NUR 419 Midterm study guide

Side effects:

things anticipated to happen in people taking certain medications.Do NOT require stopping

Based on the delivery,

blood loss and patient's history, you recommend strongly to Ruth, the midwife and her husband that she go to the local hospital by ambulance. , Although they would prefer to go by buggy, you convince them that transport is needed by ambulance. You call ahead to the hospital and receive verbal orders for the OB attending who is awaiting your arrival.

Touchpoints are,

"Any place patients and families go during the care experiences such as the waiting room, exam room, lab..."

Making the change stick,

"Hardwiring" The steps we take to prevent us from slipping back to the comfortable position after we identify a better way of doing something. Some tactics for hardwiring include: Documenting the flow of the new process — the new way of doing things Providing training on the new process Teaching people new skills that might be required of them Making changes to job descriptions, policies, procedures, and forms Addressing supply and equipment issues Assigning day-to-day ownership for the improvement and maintenance of the new process Having senior leaders remove any barriers that might allow slippage back to the old process

Warfarin 5 mg Daily,

- Drug Classification: Anticoagulant - Purpose: To prevent thromboembolism; recommended for patients with an EF <20% and/or afib - Adverse reactions: Hemorrhage, Anemia, Dizziness, LOC, Elevated liver enzymes *Monitor PT/INR to control dose administered

Ezetimibe 10 mg daily,

- Drug Classification: Antihyperlipidemic Agent - Purpose: to lower blood cholesterol - Adverse reactions: Liver enzyme abnormalities, Rhabdomyolysis, Myopathy, Angioedema *Lipid panel ordered to monitor drug effects - Hydralazine, 25 mg QID - Drug Classification: Vasodilator - Purpose: To reduce cardiac afterload, leading to increased CO; to dilate the arterioles of the kidneys, leading to increased renal perfusion and fluid loss; to decrease BP; to decrease preload; to relieve symptoms of HF (i.e., dyspnea) - Adverse reactions: N/V/D, MI, Palpitations; Angina pectoris

Torsemide 20 mg BID,

- Drug Classification: Antihypertensive Agent (Loop Diuretic) - Purpose: To decrease fluid volume; to decrease preload; to decrease pulmonary pressure; to relieve symptoms of HF - Adverse reactions: EKG abnormality, Atrial fibrillation, Hypotension, Arrhythmias, Dizziness, Angioedema, GI hemorrhage, Excessive urination; Hypokalemia, Hyponatremia, Hypochloremia, Hypovolemia *Order labs to monitor electrolytes, especially Potassium

Aspirin 81 mg daily,

- Drug Classification: Antiplatelet Agent; Nonsteroidal Anti-Inflammatory Agent (Salicylate) - Purpose: To reduce the risk of recurrent nonfatal MI or death in patients with previous MI; reduce cardiovascular risks in patients undergoing certain revascularization procedures (CABG) - Adverse effects of concern: Bleeding time prolongation (Pt is on Warfarin), Pulmonary edema, Dysrhythmias, Renal insufficiency

KCl 20 mEq Daily,

- Drug Classification: Mineral and Electrolyte - Purpose: To replenish potassium lost as a result of loop diuretic - Adverse reactions: GI obstruction, GI bleed, Arrhythmias *Order labs to monitor Potassium levels

"A Century of Change",

1900: PNA or Flu as cause of death Life expectancy = 47 Die at home Family covers medical costs Little disability before death 2000: Cardiac disease as cause of death Life expectancy = 75 Die in hospital/LTC Insurance to cover most costs At least 2 years of disability before death

The general rule:,

3-4 lbs during first trimester. 1 lb a week for the 2nd and 3rd trimesters Edema above waist-fingers, face, extremities are more significant Not related to body position Proteinuria Presence of protein in urine Dipstick +1, +2 > 300 mg /L / 24 hr. Collection Typically, a late sign Increased rate of mortality

What is Von Willebrand Disease?,

A bleeding disorder caused by missing or low levels of clotting protein in the blood. Deficiency of Von Willebrand factor (platelet adhesion) Von Willebrand disease is often inherited, but in rare cases, it may develop later in life. Most people with this condition inherited it from a parent. They have a faulty gene that causes problems with a protein important to the blood-clotting process. Symptoms: recurrent and prolonged nosebleeds, bleeding from the gums, increased menstrual flow, and excessive bleeding from a cut. Treatment focuses on stopping or preventing bleeding episodes, typically by using medications (clotting promoter ex. Demopressin). There is no cure

How will they make the diagnosis of TB vs. PJP? HIV vs. AIDS,

A blood test will show high levels of b-1 3 glucan with PJP or TB the blood test will measure interferon-gamma (IFN-γ). HIV is diagnosed by blood or saliva showing antigens. AIDS a person will have a CD4 T lymphocytes count 200 or below (500-1200 norm).

Diabetes, Scenario

A call is made to 911 because Jan Rivers, age19, who is an engineer intern, has become unresponsive. A coworker reports to the EMT that Jan stated he has not been feeling well lately—has complained of some generalized abdominal pain. The co-worker also commented that Jan was "always thirsty."

PTSD & Suicidal Veteran Case Study, Situation,

A distraught wife brings Mr. Blake, 46, to the emergency department after she finds him writing a suicide note and planning to shoot himself in the woods with a handgun. Mr. Blake is subdued, shows minimal affect, and his breath has the distinct odor of alcohol. When asked about suicidal thoughts, he states that he is worthless and that his wife and family would be better off if he were dead. He refuses to contract for safety. The decision is made to hospitalize him to protect him from danger to himself. Mr. Blake was admitted to the psychiatric unit and his care assigned to Ms. Dawson, a registered nurse. She observes that Mr. Blake is quiet and passive as he is oriented to the unit but that he looks around vigilantly and is easily startled by sounds on the unit.

Somogyi Effect,

A high dose of insulin producing a decline in blood glucose levels during the night resulting in hyperglycemia in the morning. This is dangerous because when blood glucose levels are measured in the morning, they are high and the patient or HCP may increase the insulin dose. Clinical Manifestations besides AM hyperglycemia include headaches, night sweats and nightmares Solution: checking blood glucose levels between 2-4 am for hypoglycemia will help to determine if this is Somogyi or not - a bedtime snack, a reduction in the dose of insulin or both can help to prevent.

ECG,

A rapid response is called, which quickly turns into a Code Blue because of the following ECG. General ECG Characteristics of Ventricular Tachycardia: Ventricular rate is 150 to 250 beats/minute. Rhythm may be regular or irregular. P-wave is usually buried in the QRS complex, and the PR interval is not measurable. The QRS complex is distorted and wide (greater than 0.12 seconds). T-wave is in the opposite direction of the QRS complex.

Insulin Pump,

A small battery operated device loaded with rapid-acting insulin, connected via plastic tubing to a catheter inserted into the subcutaneous tissue in the abdominal wall Programmed to deliver a continuous infusion of rapid acting insulin 24 hours a day Jan's prescription is for Detemir, a long acting insulin and Lispro, a rapid acting insulin so he would be unable to use a pump because those are for rapid-acting insulins ONLY

Lab Work and ABGs are drawn,

ABGs. An ABG is obtained with the following results: pH- 7.52 7.35-7.45 Alkalotic. pO2- 88 95-100 hypoxemia. pCO2- 28 35-45 Respiratory HCO3- 18 22-26 Acidotic. Interpretation: Respiratory Alkalosis with compensation from metabolic system Respiratory Alkalosis Carbonic acid deficit. Common Causes are hyperventilation (hypoxia, pulmonary emboli anxiety etc) or stimulated respiratory center (septicemia encephalitis brain injury etc) or mechanical hyperventilation

TB in the U.S.,

According to the CDC: A total of 9,557 TB cases (a rate of 3.0 cases per 100,00 persons were reported in the United States) This is 1.6% increase in the number of TB cases reported in 2014 There were 493 deaths from TB in 2014 Total TB deaths reported have decreased 71% since 1992 In 2015, a total of 66.4% of reported TB cases in the U.S occurred among foreign-born persons

After assessing the patient, you believe that she is experiencing what complication/condition of pregnancy?,

After assessing the patient, we believe she is experiencing severe preeclampsia as evidenced by her blood pressure changes, severe headaches with visual disturbances, edema, nausea, continuous epigastric pain, tender RUQ, changes in her urine, and weight gain Formerly called toxemia, preeclampsia is characterized by high blood pressure, in women who have not experienced high blood pressure previously Usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal If left untreated, preeclampsia can lead to serious, even fatal outcomes for mother and baby

Cultural Considerations,

Amish Education Genetic disease Herbal remedies Careful medical consumers Insurance discouraged Lack of preventative care Do not believe in BC Church permission req'd Midwives not the best historians http://allnurses.com/general-nursing-discussion/help-health-care-466423.html Education: Amish woman typically have up to a 9th grade education...Speak to them at an eighth-grade level. The Amish learn well with demonstrations, picture stories and role modeling. Take time to educate them. Genetic Disease: Since the Amish community is so restrictive to outside unions, this population is at high risk for inherited genetic mutations Herbal remedies-believe that higher medication is not necessary Insurance- by having insurance they feel they are showing a lack of faith in god Medical consumers= dont seek treatment unless they believe it is an emergency Lack of care- believe god will heal them Church permission- church sometimes helps pay for the care Amish midwives may not be reliable because they are educated on remedies and herbs to cure medical issues Education: Amish woman typically have up to a 9th grade education. Genetic Disease: Because the Amish community is so restrictive to outside unions, this population is at high risk for inherited genetic mutations Amish midwives may not be the most reliable historians as they too, are educated in the community relying on traditional passed down remedies and herbs to cure medical issues. Hemophilia is a genetic bleeding disorder that is usually (80% of cases) carried as X-linked recessive. The most common form of hemophilia is Type A, factor VIII deficiency. Von Willebrand disease is another hereditary bleeding disorder of a deficiency in Factor Vlll that affects both males and females.

Medications:

Antihypertensive Drugs, Aldomet (Methyldopia) Purpose of medication: To treat hypertension Medication classification: Antihypertensive Potential adverse effects: Decreased mental acuity, sedation, headache, orthostatic hypotension, edema, bradycardia, myocarditis, nasal congestion, dry mouth, pancreatitis, thrombocytopenia, leukopenia, bone marrow depression, hepatic necrosis, and/or hepatitis Routine labs required for monitoring drug effects: May increase creatinine level. May decrease hemoglobin level and hematocrit. May increase liver function tests values. May decrease platelet and WBC count. May interfere with results of urinary uric acid testing, serum creatinine test, and AST test.

Combination Antiretroviral Therapy Truvada (Emtricitabine 200 mg + Tenofovir 300 mg),

Antiretrovirals. Nucleoside Reverse Transcriptase Inhibitors Adverse effects: CNS - dizziness HA insomnia weakness depression nightmares. GI - diarrhea, abdominal pain, nausea, severe hepatomegaly with steatosis dyspepsia vomiting. GU - proximal renal tubulopathy renal impairment. Skin - rash skin discoloration. MS - arthralgia, myalgia. Neuro - neuropathy paresthesia. Respiratory - cough rhinitis. Miscellaneous - lactic acidosis fat redistribution immune reconstitution syndrome.

Asking,

Ask the questions. Example: blank (unfilled) data fields in EMR. Sexual history. End-of-Life desires. What do we remember?. First skill: Not first communication

Lorazepam (Ativan) & Nursing Interventions:,

Benzodiazepine: depresses the CNS by enhancing GABA effects and binds to benzodiazepine receptors. Used for anxiety disorders preanesthetic medication for sedation, and status epilepticus. Adverse reactions: sedation headache confusion apnea cardiac arrest bradycardia hypotension tachycardia depression suicidal ideation blurred vision respiratory distress respiratory failure incontinence nausea thrombocytopenia and dependence/withdrawal. Ensure safety (patient at falls risk) monitor VS caffeine intake level of consciousness liver function and emotional status.

Detemir and Lispro,

Both are classified as antidiabetics.

Heart Failure Situation,

Carlo Boccerini, 68 yo Caucasian man, has a 5-year history of systolic heart failure due to ischemic cardiomyopathy. His current ejection fraction (EF) is 15%. Carlo comes to the ED for shortness of breath for the past 3 days. First it was just dyspnea with activity, but now it occurs at rest. He reports he has now slept in the recliner the past two nights because of worsening shortness of breath. He adds that his legs are all swollen and he can't get his shoes on. After being assessed in the ED, oxygen at 6L NC is applied to Carlo and he is transferred to the cardiac step-down unit for monitoring and care management.

Based on the Assessment Findings...,

Carlo has left-sided heart failure which results from left-ventricular dysfunction. This prevents blood from properly flowing and causes back flow into the left atrium and pulmonary veins. This causes an increase in pulmonary pressure, thus causing fluid leakage from the pulmonary capillary bed into the interstitium and then the alveoli. This manifests as pulmonary congestion and pulmonary edema, which explains the coarse crackles auscultated during Carlo's pulmonary assessment. This also explains why Carlo presents as restless and pale, and why he has shortness of breath.

Pathophysiology leading to MI,

Carlo's hyperlipidemia likely contributed to atherosclerosis, the buildup of fatty plaque leading to the narrowing and hardening of his coronary arteries. The plaque builds up over time and the narrowing can decrease or obstruct the supply of blood and oxygen to the heart tissues leading to a myocardial infarction, or heart attack. Plaques can also rupture leading to a blood clot which if becomes large enough, can completely block blood flow through a coronary artery. Carlo had coronary artery bypass graft (CABG) surgery done to bypass the blocked section so that blood flow can go around the artery and deliver oxygen to the heart.

Risk Factors,

Close contact with known case of pulmonary TB. HIV infection. Birth in a country with high prevalence of TB. Homelessness. Residence in long-term care facilities and correctional facilities. Injection drug use. Residents of inner-city neighborhoods. Health care workers. Immunosuppression. Diabetes. Malnutrition. Smoking. Weakened immune systems.

Medication reactions with ART:

Co-treatment of TB and HIV presents several challenges, Rifampin may interfere with ART outcomes resulting in inadequate effects For patients taking ART, rifampin and rifapentine should replace rifampin The TB drugs pyrazinamide, isoniazid, and rifampicin have all been associated with hepatotoxicity and are increased concerns when taking with ART

"OH DEAR, I forgot to tell you that our oldest son has hemophilia.",

Concerns: herbal remedies, belief that God heals, lower hgb levels, no medical records, hemophilia is genetic Complications: excessive bleeding in past pregnancies; pt stated feeling of weakness and showed s/s of DVT in R calf; hemorrhage can occur; newborn at risk for genetic disorder and trauma from childbirth can cause internal bleeding and damage to organs while helping the midwife set up for delivery, we notice box of clotting factor on the shelf in the bathroom...ruth says...

Recommendation,

Continuous electronic fetal monitoring; Vital signs q 1hr; IV Lactated Ringers at 125ml/hr; Labs and meds as ordered

Isoniazid (latent tb infection)

Daily or twice weekly for 6 months Daily or twice weekly for 9 months Preferred treatment for: Persons living with HIV Children aged 2-11 Pregnant Women (with pyridoxine/vitamin B6 supplements)

Combination Antiretroviral Therapy Prezcobix (Darunavir 800mg + Cobicistat 150 mg),

Darunavir - Antiretroviral. Protease inhibitors. Adverse effects: GI - hepatotoxicity constipation diarrhea nausea vomiting. Endocrine - hyperglycemia. Metabolism - body fat redistribution. Skin - Stevens-Johnson's syndrome, toxic epidermal necrolysis, rash. Miscellaneous - immune reconstitution syndrome.

Carlo's Nursing Diagnoses,

Decreased cardiac output related to changes in myocardial contractility as evidence by pale, cool skin with +3 pitting edema and LE peripheral pulses +1. Activity intolerance related to imbalance between oxygenation supply/demand needs as evidenced by dyspnea. Excess fluid volume related to decreased cardiac output as evidence by abnormal breath sounds.

Nursing Diagnosis,

Deficient fluid volume. Related to vomiting, diarrhea, diaphoresis, & shift of intravascular volume to interstitial spaces. Ineffective breathing pattern. Related to rapid respirations. Ineffective tissue perfusion. Related to decreased cardiac output hypotension, & vasodilation.

Pathophysiology of Type 1 Diabetes,

Destruction of insulin-secreting beta cells in islets of Langerhans in the pancreas As beta-cell mass declines, insulin secretion decreases until normal blood glucose levels can no longer be maintained After 80-90% of the beta cells are destroyed, hyperglycemia develops and diabetes may be diagnosed

"Shadowing",

Direct observation of process, which can help you. Understand patients' and families' frustrations, confusions, and anxieties. Identify the aspects of care experiences that patients and families view as positive. Feel a renewed sense of empathy for patients and their families, which can lead to a sense of urgency to make improvements. Reveal inefficiencies that waste time — not only your time as a caregiver, but the valuable time of patients and families. Understand that data is not always the best tool to motivate change. Gain qualitative information, i.e., "This is how it feels," not just "This is how it looks." "For the sake of objectivity, it's preferable to shadow a care experience with which you are relatively unfamiliar" "Cross-shadow": Shadowing can lead to an "a-ha!" moment.

Future Considerations:,

Discharge teaching plan: Teach s/s of von Willebrand disease Recurrent bleeding episodes (i.e. nosebleeds), easily bruising, prolonged bleeding, and bleeding from mucous membranes Risks for future pregnancies: Teach Ruth that she can be at risk for bleeding up to 4 weeks after she gives birth Desmopressin: tx of choice and can be administered nasally, orally, or IV Use of hospital facilities and personnel for future pregnancies: Emphasize to Ruth that it is understood that she has strong cultural and spiritual beliefs and that they are important to her Recommend that Ruth gives birth at a hospital because of her risk for bleeding and that the hospital has resources that you would not otherwise have at home Immediate availability of clotting factors/ emergency protocols Although rare, von Willebrand disease is the most common type of hemophilia. It is the most common congenital clotting defect in US women of child bearing age. Symptoms include recurrent bleeding episodes such as nosebleeds or after tooth extraction, bruising easily, prolonged bleeding times and bleeding from mucous membranes. Women can be at risk for bleeding up to 4 weeks after birth. The treatment of choice is desmopressin which is available nasally, intravenously or orally. The nurse should make the patient and family aware of her knowledge of their cultural and spiritual beliefs and confirm their importance. Nurse should strongly recommend future births to take place in a hospital facility due to the immediate availability of clotting factors and emergency protocols in place.

X-ray of the chest,

Done if you have a cough chest pain fever and shortness of breath Checks for Fluid or air build up in or around the lungs (pneumothorax) Pneumonia lung cancer heart failure emphysema broken ribs Pneumothorax is very common in a person with Pneumocystis jiroveci pneumonia

Lung biopsy,

Done to rule out cancer and check for bacterial, viral, or fungal infection

Isoniazid,

Drug Class: Antibiotic Adverse effects: CNS - psychosis seizures. EENT - visual disturbances. GI - drug-induced hepatitis nausea vomiting. Skin - rash. Endocrine - gynecomastia. Hematology - blood dyscrasias. Neuro - peripheral neuropathy. Miscellaneous - fever.

Trimethoprim/ Sulfamethoxazole (Bactrim, Sulfatrim),

Drug Class: Antibiotic combination. Folate antagonists. Adverse effects: GI - altered taste epigastric discomfort glossitis nausea vomiting drug-induced hepatitis. Skin - pruritus rash. Hematology - megaloblastic anemia neutropenia thrombocytopenia. Miscellaneous - fever. Side effects are more common and more severe in patients with AIDS

Carvedilol 3.25 mg daily,

Drug Classification: Beta-adrenergic Blockers - Purpose: To promote reverse remodeling; to decrease afterload; to inhibit SNS; to decrease morbidity and mortality - Adverse reactions: Hypotension, Dyspnea, Pulmonary edema, Steven-Johnson, Thrombocytopenia, Anemia, Elevated liver transaminases, Dizziness; Abnormal vision.

Sulfonylureas

Drug Name: Glipizide (Glucotrol) Action: Lowers blood sugar by stimulating the release of insulin from the pancreas and increasing the sensitivity to insulin at receptor sites. Necessary Labs: CBC to monitor blood counts and HbA1C Side Effects: Dizziness, headache, increased appetite, nausea, vomiting, hypoglycemia, agranulocytosis, and thrombocytopenia.

Biguanides

Drug Name: Metformin (Glucophage) Action: Decreases hepatic glucose production, decreases intestinal glucose absorption, and increases sensitivity to insulin. Necessary Labs: HbA1C , BUN, Creatinine, CBC for serum folic acid and vitamin B12. Side Effects: Bloating, diarrhea, nausea, lactic acidosis, and a decrease in vitamin B12 levels.

Thiazolidinediones

Drug name: Pioglitazone (Actos) Action: Improves sensitivity to insulin by acting as an agonist at receptor sites involved in insulin responsiveness and subsequent glucose production and utilization. Requires insulin for activity. Necessary Labs: HbA1C, CBC with differential due to potential decrease in H+H, AST, ALT, alkaline phosphatase, and total bilirubin levels. Side Effects: CHF, liver failure, bladder cancer, anemia, and rhabdomylolysis.

Assessment Findings - DKA,

Dry mouth Thirst Abdominal pain N/V Gradually increasing restlessness, confusion lethargy Flushed, dry skin Eyes appearing sunken Breath odor of ketones (fruity) Rapid, weak pulse Labored breathing (Kussmaul respirations) Fever Urinary frequency Serum glucose >250 mg/dL (13.9 mmol/L) Glucosuria and ketonuria

Pathophysiology of Von Willebrand Disease,

Due to an abnormality of the von Willebrand factor large multimeric glycoprotein required for normal platelet adhesion also functions as the carrier protein for factor VIII (FVIII) Von Willebrand factor attaches to platelets by its specific receptor to glycoprotein Ib on the platelet surface and acts as an adhesive bridge between the platelets and the injury Von Willebrand factor protects FVIII from degradation and delivers it to the site of injury. Defect in the adhesion of platelets reduction in the plasma levels of, or the production of a defective form of, the coagulation factor known as von Willebrand factor (vWF). VWF- Allows platelets to bind together to form a clot

Genetics,

Genetically predisposed to Type 1 Diabetes if it runs in the family

Discharge Care Plan,

Education. Infection (signs methods to avoid call HCP). Diabetes care (especially for foot care). Medication education (make sure to finish entire antibiotic prescription). Diet recommendations to improve recovery. Exercise restrictions if needed. Sleep recommendations. Transitional / rehabilitation unit / home care. To aid in return to normal functioning. Follow-up care. For evaluation of recovery.

The principle goals for therapy for older patients who have poor glycemia control are:

Enhancing quality of life Decreasing the chance of complications Improving self-care through education All of the above Answer: D Explanation: The principle goals of therapy for older persons with diabetes mellitus and poor glycemic control are enhancing quality of life, decreasing the chance of complications, improving self-care through education, and maintaining or improving general health status.

Cobicistat - Pharmacoenhancers, antiretrovirals.

Enzyme inhibitors. Adverse effects: EENT - ocular icterus. GI - jaundice, nausea. GU - acute renal failure (increased with tenofovir), Fanconi syndrome (increased with tenofovir).

Postpartum Hemorrhage & Von Willebrand Disease, What is Postpartum Hemorrhage?

Excessive bleeding after childbirth Leading cause of maternal mortality in women PPH is defined as blood loss of more than 500 mL following vaginal delivery More than 1000 mL following cesarean delivery. A loss of these amounts within 24 hours of delivery is termed early or primary PPH losses are termed late or secondary PPH if they occur 24 hours after delivery. Causes: loss of tone in the uterine muscles, a bleeding disorder, or the placenta failing to come out completely or tearing. Symptoms: vaginal bleeding that doesn't slow or stop. This can lead to a drop in blood pressure. Treatment: uterine massage and medication. In rare cases, blood transfusion, removal of residual placenta, or a hysterectomy may be needed.

Exercise Therapy,

Exercise does not have to be vigorous to be effective. Exercise should be enjoyable to foster regularity It is important to have properly fitting footwear Exercise should have a warm up and a cool down period - should be started gradually and increased slowly Best done after meals, when the BG is rising Individualized and monitor by the HCP Self-monitor BG before, during and after exercise Watch for delayed exercise-induced hypoglycemia which may occur several hours after

Nursing Diagnoses,

Fluid volume deficit, related to plasma protein lost, evidenced by edema formations Interventions Weigh patient regularly. Tell patient to record weight at home in between visits. Differentiate physiological and pathological edema of pregnancy. Locate and determine degree of pitting. Note signs of progressive or excessive edema i.e., epigastric/RUQ pain, cerebral symptoms, nausea, vomiting). Assess for possible eclampsia. Rationale Abrupt, notable weight gain (e.g., more than 3.3 lb (1.5 kg)/month in the second trimester or more than 1 lb (0.5 kg)/wk in the third trimester) reflects fluid retention. Fluid moves from the vascular to interstitial space, resulting in edema. The presence of pitting edema (mild, 1+ to 2+; severe, 3+ to 4+) of face, hands, legs, sacral area, or abdominal wall, or edema that does not disappear after 12hr of bedrest is vital. Risk for Injury related to tissue edema/ hypoxia Interventions Check for alterations in level of consciousness. Assess for signs of impending eclampsia: hyperactivity of deep tendon reflexes (3+ to 4+), ankle clonus, decreased pulse and respirations, epigastric pain, and oliguria (less than 50 ml/hr). Rationale In progressive PIH, vasoconstriction and vasospasms of cerebral blood vessels reduce oxygen consumption by 20% and result in cerebral ischemia. Generalized edema/vasoconstriction, manifested by severe CNS, kidney, liver, cardiovascular, and respiratory involvement, precede convulsive state. Decreased Cardiac Output related to hypertension, evidenced by BP of 192/116 respiratory involvement, precede convulsive state. Interventions Record and graph vital signs especially BP and pulse. Institute bedrest with patient in lateral position. Give antihypertensive drugs such as hydralazine (Apresoline) PO or IV, so that diastolic readings are between 90 and 105 mm Hg. Begin maintenance therapy as needed, e.g., methyldopa (Aldomet) or nifedipine (Procardia). Rationale Improves venous return, cardiac output, and renal/placental perfusion. Antihypertensive drugs work directly on arterioles to promote relaxation of cardiovascular smooth muscle and help increase blood supply to cerebrum, kidneys, uterus, and placenta. Hydralazine is the drug of choice because it does not produce effects on the fetus.

Most at Risk population:,

Foreign-born The case rate among foreign-born persons was approximately 13 times higher than among U.S.-born persons

Assessment after verbal orders given...,

Fundus is now firm with only minimal trickle of blood Vital Signs: BP-132/84, P-108 Patient is AAOx3 and complains of no discomfort other than feeling "cold" In the ER hang another liter of D5WLR with no oxytocin Hgb is 8.9 ( her blood work indicated that Ruth is a carrier of Factor VIII AKA Von WIllebrand's disease) Clotting level at 45% of normal

Pressure Ulcers,

Goal 14: Prevent health care-associated pressure ulcers (decubitus ulcers). NPSG.14.01.01: Assess and periodically reassess each resident's risk for developing a pressure ulcer and take action to address any identified risks. Applies to: Nursing Care Center

Risk Assessment

Goal 15: The organization identifies safety risks inherent in its patient population. NPSG.15.01.01: Identify patients at risk for suicide. Applies to: Behavioral Health Care, Hospital (Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.) NPSG.15.02.01: Identify risks associated with home oxygen therapy, such as home fires. Applies to: Home Care

Patient Identification,

Goal 1: Improve the accuracy of patient identification. NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment and services. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Laboratory, Nursing Care Center, Office-Based Surgery. NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

Improve Communication,

Goal 2: Improve the effectiveness of communication among caregivers. NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. Applies to: Critical Access Hospital, Hospital, Laboratory.

Medication Safety,

Goal 3: Improve the safety of using medications. NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office Based Surgery NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. Applies to: Ambulatory, Critical Access Hospital, Hospital, Nursing Care Center NPSG.03.06.01: Maintain and communicate accurate patient medication information. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Nursing Care Center, Office-Based Surgery.

Clinical Alarm Safety,

Goal 6: Reduce the harm associated with clinical alarm systems. NPSG.06.01.01: Improve the safety of clinical alarm systems. Applies to: Critical Access Hospital, Hospital

Health Care-Associated Infections,

Goal 7: Reduce the risk of health care-associated infections. NPSG.07.01.01: Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Laboratory, Nursing Care Center, Office-Based Surgery. NPSG.07.03.01: Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care hospitals. Applies to: Critical Access Hospital, Hospital. NPSG.07.04.01: Implement evidence-based practices to prevent central line-associated bloodstream infections. Applies to: Critical Access Hospital, Hospital, Nursing Care Center. NPSG.07.05.01: Implement evidence-based practices for preventing surgical site infections. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery. NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI). Applies to: Critical Access Hospital, Hospital. (Note: This NPSG is not applicable to pediatric populations. Research resulting in evidence-based practices was conducted with adults, and there is not consensus that these practices apply to children.)

Reduce Falls,

Goal 9: Reduce the risk of patient harm resulting from falls. NPSG.09.02.01: Reduce the risk of falls. Applies to: Home Care, Nursing Care Center

TB drugs used to treat MDR-TB:,

Group A: Fluoroquinolones: Levofloxacin Moxifloxacin Gatifloxacin Group B: Second line injectable agents Amikacin Capreomycin Kanamycin Streptomycin Group C: Other core second line agents Ethionamide/Prothionamide Cycloserine/Terizidone Linezolid Clofazimine This new grouping is intended to guide the design of conventional regimens. Leading to regimens lasting only 9-12 months As of May 2016.

Dawn Phenomenon,

Growth hormone and cortisol are being excreted in increased amount during the morning, causing hyperglycemia on awakening. This affects the majoring of diabetic patients and tends to be more severe when growth hormone is at its peak in adolescence and young adulthood. Solution: increase in insulin or an adjustment in administration time

Treatment for the patient with HIV/AIDS & TB:,

HIV and TB must be managed simultaneously TB-related mortality in HIV-infected patients is high during the first few months of TB treatment TB treatment is the priority

Back to Jan,

He is treated with a continuous infusion of insulin. He quickly stabilizes and is transferred to a step down unit for further management and education.

Other Signs,

Headaches- frontal or occipital Visual Disturbances-blurred vision, visual spots Right upper quadrant pain - epigastric pain Nausea/ vomiting Oliguria < 30 ml/hr, <400 ml/24 hr Hyperreflexia Irritability Cyanosis Pulmonary edema Uric acid, creatinine, liver function tests

HELLP Syndrome,

Hemolysis Elevated Liver enzymes Low Platelets <100,000/mL B/P > 160/110 >+3 Proteinuria Decreased urine output Visual disturbances

Diagnostics - DKA,

History and PE Blood studies - immediate blood glucose, CBC, pH, ketones, electrolytes, blood urea nitrogen, arterial or venous blood gases Urinalysis - specific gravity, glucose, acetone Initial Interventions - DKA Ensure patent airway Administer O2 via nasal cannula or non-rebreather mask Establish IV access with large bore catheter Begin fluid resuscitation with 0.9% NaCl solution 1L/hour until BP is stabilized and urine output 30-60 mL/hr Begin continuous regular insulin drip 0.1 U/kg/hr Identify history of diabetes, time of last food and time and amount of last insulin injection

Treatment for Preeclampsia,

Home care Nurse needs to assess home environment, support system Modified bed rest Vital signs

Question #3

How much Magnesium Sulfate is given? 4-6 grams over 30 minutes 1-2 grams over an 60 minutes 4-6 grams over 3 hours 1-2 grams over 5 hours answer is 4 to 6 grams over 30 minutes

Classic Triad,

Hypertension Elevated Blood Pressure Compare with baseline B/P Edema 85% of all women develop edema Dependent edema Associated with elevated B/P Weight gain > than 2 lbs./week

If Carlo's Condition Were Left Untreated,

If Carlo's atrial fibrillation does not get corrected at this time, clots could form in the atria as a result of blood stasis. The clots can spread and possibly cause a stroke. Also, a continued decrease of perfusion to the kidneys can lead to renal failure. If Carlo's pulmonary edema does not get corrected at this time, it can raise pressure in the pulmonary artery (pulmonary hypertension), and eventually the right ventricle in your heart becomes weak and begins to fail If the edema is not treated, the fluid buildup can put too much pressure on the liver, cause scarring, and resulting in liver damage.

What are the risk factors for TB? PJP? ,

If you are in close contact with someone with TB Alcohol and IV drug abuse People that have Diabetes, cancer or HIV weakened immune system (PJP) neumocystis jiroveci pneumonia Causes lung infections in people with cancer long term corticosteroid use or medicines that weaken the immune system HIV/AIDS, Organ or bone marrow transplant

Viral Infection Possibility,

Immune system activation in response to viral infection Immune cells are also activated against the beta cells in the pancreas Immune cells destroy beta cells Common viruses: coxsackie and rubella

Nursing Diagnosis for Ruth #1,

Impaired gas exchange related to altered oxygen-carrying capacity of blood AEB hgb level of 8.9. Outcome: Patient maintains optimal gas exchange, AEB ABGs within patient's usual range; O2 saturation of 90% or greater; alert, responsive mentation or no reduction in LOC; relaxed breathing and baseline HR for patient. Interventions: Assess respiratory rate, rhythm and depth. The patient will adapt breathing patterns over time to facilitate gas exchange. Rapid, shallow respirations may result from hypoxia or from the acidosis with the shock state. Assess for tachycardia and SOB. These signify an increased work of breathing. With initial hypoxia, HR increases. Use pulse oximetry to monitor oxygen saturation and assess ABGs. Pulse ox is a useful tool to detect early changes in O2 saturation. Increasing PaCO2 and decreasing O2 are signs of hypoxemia and respiratory acidosis.

Nursing Interventions:,

Monitor vital signs, lab results & ABGs Encourage patient to take deep breaths Keep patient warm & dry. Be alert for changes in: neurologic, neuromuscular, and cardiovascular

Antiretroviral therapy and treatment of Tuberculosis,

In HIV-positive patient with Tuberculosis the Antiretroviral therapy (ART) should be started and continued regardless of CD4 count. Data shows that in patients with CD4 count ≤500 cells/μL starting ART during the 6 months of TB treatment leads to 56% lower mortality comparatively to those who start ART after completion of TB therapy. Refusal of ART by J.Q. had no advantages. Starting ART at a CD4 count of 200-350 cells/μL instead of waiting for it to decrease to < 200 cells/μL reduces the risk of active tuberculosis by 50%.Beginning ART early would also prevent or delay the development of Pneumocystis jiroveci pneumonia and esophageal candidiasis.

Implementation of precautions: ,

In addition to standard precautions The patient should be placed in a negative airflow room with the door shut. All staff members entering the room should wear a NIOSH approved fit-tested N-95 respirator Patient should wear mask when traveling outside the room Termination of precautions: precautions can be discontinued when patient on effective therapy is improving clinically and has three consecutive sputum smears (collected on separate days) negative for acid-fast bacilli.

Complications due to Short Umbilical Cord affect both the mother and child. These include:,

In the mother: Increased incidence of retained placenta Prolonged labor Inversion of the uterus Abruption of placenta causing severe bleeding (during late pregnancy) affecting the health of both the mother and fetus In the baby: Cerebral palsy Hypoxic ischemic encephalopathy (HIE) Intrauterine growth retardation (IUGR) Placental disruption, affecting the nutrition of the developing fetus Umbilical cord rupture Increased incidence of breech presentation Miscarriages and stillbirths http://www.dovemed.com/diseases-conditions/short-umbilical-cord/ The average amount of blood loss after the birth of a single baby in vaginal delivery is about 500 ml (or about a half of a quart).The average amount of blood loss for a cesarean birth is approximately 1,000 ml (or one quart).PPH is defined when these totals are exceeded. Most postpartum hemorrhage occurs right after delivery, but it can occur later as well. Short cords pose an increased risk for PPH because the placenta may fully or partially abrupt during descent.

Signs and Symptoms of Type 1 Diabetes

Increased thirst Frequent urination Bedwetting in children who previously didn't wet the bed during the night Extreme hunger Unintended weight loss Irritability and other mood changes Fatigue and weakness Blurred vision In females, a vaginal yeast infection

Signs and Symptoms of Type 2 Diabetes

Increased thirst and frequent urination Weight loss Fatigue Blurred vision Slow-healing sores or frequent infections Areas of darkened skin. Some people with type 2 diabetes have patches of dark, velvety skin in the folds and creases of their bodies — usually in the armpits and neck. This condition, called acanthosis nigricans, may be a sign of insulin resistance.

Countries with high prevalence of TB,

India Bangladesh Brazil Cambodia Central African Republic China Congo Ethiopia Angola Indonesia

Plan of care of three nursing diagnosis,

Ineffective breathing pattern related to fatigue Due to the patents ineffective breathing pattern the patient should be given oxygen via nasal cannula as appropriate Risk for spread of infection related to low immune response Due to risk for spread of infection the patient should be put into airborne precautions Activity intolerance related to fever and fatigue Due to the inability of patient activity the patient needs to prioritize important tasks first.

Diagnostic Criteria for Septic Shock,

Infection and some of the following are needed to diagnose septic shock. Mr. J is experiencing: Temperature >380C (39.40C). HR >90 bpm (126 bpm). Respiratory: not >20 breaths/min (18 breaths/min). White blood cell count >12,000 cells/mm3 (28,600 cells/mm3). *meets more than two of the SIRS criteria*. Has a confirmed infection (wound on foot with purulent drainage). *meets sepsis criteria. There is no indication that he has bacteremia (septicemia). Has hypotension (84/60) with sepsis despite adequate fluid resuscitation. *Has confirmed septic shock.

Change as process,

Innovation →pilot → implement → spread Unfreezing → change/transition → refreezing

Patient and Family Teaching:,

Instruct the patient to maintain respiratory isolation precautions Keep tissues and sputum cups at the bedside; dispose of secretions properly Have the patient cover the mouth when coughing, sneezing, or producing sputum Have the patient wash hands after handling sputum If the patient is transported out of room for any reason, the patient must wear a mask Instruct family members that when entering the room they must wear a mask Keep the door of the patient's room closed at all times Refer patient contacts to be assessed for possible infection

b-1 3 glucan level of the blood,

Is a marker that can diagnose invasive fungal infections it's a component of the cell wall of most fungi Candida and Aspergillus can be detected and are associated with high morbidity and mortality

SEPTICEMIA,

It is an infection of the blood, also known as bacteremia or blood poisoning. Signs and symptoms: Same as sepsis with positive blood cultures.

Background,

J. Q was first seen by an HCP 6 years ago for pain behind the sternum and difficulty swallowing diagnosed as esophageal candidiasis; positive HIV-antibody test at that time. She has consistently refused ART because "We can't afford it." She was married to Jim a former IV drug abuser for 15 years until his recent death from AIDS-related complications. She has 2 children ages 8 and 10. Her mother who is visiting from Africa also is experiencing a productive cough fevers and night sweats. Her mother has a past history of active TB and it is unclear whether she completed the prescribed course of therapy.

Discharge,

J. Q. is responding to treatment and she is being discharged on: ART Isoniazid Rifampin Pyrazinamide Ethnambutol

Case Study,

J.Q a 36 year - old African American woman was admitted to the hospital in respiratory distress. AIDS and Pneumocystis jiroveci pneumonia were both diagnosed 2 months ago. She experiences fatigue and frequent and frequent oral and vaginal candidiasis infections. She now presents with a productive cough fever weight loss and night sweats. VS in the ED: 90/68, T 100.4F (38 C) HR 120 RR 28 O2 saturation 92% on 3L of oxygen via nasal cannula and right upper lobe crackles The ED nurse inserts a peripheral IV in her right hand starts oxygen at 3L/min. starts 0.9NSS at 125 mL/h and has the lab tech draw ordered labs and sends J.Q. for a chest PA and Lateral.

Precautions,

J.Q. is placed on airborne precautions Reason for precautions: Tuberculosis is an airborne infection (transmitted in airborne particles called droplet nuclei that are expelled when persons with pulmonary or laryngeal TB cough, sneeze, shout, or sing) Mycobacterium tuberculosis can be spread over long distances when suspended in the air. These disease particles are very small and require special respiratory protection and room ventilation.

Background ,

Jan has no significant PMH. Jan has no known allergies. His BMI is 18. He is current on all immunizations.

Back To Jan...,

Jan is initially admitted to the ICU with a diagnosis of DKA and Type 1 DM.

Assessment,

Jan is unresponsive to EMTs when they arrive at his office. Jan's skin is hot and dry. His breathing is deep and fast, at a rate of 28. The EMT obtains a BP of 98/64 and a heart rate of 118. The EMT next obtains a glucose value of 378. When his parents arrive to the ED, they too report that Jan has not been feeling well the past several weeks but they thought he was experiencing stress due to school and his internship, and possibly had a "gastric virus".Based on recent events, it is suspected that Jan has Diabetes.

Left Heart Failure vs. Right Heart Failure,

L-sided HF → results from L ventricular dysfunction. Prevents normal forward blood flow so blood backs up into left atrium and pulmonary veins. ncreased pulmonary pressure causes fluid leakage which leads to pulmonary congestion and pulmonary edema. R-sided HF → results from R ventricular dysfunction. Blood backs up into right atrium + peripheral circulation. Can cause jugular venous distention, hepatomegaly, splenomegaly, vascular congestion of GI tract, peripheral edema. Commonly caused by L-sided HF, or can also be caused by pulmonary hypertension

Assessment,

Later in the shift Mr. J becomes more confused and agitated; he doesn't know where he is and doesn't want to stay in bed. Urine output is 450mL for the previous 24 hours. Mr. J's condition deteriorates quickly over the next few hours: SpO2 82%, T: 104.30F HR 128; RR 30 (shallow) BP 78 by Doppler.

OB Case Study Situation,

Lisa is an 18 year old female, single, who lives with her parents. She is currently 30 weeks pregnant and is admitted to the high risk OB unit direct from her physician's office; Lisa has a severe headache that was not relieved with Tylenol.

Diagnostics,

Made through one of the four following methods A1C of 6.5% or higher Fasting plasma glucose (FPG) level greater than or equal to 126 mg/dL (7.0mmol/L). Fasting is defined as no caloric intake for at least 8 hours Two-hour plasma glucose level greater than or equal to 200 mg/dL (11.1 mmol/L) during an OGTT, using a glucose load of 75g. In a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L). Criteria 1-3 should be confirmed by repeat testing and it should be the same as the original test performed History and PE Blood tests - FBG, postprandial blood glucose, A1C, fructosamine, lipid profile, blood urea nitrogen and serum creatinine, electrolytes, islet cell autoantibodies Urine for complete urinlysis, microalbuminuria, and acetone BP ECG Funduscopic exam (dilated eye exam) Dental exam Neuro exam - monofilament test for sensation to LE's Ankle-brachial index (ABI) Podiatric exam Monitoring of weight

Metformin 500 mg BID ,

Management for Type 2 Diabetes (antidiabetic). purpose= maintains blood glucose by decreasing glucose production, glucose absorption, and increases sensitivity to insulin. Adverse effects= abdominal bloating, diarrhea, nausea and vomiting, unpleasant metallic taste lactic acidosis, and decreased vitamin B12 levels. Labs required= blood glucose level, renal function, folic acid, and B12 levels. DO NOT use IV contrast dye within 48 hours of taking metformin due to the increased risk for lactic acidosis and renal failure!

Provide DOT (Directly Observed Therapy): ,

Requires watching patient swallow drugs. May be administered by public health nurses at clinic sites

Cholestyramine 4G TID,

Management for primary hypercholesterolemia. purpose= decreases plasma cholesterol and low density lipoproteins (LDLS) and decreases pruritus. classification= lipid-lowering agent. Adverse effects= constipation, nausea, hemorrhoids, rash, hyperchloremic acidosis, vitamin A,D,& K deficiency. Labs required. may increase AST, ALT, phosphorus, chloride, and alkaline phosphate. May decrease serum calcium, sodium and potassium levels. May prolong prothrombin time.

Morphine,

Management for relief of moderate to severe pain. Purpose - analgesia, sedation, euphoria, respiratory depression, cough suppression, and suppression of bowel motility. classification - Opioid (Narcotic) Analgesics. Adverse effects - respiratory depression, constipation, orthostatic hypotension, urinary retention, cough suppression, biliary colic, emesis, elevation of ICP, euphoria/dysphoria, sedation, neurotoxicity, miosis. Labs required- LFTs & BUN/Creatinine. Drug interactions: CNS depressants, Anticholinergic drugs Hypotensive drugs Agonist-antagonist opioids Monoamine oxidase Inhibitors Opioid antagonists.

Pathophysiology of Mr. J's Situation,

Managing Septic shock. Major goals: Resuscitate the patient from septic shock by using supportive measures to correct hypoxia, hypotension, and impaired tissue oxygenation (hypoperfusion). Start adequate antibiotics (proper spectrum and dose) as early as possible. Identify the source of infection and treat with antimicrobial therapy, surgery, or both (source control). Maintain adequate organ system function, guided by cardiovascular monitoring, and interrupt the progression of MODS.

Train of Fours,

Measures level of neuromuscular blockage. Normal results will show four equal muscle contractions. Abnormal results will show a loss of twitch height and number. 1-2 twitches indicates appropriate amount of drug given. 3-4 twitches indicates a need for further administration of the drug.

Peak and Trough,

Measures the highest and lowest concentration of a medication in the blood. Used to determine if a medication is consistently within the therapeutic range. Trough is drawn just before the drug is scheduled to be given. Peak is drawn after the drug is administered and reached peak time.

(CBC) Complete blood count,

Measures the number of red blood cells white blood cells total amount of hemoglobin Hematocrit levels (fraction of blood composed of red blood cells) platelet count. This test can show anemia, cancer, infections, kidney or liver disease, heart or lung disease, blood or water loss.

Meds:,

Metformin 500 mg BID. Cholestyramine 4G TID. Albuterol: ii puffs TID-to-QID. Lisinopril 15 mg Daily. Mr. J is admitted the Progressive Care Unit and an IV is inserted. The phlebotomist draws labs: CBC, metabolic panel, coagulation studies, and blood cultures. VS are taken again 15 minutes later and HR is 122, BP 88/54, RR 28, Sat 92% on 2L, temp, 102.60F.

NCLEX Practice #2,

Methergine or pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history? Peripheral vascular disease Hypothyroidism Hypotension Type 1 diabetes Answer is Peripheral vascular disease These medications are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction effects of these medications.

Orders,

Methylergenovine (Methergine) 0.2mg IM D5WLR with 2 units oxytocin run wide open O2 at 6L via nasal cannula Methergine http://www.empr.com/methergine-injection/drug/2702/ Following delivery of the placenta, for routine management of uterine atony, hemorrhage, and subinvolution of the uterus. For control of uterine hemorrhage in the second stage of labor following delivery of the anterior shoulder. Recognizing a hypotonic uterus is important and addressing this with a firm massage of the uterine fundus. Following this, IVF to replace volume lost and to infuse IV oxytocin to aid with increasing uterine contractility. If this fails, 0.2mg of Methergine is given IM to produce sustained uterine contractions. Oxygen is used to enhance oxygen delivery to the cells due to decreased hemoglobin/ blood loss. Methylergonovine (Methergine) .2mg IM Purpose: Treat severe bleeding for the uterus during or after childbirth Action: Works by increasing uterine contractions which helps reduce blood loss Adverse Effects: Headache, nausea and vomiting, allergic reaction (hives, difficulty breathing, tightness in chest etc). Classification: Uterotonic and analgesic

Routine labs: ,

Monitor blood pressure (Central venous pressure may be elevated) Monitor heart rate (may be decreased) Monitor Prolactin BP: may be elevated due to peripheral vasoconstriction primarily of postcapillary vessels; has sometimes been associated with preeclampsia, history of hypertension, intravenous administration of methylergonovine, or concurrent use of local anesthetics containing vasoconstrictors {13}; hypotension has also been reported Heart rate: (may be decreased due primarily to an increase in vagal tone, and possibly to decreased central sympathetic activity and direct depression of the myocardium Prolactin: serum concentrations may be decreased Prolactin is a hormone produced by the pituitary gland and its primary role is to help initiate and maintain breast milk production in pregnant and nursing women

Ongoing Monitoring - DKA,

Monitor vitals, LOC, cardiac rhythm (hyperkalemia), O2 sats and urine output Assess breath sounds for fluid overload Monitor serum glucose and serum potassium Administer potassium to correct hypokalemia Administer sodium bicarbonate if severe acidosis (pH<7.0)

Implementation ,

Mr. Blake's plan of care is below. Discuss how you might actually put the interventions into action.

Background,

Mr. Blake's wife provides further history. Her husband is a construction contractor who served in the U.S. National Guard during the Iraq War. He lost half his squad from a roadside bombing, narrowly escaping with his life. He walks with a permanent limp due to the attack. Upon returning home, he showed no signs of anxiety and refused offers of crisis treatment, stating, "I was in a war; I can handle stress." But six months later, Mrs. Blake noticed that her husband had trouble sleeping, his mood was irritable or withdrawn, he avoided news reports on television, and he started to drink daily. He complained of nightmares but would not talk to her about his fears. He only agreed to go to his primary care nurse practitioner to request sleeping medication.

Lab Results,

Mr. J's most recent labs are: · ABG: pH: 7.49 pCO2 30 pO2 90 (fiO2 50%) Now Alkalotic d/t vent · CBC: WBC 28.6 (high) RC 4 (low) Hgb 13 (normal) platelets 135000 (low). · CMP: Na 134 (low) K 5.6 (high) Creat: 3.4 (high) BUN 28 (high) Glucose 250 (high)

Situation,

Mr. J. a 67 year old Hispanic male, injured his foot while working in the yard. The area around the wound has gotten progressively redder, is more tender, and is now warm to touch; Mr. J notes purulent drainage on his sock. Today the pain in his foot is causing him difficulty in walking. He feels weak and has complaint of chills. Because it's a weekend, his wife drives him to the nearest urgent care center. The nurse at the urgent care center obtains the following VS: HR 116 RR 24 Temp 102.50F BP 104/62 and Sat 91% on RA Mr. J is told to go to the hospital because he has a serious infection and will need intravenous antibiotics. His wife drives him to the closest hospital.

Background,

Mr. J. has comorbidities of DM Type2, asthma, hypertension, and elevated cholesterol levels. He is alert and oriented X3 and weighs 110 Kg.

Nurse Self-Assessment,

Ms. Dawson is a registered nurse with 3 years of experience on this unit. Initially she feels sympathy for Mr. Blake, and he reminds her of her Uncle James, who served in Vietnam. She is concerned because his suicide plan was lethal and he is guarded in his speech, not revealing his thoughts or feelings. She realizes that as she implements suicide precautions, she must demonstrate an attitude of hope and acceptance to encourage him to develop trust. Also, she must stay neutral and not convey any pity or sympathy.

Medications used for MDR-TB: ,

Multidrug-resistant tuberculosis occurs when the bacteria that cause TB develop resistance to the antimicrobial drugs used to cure the disease. MDR-TB does not respond to isoniazid and rifampicin, the two most powerful anti-TB drugs. The treatment of drug resistant TB has always been more difficult than the treatment of drug susceptible TB. It required the use of "second line" or reverse drugs that are more costly and cause more side effects The drugs must be taken for up to two years This led to the development of the shorter Bangladesh regimen which appears to have higher cure rates and the drugs only need to be taken for eight to nine months.

Carlo's Past Medical History,

Myocardial infarction (MI) with coronary artery bypass graft (CABG x3). systolic heart failure secondary to ischemic cardiomyopathy. Implantable cardioverter defibrillator (ICD) inserted after CABG surgery. Atrial fibrillation. Hyperlipidemia. Chronic kidney insufficiency (CKI).

Labs:,

Need to check serum electrolyte concentrations, acid base imbalance 2 Units of Oxytocin Run Wide Open Purpose: It can cause or strengthen labor contractions during childbirth, and control bleeding after childbirth. It can also be used to induce abortion. Classification: Hormone and brain neurotransmitter Side effects: redness, irritation, nausea, vomiting, loss of appetite, stomach pain etc Action: Oxytocin works by increasing the concentration of calcium inside muscle cells that control contraction of the uterus O2 at 6L via nasal cannula O2 is important in this case because hgb levels are low Hemoglobin is a protein in RBC's that carry O2 to the cells Low O2 levels could lead to hypoxia Enhancing the delivery of O2 to the cells by applying nasal cannula Effects determined by pulse oximetry reading >90%, but ideally 95-100% These are some of the side effects of oxygen therapy: Bloody nose or skin irritation where oxygen is administered. Morning headaches. Fatigue.

What is the Bangladesh Regimen?,

Nine-month treatment regimen for MDR-TB patients Recommended by the World Health Organization (WHO) The intention was to develop an effective, safe and inexpensive treatment regimen Drugs used: Gatifloxacin Clofazimine Ehambutol pyrazinamide

2016 NPSGs

No new Goals for 2016 Clinical Alarms NPSG: Phase 2 is now effective. Hospitals are expected to establish and implement policies and procedures for managing clinical alarms and to educate individuals about alarm systems.

Pancuronium & Nursing Interventions:,

Non-depolarizing neuromuscular blocking agent reduces the response of the motor end plate to acetylcholine (anesthetic). Used to provide skeletal muscle relaxation during mechanical ventilation. Use Train of Fours (TOF) prior to and during to monitor neuromuscular blocking effect. Has no effect on consciousness pain threshold or cerebration. This should be used with a sedative (Lorazepam). Adverse reactions- hypotension tachycardia apnea bronchospasms respiratory depression rash paralysis and anaphylactic reactions.

Adherence to therapy:

Noncompliance is a major factor in multi-drug resistance and treatment for TB, Assess the patient and develop a treatment plan Explain the importance of adherence and provide patient education Establish efficient clinic systems for scheduling appointments, keeping records, and providing pharmacy services

Ventricular Tachycardia,

Occurs when an ectopic focus or foci fire repeatedly and the ventricle takes control as the pacemaker. Life threatening dysrhythmia because of decreased CO. VT is associated with MI, CAD, electrolyte imbalances, cardiomyopathy, etc. Could lead to ventricular fibrillation

Drugs Used for Active Tuberculosis Infection Currently there are 10 drugs approved by the U.S. Food and Drug Administration (FDA) for treating TB. ,

Of the approved drugs, the first-line anti-TB agents that form the core of treatment regimens are: isoniazid (INH) rifampin (RIF) ethambutol (EMB) pyrazinamide (PZA)

Isoniazid and Rifapentine

Once weekly for 3 months Treatment for persons 12 years or older Not recommended for persons who are: Younger than 2 years old, Living with HIV/AIDS taking antiretroviral treatment, Presumed infected with INH or RIF-resistant M. tuberculosis, and Women who are pregnant or expect to become pregnant within the 12-week regimen. Rifampin Daily for 4 months

Patient Safety Advisory Group,

Panel of widely recognized patient safety experts Nurses, physicians, pharmacists, risk managers, clinical engineers, other professionals Hands-on experience in ddressing patient safety issues in wide variety of health care settings Advises The Joint Commission how to address emerging patient safety issues NPSGs, Sentinel Event Alerts, standards and survey processes, performance measures, educational materials, Center for Transforming Healthcare projects

Collaborative Therapy,

Patient and caregiver teaching and follow up programs Nutritional therapy Exercise therapy Self-monitoring of blood glucose Drug therapy Insulin Oral and non-insulin injectable agents Enteric coated aspirin (81-162 mg/day) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Antihypertensive drugs

Outcomes Identification,

Patient will consistently refrain from attempting suicide.

Who should be treated for latent TB?,

Patients with a clinically significant result on tuberculin skin testing or a positive interferon-gamma release assay (IGRA) result once active infection and disease are ruled out. Contacts known or suspected to be HIV infected or who have other serious immunocompromising conditions should be started on treatment for LTBI regardless of their IGRA or TST result after TB disease has been excluded. People who have a positive IGRA result or a TST reaction of 5 or more millimeters HIV-infected persons Recent contacts of persons with infectious TB disease Persons with fibrotic changes on chest radiograph consistent with prior TB disease Patients with organ transplants and other immunosuppressed patients People who have a positive IGRA result or a TST reaction of 10 or more millimeters Recent arrivals to the United States (<5 years) from high-prevalence areas (e.g., Asia, Africa, Eastern Europe, Russia, or Latin America) Injection drug users Residents and employees of high-risk congregate settings (e.g., correctional facilities, nursing homes, homeless shelters, hospitals, or other health-care facilities) Mycobacteriology laboratory personnel Persons with medical conditions that increase the risk for progression to TB disease, including silicosis, diabetes mellitus, chronic renal failure, certain types of cancer (e.g., leukemia and lymphomas, or cancer of the head, neck or lung), gastrectomy or jejunoileal bypass, and weight loss of at least 10% below body weight Children younger than 5 years of age; or children and adolescents exposed to adults in high-risk categories

Change:

People and Innovation, Innovation Early adopters Early majority Late majority Laggards What have YOU observed? What can YOU change?

Would you place J.Q. on transmission based precautions? Why?,

Place J.Q. on airborne precautions because TB is spread in the air and are small particles that require respiratory protection and air ventilation Non Powered respirator N95 filter minimum

Quality Improvement and Change,

Plan Do Study Act

What laboratory tests do you expect to be ordered? Why?,

Pneumocystis pneumonia is an opportunistic infection found frequently in people with AIDs. Symptoms are Cough Fever Rapid breathing Shortness of breath especially on exertion Since the patent is exhibiting these symptoms the testing we will do to confirm this are Blood gasses Bronchoscopy Lung biopsy X-ray of the chest Sputum exam to check for fungus that causes the infection CBC b-13 glucan level of the blood

What are you looking for on the chest XRay?,

Pneumothorax or collapsed lung can be caused by TB and is checked with a chest x-ray The patient is exhibiting symptoms which point to a pneumothorax shortness of breath, easily fatigued, and rapid heart rate

Post-delivery complication,

Postpartum eclampsia Postpartum eclampsia is essentially postpartum preeclampsia plus seizures. Pulmonary edema This life-threatening lung condition occurs when excess fluid develops in the lungs. Stroke Thromboembolism HELLP Syndrome

Pathophysiology,

Preeclampsia A progressive form of Pregnancy Induced Hypertension (PIH) Pregnancy-specific syndrome Hypertension that develops after 20 weeks of gestation in previously normotensive woman Disease of reduced organ perfusion with presence of hypertension and proteinuria Can be mild to severe Signs and symptoms develop only during pregnancy and disappear after birth Associated high risk factors Primigravida Multifetal pregnancy Obesity Before age 20 and after age 40 Differs from chronic hypertension Main pathogenic factor is not an increase in BP, but poor perfusion resulting from vasospasm Arteriolar vasospasm diminishes diameter of blood vessels, which impedes blood flow to all organs and increases BP Function in placenta, kidneys, liver, and brain is depressed as much as 40% to 60% Severe Preeclampsia Proteinuria (>5g/day) BP >160 systolic mm hg BP >110 diastolic mm hg Cerebral disturbances (HA, visual changes) Systemic and pulmonary edema Hepatic tenderness HELLP

Assessments,

Preeclampsia Assess Deep Tendon Reflexes Strict Intake and Output (foley) Vital signs- q 30 minutes LOC Assess for Clonus FHR Assess Magnesium levels 1.3 to 2.1 mEq/l (theraputic 4-7) Assess for Mag Toxicity Magnesium Sulfate Toxicity Antidote Calcium gluconate Excess magnesium sulfate results in magnesium sulfate toxicity, which results in both respiratory depression and a loss of deep tendon reflexes (hyporeflexia) 1 gm of 10% given IV over 3 minutes

TB Classification,

Primary: When bacteria is inhaled. Latent: Infected but no active disease. Period of time when the immune system has been successful in containing TB and preventing disease. Active: Primary TB. TB breaks out of latency. Begins multiplying and causes disease. Person will feel sick and is contagious. Reactivation TB (post-primary)

Pathophysiology of Type 2 Diabetes,

Production of inadequate amounts of insulin to meet the demands of the body or insulin resistance has developed Insulin resistance refers to when cells of the body such as the muscle, liver and fat cells fail to respond to insulin, even when levels are high In fat cells, triglycerides are instead broken down to produce free fatty acids for energy; muscle cells are deprived of an energy source and liver cells fail to build up glycogen stores. This also leads to an overall rise in the level of glucose in the blood. Glycogen stores become markedly reduced and there is less glucose available for release when it may be needed. In type 2 diabetes instead of moving into your cells, sugar builds up in your bloodstream. As blood sugar levels increase, the insulin-producing beta cells in the pancreas release more insulin, but eventually these cells become impaired and can't make enough insulin to meet the body's demands.

Treatment for Ventricular Tachycardia,

Pulse present: IV procainamide or amiodarone can be used, then cardioversion if drug therapy is ineffective. Without a pulse present: CPR and rapid defibrillation are used then administration of vasopressors and antidysrhythmics if defibrillation is unsuccessful. Mr. J is orally intubated during the code and transferred to the ICU. Upon arrival to the ICU Mr. J is unresponsive. A PICC line is inserted via his left brachial vein. Mr. J is on a ventilator with the following settings: FiO2: .6; RR: 12 SIMV, Vt 1000cc. VS: T 103.0F HR 126 RR 18 BP 84/62

Lisinopril 15 mg Daily,

Purpose - Management for Hypertension, heart failure and to help improve survival after Myocardial infarction. Classification - ACE inhibitors block the conversion of angiotensin I to angiotensin II (antihypertensives). Adverse Effects - Blurred vision, cloudy urine, confusion, sweating, lightheadedness, decrease in urine output, weakness. Labs required - Monitor BUN, creatinine, electrolytes, and CBC. May increase serum potassium, BUN and creatinine. (lower dose if this occurs). May decrease serum sodium. May decrease hemoglobin, hematocrit, and agranulocytosis in patients with collagen vascular disease and/or renal disease. Can also be used to delay onset of overt neuropathy and can slow the progression of renal disease. ACE inhibitors reduces the glomerular filtration pressure by reducing levels of angiotensin II.

Dopamine,

Purpose Shock: major indication for shock. Increases cardiac output by activating beta1 receptors which increases tissue perfusion. dilates renal blood vessels which increases renal perfusion. Heart failure: Helps relieve symptoms by activating beta1 receptors on the heart which increases myocardial contractility and increases cardiac output. Acute renal failure: Low dose dopamine increases renal blood flow and urine output. Can preserve renal function. Classification - Adrenergic Agonists. Adverse effects - tachycardia dysrhythmias anginal pain dyspnea N/V. Labs required - monitor output of urine. Drug interactions: MAO inhibitors, tricyclic antidepressants certain general anesthetics. Diuretics can complement the beneficial effects of dopamine on the kidney

Magnesium Sulfate

Purpose of medication: To prevent or control seizures in preeclampsia or eclampsia Medication classification: Anticonvulsant Potential adverse effects: Depresses reflexes, flushing, hypotension, bradycardia, circulatory collapse, and/or respiratory paralysis Routine labs required for monitoring drug effects: May increase magnesium level and decrease calcium level Magnesium Sulfate Toxicity Decreased DTRs to loss of DTRs EKG changes (prolonged P-R and S-T, or heart block) Sleepiness or drowsiness Respiratory arrest Cardiac arrest

D5WLR- Dextrose 5% Lactated Ringer,

Purpose: Fluid and electrolyte replenishment and caloric supply in a single dose container for intravenous administration.Classification: Nonpyrogenic solution Side effects: Allergic reactions or anaphylactoid symptoms such as localized or generalized urticaria and pruritis; periorbital, facial, and/or laryngeal edema, hypervolemia, phlebitis, coughing, sneezing, and/or difficulty with breathing. **** The reporting frequency of these signs and symptoms is higher in women during pregnancy.

Norepinephrine,

Purpose: To increase vasoconstriction and myocardial stimulation which increases blood pressure and cardiac output. Drug Class: Vasopressor. Administration Guidelines: Vasoactive medications should be checked by a second practitioner to confirm dose and pump programming. For continuous infusion titrate infusion rate according to patient response. Check BP every 2 to 3 minutes until stabilized and every 5 minutes after that. Labs: None needed. Possible Adverse Effects: dyspnea arrhythmias bradycardia chest pain hypertension metabolic acidosis decreased renal output.

Levofloxacin,

Purpose: Treatment of bacterial infection. Drug Class: Anti-infective. Administration Guidelines: Should be diluted administer 750 mg by infusion over 90 minutes. Labs: May affect glucose levels. Possible Adverse Effects: elevated ICP seizures hepatotoxicity steven-johnson syndrome.

Vancomycin,

Purpose: Treatment of infection. Drug Class: Anti-infective. Administration Guidelines: Infuse over at least 60 minutes. Labs: Peak and trough levels (trough levels should be 15 to 20 mcg/mL for severe infections). Possible Adverse Effects: nephrotoxicity ototoxicity hypotension, N/V

The delivery,

ROM with large amount of clear fluid Baby is born with next contraction with feet covered in blood Emergency protocol given: 10 units oxytocin IM Female infant has very short cord EBL: 700 cc BP: 118/80; P: 100 Boggy fundus, you begin continuous massage Pt alert and talkative Placenta intact and unremarkable except for a total cord length of 9 inches Perineum intact Fundus firms slightly, +1, moderate trickle bleed ROM-rupture of membranes Estimated blood loss-EBL Concerns: Large EBL (700cc); this is not normal for a vaginal delivery Normal EBL is 500cc Short cord is anything under 13.7 inches (35 cm) and cord was only 9 inches; normal is 21.6-23.6 inches (or 55-60 cm) This can affect growth and development Associated with fetal distress, umbilical cord rupture and hemorrhage Can cause low Apgar scores Associated with higher fetal mortality rates Short cord can cause partial or complete abruption of placenta http://www.chw.org/medical-care/fetal-concerns-center/conditions/pregnancy-complications/postpartum-hemorrhage Short Umbilical Cord has been associated with fetal distress, umbilical cord rupture and hemorrhage. Studies have shown that Short Umbilical Cord can cause low Apgar scores. Apgar scores are used to assess the overall health and well-being of a child, immediately after birth Short Umbilical Cord requires appropriate treatment for an optimal outcome. The prognosis is dependent upon the severity of the condition and the stage of pregnancy. Nevertheless, a Short Cord is associated with higher fetal mortality rates

Hemophilia,

Rare disorder where your blood doesn't clot properly Lack of sufficient clotting factors Bleed for a longer time after an injury Deep bleeding inside body can occur, especially in joints Damage to tissues and organs and can be life-threatening Concern: genetic disorder with no cure; Amish culture does not seek out preventative medicine because they have faith-based healing and there are no medical records for Ruth in order to see if she has a bleeding disorder herself Hemophilia is a rare disorder in which your blood doesn't clot normally because it lacks sufficient blood-clotting proteins (clotting factors). If you have hemophilia, you may bleed for a longer time after an injury than you would if your blood clotted normally. Small cuts usually aren't much of a problem. The greater health concern is deep bleeding inside your body, especially in your knees, ankles and elbows. That internal bleeding can damage your organs and tissues, and may be life-threatening. Hemophilia is an inherited (genetic) disorder. There's no cure yet. But with proper treatment and self-care, most people with hemophilia can maintain an active, productive lifestyle https://www.cdc.gov/ncbddd/hemophilia/diagnosis.html http://www.mayoclinic.org/diseases-conditions/hemophilia/basics/definition/con-20029824

Population most at risk for TB,

Rates of TB for Different Racial and Ethnic Groups American Indians or Alaska Natives: 6.1 TB cases per 100,000 persons Asians: 18.2 TB cases per 100,000 persons Blacks or African Americans: 5.0 TB cases per 100,000 persons Native Hawaiians and other Pacific Islanders: 18.2 TB cases per 100,000 persons Hispanics or Latinos: 4.8 TB cases per 100,000 persons Whites: 0.6 TB cases per 100,000 persons

Regimens of TB Disease Treatment

Regimens for treating TB disease have an intensive phase of 2 months, followed by a continuation phase of either 4 or 7 months (total of 6 to 9 months for treatment).

Nursing Diagnoses for Jan,

Risk for Unstable Blood Glucose Level Risk factors: insulin deficiency with inability to use nutrients Outcomes: maintains BG and glycosylated hemoglobin levels within range Risk for Ineffective Therapeutic Regimen Management Risk factors: new-onset diabetes, insufficient knowledge Outcomes: demonstrates knowledge of diabetes self-care management

Nursing Diagnosis for Ruth #2,

Risk for deficient fluid volume related to excessive blood loss after birth. Outcome: Patient will have a lochia flow of less than one saturated perineal pad per 4 hours. Interventions: Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and if possible save blood clots to be evaluated by the physician. The amount of blood loss and the presence of blood clots will help to determine the appropriate replacement need of the patient. Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis. The degree of the contractility of the uterus will measure the status of the blood loss. Placing one hand just above the symphysis pubis will prevent possible uterine inversion during a massage. Monitor vital signs including systolic and diastolic blood pressure, pulse and heart rate. Check for the capillary refill and observe nail beds and mucous membranes. Increased heart rate, low blood pressure, cyanosis, delayed capillary refill indicates hypovolemia and impending shock. Decrease fluid volume of 30-50% will reflect changes in the blood pressure. Note for the presence of vulvar hematoma and apply an ice pack if indicated. Small hematoma can be managed by an ice pack and rest.

Nursing Diagnosis for Ruth #3,

Risk for excess fluid volume related to excessive/rapid replacement of fluid losses. Outcome: Ruth will maintain vital signs such as pulse and blood pressure, as well as urine specific gravity and neurologic function within normal ranges without any respiratory complications during stay. Interventions: Assess neurologic status, observing for any behavioral changes and increasing irritable episodes. Changes in the neurologic status or behavior may serve as early signs of cerebral edema caused by the fluid retention. Monitor for signs of hypertension and tachycardia; Observe for signs of dyspnea; Auscultate for signs of stridor, rhonchi or moist crackles. Symptoms of circulatory overload and respiratory difficulties may occur as a result of excessive fluid replacement. Monitor for the intake/output, urine specific gravity if indicated. Check the infusion rate of the fluids manually or preferably through the use of infusion pumps. With the stabilization of fluid levels, intake should approximate/equal to the output; Urine specific gravity results change inversely to output so that as kidney function improves, specific gravity readings decreases, and vice versa. Note: In the client with glomerular spasms caused by pregnancy-induced hypertension (PIH), the output may reduce until extracellular fluids return to the general circulation. Monitor the hematocrit levels. As plasma volume is restored, the hematocrit level decreases.

Priority teaching needs before discharge:

Screening needs for family members: J.Q's children should be screened for TB and HIV J.Q's mother should be screened for TB due to past history and uncertainty of completed course of therapy PREVENT THE SPREAD OF TB: Make sure family, friends, and the people you work with are tested Avoid close contact with others until your healthcare provider says it is OK Keep your hands clean. Be sure to wash them every time you use them to cover your mouth when you cough When you cough or sneeze, take steps to prevent the spread: Cover your mouth and nose with a tissue Put your used tissue in a closed bag and throw it away If you do not have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands Wash your hands often with soap and warm water for 20 seconds. If soap and water are not available, use an alcohol-based hand gel. Home Care: Take your medicine exactly as directed. Continue taking even if you start to feel better Not taking your medications for the full course may lead you to get sick again and increases your chance of MDR-TB If you are taking birth control pills, use an additional backup method Check with your HCP before taking any OTC medications Sleep in room alone and with good airflow (ventilation) Limit your activity to avoid feeling tired. Plan frequent rest periods Keep your health care appointments Follow-up care: Do not leave until you have a follow-up appointment scheduled Reschedule missed appointments PROMPTLY When to seek medical care: Call 911 right away if you have any of the following: Chest pain or shortness of breath Blue lips or fingernails Call your healthcare provider if you have any of the following: Fever of 100.4 F or higher Bloody material (sputum) that is coughed up from your lungs and into your mouth Worsening or recurring night sweats Increased coughing

Patient Assessment,

Screening tools include: The Primary Care PTSD Screen (PC-PTSD) (Veteran Affairs/Department of Defense, 2012) Impact of Events Scale (IES) (Horowitz et al., 1979) (Box 16-2) Impact of Events Scale-Revised (IES-R) (Weiss & Marmar, 1997) PTSD Checklist (PCL) (Lang & Stein, 2005) A more comprehensive assessment is indicated for those who initially screen positive. Additional history about the time of onset, frequency, course, severity, level of distress, and degree of functional impairment is important. Further assessment for suicidal or violent ideation, family and social supports, insomnia, social withdrawal, functional impairment, current life stressors, medication, past medical psychiatric history, and a Mental Status Exam are indicated (refer to Chapter 7).

SEPTIC SHOCK,

Sepsis with hypotension despite adequate fluid resuscitation, associated with hypoperfusion. Abnormalities. Signs and Symptoms. Typically non-specific. Fever chills, or rigors. Myocardial dysfunction. Confusion. Anxiety. Difficulty breathing. Fatigue malaise. Nausea and vomiting. Decreased urine output.

Carlo's Assessment,

Shortly after arrival to the unit, Carlo becomes anxious and restless. The nurse assesses Carlo and finds: AAOx3; restless Due to reduced oxygenation and decreased CO Coarse crackles scattered throughout both lung fields Due to pulmonary congestion and fluid filling the alveoli Carlo's CXR report stating "Bilateral diffuse pulmonary infiltrates consistent with pulmonary edema" is significant because if not treated, can lead to respiratory failure or cardiac arrest Labored respiratory effort despite patient sitting upright. Patient can only speak 4 words before needing to take a breath Due to pulmonary congestion; Carlo is trying to get good ventilation Atrial fibrillation on monitor, heart sounds irregular Due to the compensatory sympathetic mechanism trying to pump more blood and increase CO but causing an irregular pulse. This further complicates Carlo's heart failure because his heart is not contracting and relaxing to a regular beat

SBAR,

Situation. Ruth Stolzfus, F, 37 y/o; G11, P8, A2, L8; Planning homebirth; Late on receiving prenatal care @ 36 weeks gestation; all previous deliveries homebirths; pt states that she "bleeds a little too much"; pt and midwife want nurse for active 3rd stage of labor Background. Midwife controlled bleeding with herbs in past; received a "shot" from the home care nurse after delivery but does not want one this time; weakness after deliveries; varicosities in each leg with one episode prior to onset of prenatal care with swelling, lump, pain, redness, and heat in R calf following a bump to the leg; no medical care, pt used vinegar soaked bread compresses applied to leg and s/s resolved; pt does not have any medical records from previous care Gravida-how many times a woman has been pregnant Parity-# of deliveries past 20 weeks A-abortion <20 weeks L-Live child Situation: Ruth Stolzfus is a 37 year Amish woman with a significant OB history: G11, P8, A2, L8 planning a homebirth. Entry into prenatal care is late @ 36 weeks gestation. All her previous deliveries were homebirths performed by the local midwife. The client states that she usually bleeds "a little too much" after her deliveries. With the anticipation of complications, Mrs. Stolzfus and the Amish midwife have agreed to participation of a maternity nurse for the active 3rd stage of labor. Background: Prior to her last delivery her midwife controlled the bleeding with herbs. Following the last delivery she got a "shot" from the home care nurse but thought it was unnecessary and doesn't want one this time. She describes being weak for a long time after all her deliveries. Prenatal course is complicated by a varicosity in each leg with one episode prior to onset of prenatal care that is described by the patient as swelling, lump, pain, redness and heat in her R calf following a bump to the leg. The patient did not see a doctor, but stayed in bed for 3 days with vinegar soaked bread compresses applied to the leg. All signs and symptoms are resolved at this time. Patient does not have any medical records from previous care. The Amish midwife does not keep medical records. The home health agency that had provided care at previous deliveries has gone out of business. Assessment. Prenatal exam WNL; Hgb: 10.7 Contractions are strong and irregular q5-8 minutes 8 cm dilated, 90% effaced, -3 station, membranes intact and bulging bag FHR 132-144 BP 122/77 P 88 Recommendation. Monitor FHR Monitor I&O Monitor BP Type and Screen- no prior records The prenatal exam was WNL. Lab results indicate: Hgb: 10.7.

Carlo's Assessment Cont.,

Skin pale and cool to touch, LE peripheral pulses +1 Due to decreased CO and peripheral vasoconstriction in an attempt to bring more blood to the heart Pitting edema 3/4 in both lower extremities Due to the body holding on to Na+ and water Abdominal assessment negative; positive BS all 4 quadrants Urine clear yellow, no difficulty voiding

Pathophysiology of TB

Spread via tiny airborne droplets Caused by M. tuberculosis mycobacterium Transmission requires close frequent or prolonged exposure TB is NOT spread by touching sharing food utensils or other physical contact Once inhaled particles lodge in bronchioles and alveoli Local inflammatory reaction occurs Infection can become latent cleared, or produce TB Only active TB can be spread

Systemic Inflammatory Response Syndrome (SIRS),

Systemic inflammatory response to a variety of severe clinical insults manifested by two or more of the following conditions: Temperature: >38ºC or <36ºC. Heart rate: >90 beats/min. Respiratory: >20 breaths/min or PaCO₂, <32 torr (<4.3kPa). White blood cell count >12000 cells/mm3 <4000 cells/mm3 or 10% immature (band) cells.

Pathophysiology of Systolic Heart Failure,

Systolic heart failure results from an inability of the heart's ventricles to contract and pump blood effectively to meet the body's metabolic needs. Initially the heart may try to increase CO by increasing the stroke volume (the amount of blood that is ejected with each beat). It does this by stretching (Frank-Starling law) but it can only do so much. Carlo's HF is caused by a weakened heart muscle and impaired contractile function due to his ischemic cardiomyopathy. The decrease in CO leads to activation of compensatory mechanisms. Sympathetic nervous system (increases heart rate, causes vasoconstriction). Renin-angiotensin - aldosterone system (causes further arteriole vasoconstriction, Na+ and water retention). The decreased CO that is caused by Carlo's chronic HF also resulted in decreased perfusion to the kidneys which led to his renal insufficiency which we saw in his past medical history. Compensatory mechanisms can initially restore CO but if sustained, can be harmful by increasing cardiac stress and increasing energy/oxygen use. This eventually exacerbates the cycle of heart failure. A hallmark of systolic failure is a decrease in the left ventricular ejection fraction (EF). EF is the amount of blood ejected from the LV with each contraction. Normal EF is 55% to 60%. Patients with systolic HF generally have an EF less than 45% and can be as low as 10%. Carlo's EF is 15% meaning that his heart is not working very well in pumping blood into his circulation.

Labs/tests,

T&S hemolyzed AST 90; ALT 78 AST- HIGH 10-40 units per liter ALT- HIGH 7-56 units per liter Platelets 86,000 - Low Uric acid 6.0 WNL 2.4-6.0 mg/dL

Characteristics of Septic Shock,

Tachycardia; depressed contractility. Systemic vasodilation and hypotension. Compromised nutrient blood flow to organs. Vascular leakage and edema; hypovolemia. Abnormal blood gases and acidosis. Disseminated intravascular coagulation. respiratory distress and multiple organ failure. Respiratory alkalosis. Respiratory failure. Acute respiratory distress syndrome (ARDS). Decreased urine output. GI dysfunction. Bleed. Paralytic ileus

A clinical instructor teaches a class for the public about diabetes mellitus. Which individual does the nurse assess as being at highest risk for developing diabetes?

The 50-year old client who does not get any physical exercise. The 56-year old client who drinks three glasses of wine each evening. The 42-year old who is 50 pounds overweight The 38-year old who smokes one pack of cigarettes per day Answer: C Explanation: Obesity increases the likelihood of developing diabetes mellitus due to over stimulation of the endocrine system. Exercise is important, but lack of exercise is not as big a risk factor as obesity. Smoking is a serious health concern but is not a specific risk factor for diabetes. Consuming alcohol is associated with liver disease but is not as high a risk factor for diabetes as obesity

2016 National Patient Safety Goals

The National Patient Safety Goals (NPSGs) were established in 2002 to help accredited organizations address specific areas of concern in regards to patient safety, The first set of NPSGs was effective January 1, 2003 The Patient Safety Advisory Group advises The Joint Commission on the development and updating of NPSGs

Pharmacotherapy ,

The following medications may be used in the management of septic shock: Alpha-/beta-adrenergic agonists (eg, norepinephrine, dopamine, dobutamine, epinephrine, vasopressin, phenylephrine). Isotonic crystalloids (eg, normal saline, lactated Ringer solution). Volume expanders (eg, albumin). Antibiotics (eg, cefotaxime ticarcillin-clavulanate piperacillin-tazobactam imipenem-cilastatin meropenem clindamycin, metronidazole ceftriaxone ciprofloxacin cefepime levofloxacin vancomycin). orticosteroids (eg, hydrocortisone, dexamethasone).

Planning,

The initial plan is to maintain safety for Mr. Blake while encouraging him to express feelings and recognize that his situation is not hopeless.

Diagnosis ,

The initial plan is to maintain safety for Mr. Blake while encouraging him to express feelings and recognize that his situation is not hopeless. His nursing diagnosis is: Risk for suicide as evidence by suicidal plan and verbalization of intent.

NCLEX Practice #1,

The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? Obtain hemoglobin and hematocrit levels Instruct the mother to request help when getting out of bed Elevate the mother's legs Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of light-headedness and dizziness have subsided. Answer is Instruct the mother to request help when getting out of bed Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a physicians order.

What is the cure for this patient's condition?,

The only cure for preeclampsia is delivery If it is too early in pregnancy for delivery, patient must remain on bed rest and have frequent prenatal visits More frequent blood tests, ultrasounds and nonstress tests

ART in HIV-infected patients with TB:,

The optimal timing to commence ART in HIV-infected patients with TB is relatively complex Additive toxicities, drug-drug interactions, and TB associated immune reconstitution inflammatory syndrome may occur. According to WHO, ART should be started as soon as possible within the first 8 weeks

Pathophysiology of Postpartum hemorrhage,

The placenta separates from the uterine interface, exposing maternal blood vessels that interface with the placental surface. Uterine atony, or diminished myometrial contractility, accounts for 80% of postpartum hemorrhage. EBL more than 500 ml (vaginal) and 1000 ml (C-section)

SEPSIS,

The presence of SIRS associated with a confirmed infectious process. Signs and symptoms: Body temperature above 101 F (38.3 C) or below 96.8 F (36 C). Heart rate higher than 90 beats a minute. Respiratory rate higher than 20 breaths a minute. Fever. Hypothermia. Heart rate >90 bpm. Fast respiratory rate (>20 breaths per minute). confusion/coma. Edema. High blood glucose without diabetes. nausea/vomiting. Diarrhea.

Pathophysiology of Type 1 Diabetes,

The prevalence of type 1 DM is increased in patients with other autoimmune diseases, such as Graves disease, Hashimoto thyroiditis, and Addison's disease Some researchers have suggested that the development of antibodies against proteins in cow's milk may also lead to the development of antibodies that attack the beta cells of the pancreas. There is speculation that lack of vitamin D in the first year of a child's life may raise the risk of type 1 diabetes developing.

What screening tests for TB do you expect to be ordered and why?,

The tuberculosis (TB) blood test also called an Interferon Gamma Release Assay or IGRA There are two kinds of TB blood tests: QuantiFERON®-TB T-SPOT®.TB You should Test for TB for a patient with HIV or a weak immune system. This patient is exhibiting symptoms of an active TB infection persistent coughing that may contain blood night sweats fever weight loss chills and fatigue. Tuberculin skin test (TST) would be done if you could wait 72 hrs for the results

Concerns regarding her use of prenatal vitamins and TUMS,

There is a moderate interaction between Prenatal Vitamins and Tums. She may want to consult her healthcare provider and consider another combination. What medications do you anticipate the doctor will order and why? Magnesium sulfate because it is an anticonvulsant that will prevent seizures by decreasing neuromuscular irritability

Bronchoscopy,

This will allow the doctor to examine the airways and check for lung disease or infection.

Pathophysiology of Septic Shock,

Three major effects: Vasodilation Maldistribution of blood flow Myocardial depression Invasion of microorganism Cytokines TNF(tumor necrosis factor) interleukin-1, & platelet activating factors are released Inflammation & coagulation increases, fibrinolysis decreases Damage to the endothelium, vasodilation, increased capillary permeability and neutrophil and platelet aggregation occurs

Nutritional Therapy,

Total Carbohydrates Minimum of 130 g/day Include carbs from fruits, veggies, grains, legumes and low-fat milk Monitor by carb counting, exchange lists or use of appropriate portions Glycemic index may provide additional benefit Sucrose-containing food can be substituted for other carbs in the meal plan Fiber intake of 25-30 g/day Nonnutritive sweeteners are safe when consumed within FDA daily intake levels Protein 15-20% of total caloris High-protein diets are not recommended for weight loss Fat Limit saturated fat to <7% of total calories Trans fat should be minimized Dietary cholesterol <200 mg.day > 2 servings of fish per week to provide polyunsaturated fatty acids Alcohol Limit to moderate amount (max 1 drink per day for women and 2 drinks per day for men) Alcohol should be consumed with food to reduce the risk of nocturnal hypoglycemia in those using insulin or insulin secretagogues Moderate alcohol consumption has no acute effect on glucose and insulin concentrations but carbohydrate taken with alcohol (mixed drink) may raise blood glucose

The patient with DM type 1 is found unresponsive in the clinical setting. Which nursing action is a priority? Arrange from 1 to 4.

Treat the client for hypoglycemia. Call the physician STAT. Assess the vital signs. Call a code. 1, 2, 3, 4 1, 3, 2, 4 3, 1, 2, 4 4, 3, 2, 1 Answer: A Explanation: When a patient with diabetes mellitus type 1 is unresponsive, the nurse should focus on and treat for hypoglycemia, as this is more likely than hyperglycemia. This is an emergency situation where the nurse must act before calling the physician. Vital signs should be taken after the client is treated for hypoglycemia. Assessment for ABCs should precede calling a code; there is no information that the client is not breathing.

Medications include: ,

Trimethoprim/sulfamethoxazole Combination antiretroviral therapy: Tenofovir and emtricitabine (Truvada) with darunavir and cobicistat (Prezcobix) Isoniazid

Similarities Between Type 1 and Type 2 Diabetes,

Type 1 and type 2 Diabetes increase risk for serious complications Diabetes remains the leading cause of blindness and kidney failure Although monitoring and managing disease can prevent this Critical risk factor for heart disease, stroke, foot/leg amputations

Clinical Manifestations,

Type I diabetes has a rapid onset so the initial manifestations are usually acute in nature These include the three P's (polyuria, polydipsia and polyphagia) Also includes weight loss, weakness, fatigue If left untreated, this will lead to ketoacidosis

Resource Stewardship,

US leader in wasteful care: 16% GDP Norway, Germany, Switzerland, Israel: < 1.9% Think of a potential wasteful situation

The patient is diabetic and is experiencing a reaction of alternating periods of nocturnal hypoglycemia and hyperglycemia. The patient might be manifesting which of the following?

Uncontrolled Diabetes Somogyi Effect Brittle Diabetes Diabetes Insipidus Answer: B Explanation: Somogyi effect manifests itself with nocturnal hypoglycemia, followed by a marked increase in glucose and increase in ketones.

Assessment,

Upon arrival to the medical/surgical unit, J.Q. is placed on airborne precautions. VS 120/ 78, 88, 18. Oxygen saturation 96% on 4L oxygen via nasal cannula, T. 98.6 F (37 C) Right upper lobe crackles

What type of PPE is recommended before insertion of an IV?,

Use devices with safety features. Catheters that minimize blood leakage and splatter during insertion safe work practices and administrative controls protective equipment such as gloves gowns or aprons masks and protective eyewear or face shield.

Albuterol 2 puffs TID-QID,

Used as a bronchodilator to prevent airway obstruction for asthma treatment. Classification= bronchodilator & adrenergics. Adverse effects= nervousness, tremor, headache, insomnia, bronchospasm, chest pain, palpitations, nausea, vomiting, hyperglycemia, and hypokalemia. Labs required= monitor electrolytes, especially potassium (hypokalemia).

After 24 hours on the ventilator and receiving medications Mr. J has the following findings: ,

VS: T = 101F HR: 114 BP 106/58 RR: 18. Temperature and HR have decreased BP has risen. ABG: pH 7.50 pO2 99 pCO2 26. Oxygen and carbon dioxide levels have improved pH has risen slightly. WBC: 11000. WBC has decreased to almost normal (4.8 - 10.8). K 5.5 Potassium has slightly decreased but not in normal range (3.5 - 5). Creatinine 2.6 Creatine has decreased but is not in normal range (0.8 - 1.3). BUN 32 BUN has increased not in normal range (8 - 21). UOP: 30 - 50 mL/hr Within normal range

Assessment,

Vital Signs: 98.70F - 76 - 18 - 192/116 HEENT: Severe headache (8/10) with visual disturbances ("light flashes") Cardiac: HRR, No ectopic beats Resp: Lungs clear, Denies SOB/DOE GI: Admits to continuous epigastric pain (4-5/10) not relieved with TUMS Tender to palpation of mid and right upper quadrant Bowel sounds present in all quadrants Admits to mild intermittent nausea, no vomiting

Blood gasses

We want to check their O2 and CO2 levels in their blood because they are having shortness of breath and difficulty breathing Hypoxemia is characteristic of patients with HIV and Pneumocystis jiroveci pneumonia infections.

Question #1:

What does the H in HELLP Syndrome stand for? Hemoglobin Levels Hemolysis Hypertension Hypotension Answer is Hemolysis

Question #2

What is the first sign of Preeclampsia? Edema Quadrant pain Hypertension Headache answer is hypertension

What dose of medication will you give as an initial bolus?,

What is the standard maintenance dose of medication you will give? A maintenance dose of 2-4 gms/hr

Pathophysiology leading to Ischemic Cardiomyopathy,

When the arteries that bring blood and oxygen to the heart are blocked or very narrowed, over time, the lack of blood supply can cause diffused inflammation and degeneration of the myocardial fibers of the heart. Carlo's heart muscle damage from his prior infarction and ischemia leads to a weaken, dilated, and thin-walled L ventricle, the heart's main pumping chamber. This leads to decrease contractility of the heart to pump blood. This causes ischemic cardiomyopathy. Ultimately, the left ventricle cannot contract correctly and it becomes harder for the heart to push enough blood to the body. Leads to decrease cardiac output (the amount of blood the heart pumps in 1 minute). As the heart becomes weaker, heart failure occurs

NCLEX Practice #3,

Which situation might cause the nurse to think that the client has von Willebrand's disease? 1. The client has had unexplained episodes of hematemesis. 2. The client has microscopic blood in the urine. 3. The client has prolonged bleeding following surgery. 4. The female client developed abruptio placentae. Answer is 3. The client has prolonged bleeding following surgery.

Pathophysiology of Diabetic Ketoacidosis (DKA),

Without enough insulin, your body can't use sugar properly for energy. This prompts the release of hormones that break down fat as fuel, which produces acids known as ketones. Excess ketones build up in the blood and eventually "spill over" into the urine. The risk of diabetic ketoacidosis is highest if you: Have type 1 diabetes Frequently miss insulin doses Uncommonly, diabetic ketoacidosis can occur if you have type 2 diabetes. In some cases, diabetic ketoacidosis may be the first sign that a person has diabetes. Triggered by: An illness. An infection or other illness can cause your body to produce higher levels of certain hormones, such as adrenaline or cortisol. Unfortunately, these hormones counter the effect of insulin — sometimes triggering an episode of diabetic ketoacidosis. Pneumonia and urinary tract infections are common culprits. A problem with insulin therapy. Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering diabetic ketoacidosis. physical/emotional trauma Heart attack alcohol/drug use, especially cocaine Corticosteroids and some diuretics

Universal Protocol for Preventing Wrong Site,

Wrong Procedure, Wrong Person Surgery™ , UP.01.01.01: Conduct a preprocedure verification process. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery. UP.01.02.01: Mark the procedure site. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery. UP.01.03.01: A time-out is performed before the procedure. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

Carlo's Interventions,

You notify the physician of Carlo's lab results; she comes by to assess Carlo and orders the following: Titrate oxygen to maintain SpO2 > 92% Furosemide 40 mg IVP now Nitroglycerin continuous infusion: titrate to maintain SBP <130 Strict I&O Obtain K+ level now Since it is always important to first check a patient's ABC's (airway, breathing, and circulation), the first intervention performed would be to titrate oxygen in order to maintain the patient's SpO2 levels above 92%. All orders have been implemented and four hours later the nurse reassesses Carlo: General survey: less anxious, but still restless Pulmonary: coarse crackles throughout both lung fields no significant change from earlier Cardiac/CV: A-fib continues. Skin remains pale, cool; +3 pitting edema LEs persists GI: no change, +BS all quadrants GU: 30 mL urine the past 4 hours, without significant increase after furosemide. Bladder scan reveals 50 mL residual Based on this assessment, the current interventions have not been successful because no changes were observed. The 40mg of Furosemide that was given to the patient did not help the patient urinate or help reduce the patient's edema. The patient only urinated 30mL of urine in the past four hours and the bladder scan shows 50mL residual. After receiving the continuous Nitroglycerin infusion and the oxygen therapy, coarse crackles were still heard throughout both lung fields. The patient also remains in A-fib, still has cool and pale skin, and still has +3 pitting edema. It would be anticipated that Carlo's next orders would include: Warfarin to treat the a-fib. Carlo is high risk for thrombus formation. Treating the a-fib would allow better perfusion to the kidneys, and may possibly help the body excrete some of the potassium A foley catheter since he is not voiding appropriately. Strict I+O and obtain K level. An inhaled steroid to help reduce airway inflammation and to open up his airways more.

PTSD:,

how do you assess for suicide? Ask the patient. So you ask if they are suicidal and do you have a plan and a mean to complete that plan. The sad part about vets is they have the means to complete a plan. Can we prevent suicide? We can try. dealing with abstract contents of mind. We have no MRI to prove how serious you are or not so by all means if you standing un-front of me telling me I was in Iraq I am coping, I have to take you at your word unless you give me any behavior otherwise. So we can try but not always successful and how do we intervene. Easier said than done. We take away access to means. If they have a gun collection we need to get rid of that. Get rid of all the size of Tylenol if you have children around and 180 bottle of prescription meds that will make a successful suicide and the problem is we are so used to it. We all go to Costcos and have that big bottle that has 7000 pills in it just in case you have a Tylenol crisis. We all have mail away meds. Ninety and a 180 day supply it is no longer simplistic. We did talk about ways to cope with PTSD. The gentleman take home message is nothing works unless they want it to work and I think that is what is so frustrating about psychiatry in general for you I have no answer for you. There is no good answer. They have to be willing and want to go through the therapy or nothing will work at all. What are some of in effective ways veterans or anyone insert anyone copes with PTSD? Alcohol and drugs, what else? Denial. Yes. I don't have a problem. There is nothing wrong. Anger. what is the most symptom of anxiety that we see and we will say in men because it will help you identify it easier. Anger. Anger. It is manly to be angry so you deal with the group of people who are manliest of men that serve our country you will not see them shaking and crying. They are going to be mad was that is acceptable. And it is hard when you deal with psych patients and you see them and you want to act angry back. Act right, what are you doing. It is because they are terrified and that is hard thing to identify. How do you they PTSD could affect military families in general? One is divorce and dad is abusive to mom because that is who he takes his anger out on them. It is for anxiety. So then the kids see that is acceptable way to act. What else may happen? Anybody in here we don't need a show of hands that has to deal with addiction in their family? Again divorce would be such a better option. The addiction have the ability to tear the roots of the family. Murder, maybe they are woken up from a sound sleep by a noise and they reach for the gun and they murder happens accidently. Once they are awake then the suicide follows. Yes. How can we intervene and that is loaded question. I can't drag anybody in by their shirt collar. Therapy groups. Like this is how we shower. We fly by the seat of our pants and hope for the best so once we get them into the door of treatment they are empowering individual to try to make their own decisions. What are some options? Support groups. Sometimes the term support group is less intimidating than therapy. Medication. Yes, I am not somebody that loves to put people on meds I think it causes more problems than it helps. But we have had some success about antidepressants. Have national suicide hotline.

Mr. J is now ordered... ,

pancuronium 2 mg IVP q4H PRN. lorazepam: 04mg/kg first dose then .02 mg/kg q2-6H. Institute Train of Four monitoring. After 24 hours his ABG is: 7.43 pO2 100 pCO2 39. He is being weaned using the Train of Four technique.

Adverse medication reactions:

side effects of medications that are severe and warrant stopping the medications to avoid harm or damage