temperature aeer awakening from the longest sleep cycle
o During ovulaDon, there is slight elevaDon in BBT
• Body temperature rises aeer ovulaDon; remains elevated unDl 2 to 4 days prior to start of menstruaDon
• Measure body temperature upon waking each morning prior to gesng out of bed
• Decrease in body temperature prior to ovulaDon
• Body temperature rises 1 to 2 days aeer ovulaDon
49 Ovarian Cancer:
• Early manifestaDons:
o Abdominal bloaDng
o Increase abdominal girth
o Pelvic or abdominal pain
o Urinary frequency or urgency
o ConsDpaDon
Mastectomy:
• Drains are usually lee in for 1 to 3 weeks
• Remove when there is a 25 mL of output or less in a 24 hr period
• Avoid dependent posiDon, flexing the affected arm, NO VS or LAB DRWS
• Perform early arm and hand exercises
• AcDve ROM 1 week aeer
• Numbness can occur
• Wear lose fisng clothes
Nonstress Test (MNB p. 33):
• Evaluate fetal well-being
• Noninvasive that monitors response of FHR
• PaDent will push a bumon whenever they feel a fetal movement
• Completed within 20-30 minutes
• NonreacDve: test does not demonstrate 2 qualifying acceleraDons in a 20-min period
o If test is nonreacDve > contracDon test or BPP is indicated
• PaDent should seat in a reclining chair, or place in a semi-fowlers, or lee lateral posiDon
Amniocentesis (MNB p. 35):
• Done at 15-20 weeks
• Detects ® anomalies (ex. neural tube defects) and lung maturity
• Nursing acDons:
o Assist paDent into supine posiDon and place wedge under the right hip their right hip to displace uterus off the vena
cava
o Administer Rh if they are Rh-negaDve aeer
• Educate: feelings of slight pressure. Call provider if having contracDons post procedure.
AbrupDo Placentae (MNB p. 46) and Placenta previa (MNB p. 44):
• Pregnancy ComplicaDons: Analyzing Bleeding Indicators
AbrupDo Placentae: (OB p.46)
Placenta previa: (OB p.44)
• Cause: Low lying placenta
• Cause: HTN, Cocaine Abuse and abdominal trauma
• S/S:
• S/S:
o Painless, bright red vaginal bleeding
o Localized pain with dark red vaginal bleeding
o Uterus soe, relaxed, and nontender
o Uterine tenderness, contracDons
o Fundal height is greater than expected
• Increased risk for hemorrhage
• Increased risk for hemorrhage
• Have risk for increased fundal height
• Nursing care:
o Refrain from performing vaginal exams
• Nursing care:
o Strict bedrest
o immediate birth
o Do not insert anything
• Risk factor for SGA
o Monitor for respiratory distress
GestaDonal Hypertension (OB p.62)
• Findings
o HTN
o Proteinuria
Preeclampsia (MNB p. 62):
• Pregnancy ComplicaDons:
DetecDng GestaDonal Issues
• GestaDonal hypertension:
HELLP (MNB p. 62)
• Pregnancy ComplicaDons:
DetecDng GestaDonal Issues
50 o
o
o
o
o
o
o
o
o
•
o
o
Periorbital, facial hand,
and abdominal edema
Pisng edema of lower
extremiDes
VomiDng
Oliguria
Hyperreflexia
Epigastric pain
RUQ pain
Dyspnea
Diminished breath
sounds
Seizures
Jaundice
•
•
•
Labs
Elevated liver enzymes
(LDH, AST)
o Increased CreaDnine
o Increased plasma uric
acid
o Thrombocytopenia
o Hgb (decreased in
HELLP, increased in
preeclampsia)
o Hyperbilirubinemia
TX: O2 NC and Nifedipine
o
•
PaDent will have a BP
higher than 140/90
or on 2 different
readings at least 4 hr
apart
Preeclampsia S/S:
o Proteinuria greater
than or equal to 1
o Headache
Severe S/S:
o BP 160/110
o Proteinuria
Eclampsia S/S:
o BP 160/110
o RR 30<
o Blurred vision
o Seizure
§ Side lying
§ Magnesium
Sulfate ® If
allergic give
Diazepam
Nursing care:
o Strict bedrest
o Quiet nonsDmulaDng
environment
o Ck urine output
o Advise to drink 6-8 oz
of water each day
o Seizure precauDons
o
•
•
•
•
•
Hematologic condiDon + severe
preeclampsia involving hepaDc
dysfuncDon
H: Hemolysis ® anemia and
jaundice
EL: Elevated liver enzymes ®
AST/ALT
LP: Low platelets (less than
100,000) ® thrombocytopenia,
abnormal bleeding
GestaDonal Diabetes Mellitus (OB p. 59)
• Pregnancy Complica:ons: Detec:ng Gesta:onal Issues
• Findings
o Hypoglycemia: nervousness, headache, weakness, irritability, hunger, blurred vision
o Hyperglycemia: polydipsia, polyphagia, polyuria, nausea, abdominal pain, flushed dry skin, fruity breath
§ Hypoglycemia
§ Shaking
§ Clammy pale skin
§ Shallow respiraDons
§ Rapid pulse
§ Hyperglycemia
§ VomiDng
§ Excess weight gain during pregnancy
• Labs
o Glucose tolerance tests
§ PosiDve: 130-140mg/dL or greater
§ AddiDonal tesDng with a 3hr oral glucose test is indicated
Engorgement (fullness) (MNB p. 122):
MasDDs (breast infecDon): (OB p.147)
• Postpartum Infec:ons: Iden:fying Risks in
• S/S:
Breas[eeding Pa:ent s
o Area that is red, swollen, warm, tender
• Educa:ng on the benefits of breas[eeding.
• Educate:
o Nipples to air dry
• If paDent does not plan to breasueed > resolve on its
o Ice/warm packs for discomfort
own
o BUT this can help:
§ Breast binders
§ Support bras, Dght fisng
51 § Ice pack or cabbage leaves
Advise not to sDmulate the breast or express
breast milk
If paDent plans to breasueed > breast care and
frequent feedings will prevent and manage
engorgement
o Manually express milk to facilitate latch
o Warm shower prior to breasueeding
o Breast massage
o Manually put milk
o Cool compress aeer feeding
o Sore ® apply small amount of breast milk to
the nipple and air dry aeer breast feeding, alt
Start infant on pain-free breast
o
•
EndometriDs (uterine infecDon): (OB p.148)
• Postpartum Infec:ons: Detec:ng Mas::s and Endometri:s Signs
• S/S:
o Uterine tenderness and enlargement
o Dark, profuse lochia
o Lochia that is purulent-Bacteria group strep B
o Tachycardia
o Temperature 100.4 <
• Risk factor à c-secDon
Common discomforts for mothers:
• Increase intake of fiber to prevent consDpaDon
• Hormonal changes increase pigmentaDon on face, but hydrocorDsone will not resolve
• Back pain relieve with:
o Moderate exercise
o Firm mamress
o Wearing low heeled shoes
o Sleep on side > promote placental perfusion
• wear supporDve bra to promote comfort
Reducing perineal infecDon (perineal care):
• Blot the area dry
• Clean front to back
• Perform hand hygiene before and aeer
• Wash the perineal area using a squeeze bomle of warm water
Hyperemesis Gravidarum: (OB p.60)
• Pregnancy Complica:ons: Detec:ng Gesta:onal Issues
• S/S:
o Excessive vomiDng
o DehydraDon with possible electrolyte imbalance
o Weight loss
o Increase pulse rate, decreased BP
o Poor skin turgor
• Nursing care:
o Keep NPO unDl vomiDng stops
o Alternate eaDng solid foods and liquids
o Drink warm ginger ale when nauseated
o Eat every 2-3hr
o Eat foods high in protein and low In fat
52 •
•
MedicaDons:
o IV lactated ringers for hydraDon
o Pyridoxine (vitamin B6)
o Metoclopramide > NV
Educate:
o Eat every 2 to 3 hours to avoid having an empty stomach
o Separate liquids from solids
o Eat foods high in protein and that are low in fat
o Warm ginger ale or ginger tea can decrease nausea
Neonatal AbsDnence Syndrome (MNB p. 189):
• Pregnancy Complica:ons: Detec:ng Gesta:onal
Issues
• Substance use during pregnancy:
o Opioids > Heroin, Methadone
o NOT MARIJUANA OR AMPHETAMINE
• S/S:
o High pitched cry
o Increased DTR
o Hypertonicity
o Nasal congesDon with flaring
o Poor feeding
• Nursing care:
o Reduce environmental sDmuli
o Burp infant to reducing vomit and aspiraDon
o Withdrawing from cocaine > avoid eye contact
• MedicaDons:
o Morphine Sulfate
o Phenobarbital
Infant Hypoglycemia (MNB p. 190):
• Pregnancy Complica:ons: Detec:ng Gesta:onal
Issues
• Source of glucose stops when cord is clamped
• IniDal drop in blood glucose aeer birth is common
• Healthy newborn can tolerate 30 mg/dL
• > 40-45 mg/dL ® need intervenDon
• Risk:
o Preterm or small/large for gestaDonal age
• S/S:
o THINK WEAK
o Poor feeding
o Weak cry
o Flaccid muscle tone
• Nursing care:
o Heel sDck for glucose monitoring
o NIPS: Neonatal infant pain scale
o Early feedings within first hour of life
o Feed every 2-3 hours in the first 24 hours
o Skin to skin contact
• TIP: cold stress ® hypoglycemia ® respiratory distress
Hyperbilirubinemia (MNB p. 198):
• Newborn Care: Phototherapy Interven:ons for Jaundiced Infants
• Newborn Care: Interven:ons for Phototherapy Treatment
• Physiologic jaundice (benign): occurs 24 hours aeer birth
• Pathologic jaundice (underlying disease): appears before 24 hours or persistent aeer day 14
o Caused by blood group incompaDbility or an infecDon
• Direct Combs’ test reveals the presence of anDbody-coated Rh-posiDve RBCs in the newborn
• Nursing care:
o Phototherapy:
§ Eye mask
§ Keep newborn undressed
• Male: surgical mask should be placed over genitalia (remove metal strip to prevent from burning)
§ AVOID applying loDons or ointments
§ Dress in diaper only
§ Remove the newborn every 4 hr and unmask the eyes
§ ReposiDon every 2 hr
§ Check lamp with photometer
§ Turn off lights before drawing blood
§ Breast Feed every 3-4 hr
Newborn:
• Normal findings:
o HR: 110-160 bpm
53 •
•
•
•
o RR: 30-60 bpm
o Temp: 97.7-99.5
o Transient strabismus or nystagmus is normal unDl the age of 3-4 months
o Overlapping of sutures occurs with molding following a vaginal delivery
o Acrocyanosis
Not normal:
o Respiratory distress findings:
§ Nasal flaring
§ Substernal RetracDons
§ GrunDng
§ Meconium AspiraDon
Assessing HR:
o Accurate in a quiet state
o Auscultate apical pulse for 1 min
Measuring weight/height:
o Weight without diaper
o Place disposable covering
o Balance the scale to 0 prior to use
EffecDve breasueeding:
o Measuring the number of wet diapers (6-8 wet diapers)
Infant (MNB p. 164):
• Newborn Pain Assessment: EvaluaDng Pain in Full-Term Infants
• DehydraDon S/S:
o Sunken anterior fontanel
o Hyperpnea
o Weight loss greater than 10%
o Cap refill greater than 4 sec
• Pain assessment:
o CRIES scale
o Scale for Use in Newborns (SUN)
o Neonatal Infant pain scale (NIPS)
Teaching for mother of 20 weeks of gestaDon
• Prenatal Guidance: Teaching Expectant Mothers at 20 Weeks
• Preterm birth 20-37w (p.192)
• Heartburn (p.69)
• PPROM (preterm premature rupture of membranes) between 20-37w (p.69)
• Quickening (flumering movements) felt between 16-20w (p.17)
• Alpha-fetoprotein (AFP) can be measured from the amnioDc fluid between 15-20w (p.35)
o Used to assess for NTD or chromosomal disorders
Prolapsed Cord (OB p.109)
• Obstetric Emergencies: Interven:ons for Prolapsed Umbilical Cord
• FHR ® prolonged or variable deceleraDon
• Nursing Care
o CALL FOR HELP!
§ do not leave the paDent
§ NTP
o Using a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to
the fetal presenDng part to elevate it off the cord.
§ Stay in this posiDon unDl the delivery of the baby
o ReposiDon the paDent in a knee-chest, TRENDELENBURG, or side-lying posiDon with a towel under the paDent ’s
right or lee hip to relieve pressure on the cord
o Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow.
o ConDnuous FHR monitoring
o Administer O2 at 8-10L/min via face mask to improve fetal oxygenaDon
54 o
o
Ensure Iv access and administer IV fluid bolus
If cervix is fully dilated = prepare for immediate vaginal birth
§ If not fully dilated = cesarean birth
Uterine prolapse
• Urinary inconDnence
• Backache
• Urine retenDon
• ConsDpaDon
Hemorrhaging:
• Tachycardia
• Tachypnea
• Decrease in BP (hypotensive)
• Restless
MedicaDons:
• TherapeuDc Effects: IdenDfying Benefits of Magnesium Sulfate Therapy
Increase Uterine ContracDons (DOMM):
Decrease uterine contracDons (MINT):
-Post-partum hemorrhage
-Preterm labor
Oxytocin
Magnesium Sulfate:
• For Eclampsia observe for decreased clonus w DTRS
• Toxicity S/S:
o Loss of DTR
o Urine output less than 30 mL/hr
o RR <12
o PE
o Severe hypotension
o Chest pain
o AnDdote: Calcium gluconate
Methylergonovine:
Terbutaline
• Do not administer for HTN paDents
Misoprostol
Nifedipine
Indomethacin
• GI upset
Other MedicaDons:
Betamethasone
Enhances fetal lung maturity
Check LS raDo 2:1
24 weeks of gestaDon
Metronidazole
Trichomoniasis
Expect urine to turn dark
Doxycycline
Chlamydia
Penicillin
Syphilis
MENTAL HEALTH
Trauma and Stress Related Disorders (MH p. 61):
• Trauma and Stress Disorders: IdenDfying Signs Requiring AmenDon
Substance Use and AddicDve Disorders (MH p. 93):
• Substance Abuse RecogniDon: IdenDfying Signs of AddicDon
Defense Mechanisms: (MH p. 19)
• RaDonalizaDon: jusDfying
55 •
•
•
•
•
Displacement: shieing feelings related to an object, person or situaDon to another less threatening object, person, or
situaDon
Suppression: voluntarily denying unpleasant thoughts and feelings
SublimaDon: dealing with unacceptable feelings or impulses by unconsciously subsDtuDng acceptable forms of expression
ReacDon formaDon: unacceptable feelings or behaviors are controlled or kept out of awareness by overcompensaDng or
demonstraDng
Regression: childlike behavior (think Nevil)
Crisis: (MH p. 173)
• SituaDonal / external: unanDcipated loss or change experienced in everyday, oeen unanDcipated, life events (divorce or job
change)
• MaturaDonal / internal: achieving new developmental stages, which requires learning addiDonal coping mechanisms (gesng
married or reDring)
• AdvenDDous: the occurrence of natural disasters, crimes, or natural disasters
• Internal
Electroconvulsive therapy: (MH p.51)
• Used for major depressive disorder, schizophrenia spectrum disorders, acute manic episodes
• Induces seizure acDvity
• Typical course is 2-3 Dmes a week for a total of 6-12 treatments for depression
• Informed consent must be signed
• Pre-work
o CXR
o Blood work
o ECG
• Severe HTN should be controlled because a short period of HTN occurs immediately aeer the ECT procedure
• ComplicaDon:
o Short term memory loss, confusion, disorientaDon
Transcranial magneDc sDmulaDon: (MH p. 52)
• A noninvasive therapy that uses magneDc pulsaDons (MRI strength) to sDmulate the cerebral cortex of the brain
• For major depressive disorder for paDent s that are not responsive to pharmacological treatment
• ConsideraDons:
o Last 30-40 minutes
• Common A/E: mild discomfort or a Dngling sensaDon at the site and headaches
Depressive Disorders: (MH p.67)
• Risk factors:
o Family history/previous personal history of depression
o Females
o PaDent s over 65
• MedicaDons: (MH p.69)
o For ALL anDdepressants:
§ Do not disconDnue
§ Can take several weeks to reach full therapeuDc effects
§ Avoid hazardous acDviDes
§ Avoid alcohol
SSRIs
Leading treatment for depression –
increases serotonin
ParoxeDne (MH p. 53)
SNRIs
Venlafaxine
DuloxeDne
o
Adverse effects:
o Nausea
o Insomnia
Tricyclic AnDdepressants
Amitriptyline
o
Change posiDons slowly
to minimize dizziness
from orthostaDc
hypotension
Monoamine oxidase inhibitors
Phenelzine (MOAI)
Isocarboxazid
Selegiline
o
Adverse effects
56 •
Anxiety MedicaDon
EducaDon: SupporDng
PaDent s on ParoxeDne
Citalopram
FluoxeDne
Sertraline
ParoxeDne
o
o
o
o
3 S’s of SSRI
o Serotonin
Syndrome
o Sexual
dysfuncDon
o Stomach issues
Other A/E: weight gain,
faDgue, and drowsiness
May take 4-6 weeks to
take effect à SUICIDE
WARNIG
Take medicaDon in the
morning
Wt. gain
Diaphoresis
Sexual
dysfuncDon
o OrthostaDc
hypotension
May take 4-6 weeks to
take effect
Cannot mix with TCAs
or MAOIs
o
o
o
o
o
Atypical AnDdepressants
Bupropion
Serotonin syndrome
o Can begin 2-72hr aeer
staDng treatment – lethal
o use of St. John’s wort
o confusion, agitaDon, poor
concentraDon
o hallucinaDon, delirium
o seizures
o tachycardia
o fever
o hyperreflexia
o N/V/D, abdominal pain
o Coma
MAOI + SSRI = serotonin syndrome
• DisorientaDon
• IncoordinaDon
• Fever
• Hyperreflexia
• Tremors
o
o
o
Adverse Effects:
o Headache
o Dry mouth
o GI distress
o ConsDpaDon
o Tachycardia
o Nausea
o Restlessness
o Insomnia
Monitor food intake
and weight due to
appeDte suppression
Avoid administering if at
risk for seizures
o
o
o
o
o
To minimize
anDcholinergic effects,
chew sugarless gum, eat
foods high in fiber, and
increase fluid intake to 23L/day
May take 2-3 weeks to
take effect
WAIT 14 days aeer being
off MAOIs to start taking
TCAs
Weigh the paDent
weekly
AnDdote: physosDgmine
OrthostaDc
hypotension
o Dizziness
o Blurred vision
o ConsDpaDon
o Dry mouth
o N/V
AVOID tyramine –
hypertensive crisis
o Avocados
o Figs
o Fermented or
smoked meats,
liver
o Dried or cured
fish
o Aged Cheese
o Beer / wine
o Protein dietary
supplements
o Chocolate
o
o
Hypertensive Crisis
o Headache
o N/V
o Tachycardia
o HTN
o Diaphoresis
o Change in LOC
Alcohol (MH p. 94):
• IntoxicaDon:
o S/S:
§ THINK WHEN YOU ARE DRUNK
MedicaDon:
§ Disulfiram
• NO alcohol (mouthwash, vanilla extract)
o Will make paDent feel sick
• B1 (Thiamine)
Withdrawal:
o S/S:
§ Abd cramping
§ VomiDng
§ Tremors, restless
o MedicaDons: Benzodiazepine
o
•
57 §
Diazepam
• Treats withdrawal symptoms
Opioid (MH p. 94):
• Breathing Support: Interven:ons for Pa:ent s Exhibi:ng Bradypnea on Opioid Medica:ons
• IntoxicaDon:
o THINK LOW AND SLOW
o S/S:
§ Check pupil reacDon
§ Check Respiratory rate-Prepare to intubate
§ Slurred speech
§ Impaired memory
§ Impaired judgement
o MedicaDon
§ Naloxone
• Reversal agent for opioids
• Withdrawal:
o Tremors
o Irritability
o Rhinorrhea
o Pupil dilaDon
o MedicaDon:
§ Methadone
• SyntheDc opiate that blocks the cravings for and the effects of narcoDcs.
• Reduces withdrawal symptoms, but does no cause a high
• MUST be taken everyday
• HIGHLY addicDve
Smoking cessaDon
• Bupropion
IdenDfying signs of AddicDon (MH p.93)
• Blackout or loss of consciousness
• Changes in bowel movements
• Weight loss or gain
• Experience of stressful situaDon
• Sleep problems
• Chronic pain
• Concern over substance use
• Cusng down on consumpDon or behavior
Bipolar Disorders: (MH p. 129)
• Mania SXS: pressured speech, excessive spending habits, lack of sleep, hallucinaDons, and disorganized thought
processes.
• Nursing AcDons – encouraging medicaDon adherence
o Provide high caloric finger foods. Weight the paDent once daily
o Engage the paDent in conversaDon following medicaDon administraDon
o Minimize environmental sDmuli for the paDent.
•
• Bipolar Disorder Treatments: Recognizing Lithium Toxicity Symptoms
• MedicaDons:
o Mood stabilizers:
§ Lithium carbonate (0.4-1.4 mEq/L) (MH p. 129, Blue p. 55):
• Treats for acute mania/bipolar disorder
• Lithium toxicity:
o Withhold medicaDon if experiencing:
§ Diarrhea
58 •
•
•
•
o
§ NV
§ Excessive sweaDng
§ coarse hand tremors
§ Ataxia (without coordinaDon)
§ Large output of dilute urine
§ Blurred vision
o Caused by hyponatremia : RISK FOR SEIZURES
§ dehydraDon
§ exercising in hot weather
o caused by old age
§ decrease in kidney funcDon à lithium builds up in the blood
Drink with milk to decrease GI upset
NSAIDs increase lithium levels
Monitor TSH à can cause goiter and hypothyroidism
o Monitor levels prior to starDng treatment and then annually
Educate:
o Diet: adequate in sodium
o Drink 1.5-3 L of water/day
AnDconvulsants:
§ Valproate
• Hepatotoxicity:
o Check liver funcDons ALT/AST
§ Carbamazepine:
• CNS effects:
o Nystagmus
o Double vision
o VerDgo
o Staggering gait
o Headache
• Administer at bedDme
§ Lamotrigine
• Monitor for Steven-Johnson syndrome or epidermal necrolysis
o Life-threatening reacDons that manifest iniDally as a rash for the first 2-8 weeks of
treatment
o NTP immediately if rash develops
• Common A/E
o Diplopia
o Dizziness, headache
AnDpsychoDc MedicaDons
• Psychotropic MedicaDon: IdenDfying Side Effects of TradiDonal AnDpsychoDcs
First generaDon AnDpsychoDcs (FGA’s)
Second GeneraDon AnDpsychoDcs (SGAs)
Chlorpromazine
Haloperidol
Fluphenazine
Loxapine
o Controls POSITIVE symptoms
ComplicaDons
o Agranulocytosis
o DisconDnue if WBC <3,000mm
o Observe for indicaDon infecDon
o AnDcholinergic effects
o EPS
o Acute dystonia
§ Severe spasms of the tongue, neck,
face and back
Clozapine
Olanzapine
Risperidone
QueDapine
o Controls NEGATIVE and POSITIVE symptoms
ComplicaDons
o Lower risk of TD, EPS, and NMS
o Metabolic syndrome
o Loss of glucose control
§ hyperglycemia
§ wt. gain
o OrthostaDc hypotension
o AnDcholinergic effects
o SedaDon / lethargy
59 CRISIS situaDon that requires rapid
treatment
• Treat with anDparkinsonian
agent à BENZTROPINE
• IM or IV diphenhydramine
(Benadryl) can help
• Stay with the paDent and
monitor airway unDl spasms
subside
Pseudoparkinsonism
§ Bradykinesia
§ Rigidity
§ Shuffling gait
§ Drooling
§
Fine hand tremors
§ Pin rolling
• Observe first month of
treatment – can occur in 530 days following 1st dose
• Treat with anDparkinsonian
agent à BENZTROPINE or
TRIHEXYPHENIDYL
• Fall precauDons
Akathisia
§ Inability to sit or stand sDll
§ ConDnual pacing and agitaDon
• Can occur w/in 5-60 days
following the first dose
• Manage with
anDparkinsonian agents,
beta-blockers, or BENZOs
(lorazepam/diazepam)
Tardive Dyskinesia (TD)
§ Late EPS, can take years to develop
§ Involuntary movements of the
tongue, face, such as lip smacking
§ Involuntary movements of the arms,
legs, and trunk
• Evaluate the paDent aeer
12mon of therapy and then
every 3mon
• If TD appears, dosage
should be lowered or
switched to a 2nd generaDon
• Irreversible A/E
§
o
o
o
o
o
Clozapine
o Monitor WBC
o Monitor Cholesterol levels à
hyperlipidemia/ dyslipidemia
NeurolepDc Malignant Syndrome
§ Sudden high fever
§ BP fluctuaDons
§ Diaphoresis
§ Tachycardia
§ Muscle rigidity
§ Decreased LOC
§ Coma
• LIFE-THREATENING
• STOP anDpsychoDc
medicaDon
60 •
•
•
•
•
o
o
o
o
o
o
o
OrthostaDc Hypotension
SedaDon
Seizures
Severe dysrhythmias
Sexual dysfuncDon
Skin effects
o PhotosensiDvity
Liver impairment
Cooling blankets
Administer anDpyreDcs
Increase paDent ’s flid intake
Administer DANTROLENE to
induce muscle relaxaDon
Wait 2 weeks before
resuming therapy. Consider
switching to an atypical
agent
3rd generaDon anDpsychoDcs: Aripiprazole
• Treat both posiDve and negaDve symptoms
Schizophrenia: (MH p.77)
• MedicaDons:
o Olanzapine: (SAG)
§ Adverse effect:
• Weight gain
PsychoDc disorders: (MH p.77)
• PosiDve symptoms:
o Things that are not normally present:
§ HallucinaDons
§ Delusions
§ AlteraDons in speech
§ Bizarre behavior
• NegaDve symptoms:
o Absence of things that are normally present:
§ Affect
§ Alogia
§ Anergia
§ Anhedonia
§ AvoliDon
• Delusions
o Ideas of reference
o PersecuDon
o Grandeur
o SomaDc delusions
o Jealousy
o Being controlled
o Thought broadcasDng
o Thought inserDon (other minds are being inserted in their mind)
o Thought withdrawal (believes their thoughts are being removed from their mind)
o Religiosity
o Magical thinking
• AlteraDons in speech
o Associated looseness (inability to concentrate on a single thought) à disorganized speech that leads from one
thought to another
o Neologisms
61 •
•
o Echolalia
o Clang associaDon (rhyming)
o Word salad (jumble of words)
MedicaDons:
o 1st generaDon/convenDonal anDpsychoDcs:
§ Haloperidol
§ Loxapine
§ Chlorpromazine
• Monitor for EPS (dystonia, akathisia, pseudo parkinsonism tardive dyskinesia)
o 2nd generaDon:
§ Risperidone
§ Olanzapine
§ Clozapine
o 3rd generaDon anDpsychoDcs:
§ Treat both posiDve and negaDve symptoms
§ Aripiprazole
Nursing AcDons – encouraging medicaDon adherence
o Provide for once-daily dosing; sustained-release forms
o Engage the paDent in conversaDon following medicaDon administraDon
Anorexia Nervosa (MH p. 99):
• Ea:ng Disorder Support: Providing Care for Pa:ent s with Ea:ng Disorders
• Types:
o RestricDng type restricts food intake and does not binge or purge
o Binge-eaDng/purging type engages binge eaDng or purging behavior
• Expected findings:
o Body weight that is less than 85% of expected
o Lanugo (fine, downy hair)
o Pale cool extremiDes
o Yellowed skin
o Amenorrhea (no period)
o OCD features
o Russell’s sign (calluses or scars on hands)
o Purging behaviors: enlargement of the paroDd glands
• Goal: increase weight 2-3 lbs./week
Bulimia nervosa (MH p. 99):
• Ea:ng Disorder Support: Providing Care for Pa:ent s with Ea:ng Disorders
• EaDng large quanDDes of food over a short period of Dme
• Expected findings:
o maintain a weight within the normal range or slightly higher
o Hypokalemia
§ Loss of potassium due to purging
Nursing care for Bulimia and Anorexia
• Use a posiDve approach and support to promote paDent self-esteem and posiDve self-image
• Provide a structured meal environment &
• Focus on the paDent s underlying feelings
• Encourage paDent decision making and parDcipaDng in the plan of care to allow a sense of control
• Monitor VS, I/O, and weight daily (2-3lb/weeks is medically acceptable)
• Use behavioral contracts to modify paDent behaviors
• Reward the paDent for posiDve behaviors (compleDng meals or consuming a set of number of calories)
• Closely monitor the paDent during and aeer meals to prevent purging, which can necessitate accompanying the paDent to
the bathroom
MedicaDons
• SSRIs
ComplicaDon
• Refeeding syndrome: potenDal FATAL
62 o
Occurs when fluids, electrolytes, and carbohydrates are introduced to a severely malnourished paDent
§ Consult with provider and dieDDan to develop a controlled rate of nutriDon support during iniDal treatment
ADHD: (MH p.617)
• Child and Adolescent Mental Health: Educa:ng on Methylphenidate Use
• MedicaDons:
o CNS SDmulant: Methylphenidate
§ ComplicaDons:
• Insomnia, restless
• Weight loss related to reduced appeDte
• Dysrhythmias, chest pain, high BP
§ PaDent educaDon:
• Administer in an empty stomach; before breakfast (first thing in the morning)
• Administer before dinner > causes insomnia
• Decrease caffeine intake
• Avoid driving and other acDviDes that require alertness unDl the effects of the medicaDon are
known
• Nursing care:
o Break task down
o Maintain low sDmuli environment
AuDsm Spectrum Disorder: (MH p.167)
• Behaviors affecDng an individual’s ability to communicate and interact with others in a social sesng
• Expected findings:
o Delays:
§ Social interacDon
§ Social communicaDon
§ ImaginaDve play prior to age 3 years
o Distress when rouDnes are changed
o Unusual amachments to objects
o Inability to start or conDnue conversaDon
• Nursing care:
o Promote posiDve reinforcement
o Increase social awareness
o Decrease environmental sDmulaDon
• Establish a familiar daily schedule that includes minimal amount of change
• Reward system
• Trust with one person
• Difficult communicaDng with a variety of caregivers
• Prescribe with SSRIs to improve mood and reduce anxiety
• Strict adherence to rouDnes
Delirium and DemenDa (Blue p. 183):
• Empowering Families: Teaching Approaches for Caregivers of Demen:a Pa:ents
• Delirium:
o Sudden (acute)
o Factors: Fever, hypotension, infecDon
o CogniDon: impaired memory, judgement, amenDon span than can fluctuate
o Speech: rapid, inappropriate
o REVERSIBLE
• DemenDa:
o Slowly
o Factors: Alzheimer’s disease
o CogniDon: abstract thinking
o Speech: slow
o IRREVERSIBLE
63 Support for caregivers (MS p. 90):
• Encourage to seek legal counsel
• Home care and community resources
• Encourage caregivers to ask help from friends and family
• Encourage to take care of themselves and take one day at a Dme
Mental Status ExaminaDon (MSE):
o Include data:
• Ability to perform calculaDons
• Recall ability
• Long-term memory
• Level of orientaDon
o
•
Alzheimer’s (Blue p. 183):
• Damage to the brain = demenDa
• Loss of memory / cannot understand reality
• Common cause of demenDa
Mild
Moderate
Severe
Losing/misplacing items
Difficulty performing task
Assistant in ADLs
Difficulty concentraDng
Wander and get lost
Losing awareness
SDll performs ADLs
Can be inconDnent
Loses ability to move
• MedicaDons
o Cholinesterase inhibitor medicaDons
§ Donepezil, rivasDgmine and galantamine
• Improve the ability to perform self-care and slow the cogniDve deterioraDon of Alzheimer’s disease
in the mild to moderate stages
• A/E
o N/V, and diarrhea
o Bradycardia, syncope, dizziness
o BronchoconstricDon can be caused by an increase of acetylcholine
§ Use with cauDon in paDent s who have asthma or COPD
o Dyspepsia à NTP
• InteracDons
o NSAIDs à GI bleed
• AnDhistamines, TCAs, and anDpsychoDcs can reduce the therapeuDc effects of donepezil
• EducaDon
o Tapper off med, never stop abruptly
o Monitor the ability to swallow tablets
o Administer at bedDme (with or without food)
• Home safety measures (MS p. 50)
o Remove scamer rugs
o Install door locks that cannot be easily opened, and place alarms on doors
o Keep a lock on the water heater and thermostat, and keep the water temperature at a safe level
o Provide good lighDng, especially on stairs
o Install handrails on stairs and mark step edges with colored tape
o Place the mamress on the floor
o Remove clumer and clear hallways for walking
o Secure electrical cords to baseboards
o Keep cleaning supplies in locked cupboards
o Insta;; handrails in the bathroom, at bedside, and in the tube
o Place a shower chair in the tub
o Wear a medical ID bracelet if living at home with a caregiver
o ParDcipate in an exercise program to maintain mobility
• CommunicaDon
o Distract & REDIRECT from reality
64 Personality Disorders (MH p.83)
Cluster A
ODD OR ECCENTRIC
• Paranoid
o Suspicious of others
o Thinks everyone wants
to harm them
• Schizoid
o Indifferent
o Seclusive
o Detached
o Doesn’t care for close
relaDonships
• Schizotypal
o Odd thinking
o Strange appearance
•
•
•
•
Cluster B
DRAMATIC OR EMOTIONAL
AnDsocial
o No care for others
o Aggressive
o ManipulaDve
o Doesn’t follow the rules
Borderline
o Impulsive
o Unstable
o ManipulaDve to self and
others
o Fear of neglect
Histrionic
o AmenDon seeking
o SeducDve
o FlirtaDous
NarcissisDc
o Egocentric
o Grandiose views of selfimportance
o Need for consistent
admiraDon
•
•
•
Cluster C
ANXIOUS OR INSECURE
Avoidant
o Anxious in social sesng
o Avoids social
interacDons but desires
close relaDonships
o Fear of abandonment
Dependent
o Extreme dependency
on someone
o Searches urgently to
find a new relaDonship
when the other fails
Obsessive-Compulsive
o PerfecDonist
o Control issue
o Indecisiveness
o Goal-oriented
Obsessive-Compulsive Disorders (MH p. 58):
• IdenDfying Traits: Recognizing Expected CharacterisDcs in Obsessive-Compulsive Personality Disorder
• OCD: intrusive thoughts of unrealisDc obsessions and control thoughts with repeDDve cleaning
• Hoarding disorder
• Body dysmorphic disorder
• Nursing care:
o Structured interview
• TherapeuDc procedure:
o Thought stopping
Histrionic Personality Disorder (MH p. 83):
• Recognizing Histrionic Traits: Expected Behaviors in Histrionic Personality Disorder
• Traits:
o AmenDon-seeking behavior
o Oeen seducDve
o FlirtaDous
Psychosis (MH p. 77):
• PsychoDc Disorder Awareness: Recognizing Symptoms of Psychosis: Pressured speech, lack of sleep, hallucinaDons, and
disorganized thoughts
• CommunicaDon:
o Appropriate communicaDon to address hallucinaDons and delusions:
§ Ask the paDent directly about hallucinaDons
§ Do not agree but can offer ® “I don’t hear anything, but you seem to be frightened.”
§ Command hallucinaDons ® safety
SomaDc Symptom disorder: (MH p.105)
• Psychological stress through physical manifestaDons
• Anxiety and depression are oeen comorbidiDes
• PaDent s experience physical manifestaDons but no medical cause
• MulDple doctor visits
• Symptoms are real
65 •
•
Expected findings:
o Disrupt of paDent ’s daily life
o Overmedicated: Starts smoking marajuana to stop the emoDonal pain
Nursing care:
o IdenDfy secondary gains from somaDc manifestaDons (amenDon, distracDon from personal obligaDons)
NicoDne: (MH p.155)
• Medica:on Safety: Proper Applica:on of Nico:ne Transdermal Patches
• Educa:ng on nico:ne withdrawal treatment op:ons.
• MedicaDons:
o Bupropion:
§ Decrease cravings TOB
• Gum:
o Slowly and intermimently over 30 minutes
o Avoid eaDng and drinking 15 minutes prior to and while chewing the gum
o Not recommended for longer than 6 months
• Patch:
o Apply clean, dry, skin
o Remove prior an MRI
o Stop patches if local skin reacDons occur
Stress management – PaDent EducaDon (MH p.47)
• Nursing care involves teaching stress-reducDon strategies to paDent s
• CogniDve techniques
o CogniDve reframing: restructure irraDonal thoughts in a more posiDve way
• Behavioral techniques
o Guided imagery
o Breathing techniques
o Breathing exercises
o Progressive muscle relaxaDon
o Physical exercise
• Journal wriDng
• Priority restructuring
o Reduce the number of stressors affecDng them
• Biofeedback
o SensiDve mechanical device to assist the paDent to gain voluntary control of HR and BP
• AsserDveness training
o The paDent learns to communicate in a more asserDve manner in order to decrease psychological stressors.
__________________________________________________________________________________________________
LEADERSHIP / COMMUNITY
Quality Improvement (Leadership p. 11)
• IdenDfying and addressing quality improvement prioriDes.
• StandardizaDon:
o Provide consistent guidelines to ensure safe and quality care
Nursing Role (Leadership p. 69)
• Nurse responsibiliDes during facility emergencies.
Legal PracDce (Leadership p. 40)
• Recognizing legal issues in nursing pracDce.
Home oxygen therapy (Leadership p. 57):
• Teaching paDents about home oxygen therapy.
• Check funcDon of equipment daily
• Wear clothing made with comon fabrics
66 •
•
Apply water-soluble lubricant to sooth irritaDon of the mucous membrane
Store full tanks in an upright posiDon
Leadership Styles (Leadership p. 3):
• AutocraDc/authoritarian:
o Makes decisions for group
o Resolve Conflict: Facilitate discussion unDl all parDes agree
• DemocraDc:
o Includes the group when decisions are made
• Laissez-faire:
o Makes very few decisions, does limle planning
Intrapersonal vs Interpersonal:
• Intrapersonal:
o “self-talk”
o Occurs with one’s self
• Interpersonal:
o CommunicaDon that occurs one-on-one with another individual
EffecDve Time Management:
• Making the most of your :me while caring for pa:ents.
• Planning is the most important step in managing Dme effecDvely
• Complete acDviDes for one paDent before moving to the next
paDent
Nurses should make a list of acDviDes to complete
o Sesng goals
o Establishing prioriDes
o Scheduling acDviDes
Task Roles:
• Orienteer: noDng the progress of the group toward assigned goals
• Evaluator: measuring the group’s work against objecDves
• InformaDon giver: sharing experiences as an authority figure
• IniDatory contributor: offering new and fresh ideas on an issue
• CNA: post mortem care, paDent care needs, take specimens to lab, VS, IXO
Botulism:
• NoDfy the CDC REPORTABLE DISEASES
• Can cause paralysis within hours of exposure
• NV and diarrhea
Ethical Principles:
• Beneficence: to do good
• Autonomy: paDent s right to make their own decision
• JusDce: fair and equality
• Fidelity: loyalty and faithfulness (promise)
• Veracity: honesty
Torts:
•
•
•
•
•
False imprisonment
Assault: threatening a paDent
Bamery: touching a paDent in a harmful or physical way
Negligence: failing to provide adequate care in a personal or professional sesng
MalpracDce
Indicators of Sexual Abuse:
• Bruises, laceraDons
67 •
•
Bleeding of genitalia, anus
Difficulty walking or standing
Triage Tagging
____________________________________________________________________________________________________________
PHARMACOLOGY
EpoeDn Alfa (Pharm p. 205)
• Growth Factor Response: Monitoring PaDent ReacDon to EpoeDn Alfa
• EpoeDn alfa is an anDanemic medicaDon à anemic paDent s
• TherapeuDc effect à increased RBC, H&H
• Increased iron is needed for the producDon of hemoglobin and RBCs by the bone marrow
AnDbioDcs (Pharm p. 361)
• AnDbioDc AdministraDon: PrevenDng ComplicaDons from Drugs AffecDng Bacterial Cell Walls
• Penicillin
AnDdotes
•
•
•
•
•
•
Heparin: Protamine
Warfarin: Vitamin K
Magnesium Sulfate: Calcium Gluconate
Benzo: Flumazenil
Opioids: Naloxone
Atropine/scopolamine/phenothiazines/ TCAs: physosDgmine
AnDlipemic (Pharm p. 185):
• Managing Cholesterol MedicaDon: Recognizing Adverse Effects of SimvastaDn
• (-staDns) – AtorvastaDn
o AE:
§ Hepatotoxicity (AST )
§ Myopathy (muscle aches, pain, tenderness) ® Rhabdo
o AVOID grapefruit juice à slows the metabolism of medicaDon
§ Can cause elevated liver enzymes and Rhabdomyolysis
o Monitor CreaDnine Kinase
§ Will be elevated in response to muscle injury (Rhabdo)
o Take medicaDon in the evening to increase efficacy
o Can cause
§ Dark urine
§ Muscle pain/weakness/spasms à rhabdo
§ Dizziness, headache, confusion, and faDgue
o Life-long medicaDon
Sumatriptan
• Treats headaches / migraines
o PRN, not daily
o Can repeat dose in 2hr for unrelieved headache
• NTP of swelling of eyelids and lips to provider à indicates allergic reacDon
• Adverse effects:
o feeling of pressure in the chest or arm à NTP
o faDgue
Herbal Supplements:
• Echinacea: promote immunity
• Feverfew:
68 •
•
•
•
•
Ginger: relieve nausea and vomiDng
Ginkgo biloba: improve memory and reduce stress
Black cohosh:
Saw palmemo
Valarian root
Digoxin (0.8-2.0 ng/mL):
• Toxicity ManifestaDons:
o Anorexia
o NV
o VomiDng
o Visual disturbances
o Dysrhythmias
o Diarrhea
o Muscle weakness
Warfarin:
• Brusing, Red, black, or tarry stools indicate bleeding > report to HCP
• Avoid acetaminophen > risk for bleeding
• INR elevated only 2 Dmes normal.
• AnDdote Vit K
Ear drop:
• MedicaDon stored in the refrigerator to warm to room temperature
• Pull pinna upward and back for paDent s 3y/o and older
• Pull pinna down and back for paDent s under 3y/o
Epinephrine:
• MOA: increases cardiac workload and oxygen demand
• Adverse effect:
o Hypertension
o Chest pain
Fentanyl Patch:
• Pain Management Educa:on: Instruc:ng Pa:ent son Fentanyl Patch Use
• No hot tubs can cause increase sensi:vity and brady breathing
• If paDent declines, request a prescripDon for an alternaDve pain medicaDon
• Have another nurse witness the waste
• Waste the medicaDon in a secure receptacle according to agency policy
• Do not discard in a trash basket
• Fold patch in half
• Change aeer 72 hours
Nitroglycerin Patch: (Pharm p.174)
• Do not cut patches
• Place patch on a hairless area of skin (chest, back, or abdomen) and rotate sites to prevent skin irritaDon
• Remove old patch,. Wash skin with soap and water, and dry thoroughly before applying new patch.
• Remove the patch at night to reduce the risk of developing tolerance to nitroglycerin.
o Be medicaDon free between 10-12hr/day
o Apply new patch in the morning
Sildenafil citrate
• Used for erecDle dysfuncDon
• ContraindicaDon with Nitrates
o Isosorbide and nitroglycerin
69 o
Can cause life-threatening hypotension
Tetracycline anDbioDc
• Doxycycline
o photosensiDvity
o diarrhea
o interferes with color vision
Aminoglycosides
• gentamycin
o ototoxicity
§ Dnnitus
o nephrotoxic
§ proteinuria
§ monitor oliguria / hematuria
• vancomycin
o further damages the kidneys
Beta-blockers
• Metoprolol
o Do not abruptly stop taking medicaDon
§ Increases their risk for angina, HTN and MI
o Count your radial pulse daily
o Change posiDon slowly
§ OrthostaDc hypotension
NPH insulin
• Roll the vial between palms of the hands, do not shake it
• To prevent lipodystrophy, the paDent should rotate injecDon sites, making them about 2.5cm (1in) apart, within the same
anatomical area
Alendronate (Biphosphates)
• Treats osteoporosis and Paget’s disease of the bone
• Keep the paDent sisng up for 30min aeer à can cause stomach ulcers
• Give in the AM before breakfast
Clonidine
• Used for HTN, severe pain and amenDon deficit disorder
• Inform the paDent that dry mouth, consDpaDon, and dry eyes is a common A/E
Midazolam
• SedaDve
• Reversal agent: flumazenil
• Monitor for respiratory depression
• Expect the paDent to maintain spontaneous respiraDons and respond to simple commands
ErythropoieDn
• Increases the level of Hct in paDent s who have anemia
• EffecDve: increase in energy levels
Iron supplements
• Take with vitamin C
• Eat high-fiber foods to prevent consDpaDon
• A/E:
o Heartburn
o Nausea
o BloaDng
70 Ipratropium
• Bronchodilator
• AnDcholinergic effects à offer sugarless gum, hard candy, or frequent drinks to relieve the paDent ’s dry mouth
Gemfibrozil
• Treats high cholesterol and triglycerides in the blood
• Hepatotoxic
o Monitor AST/ALT
Sodium polystyrene sulfonate
• Treats hyperkalemia
• A/E: consDpaDon à leads to fecal impacDon
Fluoroquinolones
• Broad-spectrum anDmicrobials treat a wide variety of micro-organisms
• Urinary, respiratory, and GI tract infecDons
• PrevenDon of anthrax for paDent s who have inhaled spores
• Ciprofloxacin
Pharm Notes
Aspirin
• Contraindicated for children (except for Kawasaki)
o Causes Reye’s syndrome
• NTP of hypervenDlaDon (resp. alkalosis)
o Salicylate poisoning
EpoeDn alfa
• SDmulates erythropoiesis in the bone marrow to
increase RBC producDon
• Reduces anemia
o Common seen in chronic kidney failure, b/c
erythropoieDn is produces in the kidneys
• Monitor BP and H/H
FilgrasDm
• Increases WBC producDon
• Used for neutropenia paDents
• Reduces the risk of infecDon in chemo paDent s
Oprelvikin
• Increases Platelet producDon
NSAIDs
• Ibuprofen, Naproxen, Aspirin
• Contraindicated for paDent s with pepDc ulcer disease
– bleeding risk
Acetaminophen
• Can be given to a pepDc ulcer paDent
• Does not affect blood coagulaDon à no risk for
bleeding
• Monitor Liver enzymes
Clopidogrel (Plavix)
• AnDthromboDc – inhibits platelet aggregaDon
• Monitor for bleeding
Allergy to penicillin
• Cross sensiDvity to ceeriaxone (third-gen
cephalosporin)
o Contraindicated for paDent s with allergies
to penicillin
Chlorpromazine
• 1st generaDon anDpsychoDc medicaDon
• A/E: parkinsonism
o Mask like face
o Involuntary movements
o Tremors
§ Treatment: Benztropine /
Amantadine
• AnD-parkinsonism
medicaDon
• Treats EPS
Bupropion
• Atypical anDdepressant
• Smoking cessaDon
• AE
o AgitaDon
o Tremors
o Mania
o Insomnia
71 UTI treatment
• Phenazopyridine
o Urinary tract analgesic used to relieve
pain/urinaDon
o Can cause mild GI upset, take with meals
o Can turn urine orange/red (normal)
• Ciprofloxacin
o Fluoroquinolone anDbioDc
o Drink 2-3L
Zolpidem
• Promotes sleep
• A/E: dizziness and dayDme drowsiness
Somatropin
• Growth hormone
• Used for paDent s with growth hormone deficiency of
the anterior pituitary gland
Hydrochlorothiazide
• Take in the AM
o Allow diuresis during the day and prevent
nocturia
o Weigh daily
o Take with food à prevents GI upset
Chlorothiazide
• Thiazide diureDc (K wasDng)
• Hypokalemia
o Muscle weakness
o Muscle cramps
o Dysrhythmias
o
Eliminated through the kidneys
Gemfibrozil
• Lowers cholesterol and triglyceride by destroying
livers uptake of famy acids
• Liver toxicity – monitor AST/ALT
Ergotamine
• Prevents / stops migraine headaches
• Take one tablet at the onset of aura of a headache
• Max. 3 tablets in a 24hr period
Tamoxifen
• AnDestrogen medicaDon
• Treats breast cancer
• AE
o Thromboembolism
§ Monitor for pulmonary embolus
o Leg tenderness
o Redness, swelling
o SOB
o Menstrual irregulariDes (hot flashes)
Sulfasalazine
• Disease-modifying anD-rheumaDc (DMARD)
• Treats ulceraDve coliDs and RA
• AE:
o Jaundice à NTP
o Bloody diarrhea
o StomaDDs
o Headache
o Peripheral neuropathy
Oxytocic meds (DOMM)
• Oxytocin / Dinoprostone
o SDmulates uterine contracDons
o Controls postpartum hemorrhage
TocolyDc meds (MINT)
• Nifedipine
o Stops pre term labor
Prostaglandin med
• Misoprostol
o Promotes cervical ripening and induces
labor
Valproic acid
• Treats seizures
• Monitor
o aPTT (alters coag)
o AST/ALT (hepatotoxic)
Amitriptyline
• TCA: treats depression
• A/E:
o tachycardia – ECG prior to treatment
o blurry vision
Morphine
• Respiratory depression can occur w/in 7min (IV
bolus)
• Withhold med if RR is <12/min
• Reversal: Naloxone
• Administer IV bolus slowly 4-5min to prevent
hypotension and resp. depression
Allopurinol
• GOUT med
• Fever = fatal hypersensiDvity reacDon
o NTP of fever or rash
• Drink 2L of water to prevent renal store formaDon
and kidney injury
Amphotericin B
• Treats fungal infecDons
• Nephrotoxicity
o Monitor CreaDne every 3-4 days
o Increase fluid intake
Cromolyn
• Mast cell inhibitor and has a slow onset
• Given for prophylacDc treatment
72 Exercise- induced asthma
Apply 10-15min before exercise to prevent
bronchoconstricDon
• Not a rescue medicaDon
• Rinse mouth aeer each use
• RouDne medicaDon (3-4/day)
Montelukast
• AnD-inflammatory
• Take before exercise
• AE
o Depression
o Behavior changes
o HallucinaDons
o Suicide ideaDon
MDI
• Use with spacer
o Increases the amount of medicaDon to the
lungs
o Inhale slowly 3-5 seconds
o
o
Hydroxyzine
• AnDhistamine
o Treats anxiety, n/v, skin rash, hives, and
itching
• Used to treat mild-moderate anxiety
• AnDcholinergic effects
• Contraindicated with pregnant paDent s
• Give prior to surgery
o Controls emesis
o Decreases anxiety
o Decreases amount of narcoDcs needed for
pain relief
o Drying secreDons
Prednisone therapy
• Long-term: schedule the medicaDon on alternaDve
days to decrease A/E
• Eat more K+ rich foods (prednisone can cause loss of
K+)
Metoprolol
• Beta-blocker
• Can mask symptoms of hypoglycemia
Aldosterone
• Blocks the acDon of serotonin on the intesDne
• Treatment for severe IBS-D
• PaDent must sign an agreement with the provider
before beginning treatment
• NTP
o Tachydysrhythmia
o Diarrhea is not controlled aeer 1 month
Verapamil
• Calcium channel blocker
• Used for HTN and anginal pain
• Dilates arteries and decreases aeerload
Cyclosporine (immunosuppressant medicaDon)
• Kidney transplant medicaDon – lifelong
o Prevents rejecDon
• PaDent may develop high BP (give anDhypertensive
medicaDon)
• Causes HirsuDsm
• NEPHROTOXIC – monitor liver
• NO grapefruit juice
Warfarin
• PT/INR are taken daily for the first 5 days, twice
weekly for the next 1-2w
• Decrease intake of green leafy vegetables (Vit K)
Iron Dextran IV
• Treats iron deficiency
• Administer small dose before giving the full dose
• AnDdote – deferoxamine
Oxycodone
• Opioid
o Relieves moderate to moderately severe
pain
Spironolactone
• K sparing diureDc : NO for CKD paDents
• Derived from steroids, can cause endocrine effects
o GynecomasDa
o Irregular menses
o HirsuDsm
Meuormin
• Can cause blockage of lacDc acid oxidaDon
• LacDc acidosis
o Myalgia (muscle pain)
o Malaise
o Somnolence
o HypervenDlaDon
Saw Palmemo
• Benign prostate hypertrophy (BPH)
Nifedipine
• Calcium channel blocker
• Causes uterine relaxaDon by blocking the flow of Ca
to the myometrial cells of the uterus
Opioid Toxicity
• Pinpoint pupils
• Euphoria / relaxaDon
73 • Decrease RR
Opioid withdrawal
• Fever
• Increased pupil size (dilated)
• Severe abdominal cramping, muscle spasms, and
bone pain
Amitriptyline
• Take at night (sedaDve effect)
• Causes orthostaDc hypotension
• AnDcholinergic effects
Adenosine
• BronchoconstricDon – dyspnea
• 10 second half-life
Chlordiazepoxide
• Long-acDng benzo
• 1st line med for a paDent with acute alcohol
withdrawal
o Prevents delirium tremens
IneffecDve labor – taking oxytocin
• Increase dose of oxytocin to obtain uterine
contracDons that occur every 2-3min
DilDazem
• Ca channel blocker
• Monitor for hypotension
•
Check HR prior to administering medicaDon à can
cause bradycardia
Lithium toxicity
• VomiDng + diarrhea = electrolyte imbalances
o Decrease Na = lithium is retained in kidneys
à lithium toxicity
• NO NSAIDs
o NSAIDs can increase lithium levels
• Can lead to thyroid dysfuncDon
o Monitor T3 / T4
• Daily weights
o Risk for fluid imbalance
Omeprazole
• PPI
• Take before breakfast
• Use for no longer than 1-2mon
o Long term s/e: increase risk for factors and
hypomagnesemia
o Increase risk for pneumonia
§ Diarrhea, N/V, headache
• Increased risk for C. diff
Lorazepam
• Benzodiazepine
• AnD-anxiety / sedaDve effects
• Treat for seizures too
Oxybutynin
• Used for urinary inconDnence
• AE: anDcholinergic effects
Haloperidol
• 1st generaDon
• EPS
o Dystonia
o Pseudoparkinsonism
o Akathisia
Dopamine
• Adrenergic med
• Treatment of shock and HF
• Increases cardiac output and improves perfusion
• Dilates renal blood vessels, which increases renal
perfusion and increases the paDent ’s output
Sucralfate
• Mucosal protectant
• Forms a gel-like substance that coats the ulcer
FamoDdine
• H2 receptor blocker
• Decreases stomach acid producDon
• Hepatotoxic à monitor for jaundice
Aluminum hydroxide
• Antacid
• Neutralizes acid in the stomach (treats heartburn)
• Can cause consDpaDon
Zolpidem
• Short-term treatment for insomnia
• Reassessment is needed before refilling the
prescripDon
• PaDent should experience improved sleep w/in 2
days of starDng the medicaDon
Methadone
• Opioid use disorder
Bupropion
• Smoking cessaDon
Disulfiram
• Maintaining absDnence from alcohol
Modafinil
• Assist with faDgue and prolonged sleep from
methamphetamine withdrawal
NeurolepDc malignant syndrome
74 •
AE of 1st gen anDpsychoDc
o High fever
o Respiratory distress
o Diaphoresis
o Hypotension or hypertension
o Tachycardia
o InconDnence
o Severe muscle rigidity
Ciprofloxacin
• Fluroquinolone anDbioDc
• Contraindicated for paDent with tendoniDs due to
risk of tendon rupture
• PhotosensiDvity
o Sunglasses
o Sunscreen
o ProtecDve clothing
Flumazenil
• Reversal agent for diazepam
• Diazepam toxicity
o Respiratory depression
o Hypotension
Docusate sodium
• Surfactant that soeens stool by reducing surface
tension, allowing water to penetrate the stool
Clozapine
• 2nd gen anDpsychoDc med
• Can cause hyperlipidemia
Insulin
• Store unopened bomles in the fridge
• Once opened, the insulin can remain at room
temperature for 1 month
Nitroglycerin transdermal patches
• Remove patch every evening to allow free Dme of 1214hr
• Reduces tolerance to med
Nitroglycerin oral sustained-release capsules
• Not used for acute angina
•
Take capsules whole
Calcium gluconate
• Can cause hypercalcemia à increases the risk of
digoxin toxicity
FluoxeDne
• SSRI
• Suppresses platelet aggregaDon
o NO NSAIDs
Atropine eye drops
•
•
Blurry vision (expected)
DilaDon of the pupils
Carbamazepine
• AnDconvulsant
• Interferes with effecDveness of oral contracepDves
Cyclobenzaprine
• Muscle relaxant
• Tapper off medicaDon to prevent absDnence
syndrome or rebound insomnia
Beclomethasone
• CorDcosteroids
• Pt teaching: Increase intake of Ca and vit D to
minimize bone loss
• Rinse mouth aeer every use
Enoxaparin (Lovenox) Monitor PLTS
• Prevents DVT
• PaDent takes Lovenox at home- leave bubble in the
shot
•
NTP
o
o
o
Headache
Nausea
Pinpoint petechiae
AtorvastaDn
• SE:
• dark urine
• Muscle pain / Muscle spasms à Rhabdomyolysis
• Weakness
• Liver damage
Bupropion
• SNRI / smoking cessaDon
• AE
o Changes in libido
o ConsDpaDon
o Weight LOSS
Omeprazole
• Long term use: risk for developing hypomagnesemia
à monitor magnesium labs
o Tremors
o Seizures
o Muscle cramps
Methylprednisone
• Check BS levels
• Avoid contact w/ people with infecDons
• Take with food
• Intake K+ foods (steroids deplete K)
• Grapefruit juice can increase effects of med
75 Sodium polystyrene sulfonate
• Treats hyperkalemia
• AE: consDpaDon
o Can lead to fecal impacDon à NTP
Hypomagnesemia
• can be caused by use of PPIs (omeprazole)
• AE
o Tachycardia
o HTN
o Tremors
o DisorientaDon / confusion
§ Assess for posiDve Chvostek’s and
Trousseau’s sign
Digoxin
• Digifab (anDdote)
• Normal response indicates therapeuDc response
Enalapril
• ACE inhibitor
• Causes hyperkalemia due to K+ retenDon
• AE
o Hypotension
o Tachycardia
o Dysrhythmias
SimvastaDn
• Report muscle pain
• NO grapefruit juice
• Lifelong therapy
AtorvastaDn
• Treats hyperlipidemia
• AE : rhabdomyolysis
o Muscle pain/ weakness
o CreaDnine Kinase levels rise
NeosDgmine
• Treatment for myasthenia gravis à muscle
strengthener
• AE :
o pupil constricDon
o Increased salivaDon
o Urinary urgency
o Bradycardia
Baclofen
• AnD-spasmodic medicaDon
• Used for paDent with spinal cord injury and MS
• Decrease in the frequency and severity of muscle
spasms and in flexor and extensor spasDcity
Furosemide (K wasDng)
• Take with milk or food to reduce GI irritaDon
• Given to paDents with hyperkalemia
Acetazolamide
• Used for chronic open-angle glaucoma
• AE: Dngling of the fingers
NystaDn
• Store in room temp
• Swallow aeer swishing in the mouth
Diphenhydramine
• AnDhistamine
• Treat rhiniDs
• Causes sedaDon
Glucosamine
• Used for osteoarthriDs
• Increases joint funcDon by decreasing destrucDon of
carDlage
Diazepam
• Benzo
• Prevents complicaDons of alcohol withdrawal
(delirium tremens)
Baclofen
• Muscle relaxant
• NO anDhistamines
o Intensifies the depressant effects of baclofen
Alprazolam
• Benzodiazepine
• CNS depressant
• Causes orthostaDc hypotension
o Fall risk
Colchicine
• Treats GOUT
• AE: diarrhea
Phenytoin
• Used for seizures (lifeDme treatment)
• Alcohol intensifies toxicity
• AE: rash à NTP
o Steven Johnson Syndrome
o Toxic epidermal necrosis
Metronidazole
• AnDbioDc for vaginal infecDon
• AE
o Metallic taste
o Headaches
o Nausea
o Dry mouth
o Visual disturbances
Theophylline
• Bronchodilator (long-term)
76 •
Administer with an infusion pump
o Rapid infusion = hypotension à death
Aspirin toxicity
• SweaDng
• Headache
• Dizziness
• Tinnitus
Midazolam toxicity
• Administer flumazenil to reverse toxicity
Codeine for cough suppression
• NTP à agitaDon indicates neurotoxicity
Hydroxychloroquine (DMARD)
• NTP à blurred vision
o ReDnal damage
FluDcasone / salmeterol
• GlucocorDcoid
• AE: candidiasis
o Gargle aeer each use
Pioglitazone
• T2DM medicaDon
• Daily weight
• PaDent educaDon: increase Ca in diet
o Med increases risk for fractures for women
Topotecan IV (chemo)
• MetastaDc ovarian cancer
• AE: nausea
o Give Ganisetron transdermal patch
Ondansetron
• Treats chemo-induced nausea
• AE: headache
Chemo – induced N/V
• CombinaDon therapy with anDemeDcs
Phenylephrine
• MydriaDc medicaDon à dilates pupils
Meuormin
• Contraindicated for alcohol use disorder
• Inhibits the breakdown of lacDc acid = lacDc acidosis
Leuprolide
• Treatment for prostate cancer
Sumatriptan
• Contraindicated in paDents with angina pectoris
• vasoconstricDon that can cause angina as a result of
coronary vasospasm
Clopidogrel
• herbal supplements that interact with med: (interacts
with coagulaDon)
o chamomile
o feverfew
o ginseng
o ginkgo biloba
combinaDon oral contracepDve
• causes breakthrough bleeding and sposng
o results within 3-4 months
H2 receptor antagonists
• treat duodenal ulcers
• prevent heartburn, acid ingesDon, and sour stomach
H2 receptor blockers
Captopril
• ACE inhibitor
• Can cause hyperkalemia due to K+ retenDon in the
kidney
• NO salt subsDtutes (has an increase amount of K+)
Insulin glargine
• Long acDng (18-24hr)
Red Man Syndrome – Vancomycin Adm x 60 min IVPB
• Flushing of the neck, face, upper body, arms/back
• Tachycardia
• Hypotension
• UrDcaria
• AnaphylacDc reacDon when infused too fast
MedicaDons that cause orthostaDc hypotension
• Furosemide
• Telmisartan
• DuloxeDne
• DiureDcs
• Amitriptyline
Feverfew
• Avoid while on warfarin à increases anDcoagulaDon
effect
Methotrexate
• Drink fluids 2-3L / day
o Renal toxicity
Closing airway on a paDent
1. Assess airway
2. Call emergency response
77 3.
4.
5.
6.
Apply high-flow O2
IV access
IV epi
IV anDhistamine
Ketorolac
• AE: renal toxicity
• NTP à oliguria
Esomeprazole
• PPI, treatment for GOUT
• Risk for pneumonia
o Increases gastric pH
o NTP
Androgen therapy
• Treatment for endometriosis and fibrocysDc breast
cancer
o Causes fluid retenDon
§ Monitor for edema
Expectorant
• Treats cough by increasing secreDons to improve
cough’s producDvity
Acetaminophen toxicity
• Diaphoresis
• Abd. Discomfort
• Increased ALT
Zidovudine
• HIV anDviral
• AE: aplasDc anemia
MDICATIONS THAT CAUSE STEVEN-JOHNSON SYNDROME
• Mood stabilizing anDepilepDcs
o Carbamazepine
o Valproic acid
o Lamotrigine
• Phenytoin
• Monitor for a rash
MEDICATIONS THAT CAUSE RED-MAN SYNDROME
• AnDbioDcs
o Vancomycin
o Ciprofloxacin
o Amphotericin B
• Rashes
• Flushing
• Tachycardia
• Hypotension
Diclofenac
• NSAID
• Give with food or milk to reduce GI irritaDon
Acyclovir
• AnDviral agent – herpes/ varicella
• Nephrotoxic
o Increase fluid intake
Acetazolamide
• Treats edema due to HF and glaucoma
• Monitor electrolyte imbalances
Pseudoephedrine
• Treats allergic rhiniDs
• Causes vasoconstricDon
o Monitor for HTN
Amantadine
• Alleviate dyskinesia (due to levodopa/carbidopa)
Amiodarone
• Liver toxicity
o NTP à jaundice
Raloxifene
• Reduce the risk of breast cancer
• Treats post-menopausal osteoporosis
Ipratropium inhaler
• AE: dry mouth (xerostomia)
EzeDmibe
• Lowers cholesterol levels
• Risk for liver damage
Somatropin
• Growth hormone
• Monitor height monthly
Beclomethasone
• Inhaled corDcosteroid
• Gargle with water aeer dose
Wernicke-Korsakoff syndrome
• Lack of vitamin B1 (thiamine)
Delirium tremens (alcohol withdrawal delirium) pg.94
• Administer Benzos
Somogyi
• Happens when a low blood sugar episode overnight
leads to high blood sugar in the morning due to a
surg of hormones
o Adjust the Dme of insulin administraDon
o Lower the dose of insulin before bed
o Eat a snack with the evening insulin dosage
Didanosine
• Treatment for HIV
78 Other Topics
*I can’t find the topics BUT raDonales are from weekly quizzes*
Ticks with Lymes disease. Nurse is assessing paDent with a red circular rash with dark red in the center, approximately 6 inches in
diameter “bullseye”
Mosquito, Mice and Ticks- These are examples of a vector that can spread infecDon.
Planning care for paDents with weakened immune systems.
• Wear mask, gloves, and gown
• Bathe daily
• Restrict visitors who have an infecDon
• Dispose all linen in a linen trash
• Eat cook meals only
Strategies for resolving conflicts in healthcare sesngs.
• Interpersonal
• Intrapersonal
• Intergroup
Using interpreters respecuully for diverse paDent needs.
• Use medical interpreter, never family
• Determine level of fluency
• Address the paDent directly even if interpreter is available
• Do not encourage nod (not accurate)
CollecDng urine samples for tesDng.
• Begin urinaDng, then move container into stream
• Clean front to back
• Avoid touching inside the container
• Use each wipe only once
Managing hyperthermia-related seizures in adolescents.
• If blanket is used in ow temperatures and without skin protecDon ® paDent will be cold too fast ® shivering
• S/S: Dehydrated, metabolic rate, HR- Hypercapnia- muscle rigidity
• Latex Allergy : urDcaria, wheezes and HR
• Hypovolemic Shock: HR
• Family and Community Violence: IdenDfying Examples of Neglect and Maltreatment for a Client
ATI Mental Illness E-Book p169-172
Week 7
• Assigning tasks to support staff while ensuring quality care.
79 •
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•
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•
Steps to effecDvely delegate tasks to other healthcare workers.
What to do if a paDent refuses treatment?
o document refusal in the paDent chart
Caring for a comatose paDent scheduled for surgery.
Working effecDvely with language interpreters.
o Speak to the paDent when having an interpreter present
o Ensure the interpreter is facility approved
Handing over paDent informaDon during shie changes.
ReporDng test results for paDents on blood-thinning medicaDon.
Nurses' role in ensuring paDents understand treatment risks.
Handling biohazard spills safely.
o Blood à 10:1 bleach
o Cancer spills
Assessing home safety aeer joint replacement surgery.
Responding to heparin overdose.
o Protamine sulfate
Recognizing adverse reacDons to medical equipment.
Teaching paDents about phenytoin for seizures.
o Phenytoin à lifelong medicaDon
o Have a different from of contracepDves
§ Can interfere with contracepDves
o Cannot take PPIs with phenytoin
§ Can increase blood level of phenytoin
o A/E:
§ CNS: nystagmus, sedaDon, ataxia, double vision, cogniDve impairment
§ Gingival hyperplasia: soeening and overgrowth of gum Dssue, tenderness, and bleeding gums
• Maintain good oral hygiene (dental flossing, massaging gums)
• Folic acid can decrease this occurrence
§ skin rash à STOP medicaDon
§ Cardiovascular effects: dysrhythmias, hypotension
• Administer at slow IV rate (no faster than 50mg/min)
• Avoid administering to a paDent who has sinus bradycardia
§ Endocrine and other effects
• Coarsening of facial features, hirsuDsm, and interfere with vitamin D metabolism
o Consume adequate amounts of calcium and vit D
Normal growth and development in infants.
Assessing condom use knowledge in young adults.
Week 8
• NavigaDng Crisis: IniDal Steps for Individuals Coping with Personal Loss
• Compassionate CommunicaDon: Engaging with Terminally Ill PaDent s
• SupporDng Grieving Parents: Steps for Providing Assistance (Peds p.55)
o Aeer Death
§ Allow family to stay with the body as long as they desire
§ Allow family to rock the infant/toddler, if desired
• Take pictures of the baby if the family desires
§ Remove tubes and equipment
§ Offer to allow family to assist with preparaDon of the body
§ Assist with preparaDons involving the death ritual
§ encourage family to prepare siblings for the funeral and related death rituals
§ remain with the family and offer supper
§ allow family to share stories about the paDent ’s life
§ refer to the paDent by name
§ allow all family members to communicate feelings
• Managing HallucinaDons: Strategies for CommunicaDng with PaDent Experiencing PsychoDc Episodes (MH p.79)
80 Provide a structured, safe environment for the paDent in order the decrease anxiety and to distract the paDent from
constant thinking about hallucinaDons
o Use appropriate communicaDon to address hallucinaDons and delusions
§ Ask the paDent directly about hallucinaDons. The nurse should not argue or agree with the paDent ’s view
of the situaDon, but can offer a comment such as, “I don’t hear anything, but you seem to be feeling
frightened”
§ Do not argue with a paDent ’s delusions, but focus on the paDent ’s feelings and possibly offer reasonable
explanaDons, such as “I can’t imagine that the president of the U.S. would have a reason to kill a ciDzen, but
it must be frightening for you to believe that”
§ Assess the paDent for paranoid delusions, which can increase the risk for violence against others
§ If the paDent is experiencing command hallucinaDons, provide for safety due to the increased risk for harm
to self or others
§ Amempt to focus conversaDons on reality-based objects
Addressing FrustraDon: EffecDve Responses to PaDent 's Expressions of Discontent
Establishing Trust: Techniques for CulDvaDng TherapeuDc RelaDonships in Healthcare Sesngs
NutriDonal Assessment: CalculaDng Weight Loss for PaDent EvaluaDon
o 7.5%
Plant-Based Guidance: Advising PaDent s on TransiDoning to Vegan Diets
o Best foods for protein intake
§ Nuts, legumes (lenDls)
o Vitamin D
Safe Recovery: PostoperaDve Home Safety Measures -FALL PREVENTION
MedicaDon Management: Dietary Counseling for PaDent s with Depressive Disorders
Intravenous Therapy Oversight: Recording ComplicaDons for PaDent Safety
Psychotropic MedicaDon: IdenDfying Side Effects of TradiDonal AnDpsychoDcs
Dosage ComputaDon: ConverDng Dosages from Micrograms to Milligrams
Substance Use and AddicDve Disorders: Adverse Effects of Disulfiram
ATI Psych E Book p118
Stress Management
Stress Management: Teaching Progressive Muscle RelaxaDon
ATI Psych E Book p50
AssisDve Devices
Disorders of the Eye: IdenDfying a ManifestaDon of Cataracts
ATI Funds E-Book p259-262
Sensory PercepDon: EvaluaDng Understanding of Hearing Aid Care
ATI Funds E-Book 262-264
EliminaDon
Urinary EliminaDon: Strategies for PromoDng UrinaDon
ATI Funds E-Book p252
NutriDon and Oral HydraDon
Enteral NutriDon: Intervening for Hyperosmolar DehydraDon
ATI Funds E-Book p223
MedicaDon AdministraDon (4 items)
TherapeuDc Procedures to Assist with Labor and Delivery: ContraindicaDon for AdministraDon of Misoprostol
ATI Pharm E-Book p251
MedicaDons for Depressive Disorders: ReporDng ManifestaDons of Serotonin Syndrome
ATI Pharm E-Book p52
o
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Week 9
• Cardiac Monitoring Skills: ECG InterpretaDon Techniques
o First degree heart block
o Atrial FibrillaDon
• Health Assessment: Recognizing Abnormal Findings Requiring Follow-up
• Depression MedicaDons: Sposng Adverse Effects
81 •
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•
Cardiac Emergency PrioriDzaDon: Managing Chest Pain Reports
Individualized Care Planning: IdenDfying Key AcDons for PaDent Care
PaDent Safety: PrioriDzing AcDons to Reduce Harm
Trauma and Anxiety Disorders: EducaDng PaDent s on Stress Management
Treatment Response EvaluaDon: Assessing PaDent Progress
Evening with DR. Khan Lectures
Breasueeding (OB p. 119)
• Breasueeding sDmulates the release of endogenous oxytocin from the pituitary gland
o Increases uterine contracDons post-partum
• The return of ovulaDon is influences by breasueeding frequency, the length of each feeding, and the use of supplementaDon
• Encourage early breasueeding for a paDent who is lactaDng. This will sDmulate the producDon of natural oxytocin and
prevent hemorrhage
Breasts (OB p.122)
• Colostrum (early milk) transiDons to mature milk by about 72-96hr aeer birth; this transiDon is referred to as the milk coming
in.
• Engorgement (fullness) of the breast Dssue is a result of lymphaDc circulaDon, milk producDon, and temporary vein
congesDon. The breast will appear Dght, tender, warm, and full
o Inform paDent s who do not plan to breasueed that this will resolve on its own, but breast binders or support bras
can be used, or an ice pack or cabbage leaves can be applied
o Inform paDent s who plan to breasueed that breast care and frequent feedings will prevent or manage engorgement
• Observe for erythema, breast tenderness, cracked nipples, and indicaDons of masDDs (infecDon in a milk duct of the breast
with concurrent flu-like manifestaDons)
• Determine the paDent ’s ability to assist the newborn with latching on, and ensure the newborn has latched on correctly to
prevent sore nipples
• IneffecDve newborn feeding pamerns are related to maternal dehydraDon, maternal discomfort, newborn posiDoning, or
difficulty with the newborn latching onto the breast
o Promote early breasueeding within the first 1-2hr aeer birth
o Encourage early demand feeding for the paDent who chooses to breasueed. This will also sDmulate the producDon
of natural oxytocin and help prevent uterine hemorrhage
o Assist the paDent into a comfortable posiDon and have them try various posiDons during breasueeding. The four
transiDonal posiDons for breasueeding are football hold (under the arm), cradle, across the lap (modified cradle),
and side-lying.
o Teach the paDent the importance of proper latch techniques (the newborn takes in part of the areola and nipple,
not just the Dp of the nipple) to prevent nipple soreness
o Inform the paDent that breast feeding causes the release of oxytocin, which sDmulates uterine contracDons. This is a
normal occurrence and beneficial to uterine tone.
o Advise paDent s who do not plan to breasueed to not sDmulate the breast or express breast milk
Breast care (OB p.133)
• PaDent s who plan to breasueed
o Hand hygiene prior to feedings to prevent infecDon
§ Well-fisng, nonbinding bra if breast support is needed. (NO UNDERWIRE)
§ Allow the infant to nurse on demand, which would be about 8-12 Dmes in a. 24hr period. Allow the infant
to feed unDl the breast soeens. Off the second breast to the infant before compleDng the feeding, and start
each feeding with a different breast
§ To relieve breast engorgement, take a warm shower or apple warm compresses BEFORE breasueeding to
promote letdown and milk flow. Empty each breast completely at feedings, using a pump if needed aeer
the infant has finished feeding. Apply cool compress AFTER feedings
§ Apply breast creams as prescribed and wear breast shells in the bra to soeen the nipples if they are irritated
and cracked
§ For sore nipples, apply small amount of breast milk to the nipple and allow it to air dry aeer breasueeding
§ Drink adequate fluids to saDsfy the thirst
• PaDent who DO NOT plan to breasueed
§ Well-fisng, supporDve bra conDnuously for the first 72hr
82 §
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Avoid breast sDmulaDon and running warm water over the breast for prolonged periods unDl no longer
lactaDng
For breast engorgement, which can occur on the 3rd or 5th postpartum day, apply cold compresses 15min on
and 45min off. Fresh, cold cabbage leaves can be placed inside the bra. Mild analgesics or anD-inflammatory
medicaDon can be taken for pain and discomfort of breast engorgement
Mastectomy
• PaDent can sDll breasueed
Baby nutriDon
• 6-8 wet diapers
• Feed q2-3hrs
Maternal vaccinaDons
• CONTRAINDICATED (live)
o MMR
o Varicella
o Rubella
§ Cannot get pregnant within 4
weeks
• CAN GIVE
o Flu
o Swine
o COVID
Cardiac tamponade
• paradoxical pulses
o SBP is 10mmHg higher on EXPIRATION than
on inspiraDon
o Occurs b/c the sudden decrease in cardiac
output from the fluid compressing the atria
and ventricles
A-fib
• Pulse deficit
o Apical and peripheral pulses are different
ContraindicaDons for birth control
• Stroke
• HTN
• Smoking
• ReproducDve cancer
Diaphragm
• Leave it in 6hr prior to intercourse and 6hr post
intercourse
• Will need to be refimed when paDent loses/ gains
weight
• Wash with warm water
Depot-shot (birth control short)
• AE: osteoporosis
o Lack of vitamin D
• Wait for 1 year for ferDlity to return
IUD
•
•
5-10y
Monitor string / month
BP cup sizes
• What amount does the BP cuff need to cover? à
80%
• Don’t cross legs
Sexual abuse
• Stay with the child
• Contact Child ProtecDve Services
• Never suspect parents
• Never take the child’s clothes off
Group therapy
• Have orientaDon in private
• Goal: opDmal growth
• If bullying occurs à re-focus conversaDon back to
group therapy
Role stress in family
• FaDgue/ stress
Opioid withdrawal
• Abdominal cramping
• Yawning
• Diarrhea
• Mild fever
• Stuffy nose
Uppers
Downers
Opioids
Substance
Alcohol
• 3 quesDons
Conduct disorder
• Animal abuse
• Leads to anDsocial disorder
• THINK DAHLMER
Defiant disorder
83 •
Hates authority
Kosher diet
• Always ask diet preference
Family members and suicide
Panic amacks
• Impending doom
• Delusions
• HallucinaDons
MILD
Normal/ healthy amount of
anxiety. Allows one to have
sharp focus and problem solve
Nail-biDng
Tapping
Foot jimers
MODERATE
Thinking ability is impaired.
Sharp focus and problem
solving can sDll happen just at
a lower level
GI upset
Headache
Voice is shaky
•
•
CommunicaDon during grief
Offer silence / offer self
Alzheimer’s / DemenDa / Delirium intervenDons
• Delirium: neurovascular checks
• Refer to pg. 59 of this booklet J
SEVERE
Focus and problem solving are
NOT possible. Feelings of
impending doom may be felt.
PANIC
Most extreme anxiety.
Unstable and not in touch with
reality
Dizziness
Headache
Nausea
Sleeplessness
HypervenDlaDon
Pacing
Yelling
Running
HallucinaDons
ReDnal detachment
• Curtain closing
• Dark floaters
• MEDICAL EMERGENCY
MS p.137 COPD
Chronic BronchiDs
• InflammaDon of the bronchi and bronchioles due to
chronic exposure to irritants
Emphysema
• Loss of lunch elasDcity and hyperinflaDon of lung
Dssue. Causes the destrucDon of the alveoli, leading
to a decreased surface area for gas exchange, carbon
dioxide retenDon, and respiratory acidosis
Expected findings
• Chronic dyspnea upon exerDon. RR can reach 40-50/min during acute exacerbaDons.
• ProducDve cough that is most severe upon risking in the AM
• Hypoxemia
• Crackles and wheezes
• Rapid and shallow respiraDons (Kussmaul)
• Barrel chest
• Hyperresonance on percussion due to “trapped air”
• Irregular breathing pamern
• Dependent edema secondary to R-sided HF
• Clubbing of the fingers and toes (late stage)
• Pallor and cyanosis of nail beds and mucosal membranes (late)
• Decreased oxygen saturaDon levels (<95%)
Nursing care
• High-Fowlers posiDoning
• Coughing or sucDon to remove secreDons
• Encourage deep breathing and use of incenDve spirometer
• Administer O2 to main saturaDon between 88-92%
• NutriDon
o Soe, high-calorie foods
o Encourage fluid intake
• For diaphragmaDc (abdominal breathing)
o Take breaths deep from the diaphragm
84 o Lie on back with knees bent
o Rest a hand over the abdomen to create resistance
o If the paDent ’s hand rises and lowers upon inhalaDon and exhalaDon, the breathing is being performed correctly
• For pursed-lip breathing
o Form the mouth as if preparing to whistle
o Take a breath in through the nose and out through the lips/ mouth
o not puff the cheeks
o take breaths deep and slow
medicaDons
• albuterol
• Ipratropium (anDcholinergic medicaDon)
• Theophylline (relaxes smooth muscles of the bronchi)
• CorDcosteroids
• MucolyDc agents to thin secreDons
CHF
•
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Lee sided vs. Right sided
Refer to page 31 J
Crohn’s vs. UlceraDve coliDs
• Refer to page 12 J
Rheumatoid arthriDs vs. OsteoarthriDs
• Refer to page 22 J
GlomerulonephriDs vs. NephroDc syndrome
• Refer to page 42 J
Cane, walkers, crutches
• Non-weight bearing à 3 point gait
• Cane:
o Good leg first going up stairs
o Bad leg first going down stairs
MI
•
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Monitor H/H
Refer to page 29 J
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•
Chest pain, Dghtness, radiates to the LEFT shoulder
At risk: elderly, diabeDc, CHF
Alcoholic Cirrhosis
• 1st Famy liver
• Scaring/ shrinks
• Decrease protein diet
• Neomycin (anDbioDc)
• Lactulose (to excrete ammonia into stools)
• Contraindicated with acetaminophen
Alcohol abuse
• Naltrexone: decrease craving
• Disulfiram / Acomprosat: avert cravings
EpiglosDs
• Refer to page 41 J
TURP complicaDons
• Refer to page 7 J
32 weeks preterm
• Lungs for babies (L/S 2:1)
• Trisomy 21 (down syndrome)
• NTD 21 à lungs à betamethasone
• Terbutaline à monitor HR
• Steroids à monitor glucose
Peripheral vascular disease
• Buerger Disease
o Necrosis in the peripheral vasculature
o Doppler
Peripheral arterial disease
• Raynaud’s syndrome (autoimmune)
Neutropenic precauDons
• Refer to page 18 J
Anorexia vs. Bulimia
• Refer to page 57-58 J
SSRIs
Psychosis
• Refer to page 61 J
•
Refer to page 52 J
Hospital à immobile à pressure ulcers à consDpaDon
• FloaDes heels
• Contraindicated with high Fowlers
PepDc ulcer
• NSAIDs, steroids increase risk
EPS
•
Refer to page 55 J
Clozapine
• Decreases WBC
85 Stroke paDents
• Keep cane on strong side
• Wear shoes when measuring the cane at the waist
• 30 degree elbow angle
Walker for Parkinson’s
• No rollers on the walker
Trendelenburg syndrome (blue book pg. 269)
• Hip dysplasia
• Caused by polio virus
Bowel training program
• Ask the ATI educator… cannot find in the book L
Fractures
• 6 P’s
• Blue book pg. 112
• Refer to page 25
o Neurovascular (pain, pressure, pallor,
pulselessness, paresthesia)
o Skin temp
o Fat embolism (petechiae, confusion)
o Compartment: pain, cyanosis, Dngling,
paralysis
Surgery
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•
Passive ROM
ConDnuous passive moDon
ElevaDon
DVT prophylacDc
DVT: elevate, warm compress
Phantom limb pain
• Calcitonin (MS p.460)
Enteral feeding – intermiment vs. ConDnuous
1. IntervenDons
2. How oeen check residual
3. How oeen change bag
4. Amount of fluid you push
5. How do we remove blockage
6. I&O measurements
7. Amount of fluid to push (post/prior meds)
Heart Failure
• AcDvity intolerance
• Decrease urine output
• Give Digoxin à monitor for Magnesium and K+
o Digoxin will also decrease urine (AE)
CHF
• Pulmonary artery wedge pressure (lee sided HF)
o Indirect pressure
Postmortem care for child
• Prepare body for viewing
•
Keep hair for mom or take photo
Penicillin G
• AnaphylacDc concern
o Have Epi readily available
Contraindicated for thrombolyDcs
• CT scan
• Stroke
• Hematoma
• Heparin drip
Enoxaparin
• Return demonstrate
• Subcutaneous
• PaDent on epidural and enoxaparin à be careful
blood risk
AnDpsychoDc
• Pseudoparkinsonism
o Give benztropine
Ambien
• Myasthenia gravis (helps with acetylcholine)
o Tensilon test
o Vagus nerve sDmulate à bradycardia à give
atropine
Implant ports
• Refer to page 34 J
Blood transfusion
• What lab values do we check aeer?
• Refer to page 20 J
Furosemide
• Monitor electrolytes
• Ototoxicity
Steroids
•
•
•
•
•
•
•
•
•
•
•
•
Osteoporosis
HTN
Hyperglycemia
GI bleeding
Immunosuppression
Pigment of the skin
Steroid rage
H20 retenDon
Hyponatremia
Monitor skin breakdown
Glucose checks
Postpone allergy tesDng
Vancomycin
• Give slowly
• PhlebiDs
86 •
RED MAN SYNDROME
•
Amitriptyline
• OrthostaDc hypotension
• Takes few weeks to take effect
SSRI: increases serotonin
TCA: increases norepinephrine + serotonin
MAOI: increases norepinephrine + serotonin
2 quesDons on dosage calculaDons
AppendiciDs
• No warm compress
• Sudden stop of pain = rupture
• NPO à Ng tube à monitor hyperkalemia and
metabolic alkalosis
TPN (refer to page 17)
• Q24hrs
o Bag
o Change tubing
• Q72hr: dressing change
• Q4hr: glucose
• Q1hr: glucose if giving with insulin
• Too fast = Dumping syndrome (fat overload
syndrome)
Concussion vs. contusion (page 81 MS book)
o Concussion: mild traumaDc brain injury
§ will show in imaging
o Contusion: bruising from direct hit
§ Will not be shown in CT scan
Epidural hematoma
• Arterial
• Fast bleed
• Drill into skull (burrow hole)
• Herniated à dead
Subdural
• Venous
• Slow
Aneurysms
• Check all siblings
• Hereditary
• Increase cholesterol + smoking = increases risk
• Mesh viral à no MRI
o Nesng
Refeeding syndrome (refer to page 36)
Peak flow meter
• PaDent blows out
• Record the highest reading of 3 total readings
IncenDve spirometer
• PaDent breathes in and holds for 5-10 seconds
• Increases lung expansion aeer procedures
• Prevents atelectasis
Kid photo (hot spot)
• Picture of ecchymosis
• What is important to monitor à platelets / H&H
Rubella
•
•
Hypocalcemia (hot spot)
• Chvostek’s sign à the cheek
PancreaDDs
Internal bleeding
• Turner’s sign
• Cullen’s sign
DiabeDc foot care
Sterile sample from catheter
Cardiac catheter
• Keep leg straight 4-6hr post
• Chest pain (complicaDons)
• Refer to page 6 J
Paracentesis
• Refer to page 17 J
Head injuries
• Refer to page 20 J
Droplet precauDon
MMR vaccine
o Contraindicated for pregnant paDent s
o Use with cauDon when administering to a
paDent who has history of
thrombocytopenia
SucDoning
• Refer to page 5 J
• Know them in order
Abdominal incision
• Dorsal recumbent
• Dehiscence vs. evisceraDon
• Binder
• Stool soeener
• Increase protein
CysDc fibrosis at home (refer to page 43 J )
• PancreaDc enzymes with food
• Include salt
• Acetylene (helps decrease diet)
• Needs ADEK vitamins in diet
• Autosomal recessive disease
87 Hemophilia (PEDS p. 129)
• A/B à X-linked recessive disorders
• Hemophilia A
o Deficiency of factor VIII (8)
o Referred to as classic hemophilia
o Accounts for 80% of cases
• Hemophilia B
o Deficiency of factor IX (9)
o Referred to as Christmas disease
• Expected findings à episodes of bleeding
• Nursing care
o Administer injecDons via subcutaneous
route instead of the intramuscular route
whenever possible
o Avoid unnecessary skin punctures and use
surgical asepDc technique
o Venipunctures are preferred over finger or
heel sDcks for blood sampling
o
o
o
Monitor urine, stool, and nasogastric fluid
for occult blood
NO aspirin, give acetaminophen
Control localized bleeding
§ Administer factor replacement
§ Observe for AE, including
headache, flushing, low Na, and
alteraDons in HR and BP
§ Encourage the child to rest and
immobilize the affected joints
§ Elevate and apply ice to the
affected joints
Amniocentesis
• 16-20 weeks
• Edwards syndrome (T18)
• Down syndrome (T21)
• T31
88
Nursing Concepts Note
of 88
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