NUR1129 Final Exam Study Guide MSC 2020

Renal Calculi: Nursing Intervention

(Kidney Stones) *Report laboratory and diagnostic findings to HCP. *Provide pre-op and post-op care *Admin prescribed meds *Strain all urine to check for passage of the stones, and save them for lab testing. *Encourage fluid intake to 3L/day *Encourage the use of hot baths and moist heat to promote comfort. *Administer IV fluids as prescribed *Try to get pt to ambulate *Assess &Monitor: Pain status, I&O, and Urinary pH. (ATI pg 408)

Nitroglycerin Patient Education

**Acute Anginal Attacks: Advise pt to sit down and use meds at first sign of attack. Releif usually occurs in 5 min. Dose may be repeated if not relieved in 5-10 mins. Call HCP or go to ER if not relieved by 3 tablets in 15 mins.** -Take as directed, take missed dose as soon as remembered unless next dose is due within 2 hrs. Don't discontinue abruptly. -Change positions slowly. -Avoid concurrent use of alcohol with this med. Consult with HCP about OTC meds. -Inform that a headache is a common side effect. (Aspirin or acetaminophen may be ordered to treat) -Notify HCP if dry mouth or blurred vision occurs. Davis Drug Guide Pg 916

Albuterol Administration

**Assess lung sounds, pulse and BP before administration and during peak of med. Monitor PFT before initiating therapy. Observe for wheezing, if occurs withhold med and call HCP.** PO: Administer med with meals to minimize GI upset. Inhaln: Shake inhaler well and allow at least 1 min between inhalations. Prime inhaler before first use by releasing 4 test sprays into the air away from the face. Use spacer for child under 8. Nebulization or IPPB: the 0.5, 0.83, 1 and 2 mg/ml solutions don't require dilution. The 5 mg/ml must be diluted with 1-2.5 ml of 0.9% NaCl. (Diluted solutions are stable for 24 hrs at room temp or 48 hrs in refrigerator) -For nebulizer, compressed air or oxygen flow should be 6-10L/min; single treatment of 3ml lasts about 10 min. -IPPB lasts 5-20 min. Davis Drug Guide Pg 118

DM Type 1 and 2: Diet

*15 g carbohydrates is equal to 1 carbohydrate exchange. *Restrict calories and increase physical activity as appropriate to facilitate weight loss. *Include fiber (25-30g/day) in the diet to increase carbohydrate metabolism and to help control cholesterol levels *Use artificial sweeteners *Reduce the use of saturated and trans fat. *Include fruits, veggies, grains, low-fat milk for carbs *Consume alcohol with food to reduce risk of hypoglycemia who use insulin (type 1) *Limit to moderate intake of alcohol (ATI pg. 551, Lewis pg. 1133)

Client Education after TURP

*Avoid heavy lifting, strenuous exercise, and sexual intercourse for 2-6 weeks. *Drink 12 or more 8 oz glasses of water. *Avoid NSAIDS (due to increased risk for bleeding) *Avoid bladder irritants (caffeine, alcohol)

Diabetic Ketoacidosis (DKA): Nursing Interventions

*Check vital signs every 15 mins until stable, then every 4 hr. *Check for indications of dehydration (weight loss, skin tugor, oliguria, rapid or weak pulse) *Always treat the underlying cause (ex.infection) *Provide Isotonic fluid replacement (6-10L of IV Fluids) *Start with a rapid infusion of 0.9% sodium chloride for the first 1 to 3 hr. *Follow with a hypotonic fluid *When Blood Glucose Level is around 250 mg/dl change the IV solution to 5% Dextrose to minimize cerebral edema. *Admin regular insulin IV bolus *Monitor Blood Potassium levels, provide potassium replacement therapy in IV fluids to prevent hypokalemia. *Monitor cardia rhythm constantly (Have ECG machine close by or on pt during therapy)

CKD: Nutrition

*Diet that is high in carbs and moderate in fat *Restrict dietary sodium, potassium, phosphorous, and magnesium. *Restrict intake of fluids (based on urinary output) (ATI pg 394)

Fluid Volume Excess (Hypervolemia) Risk Factors

*Excessive isotonic or hypotonic fluids *Heart Failure *Renal Failure *Primary Polydispia *SIADH *Cushing syndrome *Long-term use of corticosteroids (Lewis pg 276)

Fluid Restrictions Pt Education:

*Fluids need to be restricted for pts in oliguria phase(kidney insult), CKD, AKI, and PKD. *Fluid restriction is calculated by total loss (output) from previous 24 hours and adding 600. *During the diuretic phase fluids are based on the output. *Monitor daily intake of carbs, proteins, potassium, and sodium. *Avoid antacids containing magnesium *Measure BP and Weight daily *Diet, exercise, and take medications as prescribed. *Follow your instructions for Hemodialysis or Peritoneal Dialysis. (Lewis pg 1082, ATI pg 394)

Fluid Volume Excess (Hypervolemia) Manifestations

*Headache, confusion, lethargy *Peripheral edema *JVD *S3 heart sound *Bounding pulse, HTN *Polyuria *Dyspnea, crackles, pulmonary edema *Muscle spams, weight gain, seizures, and coma (Lewis pg 276)

DM Type 1 and 2: Manifestations of Hyperglycemia

*Hot, dry skin *Fruity breath *Polyuria *Irritable (ATI pg. 548 chart box)

DM Type 1 and 2: Manifestations of Hypoglycemia

*Hunger *Anxious *Tachycardia *Confused *Blurred or double vision *Sweaty *Palpations *Nervousness *Restlessness *Cool, clammy skin *Shaky *Too much insulin (Type 1) (ATI pg. 548 chart box)

Hemodialysis: Complications

*Hypotension *Muscle cramps *Loss of blood (Anemia) *Hepatitis *Clotting/infection of the access site *Disequilibrium syndrome (results from too rapid a decrease in BUN or fluid volume... cerebral edema & intracranial pressure) (ATI pg. 380)

AKI: Nutrition

*Implement potassium, phosphate, sodium, and magnesium restrictions, if prescribed. *Restrict fluid intake *High-protein diet to replace the high rate of protein breakdown due to stress from the illness. Possible total parenteral nutrition (ATI pg 392)

Fluid Volume Deficit (Hypovolemia) Risk Factors

*Increased water loss or perspiration *Diabetes Insipidus *Hemorrhage *GI losses: vomiting, NG suction, diarrhea *Overuse of diuretics *Burns, trauma (Lewis pg 276)

Indwelling Catheter Care

*Keep bag below the level of the bladder *Assess for kinks, obstructions etc., and fix if so *Make sure catheter is secured to inside of pt thigh *Do not tie on catheter or block the flow of urine. *Maintain patency *Provide pt comfort and safety *Assess psychological implications of pt having a catheter. *Wash the peri area with soap and water daily to reduce infection *Assess for skin changes *Empty the drainage bag when it gets 2/3 full *Never disconnect tubing to collect a specimen or empty bag *Wash your hands and wear gloves when handling the catheter. (Lindsey's Quizlet from Renal)

Peritoneal Dialysis: Complications

*Peritonitis: is when micro-organisms enter the peritoneum(surrounding the abdominal organs) *INFECTION at the access site (can result from leakage of dialysate) *Protein loss (PD can remove protein from the blood) *Hyperglycemia and hyperlipidemia (due to high blood sugar levels from the dialysis) *Poor dialysate inflow or outflow (kinks in tubing, constipation, clot formation) (ATI pg 381)

DM Type 1: Symptoms

*Polyuria *Polydipsia *Polyphagia *Weight loss *Fatigue *Recurrent infection risk *Rapid onset *Insulin Dependent *Familial tendency *Peak incidence from 10-20 years old (Mind Map Pictures from Unit 5)

Indwelling Catheter Indications:

*Relief of urinary retention caused by lower urinary tract obstruction, paralysis, or inability to void. *Bladder decompression pre-op and operatively for lower abdominal or pelvic surgery. *Facilitation of surgical repair of urethra and surrounding structures. *Splinting of urethra to facilitate healing after surgery or other trauma in area *Accurate measurement of urine output in critical ill pt *Contamination of stage 3 or stage 4 pressure ulcers with urine that has impeded healing, despite appropriate personal care for the incontinence. (catheters should be last resort) *Terminal illness or serve impairment which makes positioning or clothing changes uncomfortable or which is associated with intractable pain. (Lindsey's quizlet from renal)

Fluid Volume Deficit (Hypovolemia) Manifestations

*Restlessness, drowsiness, lethargy, confusion *Thirst, dry mucous membrane *Cold, clammy skin *Decreased skin tugor, and capillary refill *Hypotension, Increased HR, Decreased urine output, Increased RR, *Weakness, dizziness, weight loss, seizures, coma (Lewis pg 276)

DM Type 2: Symptoms

*Sedentary Lifestyle *Familial Tendency *Average Age 50 Years *Hx of high BP *Obese *Recurrent infections *Polyuria *Polydipsia *FBS > 126 mg/dl (Mind Map Pictures from Unit 5)

Pre-Op Procedure Education of: TURP (Transurethral Resection of the prostate)

*Transurethral resection is performed using a resectoscope that is inserted through the urethra, it removes the excess prostate tissue, enlarging the passageway of the urethra. *Most common surgical procedure for BPH *Watch for TURP syndrome--due to hyponatremia *S/S: Bleeding and clot retention(hemorrhage). nausea, vomiting, confusion, bradycardia, HTN. *Teaching: bc the bleeding is common pt should STOP taking warfarin, aspirin, and other anticoagulants, several days before surgery. ATI pg.440-441 & Lewis pg 1274

After an indwelling catheter is removed...what would you be watching for? If a patient hasn't voided in 6-8 hours after catheter is removed what is the nurse's first action to assess for urinary retention?

*Urinary Retention *Bladder Scanner

Specimen Collection: Urine (Obtaining and Care)

*Wash peri area first *Void before collection *Then collect next void in specimen container *Best to obtain specimen 1st thing in the morning *Keep specimen on ice if urine can not be examined right away. *Best if examined within 1 hour after collected

Labs:

*troponin* = cardiac specific troponin is a heart muscle protein released into the circulation after injury or infarction.-normally very low level in the blood so any rise is diagnostic of MI-cTnT and cTnI are detectable within 4-6 hours of MI or injury, peak at 10-24 hours, and can be detected for up to 10-14 days.*troponin is the biomarker of choice for an MI* Labs: *Troponin I:* normal = <0.5 suspicious = 0.5-2.3 postive for an MI = >2.3 Troponin T: <0.1 normal *CBC*: RBC = men --> 4.7-6.1 million, women = 4.2-5.4 million WBC = 4,000-11,000 Hematocrit = men--> 45-52% women--> 37-48% Hemoglobin = men--> 13-17 women--> 12-15 Platelets = 150,000-400,000 *serum albumin* = 3.4-5.4 *TSH*: 0.4-4.2 -used to evaluate if the thyroid is producing enough, not enough, or too much thyroid stimulating hormone. *BMP*: -*CBC:* -Na+ = 135-145 -K+ = 3.5-5.0 -BUN = 7-20 -Creatine = 0.2-1.0 -GFR = 125 mL/min -Chloride = 98-106 -Phosphorus = 3.0-4.5 -Calcium = 9.0-10.5 -Magnesium = 1.3-2.1 -Uric Acid --> male = 4.4-7.6, female = 2.3-6.6 Labs affecting wound healing: -Low hemoglobin levels= Hgb is essential for oxygen delivery to healing tissues -Decreased leukocyte (WBC) count= delays wound healing because the immune system's function is to fight infection by destroying invading pathogens. -dereased serum albumin (protein)

wound care/pressure ulcer management & care, interventions:

*wounds*: -note color --> red = healthy. yellow = presence of purulent drainage & slough. black = presence of eschar that hinders healing & requires removal -assess length, width, depth, & any undermining sinus tracts or tunnels & redness or swelling. use a clock face with 12 towards pt head to document location of sinus tracts. -closed wounds --> skin edges should be well-approximated. *drainage:* -note amount, odor, consistency, & color of drainage from or on a dressing. -note integrity of surrounding skin -with each cleansing, observe skin around a drain for irritations & breakdown. -for accurate measurement of drainage, weigh dressing. 1gram =1mL -note & document the # of dressings & frequency of dressing changes. -serous = portion of blood (serum) that is watery & clear or slightly yellow (like the fluid in a blister) -sanguineous = contains both serum & blood cells. thick & appears reddish. -serosanguineous = contains both serum and blood. watery & looks pale & pink due to a mix of red & clear fluid. purulent = result of infection. thick & contains WBC, tissue debris, & bacteria. may have foul odor & color (yellow, tan, green, brown) reflects type of organism present. purosangious = mix of pus & blood (new infection) -provide adequate hydration & meet protein & calorie needs. (2500 mL/day fluids) -education on good sources of protein --> meat, fish, poultry, eggs, dairy, beans/nuts, whole grains. *-note if blood albumin are low (below 3.5) bc lack of protein delays wound healing.* -1500 calories/day *wound cleansing & irrigation*: -clean wounds (surgical incision) cleanse from least contaminated (incision) to most -use general friction to avoid bleeding -isotonic solutions = preferred cleansing agents -never use same gauze across incision or wound more than 1x. -do not use cotton balls & other products that shed fibers. -if irrigating, use piston syringe or sterile straight cath for deep wounds with small openings -administer analgesics & monitor pain management -administer antimicrobials & monitor effectiveness. -document location & type of wound/incision. *pressure ulcer*: -stage 1 = nonblanchable erythema of intact skin -stage 2= partial thickness skin loss with exposed dermis -stage 3 = full thickness skin loss (some slough/eschar present) -stage 4= full thickness skin & tissue loss (bone and muscle showing) -unstageable = obscured full thickness skin and tissue loss (no stage due to slough/eschar obscures in wound bed.) all black. -relieve pressure & provide optimal nutrition & hydration. -use braden or norton scale for systemic monitoring for skin breakdown risk -vitamins and mineral supplements --> esp A, C, zinc, & copper. -monitor lymphocyte count -life rather than pull pts up in bed due to lower friction. fundamentals ati 341

Congestive Heart Failure: s/s

-#1 cause of hospitalizations -complication that occurs when the right or left side of heart's pumping action is reduced. -L sided HF = dyspnea, restlessness, agitation, or slight tachy. pulmonary congestion on chest x ray, s3 or s4 heart sounds on auscultation, crackles on lungs, paroxysmal nocturnal dyspnea, & orthopnea. -R sided HF = JVD, hepatic congestion (liver), lower extremity edema (peripheral edema) -L sided = coming from aorta *most common HF* -R sided = coming from unoxygenated blood-HF is exacerbated easily

Nursing Interventions for an immobilizied pt:

-*integumentary:* identify pts at risk for pressure injury development, position using corrective devices (pillow, foot boots, trochanter rolls, splints, wedge pillows.) turn every 1-2 hrs & use support devices. provide pt who is sitting in a chair with a device to decrease pressure. limit chair sitting to 1 hr. shift wt if at all possible. use therapeutic bed or mattress for pts in bed for an extended time. monitor nutritional intake. provide skin & peri care. -*respiratory:* remove abd. binders every 2 hr & replace correctly. use chest physiotherapy. auscultate lungs to determine effectiveness of chest physiotherapy or other resp therapy. monitor ability to expectorate (spit up) secretions. use suction if unable to expectorate secretions. turn cough & breathe deeply every 1-2 hrs. use incentive spirometer while awake. consume 2,000 mL fluid per day unless fluid is restricted. -*CV:* increase activity ASAP by dangling feet on side of bed or transferring to a chair. change positions as much as possible. move pt gradually during position changes. avoid valsalva maneuver. give stool softener, no straining. teach ROM & antiembolic exercises. use elastic stockings. use SCDs. administer low dose heparin subq prophylactically. contact HCP immediately if there is an absence of a peripheral pulse in lower extremities or assessment data that indicates venous thrombosis. avoid placing pillows under knees, or lower extremities, crossing legs, wearing tight clothes, sitting for long periods of time, massaging legs, etc. -*metabolic:* provide high calorie, high protein diet with vitamin B and C supplements. monitor and evaluate oral intake. for pts who cannot eat or drink, provide enteral or parenteral nutritional therapy. -*elimination:* maintain hydration, teach bladder and bowel training, insert straight or indwelling catheter to relieve or manage bladder distention. promote urination by pouring warm water over the peri area. consume a diet that includes fruits and veggies and is high in fiber. -*musculoskeletal:* change positions every 1-2 hrs and wt shifts in wheelchair every 15 min. encourage active or passive ROM 2 or 3x/day. continuous passive motion device might be prescribed. develop an individualized program for each pt. older pts can require a program that addresses the aging process. cluster care to promote a proper sleep wake cycle. request physical therapy for pts who have decreased mobility. assist pts with ambulation. use assistive devices as needed. -*psychosocial:* assist in using usual coping skills or in developing new coping skills. maintain orientation to time (clock and calendar with date), person (call by name and introduce self) and place (talk about treatments, therapy, length of stay). develop schedule of therapies, and place it on a calendar for pts. arrange for pts who have limited mobility to be in a semiprivate room with an alert roomate. involve pts in daily care. provide stimuli (books, crafts, televison, newspapers, radio). help pts maintain body image by performing or assisting with hygiene and grooming tasks (shaving or applying makeup). have nurses and other staff interact on a routine and informal social basis. recommend a referral for consultation (psychological, spiritual, or social worker) for pts who are not coping well. -*developmental:* implement activities that stimulates physical and psychosocial systems. increase mobility and involve play therapists in age appropriate activities. use measures to prevent falls. develop strategies for maintaining or enhancing the developmental process. teach families that their perception of immobility can affect progress and ability to cope. encourage parents to stay with children. incorporate children's involvement if age appropriate, in their treatments. place children in a room with others who are age appropriate. -*application of heat & cold:* apply to the area. make sure call light is within reach. asses site every 5-10 min. check for pallor, redness, pain or burning, numbness, shivering (with cold appliances) blisters, decreased sensation, mottling of skin, cyanosis (with cold), discontinue the application if any of the above occur, or remove the application at predetermined time (usually 15-30 min). fundamentals ati pg 227

IV insertion/management

-*older pts, pts taking anticoagulents, or pts who have fragile veins:* avoid tourniquets. use a BP cuff instead. do not slap the extremity to visualize veins. avoid rigorous friction while cleaning site. -*edema in extremities:* apply distal pressure over the selected vein to displace edema. apply pressure with a swab of cleaning solution. cannulate the vein quickly. use anatomical landmarks to find veins on obese pts. -*IV insertion:* 1. prescription (solution/rate) 2. identify allergies (latex/tape). 3. med rights. 4. check compatibilities of IV solutions & meds. 5. hand hygiene. 6. examine IV solution for clarity, leaks, expiration date. 7. don clean gloves. 8. evaluate extremities & veins. clip hair at and around the insertion site with scissors. DO NOT SHAVE AREA bc abrasion can occur, increasing risk of infection. 9. tourniquet. 10. select vein (distal veins first, non-dominant hand. site that is not painful, bruised etc. vein that is resilient with soft bouncy sensation. avoid varicose veins, veins in inner wrist, veins in back of hand, veins that are sclerosed or hard, veins in an extremity with impaired sensation, veins with previous venipuncture. 11. clean area. circular motion from middle and outward with chlorhexidine etc. allow to dry for 1-2 min. 12. remove cover from catheter. 13. anchor vein below site of insertion. 14. pull skin taut and hold it 15. warn pt of stick 16. bevel up, insert catheter into skin at 10-30* angle. 17. watch for flashback of blood 18. lower hub of cath close to skin 19. loosen needle from cath & pull back on the needle 20. use thumb & index finger to advance the cath into the vein until hub rests against insertion site 21. stabilize IV cath with one hand and release tourniquet/BP cuff with other 22. apply pressure above insertion site & stabilize cath. 23. remove needle and activate safety device. 24. maintain pressure above IV site and connect equipment. 25. apply dressing. 26. dispose of supplies in SHARPS container. 27. document date & time of insertion, site & appearance, catheter size, type of dressing, IV fluid and rate, number locations and conditions of previously attempted catheterizations, & the pts response. -*management of IV:* preventing infections --> change IV sites according to facility policy (every 72 hr). avoid writing on bags/solutions (contamination). do not hang fluids for more than 24 hrs. wipe all ports with alcohol or antiseptic swab. phelbitis or thrombophelbitis --> edema, throbbing, burning, or pain at site. fluid overload--> distended neck veins, increased BP, tachycardia, etc. cellulitis --> pain, warmth, edema, induration, red streaking, fever, chills, malaise catheter embolus --> missing catheter tip on removal. infiltration/extravasation--> infiltration = leak of non vesicant. extravasation = leak of a vesicant solution which can damage tissues. fundamentals ati pg 299

prioritization of pt care:

-ABC's --> airway, breathing, circulation. -ADPIE --> assessment, diagnosis, planning, implementation, & evaluation -chest pain -emergent care -Maslow's hierarchy of needs --> physiological, safety, love, esteem, and self-actualization.

levothyroxine (Synthroid) Administration

-Assess apical pulse and BP prior and during therapy. Assess for tachyarrhythmias and chest pain. -PO: Administer with a full glass of water, on an empty stomach, 30-60 min before breakfast, to prevent insomnia. Initial dose is low and increased gradually, based on thyroid function tests. For pts with difficulty swallowing, tablets can be crushed and placed in 5-10 ml of water. -IV: Reconstitute the 200 mcg and 500 mcg vials with 2 or 5 mls of 0.9% NaCl. 100mcg/ml. Shake well and administer at a rate of 100 mcg over 1 min. Davis Drug Guide pg 770

digoxin (Lanoxin) Administration

-High alert med, have a second practitioner check order and calculations. -For rapid digitalization, initial dose if higher than maintenance dose. 50% of total dose is given initially then 25% at 4-8 hr intervals. -Changing from parenteral to oral dose forms may require dosage adjustments. -PO: administer oral preparations consistently with regard to meals. Tables can be crushed and administered with food or fluids if pt has trouble swallowing. -IM: administer deep into gluteal muscle and massage well to reduce pain. Do not administer more than 2 ml in each IM site. IM administration is generally not recommended. Davis Drug Guide pg 432

furosemide (Lasix)

-Inhibits the re-absorption of sodium and chloride from the loop of Henle and distal renal tube. Increases secretion of water, sodium, chloride, magnesium, potassium and calcium. Effectiveness persists in impaired renal function. -Side Effects: hypotension, blurred vision, dry mouth, tinnitus, muscle cramps, anemia, photosensitivity. -Assess fluid status, monitor I&O, daily weights, skin turgor, edema. -Monitor BP and pulse before and during therapy. -Assess for skin rash frequently during therapy. -Monitor electrolytes, renal and hepatic function, glucose, and uric acid levels. (may decrease K, Na, Ca, Mg) (may increase BUN, glucose, creatinine, and uric acid levels) Davis Drug Guide pg 602

Epoeitin Alfa

-Maintains and may elevate RBCs, decreasing the need for transfusions. -Side Effects: seizures, HF, MI, stroke, thrombolytic events -May cause increase in WBC and platelets. -May decrease bleeding times.. -Driving and activities requiring continuous alertness should be avoided. -Pt should contact HCP if signs of blood clotting, SOB, pain in the legs, sudden confusion, loss of balance, cool or pale extremities, or LOC occur. Davis Drug Guide pg 509

levothyroxine (Synthroid) Lab Values

-Monitor thyroid function studies prior to and during therapy. -Monitor thyroid-stimulating hormone serum levels in adults 8-12 wks after changing from one brand to another. -Monitor blood and urine glucose in diabetic pts. Insulin or oral hypoglycemic dose may need to be increased. Davis Drug Guide pt 770

Reporting and Documenting Medication Errors

-Notify HCP of all errors. -Complete an incident report within the time frame of facility, usually 24 hrs. (should include client's identification, name and dose of med, time and place of incident, accurate and objective account of the event, who you notified, what actions you took, your signature) -Do not reference of include the incident report in client's chart. ATI Pharmacology Pg 15

glipizide (Glucotrol) Patient Education

-Take medication at same time each day, take missed dose unless time for next dose, don't take if unable to eat. -Explain that this med controls glucose but does not cure diabetes. Therapy is long term. -Review s/s of hypo and hyperglycemia. -If hypo occurs advise pt to take a glass of OJ or 2-3 tsp of sugar, honey, or corn syrup dissolved in water or an appropriate number of glucose tabs and notify HCP. -Instruct pt to monitor glucose and ketones, especially if sick or stressed. -Can cause dizziness or drowsiness. -Use sunscreen and protective clothing to prevent photosensitivity reactions. -Advise pt to carry a form of sugar and identification describing disease process and medication regimen at all times. -**Advise pt to notify HCP if unusual weight gain, swelling of ankles, SOB, drowsiness, muscle cramps, weakness, sore throat, rash or unusual bleeding or bruising occurs. ** Davis Drug Guide pg 1156

digoxin (Lanoxin) Toxicity

-Therapeutic serum levels range from 0.5-2 ng/ml. Serum levels may be drawn 6-8 hrs after dose but often are drawn before next dose. -Geri pts are at increased risk due to age-related decreased renal clearance. -Observe for s/s; Adult: abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and other arrythmias. Child: first are usually cardiac arrythmias. If they occur withhold dose and contact HCP. Davis Drug Guide pg 432

Basic EKG tracings--> electrolyte imbalances:

-U waves are present in HYPOkalemia (low potassium below 3.5). flatted T wave, presence of U wave, ST depression, prolonged QRS, peaked P wave, ventricular dysrhythmias, 1st & 2nd degree heart block. -The U wave comes after T wave of ventricular repolarization & may not always be observed. -critically low potassium levels can lead to torades de pointes (ventricular tachycardia) *-normal K+ levels: 3.5-5.0* -HYPERkalemia (above 5.0)--> ECG changes = tall peaked T wave, prolonged PR interval, ST segment depression, widened QRS, loss of P wave, VF, ventricular standstill.

urinary catheter - expected outcomes post catheterization removal:

-assess for urinary retention. if no urination, in 6-8 hr then re-cath. first, try getting up & moving around, sitting on the toilet, running water, warm water in peri area, drinking fluids/tea, bladder scanner, etc. -urine frequency a few HOURS after a catheter is removed is normal, although if urine frequency is still there a few DAYS later this would cause it to be abnormal and the nurse should assess for a UTI.

Cardiac catheterization: bypass surgery --> assessment of distal pulses:

-check the operative extremity every 15 min initially and then hourly for color, temp, capillary refill (> 3 sec in PAD pts), presence of peripheral pulses. -loss of palpable pulses or change in doppler sound over a pulse require immediate HCP attention -compare all assessment findings with pt baseline -many PVD pts have hx of chronic rest pain & developed a tolerance to opioids so aggressive pain management is needed -assess for potential complications such as bleeding, hematoma, thrombosis, embolization, and compartment syndrome. -dramatic increase in pain, loss of palpable pulses, extremity pallor or cyanosis, numbness, tingling, or cold extremity suggests blockage of graft or stent. -avoid knee flexed position except in ROM exercises. turn pt and position frequently to support incision. -pt should get out of bed many times a day for movement. discourage prolonged sitting as it causes thrombosis and edema. -compression stockings may be used to control edema. -pts with peripheral bypass surgery are given a dual antiplatelet therapy (aspirin + clopidogrel) for 1 year then lifelong single antiplatelet therapy.

Fall prevention:

-complete fall risk assessment -be sure pt knows how to use the call light & its within reach. -respond to call lights in a timely manner -use fall risk alerts (color coded wristbands) -provide regular toileting and orientation of pts who have cognitive impairment. -provide adequate lighting -orient pts to the setting to make sure they know how to use all assistive devices (grab bars) and can locate necessary items -place pts at risk for falls near the nurses station -provide hourly rounding -make sure bedside tables, overbed tables, and frequent use items (telephone, water, facial tissues) are within reach -keep the bed in low position and lock the brakes -for pts who are sedated, unconscious, or otherwise compromised, keep side rails up -avoid the use of full side rails for pts who get out of bed or attempt to get out bed without assistance. -provide nonskid footwear and nonskid bath mats for use in tubs and showers -use gait belts, and additional safety environment when moving pts. -keep floor clean, dry, free from clutter with a clear path to bathroom (no scatter rugs, cords, or furniture) -keep assistive devices nearby after validation of safe use (eyeglasses, walkers, transfer devices) -educate pt and family about safety risks and the plan of care. pts and families who are aware of risk are more likely to call for assistance. -lock the wheels on beds, wheelchairs, and carts to prevent them from rolling during transfers or stops. -use electronic safety monitoring devices (chair or bed alarm) for pts at risk of getting up without assistance to alert staff. -report and document all incidents. fundamentals ati pg 59 & 60.

contact, standard, airborne, & droplet precautions:

-contact: protects visitors & caregivers when they are within 3 ft of pt against direct pt and environmental contact infections (resp, virus, shigella, diseases caused by mircoorganisms, wound infections, herpes, etc. --> contact precautions require: private room or a room with other pts who have same infection, *gloves and gowns* worn by caregivers/visitors, disposal of infectious dressing material into a single nonporous bag without touching outside of bag. -standard: applies to all body fluids. --> hand hygiene using alcohol based waterless product after contact with pt when hands are not visibly soiled/contaminated. wash hands with soap and water after C.diff pt. masks, eye protection, and face shields are required when care might cause splashing, or spraying of body fluids. -airborne: use to protect against droplet infections smaller than 5mcg (measles, varicella, pulmonary or laryngeal TB) --> private room, masks & respiratory protection devices for nurses & visitors. *N95 or high efficiency particulate (HEPA) respirator if pt has suspected TB. negative pressure airflow exchange in room of at least 6-12 exchanges per hr. if splashing or spraying is a possibility, wear full face (eyes, nose, mouth) protection. pts need to wear a mask while outside of room/home. -droplet: protect against droplets larger than 5 mcg and travel 3-6ft. from pt (pharyngitis, pneumonia, influenza, mumps, etc.) --> private room or room with other pt who has same disease. pts must have own equipment. masks for nurses & visitors. pts need to wear mask while outside of room. fundamentals ati pg 56

home safety assessment for older pt:

-decrease in tactile sensitivity can place pt @ risk for burns & other types of tissue injury. -risk factors for falls --> physical, cognitive, & sensory changes. changes in muscoskeletal & neurological systems. impaired vision or hearing & frequent trips to the bathroom. -remove items that could cause pt to trip (throw rugs & loose carpet) -place electrical cords & extension cords against a wall behind furniture -monitor gait & balance & provide aids as need (wheelchair, walker, etc) -make sure that steps & side walks are in good repair -place grab bars near toilet & in the tub/shower. install a stool riser -use nonskid mat in tub/shower -place shower chair in shower & provide bed side commode if needed -ensure lighting is adequate inside and outside home and remove clutter -emergency phone #s close (for fire) -fire extinguishers & smoke alarms routinely change batteries in smoke alarms. -exit plan for fire -review 02 safety measures --> no smoking sign @ front door & pts bedroom. pt should not smoke while using 02, ensure electrical equipment is in good repair and well grounded, only use cotton blankets NOT wool, keep heating oil/nail polish remover away from 02. wear water based lubricant under nares if 02 dries them out. no smoking while using 02. -check for CO2 monitors & food poisoning (old food) fundamentals pg 65

therapeutic communication -newly diagnosed diabetic pt.

-elicit and attend to pts thoughts, feelings, concerns, and needs. -express empathy and genuine concern for pts and families issues -obtain info and give feedback about pt status -intervene to promote functional behavior and effective interpersonal relationships -evaluate pts progress toward desired goals and outcomes. -children and older adults often require specific age appropriate techniques to enhance communication. -use of nursing process depends on therapeutic communication among the nurse, pt, family, significant other and the interprofessional health care team. -use of verbal and non verbal communication) face client, eye contact, get on their level with child, (silence, listening, open ended questions, express empathy, reinstate, reflect, paraphrasing, exploring... etc) fundamentals ati pg 178

sleep--> pt education:

-exercise regularly at least 2 hr before bedtime -establish bedtime routine & regular sleep pattern -arrange sleep environment for comfort -limit alcohol, caffine, & nicotine at least 4 hr before bed. -limit fluids 2-4 hr before bedtime -engage in muscle relaxation if anxious or stressed *Narcolepsy*: -exercise regularly -eat small meals that are high in protein -avoid activities that increase sleepiness (sitting too long, warm environments, drinking alcohol) -avoid activities that could cause pt to fall asleep (driving/heights) -take naps when drowsy. -take prescribed stimulants *Hypersomnolence disorder*: (excessive day time sleepiness lasting at least 3 mo) -maintain regular sleep -wake schedules -provide ample sleep opportunities -take prescribed stimulants. fundamentals ati pg 217

CVD: risk factors/prevention/focused assessment:

-non-modifiable risk factors: age, gender, ethnicity, family hx, & genetics.-modifiable risk factors: elevated serum lipids, elevated BP, tobacco use, no physical activity, obesity, diabetes, metabolic syndrome, psychologic states & elevated homocysteine levels. *focused assessment:* -lipids --> -one of the 4 most firmly established risk factors for CAD-anything greater than 200 is considered elevated. (cholesterol)-fasting triglyceride needs to be <150-LDL <160 = low risk for CAD-needs to be <70 for high risk pts -Hypertension-->goal of 150/90 for pts older than 60-normal pt goal is 120/80-HTN increases risk of death for people with CAD-in postmenopausal women, HTN is associated with higher incidence of CAD than men & premenopausal women.

Hypertension: stages

-normal BP: <120 systolic and <80 diastolic -prehypertension: 120-139 systolic and 80-89 diastolic -stage 1 hypertension: 140-159 systolic and 90-99 diastolic -stage 2 hypertension: >160 systolic and >100 diastolic -primary HTN is idiopathic meaning unknown cause. in 90-95% of all cases. -3 contributing factors = 1) endothelial function r/t either vasoconstriction or vasodilating agents. 2) increased SNS activity 3) overproduction of sodium-retaining hormones, increased sodium intake, overweight, diabetes, tobacco, & excessive alcohol. -secondary HTN is HTN with a cause (underlying issue) can be corrected. only in 5-10% of cases. occurs when pts suddenly have high BP *-the hallmark of HTN is persistently increased SVR. (systemic vascular resistance)*

pain & pain management --> assessment/manifesations:

-pts report of pain is most reliable diagnostic measure of pain. -self report using standardized scales for pts over 7 yrs old. pain scales can include #s, words, or other intensity markers that allow pt to select a pain level. -assess & document pain level frequently. -use sypmtom analysis to obtain subjective data. -PQRST -provokes, quality, radiates, severity, time. *s/s:* -facial expressions (grimacing, wrinkled forehead) -body movements (restlessness, pacing, guarding) -moaning/crying -decreased attention span -BP, pulse, resp rate increased temporarily with acute pain. -use anatomical terminology & landmarks to describe location -intensity, strength, & severity = measures -setting --> how pain affects daily life. fundamentals ati pg 235

anxiety

-separation anxiety --> 4-8 months. continues when left. -young adults: increased anxiety/depression -increases the rate/depth of respirations, increases pain sensitivity. -characteristic of discomfort -opioids can reduce anxiety. online ati: searched "anxiety"

Peripheral vascular disease: nursing interventions

-teach pt diet modification --> low cholesterol, saturated fats, and refined sugars. -teach pt daily foot care and inspection as well as avoidance of injury-assess legs/feet for changes in skin color, texture, and reduction of hair -thick or overgrown toenails and calluses are potentially serious and require HCP attention -pts should wear clean all cotton or all wool socks and comfortable rounded (NOT POINTED) shoes with soft insoles. pts should lace shoes loosely and break in shoes gradually. -doppler ultrasound with duplex imaging maps blood flow throughout the entire region of an artery. when palpation of a peripheral pulse is difficult bc of severe PAD, the doppler ultrasound can determine the degree of blood flow. -risk factor modification: 1st treatment goal is reduce CVD risk factors regardless of severity of symptoms. risk factors must be modified with drug therapy and lifestyle changes. -tobacco cessation, diabetes management (hemoglobin A1C below 7%), aggressive lipid management (dietary & drug therapy) -> STATINS. cholesterol <70. -HTN in people with PAD -> BP needs to be <140/90 and if diabetic or renal insufficiency needs to be < 130/80. -ACE inhibitors (PRILS) are used for symptomatic pts with PAD. -lifestyle changes are encouraged and DASH diet (low fat, low calorie, low sodium) -drug therapy: antiplatelet agents are critical for reducing risks of CVD events in PAD pts. oral antiplatelets should include 75-325 mg of aspirin/day. -ANTICOAGULENTS ARE NOT RECOMMENDED FOR PAD PTS -exercise: a 30-45 min exercise preformed at least 3 days/week for minimum of 3 mo. walking, cycling, etc. encouragement of participation is important esp in women since women have a greater decline of mobility than men do.

physical restraints:

-use seclusion or restraints for shortest duration necessary and only if less restrictive measures are not sufficient. they are for physical protection of pt or protection of other pts & staff. -restraints can be physical or chemical (sedatives) -it is INAPPROPRIATE to use restraints for --> convenience of staff, punishment for pt, pts who are extremely physically or mentally unstable, pts who cannot tolerate the decreased stimulation of a seclusion room. -restraints SHOULD --> never interfere with treatment, restrict movement as little as necessary, fit properly (can fit 2 fingers under restraint) be discreet as possible, and be easy to remove or change. -provider must prescribe seclusion or restraints in writing, after a face to face assessment of pt. *in an emergency situation, when there is immediate risk to pt or others, nurse can place restraints on pt. nurse must obtain a prescription from a provider ASAP (usually within 1 hr) -prescription must include reason for restraints, location of restraints, how long to use them, and type of behavior that warrants use of restraints. -prescription allows only 4 hr of restraints for an adult, 2 hr for pts 9-17, and 1 hr for pts younger than 9. providers can renew prescriptions with a max of 24 consecutive hrs. -CANNOT HAVE PRN RESTRAINT ORDERS -explain need for restraints to pt, family, emphasizing the restraints are to keep pt safe. -ask pt or guardian to sign consent form -assess skin and provide skin care every 2 hrs -offer food and fluids -provide a means for hygiene and elimination -monitor VS -offer ROM exercises of extremities. -pad bony prominences to prevent skin breakdown -secure restraints to a MOVABLE part of bed frame. if restraints with a buckle strap are not available, use a quick release knot. -make sure restraints are loose enough for ROM and 2 fingers can fit underneath them -remove or replace restraints frequently to ensure good circulation and allow for full ROM of limbs -regularly determine need to continue using restraints. -never leave pt alone without restraints fundamentals ati pg 60

steps for using solutions during a sterile procedure:

1. remove bottle cap. 2. place bottle cap face up on a clean (nonsterile) surface. 3. hold bottle with the label in the palm of hand so that the solution does not run down the label. 4. 1st pour a small amount (1-2mL) of solution into an available receptacle. 5. pour solution (without splashing onto the dressing or site without touching the bottle to the site. 6. sterile solutions expire 24 hr after opening and recapping in some facilities. other facilities policies state that once a sterile solution is opened, it can be used only once and then thrown away. fundamentals ati pg 50

lisinopril (Prinivil)

ACE Inhibitor -manages hypertension -Side Effects: hypotension, agranulocytosis, angioedema, taste disturbances, and cough. -pt should notify HCP if rash, mouth sores, sore throat, fever, swelling of hands, irregular HR, chest pain, dry cough, hoarseness, or difficulty swallowing occur. Davis Drug Guide pg 163

Chronic Bronchitis Education

Adhere to activity limitations. Avoid spicy foods or extremely hot or cold foods. Avoid crowds. Avoid extreme temperatures Avoid allergens and power odors Meet nutritional requirements Receive immunizations Recognize s/s of resp infection or hypoxia. Stop smoking. Use meds/inhalers/oxygen as prescribed. Use pursed lip and diaphragmatic or abdominal breathing. When dusting use a wet cloth. NCLEX RN Suanders pg 723

Oxygen Therapy

Adverse effects: Oxygen toxicity, hyperventilation, combustion, infection. ATI Med Surg pg 118, Lewis pg 565

COPD

Assessment; risk factors: advanced age, smoking, AAT deficiency, air pollution. expected findings: dyspnea upon exertion, productive cough, crackles and wheezes, hypoxemia, use of accessory muscles, barrel chest, irregular breathing pattern, clubbing of fingers and toes, dependent edema secondary to right sided HF, pallor and cyanosis, decreased 02. ATI Med Surg pg 137

Neutropenic precautions

Avoid sick people, stay clean, avoid large crowds, restrict hazard food (raw meats, eggs, soft cheese w/mold). Do not preform gardening or clean up after pets. Have pt in private room.

Rhonchi

Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.

Wheezing

Continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls. First evident on expiration but possibly evident on inspiration as obstruction of airway increases. Lewis pg 468

Stridor

Continuous musical or crowing sound of constant pitch. Result of partial obstruction of larynx or trachea. Lewis pg 468

propranolol (Inderal) Contraindications

Contraindicated in hypersensitivity; uncompensated HF; pulmonary edema; cardiogenic shock; bradycardia;heart block; pheochromocytoma. Davis Drug Guide pg 1059

Rales

Crackles; wet crackling noise in lungs

COPD

Drug Therapy; Oxygen Bronchodilators (inhalers): Short-acting beta 2 agonists, such as albuterol provides rapid relief. Cholinergic antagonists, ipratropium, blocks parasympathetic nervous system. Methylxanthines, such as theophylline, relax smooth muscles of the bronchi. Monitor for toxicity when taking theophylline (tachycardia, nausea, diarrhea) Watch for tremors and tachycardia when taking albuterol. Observe for dry mouth when taking ipratropium. Have pt suck on hard candies to moisten the mouth, increase fluids, report headaches, or blurred vision. Monitor HR. Anti-inflammatory agents; Corticosteroids (fluticasone and prednisone) Leukotriene antagonists (montelukast) Mast Cell Stabilizers (cromolyn) Monoclonal antibodies (omalizumab) Watch for fluid retention, hypokalemia, hyperglycemia if corticosteroids are given systemically. Mucolytic Agents; loosen secretions Nebulizer treatments Guaifenesin ATI Med Surg pg 139

Crackles

Fine: series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration. Similar sound to rolling hair between fingers. Coarse: series of long-duration, discontinuous, low-pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall. Similar to sound blowing through a straw under water. Lewis pg 468

Prednisone

Glycemic Control: prednisone can cause a spike in blood sugar levels. May require insulin or oral hypoglycemic agents. Davis Drug Guide pg 362

0.45% NS / 5% Dextrose

Hypertonic solution Provides Na, Cl, and free water Used as a maintenance solution

0.45% NS

Hypotonic solution Contains free water, Na, Cl, no calories Used to treat hypernatremia and uncontrolled hyperglycemia. Used as a maintence solution. Lewis pg 293

Post-Op Procedure Education of: TURP

Includes: *Placement of a indwelling three-way catheter (usually a CBI). CBI is used to reduce catheter obstructions. *If a catheter obstruction (bladder spams, or reduced outflow) occurs irrigate w/ 50 mL solution to dislodge a clot. *Avoid kinks in the tubing (ALWAYS CHECK FOR KINKS) *Monitor vital signs and I&O *Admin prescribed fluids *Monitor for bleeding (HEMORRHAGE) *Assist the client to ambulate ASAP *Admin medications: Analgesics, Antispasmodics, Antibiotics, Stool Softeners *When cath is removed monitor: urine output, bleeding. *Instruct the client that 150-200mL of urine is expected every 3-4 hours after removal of cath. ATI pg.440-441 & Lewis pg 1274

ABG's

Interpretation: reports the status of oxygenation and cid-base balance of the blood. measures ph, PaO2, PaCO2, HCO3, and SaO2. can be obtained by arterial puncture or through an arterial line. ATI Med Surg pg 105 Lewis pg 456, 290

ABG's

Interventions: give meds, encourage fluids.

COPD

Interventions; Position pt into high-fowler's. Encourage deep breathing and spirometry. Encourage effective coughing or suctioning. Administer breathing treatments, o2 and meds as prescribed. Monitor for skin breakdown around the nose and mouth. Promote adequate nutrition. (soft, high calorie meals, encourage fluids) Monitor weight and note changes. Have pt walk 20 mins 2-3 times a week (provide periods of rest) Encourage client to drink 2 to 3 L/day to mobilize secretions. ATI Med Surg Pg 138

D5W

Isontonic solution, but physiologically hypotonic. Contains free water only, no electrolytes. Provides 170 cal/L Used to replace water losses and treat hypernatremia.

Lactated Ringers

Isotonic Solution Similar in composition to normal plasma except does not contain Mg2+ Does not provide free water or calories Used to treat hypovolemia, burns, and GI fluid losses. Cannot be used in pts with alkalosis or lactic acidosis.

0.9% NS

Isotonic solution Contains Na, Cl in excess of plasma levels. Does not contain free water or calories. Used to expand intravascular volume and replace extracellular fluid losses. Only solution that may be administered with blood products. May cause volume overload in pts with cardiac or renal disease

Chemotherapy pt lab changes

Low RBC count (anemia) Low WBC count (leukopenia) Low Platelet count (thromboctyopenia) Increased Ca and Creatine NCLEX RN Saunders pg 449

Pneumonia

Manifestations in Geri pts: Confusion or stupor may be the only s/s. Hypothermia, rather than fever may be found. Nonspecific s/s include diaphoresis, anorexia, fatigue, myalgias, and headache. Lewis pg 502

Asthma

Manifestations of an asthma attack: SOB, Cough, wheezing, chest tightening, use of accessory muscles, low 02 sat, barrel chest or increased chest diameter, and airflow obstruction. Lewis pg 542, ATI Med Surg pg 133-134

Inadequate Oxygenation

Manifestations: CNS: unexplained apprehension, restlessness, irritability, confusion, lethargy, combativeness, and coma. Respiratory: Tachypnea, dyspnea on exertion, dyspnea at rest, use of accessory muscles, retraction of interspaces on inspiration, and pauses for breath between sentences/words. Lewis pg 457 Table 25-2

DM Type 1 and 2 Nursing Intervention:

Monitor the following: *Blood glucose levels, I & O's and weight, skin integrity and poor wound healing, tingling and numbness of extremities, visual alterations, dietary practices, exercise patterns, SMBG skill proficiency, and self-admin of medications (insulin, and oral diabetic meds). *Adjustments to the client's antidiabetic therapy if pt is NPO, on a clear liquid diet, or is receiving enteral or parenteral nutrition. *Monitor Blood Glucose Levels regularly *Teach pt to cut toe nails straight across. *Wear closed toe shoes, and a flat sole (ATI pg. 550)

Sickle Cell Anemia/ Crisis

Nursing Care: Encourage fluids, control pain, administer antibiotics and O2. Pt education: Avoid high altitudes, maintain hydration, treat infections promptly. Lewis pg 617

Hematology s/s of infection

Older Adult: Confusion/cognitive changes, behavioral changes, pain, fever > 100.4, & changes in labs. Adult: Fever, chills, swollen lymph nodes, aches, cough, congestion, headaches, fatigue, nausea, malaise, rash, WBC increase.

Nitroglycerin Administration

PO: Administer dose 1 to 2 hr after a meal with a full glass of water. SL: Tablet should be helf under tongue until dissolved. Avoid eating, drinking, or smoking until tab is dissolved. SL Powder: Administer 1-2 packets under tongue at onset of attack. Place under tongue, close mouth and breathe normally. Allow powder to dissolve before swallowing. Do not rinse mouth or spit for 5 min after dose. Translingual Spray: Spray under tongue. IV: dilute and administer as infusion Continuous Infusion: Dilute in d5W or 0.9% NaCl. **Monitor BP and pulse before and after administration. IV therapy pts may need continuous ECG and BP monitoring.** Davis Drug Guide Pg 916

Incentive Spirometer

Patient Education: Keep a tight mouth seal around the mouthpiece and inhale and hold breath for 3-5 secs. During inhalation, the needle of the spirometry machine will rise. ATI Med Surg pg Instruct pt assume a sitting or upright position. Instruct pt to place mouth tightly around the mouthpiece. Instruct pt to inhale slowly to raise and maintain the flow rate indicator, usually between 600 and 900 marks. Instruct client to hold the breath for 5 secs and then exhale through pursed lips. Instruct the client to repeat process 10 times every hour. NCLEX RN Saunders pg 216

Cromolyn Administration

Requires several days of treatment before effects are seen. 1-2 drops of 4% solution 4-6 times daily. Davis Drug Guide Pg 1403

10 rights of medication administration

Right Client Right Medication Right Dose Right Time Right Route Right Documentation Right Client Education Right to Refuse Right Assessment Right Evaluation ATI Pharmacology pg 13

NPH Insulin (Humulin N, Novolin N)

SubQ Onset: 2-4 hr SubQ Peak: 4-10 hr SubQ Duration: 10-16 hr Davis Drug Guide Pg 1353

Lantus (glargine)

SubQ Onset: 3-4 hr SubQ Peak: none SubQ Duration: 24 hr Davis Drug Guide Pg 1353

Regular Insulin (Humulin R, Novolin R)

SubQ Onset: 30-60 mins SubQ Peak: 2-4 hr SubQ Duration: 5-7 hr IV Onset: 10-30 min IV Peak: 15-30 min IV Duration: 30-60 min Davis Drug Guide Pg 1353

DM Type 1: Diagnosis

Type 1 DM is an autoimmune disorder, that destroys glucagon in the cells, which produce insulin in the islets of Langerhans in the pancreas. (ATI pg. 545)

DM Type 2: Diagnosis

Type 2 DM is a progressive condition, the body has become insulin resistance and can not secrete insulin by the beta cells. (ATI pg. 545, Lewis pg 1130)

Atelectasis

a lung condition characterized by collapsed, airless alveoli. There may be diminished or absent breath sounds and dullness to percussion over the affected area. The most common cause is obstruction of small airways with secretions. This is common in bedridden pts and in post-op abdominal and thoracic surgery pts. Deep inspiration is necessary to open up the pores effectively. Use spirometry, deep breathing exercises, and early mobility to prevent atelectasis. Lewis pg 528

Warfarin

anticoagulant, prevention of thromboembolic events. -PO -Side Effects: bleeding, fever, cramps, calciphylaxis -Monitor stool for occult blood -NSAIDS, aspirin, acetaminophen increase risk of bleeding. -Pt should avoid alcohol herbal products, or other OTCs. Davis Drug Guide pg 1283

Heparin

anticoagulant, prevents formation of thrombus. -Given IV or SubQ -Side Effects: bleeding, HIT, anemia, osteoporosis. -Risk of bleeding may increase with concurrent use of NSAIDS and aspirin. -Monitor aPPT and Hemocrit. -Monitor platelet count every 2-3 days. -May cause HYPERkalemia. -Fatal hemorrages can occur. -Advise pt to reports s/s of unusual bleeding or bruising to HCP Davis Drug Guide pg 635

Mycostatin Elixir (Nystatin)

antifungal (topical/local) -inspect oral mucous membranes before therapy. -Risk for infection or impaired skin integrity. -Place 1/2 dose in each side of mouth. pt should hold suspension in mouth or swish throughout mouth for several minutes before swallowing. -Use cautiously in denture wearers. -Contraindicated in products that contain ethyl alcohol or benzyl alcohol. Davis Drug Guide pg 926

Diuretic therapy:

furosemide: -IV can be given IV push 20 mg -can have hearing loss with IV. -mainstay of treatment in pts with volume overload -decreases sodium reabsorption at various sites within the nephrons, thereby enhancing sodium & water loss. -decreases intravascular volume with the use of diuretics (relieves congestion and makes lungs clear). -reduces venous return (preload) & also the volume returning to the LV, in the loop of Henle. -lowers BP -reduces vasoconstriction -this allows the LV to pump more efficiently -CO is increased, pulmonary vascular pressures are decreased, & gas exchange is improved. -IV furosemide acts rapidly in kidneys (you pee a lot!) -decreases fluid volume -decreases preload -decreases pulmonary venous pressure -relieves symptoms of HF (edema) -monitor for orthostatic hypotension & electrolyte abnormalities (esp. potassium) -loop diuretics (furosemide) remain effective despite renal insufficeny -diuretic effect of drug increased at higher doses -can cause dehydration as pt is loosing electrolytes -monitor potassium levels-make sure to monitor pt's I&0 and daily weight

HIPPA/Legal ethical:

health insurance portability & accountability act. -keep pts care private -Legal ethical --> torts: assault = one person makes another fearful & apprehensive. ex: nurse threatens to place an NG tube in a pt who is refusing to eat. battery: intentional and wrongful physical contact with a person that involves an injury or offensive contact. ex: nurse restrains a pt & administers an injections against their will. false imprisionment: a person is confined or restrained against their will. ex: a nurse uses restraints on a competent pt to prevent their leaving of the hospital. -informed consents --> pts written permission for a procedure/treatment. PROVIDER must explain the consent. NURSE'S role is to witness pts signature and ensure provider has obtained the informed consent responsibly. -advanced directives --> living will, durable power of attorney for health care, provider's orders (unless a provider writes a do not resuscitate, or allow natural death in pt medical record, then nurse initiates CPR. fundamentals ati pg 17

glipizide (Glucotrol) Method of Action

lowers blood glucose by stimulating the release of insulin from the pancreas and increasing the sensitivity to insulin at receptor sites. May also decrease hepatic glucose production. Davis Drug Guide pg 1156

nursing interventions in confused pts:

try to reorient pt if. remind them where they are, what their name is, the year, president, etc. -safety --> room close to nurses station -bedalarm -don't try to convince pt otherwise, listen to them.

Cardiac Enzymes: pt education

when cells are injured they release their contents, including enzymes and other proteins into the circulation. useful in diagnosis of acute coronary syndrome (ACS) (BNP, Troponin T and I) *BNP Labs: <100 (no HF) 100-300 (HF present) 300-600 (Mild HF) 600-900 (moderate HF) >900 (SEVERE)* *Troponin Labs: Troponin I: normal = <0.5 suspicious = 0.5-2.3 postive for an MI = >2.3 Troponin T: <0.1 normal*