level 4 exam 1 review

Total Parenteral Nutrition pp

A solution with concentrated nutrition to provide adequate nutritional support to a client who cannot maintain nutrition through oral intake or tube feedings Components of TPN: High concentration dextrose Amino acids Fat emulsion Electrolytes Minerals Trace elements Vitamins Types of Patients Needing TPN: -Inability to feed gut: Hyperemesis Gravidarum Intestinal obstruction Anorexia Nervosa -Cancer - obstruction, effects of radiation, chemotherapy -Critically ill patients unable to meet their caloric needs D/T illness or being physically unable to ingest, digest food Delivery Method: -Central Line Usually through the subclavian or internal jugular veins (X-rayed after insertion for placement) PICC -Use of pump or infusion control device required Side Effects or Complications: -Infectious Localized & systemic infection -Metabolic Hyper/Hypoglycemia Altered renal function' EFA, vitamin, trace element deficiency Fluid volume & electrolyte imbalances Refeeding syndrome -Mechanical Air embolus, hemo, pneumo, hydro thorax Hemorrhage Thrombosis Nursing Care: -Metabolic Complications Start slowly End slowly -Use Pump -For emergency stop Hang Dextrose 10% -Check bag for contaminants -Keep bag refrigerated (take out ½ hour before use) -Never add to bag or tubing contamination & incompatibility risk -Never draw blood from line -Verify contents -Change dressing per protocol -Change bag and tubing Q 24 hours Use filter -FSG q 4-6hrs Sliding scale insulin coverage Expect slightly elevated blood glucose -Daily weights -Monitor I & O Peripheral Parental Nutrition: -Delivered through a catheter in a large peripheral vein -Short term use 7-10 days -Protein & calorie requirements are not as high Can supplement po intake -Emergency Stop Dextrose 5%

Central Venous Access Devices CVAD pp

CVAD aka CVC Central Venous Catheters -Used for administration of: Chemo Blood Long term antibiotics TPN Vesicants Complications: Sepsis- -Most common -Bio-patch reduces risk -Maintain sterile technique when assisting with catheter insertion and during catheter care procedures or manipulation Other Complications: -Air embolism Bolus of air enters catheter & circulation...may cause neurologic, respiratory or cardiac decompensation -Thrombosis Develops over time when thrombin builds up near or around the tip of the CVC Patency of CVC: -Check patency before administering any medication / infusion Flush with 10ml syringe -Verify patency Ease of flushing Blood return -Especially important to prevent extravasation of vesicant agents Types of Central lines: -PICC—peripherally inserted central catheters -Non-tunneled -Tunneled -Implanted ports -Other factors Multi or single lumen Groshong (slit valve) Lumens: Staggered openings- -Each lumen opens into the circulation at a different position along the length of the catheter -Permits simultaneous infusion of drugs or fluids that would otherwise be considered incompatible -Labeled -Distal port (farthest away from insertion site) Largest port CVP monitoring and high volume Viscous fluids - colloids or medications -Medial port TPN -Proximal port Blood sampling Blood administration Medications Central Venous Catheters (nontunneled): -Inserted in the: subclavian - superior vena cava jugular - superior vena cava femoral vein - inferior vena cava -Risk of pneumothorax during insertion -Chest x-ray to confirm placement before use (also will show pneumothorax) -Inserted by MD PICC: -Peripherally inserted central catheter Placed by MD or specially trained nurse Inserted in the basilic or cephalic vein Catheter is up to 60cm in length Benefits: No risk of pneumothorax Lower infection risk Often placed in patients requiring long term IV antibiotic treatment at home -Dressing change & flush IAW agency protocol -Do not use arm for blood pressures -Do not to immerse arm in water Cover site & catheter with occlusive dressing for shower -Watch for redness, tenderness at site -PICC should be removed for signs of infection and tip should be cultured (notify MD) Tunneled catheters: -Many types -Inserted into the internal jugular vein or the subclavian vein below the clavicle It is then tunneled from the puncture site through the subcutaneous tissue and out through the skin of the chest or abdomen. 1 - 3 lumens -Placement by CXR prior to use -Antimicrobial cuff is under the skin. Helps to hold the catheter in place and helps to prevent infection. -Care and flushing will be the same as previously listed with central line. Implanted infusion port: -Used for chronic illness: Long term Chemotherapy TPN Frequent blood sampling -Designed to provide repeated access to the central venous system without the trauma of multiple venipunctures -Inserted into small subcutaneous pocket usually in the upper chest -Access port with a special needle called a Huber needle -Feel for edges of port (hard circle) and place needle into center of port -This may be done by a specially trained IV nurse Flushing: -Syringe size Use 10ml syringe for central lines Small syringe barrel = more pressure generated High pressure may damage catheters -Flush the port with NS before and after every use and then with heparin flush solution Flush all lumens No heparin with Groshong Central venous catheters: -Site care Dressing Change Strict aseptic technique Dressing change every 3-7 days (per hospital policy) and when loose or soiled Assess site for any redness, swelling, tenderness or drainage Be aware of swelling, jaw and/or neck pain on the side of the catheter -Catheter care and flushing Change cath caps IAW facility protocol, usually q 3 - 7 days Flush per hospital policy

blood transfusion pp

Composition of Blood -plasma, WBCs & platlets, RBCs Blood Types -Types A B AB O -Rh Negative Positive Reasons for RBC transfusion: Surgical / Trauma losses Anemia - Hgb < 8 Bone marrow failure Increases Hgb ~ 1 g/dl + Hct ~ 3% Replaces both volume and oxygen carrying ability to CV system Reasons for platelet transfusion: Thrombocytopenia < 10-20,000 DIC Reasons for Fresh Frozen Plasma (FFP) transfusion: Deficiency in clotting factors: Warfarin OD Liver Disease DIC Albumin: -Prepared from plasma Available in 5% or 25% sol -Hyperosmolar Pulls 3.5 times its volume -Used to tx: Hypovolemic shock Hypoalbuminemia Refractory edema Administration Procedure: Preparation -Verify Order Ensure consent has been obtained Start 18 gauge IV - ideally Take initial VS Prime "Y type" blood tubing with 0.9% NS (Contains in line filter ) Administration Procedure: Administration Stage -Obtain blood from blood bank Hang within 30 mins -2 nurses verify correct blood product + Pt Most common error! Check verbally, ID band, + Blood band # Administration Procedure: Administration Stage -Initial Rate = 2ml/min 1st 15 min Then remainder over 2hrs Never exceed 4 hrs for 1 unit -VS per policy Always at 15 min mark and throughout Administration Procedure: Final Stage -Monitor for reactions (see following slides) -Dispose of blood bag + tubing Red bag -Document Amount, patient reaction, duration Reactions to Blood Transfusions: -ACUTE Acute hemolytic Febrile, non-hemolytic Mild allergic Anaphylactic Circulatory Overload Sepsis TRALI -DELAYED Delayed hemolytic Hepatitis B or C Iron Overload Other infectious Acute Hemolytic Transfusion Reaction Symptoms: -fever hypotension nausea, vomiting tachycardia dyspnea chest or back pain flushing severe anxiety WHAT TO DO: Stop transfusion Change IV tubing/start 0.9%NS Monitor Pt. Vital signs/Urine output/renal function Notify MD + Lab Send Bag & tubing to lab Recheck blood # + tags Collect specimens & document Reaction form Massive Blood Transfusion Reaction: -Replacement of blood exceeds total blood volume in body within 24 hr -Complications: Citrate toxicity Hypocalcemia Hyperkalemia Arrhythmias Hypothermia

hospice pp pain management

Controlling physical pain allows a person to maintain their dignity, have a sense of peace, hope and good quality of life. Who has Pain? -More than 1/3 of hospice patients have a cancer Pain Affects Well-Being -spiritual, physical, emotional, psychosocial Spiritual Components of Pain: -Loss of trust, faith "Why me?" -Feel abandoned "Why are you allowing me to suffer?" -Feel punishment "My pain is so bad, because I was." -Become isolated "I haven't been able to attend church." Psychosocial Components to Pain -"I'm not sure who I am anymore... I've just become that old man who is in pain." -pain -> isolation -> relationships -> meaning & purpose Emotional Components of Pain: pain -> fear anxiety -> anger frustration -> hopelessness -> depression Treating Pain to Break the Cycle: -Treat pain before it becomes severe. -The bigger the pain the harder it becomes to bring under control. Acute Pain: Short duration Tissue damage Can trigger nervous system changes Chronic/Terminal Pain: Persistent Nerve damage May be unrelated to actual tissue damage Classifications of Chronic/Terminal Pain: -Baseline Pain Background Pain -Breakthrough Pain Incident Pain Facts about Physical Pain: -Pain is whatever the patient says it is. It is a patient's right to have their physical pain believed and managed. -Every person deserves to be as comfortable as they want to be. -Every person should be asked about their level of comfort at every visit by every discipline. Types of Pain are based on where it originates: pain - Bones Muscles Tissue, organs, nerves Bones, Muscle, Tissue, Skin Pain (Somatic): Constant Aching Deep, throbbing Dull Cramping Worse on movement Pain you can point to ex: Muscle strain Arthritis Headache Bone pain Mouth pain Bone metastasis Damage to Organs (Visceral Pain): Intermittent Poorly localized Hard to point to Sharp, deep Squeezing Cramping Stabbing Crushing Pressure Nausea, sweating ex: Angina/ heart attack Bowel obstruction Colon cancer Gastrointestinal disease "Gas" pain Liver disease Pancreatic disease Uterine cancer Neuropathic Pain: Intermittent Stabbing Searing, stinging Shooting Burning, tingling Electric Worse at night Painful to be touched ex: Diabetic neuropathy Post herpetic neuralgia Neuropathy Sciatica Spinal cord compression Somatic Pain tx: -NSAIDs (non-steroidal anti- inflammatory) -Corticosteroids (dexamethasone) -Opioids Visceral Pain: -Opioids -Corticosteroids Neuropathic Pain: -Tricyclic antidepressants -Anticonvulsants -Opioids Meds Step One: Aspirin Acetaminophen NSAIDs Meds step two: Combination medication Acute Pain ceiling Meds Step Three: Opioids- morphine hydromorphone fentanyl methadone hydrocodone oxycodone Opioid SE: constipation sedation respiratory changes confusion nausea vomiting Constipation: -Most opioid side effects resolve within 72 hours with consistent dosing... -EVERY PERSON ON OPIOIDS will usually have a "bowel regimen" ordered stool softener and stimulant laxative Sedation: Sedation (feeling drowsy or very sleepy) may happen when first beginning to take an opioid medication or after an increase in the dose. It usually resolves within 2-3 days. Nausea and Vomiting: Common Usually resolves Antiemetics Change Opioid Sedation/Respiratory Changes: For Opioid Naïve Double Effect Opioid medications can be taken in different ways: Oral Rectal Transdermal Sub Q. Intravenous Epidural Help Control Pain: -If you visit a patient who has pain that is not well managed or is suffering from nausea, vomiting, constipation or other symptoms of physical suffering, notify the hospice nurse or your manager promptly. -Treating pain is important and there are many medications and treatments that can be used. If one medication or treatment does not work, there are others that can be tried. -Medication schedules can be changed or adjusted to work best for the patient. The hospice nurse or physician work together with the patient and family to find the pain medication and treatments that can help. Barriers to Pain Control: -Patients/Families- Addiction Sedation Allergies Advancing Disease -Healthcare Providers- Addiction Sedation Drug Seeking Last Dose -ex. "I'm tough, I don't need that stuff.", "I don't want to bother the nurse.", It won't work when I really need it.", "I can't take opioids, they make me throw up." Concerns about Addiction: -Many people worry that if they take pain medication regularly, they will become addicted. -Addiction is loss of control over use of a substance. -People who need opioid medication to control pain very rarely become addicted. Facts about Physical Pain: -With prompt attention and dynamic interdisciplinary care 90% of physical pain can be controlled with oral (by mouth) medication -"The right medication for the right pain" -Pain relief is guided by patient choice Talking about Pain: -Where is the pain? Pain can be in more than one place. Ask the person to point out all the areas where they have any pain. Which site (location) of pain is the most severe or bothersome? -What does the pain feel like? Their description of the pain is very important. If they have difficulty finding the right words to tell about their pain, ask if any of the words below might describe their pain? Aching, Searing, Tearing, Burning, Sharp, Throbbing, Cramping, Shooting, Tingling, Cutting, Squeezing, Stinging, Crushing, Stabbing, Pressure -Using a Pain Scale: 1-10 Patients are taught to use a pain scale to help others understand the intensity of pain they are experiencing. On the 0 to 10 scale, 0 means no pain at all and 10 means the most severe pain. Pain Questions: How does pain change? What makes it better/worse? Worst pain, least pain? Integrative Therapies: -Promote a sense of well being -Aid in relaxation, rest -Help relieve stress -Create a sense of balance -Not all therapies work for everyone -Not to be used in place of medical interventions Healing Touch Therapies: Back rub, massage, foot or hand rub Acupressure, acupuncture Heat or cold applications Therapeutic Touch ex. reiki Using Heat and Cold Applications: -Around pain site if tolerated -Between the pain and the brain. -Contralateral (opposite) side of the body Heat Application: -Apply for 20-30 minutes -Check the skin frequently -Alternate hot with cold application for skeletal muscle spasms -Equipment Hot packs- home made, or those available at stores containing a heating compound (such as a gel) Warm moist towels Hot water bottles Electrical heating pads- encourage the use of "timed" devices that turn off automatically after a prescribed time Warm baths/showers or whirlpool treatments Cold Application: -Apply for 20-30 minutes at a time -Protect skin -Equipment Chemical gel packs Cold or frozen damp towel Ice packs (sealed plastic bag with 1/3 alcohol and 2/3 water frozen until slushy) Bag of frozen peas/beans (separate for flexibility) Tx music, humor, spiritual care, life review, aromatherapy, art, pet therapy, relaxation techniques Treating Pain is Important: We should and can find ways to relieve physical pain. If this opportunity is lost, increased suffering may occur.

hospice pp -Orientation to Hospice Care for Nursing Students

Experience Approach: -Patient/caregiver guide their own end-of-life experiences. "What is important to you?" -How are symptoms, issues, opportunities helping or hindering them from reaching their goals & meaningful experiences? -Choices & options to help them reach their goals -Quality of experiences through meaningful life & relationship completion & closure Disease Approach: Diagnosis of disease & related symptoms Curing of disease & symptoms Treatment of disease & symptoms Evaluate if they met our goals Holistic and Person-Centered family & patient center -physical, functional, interpersonal, well being, spiritual The Experiences of Completion & Closure: Life Affairs Relationships with Community Personal Relationships Love of Self & Others Finality of Life & Relationship Meaning of Life Bereavement, Renewal and Re-socialize Regulatory Snapshot: -State licensure -Federal regulations and requirements for reimbursement -Conditions of Participation (CoPs) Certification of limited prognosis Interdisciplinary team members & care planning Frequency of visits Documentation requirements Included & excluded services Locations & levels of care Hospice as a Nursing Specialty: -Certifications CHPN Thanatology -Integrative/holistic practice -Roles for ARNPs/DNPs You Might See: Patients who are A&Ox3 and functionally independent Patients who are unresponsive and bedbound Patients who are actively dying or have recently died Families who are visibly upset Families who are outwardly calm and composed Staff who are assessing, planning, consulting, teaching, performing, consulting, documenting, coaching Low-tech care High-tech care Patients of all ages You Will Hear: What is most important to you right now? You look uncomfortable. Tell me about your ______ (pain, dyspnea, N/V, anxiety, fatigue, etc) are you having? Tell me more about.... What I'm hearing you say is... I'm noticing... Is now an ok time to talk about... People often ask me about...I'm wondering what questions you might have... Let's go over a plan to prevent constipation with these pain medications you are starting to take. Expectations: Respect for those we serve as well as our staff and volunteers Professional dress and grooming Protect privacy Empathy in action Growth mindset - ask, participate Active listening skills Full presence No distractions Mindfulness of the people around you Self-awareness and seeking support

hospice pp -Advance Care Planning, "What You Need to Know"

History: Until the late 19th century, most illnesses had rapid onset and resolution, not chronic -Death often occurred in less than 8 weeks -Main causes of death: pneumonia, influenza, tuberculosis, diarrhea What's Changed?: -Unprecedented change in world population --Not only living longer, but older adults are an even higher percentage of the world population (Population Ref. Bureau 2014; US Census 2014; et al.) -Change from acute conditions as leading cause of death to chronic -Leading causes of death in the US: heart disease, cancer, lung diseases, cerebrovascular disease Studies show: Less than 30% of adults in the US have an advance directive (PEW Report, 2006) Nearly 60% of those over 65 will die in a hospital or a nursing home (Nat'l Vital Statistics System, 2009) Of those 85 and over, roughly 55% require long-term care. Nearly 50% over 85 may be affected by dementia Talk to Your Doctor: -Discuss medical treatments with your doctor. He/she knows you and what your health is normally like. -Good communication is key -Understanding gray areas -Be empowered "no decision about me, without me Patient Choice: It's not just about what you don't want...it's about what you do want. Thinking About Values : -No one can define quality of life but you -What qualities in life are valued? Family Independence Spirituality Mobility Mental capacity Quality of Life Values: -I want to live as long as possible, regardless of the quality of life that I experience. -I want to preserve a good quality of life, even if this means that I shall not live as long. Talking About Decisions: Communicating preferences to- Family Loved ones Health care professionals Documenting Wishes: Living Will- -Written instructions for medical treatment -ONLY when you are no longer able to communicate your choices yourself What makes a Good HCS? Able Willing Local, preferably Not intimidated by hospital or physicians Will follow your wishes, even if they disagree Able to ask questions and make decisions Is aware of your wishes and values, because you have discussed them A strong advocate What does the surrogate do?: -Makes healthcare treatment decisions -Takes steps to see that wishes are honored -Talks to the doctor/health care team -Authorizes treatment or has it withdrawn per pt. wishes -Has access to medical records -Can authorize transportation to another facility The document is complete, now what?: -Keep original where it can be easily found -Copies to: Physician (s) Healthcare surrogate Family and caregivers Hospital medical records Spiritual advisor How often should it be reviewed?: Remember the 5 Ds a Decade a Divorce a Death a Diagnosis a Decline What NOT to Do: -Don't wait to address advance care planning -Don't assume your health care surrogate knows what you want without discussing it -Don't choose more than one person as your primary HCS The Benefits of Planning in Advance: -Prevents under treatment/over treatment -Reduces stress of medical decision process on others -Enhances guidance to surrogate Why Should Nurses Care?: -Numerous studies show patients and families want clear and direct information about treatments and prognosis -Physicians are often not aware that patients have completed an advance directive The Nurse's Role in ACP: Nurses have a key role in providing care and are well placed to facilitate the advance care planning process which has the potential to improve the quality of end-of-life care that patient's receive. -This could include: Providing information Emotional support Facilitating dialogue - patient/family/healthcare team Promoting the completion of a living will Empath health Services: -Assistance for individuals and families -Professional training courses -Community and corporate presentations -Advance directives - free of charge -Continuing education courses for healthcare, legal and faith professionals -Resource library

Self Expression pp

Home Health Care: Types of services provided in home health care: New "Ostomy" Foley Catheter Complicated Medical Condition Medication Monitoring Patient Education IV antibiotics TPN Tube feeding Home Chemo PICC line management Complicated wounds and dressing Rehabilitation Palliative Care -PT OT speech CNAs etc +RNs (manage team) Eligibility requirements for home health services: -Medicare, HMOs & other insurances -Patients must qualify for the service --"homebound status." --Need intermittent professional, skilled care (RN care). Contrast the responsibilities between the members of the home health team: -The RN is the coordinators of care -Accountable for supervision of care given by home health aides and for case management services - ALL aspects of care in the home. -Observation, assessment, management, teaching, training, medication administration, wound care, tube feedings, catheter care, and behavioral health interventions. -Verify progress, getting what need -Very autonamous- a lot of paperwork -observation skills, confidence, assessment skills, manage all diseases (not good for new grads), spot abuse, avocate -Report abuse to immediate supervisor RN cordinator, responsible for everything, make sure everybody doing their job Patient need for RN servies, homebound status Palliative and Hospice Care: Advanced Directives: Healthcare Surrogate Living Will Organ donation -Aka patients wishes (advance directions) -living will- directions if XYZ happens (ex. month on ventilator then unplug) -DNR does not equal do not treat! (no restarting heart) -Proxy- appointed by the court -HCS (ethics commite) Next of kin- spouse, adult children (oldest or majority rule) -Florida 5 wishes state (pam phlet) -Project- diff types of living wills / advance directives Goals of Palliative Care: -Provide relief from symptoms, including pain. -Regard dying as a normal process. -Affirm life - neither hasten nor postpone death. -Support holistic patient care and enhance QOL. -Offer support to patients to live as actively as possible until death. -Offer support to the family during the patient's illness and in their own bereavement. --Encourage patient to express wishes to family Ex. patient DNR then family surgaete demands full code (not good patient dies anyone) -Pallative care (still curative tx) Hospice (nothing curative) but pallative care also done -both pain & symptom relief -refere dying as natural process -Hospice Family gets 2 yrs of support care therapy -Early consult to hospice --even if only 1 day What is hospice? A concept, not a ______. Focuses on ____ and ____ at the end of life. Usually limited to the last __ ____ ____ ____. Assists patients to fully live as ______ __ _____. Includes ________ management, family care, & spiritual care including bereavement Care generally provided ___ ___ _____. Multi__________. -Place Quality comfort Last 6 months of life As they can before they pass Symptom In the home Disciplinary Unique characteristics of end of life/hospice care for the dying and their significant others: Quality of Life Freedom from pain Symptom management Preparation for death Achieving a sense of completion Decisions about treatment preferences Being treated as a "whole person" -Keep for high quality of life (ex. gardening, playing cards, drinking every night, etc = happiness) -Hospice- treat all symptoms ex copd etc Hospice criteria: -The patient must desire the service and agree in writing that only hospice care (and not curative care) will be used to treat the terminal illness. -The patient must meet eligibility requirements: 2 MDs certify the patient's prognosis is terminal w/less than 6 months to live -1 primary care dr 1 hospice dr -Patient must desire hospice services! (not pallitive or HHC) -If refuse HHC than patient admitted into SNIFF -After 6 months needs to be recertified than recertified after every 2 months -recertified if any decline (ex. loosing 1 pound, etc) NP assess make narritive than Dr recertify -Ppl graduate from hospice care than end up coming back (cause no longer getting the care provided) Hospice care provides- Spiritual Therapy Beheverment Short term inpatent care (usually there for exacerbation 2 weeks or less) CNA Pharmasit PT RT ST etc -Respic care- 5-7 days a month to take care of family member (normally taken care of full time by fam- but fam needing break/going out of town etc) Barriers to Hospice care: Communication and language barriers Underutilization by minorities Lack of knowledge Lack of minority employees -May need interpreter/ blue phone -Hospice never denies care! If cant pay -Explain what hospice does, benefits etc still treating-not means giving up -Drs may believe hospice care = failure = delaying transfer, waiting till too late, not wanting to fail/give up Psychosocial Manifestations: Life review Peacefulness Restlessness Saying goodbyes Unusual communication Vision-like experiences Withdrawal Altered decision making Anxiety: unfinished business ↓ Socialization Fear of loneliness Fear of meaninglessness Fear of pain Helplessness -When dying- Have fam reminice with them happy good times CM Hearing last this to go! --explain this to families, express happy last words to family member! -Patient suddenly seeming better = may be sign -Roll to make gargling stop (mouth secretions not being swalled) -Haulcenating = taking to ppl that have already died -Listen to patients story -Cheyne stoke resp (stop breathing than breathing again) -No full head to toe ex. assess whats wrong -GI - don't force food, let eat whatever they want --no BM may stop producing urine, may not pass stool -Post mortum care- involuntary care gas BM etc Stages of grief and bereavement at the end of life: Denial Anger/bargaining Depression Acceptance -Not always make it thru stages Sometimes internal only Maladaptive grieving- not healthy ex. 3 yrs still crying q day afte cat dying Normal grieving time months - years Encourage expression of feelings- counseling Conflicted grief Assess the importance of client culture/ethnicity when planning/providing/evaluating care: Ask- any cultural beliefs- death and dying How can the rn assist the client and family in coping with suffering, grief, loss, dying, and bereavement? -Allow expression of feelings State grief is normal, its okay to cry Have fam members comfort be involved with main suporter

ADMINISTERING MEDICATIONS VIA IV BOLUS OR IV PUSH

Intravenous bolus: -the administration of a medication directly into a vein via a heparin lock or through the injection port of a previously placed IV line. IV push: -the method used to administer a bolus dose. -Intravenous bolus dosing is used when the effect of a medication is desired immediately, as in a cardiac emergency or IV sedation. Direct intravenous administration of a drug provides immediate distribution, therefore, it also carries with it the highest risk of side effects as well as the inability to correct a medication administration error. The nurse must follow institutional as well as pharmacological guidelines regarding which medication may be given IV push. -Many intravenous medications (irritants) cause injury to the lining of the blood vessel and may cause chemical phlebitis. Other intravenous medications (vesicants) will cause tissue sloughing and necrosis if injected into an infiltrated IV line. The nurse must not only make certain that the IV line is patent and free-flowing, but also that it is an appropriate access device for the specific medication that is to be given. Medications with a pH below 5 or above 9 should be administered through central lines. Important factors with IV administration: R - rate I - incompatibilities N - normal dose range D - diluent Equipment needed: -Gloves -Medication in vial or ampule -Syringe, 3-5 ml -Sterile needles, 22 and 25 gauge -Filter needle -Antiseptic swab -Two syringes with saline flush solution -Syringe with heparin solution if applicable Pre-procedure: 1. Check the physician's order for dosage, time, and route. 2. Review information on the drug including action, purpose, side effects, normal dose, peak onset, and nursing implications in order to administer the drug safely. -Make certain you have the information for intravenous administration of the drug rather than general information. Consult the pharmacy or your specific intravenous drug text. 3. Determine additives and type of solution in existing IV line and check for incompatibilities with medication to be given. 4. Assess placement and patency of existing IV line and surrounding site. 5. Check the client's allergy history. Procedure: 1. Wash hands and put on clean gloves. 2. Draw up medication in syringe. Use only medication that is clear and without undissolved particles. -Use a filter needle when withdrawing from a glass ampoule and then change needles to administer. 3. Check client's identification bracelet and allergy band. 4. Explain procedure to the patient. 5. To inject meds using an injection port on an existing primary IV: -Select an injection port close to the IV insertion site. -Clean the injection port with an antiseptic swab. -Check for a blood return by pinching the tubing above the injection port and pulling back on the plunger of the syringe. -Administer the medication by continuing to pinch the tubing and slowly injecting the medication over the prescribed time period. Look at your watch, don't guess. -Clear the tubing by releasing the pinched tubing and allowing the infusion to resume. (In the case of medication that is not completely compatible with the infusion, a saline flush before and after medication administration is required. Check hospital policy and hospital pharmacy). 6. To inject meds using a reseal: -Clean reseal port with antiseptic swab. -Insert saline syringe and check for blood return by pulling back gently on plunger of syringe. -Flush with saline. -Clean injection port again with antiseptic swab and inject medication slowly over the entire prescribed time. Remove medication syringe. -Cleanse with antiseptic swab again and slowly flush with second syringe of saline. 7. Remove gloves, wash hands. 8. Observe client response to medication. 9. Document medication administration and client response.

Mobility spinal cord injury pp

Most at risk- young males 1 automobile accidents, diving accidents Primary- damaged to cord - Secondary- edema swelling on spinal cord resulting from ischemia, apoptosis cellular death (spinal cord not getting O2 lactic acid builds up acidic environment 24 hrs perminant damage ishcemia -prevent edema! -imobilization of cervical spine no movement collar-manage inflammation -roll patient log roll stick straight to check back C 1-7 (breathing! C 3 and above no RR/ventilation = vent) T 1-12 (issues edema spreading up to the Cs) L 1-5 Physical Challenges: Secondary Injury r/t ischemia Spinal Shock/Neurogenic Shock Respiratory complications Cardiovascular complications (above T-6) Urinary System complications GI complications: Above T5 Skin complications Nutritional complications Peripheral Vascular Problems -Many resp difficulties develop pneumonia (IS, SIRS, chest physiotherapy) Resp arrest c3 and above -airway cervical stablization C collar monitor SIRS critera ABGS indicate intubation High flow oxygen to perfuse spinal cord Cardio probs- bradycardia, hypotension (neurogenic shock- bradycardia! Tx brady with atropine flaccid paralysis below level of injury (it is expected/anticipated) happens cause lost ability to control with SNS (fight or flight), polikothermia Ex. neurogenic shock brady- fluids + atropine (emergency situation-ex fill pipes before constrict them with dopamine) Patient on cardiac monitor, atropine for bradycardia, flluids, vasoconstrict for hypotention, MAP greater than 90 Neurogenic bladder Urinary symtom complications- urinary retention tx straight cath or perminant foley indwelling catheter Comp- infection UTI Teach intermittent cath q 3-4 hrs (to prevent autonomic dyreflexia), drink lots of fluids 1800-2000ml/day keep urine flushing system Ditropine detrol hytrine to supres bladder spasms Dexozazine idk relax sphincter pelvic floor muscles etc tx urinary symtoms GI comlications Perilitic ileus, gastric distention, stress ulcers, tx NG suction, reglan increases parastalsis, stress ulcer prophylaxis meds, measure abdominal girth Neurogenic bowel and constipation -regular bowel program ex. colace miralax Make pt go everyday (ensure they go by certain time ex 30-60min after breakfast, digital stimulation) high fiber +lots fluids Skin breakdown- wheel chair teach reposition q 15-30min, bed turn q 2hrs , special pillows, monitor skin daily Huge ulcers Polkiothermia- don't sweat or shiver under where injured cant regulate heat NG tube suctioning protect from ileus, elcetrolyte comp metabolic alkolosis, wt loss common, high fiber high protein (skin healing, prevent muscle atrophy & skin breakdown) diet, special meals + fam, give a lot of control, calorie count, daily wts High incidence DVT and PE in 1st 3 months leading cause of death, venous stasis, prophylactic DVT tx, SCDs Airway- cervical collar backboard neutral position (prevent secondary injury) Ex T3 Decrease RR, perform good resp assessment, swelling may spread up c1-c3 Drug nephetarine IV fluids vasopressor cardiac prob hypotension bradycardia = neurogenic shock +atropine tx bradycardia Chronic, decreased resp reserve cough deep breath prevent pneumonia IS Psychological Challenges: Fear Denial Anger Depression/PTSD/Grief Sensory Deprivation Embarrassment -Spinal shock Tx therapeutic communication -tx patients in crisis Sex, kids, work Fear- honest info, use simple diagrams to explain injury Anger- allow patients outburts, acknowledge (behaviors- talk to me about that) the ager say that they would be angry too, give back a lot of control Depression- kuglar 5 stages allow grief, say it ok to grief/cry, cheerful + willing help with ADLs Sensory- stimulate above injury Prism glasses, tv read Embarrassment- hyperreflexia (some multiple times day) spasms erectile, often cath -drugs to help with spasm Spiritual Challenges: Lack of independence and feelings of purpose Sexuality Neurogenic Shock: Bradycardia and hypotension caused by loss of vasomotor tone and sympathetic nervous system innervation which causes peripheral vasodilation, venous pooling, and decreased cardiac output. -Patients with cervical injuries or thoracic injuries, especially above the level of T6 may show signs of hypotension, bradycardia, and lowered body temperature. These symptoms are a result of loss of vasomotor tone and sympathetic nervous system innervation. Autonomic Dysreflexia: AKA Autonomic Hyperreflexia: massive uncompensated cardiovascular reaction mediated by the SNS. Most common cause: distended bladder or rectum, stimulation of the skin, or stimulation of pain receptors. -It involves stimulation of the sensory receptors below the level of injury which causes hypertensive crisis and bradycardia. It is life threatening and should be carefully monitored. HA = HTN constricts, autonomic dysreflexia very high BP ex. 300! -Check kink in foley cath, have patient lye down and take BP, niphetamine or procarbonate ? Autonomic Dysreflexia Assessment Data: Hypertension (up to 300 systolic) Throbbing headache Marked diaphoresis above the level of injury Bradycardia Piloerection Flushing of the skin above the level of injury Blurred vision or spots in visual fields Nasal congestion Anxiety/nausea -It is important to measure the blood pressure of any SCI patient that complains of headache. As I said before, it is life-threatening and can lead to status epilepticus, stroke, MI and death. Not emotional stress! Piloerection = goosebumps AD Interventions: Elevating the HOB to 45 degrees or having patient sit up Notify the physician Determine the cause -Since the most common cause is distended bladder, immediately catheterize the patient. If a catheter is already in place, check it for kinks or obstruction. Perform a digital rectal exam after applying anesthetic ointment. Remove all skin irritants, constrictive clothing or tight shoes, for example. Monitor BP frequently and if symptoms persist, Procardia might need to be administered. SCI Diagnostic Studies CT Scan/MRI UA Labs Doppler Ultrasound Comprehensive Neuro Exam Nonoperative stabilization Surgery -A CT scan is the gold standard for diagnosing the location and degree of injury and degree of compromise. The Doppler ultrasound will be used to diagnose what? DVT! TPN might be ordered if the patient has paralytic ileus. Monitor fluid and electrolyte status for need to initiate TPN. Once the patient has bowel sounds again and passing flatus, gradual introduction of food and fluids will begin. The patient will be started on a high protein diet, high calorie diet for energy and tissue repair. Always evaluate swallowing before beginning feedings/fluids. If the patient cannot tolerate due to swallowing deficits, enteral feedings will be initiated. Know that patients may not desire to eat because they may be suffering from issues of loss of control or depression/anxiety. Thoroughly assess the reason behind not eating. Include the patient in goal setting - thus giving back some of the control. Allow families to bring in food that is appetizing. Keep a calorie count and daily weights to ensure adequate intake. Increase fiber to help with bowel function. Although initially the patient will receive an indwelling urinary catheter, the risk for infection typically results in the removal of that device and from then on out, the patient will be intermittently catheterized. Constipation is a real problem for the SCI patient. A bowel program will need to be initiated during the acute phase which consists of choosing a rectal stimulant (suppository or small-volume enema) to be inserted daily at a regular time, followed by gentle digital stimulation or manual evacuation until evacuation is complete. You need to compensate for the patient's absent sensations to prevent sensory deprivation. Do this by stimulating the patient above the level of injury. Conversation, music, strong aromas, and interesting flavors should be a part of the nursing care plan. Provide prism glasses so that the patient can read and watch television. Make every effort to prevent the patient from withdrawing from the environment. Once spinal shock has resolved, the patient might experience spasms and hyperreflexia. Explain the reason for this and antispasmodic drugs may be ordered. Drug Therapy: Low-molecular weight heparin (Lovenox) Vasopressors (acute phase) like Dopamine to maintain MAP greater than 90 so perfusion of the cord is improved. -Low-molecular-weight heparin (e.g., enoxaparin [Lovenox]) is used to prevent VTE unless contraindicated. Contraindications include internal bleeding and recent surgery. Oral anticoagulation alone is not recommended as a prophylactic treatment strategy.22 Vasopressor agents such as dopamine (Intropin) are used in the acute phase as adjuvants to treatment. These agents are used to maintain the mean arterial pressure at a level greater than 90 mm Hg so that perfusion to the spinal cord is improved. Neuro 35 SC 45 SCI Related Nursing Management: Frequent respiratory monitoring including continuous pulse oximetry. Intubation might be necessary. Atropine, fluids and vasopressors may be needed. Carefully monitor the patient's vital signs. An indwelling catheter will be inserted to drain the bladder. T5 and higher = worry about neurogenic shouck hypotension bradycardio CM SCI to the level of disruption and rehabilitation potential: FUNCTIONAL LEVEL OF SPINAL CORD INJURY AND REHABILITATION POTENTIAL Level of Injury Movement Remaining Rehabilitative Potential ER care: Put oxygen on the patient Maintain spinal immobilization Assess the patient's IV - flush to ensure patency Explain spinal shock to the patient and monitor for neurogenic shock Put patient on the heart monitor - cardiac rhythm = sinus Insert a foley catheter - output 50-75 mL/hr Assess Glascow Coma Scale: Assess verbal response - appropriate Eyes open spontaneously Pupils equal Assess for pain: c/o left arm pain - painful to touch and hand pain 8/10 - medicates for pain Get temperature: 98 degrees - Put warm blanket on patient Get patient's baseline weight: 75 kg/172 lbs. Assess skin - cool to touch - put warm blanket on patient Assess capillary refill - brisk Assessment movement in upper and lower extremities - able to wiggle fingers of left; unable to move or feel lower extremities bilaterally Assess pupils - 4 mm and reactive Get baseline labs - CBC/BMP - WBC 10; Hgb/Hct: 14.6 and 48; Na 143 and K 4.1 Get baseline CXR - clear Get left arm and shoulder x-ray - fracture of the left clavicle, humerus and radial bones CT scan or MRI - T6 spinal cord injury Map 90 to perfuse the cord O2 100% nonrebrethers IV fluids (ex 2L), vasopressers raise BP Ex. 5 L of blood, but all in legs edema Respiratory difficulties - low 02 saturation; tachypnea Autonomic dysreflexia - diaphoresis, flushing above the level of injury, increased systolic BP, and pounding headache Neurogenic shock - bradycardia, hypotension, and hypothermia So, what do you think might be happening to your patient? Neurogenic shock. What causes this? Disruption of SNS and loss of vasomotor tone. Why is this happening in your patient? A spinal cord injury of T6 and above is the most common cause of neurogenic shock For bradycardia: atropine For low blood pressure: fluid volume replacement and vasopressors For low temperature: rewarming Neurogenic shock Vit C: It acidifies the urine and is given to SCI patients to prevent UTIs. A urine pH of 5.5 must be maintained for this medication to be effective. In addition to vitamin C, the patients must also consume 3000 to 5000 mL of fluid daily. Cranberry and apple juice should be included in the fluid intake to help acidify the urine. Vit C changes acidity of urine Case study review Measure his vital signs, particularly his BP and heart rate. His BP is 210/110. Autonomic dysreflexia Good morning Dr. Dogood! This is Kristina Patterson. I am a nurse at St. Petersburg Hospital and I'm taking care of your patient, Mr. T.W., a 20 y/o male who fell off the roof and has a T6 spinal cord injury. He turned on his call light complaining of a headache. I took his vital signs and he has a BP of 210/110. I think he might be experiencing autonomic dysreflexia. Would you like to order something for his blood pressure? Nursing interventions are aimed at preventing conditions that are known to trigger AD and to remove any noxious stimuli that are causing AD. • Call for help but stay with the patient. • Raise the HOB and dangle legs over the edge. • Monitor VS every 5 minutes. • Loosen clothing. • Search for a cause; begin with the urinary system. If an indwelling catheter is present, check for and address drainage problems. If no indwelling catheter is present, catheterize the patient and then reassess. • If the AD does not resolve, continue to look for the cause, such as fecal impaction, pressure ulcer, etc. • If SBP is over 150 mm Hg, administer antihypertensive medication as ordered. HA = autonomic dysreflexia! -spinal cord injury patient Check BP, head 45 degrees, find cause eliminate issue maslow lowest - highest priority rehab: 1=e (stabilization of the physiologic systems and early psychological support). 2=g (participation in PT, OT and social work; use of assistive devices, and bowel and bladder training) 3=c (accomplishment of self-care and ADLs 4=f (adjustment to living at home) 5=a (community integration) 6=b (gainful employment) 7=h (independence) 8=d (self-actualization) -physiologcal, safety, social, esteem, self actualization diagnosis: Ineffective breathing pattern related to respiratory muscle fatigue, neuromuscular paralysis, and/or retained secretions • Impaired skin integrity related to immobility and/or poor tissue perfusion • Impaired urinary elimination related to spinal injury and/or limited fluid intake • Constipation related to neurogenic bowel, inadequate fluid intake, and/or immobility • Risk for autonomic dysreflexia related to reflex stimulation of sympathetic nervous system * Ineffective coping planning-goals-acute-chronic: Immediate post-injury goals include maintaining a patent airway, adequate ventilation, and adequate circulating blood volume and preventing extension of cord damage (secondary injury). (Lewis 1473-1474) Long term overall goals will include: (1) maintain an optimal level of neurologic functioning; (2) have minimal or no complications of immobility; (3) learn new skills, gain new knowledge, and acquire new behaviors to be able to care for self or successfully direct others to do so; and (4) return to home and the community at an optimal level of functioning.

neuro pp

Normal ICP: 5-15 mm/Hg Measured using a pressure transducer in spaces that contain CSF ventricles subarachnoid space subdural space epidural space brain tissue -ICP 20 + reported to physician and should be tx Measuring ICP via ventriculostomy: -Tranducer level to ear or monroe - make sure leveled Biggest nursing concern- infection from catheter going into ventricle SIRS criteria (may not have high WBC or fever, but elderly may be confused is S&S of infection) -fever/temp >100.5 or less than 95.7), RR >20, HR >90, WBC > 12 or <8, glucose? Over 140 w/o DM 1320 bag drain some CSf (makes 30ml/hr 50ml at all times) Regulation and Maintenance of Normal ICP: Compensatory Adaptation- automatic adjustment in the diameter of the cerebral blood vessels CSF displacement brain tissue compression expansion of dura space -Maintenence of norm ICP- CSF displacement, vasodilation, vasoconstriction If volume of 1 changes, others have to compensate Monroe-Kellie Doctrine: The 3 components of the closed box (skull) must remain constant. If the volume of one changes, the others must compensate. -Autoregulation occurs MAP 70-150 (higher or lower brain cant compensate) S + 2 *D /3 vasoconstricton high BP HA Low BP dilate so brain gets what it needs CEREBRAL BLOOD FLOW: Cerebral blood flow (CBF) is critical because the brain requires a constant supply of O2 and glucose. The brain regulates the cerebral blood flow despite WIDE fluctuations in arterial blood pressure. Autoregulation: automatic adjustment in the diameter of the cerebral blood vessels by the brain to maintain a constant blood flow during changes in arterial blood pressure (BP) Provides for metabolic needs Maintains CPP within normal limits Lower limit = MAP of 70 - below this = low CBF w/s&s of ischemia such as syncope and blurred vision Upper limit = MAP of 150 -Metabolic needs- oxygen & glucose CPP cerebral perfusion pressure by maintaining MAP between 70-150 Cerebral Perfusion Pressure (CPP): is the pressure needed to ensure blood flow to the brain. Normal = 60 to 100 mm Hg CPP less than 50 mm Hg is associated with ischemia and neuronal death CPP of less than 30 mm Hg results in ischemia and is incompatible with life MAP - ICP = CPP Increased ICP: Any patient who becomes unconscious acutely, regardless of the cause, should be suspected of having increased ICP. A sustained pressure greater than 20 mm Hg is considered abnormal and must be treated. Common causes of increased ICP include: mass (e.g., hematoma, contusion, abscess, tumor) cerebral edema (associated with brain tumors, hydrocephalus, head injury, or brain inflammation Primary Injury Secondary Injury -Hemorrhagic stoke (displaces brain tissue, like tumor) high ICP Brain traumas TBI traumatic brain injury -may die within hours days weeks brain keeps swelling (drill hole etc for room) Primary- initial impact e. 60mph car accident slammed into vehicle hitting front head then back of head Secondary- ischemia, edema (causes pain, swelling), inflammation Only so much swelling can do in brain like closed box Coup (primary impact) Contercoup (secondary impact) bam bam Increased ICP Clinical Manifestations/Signs and Symptoms: Change in LOC Changes in Vital Signs Change in Body Temperature Ocular Signs Decrease in motor function Headache Vomiting -Changes in LOC most sensitive indicator of ICP -ex. acutely unconious into coma or change in affect, use GCS Collaborative Interventions: ICP: Identify the underlying cause CT Scan/MRI ICP Management: Elevation of head of bed to 30 degrees with head in a neutral position Intubation and mechanical ventilation ICP monitoring Brain tissue oxygenation measurement via the LICOX catheter -HOB up promotes venous drainage -Monitor VS O2, fever -Maintenance of PaO2 ≥100 mm Hg Maintenance of fluid balance and assessment of osmolality Maintenance of systolic arterial pressure between 100 and 160 mm Hg Maintenance of CPP >60 mm Hg -Serial ABGs CO2 35-45 Keep norm thermia (prevent shivering) If low CPP then increase MAP ex. orders to keep SBP over 160 = permissive HTN ICP Drug Therapy Osmotic diuretic (mannitol) Hypertonic saline Anti-seizure drugs (e.g., phenytoin [Dilantin]) Corticosteroids (dexamethasone) for brain tumors, bacterial meningitis Histamine (H2)-receptor antagonist (e.g., cimetidine) or proton pump inhibitor (e.g., pantoprazole [Protonix]) to prevent GI ulcers and bleeding Reduction of cerebral metabolism (e.g., high-dose barbiturates) -Mannitol cant keep long period of time or refredgerated Osmotic diuretic- from tissue into vascular space so can drain out- complication vascular overload/ fluid volume overload -hypertonic solution same effect Increased ICP prone to seizures No corticosteroids for TBI All vent or critically ill patints = foley cath and PPI NG vent Hypertonic Solutions: -Hypertonic: Draws water out of the intracellular space, increasing extracellular fluid volume, so they are used as volume expanders. -3% sodium chloride (NaCl) -Used to treat symptomatic hyponatremia. May be used with cerebral edema - produces massive movement of water out of edematous swollen brain cells and into the blood vessels. -Intravascular volume overload and pulmonary edema. -Must be administered very slowly and cautiously Must only be administered in high acuity areas like the ICU because constant nursing surveillance is necessary to monitor for potential complications. Requires frequent monitoring of blood pressure and serum sodium levels. Malnutrition promotes continues cerebral edema Start good nutrition within couple days enteral - better outcomes Nutritional Therapy: Malnutrition promotes cerebral edema Optimal nutrition is imperative Need additional glucose to fuel the injured brain Will require enteral or parenteral nutrition Early feedings (within 3 days) improve outcomes Patients should remain in normovolemic fluid state 0.9% NS should be used for all piggyback medications -Make sure patient has nutrition orders COMPLICATIONS OF INCREASED INTRACRANIAL PRESSURE: 1. DI - Diabetes Insipidus Polydipsia Polyuria 2. SIADH - Syndrome of Inappropriate Antidiuretic Hormone Low urine output Sudden weight gain Decreased serum sodium level DI diuresis, excessive urinary output -when have brain trauma affects ADH (pushes on pituitary) between 2-20 L /day, severe dehydration, big complication= hypovolemic shock (& hypo Na) -hypotension (low MAP) ex. 70/30 MAP = 43 ICP 12 CPP 31 -tachycardia (hypovolemic, heart compensates to maintain CO perfusion = higher HR increasing metabolic demand) -don't have enough ADH -tx DDADP (synthetic version of ADH, causes pt to not wet the bed) and fluids SIADH excess ADH - retain fliud, decrease urine output, increasing weight, dilutional hyponatremia, change LOC seizure coma Tx. Fluid restrictions ex 1000ml/day, daily wts, seizure precautions -hypertonic saline + lasix Neurologic Assessments: Behavior - Remember "AIR" Affect Irritability Restlessness Speech Appropriateness Slurring Orientation Person, Place, Time and Situation Arousability Pupils -Looking for changes in baseline - must get appropriate assessment! Maximum stimulation for maximum response Neuro floor q 1 hr On norm floors vary ex. q 2 hrs - q shift etc 1st check ABGs (oxygen) and glucose Pt speaking acting very inappropriate - frontal lobe prob behavioral change Person, place, time, situation (what brought u to hospital) GCS untestable ex no arms Guiding principle: MAXIMUM STIMULATION FOR MAXIMUM RESPONSE! (1) Trapezius Squeeze (muscle over shoulders squeeze with hand twist) (2) Supraorbital pressure (feel rim below eyebrow notch push hard) (3) Mandibular pressure (index + middle finger push up and inwards at angle of jaw -under chin area) (4) Sternal rub (like grinding pill hard as long as 30 sec imprint on sternum (bruise) + finger nails on hand) -Yell, shake, inflict pain ex. sternal rub Central response Peripheral response (if not respond to central pain or if 1 limb not responding) Peripheral pain -Pencil finger response bruising Use more thorough neuro assessment- person, place, time, memory (not yes or no Qs) Mini mental status exam Ex. remember 3 things ex. nurse name cup brush -after head to toe -Accurate assessment SAVES LIVES!!! Guiding principle: MAXIMUM STIMULATION FOR MAXIMUM RESPONSE! Inadequate baseline assessment Inaccurate descriptions of our assessments Failure to recognize subtle clues Failure to persist and pursue Measuring ICP via ventriculostomy -transducer make sure equal level The CPP should be maintained between 60-100, so around 80. If it drops below 60, ischemia might develop, so this number is too low. Normal ICP is 5-15 and sustained pressure of 20 should be immediately addressed so, one would notify the MD with pressure of 20, not 30. Elsiver, resources for lewis ND ICP Decreased intracranial adapted capacity r/t decreased ICP or decreased tissue perfussion Tx goals neuro pt. Prevent herniation (ex. maintain MAP between 70-100), maintain norm ICP, fluid volume status, closely monitor I&O (look for DI and SIDIH), hyper hypo Na osmolality electrolytes, daily wts Intubated -ventilator Skin integrity, immobility (cnstipation, DVT prophylaxis, contractions), pneumonia, metabolic needs (SaO2 80-100oxygen 90+, glucose early nutrition), prevent acidosis high Co2, no S&S of SIRS maintain temp HR WBC etc, no infection, seizure precautions med dilanton Clients with ICP r/t Fractures, Concussion or Contusion: Mechanism of Injury and Clinical Manifestations -Fractures Concussions Contusions -Head trauma - increased ICP Fractures Head trauma- MVA, falling, etc Supra orbital echymosis = racoon eyes Possible rinorea CSF Skull Fractures: Basilar (involving the base of the skull) Battle's Sign Halo sign: possible complication PC: Infection; hematoma; brain tissue trauma -Dextro strips -see if positive for glucose Concertive tx unless boney fragments PC = possible complication Tx antibiotics Blood behind left tympanic membrane Discoloration behind left mastoid process Clear drainage coming from left naris = NG tube contrainindicated in basal or skull fracture SIRS criteria: temperature (less than 36, greater than 38), WBC (less than 4K or greater than 12K), HR>90, RR>20 this needs to be combined w/ clinical judgment Signs and Symptoms of Concussion: Brief disruption of LOC Amnesia regarding the event (retrograde amnesia) Headache, dizziness, anxiety & fatigue No loss of consciousness or loss of consciousness less than 5 minutes, patient is typically discharged with instructions -Discharged from ER with instructions - important make sure patient understands! S&S of increased ICP Retrograde amnesia = don't remember the event Has long term effects Head injury: Notify your healthcare provider immediately if you experience any of the following: Increased drowsiness (e.g. difficulty arousing, confusion) Nausea and or vomiting Worsening headache or stiff neck Seizures Vision difficulties (e.g. blurring) Behavioral changes (e.g. irritability, anger) Motor problems (e.g. clumsiness, difficulty walking, slurred speech, weakness in arms or legs) Sensory disturbances (e.g. numbness) A heart rate below 60 bpm Have someone stay with you Check with your HCP before taking drugs Avoid driving -Increased ICP (vomiting w/o nausea) GCS chushing triad Check with HCP before taking drugs (no BP may lower MAP if ICP, opiod masking ICP symtoms) Clinical Example: Contusions -Bruising of brain tissue within a focal area Usually a closed head injury Often involves coup-contrecoup injury -Infection not main focus -infection big deal when CSF leaking Bam bam inury (ex front & back head impact) Seizure of focal manifestations depending place injury is in (ex frontal diff personalitiy, possibly multiple areas)) Epidural Forms between the dura and the inner surface of the skull Subdural Forms between the dura and the arachnoid membrane Medical emergencies-surgery Epidural worse- potentially venous leak (slower) or arterious (worse, die fast) Epidermal hematoma Classic sign- initial period of unconsiousness at scene- brief lucid interval (seems ok) then decrease LOC at rapid rate ICP S&S (deteriates fast) Know if / ask Mechanism of injury, if anticoagulants, alcohol, drug use, if lost conciousness, ICP S&S (know), altered RR (ex cheyne stokes etc), cradycardia widening pulse pressure cushings, postering -> CT scan -> neuro surgery (code ASAP) Mannitol, raise HOB 30 degrees (head neutral alignment, ABGs (make sure enough oxygen and not too much CO2)- maintain, maintain CPP = MAP-ICP Medical mangement decrease ICP Subdural hematoma Usually venous (slower progression) can be acute 24-48 hrs after trauma deteriation, subacture 48 hrs- 2 weeks after trauma or chronic Tx. Craniotomoy burr holes emergency surgery Ask How much time since trauma, GCS, all meds, MAP, need surgery! S&S same as increased ICP (LOC GCS) Monitor urine output- diabetes insipidus D5W Bad = increased cerebral edema Dextrose gets eating up just putting in water ICP 30 degrees had neutral position Nuero ICU ventrocitostomy to measure ICP Meningioma - 34% of all primary brain tumors Gliomas - 30% of all tumors but 80% of malignant tumors Astrocytoma Glioblastoma Multiforme - most common type of glioma - highly malignant and invasive - most devastating of primary brain tumors. -Know tumors = increased ICP Tx tumors with steroids CM a brain tumor: Headache is a common problem Seizures Nausea/Vomiting Cognitive dysfunction including memory problems or mood or personality changes Muscle weakness Sensory losses Aphasia Cerebral Edema/Increased ICP Distinguish appropriate nursing interventions related to collaborative care, including diagnostic tests and pharmacological therapies, associated with brain tumors: CT, MRI, PET Scans Biopsy Chemo/Radiation Surgical Intervention Ventricular Shunts types of cranial surgery: Craniotomy Stereotactic Procedures The nursing interventions for cranial surgery are the same as that for increased ICP. Manage ICP Post op complication- infection, pain, pneumonia, DVT, ileus Traumatic Brain Injury: GCS equal to or less than 8 Emergency Personnel (Paramedics) treat the patient according to advanced trauma life support (ATLS) protocols Initial emergency nursing management focuses on: Airway management and Cervical Spine Immobilization Oxygenation and ventilation management Circulation and Fluid Balance Disability and ICP management ICP meds Dexomethazone if tumor, mannitol duiretic, hypertonic solution 3% (works like mannitol), barbituates, dilantine Osmotic diuretic NIH stroke scale: LOC, Questions, commands Best Gaze Visual fields Facial Palsy (movement) Motor function arm and leg Limb ataxia Sensory Best language Articulation/dysarthria Extinction or inattention 0-4 (0 norm)

Pain, Rest, Sleep pp

Pain -> nociceptive (somatic, visceral) & neuropathic (CNS, PNS) 5th VS, scale 1-10 Characteristics: Location, Intensity, Type, When? What relieves it, activities that worsen/helps Subjective data- patients descriptions. Objective data- observations. Pain tx: -DRUG THERAPY- Non opioids, Opioids, Antidepressants, Antiseizure drugs, Corticosteroids -THERAPEUTIC NERVE BLOCKS -PHYSICAL THERAPIES- Accupuncture, Exercises, Heat & Cold application, Massage, TENS, PENS. -COGNITIVE THERAPIES- Distraction, Hypnosis, Imagery, Relaxation exercise. Etiology-based Treatment: -Somatic & visceral -> (NSAIDs/steroids, opioids, muscle relaxants, tramadol) -neuropathic & neuralgic (baclofen) -> (anticonvulsants, antidepressants) Client's rights: Every patient deserves adequate pain management -Even if drug abuser, clock watching, drug seeking etc Side effects of Drug therapies: Side effects are a major reason for treatment failure and non adherence -Constipation! (stool softener- colac ex) -teach eat more fiber, fluids, exercise etc -NV itching temp after view days resolves (usually), norm to itch with morphine -meds added to help SE -Lethargic -1st week or 2 rough- SE wear off -Elderly- respiratory depression increased 65+ day time sleepnis snoring tx narcan Untreated pain: Unnecessary suffering, physical and psychosocial dysfunction, immunosuppression and sleep disturbances -Patient perception + response to pain - varies Ex. 1 jogging 10 hit by bus -PRN for break thru pain --additional med to relieve Classifications of pain: -Acute- less than 3 months ex. knife, trauma, surgery, medical procedures --untreated can lead to chronic --can turn into chronic pain -Chronic- after 3 months, months-years-lifetime, disabling, anxiety, depression, hard to tx Somatic- skin, joints Visceral- organs neuro- ex. shingles, phatom, diabetic Nociceptic Deep aching throbing loacalized -bone, joint, muscle, connective tissue Visceral ex. IBS appendicities Neuropathic pain- burning shooting numbness stabing electric Chronic- ask what pain level are you okay being at? Their norm 4 or 5/10 -not as verbal about pain -If believe patient over medicated or drug seeking notify dr -Know patient goal pain # tx Adjuvant drugs- more relief with less SE -Off label uses Ex. anticonvulsant and depresant meds for pain ex. often neuroceptive pain - gabapentin? (prevent nerve pain too) + lurika -eleival antidepressant -Lidocain patches (neuro pain) -Corticosteroids, antiseziure, local anesthetics, antispaz -Acupuncture, exercise, heat cold

hospice pp -Advance Care Planning, the nurses role

Patient Self Determination Act (1990): -Direct result of the Nancy Cruzan case -Promote awareness/discussion of medical decisions at EOL -Affects any healthcare institution which receives Medicare/ Medicaid funds (hospitals, skilled nursing facilities, home health agencies, hospice programs) -Significant fines for failure to comply Requires: At admission provide patient w/written summary of: health care decision-making rights, policies on recognizing advance directives Ask patient if they have an advance directive, and document in the medical record Educate staff & community Cannot require a person to have/not have an advance directive Advance Care Planning: Process of planning for future medical care when a person can no longer make decisions for him/herself -Learning about options Thinking about values Talking about decisions Documenting wishes Sharing them with others Two components: -Designating a surrogate decision maker -Documenting medical care that a person does or does not want under certain conditions ACP is everyone's business, from primary care to intensive care settings, and all nurses, regardless of where they work. Desired Outcomes of ACP: Ideally to "know" and to "honor" a patient's informed plans, by... 1.Creating an effective planning process selecting a well prepared healthcare surrogate creating specific instructions that reflect informed decisions 2.Having plans available to the treating health professionals 3.Assuring that plans are incorporated into medical decisions when needed Terms: -Advance Directive (Not "Advanced") Umbrella term for written/verbal instructions to plan for a time when you are unable to communicate (living will, designation of healthcare surrogate, organ/tissue donation, preplanned funeral -Living Will written or oral instructions regarding your preferences for medical care if you are unable to make decisions for yourself -Last Will & Testament legal document to designate how a person's estate (assets) will be distributed -Healthcare Surrogate a trusted person designated by an individual to make medical decisions upon incapacity -Healthcare Proxy an adult who has not been expressly designated but is authorized to make health care decisions (absence of HCS) -Durable Power of Attorney Durable, meaning it is not affected if a person becomes incapacitated and it lasts until the death of the person who gave it Only for financial unless medical is specifically spelled out in DPOA FL has HCS, some states have DPOA /Healthcare Capacity & Competency What's the Difference?: -Competency Legal term Presumed unless a court has determined Made by a judge -Considerations We mistakenly use competence/capacity interchangeably Words matter -Capacity Clinical term Degrees patient may not have capacity to make a decision for/against surgery, but may have capacity to decide on sleeping pill/laxative Made by a physician Capacity to make medical decisions: recognize there is a decision to be made understand the needed information understand treatment options understand the benefits/burdens rational decision consistent with values Learning About Options: -Make informed treatment decisions CPR Breathing Machines Antibiotics Dialysis Tube Feeding -Benefits/Burdens and Possible outcomes Personal Values: Abundance•Acceptance•Accessibility•Accomplishment•Accountability•Accuracy•Achievement•Acknowledgement•Activeness•Adaptability•Adoration•Adventure•Affection•Affluence•Aggressiveness•Agility•Alertness•Altruism•Amazement•Ambition•Amusement•Anticipation•Appreciation•Approachability•Approval•Art•Articulacy•Artistry•Assertiveness•Assurance•Attentiveness•Attractiveness•Audacity•Availability•Awareness•Awe•Balance•Beauty•Belonging•Benevolence•Bliss•Boldness•Bravery•Brilliance•Buoyancy•Calmness•Camaraderie•Candor•Capability•Care•Carefulness•Celebrity•Certainty•Challenge•Change•Charity•Charm•Chastity•Cheerfulness•Clarity•Cleanliness•Clearmindedness•Cleverness•Closeness•Comfort•Commitment•Community•Compassion•Competence•Competition•Completion•Composure•Concentration•Confidence•Conformity•Congruency•Connection•Consciousness•Conservation•Consistency•Contentment•Continuity•Contribution•Control•Conviction•Coolness•Cooperation•Correctness•Country•Courage•Courtesy•Craftiness•Creativity•Credibility•Cunning•Curiosity•Daring•Decisiveness•Decorum•Deference•Delight•Dependability•Depth•Desire•Determination•Devotion•Devoutness•Dexterity•Dignity•Diligence•Direction•Directness•Discipline•Discovery•Discretion•Diversity•Dominance•Dreaming•Drive•Duty•Eagerness•Ease•Economy•Ecstasy•Education• What is Quality of Life?: independence, empowerment, awareness, mobility, dignity, joy, love, family, dignity, relationships COMMUNICATION is Critical: -Healthcare surrogate values, choices, goals -Family/loved ones HCS, goals & values -Health care professionals informed consent appropriate choices honor decisions -Others Support Issues around ACP: Conversations happen way too late Patients/families unprepared to make decisions in a critical care situation No documentation No standard practices around ACP Associated with dying & bad news Providers not comfortable/confident Primary Care Providers Specialist Team members unclear about roles Communication Table: -patient, family, healthcare team, healthcare surrogate - ACP strategy is needed Until the problem is resolved patients will continue to bounce back and forth to the hospital Bad for the patient Bad for the hospital The Nurse's Role in ACP: -Reflect on the patient's goals, values, and beliefs, discuss current/future medical care, accurately document future health care choices -Responsible for informing patient about: diagnosis & prognosis treatment options (benefits/burdens) formulating a plan based on his/her goals for care -Within your scope of practice ACP is part of the Code of Ethics for Nurses Intimate understanding of patients, their care & concerns Ideally situated to educate, facilitate & promote Advocate (preferences & values are honored) Clinical liaison with physician, social worker, liaison, ethics committee Influencer of change -Preparing the family Alleviate the heavy burden "you are not making the decision to end your loved ones life you are honoring decisions he/she already made" -Moving the family along in the decision making process -Facilitating a smooth transition from curative to palliative care Guilt of removing someone from life support "your decisions are not ending your loved one's life their disease/condition is ending their life" Two simple questions to start the process: -Have you discussed with your family who can make decisions for you if you become too sick to make decisions while you are in the hospital? -Have you discussed this responsibility with the person you have chosen, and does she or he know what is important to you? ACP Strategy Effectiveness: -I patients receiving value-concordant care -I completion of living wills -I clinicians & families understand & comply with patient wishes -I utilization of hospice services -I likelihood patient will die in their preferred place -d hospitalization & intensive Tx at EOL -d decisional conflict, anxiety & depression experienced by family FACT: Not making a decision IS making a decision Florida Medical Proxy Statute: Spouse Adult child(ren) Parent(s) Adult sibling Adult relative Close friend Clinical social worker Court Appointed Guardian Helping Patients Choose a HCS: Willing & able Local, preferably Not intimidated by hospital or physicians Will follow your wishes, even if they disagree Able to ask questions and make decisions Is aware of your wishes and values A strong advocate Role of the Healthcare Surrogate: Makes healthcare treatment decisions Takes steps to see that wishes are honored Talks to the doctor/health care team Authorizes treatment or has it withdrawn per pt. wishes Has access to medical records Can authorize transportation to another facility Changes to Florida Law - FS765: Significant changes (2015) Powers of the Healthcare surrogate Competent adults can authorize HCS to make decisions before determination of incapacity Authority of HCS to receive health information before determination of incapacity Written Discussions w/physician Dementia Extension: Extension of living will Tool to help communicate goals for care early in the process Focus on hospitalization & artificial nutrition Final Thoughts: -ACP is everyone's business, from primary care to intensive care settings. -Because nurses make up the largest single body of health care providers, you can have a big impact on creating cultural change in organizations' attitudes toward ACP. -DIY (healthcare professionals need to set the example) -Know what resources are available near you so you can help your patients.

ADMINISTERING A BLOOD TRANSFUSION

Purpose: -To increase blood volume after surgery, trauma or hemorrhage. -To increase red blood cells in various types of anemia. -To increase white blood cells or platelets when depleted or suppressed. -To replace clotting factors in plasma for patients with coagulopathies. -To replace depleted plasma products. Blood components: -Red blood cells may be given as whole blood, or, more often, as packed red blood cells where the plasma has been removed. -Fresh frozen plasma (FFP), cryoprecipitate, Factors VIII and IX concentrates, and platelets are given for alterations in coagulation. -Granulocytes (WBCs) and immune serum globulin (IgG) are given to enhance the immune system. -Colloids are given in protein depletion, hypovolemia and third spacing. Equipment needed: -Blood administration set and filter -Intravenous solution of normal saline (0.9% NaCl) and tubing -Clean gloves -Leukocyte depleting filter if ordered Prior to administration procedure: 1. Review hospital policy and procedure for the administration of blood products. 2. Assess reason for administration and check on recent hematocrit or platelet counts to establish pre-transfusion levels. 3. Verify the physician's order for the type of blood product to be given. 4. Check for signed consent form. 5. Determine any history of previous transfusions and any previous blood transfusion reactions. 6. Assess the type, integrity and patency of the venous access in place to determine if free flowing and adequate for the transfusion. Document assessment. Replace venous access if flow is sluggish, there is poor blood return, or other signs/symptoms of infiltration or phlebitis are present at site. 7. Verify that a #18 to #20 gauge venous access device is to be used to prevent hemolysis of red blood cells. 8. Obtain full current set of vital signs and record to use as baseline values. 9. Prepare bag of normal saline and prime the tubing; hang by bedside. 10. Obtain blood from the lab only after all of the above are done and immediately before the procedure. Blood products must be given within 30 minutes of removal from the blood bank to prevent increased bacterial growth and red cell destruction in the products. Administration procedure: 1. Administer any premedication ordered. 2. Inspect blood bag for bubbles, separation or presence of clots. Do not use if present. 3. Verify and record the blood product and identify the client with another nurse. Strict verification procedures will reduce the risk of administering blood products to the wrong client. If there is an error during this procedure, notify the blood bank and do not administer the product. Verify the following: -client name, blood group, Rh type -cross-match compatibility -donor blood group and type -unit number and hospital number -expiration date and time on the blood bag -blood product compared to physician's order 4. Open blood administration kit and move roller clamps to "off" position. -spike blood unit -squeeze drip catheter and allow the filter to fill with blood -open roller clamp and allow tubing to fill with blood to the hub -attach tubing to venous catheter hub using sterile precautions and open lower clamp 5. Infuse at the rate of 2-5 ml/min according to the physician's order. The entire infusion must be completed by 4 hours after removal from the blood bank or be discarded per AABB (American Association of Blood Banks) standards. Bacterial contamination, if present, will grow rapidly at room temperature. If the patient's condition requires slower infusion, the blood bank can supply half units. 6. Remain with the patient for the first 15 minutes, taking vital signs every 5 minutes x 3, then every 15 minutes for the first hour, then hourly until the infusion is complete. 7. Observe for signs of transfusion reaction. 8. Observe client and client's laboratory values to determine response to transfusion. 9. Document procedure and each frequent observation. -Never add medication to any blood products. -Do not administer medications capable of causing allergic-type reactions simultaneously with blood. -INS (Infusion Nurses Society) standards require the use of a new blood filter set with each unit administered. -Leukocyte filters may be used in patients who are immunosuppressed and/or have a history of frequent transfusion to decrease the presence of antigens and viruses in donor white blood cells.

TPN CVAD notes

TPN aka CPN (central) PPN (peripheral) -lipids hung in separate bag normally madetv- minerals, amino acids, dextrose, electrolytes, trace elements, vitamins different types of TPN- check order -type varies depending on electrolyte values etc patient specific who moms hyper emesis gravidarum, intestinal blockages (rest gut), anorexia nervosa, cancer pts, anybody who cant take caloric intake to heal (sepsis/shock etc need x2 ½ amount of calories) never use line that hasn't been x rayed for placement! Filters used on TPN between lines SE infection, bacteria loves sugar dextrose Never used lines for more than 24 hrs or let bags hang for 24 hrs EFA estential fatty acids Refeeding syndrome -super malnourished have patient bear down when taking cap off! Don't want air in tube finger sticks sliding scale q 4-6 hr emergency stop- hang TPN 10% dextrose PPN 5% dextrose -hand the dextrose when needing to remove old 24+ hrs while waiting for new bag from pharm it is cold, before starting wait room temp for 30min-1 hrs TPN tubing only used for TPN! Make sure info on bag matches paper order Elevated blood glucose is expected -should get insulin norm CVAD aka CVC Most common complication- sepsis Bio patch white thing surrounding line RN and patient wear mask, have patient turn head away When changing caps keep clamps closed Never force a flush! -can have patient try moving arm around 1st -never use syringe smaller than 2ml (or 5ml) always used atleast 10ml + ! (when flushing or pushing meds into line) -can flush line, cant push or pull blood from lines -if edema stop and x ray tunneled, not direct access into vein antimicrobial patch perminantly under skin types of central line- PICC non tunneled tunneled implanted ports implanted ports- chemo/long term, external plastic, no dressing -cant really see unless know it there lumen- one or multi (amount of holes, usually 3) groshoong (slit valve) hole that seals back up -doesn't need heparin distal, largest (thicker) medial TPN proximal pull blood for labs / give meds, run fluids femorl- not good 1st choice but sometimes only choice usually have PICC team use ultrasound machine (then if get ok by them don't need x ray) -make sure charted PICC team etc whoever puts it in, exact length (make sure it all gets out!) when removed length needs to match whats charted usually flush 1x a shift -triple lumen 1 flush per line only take flush when need don't use PICC line arm for BP! If shower cover with specimen bag to protect (don't want wet) Infection -pull it out -cut bottom end and send to lab (culture) tunneled caths -subclavian vein implanted infusion port -hard to get through rubber -may be pain, can use something numbing cream? Always 1st flush NS before using for anything else (make sure patent) Never use heparin central lines Also dressing change if dirty or loose dressing If surgical not looking good and dr hasn't yet seen don't touch dressing! Just keep reinforcing Notify dr Everytime change dressing change cap Patho- how to teach patient at their learning level -diagnosis lip avid - cite Therapeutic regiment- compare what lewis text say nursing + collaboratively and compare to reality whats actually happening

UNIT II: Pain / Rest / Sleep

Terms: Acute Pain Addiction Adjuvant Analgesics Alternative Pain Therapies Chronic Pain Neuropathic Pain Nociceptive Pain Physical Dependence Somatic Pain Tolerance Visceral Pain -pain management

Unit 1: self expression home health care, hospice

Terms: Advanced Directives Ageism Bereavement End-of-Life Grief Health Care Surrogate Homebound Status Home Health Care Hospice Living Will Loss Medicare Medicaid Mourning Palliative Care Patient Advocate Power of Attorney Resources available for elder services: -Administration on Aging -Medicare: Parts A, B, D -Medicaid --Medicare- once 65 gov insurance ABD- all ppl have (parts of medicare) Preventative B- inpatient, outpatient A- Hospital care D- covers drugs Medicaid- anyone that qualifies (diasability, disavantaged, low income, foster kids, pregnant) Factors Home Health Care: -Socioeconomic -Health Care Reform -Changing Demographics -Nature and Prevalence of Illness -Technology -Increasing Consumerism -Y out quick -insurance not paying for long stay -healthy enough to go home/leave hospital/SNIFF but need HHC -HHC used more cause sending home patients earlier Ex. needing antibiotics PICC line, chest tubes HHC services: -Health Maintenance -Education -Illness Prevention -Diagnosis and Treatment of Disease -Palliative Care -Rehabilitative Care: Physical Therapy, Occupational Therapy, Social Work Services HHC eligibility: -Homebound Status -Professional Nursing Care Advanced directives: -DNR -Durable Power of Attorney for Healthcare (in Florida, this is called Healthcare Surrogate) -Living Will -MOLST/POLST Barriers to receiving hospice care: -Lack of Information -Cultural/Ethnic Concerns -Physician Reluctance -Client and Family Concerns Physical Manifestations of End of Life: -Sensory -Cardiovascular -Respiratory -GI/GU -Musculoskeletal -Integumentary Psychosocial Manifestations at End of Life: -Fear (pain, shortness of breath, loneliness and abandonment, and meaninglessness) -Anxiety and Depression -Hopelessness / Powerlessness -Unusual Communication NM Physical: -Pain -Delirium -Restlessness -Dysphagia -Weakness and Fatigue -Dehydration -Dyspnea -Myoclonus -Skin Breakdown -Bowel Patterns -Urinary Incontinence -Anorexia, N/V NM Psychosocial: -Life Review -Patient Decision Making -Presence -Empathy Grief Experiences: -Anticipatory Grief -Adaptive Grief -Prolonged Grief Disorder (formerly known as complicated grief)

UNIT VIII: nutrition IVs, blood administration

Terms: Albumin Broviac Central venous access device Colloids Crystalloids Extravasation Groshong Hypertonic solution Hypotonic solution Implanted ports Intralipids Isotonic solution Malabsorption syndrome Midline catheter Peripheral parenteral nutrition (PPN) Peripherally inserted central line (PICC) Total parental nutrition (TPN) Vesicant Central venous access device: nontunneled, tunneled, implanted ports, PICC Parenteral Nutrition: -Indications -Composition --Calories, Protein, Carbohydrates, Electrolytes, Trace elements, Vitamins -Lipids -Total Parenteral Nutrition (TPN) -Peripheral Parenteral Nutrition (PPN) -Complications of Parenteral Nutrition -Nursing Management Central Venous Access Devices: -Types --Non-tunneled, Tunneled, Implanted ports, PICC -Indications -Complications --Catheter occlusion ---TPA --Embolism -Catheter-related infection -Pneumothorax -Catheter migration --Nursing Management --Removal Intravenous Therapy Solutions: -Crystalloids --Isotonic solutions, Hypertonic solutions, Hypotonic solutions -Colloid Solutions --Albumin, Hetastarch (Hespan), Dextran -Complications/Nursing Responsibilities of IV Therapy Administering Intravenous Push (Bolus) Medications: -Indications, Risk, Technique Blood Administration: -Indications -Compatibility -Blood Products -Nursing Management --Administration --Reactions ---Types of reactions: acute, delayed ---Nursing interventions for reactions ---Documentation of reactions TRANSFUSIONS: Blood Types: A+ A- B+ B- AB+ AB- O+ O- Compatible Donor Blood: A+, A-, O+, O- A-, O- B+, B-, O+, O - B-. O- A+, A-, B+, B-, AB+, AB-, O+, O- (UNIVERSAL RECIPIENT) A-, B-, AB-, O- O+, O- O- (UNIVERSAL DONOR) BLOOD CONSTITUENTS: -plasma 55% -> water 93% & colloids (proteins 7%) -> albumin 55% globulin 38% fibrinogen 7% prothrombin -formed elements 45% -> RBC 4.5-6 (carry O2) & WBCs 5000-10000 (fight infection & platelets 150000-400000 (clotting) Drugs: -adenosine -ativan -atropine sulfate -cardizem -D50 -digoxin -dilantin -dilaudid -insulin -lasix -lidocaine -lorpressor -morphine -pepcid -protonix -reglan -solu-medrol -toradol -valium -vasotec -vitamin k -zofran Blood Products: -Packed red blood cells (PRBC) are whole blood with most of the plasma removed. The hematocrit value of packed cells is approximately 70%. Packed red blood cells are administered to increase the red cell mass and improve oxygen delivery. --The administration of one unit of packed red blood cells increases the hemoglobin value by 1 gram and the hematocrit value by 3-4%. -Platelets are administered to correct thrombocytopenia. Platelets are essential for the coagulation of blood and the maintenance of hemostasis. --The administration of one unit of platelets increases the platelet count by 5000-10,000/mm3. -Fresh frozen plasma (FFP) is administered to restore clotting factors. It contains water and proteins as well. --It is important to remember that fresh frozen plasma takes approximately 20 minutes to thaw and must be administered within 6 hours of thawing. --One unit of fresh frozen plasma can raise coagulation factor levels by 8% and fibrinogen by 13 mg/dL.

UNIT IV: Mobility spinal cord injury

Terms: Autonomic dysreflexia Complete cord injury Incomplete cord injury Neurogenic bladder Neurogenic shock Neurologic level Poikilothermia Spinal cord trauma Spinal shock Tetraplegia Spinal Cord Injury Etiology and Pathophysiology: -Initial Injury: Primary, Secondary -Classification: Mechanism, Level and Degree Injury -Physical Manifestations: Respiratory, Cardiovascular, Urinary, GI, Skin, Thermoregulation, Metabolic, Peripheral Vascular -Psychological and Spiritual Challenges: Grief, Depression -Nursing Care: ABCD Plan of Care for Spinal Cord Injury Patient: -Ineffective Breathing Pattern -Impaired Skin Integrity -Constipation -Impaired Urinary Elimination -Risk for Autonomic Dysreflexia / Neurogenic Shock, Spinal Shock -Ineffective Coping Collaborative Care: -Airway/Oxygenation -Circulation -Prevent Cord Damage -Shock --Neurogenic Shock --Spinal Shock -Immobilization -Diagnostics -Medication -Prevent Complications: DVT, Stress Ulcer -Elimination -Autonomic Dysreflexia Functional Level of Injury: -Level of Injury/Movement Remaining/Rehab Potential in General Terms --C1-3 --C-4, C-5, C-6, C-7 --T1-6 --T6-12 --L1-2 --L3-4

UNIT III: Neurosensory ICP, head injury, brain tumor

Terms: Autoregulation Cerebral edema Cerebral perfusion pressure (CPP) Concussion Contusion Coup - contracoup phenomenon Craniotomy Cushing's triad Decerebrate posturing Decorticate posturing Diabetes insipidus Epidural hematoma Glasgow Coma Scale ICP monitoring (Intracranial Pressure) Intracerebral hematoma Monro-Kellie doctrine Subdural hematoma Syndrome of inappropriate antidiuretic hormone Intracranial Pressure: Regulation and Maintenance of Normal ICP: -Compensatory Adaptation -Modified Monro-Kellie Doctrine -Cerebral Blood Flow --Autoregulation --Factors Affecting Cerebral Blood Flow Increased Intracranial Pressure: -Clinical Manifestations/Signs and Symptoms --LOC, VS, Ocular Signs, Motor Signs, Headache, Vomiting -Collaborative Care --Identify/Treat Underlying Cause --Monitor/Measure ICP --Medications --Oxygenation/Ventilation --Reduce Metabolic Demands --Fluid/Electrolyte Balance --Nutritional Therapy --Positioning Neuro Assessment: -GCS/LOC -Pupillary Response/Cranial Nerves -Motor Strength -Reaction to Pain/Noxious Stimuli -VS/Cushing's Triad Diagnostics: -H and P -CT, MRI, PET, EEG, Angiography -ICP Measurement Types of Head Injury/Clinical Manifestations: -Lacerations -Fracture -Concussion -Contusion -Hematoma: Epidural, Subdural, Intracerebral -Coup/Contrecoup Injury CC and NM of Patients with Head Injury and Cranial Insult: -ABCs/Stabilize, O2, IV Access, VS, Control Bleeding -Neuro Assessment -Diagnostics -OR/Evacuate Hematoma/Relieve Pressure/Decompress -Thermoregulation -Manage Fluid/Electrolytes -Protect Eyes -Immobility and Associated Problems -DI -SIADH Brain Tumors: Classification, Primary, Secondary, Benign, Malignant: -CM: Headache, N/V, Cognition / Motor, Sensory, Aphasia, Spatial Collaborative Care: -Goals: identify type/location remove/decrease tumor mass prevent/manage IICP -Surgery -Radiation -Chemotherapy -Medication Post-Surgical Care: -Patient/Family Education -Monitor/Assess/Manage ICP -Maintain Tissue Perfusion -Manage Fluid Status -Protect from Injury -Prevent Post-op Complications

palliative class notes

palliative care- life limiting diagnosis (chronic ex. heart failure, COPD) -symptom management and disease help long term if no surrogate then proxy fl HCS other states DPOA -the last one made is inforced if have both use word incapacitated not incompetent CPR 2% success rate for seniors with health issues -ribs break, sepsis, death anyway -encourage fam to watch codes, violent -burdens after CPR, issues, likely life not the same ex. we ask all patients for living wills, would like to have in record ACP, fam communicating patients wishes probs ⎝ Ethics commite 3 in 5 ppl dementia Suncoast hospice free living wills Pain notes: Patient cant communicate- furrowed brow (sign in pain) Cancer pain- tumors, mouth sores, bones, chemo, radiation -post cancer severe pain neuropathy other pain causes- arthritis (very common elderly), dementia, surgery, emotional, heart disease, liver etc fentanyl very potent - don't use as 1st opiod- must be absorbed through fatty tissue -use cautiously in elderly, in fever absorbed more rapidly SE opiods sedeation - good thing let them sleep for 2 or 3 days -make sure can respond/wake up easily -resolves after few days addict- thoughts who what where when can get next dose pain scale- 0 no pain can do anything, 10 cant move at all without hurting acute- cold chronic- heat