Mix #1

This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment.

"typical" antipsychotics and neuroleptic malignant syndrome (NMS)

When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration. If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching.

6 rights of medication administration

A balloon tamponade tube (eg, Sengstaken-Blakemore, Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal

A balloon tamponade tube client experiences respiratory distress

Aspirin should not be used in children to treat fever, except in a setting such as Kawasaki disease; this is because aspirin use is associated with Reye syndrome (swelling of the liver and brain). Fever in children is treated with ibuprofen or acetaminophen.

ASA use in children

Acanthosis nigricans is a skin disorder characterized by the presence of symmetric, hyperpigmented velvety plaques located in flexural and intertriginous regions of skin (axilla, neck). Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans. Both indicate insulin resistance (diabetic dermopathy). The client should be referred to the primary health care provider for evaluation of undiagnosed diabetes mellitus and/or metabolic syndrome.

Acanthosis nigricans

Acute severe asthma exacerbations (status asthmaticus) occur when severe airway obstruction and lung hyperinflation (air trapping) persist despite aggressive treatment with bronchodilators and corticosteroid therapy. Clinical manifestations indicating impending respiratory failure include: -PaCO2 ≥45 mm Hg (6.0 kPa): Indicates hypercapnia and hypoventilation resulting from fatigue and labored breathing. As initial tachypnea subsides and respiratory rate returns to normal, PaCO2 rises and respiratory acidosis develops -PaO2 ≤60 mm Hg (8.0 kPa): Indicates hypoxemia resulting from increased work of breathing, decreased gas exchange (hyperinflation and air trapping), and inability of the lungs to meet the body's oxygen demand -Paradoxical breathing (ie, abnormal inward movement of the chest on inspiration and outward movement on expiration): Indicates diaphragm muscle fatigue and use of respiratory accessory muscles -Mental status changes (eg, restlessness, confusion, lethargy, drowsiness): Sensitive indicators of hypoxemia and hypoxia -Absence of wheezing and silent chest (ie, no sound of air movement on auscultation): Ominous signs indicating severe hyperinflation and air trapping in the lungs -Single-word dyspnea: Inability to speak >1 word before pausing to breathe due to shortness of breath -Normal arterial pH is 7.35-7.45. A pH of 7.50 indicates alkalosis, which could be respiratory or metabolic. Clients with respiratory failure have respiratory acidosis (low pH and elevated pCO2).

Acute severe asthma exacerbations and respiratory failure include:

Adolescent clients who are hospitalized often fear separation from their friends and altered body image related to disease processes or treatment. Interaction with peers who are experiencing similar health issues can help alleviate anxiety. Clients should be offered opportunities to discuss fears and experiences with peers in a supportive environment (eg, "teen rooms")

Adolescent clients who are hospitalized

Parkinson disease (PD) is a progressive neurological disorder characterized by bradykinesia (loss of autonomic movements), rigidity, and tremors. Clients with PD have an imbalance between dopamine and acetylcholine in which dopamine is not produced in high enough quantities to inhibit acetylcholine. Anticholinergic medications (eg, benztropine, trihexyphenidyl) are commonly used to treat tremor in these clients. However, in clients with benign prostatic hyperplasia or glaucoma, caution must be taken as anticholinergic drugs can precipitate urinary retention and an acute glaucoma episode. As a result, such medications are contraindicated in these clients. Constipation is a common side effect of benztropine. Due to the characteristic decreased mobility, PD can also cause constipation. The client should be instructed to increase dietary fiber intake and drink plenty of water. However, this is not the most concerning issue.

Anticholinergic medications (eg, benztropine, trihexyphenidyl):

UC is a chronic disease characterized by inflammation and ulcerations in the large intestines resulting in urgent, frequent, bloody diarrhea; abdominal pain; anorexia; and anemia. Appropriate NDs for a client with UC include: Acute pain related to an intestinal inflammatory process as evidenced by the client's verbal reports of abdominal pain and self-focusing Altered nutritional status related to decreased appetite and intestinal malabsorption Hopelessness related to chronic illness and prolonged treatments with no positive results as evidenced by the client asking, "What's the point of taking medication? It doesn't help anyway" Risk for deficient fluid volume related to active fluid losses secondary to frequent diarrhea; blood loss secondary to an inflamed bowel; and poor oral intake

Appropriate NDs for a client with UC include:

Spirituality, religious beliefs, and traditions are important to include in client care. Aspects of care for Muslim clients include: Facilitating client to face Kaaba in the holy city of Mecca, generally northeastward from North America, during prayer - Ritual daily prayers occur 5 times a day, and dying clients may pray more often. Modesty - Care providers should be the same sex as the client whenever possible. The female client may require a hijab (traditional head covering) and/or gown to cover most of the body. Providing foods that are halal (lawful), or acceptable for consumption (eg, no pork) - Kosher and vegetarian meals are acceptable if a specific halal menu is unavailable. During Ramadan, the sick and dying are not required to fast with other Muslims from dawn until sunset. If the client chooses to fast, meals and medications should be rescheduled accordingly. Postmortem care of the Muslim client involves ritual washing, usually performed by family members, in preparation for burial. Burial occurs quickly after death, sometimes the same day In Islam, the family is the most important unit, and family presence brings strength to the individual. Multiple visitors should be accommodated unless they interfere with care.

Aspects of care for Muslim clients include:

A coup-contrecoup head injury occurs when the head strikes an object and the brain receives an injury under the area of impact (coup), after which it rebounds to the opposite side of the skull and sustains injury on that side as well (contrecoup). This type of injury is common in motor vehicle accidents and shaken baby syndrome. Visual processing occurs in the occipital lobe. The rate and depth of respirations are regulated by the medulla oblongata at the base of the brainstem. Expressive aphasia, the inability to express spoken words, occurs after a transient ischemic attack or stroke. This will occur if the frontal lobe (Broca aphasia) or temporal lobe (Wernicke aphasia) is injured. Inability to recognize being touched is indicative of injury to the parietal lobe of the brain.

Brain Damage from injury

Nutritional therapy includes the administration pancreatic enzyme supplements with or just before every meal or snack. These enzymes are enteric-coated beads designed to dissolve only in an alkaline environment similar to that of the small intestine. They must not be mixed with a substance that would cause them to dissolve prior to reaching the jejunum (not with milk). Capsule contents may be sprinkled on applesauce, yogurt, or acidic, soft, room-temperature foods with pH <4.5. Capsules should be swallowed whole and not crushed or chewed; chewing the capsules could cause irritation of the oral mucosa. Excessive intake of pancreatic enzymes can result in fibrosing colonopathy: so monitor total amount given every day

CF Nutritional therapy: pancreatic enzyme supplements

Carbon monoxide (CO) is a colorless, odorless gas produced by burning fuel (eg, oil, kerosene, coal, wood) in a poorly ventilated setting. CO toxicity (poisoning) is most often associated with smoke inhalation from structure fires, but is also generated by furnaces/hot water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust. Clients with CO toxicity often have nonspecific symptoms, and the diagnosis can be missed. It is important to assess for possible CO exposure to initiate appropriate emergency care and prevent hypoxic neurologic impairment. To help identify elevated CO levels in the home, the nurse can ask about the following: Similar symptoms in other family members, or an illness in an indoor pet that developed at the same time Fuel-burning heating/cooking appliances; risk of CO toxicity increases in the fall and winter due to increased used of heat sources in an enclosed space

Clients with CO toxicity

Clostridium difficile requires contact precautions under the guidelines published by the Centers for Disease Control and Prevention. Place the client in single-room isolation (preferred) or cohort with other C difficile-infected clients All surfaces within 3 feet of the bed are considered contaminated Personal protective equipment (gown and gloves) must be discarded before leaving the room Hand hygiene must be performed with soap and water Alcohol-based hand sanitizers do not kill C difficile spores (Option 1) Dedicated medical equipment (stethoscope, blood pressure cuff) should remain in the room

Clostridium difficile requires contact precautions

Numbness and tingling in both lower extremities are classic examples of neuropathic pain. The common causes of bilateral peripheral neuropathy include the following: Diabetic neuropathy - most common; distribution is usually sock-and-glove pattern Autoimmune neuropathy - Guillain-Barré syndrome Toxic neuropathy - alcohol use Establishing that the sensations the client is experiencing were present before surgery indicates whether this is a complication of surgery. Because the sensation is bilateral and the surgery was on the right knee, the "numbness and tingling" are probably baseline diabetic neuropathy. This should be confirmed by gathering more information from the client

Diabetic neuropathy

In this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and this should not be postponed. Maintenance doses of cyanocobalamin for vitamin B12 deficiency are usually administered every 4 weeks. Although this client should receive the injection as soon as possible, postponing the home care visit for 1 or 2 days will not harm the client. During a weather-related emergency, home care visits are classified as: -High priority - unstable clients who need care and are at risk for hospitalization if not seen. -Moderate priority - clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care management can be provided to these clients. -Low priority - clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care.

During a weather-related emergency, home care visits are classified as:

Late decelerations occur after the onset of a uterine contraction and continue beyond its end. They are caused by uteroplacental insufficiency. The lowest point of a late deceleration occurs near the end of the uterine contraction and may occur with marked hypertonia or increased uterine tone caused by oxytocin. Immediate steps must be taken to correct this deceleration. The client should be given oxygen by facemask, repositioned to the right or left side, oxytocin stopped if being administered, and an IV fluid bolus provided. The nurse will need to prepare for delivery if the deceleration pattern persists or variability becomes abnormal.

FHR: Late decelerations

Factor Xa inhibitors (eg, rivaroxaban [Xarelto], edoxaban, apixaban) are anticoagulants used to prevent and treat venous thromboembolism. Factor Xa inhibitors are being prescribed more frequently than other oral anticoagulants (eg, warfarin), as they have a lower risk of bleeding and require less ongoing monitoring (eg, PT/INR). Clients prescribed rivaroxaban should be educated to avoid taking over-the-counter medications or supplements that increase bleeding risk, such as NSAIDs (eg, aspirin), garlic, and ginger. The combined effects of rivaroxaban and other anticoagulants may greatly increase the risk of uncontrolled bleeding (eg, epidural, intracranial, gastrointestinal) and hemorrhage Unlike warfarin, factor Xa inhibitors are not affected by vitamin K, which is found in many green, leafy vegetables (eg, spinach, kale). Anticoagulants, particularly factor Xa inhibitors, increase the risk for spontaneous intracranial bleeding or formation of epidural hematomas. Clients taking factor Xa inhibitors should be instructed to immediately contact their health care provider for symptoms of neurological impairment (eg, extremity weakness, altered sensation, numbness). Routine monitoring of clotting times (eg, PT/INR, PTT) is unnecessary for clients prescribed factor Xa inhibitors.

Factor Xa inhibitors:

Fecal incontinence (ie, encopresis, soiling) refers to the repeated passage of stool in inappropriate places by children age ≥4 years. Management of fecal incontinence/constipation primarily includes 3 components: Disimpaction followed by prolonged laxative therapy, dietary changes (increased fiber and fluid intake), and behavior modification. Behavioral strategies are used to promote and restore regular toileting habits and to gain the child's cooperation and participation in the treatment program. Behavioral interventions include the following: Regularly schedule toilet sitting times 5-10 minutes after meals for 10-15 minutes Provide a quiet activity for the child during toilet sitting, which will help pass the time and make the experience more "enjoyable" Initiate a reward system to boost the child's participation in the treatment program; the reward would be given for effort, not for success of evacuation in the toilet (children with retentive encopresis have dysfunctional anal sphincters and little control over bowel movements; giving a reward for something the child has no control over would not be effective) Keep a diary or log of toilet sitting times, stooling, medications, and episodes of soiling to evaluate the success of the treatment

Fecal incontinence Management

Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days. Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition.

Fifth disease

Gonorrhea and chlamydia can lead to pelvic inflammatory disease (PID) and infertility. They are referred to as "silent infections" because many affected women show no symptoms. Infections of the fallopian tubes and uterus can lead to permanent damage and infertility. The Centers for Disease Control and Prevention recommend annual chlamydia and gonorrhea screening for all sexually active females age <25 and older females with risk factors. Both chlamydia and gonorrhea are treatable. The use of latex condoms is recommended to reduce the risk of contracting chlamydia and gonorrhea.

Gonorrhea and chlamydia can lead to pelvic inflammatory disease (PID) and infertility

Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention. Clients with hemophilia who are injured should be monitored closely for bleeding (eg, intracranial bleeds, bleeding into joints). Signs of an intracranial bleed include lethargy, headache, irritability, and vomiting. An intracranial bleed is lethal if unchecked, so administration of factor VIII to a client with hemophilia A is the first order of action, followed by a CT scan.

Hemophilia and potential head injury

Hospitalization for toddlers (ie, 12-36 months) is particularly difficult due to separation anxiety and a limited ability to cope with stress. Toddlers thrive on home rituals and routines, which bring stability and reassurance. Hospitalization can severely disrupt these routines, triggering frustration and temper tantrums. Caregivers should maintain as many home routines as possible (eg, sleeping, eating) to help the child cope with unfamiliar hospital surroundings and procedures. Parents should also stay with the child as much as possible, including overnight (ie, rooming-in), to provide consistency and alleviate separation anxiety Play, an important part of a child's emotional and social well-being, is an effective coping mechanism for children of all ages to deal with the stress of being away from home. The playroom is a safe place for children to act out their fears and anxieties related to illness and hospitalization A visit from friends is not likely to provide much comfort to a toddler and may actually cause additional stress. Adolescents, who are driven by peer interaction, would be more likely to benefit from this strategy. Preschool-aged children (3-5 years) have egocentric and magical thinking, which may cause them to think that their illness is due to something they have done or thought. Toddlers do not think this way.

Hospitalization for toddlers

Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. The American Heart Association recommends treatment with IV magnesium sulfate.

Hypomagnesemia and EKG

Infant formula is readily available in 3 forms: ready-to-feed, concentrated, and powder. Parents who feed their infants commercial formula should closely follow the manufacturer's recommendations for preparation, particularly if the product requires dilution or reconstitution. Parents should also adhere to basic guidelines for safe storage and handling. Key teaching points include: Keep bottles, nipples, caps, and other parts as clean as possible, either by boiling or washing in the dishwasher Wash the tops of formula cans prior to opening to prevent contamination Prepared formula or opened cans of ready-to-feed or concentrated formula should be kept in the refrigerator and discarded after 48 hours if unused. There is a risk of bacterial growth after this time. Prepared bottles can be warmed by placing in a pan of hot water for several minutes Test temperature on the inner wrist before serving to the infant; formula should feel lukewarm, but never hot Never microwave formula as it can cause mouth burns

Infant formula

Involuntary bed-wetting at night in a child who is beyond the age of expected bladder continence is known as nocturnal enuresis. Certain medications (eg, oral desmopressin) may be useful in treating nocturnal enuresis; however, nonpharmacologic techniques should be attempted first. The child's parents should be educated about the following strategies: Encourage fluids during the day, but restrict to small sips after the evening meal Have the child void before going to bed. Use positive reinforcement and motivation (eg, a calendar showing wet and dry nights) Avoid punishing, scolding, or ridiculing the child. Avoid the use of disposable training pants and diapers at bedtime, as these discourage the motivation to get up to void Have the child assist with wet linen changes but reassure that this is not a punishment Awaken the child at a specified time each night to void Use an enuresis alarm (ie, a moisture-sensitive alarm that is worn on the child's sleep clothes and will awaken the child if the child starts to void).

Involuntary bed-wetting at night in a child who is beyond the age of expected bladder continence is known as nocturnal enuresis:

Clients from Japanese culture may value silence and nonverbal communication over overt forms of communication. It may be considered culturally appropriate to be stoic (ie, showing admirable patience) during labor, and pain may be accepted as a part of the process. Therefore, the client may not desire pharmacologic pain management. In addition to performing frequent pain assessments, the nurse should assess the client's ability to cope with labor by asking about the client's comfort and perceptions of labor, as well as monitoring for nonverbal cues of ineffective coping (Option 3). Clients may report a high pain score, yet be coping effectively and not desire pharmacologic pain relief.

Japanese culture in labor

KCL, an electrolyte replacement to correct hypokalemia, is a high-alert drug that is never administered by the IV push, intramuscular, or subcutaneous routes. The recommended peripheral infusion rate is 5-10 mEq/hr. However, the nurse should always follow institution IV guidelines and policy and procedure for administering KCL. The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the infusion rate is effective in alleviating discomfort.

KCl, client reports feeling burning and discomfort at the IV site

Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Chronic toxicity can result in: Neurologic manifestations - ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks) Nephrogenic diabetes insipidus - polyuria and polydipsia (increased thirst)

Lithium Chronic toxicity

Lithium carbonate is used as a mood stabilizer in clients with schizoaffective disorder (combination of schizophrenia and a mood disorder) and bipolar disorders. Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity can be acute (eg, ingesting a bottle of lithium tablets in a suicide attempt) or chronic (eg, slow accumulation due to decreased renal function or drug-drug interactions). Acute or acute-on-chronic toxicity presents predominantly with gastrointestinal symptoms (eg, nausea, vomiting, diarrhea); neurologic manifestations occur later. However, neurologic manifestations occur early in chronic toxicity. Common neurologic manifestations include ataxia, confusion, or agitation, and neuromuscular excitability (eg, tremor, myoclonic jerks). Chronic toxicity also manifests as diabetes insipidus (eg, polyuria, polydipsia).

Lithium carbonate therapeutic index

Long-term therapy with a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption of calcium and promote osteoporosis. A bone density test can assess if the client already has osteoporosis. Hospitalized clients also have an increased risk of diarrhea caused by Clostridium difficile. PPIs cause suppression of acid that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. The medication should be taken prior to meals.

Long-term therapy with a proton pump inhibitor

Some children have a mild reaction to the MMRV vaccine within 5-12 days after the first dose. Problems include low-grade fever, mild rash, swelling and erythema at the injection site, irritability, and restlessness. Although rare, fever after MMRV vaccination can lead to febrile seizures. Therefore, it is important for the nurse to determine the child's temperature to evaluate the risk for a febrile convulsion. It would also be important for the nurse to instruct the parent to monitor the child's temperature and administer acetaminophen for a fever above 102 F (38.9 C). Children with a history of seizures should be vaccinated with separate MMR and varicella vaccines instead of the combination MMRV vaccine.

MMRV vaccination

Codeine is a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (eg, asthma, COPD). Calcium channel blockers (eg, amlodipine, nifedipine) are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (eg, metoprolol, atenolol). Ipratropium (Atrovent) is a short-acting inhaled anticholinergic often used in combination with a short-acting beta-agonist (eg, albuterol) to promote bronchodilation and reduce bronchospasm. Methylprednisolone (Solu-Medrol) is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD.

Meds to take and to avoid with COPD and hypertension

Metoclopramide is a commonly used antiemetic medication that treats nausea, vomiting, and gastroparesis by increasing gastrointestinal motility and promoting stomach emptying. With extended use and/or high doses, metoclopramide may lead to the development of tardive dyskinesia (TD), a movement disorder that is characterized by uncontrollable motions (eg, sucking/smacking lip motions) and is often irreversible (Option 4). The movement alterations of TD may impact a client's essential activities of daily living (eg, eating, dressing) and overall quality of life. The nurse should question the administration of a medication associated with TD in clients experiencing movement alterations.

Metoclopramide and tardive dyskinesia (TD)

Morphine is an opioid analgesic that can be given intravenously for moderate to severe pain. An adverse reaction to morphine administration is respiratory depression. A respiratory rate <12/min would be a reason to hold morphine administration. The nurse should perform a more in-depth assessment of the client's pain and causes. The morphine dose may need to be decreased or the time between administrations may need to be increased. The nurse should not administer additional doses until the respiratory rate increases. Morphine can cause burning during IV administration. This can be reduced by diluting the morphine with normal saline and administering it slowly over 4-5 minutes. The nurse should instruct the client to call for help before getting up to go to use the bathroom to avoid falls caused by dizziness from the morphine. Morphine can lower blood pressure, and clients receiving it should have blood pressure monitored.

Morphine/opioid analgesic IV administration

Myasthenia gravis is an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction. As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar signs (difficulty speaking or swallowing), and difficulty breathing. Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted. Treatment includes anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before meals so that the client's ability to swallow is strongest during the meal Semi-solid foods (easily-chewed foods) are preferred over solid foods (to avoid stressing muscles involved in chewing and swallowing) or liquids (aspiration risk) All clients with a serious chronic co-morbidity should receive the annual flu vaccine (also the pneumonia vaccine if appropriate) as they are more likely to have a negative outcome if the illness is contracted. It is especially important in clients with myasthenia gravis as the flu (or pneumonia) would tax the already compromised respiratory muscles

Myasthenia gravis acute exacerbation

Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation. All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following: Gastrointestinal (GI) toxicity - symptoms of GI bleeding such as black tarry stools should be reported. Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. Kidney injury - long-term use is associated with kidney injury Hypertension and heart failure - NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension Bleeding risk - clients should notify the HCP if taking concurrently with aspirin, other NSAIDs, or anticoagulant or antiplatelet drugs as they can increase the risk of GI bleeding.

Naproxen and nonsteroidal anti-inflammatory drug (NSAID) are associated with the following:

Nursing responsibilities prior to surgery include assessment, client teaching, and communication with the health care provider. Client allergies and history are confirmed while baseline vital signs are collected. Other nursing preoperative responsibilities include: Confirming that informed consent has taken place and signed documents are placed in the client's chart Encouraging the client to void to reduce the risk of retention in the immediate recovery period Ensuring that the client has been on NPO status to avoid aspiration during surgery and documenting when it started Witnessing and documenting preoperatively that the correct surgical site is marked by the surgeon with a permanent marker. Verify this with the client, ensuring that surgery will take place on the correct side/site

Nursing responsibilities prior to surgery

Bipolar disorder is a psychiatric condition characterized by cycling periods of depression and mania. Clients with acute mania often display elevated mood, increased and excessive activity levels, and altered decision-making that can result in high-risk behavior (eg, hypersexuality, excessive spending). Clients with mania are also easily distractible, leading to neglect of personal needs (eg, hydration, nutrition, sleep, hygiene) and the need for medical intervention. When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars). These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional meal

Nutrition for Bipolar disorder

Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher (fit to be consumed). Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill.

Orthodox Jewish faith dietary laws and capsule form medication

The nurse should assess the postoperative client who had the bowel resection and is currently reporting shortness of breath and chest pain first. Abdominal surgery can cause engorgement of the large vessels in the pelvis leading to venous stasis and increased risk for a pulmonary embolism (PE). Therefore, this client's problem poses the greatest threat to survival and requires immediate attention. (Option 2) This client likely developed postoperative pneumonia. Though pneumonia needs to be assessed and treated as soon possible, it is not as life-threatening as acute PE. Pneumonia is fatal to clients within a period of days (rarely hours), but PE can lead to death in minutes to hours, depending on its severity.

PE and pneumonia post-op

Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) often prescribed for major depression and anxiety disorders. Other SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft). Weight gain is a common side effect of long-term SSRI use. The nurse should teach the client to eat a healthy diet and engage in regular exercise to combat the weight gain. Other major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual dysfunction, and serotonin syndrome when taken in excess doses. SSRIs should not be stopped abruptly without discussion with the HCP. Dosages should be gradually tapered before discontinuation to avoid withdrawal symptoms. Most clients will start to see symptom improvement in 1-2 weeks. However, some may take several weeks and require dose adjustments. Clients should continue to take the medication and discuss it with the HCP.

Paroxetine (Paxil)

Phenytoin is an anticonvulsant prescribed for the treatment of seizures. Clients should never abruptly stop taking the medication due to the possibility of seizure reoccurrence and status epilepticus. An exception is the development of a rash, which may indicate Stevens-Johnson syndrome (SJS). SJS is a rare but potentially life-threatening hypersensitivity reaction. SJS often starts with flu-like symptoms and a painful, purple or red rash to the skin or mucous membranes that may resemble a third-degree burn. Immediate discontinuation of the triggering agent and notification of the health care provider is necessary to prevent rapid progression and multiple organ failure. Gingival hyperplasia (ie, swollen, bleeding gums) is common with cyclosporine and phenytoin. Clients should be instructed on proper dental hygiene.

Phenytoin adverse reactions:

Polycythemia vera (true primary polycythemia) is a chronic myeloproliferative disease characterized by bone marrow overproduction of red blood cells, white blood cells, and platelets. This leads to increased hematocrit (>53% [0.53]) and blood volume, enhanced blood viscosity, and abnormal clotting.

Polycythemia vera

Aspirin is administered as an antiplatelet medication to clients with heart disease. Reduces inflammation and inhibits platelet aggregation. The client's platelet count is within normal range (150,000-400,000/mm3 [150-400 × 109/L]) and the hemoglobin and hematocrit are normal, so it is safe to administer this medication. Docusate sodium is a stool softener. The client who has had a (MI) should not strain during bowel movements due to the risk of producing a vagal response, putting the client at risk for bradycardia and other dysrhythmias. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor commonly given to clients post MI to prevent ventricular remodeling (hypertrophy) and the progression of heart failure. Because ACE inhibitors have the potential to cause hyperkalemia, the nurse should assess the potassium level when available. This client's potassium level is within normal range (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). The nurse should check the client's blood pressure (BP) prior to administration as ACE inhibitors can lower BP. This client's BP is within the normal range. Metoprolol is a beta blocker given to clients post MI to reduce the risk of reinfarction and the occurrence of heart failure. A side effect of this medication is bradycardia (<60/min). This client is experiencing bradycardia with a heart rate of 52/min. The nurse should hold this medication and notify the health care provider.

Post MI Medications

Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). Symptoms of PTSD include re-experiencing the traumatic event via flashbacks, nightmares, and feelings of distress in reaction to reminders; avoiding reminders of the trauma (eg, places, activities, thoughts, other triggers); and increased anxiety and emotional arousal (eg, insomnia, hypervigilance, outbursts of rage, irritability). Clients with an anxiety level of 8/10 and pacing behavior are demonstrating distress and require immediate attention as they might harm themselves or others.

Post-traumatic stress disorder (PTSD) with increased anxiety and demonstrating distress

Postpartum hemorrhage (PPH) may be primary (ie, <24 hours since birth) or secondary/delayed (ie, >24 hours but <6 weeks postpartum). Secondary PPH usually results from uterine subinvolution, retained placental fragments/membranes, or uterine infection. The nurse should expect a client >3-4 days postpartum to report a progressive change in lochia from lochia rubra (dark-red vaginal bleeding) to lochia serosa (pink or brown discharge). A gradual decrease in the amount of lochia is reassuring and expected. However, reports of increased vaginal bleeding, soaking a pad in <1-2 hours, reverting from lochia serosa back to lochia rubra, or passing several/large clots (ie, larger than a nickel) are concerning findings that require the nurse's immediate follow-up

Postpartum hemorrhage (PPH)

Postpartum fatigue is common due to the adjustments needed to provide newborn care or may be related to postpartum anemia. Follow-up is necessary, but it is not the most concerning statement. Bright red bleeding with defecation is associated with hemorrhoids, a common finding in pregnancy. Hemorrhoids usually begin to shrink following birth. Physiologic fluid retention in pregnancy may cause medial nerve compression (ie, carpal tunnel syndrome), an expected discomfort of pregnancy marked by a tingling or burning sensation of the hands.

Postpartum s/s

Antiplatelet medication (eg, prasugrel [Effient], clopidogrel [Plavix], ticagrelor [Brilinta]) are often prescribed to a client after a percutaneous coronary intervention such as angioplasty or stent placement. These agents should be stopped at least 5-7 days prior to the surgery to reduce the chance of intraoperative and postoperative bleeding. The nurse should immediately report to the HCP that the client is still taking prasugrel and took it the morning of the surgery. Unless the surgery is emergent, it will most likely be postponed at least a week.

Pre-op/CABG contraindications:

Professional boundaries set limits to maintain a therapeutic professional relationship between the nurse and client. Line between professional and personal interactions is sometimes blurred in extended relationships or when care is given in the client's home. The nurse should always put the client's needs first and never seek personal gain (eg, accepting gift worth >$20, asking for financial investment/loan) (Options 1 & 5). The nurse should follow a facility's policy on professional standards of behavior (eg, flirting with client, consuming alcoholic beverages with client) An occasional visit to a previous client in a different circumstance (hospital, nursing home) is considered appropriate and caring. It is appropriate for the nurse to offer assistance in meeting a client's spiritual needs if the client desires it. The nurse should not force their own beliefs, religion, or practices on the client. Sending a sympathy card to acknowledge a family's loss is a holistic and therapeutic measure.

Professional boundaries

Psychomotor retardation is a clinical symptom of major depressive disorder. Manifestations of psychomotor retardation include slowed speech, decreased movement, and impaired cognitive function. The individual may not have the energy or ability to perform activities of daily living or to interact with others. Psychomotor retardation may range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and behavior). Specific clinical findings of psychomotor retardation include the following: Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait Lack of facial expression Downcast gaze Speech impairment - reduced voice volume, slurring of speech, delayed verbal responses, short responses Social interaction - reduced or non-interaction Clients with major depressive disorder may also show symptoms of psychomotor agitation, characterized by increased body movement, pacing, hand wringing, muscle tension, and erratic eye movement.

Psychomotor retardation in major depressive disorder

Refractory hypoxemia is the hallmark of acute respiratory distress syndrome (ARDS), a progressive form of acute respiratory failure that has a high mortality rate. It can develop following a pulmonary insult (eg, aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (eg, sepsis, multiple blood transfusions, trauma) to the lung. The insult triggers a massive inflammatory response that causes the lung tissue to release inflammatory mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane. As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar space, resulting in a noncardiogenic pulmonary edema. The lungs become stiff and noncompliant, which makes ventilation and oxygenation less than optimal and results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia. Profound hypoxemia despite high concentrations of oxygen is a key sign of ARDS and is the most important assessment finding to report to the HCP.

Refractory hypoxemia acute respiratory distress syndrome (ARDS) and high concentrations of oxygen

Repair of abdominal aortic aneurysms can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm and placement of a synthetic graft. With either procedure, postoperative monitoring for graft leakage or separation is a priority. Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum, or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back, or groin; and decreased urinary output (Options 1, 2, and 4). Urinary output would be decreased due to inadequate perfusion to the kidney if a newly placed graft were leaking, causing hypotension.

Repair of abdominal aortic aneurysms graft leakage

Rifapentine (Priftin), a derivative of rifampin, is an antitubercular agent used with other drugs (eg, isoniazid) as a combination therapy in active and latent tuberculosis infections. Both rifampin and rifapentine reduce the efficacy of oral contraceptives by increasing their metabolism; therefore, this client will need an alternate birth control plan (non-hormonal) to prevent pregnancy during treatment Rifapentine should be taken with meals for best absorption and to prevent stomach upset. Hepatotoxicity may occur; therefore, liver function tests are required at least every month. Signs and symptoms of hepatitis include jaundice of the eyes and skin, fatigue, weakness, nausea, and anorexia. Rifapentine may cause red-orange-colored body secretions, which is an expected finding. Dentures and contact lenses may be permanently stained.

Rifapentine (Priftin) teaching:

Rotavirus: leading cause of diarrhea in children less than 5 years old & cause of many nosocomial infections. Spread via the fecal-oral route. Transmission can occur through contact with food, toys, diapers, and hands. Meticulous handwashing and proper diaper disposal prevent the spread of the virus Symptoms: foul-smelling, watery diarrhea that lasts 5-7 days and accompanied by fever and vomiting. Vaccination available- given before the child is 8 months old. Antibiotics are not effective against this viral agent. Can easily lead to dehydration, parents should be taught the symptoms (eg, lack of tears when crying, extremely fussy or sleepy, decreased urination, dry mucous membranes). Oral rehydration solutions should be used to combat dehydration Breastfeeding and normal diet should be maintained Parents should change the child's diapers more frequently and wash the perianal area with mild soap and water. Commercial baby wipes containing alcohol should not be used as they are irritating. Protective zinc oxide can be applied instead.

Rotavirus:

Selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram) cannot be combined with monoamine oxidase inhibitors (MAOIs) (eg, phenelzine) as there is a risk of serotonin syndrome. MAOI effects persist long after dosing stops. An MAOI should be withdrawn at least 14 days before starting an SSRI.

SSRIs and MAOIs combined

Sexual assault is a medical emergency requiring a thorough head-to-toe physical examination by a specially trained health care provider (eg, sexual assault nurse examiner) to identify and treat injuries. A student reporting potential sexual assault (eg, waking in a strange room, signs of physical assault) should be instructed to seek immediate medical attention and not to bathe, brush teeth, urinate, douche, or change clothes. These activities can delay a medical-forensic examination and interfere with evidence retrieval and preservation. Many college and university health centers have providers for this specialized physical and emotional care, but if they do not, the student should be referred to a local hospital emergency department.

Sexual assault

Shaken baby syndrome (SBS) is a type of abusive head injury and is defined by the Centers for Disease Control and Prevention (CDC) as severe physical child abuse resulting from violent shaking of an infant by the arms, legs, or shoulders. The impact of the shaking causes bleeding within the brain or the eyes. It is not uncommon for the diagnosis of SBS to be missed as the clinical findings are often vague and nonspecific—vomiting, irritability, lethargy, inability to suck or eat, seizures, and inconsolable crying. Usually, there are no external signs of trauma except for occasional small bruises on the chest or upper arms where the child was held during the shaking episode. The most common reasons that caregivers seek medical attention for children with SBS are breathing difficulty, apnea, seizures, and lifelessness. Caregivers typically do not offer a history of trauma nor do they report the episodes of shaking. By contrast, children who have sustained unintentional head injury are typically brought for treatment out of concern by their caregivers even when the children are asymptomatic.

Shaken baby syndrome (SBS)

Shoulder dystocia is an obstetrical emergency in which the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse may initially observe the fetal head retracting back toward the maternal perineum after birth of the head (ie, turtle sign). The condition is frequently associated with macrosomia (fetal weight >8 lb 13 oz [4000 g]) secondary to gestational diabetes mellitus. However, the occurrence of shoulder dystocia is unpredictable and may be related to maternal factors, such as suboptimal pelvic shape, obesity, or short stature, rather than fetal size. The nurse's primary responsibilities during shoulder dystocia include performing the McRoberts maneuver (ie, sharp flexion of maternal thighs toward abdomen to widen space between pubic bone and sacrum) and applying suprapubic pressure (ie, downward pressure applied to maternal pubic bone to dislodge fetal shoulder)

Shoulder dystocia interventions

Synchronized cardioversion is a procedure used to convert tachyarrhythmias (eg, supraventricular tachycardia, ventricular tachycardia) with a pulse to stable cardiac rhythms via transcutaneous electrical shock. The shock in cardioversion is timed by the defibrillator ("sync" feature enabled) to be delivered only during the R wave of the QRS complex, when the ventricles depolarize. Accidentally delivering shocks during the T wave, when heart ventricles are repolarizing, causes R-on-T phenomenon, which frequently results in lethal arrhythmias (eg, ventricular fibrillation). The nurse must ensure that the defibrillator's "sync" feature is enabled when preparing to perform synchronized cardioversion. Disabling or failing to enable the "sync" feature may result in a potentially lethal, asynchronous shock being delivered to the client During nonemergent cardioversion of a hemodynamically stable client, a sedative (eg, midazolam) is often administered for client comfort. Defibrillator pads should be placed on the right upper chest next to the sternum and on the left lower chest. Prior to delivery of electrical shock (eg, cardioversion, defibrillation), oxygen should be turned off and moved away. Oxygen is flammable and may explode when subjected to electric currents.

Synchronized cardioversion

The RN can safely delegate the following tasks to the UAP to promote client safety during toileting and ambulating: Place the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing aids, cell phones) as close to the client as possible Remind the client of the importance of changing position slowly to minimize orthostatic hypotension Report observations of changes in the client's condition (eg, level of consciousness, vital signs, pain level) immediately Keep the bed in the lowest position (locked) as it reduces the distance to the floor in the event of a fall Provide nonskid footwear for the client before ambulating Keep the environment dry and free of clutter and obstacles (eg, intravenous infusion device tubing and poles, electronic device wires and cords) The risk of falling is highest on the night of admission. Clients wake in the middle of the night, attempt to get up unassisted in unfamiliar surroundings, and fall. Client orientation and teaching are the responsibilities of the RN and are not appropriate to delegate to the UAP. Alterations in gait, balance, and range of motion places the client at a higher risk for falling. Evaluating the client for gait and balance deficits requires assessment and is a function of the registered nurse. The UAP may assist the client in ambulating with assistive devices, but evaluating and educating are not delegated.

The RN can safely delegate the following tasks to the UAP to promote client safety during toileting and ambulating:

The sterility of an opened bottle of sterile saline cannot be guaranteed. Some institutions' policies permit recapped bottles of solution to be reused within 24 hours of opening, and some require disposal of the remaining solution. Therefore, the nurse should intervene when the student uses sterile saline from a bottle that was opened >24 hours ago. The general steps for preparing the sterile field for a wet-to-damp dressing change include: Perform hand hygiene. Open a sterile gauze package that has a partially sealed edge with ungloved hands by grasping both sides of the edge, one with each hand, and pull them apart while being careful not to contaminate the gauze (Option 2). Hold the inverted opened gauze package 6" (15 cm) above the waterproof sterile field so it does not touch the field, and then drop the gauze dressing onto the sterile field (Option 1). Place the sterile dressings on the sterile field 2" (5 cm) from the edge; the 1" (2.5 cm) margin at each edge is considered unsterile because it is in contact with unsterile surfaces (Option 3). Use sterile NSS from a recapped bottle that was opened <24 hours ago

The general steps for preparing the sterile field for a wet-to-damp dressing change include:

The proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When educating a client on how to self-administer nasal sprays, the nurse teaches the client to: Assume a high Fowler's position with head slightly tilted forward Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger Point the nasal spray tip toward the side and away from the center of the nose Spray the medication into the nose while inhaling deeply Remove the nozzle from the nose and breathe through the mouth Repeat the above steps for the other nostril Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation

The proper positioning and administration of nasal sprays

Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) are often prescribed to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive pulmonary embolism). They are recombinant plasminogen activators that activate the blood fibrinolytic system and dissolve thrombi. Thrombolytic agents are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood pressure >180/110 mm Hg). Therefore, the health care provider should be consulted for clarification. Administering alteplase in the presence of these conditions can cause hemorrhage, including life-threatening intracerebral hemorrhage

Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) contraindications:

Troponin is a cardiac specific serum marker that is a highly specific indicator of MI and has greater sensitivity and specificity for myocardial injury than creatine kinase (CK) or CK-MB. Serum levels of troponin T and I increase 4-6 hours after the onset of MI, peak at 10-24 hours, and return to baseline in 10-14 days. However, MI is not diagnosed alone by serum cardiac markers. Electrocardiogram findings and client health history along with a history of pain and risk factors are also used to make the diagnosis of MI.

Troponin

Postmortem care involves the following series of steps: Wash and straighten the body, change the linens, and place a pad under the perineum to absorb stool and urine from relaxed sphincters. Place a pillow under the head to prevent blood from pooling and discoloring the face. Place dentures in the client's mouth before rigor mortis sets in and close the mouth. Gently close the eyes. Remove tubes, lines, and dressings per institutional policy unless an autopsy or organ donation is to be performed. After the family leaves, take the client to the morgue or notify the funeral home to arrange transportation

UAP and postmortem care

Umbilical cord prolapse may occur after rupture of membranes if the presenting fetal part is not firmly applied to the cervix. Cord compression caused by a prolapsed cord will produce abrupt fetal heart rate deceleration, fetal bradycardia, and disruption of fetal oxygen supply. The priority action is to inspect the vaginal area and perform a sterile vaginal examination to assess for a prolapsed cord. If a prolapsed cord is visualized or palpated, the nurse should then manually elevate the presenting fetal part off the umbilical cord, leave the hand in place, and call for help.

Umbilical cord prolapse

Umbilical cord prolapse occurs when the umbilical cord slips below the presenting fetal part and may cause cord compression and impaired fetal oxygenation. A loop of cord may be palpated during a vaginal examination or visualized protruding from the vagina. An emergency cesarean section is usually required unless vaginal birth is imminent and considered safe by the health care provider (HCP). Positioning the client on hands and knees (eg, knee-chest position) or Trendelenburg position is used to relieve pressure on the compressed cord (Option 4). The nurse may also use a sterile, gloved hand to help lift the presenting part off the cord; the hand should remain in the vagina until the HCP arrives. Other actions include administration of oxygen and IV fluids. Leopold maneuvers are used as a systematic approach to palpating the pregnant abdomen to identify fetal presentation. These are not used as emergency interventions for umbilical cord prolapse.

Umbilical cord prolapse

Vancomycin is a very potent antibiotic that can cause nephrotoxicity and ototoxicity. Measuring for serum concentrations is a way to monitor for risk of nephrotoxicity as well as for therapeutic response. Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A trough should be obtained just prior (about 15-30 minutes) to administration of the next dose. Unlike some chemotherapy medications, vancomycin does not commonly cause nausea or vomiting. Premedication with antiemetics is not required. However, premedication with antihistamines (diphenhydramine) is recommended if the client had developed red man syndrome, also known as red neck syndrome, with prior vancomycin infusion. This syndrome is characterized by red blotching of the face, neck, and chest due to too rapid administration. Vancomycin should be administered over a minimum of 60 minutes. Too rapid administration can cause red man syndrome, considered a toxic effect rather than an allergic reaction.

Vancomycin administration

The National Council of State Boards of Nursing advises any individual who has knowledge of a potential violation of a nursing law or rule to file a complaint with the appropriate state board of nursing. A nurse should be knowledgeable concerning the presiding board's stance on mandatory reporting and which actions are considered reportable. In general, reportable actions may include any behavior by a licensed nurse that is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical condition), or in violation of nursing law. Practicing outside of the scope of the license is reportable even if the practice meets quality standards (Option 1). Documenting an intervention that was not performed is considered falsification of records regarding client care and is a reportable action (Option 3). Stealing narcotics is a criminal offense (a violation punishable by the state that can result in prison or a fine) and is reportable in all states. Many states offer an alternate rehabilitation program to nurses who diverted or abused drugs (Option 4). Abandonment (eg, leaving without proper replacement of personnel and transfer of responsibility for client care) is reportable in all states

What to report to the State Boards of Nursing :

The greatest immediate threat to a client with severe and extensive burn injuries is hypovolemic shock and electrolyte imbalance. This is due to cellular damage and increased capillary permeability caused by direct thermal trauma, which result in fluid loss. In the emergent phase of burn management, it is critical to establish an airway and replenish lost intravascular fluid, proteins, and electrolytes. Lactated Ringer's (LR), also known as Ringer's lactate, is the solution of choice for fluid resuscitation of a burned client due to its similarity in chemical composition to human plasma (Option 4). LR remains in the intravascular space longer than other solutions, which helps to stabilize blood pressure and avert shock.

Which solution is the best choice for fluid resuscitation in client after sustaining third-degree burns over 50% of the body

Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2.0 times the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin).

aPTT Heparin Protamine

When an acute asthma exacerbation occurs, the child has rapid, labored respirations using accessory muscles. The child often appears tired due to the ongoing effort. In the case of severe obstruction (from airway narrowing as a result of bronchial constriction, airway swelling, and copious mucus), wheezing/breath sounds are not heard due to lack of airflow. This "silent chest" is an ominous sign and an emergency priority. In this situation, the onset of wheezing will be an improvement as it shows that air is now moving in the lungs.

acute asthma exacerbation and "silent chest"

IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the dose above, use the following formula: (160 mg) / (4 mg/min) = 40 min Hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic. However, slower infusion is unlikely to prevent this adverse effect. Although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of administration.

adverse effect of furosemide.

When oxygen is delivered via a nasal cannula, the concentration of inspired oxygen will vary with changes in ventilation and respiratory pattern. In a deep sleep, with smaller tidal volumes and decreased respiratory rate, the concentration of inspired oxygen increases. In some clients with COPD, too high a level of inspired oxygen can depress the respiratory drive to breathe, causing alveolar hypoventilation. Because the saturation has remained constant at 91% while the client sleeps soundly, the nurse should remove the nasal oxygen, recheck the saturation, and re-evaluate. Removing the supplemental oxygen may actually increase the reading.

alveolar hypoventilation in COPD patients

An atrioventricular pacemaker (also known as a sequential or dual chamber pacemaker) paces the right atrium and right ventricle in sequence. The ECG will have 2 pacer spikes, one before the P wave and one before the QRS complex. The P wave following the atrial pacer spike may be normal or abnormal appearing. The QRS complex following the ventricular pacer spike is typically wide and distorted. An atrioventricular pacemaker can improve synchrony between the atria and ventricles. It may be implanted in the client with bradycardia, heart block, or cardiomyopathy.

atrioventricular pacemaker

An aura is a sensory perception that occurs prior to a complex or generalized seizure. The client will most likely have a tonic-clonic seizure soon, and the nurse should attend to this client first to ensure safety measures (ie, seizure precautions) are in place.

aura

Meconium ileus is classic for cystic fibrosis, a genetic disorder. Floppy muscle tone is typical for Down's syndrome, a genetic disorder. Microcephaly is an effect of fetal alcohol syndrome or cytomegalovirus infection. Craniofacial defects, including cleft lip and palate (eg, congenital anomalies), can be caused by maternal anticonvulsant use (eg, valproic acid)

birth defects

Atropine is an anticholinergic agent used to increase heart rate in clients with symptomatic bradycardic (<60/min) rhythms. Defibrillation is used only in clients with ventricular fibrillation and pulseless ventricular tachycardia. Cardioversion would be considered if drug therapy is ineffective for PSVT. External pacing is indicated in symptomatic bradycardic (<60/min) rhythms.

cardiac treatments/interventions

In developing a care plan for a client experiencing acute mania, the nurse is aware that an acute manic episode is characterized by the following: Excessive psychomotor activity Euphoric mood Poor impulse control Flight of ideas, non-stop talking Poor attention span, distractibility Hallucinations and delusions Insomnia Wearing bizarre or inappropriate clothing, jewelry, and makeup Neglected hygiene and inadequate nutritional intake The care plan for a client experiencing an acute manic episode includes the following: -Reduction of environmental stimuli -Providing a quiet, calm environment -Limiting the number of people who come in contact with the client -One-on-one interactions rather than group activities -Low lighting -A structured schedule of activities to help the client stay focused -Physical activities to help relieve excess energy -Providing high-protein, high-calorie meals and snacks that are easy to eat -Setting limits on behavior Not ready to participate in group activities.

care plan for a client experiencing an acute manic episode

Parents of children with casts are taught to check for emergency signs of circulatory impairment, including changes in sensation and motor function, which could indicate early signs of compartment syndrome due to swelling within the confined space of the cast. However, some swelling is expected, so this symptom alone is not indicative of compartment syndrome. The 6 Ps of compartment syndrome include: Pain: Increasing despite elevation, analgesics, and ice. Pain will also increase with passive stretching/movement. Increasing pain is an early sign and indicates muscle ischemia Pressure: Affected extremity or digits are firm and tense; skin is tight and appears shiny. Paresthesia: Tingling, numbness, or burning sensation, which is also an early sign and indicates nerve ischemia Pallor: Skin appears pale; capillary refill is >3 seconds. These indicate poor perfusion. Pulselessness: Pulse distal to injury or compartment is impalpable. Absent pulses are a late sign. Paralysis: Loss of function or inability to move extremity or digits. Muscle weakness occurs before paralysis which is also a late sign and indicates dead muscle tissue. An itching sensation under the cast is expected, clients and parents are taught to avoid inserting anything into the cast to scratch the skin. Instead, they should use a hair dryer on the cold setting. Arm elevation is indicated for the first 48 hours after cast placement to reduce edema. However, if compartment syndrome develops, the arm should be kept at torso level (not high or low).

cast discharge instructions

The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous headaches (including migraines). Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival.

cerebral aneurysm rupture

When the nurse suspects that a child may be the victim of child abuse, the parent or caregiver should be questioned, and all possibilities (eg, alternate caregivers) should be explored to find the source of the abuse. If possible, the interview should be done without the child present. The nurse should remain supportive and empathetic and convey a nonjudgmental, nonthreatening attitude, avoiding words such as "abuse" and "violence." Open-ended questions are less threatening and provide more detailed responses. Information to gather includes: Caregiver's perspective on the child's behavior Methods of discipline used with the child Routine caregivers for the child Caregiver stress, coping, and support systems Person or persons who care for the child when regular caregivers are away

child abuse

A 9-year-old's understanding of death is the same as that of an adult. The parents try to "protect" the child, but the child senses the truth at some level and wants to discuss it. A child may be aware of impending death even before being told. Not being told may make the child feel isolated. Children sometimes feel a need to "protect" parents because they fear that their understanding will burden them. The nurse can offer self or other appropriate people to talk to the child if the parents cannot do it themselves. However, the nurse should first discuss the child's concerns with the parents and not talk with the minor child on the nurse's own initiative. Discussing the child's questions about death would support the parents' autonomy and advocate for the child's needs.

child with terminal illness

Too rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation.

cleansing enema

This client has a very low absolute neutrophil count (normal: 2200-7700 cells/mm3 [2.2-7.7 ×109/L]); having <500 cells/mm3 (0.5 ×109/L) indicates severe neutropenia and increases the risk of infection. All risks for infection should be minimized in a client with neutropenia. Soil contains many pathogens, including Aspergillus fungus, which could expose this client to infection. Gardening and contact with fresh flowers and plants should be avoided when a client is at increased risk for infection. In addition, the client's room should not have standing water. Strict hand-washing is recommended. The client should be placed in a private room while in the hospital and all visitors should wear a mask. The client with neutropenia is allowed to consume cooked vegetables. However, raw or unwashed vegetables should be avoided due to possible contamination with pathogens as this can increase the risk of infection. A healthy diet containing vegetables is encouraged to increase consumption of necessary nutrients. Protein is a necessary component in the diet of a client receiving chemotherapy. Protein aids in the healing process of the body. As long as the meat or seafood is fully cooked, it is safe for the client with neutropenia to consume. Raw or undercooked meat/seafood is to be avoided due to possible exposure to pathogens. Clients with neutropenia are encouraged to bathe daily to remove pathogens that could cause infection. Moisturizer should be applied to prevent dry skin. If the skin becomes dry or cracked, pathogens could use these openings as portals of entry; this can lead to infection in the host.

client receiving chemotherapy with neutropenia

The clinical indications of a cold injury include redness and swelling of the skin (chilblains or pernio) and blanched skin with hardness of the affected area (frostbite). For any cold injury, it is important to re-warm the area as soon as possible to restore blood flow and reduce the risk of permanent tissue damage. The recommendation for re-warming is immersion of the affected area in warm water (104 F [40 C]) for about 30 minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of warm facecloths (Option 4). Once re-warming has been effective, the child should be seen by an HCP as soon as possible *Massaging a body part that has sustained a cold injury is contraindicated due to the risk of tissue injury.

cold injury

Orthostatic hypotension is a common side effect of antihypertensives, antipsychotics, antidepressants, diuretics, narcotics, and vasodilator medications. Sildenafil (Viagra) and tadalafil (Cialis), commonly used to treat erectile dysfunction, can cause vasodilation and orthostatic hypotension. Clients should move slowly and carefully when changing to a standing position to decrease the risk for falls. Photosensitivity reactions are common with tetracycline antibiotics and sulfa drugs. Clients should wear protective clothing and sunscreen when outdoors. This client requires treatment for sunburn, but the condition is not life-threatening.

common side effects/reactions with medications

Increased consumption of fiber is the best recommendation for a client with heart failure who has constipation. Diuretics may lead to dehydration; however, fluid intake is usually limited for clients with heart failure. This client's history of heart failure is a contraindication to increased fluid intake due to potential fluid overload and increased workload on the heart. The nurse should consult the health care provider before recommending a specific amount of fluid intake. Exercise is important, but clients with heart failure may not exercise for long periods due to fatigue.

constipation in heart failure patients

Using a syringe to measure the medication is the most accurate technique to ensure that the proper amount of medication is being administered. The correct procedure for administering oral medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk for choking and ensures that all the medication is consumed.

correct procedure for administering oral medication to an infant

Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axilla. This leads to a reversible condition known as crutch paralysis, or palsy, which manifests as muscle weakness and/or sensory symptoms (tingling, numbness) of the arm, wrist, and hand. It is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Therefore, clients are taught to support body weight on the hands and arms, not the axillae, when ambulating to ensure that there is a 1-2 in (2.5-5 cm) space between the axilla and the axilla crutch pad. Crutches should be checked for proper length.

crutch paralysis, or palsy

It is normal for parents to feel devastated when their child is diagnosed with a chronic illness (eg, diabetes). Reactions include shock, denial, helplessness, anger, fear, and anxiety. They may have feelings of guilt that they contributed to or failed to prevent the development of the disease. The parents' emotional response, adaptation, and coping strategies will greatly impact the child's perception of self and the ability to self-manage the disease. In providing diabetes education, the nurse needs to emphasize and reinforce that with planning and preparation, diabetes can be managed and controlled, regular day-to-day activities can be resumed, and the child can have a normal life. When clients feel in control rather than victimized and dependent, it increases the likelihood that they will be actively engaged in diabetes self-management activities.

diagnosed with a chronic illness emotional response, adaptation, and coping strategies

A critical part of self-care for a person with a history of anaphylactic reaction is the use of emergency epinephrine injection (EpiPen or EpiPen Jr). The client and/or caregiver should be taught the following principles: The EpiPen should always be available for emergency use and so should be taken along (in purse, pocket, backpack) when the client leaves home The EpiPen should be given when the client first notices any anaphylactic symptoms, such as tightening or swelling of the airway, difficulty breathing, wheezing, stridor, or shock The injection should be given in the mid-outer thigh and can be given through clothing The client should receive emergency care as soon as possible by calling 911 or going to the emergency department to monitor for further problems

emergency epinephrine injection (EpiPen or EpiPen Jr)

Normal eosinophil count is 1%-2%. Elevated eosinophils are seen in allergy. In a client with an asthma exacerbation, a high eosinophil count would indicate an allergic trigger for the asthmatic response. The nurse should explore the client's allergy history and ways to reduce the allergic exposure that may be contributing to the exacerbation.

eosinophil count

This client likely has febrile seizures. It is important to never leave seizing clients alone as the goal is to prevent them from causing self-injury. The nurse should call out for help if needed. The main objective is to ensure that seizing clients maintain their airway; therefore, it is important to monitor their oxygen saturation levels. If these levels begin to drop or cyanosis occurs, prompt intervention is needed, which may be as simple as a head tilt or jaw thrust.

febrile seizures

A hypertensive crisis is an elevation in blood pressure (BP) >180 mm Hg systolic and/or >120 mm Hg diastolic with evidence of organ damage (eg, kidney damage, retinopathy). The goal of treatment is to slowly lower BP using IV antihypertensive medications (eg, vasodilators) to limit end-organ damage. Once the client's condition is stabilized, oral antihypertensives are prescribed and IV medications are titrated off. Float nurse assignments should be made on the basis of what is within the knowledge and skill of the generalist nurse. The float nurse can safely care for the client whose BP is controlled by oral medication, and has the knowledge and skill to assess vital signs

float nurse to cardiac unit

With a heparin drip infusion, the goal is to reach the therapeutic range of the drug's effect and not the "normal" or "control value." Once the therapeutic effect range has been reached (usually 1.5-2.0 times the control value), it usually remains within this range without titrating the heparin infusion rate. Heparin has a short duration (approximately 2-6 hours IV). Therefore, if it is not being infused, the aPTT level will go back to the control value (aPTT level without administration of anticoagulants). In addition, the volume of heparin being infused is small (because the standard concentration is 100 units/mL) so it is possible to miss an infiltration.

heparin drip infusion therapeutic range and "normal" or "control value"

Postoperative clients are at risk for atelectasis and possibly for pneumonia following surgery as a result of retained secretions. Effective coughing is essential to prevent these complications. The nurse can promote many client actions that will facilitate effective coughing. These include splinting the incision while coughing, changing position every 1-2 hours, ambulating early, using an incentive spirometer, and hydrating adequately to thin the secretions. However, all of these interventions are less effective if the client is in pain. The nurse should instruct the client to request pain medication before the pain becomes intense. Pain relief should be addressed prior to implementing coughing exercises and ambulation

ineffective airway clearance related to pain ND

The American Heart Association's guidelines for infant cardiopulmonary resuscitation (CPR) are used on children age <1 year. To check a pulse on an infant, the nurse should palpate the brachial artery by placing 2 or 3 fingers halfway between the shoulder and elbow on the medial aspect of the arm. The pulse should be assessed for 5-10 seconds to determine its presence and quality before CPR is initiated. The brachial pulse is preferred in infants as the brachial artery is close to the surface and is easily palpable. The carotid pulse can be difficult to assess due to a child's shorter neck. Extending an infant's neck to attempt to palpate the carotid pulse can cause injury. This pulse is recommended for clients age >1 year. The femoral pulse may be used for all clients; however, it is often not easily accessible for palpation due to diapers and clothing. The radial pulse is used in responsive clients age >1 year. It is not a recommended method of pulse detection in an unresponsive client as a weak or thready pulse is difficult to palpate at this location.

infant cardiopulmonary resuscitation (CPR), To check a pulse on an infant

Infants <30 days old have immature immune systems and a blunted response to infection. The 7-day-old infant is at high risk for bacteremia. Infectious manifestations are often subtle at this age (eg, fever can be the only symptom), although some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0 C) is a "red flag" in a neonate.

infection in Infants <30 days old

An inguinal hernia is a protrusion of intraperitoneal contents (eg, bowel, tissue) through a weakened area in the abdominal wall (eg, groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical.

inguinal hernia and mechanical bowel obstruction

Inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-36 months could indicate intussusception or some other abdominal pathology (eg, appendicitis). Additional findings in intussusception include stools that have mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt blood supply, and cause intestinal tears (perforation). It is an emergency, and the client should be brought to the emergency department for further evaluation.

intussusception

The isosorbide has actions identical to nitroglycerin and can cause hypotension from vasodilation. It should be held when the systolic blood pressure is <90 mm Hg. Perfusion to the kidneys is inadequate if the systolic blood pressure is <80 mm Hg.

isosorbide

Acute gastroenteritis is associated with nausea, vomiting, diarrhea, and dehydration. An isotonic crystalloid intravenous (IV) solution (eg, 0.9% normal saline, lactated Ringer's) has the same tonicity as plasma and when infused remains in the vascular compartment, quickly increasing circulating volume. It is appropriate to correct the extracellular fluid volume deficit (dehydration) in this client.

isotonic crystalloid intravenous (IV) solution eg, 0.9% normal saline, lactated Ringer's)

The complete blood count (hemoglobin, hematocrit, platelet count) should be assessed periodically with the administration of enoxaparin, an anticoagulant that can cause bleeding and thrombocytopenia (Option 4). Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL) (Option 1). Potassium levels should also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity (Option 5). Prednisone is a glucocorticoid that can cause hyperglycemia. Glucose levels should be monitored periodically in clients receiving this medication

labs monitored with certain meds

Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Clients with classic hemophilia, or hemophilia A, lack factor VIII. Clients with hemophilia B (Christmas disease) lack factor IX. When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding. The most frequent sites of bleeding are the joints (80%), especially the knee. Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is active and ambulatory. Over time, chronic swelling and deformity can occur: joint destruction

long-term complications of Hemophilia

All macrolide antibiotics (eg, azithromycin, erythromycin, clarithromycin) can cause a prolonged QT interval, which may lead to sudden cardiac death due to torsades de pointes. Therefore, an electrocardiogram (ECG) should be monitored. Concurrent use of macrolide antibiotics with other drugs that prolong QT interval (eg, amiodarone, sotalol, haloperidol, ziprasidone, azole antifungals) will further increase this risk. Macrolides can also cause hepatotoxicity when taken in high doses or in combination with other hepatotoxic medications such as acetaminophen, phenothiazines, and sulfonamides. Elevation of aspartate transaminase and alanine transaminase levels (liver enzymes) may indicate that hepatotoxicity is occurring, and the nurse should report these results to the HCP.

macrolide antibiotics

MIDCAB does not involve a sternotomy incision or placement on cardiopulmonary bypass. Several small incisions are made between the ribs. A thoracotomy scope or robot is used to dissect the internal mammary artery (IMA) that is used as a bypass graft. Radial artery or saphenous veins may be used if the IMA is not available. Recovery time is typically shorter with these procedures and clients are able to resume activities sooner than with traditional open chest coronary artery bypass graft surgery. However, clients may report higher levels of pain with MIDCAB due to the thoracotomy incisions made between the ribs.

minimally invasive direct coronary artery bypass (MIDCAB) grafting:

The needle length and injection site for IM injections are dependent on a client's age and muscle mass. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred IM injection site for newborns (age <1 month) and infants (age 1-12 months). Selection of the most appropriate needle length is an important factor in ensuring immunization success and minimizing local reactions to vaccine components. If the needle is too short, the IM vaccine is injected into subcutaneous fat, resulting in vaccine failure due to poor mobilization of the antigen within adipose tissue. Infants typically require a 1-in (25-mm) needle for IM injections A 3⁄8-in (9-mm) needle is too short to penetrate the deep vastus lateralis muscle of the thigh. The ventrogluteal area in an infant does not have enough muscle mass for use and is not recommended until at least age 3. A 5⁄8-in (16-mm) needle is too short and does not penetrate the deep muscle. A 1½-in (38 mm) length is too long and is normally used on older children and adults with sufficient muscle mass.

needle length and injection site for IM injections in infants

A pregnant client's repeated use of illicit drugs will cause dependence in the neonate. The abrupt withdrawal from the drug due to delivery can cause abstinence syndrome in the neonate. This is most commonly seen with opioid use, although other central nervous system depressant drug use (eg, benzodiazepines) can contribute. Manifestations include: Autonomic nervous system symptoms - stuffy nose, sweating, frequent yawning and sneezing, tachycardia, and tachypnea. Treatment includes swaddling and keeping nasal passages clear Central nervous system symptoms - irritability, restlessness, high-pitched crying, abnormal sleep pattern, and hypertonicity/hyperactive primitive reflexes. Treatment includes medication and protecting the skin Gastrointestinal symptoms - poor feeding, vomiting, and diarrhea. These are treated with small, frequent feedings

neonatal abstinence syndrome (NAS)

The client's laboratory results show severe neutropenia, with a reduced white blood cell count (normal 4,000-11,000/mm3 [4.0-11.0×109/L]) and reduced absolute neutrophil count (normal 2200-7700/mm3 [2.2-7.7 ×109/L]). Protection against infection is the most important goal for this client. The following neutropenic precautions are indicated: A private room Strict handwashing Avoiding exposure to people who are sick Avoiding all fresh fruits, vegetables, and flowers Ensuring that all equipment used with the client has been disinfected

neutropenic precautions

Two groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta blockers), have the potential to cause problems for clients with asthma. Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain, discomfort, and fever. About 10%-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion. This is prevalent in clients with nasal polyposis.

nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta blockers) in client with asthma

Extravasation is the infiltration of a drug into the tissue surrounding the vein. Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: Stop the infusion immediately and disconnect the IV tubing Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. Elevate the extremity above the heart to reduce edema Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine)

norepinephrine extravasation:

Internal radiation (brachytherapy) involves direct application of a radioactive implant to the cancerous site or tumor for a short time, usually 24-72 hours. Implementation of the following nursing measures is vital as the client receiving brachytherapy emits radiation. Following the principles of time, distance, and shielding provides staff and visitors protection from exposure to radiation. Time spent near the radiation source is restricted. The guideline is to limit staff time spent in the room to 30 minutes per shift. -Cluster nursing care to minimize exposure to the radiation source -Rotate daily staff responsibilities to limit time spent in the client room -All staff must wear a dosimeter film badge when assigned to care for a client receiving internal radiation -No individuals who are pregnant or under age 18 may be in the room All staff and visitors must keep the maximum distance possible from the radiation source. Maintaining a distance of at least 6 feet is an established standard. -Assign the client to a private room with a private bath -Keep the door to the room closed -Ensure that a sign stating, "Caution, Radioactive Material" is affixed to the door -Instruct the client to remain on bedrest to prevent dislodgment of the implant Shielding with lead diminishes exposure to radiation. All staff providing nursing care that requires physical contact must wear a lead apron.

nursing measures for the client receiving brachytherapy

Aspart (NovoLOG) is a rapid-acting insulin with an onset of 10-15 minutes. Onset is the time it takes for the insulin to enter the circulation and begin to lower blood glucose. The peak effect takes 30 minutes-3 hours and the duration of action is 3-5 hours. It is important for the nurse to ensure that the client eats within 15 minutes of administration of aspart/lispro/glulisine to prevent an insulin-related hypoglycemic reaction

nursing priority after administering aspart insulin

Diet and exercise modifications are the main components of weight reduction. Clients with obesity may also require education and assistance with psychosocial aspects and behavioral modification. Behavioral management includes: Creating a reward system with many small, attainable goals to incentivize positive health behaviors Developing health goals unrelated to weight (eg, climbing stairs without shortness of breath) to measure progress regardless of current weight Adopting anxiety-reducing diversional activities (eg, reading, meditating, listening to music) as coping mechanisms to reduce stress eating Placing visual cues (eg, motivational quotes) throughout the environment as positive reinforcement Avoiding social activities in a food setting promotes isolation and negative perceptions. Clients who struggle to make healthy choices in these settings should plan ahead for what will be eaten or bring a separate meal.

obesity may also require education and assistance with psychosocial aspects and behavioral modification and weight loss

Iron deficiency anemia is the most common chronic nutritional disorder in children. There are many risk factors for iron deficiency, including insufficient dietary intake, premature birth, delayed introduction of solid food, and consumption of cow's milk before age 1 year. One common cause in toddlers is excessive milk intake, over 24 oz/day. In addition to becoming overweight, toddlers who consume too much milk develop iron deficiency due to the likely exclusion of iron-rich foods in favor of milk, a poor source of available iron. Treatment of iron deficiency anemia includes oral iron supplementation and increased consumption of iron-rich foods (eg, leafy green vegetables, red meats, poultry, dried fruit, fortified cereal). It is also important to limit milk intake (16-24 oz/day) in toddlers to ensure a balanced diet.

overweight and Iron deficiency anemia in children

This client is experiencing paroxysmal supraventricular tachycardia (PSVT). In PSVT, the heart rate can be 150-220/min. With prolonged episodes, the client may experience evidence of reduced cardiac output such as hypotension, palpitations, dyspnea, and angina. Treatment includes vagal maneuvers such as Valsalva, coughing, and carotid massage. Adenosine is the drug of choice for PSVT treatment. Due to its very short half-life, adenosine is administered rapidly via IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose may be given twice if previous administration is ineffective. Beta blockers, calcium channel blockers, and amiodarone can also be considered as alternatives. If vagal maneuvers and drug therapy are unsuccessful, synchronized cardioversion may be used.

paroxysmal supraventricular tachycardia (PSVT) and treatment

The nurse should plan to assess the toddler client in a nonthreatening environment, taking time to develop rapport prior to beginning the examination. This can be achieved by talking to the toddler about favorite objects and slowly initiating contact. Parent involvement, such as holding the child and assisting the child with examination activities, reduces anxiety and encourages cooperation in toddler clients. Age-appropriate games or toys may be used if needed to gain the client's cooperation. Medical equipment may appear frightening to a toddler and should remain out of sight until needed. It may also be beneficial to allow the child to inspect and touch new pieces of equipment as they are used. It is best to order a physical examination for a toddler from least to most invasive, which commonly means assessing ears, nose, and mouth toward the end of a visit. Head-to-toe ordered assessments are more appropriate for school-age children.

physical examination of a toddler

Nausea, vomiting, abdominal distension, and decreased stool production may signal a bowel obstruction or obstructed ileostomy. Bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis. It is urgent and potentially life-threatening. The client must be evaluated by the health care provider in a timely manner.

post-op ileostomy complications

Clients most at risk for catheter-related bloodstream infections are those with compromised immune systems; therefore, this client is at high risk. The IV site chosen for catheter insertion can influence the infection risk. The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed.

preventing catheter-related bloodstream infections

Drinking extra water and being upright for 30 minutes after taking bisphosphonates (eg, risedronate, alendronate) is necessary to prevent esophagitis.

preventing esophagitis in bisphosphonates

The core symptoms of ADHD include hyperactivity, impulsiveness, and inattention. Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking, blurting out answers prematurely, and interrupting others. Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow through (eg, homework, chores). The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and in social situations. Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment by peers. The negative consequences of ADHD include: Poor self-esteem Increased risk for depression and anxiety Increased risk for substance abuse Academic or work failure Trouble interacting with peers and adults

primary symptoms of ADHD negative impact:

The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate them from providing truthful responses. In this case, the spouse appears angry and should, as a priority, be removed from the room to prevent further potential harm to the client or staff

priority for possible domestic abuse victims

The following are at greatest risk for respiratory depression related to opioid use for analgesia: the elderly; those with underlying pulmonary disease, history of snoring (with or without apnea), obesity, or smoking (more than 20-pack-year history); the opiate naïve, especially if treated for acute pain; and post surgery (first 24 hours). The 70-year old client has 3 significant risk factors: advanced age, COPD, and surgery within 24 hours. COPD clients who have hypercarbia and hypoxemia are at even greater risk for respiratory depression when receiving opioids.

risk for respiratory depression related to opioid use for analgesia

The rotator cuff is a group of 4 shoulder muscles and tendons that attach to the humeral head. It allows for rotation of the arm. A partial or full thickness rotator cuff tear can occur gradually over time as a result of aging, repetitive use, or an injury to the shoulder. It can also occur as a result of a sports injury involving repetitive overhead arm motion (eg, swimming, tennis, baseball, weight lifting). Characteristic symptoms of rotator cuff injury usually include shoulder pain and weakness. Severe pain when the arm is abducted between 60 and 120 degrees (painful arc) is characteristic

rotator cuff injury

The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows: Using pictures and simplified text is beneficial to the older adult with low literacy. Including a family member in the teaching process will assist the client in reinforcement of the material at a later date. Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory content in lay person's language. Older adults are using the internet in increasing numbers as are clients with low literacy. Several organizations are developing and promoting user-friendly websites. Society in general relies heavily on web-based health information. It is important for the nurse to teach the client and possibly supply a list of reputable sites for the client to view.

selecting teaching strategies: older adult with low literacy level

This client is exhibiting localized (eg, pain, limited range of motion) and systemic infection symptoms (eg, fever), which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection (eg, cellulitis). A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis (eg, damage to the femoral head) from compromised blood supply due to infection or injury (eg, fracture). This can result in sequelae that are significant in both the short term (eg, sepsis, death) and long term (eg, joint destruction). Management includes culturing synovial fluid and blood, giving antibiotics, and debriding the infected joint.

septic arthritis

Suprapubic pressure helps to dislodge an impacted anterior shoulder from under the client's pubic bone in the event of shoulder dystocia and will not relieve pressure off a prolapsed umbilical cord. The McRoberts maneuver consists of sharply flexing the thigh onto the maternal abdomen to straighten the sacrum. It is used for shoulder dystocia and will not take pressure off a prolapsed umbilical cord.

shoulder dystocia

Client education on early detection of skin cancer is important as most cases of malignant melanoma are discovered by the client. A full medical workup of every mole is unnecessary. Routine self-evaluation followed by medical assessment of questionable growths is sufficient. Clients with advanced age or reduced mobility may need to see a dermatologist for a full-body skin survey.

skin cancer

This client is in status epilepticus, a serious and life-threatening emergency in which a client has been seizing for 5 minutes or longer. Grunting and a dazed appearance are 2 common signs. A client with hydrocephalus (abnormal collection of cerebrospinal fluid in the head) and a ventriculoperitoneal (VP) shunt is at a higher risk for seizures. Stopping seizure activity is the first nursing priority. IV benzodiazepines (diazepam or lorazepam) are used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable or problematic. Parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the emergency department.

status epilepticus interventions/treatment

When administering subcutaneous anticoagulant injections (eg, heparin, enoxaparin), the nurse must select the appropriate needle length and angle to avoid accidental intramuscular injection, especially in clients with insufficient adipose tissue (eg, cachexia). Intramuscular injection of heparin would cause rapid absorption, resulting in a hematoma and painful muscle irritation. The nurse should administer subcutaneous injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped, or at 45 degrees if only 1 in (2.5 cm) can be grasped. Anticoagulants are best absorbed if administered in the abdomen at least 2 in (5 cm) away from the umbilicus. A 90-degree injection angle is appropriate for clients with sufficient adipose tissue (ie, at least 2 in [5 cm] can be grasped).

subcutaneous anticoagulant injections

Petechiae (small pinpoint red/purple spots on mucus membrane or skin) and purpura (irregular purplish blotches) can be a sign of blood dyscrasia, including thrombocytopenia due to a severe drug response. This systemic symptom takes priority over a more localized dermatological presentation.

sulfa Rash

A nurse who suspects child abuse should conduct a detailed interview and physical examination to identify potential indicators of abuse. In addition to obvious injuries, abused children may show extremes in behavior, including being overly shy, fearful, or even unusually affectionate. Parents should remain present during the admission process and the nurse should observe parent-child interactions for signs of abusive behavior (eg, refusal to comfort, blaming, belittling) Abusive parents may be hostile or uncooperative with the health care team. The nurse should also assess for inconsistencies between the parents' report and the actual findings.

suspected child abuse

Trazodone (Oleptro), a serotonin modulator, is used to treat major depressive disorders. In addition to affecting serotonin levels, the drug blocks alpha and histamine (H1) receptors. Blockade of alpha receptors can cause orthostatic hypotension similar to that from other alpha blockers (eg, terazosin, tamsulosin) used to treat benign prostatic hyperplasia. Blockade of H1 receptors leads to sedation. Therefore, this drug is particularly effective in treating insomnia associated with depression. However, concurrent intake of other medications or substances that cause sedation can be detrimental; these include benzodiazepines (eg, alprazolam, lorazepam, diazepam), sedating antihistamines (eg, chlorpheniramine, hydroxyzine), and alcohol

things contraindicated when taking Trazodone:

Activated charcoal is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for gastrointestinal decontamination in clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, restlessness) as well as in those who are asymptomatic. Activated charcoal binds to available salicylates, thus limiting further absorption in the small intestine and enhancing elimination. IV sodium bicarbonate is an appropriate treatment for aspirin toxicity after the administration of activated charcoal. It is given to make the blood and urine more alkaline, therefore promoting urinary excretion of salicylate.

treatment in acetylsalicylic acid (ASA) toxicity

Restriction of active and passive ranges of motion of the shoulder (complete stiffness) is seen with frozen shoulder. Pain and paresthesia over the first 3½ fingers suggest carpal tunnel syndrome. Tenderness over the lateral epicondyle is seen with tennis elbow.

upper extremity injuries