NCLEX Key Concepts

Preview (48 of 159 Pages)

100%

Purchase to unlock

Loading page image...

1IMPORTANT NOTESBladder Irrigation•Continuous Bladder irrigation done mostly in HJRP•This is a three way catheter that keeps blood from accumulating•This is done with normal saline•Color of the urine should slowly progress to an amber colorOThe initial voidingfollowing removal may be uncomfortable, red in collorand contain dots. Thecolor of the urine should progress toward amber in 2 to 3 days.0On the fourth day the urine should be clear -4t-day if you see blood thisis NOT a good thing0If bright-red or ketchup-appearing (arterial) bleeding with clots is observed, the nurse shouldincrease the rate•If the catheter becomes obstructed (bladder spasms, reduced irrigation outflow),turn offthe CBI andirrigate with 50 mL of irrigation solution using a large piston syringe.0Contact the primary care provider if unable to dislodge the clot.•Record the amount of irrigating solution instilled {generally very large volumes) and the amount ofreturn. The difference equals urine output•Instruct the client to not try to push pee0The catheter has a large balloon (30 to 45 mL) that is taped tightly to the leg. creating tractionso that the balloon will apply firm pressure to the prostatic fossa to prevent bleeding. Thismakes the client feel a continuous need to urinate.OTell patient not to push (muscle spasms) can cause more bleeding■Once an obstruction is ruled out administer an antispasmodic to stop spasms•Expected output 150-200ml q2-3hr (normal is 30ml/hr)OInstruct the client that expected output is 150 to 200 mL every 3 to 4hr. The client shouldcontact the provider if unable to void.•Need to watch out for blockage•Sodiumcan be absorbed through bladder irrigation•Avoid kinks in the tubing.•ComplicationsUrethral trauma, urinary retention, bleeding, and infection are complicationsassociated with TURP. Other complications include re-growth of prostate tissue and reoccurrence ofbladder neck obstruction.Crutches•Withcrutches elbows should be flexed 30 degrees•Do not alter crutches after proper fit has been determined. Follow the prescribed crutch gait.•Support body weight at the hand grip with theelbows flexed at 30°.•Position the crutches on the unaffectedside when sittingor risingfrom a chair.Climbing the Stairs with Crutches•Upstairs-Good foot {good up to heaven)•Downstairs Bad (bad go down hell)

Loading page image...

2Cane■Important to always have TWO CONTACT POINTStouching at all times - two points of support■Keep the cane on the STRONG SIDEof the body■When moving with the cane: support body weight on both legs, move the cane forward6to 10inches, then move the weaker leg forward toward the cane. Next, advance the stronger leg.Ambulating w/ devices■Cane: When ambulating with the cane- have client keep the cane on the strong side of the body. Movecane up to 4 inches, ther WEAK LEG- strong leg.0Upstairs with Cane: (UP-STRONG/DOWN- STRONG).Take first step with the strong legMove the affected leg to the same step0Downstairs with Cane:Take first step by placing cane and unaffected(strong) legon the step,Lower the affected leg to the same step•Walker:Adjust walker to client s height. Allow 20 to 30 degree flexion of the elbows when graspingthe hand grips0Move walker up 6 to 8 inches & move the WEAK LEG & then bring the strong leg equal with theweak leg. WWS!•Crutches: Axillary crutch is more commonly used and must be measured to fit an individual. Crutchshould be2 fingers width from the axilla and 15 cm lateral to client's heel■The basic crutch stand isthetripod position the crutch is placed 15 cm (6 inches) in front of and 15 cm (6 inches) to the side ofeach foot. It improves a person's balance.The axilla should not bear weightand client assumes tripodposition before crutch walking.Types of Crutch Gaits:•Four-point gait- {Alternating Gait) gives stability to client- requires weight bearing on both legs. Eacheg is moved alternatively with each opposing crutch.•Three-point gait- requires the client to bear all of the weight on one foot. Client will bear all theweight on both crutches and then on the uninvolved leg- affected leg does not touch the ground.•Two- point gait-requires partial weight bearing on each foot. The client moves the crutch at the sametime as the opposing leg.■Swing-through gait- (paraplegics wear weight supporting braces use this gait)With weight placed onboth legs,the client will place the crutches one stride in front and then swings through the crutches.Dumping Syndrome•After bariatric surgery observe pt for S/S of dumping syndrome.■Dumping syndrome is a complication of gastric surgery that consists of vasomotor symptoms occurringin response to food ingestion. Symptoms result from the rapid emptying of gastric contents into thesmall intestine.

Loading page image...

3■ClientEducation- DumpingSyndromeQLay down after meal - because it will slow the movement of food within the intestinesOLimit the amount of fluids ingested at one time■Eliminate liquids with meals and for 1 hr prior to and following a mealOConsume a high fat, high proteins, low to moderate carbs dietOAvoidmilk,sweets, and sugars - because these can cause diarrheaOSmall frequent meals rather than large mealsOPernicious anemiaiscommonhere- Give Vit B12Crohn's Disease•Intermittent involvement of throughout the entire lower Gl tract, most commonly in the small intestineand the terminal ileum.•Inflammation and ulceration throughout the Gl tract - see sporadic lesions and fistulas are common•Diarrhea and colicky abdominal pain•Monitorfor Megaloblastic (perniciousJanemia - GiveVITAMINB12injectionmonthlyfor life•UTI -first sign in bowel/bladderfistula (Feces times seen in urine and vagina)•S/S:Abdominal pain/cramping: Often right-lower quadrant painOAnorexia and weight loss, fever, diarrhea, high-pitched bowel sounds, steatorrhea•Acute treatment is fluid and bowel rest•More difficult to cure and manage- Commonly in small intestines•Perineal abscessand fistulas-common in Crohn's disease■Lowfiberdiet or NPO (severeinflammation)•Long term treatment is low fiber diet and medicationUlcerativecolitis•TOXIN MEGACOLON- common in ulcerative colitis•More acute - see blood and mucus•Bloodyand frequentdlarrhea and abdominal pain,tenesmus & rectaIbIeeding•See in theDESCENDING COLON•Common to see joint pain/ arthritis (inflammation)•Antiinflammatory med:oGive sulfasalazine (Azulfidine)1May cause yellowish orange discoloration of skin and urine■Avoid sun exposure - wear sun blocked•Low fiber diet or NPO (severe inflammation)Ulcerative Colitis Interventions•Priority Intervention:NPO (they will have 20 to 25 stools a day)•Diaper & bowel rest/ colitis can lead to TOXIC MEGA COLON•Only in the rectum/TREATWITH SITZ BATH OF WITCH HAZELCOMPRESSION•Medication- antibiotics: SULFASALAZINE (AZULFIDINE) - decrease inflammation of intestinal mucosa(can be given rectally)

Loading page image...

4Ulcerative Colitis and Crohn s Disease Nursing Care■Educate the client in eating foods that are high in protein and calories, and low in fiber.•Instruct the client to avoid caffeine and alcohol, and take a multivitamin that contains iron.■Advise the client that small frequent meals may reduce the occurrence of symptoms.•Inform the client that dietary supplements that are high in protein and lowinfiber may be used.•Monitor for an electrolyte imbalance, especially potassium. Diarrhea can cause a loss of fluids andelectrolytes.■Monitor fluids and assess for dehydration.•Educate the client regarding the useof vitaminsupplements and B12injections,if needed.•Assist the client in identifying foods that trigger symptoms.Diverticulitis•Saccular Dilations or Outpunching of the Diverticula■Abdominal pain -SIGMOID COLON LLQ.abd. distension, bloating, flatulence & bowel changes•Increase-Highfiberdiet &increasefluids- is very important inpreventing future diverticulitisattacksbut during EXACERBATIONOF DIVERTICULITISput patient onLOWfiber diet•Encourage walk daily for 30mins (for no constipation)- No strenuous exercisesAcute Diverticulitis•Priority intervention: NPO-BoweI rest.Example Q:Which of the following comments made by the patient indicates that additional instruction aboutthe care of a new ileostomy is needed?1. "I should change the appliance daily to prevent odors.2. "When I change the appliance. I should check the skin for irritation."3. "I should clean around the stoma with mild soap and water and pat dry."4."I'll need to alter the appliance opening when the stoma becomes smaller as the areaheals."Rationale: The appliance is changed every 4 to 7 days unless leakage occursHeat and Cold Therapy•First 24hrs -cold0Prevents swelling, decreases inflammation, reduces bleeding, reduces fever, diminishes musclespasms decreases pain by decreasing the velocity of nerve conduction•After 24 hrs - heat•Heat increases blood flow0Increases tissue metabolism0Relaxes muscles0Do not take long showers0Eases joint stiffness and pain•Avoid heat application over metal devices to avoid deep tissue burns■Heat-Monitor bony prominences carefully as they are more sensitive to heat applications.0Avoid the use of heat applications over metal devices (pacemakers, prosthetic joints) to preventdeep tissue burns.0Do not apply heat to the abdomen of a pregnant woman to preventharmto the fetus.0Do not place a heat application under an immobile client as this may increase the risk of burns

Loading page image...

5Cold- Decreases inflammation•Prevents swelling•Reduces bleeding•Reduces fever•Diminishes muscle spasms•Decreases pain by decreasing the velocity of nerve conductionAvoid cold application for cold intolerance•Hyperthyroidism•Peripheral arterial disease•Raynauds phenomenonHot compress causes vasodilation and delivers more blood to the site.•If a patient is in pain, you could apply a hot compress to direct blood, which carries oxygen andnutrients to the area, which will alleviate pain.Cold compresses cause vasoconstriction in the area and divert blood flow.Cognitive Disorders/Alzheimer's•How do you promote hygiene/proper careinpt with Alzheimer's?•Alzheimer's disease (AD) is a nonreversible type of dementia that progressively develops throughseven stages over many years•AD is a type of dementia. Dementia is defined as multiple cognitive deficits that impair memory andcan affect language, motor skills, and/or abstract thinkingNursingCare for Alzheimer•Assess cognitive status, memory, judgment, and personality changes.•Initiate bowel and bladder program with the client based on a set schedule.•Encourage the client and family to participate in an AD support group.■Provide a safe environment.•Keep the client on a sleeping schedule and monitor for irregular sleeping patterns.•Provide verbal and nonverbal ways to communicate with the client.•Offer snacks or finger foods if the client is unable to sit for long periods of time.•Check the client's skin weekly for breakdown.•Provide cognitive stimulation: fa mj|y pjC S it i m eplace andp e r s o n•Offer varied environmental stimulations such as walks, music, orcraftactivities.•Keep a structured environment and introduce change gradually (client's daily routine or a roomchange}.•Use a calendar to assist with orientation.•Use short directions when explaining an activity or care the client needs, such as a bath.•Use therapeutic touch•Place stop signsonthe door. Have the client wearID,Have client walk with supervision. Apply physicalrestraints only as a last resort.Provide Memory Training!•Reminisce with the client about the past.

Loading page image...

6■Use memory techniques such as making lists and rehearsing.•Stimulate the client's memory by repeating the client's last statement.•Avoid overstimulation (keep noise and clutter to a minimum and avoid crowds).•Promote consistency by placing commonly used objects in the same location and using a routineschedule.■Reality orientation (early stages)•Easily viewed clock and single day calendar•Pictures of family and pets•Frequent reorientation to time, place, and person•Validation therapy (later stages)•Acknowledge the client’s feelings.•Don't argue with the client; this will lead to the client becoming upset.■Reinforce and use repetitive actions or ideas cautiously.•Promote self-care as long as possible. Assist the client with activities ofdailyliving appropriate.■Speak directly to the client in short, concise sentences.•Reduce agitation (use calm, redirecting statements: provide a diversion).■Provide a routine toileting schedule.If patient has CHOLECYSTITIS. What kind of diet restrictions should be on?■Cholecystitis is an inflammation of the gallbladder wall, it is most often caused by gallstones(cholelithiasis) obstructing the cystic and/or common bile ducts (bile flow from the gallbladder to theduodenum) causing bile to back up and the gall bladder to become inflamed.•Sharp pain in the RightUpper Quadrant of the abdomen, often radiating to the right shoulder.•Pain with deep inspiration during right subcostal palpation(Murphy ssign)•Jaundice, clay-colored stools, steatorrhea (fatty stools),dark urine, and pruritus (accumulation ofbile salts in the skin) may be seen in clients with chronic cholecystitis (due to biliary obstruction).Diagnostic Procedures:•A right-upper quadrant (RUQ) ultrasound visualizes gall stones and a dilated common bile duct.■An abdominal x-ray or CT scan can visualize calcified gallstones and an enlarged gall bladder.•A hepatobiliary scan (HIDA) assesses the patency of the biliary duct system after an IV injection ofcontrast.Diet:■Encourage a LOW-FATdiet(reduce dairy and avoid fried foods, chocolate, nuts, gravies). Promoteweight reduction.■Avoid gas-forming foods (beans, cabbage, cauliflower, and broccoli).•Small, frequent meals may be tolerated.Kegel Exercises■For person with strong risk for urinary incontinence

Loading page image...

7•Tighten pelvic muscles for a countof 10,relax slowly for a count of10 .and repeat in sequences of15in thelying-down, sitting and standing position0Perform fourtimesaday•Keep abdominal muscles relaxed during contractions.•Contract the circumvaginal and/or perirectal muscles.Sleep Disorders•Recognizing and reporting sleep disorders•How does it affect medications (cholesterol meds work better during sleep)•insomnia,the most common sleep disorder, is defined as the inability to get an adequate amount ofsleep and to feel rested. The person may have difficulty falling asleep, have difficulty staying asleep,awaken too early, or not get refreshing sleepQAcuteinsomnia lasts for only a few days and may be due to personal stressors.OChronic insomnialasts a month or more. Some people experience intermittent insomnia, wherethey are able to sleep well for a few days and then experience insomnia for a few days. Womenand older adults are more likely to experience insomnia.•Sleep apnea is a disorder in which there are more than five apneic occurrences lasting longer than 10seconds/hr during sleep, resulting in decreased arterial oxygen saturation levels•Narcolepsy - a disorder of the sleep and wake mechanism. The person may lose the ability to stayawake. It often happens at inappropriate times and can put the person at risk for injury.•Assessment/Data Collection:OAsk the client about sleep patterns, history, andifany changes have occurred.OAsk the client about sleep problems, which includeOType of problem, symptoms, timing, seriousness, related factors, how the lack of sleep hasaffected the client.0Use a linear scale or visual with "best sleep" on one end and "worst sleep" on the opposite end.Also, the nurse could ask the client to rate sleep on a 0 to 10 scale.OAssess for common factors that interfere with sleep, which include:■Illness - may require more sleep or disrupt sleep, such as nocturia■Current life events (traveling more, change in work hours).■Emotional stress or mental illness (anxiety, fear).■Diet (caffeine consumption, heavy meals before bedtime).OExercise - promotes sleep if done at least 2 hr before bedtime: otherwise, it can disrupt sleepOSleep environment that is too light, the wrong temperature, or too noisy (children, pets, loudnoise, snoring partner).•Amino acid inmilk-TRYPTOPHAN-helps in sleep•MELATONIN-hormone-helps in sleep•Medications - may induce sleep but interfere with the restorative sleep cyclesOAsk patient if they dream (REM SLEEP)OLoop diuretics should be avoided at night to prevent falls and will most likely interrupt theclient's sleepNonpharmacological Pain Therapy*TENS (Transcutaneous ElectricaI Ne rve Stimulation)

Loading page image...

8•Therapeutic Touch•PainPathways - GateControlTheory: The theory guided research toward the cognitive behavioralapproaches to pain management. This theory helps to explain how interventions based onsomatosensory (auditory, visual and tactile) stimulation such as friction, music therapy and distractionprovide pain relief.0Two receptors for opioidsoNu and Kappa•Distraction-Includes ambulation, deep breathing, visitors, television, and music0Distraction therapy works best with children•Relaxation-Includes meditation, yoga, and progressive muscle relaxation•Imagery- Focusing on a pleasant thought to divert focus0Requires an ability to concentrate•Acupuncture - vibration or electrical stimulation via tiny needles inserted into the skin andsubcutaneous tissues at specific pointsOReduction of pain stimuli in the environment•Elevation of edematous extremities to promote venous return and decrease swellingStumpPain after Amputation•Elevation for edema•Phantom painOTreated as real painOPatient says they have pain - give them pain medsAcute and Chronic Glomerulonephritis•Glomerulonephritis is an inflammation of the glomerular capillaries, usually following a StreptococcalInfection. It is an immune complex disease, not an infection of the kidney•Due to swelling and capillary cell death0Also getit fromSLE, hypotension and diabetes mellitus•Patient will have a spontaneous recovery•Diet includes:OFluid restriction (24 hr output +500 mL).0LOW SODIUM, LOW PROTEIN AND LOW POTASSIUM DIETOPROTEINrestriction {if Azotemia is present = increasedBUN).•Important to watch BUN andcreatinine levels•CARE after dischargeOAdvise the client to maintain fluid and sodium restriction - a dietary consultmaybe necessary.•ClientEducation:Encourage the client to rest in order to conserve energy.OMaintain prescribed dietary restrictions.Acute Glornerual Nephritis•Strep infection•Askpt. aboutsore throat•S/S:body edema, HTN & oliguriaRenal Failure•Early symptomsofAcute RenalFailure:Oliguria (decreased urinary output)

Loading page image...

9*BUN (10-20)- increased*Creatinine (0.8-1.2}- increased*Anuria: non-passage of urineEnd Stage Renal failure means hemodialysis for life*DAILY weights-loss of 2 lbs in 24 hrs, little urine output, fever -sign of infection*DM+HTN are the most risk factorsDiet Teaching Uric Acid- to prevent hyperuricemia*Avoid -Red meat (beef, pork and lamb), fatty fish and seafood (tuna, shrimp, lobster and scallopsshellfish like scallop, lobster, oyster, clam, and shrimp will have more purine levels than normal fish.)*Avoid beans and legumes*Avoid dark green leafy vegetable, cauliflower, spinach, mushrooms and asparagus*Limit or avoid alcohoi & sugar*Choose low-fat o r f at-f ree dai ry prod ucts: Drinking skim or low-fat miIk & yogurt*Choose complex carbohydrates:whole grains and fruits and vegetablesChronic Kidney Disease*Which priority Intervention for CKD can be delegated to UAP? Monitor l&O*Canned, pickled and smoked food is prohibited*Know the im portance of mon ito r I£.0? LIM IT FLUID INTAKE*Assess protenuria- teach patient toAVOID EXCESS PROTEIN because increased protein intake canaffect mental status £ cause confusionPeritoneal dialysis*Therapeutic procedure for CKD utilizes the patient's abdominal cavity lining as a natural filter*Interventions: STERILE*Cloudy Urine dialysis: IM MEDIATE INTERVENTION*Abdominal cramping: SLOW THE INFUSION*Assess for infection -clean the pins with HYDROGEN PEROXIDE AND NSKayexalate■Normal potassium level 3.5-5.0*Therapy for elevated potassium (hyperkalemia)*Kayexalate - never give it to patient with PARALYTIC ILEUSAV Shunt*Assess:thrill and bruit (thrill is palpated £ bruit is heard)*Take BP on opposite arm of shuntKosher Diet*Prohibits eating meat and dairy together. This separation includes not only the foods themselves, butthe utensils, pots and pans with which they are cooked, the plates and flatware from which they are

Loading page image...

10eaten, the dishwashers or dishpans in which they are cleaned, the sponges with which they arecleaned and the towels with which they are dried.•A kosher household will have at least two sets of pots, pans and dishes: one for meat and one fordairy. One must wait a significant amount of time between eating meat and dairy. Opinions differ, andvary from three to six hours after meat. This is because fatty residuesand meat particles tend to clingto the mouth. From dairy to meat, however, one need only rinse one's mouth and eat a neutral solidlike bread, unless the dairy product in question is also of a type that tends to stick in the mouth.•All fruits and vegetables are kosher. However, bugs and worms that may be found in some fruits andvegetables are not kosher.Jehovah's Witnesses•Jehovah's Witnesses do NOT accept blood transfusions.•Clients avoid foods having or prepared with blood.•Can recommend anAUTOLOGOUSblood transfusion0When the patient goes in a couple of days before and donates their own bloodStoma Care■An ostomy is a surgical opening from the inside of the body to the outside. Ostomies can be permanentor temporary and are located in various parts of the body.•Jleostomy opening atthesmall intestine0See more fluids and more skin degeneration■Colostomy opening at the colonoSee more solid ...change bag more often-%toVSfull- change it!•Nursing Actions0Assess the type and fit of the ostomy appliance.0Monitor for leakage (risk to skin integrity).0Fit the ostomy appliance based on:■Type of ostomy.■Location of the ostomy.■Visual acuityandmanualdexterity of the client.0Visual acuity and manuaI dexterity of the client.0Assess peristomal skin integrity and the appearance of the stoma.0The stoma should appear pink and moist.0Apply skin barriers and creams,such as stoma adhesive paste, when applying wafers to protectthe peristomal skin.0Let the skin sealants dry before applying a new appliance.0Evaluate output from the stoma.Normal post-op outputisless than 1000 ml/day.TOhe higher up an ostomy is placed in the small intestine, the more liquid and acidic theoutputwill be from the ostomy.OAssess for fluid and electrolyte imbalances, particularly with a new ileostomy.OEducatethe client regarding dietary changes and ostomy appliances that can help manageflatus and odor.■Foodsthatcancause odor includefish, eggs, asparagus, garlic, beans, and dark greenleafy vegetables.

Loading page image...

111Foods that can cause gas includedark green leafy vegetables, beer, carbonatedbeverages, dairy products, and corn. Yogurt can be ingested to help decrease gas.•After an ostomy is placed involving the small intestine, the client shouldOBe instructed toavoid high-fiber foodsfor the first 2 months after surgery, chew food well,drink plenty of fluids0Evaluate for any evidence of blockage when slowly adding high-fiber foods.ODo not put anything in the bag to mask odor such as a mint.0Keep appliance clean and empty frequently to decrease odor.•Normal and Abnormal FindingsOImmediate postoperative stoma should be reddish pink, moist, and may have a small amount ofvisible blood: report any evidence of stoma ischemia or necrosis0If some skin is hanging off post op that is a normal finding0Signs of stomal ischemia are pale pink or bluish/purple in color and dry in appearance.OIfthestoma appears black or purpleincolor, this indicates a serious impairment of blood flowand requires immediate intervention.Spinal Cord Injury•Autonomic Dysreflexia•Stimulation of the sympathetic nervous system causes extreme hypertension, sudden severeheadache, pallor below the level of the spinal cord's lesion dermatome, blurred vision, diaphoresis,restlessness, nausea, and piloerection (goose bumps).•Clients who have lesions below T6 do not experience dysreflexia because the parasympatheticnervous system is able to neutralize the sympathetic response.•Nursing ActionsODetermine and treat the cause.OSit the dient up (to decrease blood pressure secondary to postural hypotension).ONotify the provider.0Determine The Cause.■DISTENDED BLADDER'Sthe most common cause(kinked orblockedurinarycatheter, urinary retention, or urinary calculi)■Fecal impaction■Cold stress or drafts on lower part of the body■Tight clothing■Undiagnosedinjury or illness(kidney infection or stone, lower extremity fracture)0Treat The Cause■Relieve the kink in the catheter or irrigate to remove blockage.■Catheterize the client (use anesthetic ointment on the tip of the catheter).■Remove the impaction (use anesthetic ointment prior to removal).■Adjust the room temperature and block drafts.■Remove tight clothing.■Assess for injury, such as lower extremity fracture or kidney/bladder infection.■Monitor vital signs for severe hypertension and bradycardia.■Administer antihypertensives (nitrates or hydralazine).

Loading page image...

120Client Education:Instruct the client to space out fluid intake and increase frequency ofintermittent catheterizations if fluid intake is temporarily increased.•Perineal Care0Development of a schedule as part of bladder and bowel training is critical for theestablishment of a routine0Flaccid NeurogenicBladder -Clients who have LOWER MOTORNEURONINJURIES will developa flaccid bladder. Bladder management options for males and females include intermittentcatheterization and Crede's method (downward pressure placed on the bladder to manuallyexpress the urine).0Spastic NeurogenicBladder -Clients who haveUPPER MOTOR NEURONINJURIES will developa spastic bladder after the spinal shock resolves. Bladder management options for male clientsinclude condom catheters and stimulation of the micturition reflex by tugging on the pubichair.Female clients will need to use an indwelling urinary catheter duetotheunpredictably of therelease of urine.0Neurogenic bowel functioning does not differ a lot between upper and lower motor neuroninjuries.ODaily use of stool softeners or bulk forming laxatives is recommended to keep the stool soft. Abowel movement can be stimulated daily or every other day by administration of a bisacodyl(Dulcolax) suppository or digital stimulation (stimulation of the rectal sphincter with a glovedand lubricated finger).■Docusate sodium (Colace) or polycarbophil (Fibercon) to prevent constipation and keepthe stool soft.•A client who has a cervical spinal injury will also have an upper motor neuron injury, which willmanifest itself by creating aspastic bladder. Since the bladder will empty on its own. a condomcatheterisan appropriate method.•Develop a schedule as part of the bowel and bladder training.PharmacologyLeukotriene Modifiers: Montelukast (Singulair), Zileuton (Zyflo), Zafirlukast (Accolate)■Respiratory Drugs•Suppress inflammation, bronchoconstriction, airway, edema and mucus production.•Used for long-term therapy of asthma in adults and children 15 years and older and to preventexercise-induced bronchospasm.•Take these drugs everyday- they areNOT rescueinhalersWhat groupdoesSpiriva(Advair) Elelongto? Respiratory- Bronchodilator- Leukotriene Modifier•Works in a different way- NOT a rescue inhaler- taking it regularly reduces number of asthma attacks•Control inflammation- preventsitovertime•Spiriva (tiotropum)- inhaled anticholinergic- blocks muscarenic receptors of the bronchi, resulting inbronchodilation.•Advair(Fluticasonepropionate)- GlucocorticoidsOThese medications prevent inflammation, suppress airwaymucus production,and promoteresponsiveness of beta2 receptors in the bronchial tree.

Loading page image...

13Antibiotics*Antibiotics that affect theCELLWALLare BACTERICIDAL.This group of antibiotics includes penicillin's,cephalosporin's, carbapenems and monobactams.Penicillin s•Penicillin G (BiciIlin LA)•Broad-Spectrum•Amoxicillin-clavulanate (Augmentin))•Ampicillin (Principen)•Antistaphylococcal•Nafcillin (Unipen)•Methicillin•Antipseudomonas•Carbenicillin (Geoillin)•Ticarcillin-clavulanate (Timemtin)•Piperacillin tazobactam (Zoysn)Cephalosporin's*Cepalexin (Keflex)- 1- generation*Cephradine. Anspor, Velosef- 1"generation*Cefaclor (Celcon), Cefotetan (Cefotan)-2ndgeneration*Ceftriaxone (Rocephin), Cefotazime(Claforan). Cefoperazone (Cefobid)- 3rdgeneration*Cefepime (Maxipime)- 4rhgenerationCarbapenems•Imipenem (Primaxin)•Meropenem (Merrem IV)MonobactamsNo cross-hypereensitivity reactions withpenicillin but like penicillins can trigger seizuresin patients with history of seizures.•Vancomycin (Vancocin)•Aztreonam (Azactam)•Fosfomycin (Monurol)•Penicillin-anaphylactic reaction of antibiotic that breaks theCELL WALL-also cephalosporinCAnaphylaxis:■Interview clients for prior aIlergy.1Advise clients to wear an allergy identification bracelet.■Gentamicin- Interfere with PROTIEN SYNTHESIS0Can causeOTOTOXCICTY (ringing inthe ears) andNEPROTOXCICTY0Most common IV medication0Dosage is reduced in the elderly due to decrease in renal clearance- after 65 kidneys function less0Side Effects/Adverse Effects:1Ototoxicity: Monitorclients for symptoms ofTINNITUS (ringing inthe ears), headache,hearing loss, nausea, dizziness and vertigo. STOP medication if this occurs.■Nephrotoxicity: Monitor l&O,BUN andCreatinine levels. Instruct client to reportsignificant decrease in the amount of urine output.Medications That Cause Nephrotoxicity:•Amphoteracin B (antifungal)■Cyclosporins•ACE inhibitors■Cisplatin (cancer medication)

Loading page image...

14•NSAIDsLithium (Lithane, Eskalith**, and Lithonate): MOOD STABILIZER***Effective in thetreatmentofbipolarI acute and recurrent manic and depressive episodes.•It usuai/y takes 7 to 14 days to reach therapeuticlevels.■Antipsychotic or benzodiazepine can be used to prevent exhaustion, coronary collapse, and deathuntil Lithium reaches therapeutic levels*METALLICTASTE-telI patient to chew hard candy or use oral swabs•During initial treatment of manic episodes-levels0.8-1.4 mEq/L*Instruct clients to monitor signs of toxicity and when to contact the provider.. Clients should stoptakingmedication and seek medical attention if experiencing diarrhea, vomiting, or excessivesweating.•Need to watch for HYPONATREMIAoReduced serum sodium decreases lithium excretion, which can lead to toxicity.0Adequate fluid and sodium intake should be maintained.0If taking diuretics- risk for hypokalemia0Side effects:Polyuria and mild thirst0Intervention: Use a potassium-sparing diuretic, such as spironolactone (Aldactone).Pharmacological Interventions:•Lithium carbonateTherapeutic and toxic levels0Therapeutic blood level 0.8 to 1.2 mEq/L0Maintenance blood level 0.4 to 1.3 mEq/LoToxic blood level: 1.5 to 2.0 mEq/LLithium Toxicity: Symptoms of Li Toxicity•Levels1.3to1.5 mEq/L-Fine hand tremors, nausea,vomiting, diarrhea, confusion, ataxia, slurredspeech, lethargy, thirst and polyuria, muscle weakness.•NursingConsideration:Medication should be withheld. Assess patient for toxicity symptoms, bloodlevels measured, and evaluate dosage. Dehydration should be addressed.•Levels1.6to 2.0Course hand tremors, Gl upset, mental confusion, muscle hyperirritability,incoordination, and sedation.•NursingConsideration:Medication should be withheld, Assess patient for toxicity symptoms, bloodlevels measured, and evaluate dosage. Dehydration should be addressed.•Levels >2.1 to3.0 mEq/L-Ataxia, Confusion, blurred vision, hypotension, Profound CNS depression,arrythmias, seizures, coma, death due to pulmonary complications.•Nursingconsiderations: All of the above & administer emetic to alert the clients or administer gastriclavage.•Greater than 2.5 mEq/L-rapid progression of symptoms leading to coma & death-NursingConsiderations!Allofthe above & Hemodialysis maybe used in severe cases.Lithium levels should be measured at leasts days after beginning therapy and after any dosage change.Blood should be drawn in the MORNING. 8 to 12 hours after the last dose was taken.•For older adult patients, Start low and go-slow applies. Lithium levels should be drawn every 3 to 4days for them.

Loading page image...

15•Someone can go toxic at anytime in treatment - even iff they have been taking it for years so it isimportant to teach patient to get routine blood work done.■Suddenly stopping lithium can lead to relapse and recurrence of MANIA.•Two majorlong-termrisksof lithiumtherapy areHYPOTHYROIDISMandIMPAIRMENTof theKIDNEYSabilityto CONCENTRATE URINE•Before starting therapy, you should assess:Renal Function,ThyroidStatus,DementiaAndNeurological Disorders.•Shouldn'tbe given to patients with cardiovascular disease, brain damage, renal disease, thyroiddisease, or myasthenia gravis.•It can harm a fetus, shouldn't be used when breast feeding, and shouldn't be used for children under12 years of age.•Lithium is a naturally occurring salt - but you need to teach the patient NOT to change their diet to oneof low sodium - THEYNEED TOKEEP A REGULAR DIET•Kidney function test- AST &ALT- NoNSAIDS such as Ibuprofen use aspirin•Have to be extremely careful with a patient who is having a manic episode because they might have anelectrolyte imbalance that can lead to lithium toxicity■Lithium with an SSRI for a manic pt. can cause RAPID CYLING!Q:Ifa patient comes in with a lithium level of 1.6 what do you do?A: Assessthepatient,hold the doseand then callthe doctor.Digoxin:•NormaIlab vaIue-0.5 to2.0ng/mL•Watch for HYPOKALEMIA•Checkapical pulse-if lessthan 60/min in an adult,lessthan 70/min in children,lessthan 90/min ininfants- Hold Digoxin &notify provided•Instruct client to observe symptoms of toxicity: Anorexia, fatigue, weakness, nausea and vomiting•Managementoftoxicity:ODigoxin and potassium-sparing medication should be stopped immediately.OMonitor potassium levels. For levels less than 3.5 mEq/L, administer potassium intravenously.OIf K+-levels greater than 5.0 mEq/L-Putpt. on a cardiac monitor.OTreat dysrhythmias with phenytoin (Dilantin} or Udocaine.OTreat bradycardia with atropine.OFor overdose treat with: activated charcoal, cholestyramine orDIGIBINDcan be used to binddigoxin and prevent absorption.•How it interferes with K+OThiazide diuretics, such as hydrochlorothiazide (HCTZ), and loop diuretics, such as furosemide(Lasix), may lead to HYPOKALEMIA- Increase the risk of DYSRHYTHMIAS!OAce inhibitors and ARBS increase the risk ofHYPERKALEMIA-leads to decreased therapeuticeffects of digoxin.OMonitor k+ levels to maintain 3.5 to 5.0 mEq/LOInstruct client to report signs of hypokalemia (nausea, vomiting and weakness)0Teach clients to consume high potassium foods (Spiniach, bananas, potatoes).•MonitorDigoxin LevelsOSigns of toxicity may appear less than 1.75 ng/mL0Teach clients to monitor apical pulse. The rate maybe irregular with early or extra beats noted.

Loading page image...

160Clients with heart failure respond best to serum levels between 0.5- 0.8ng/mL0Nausea &Vomitinsare significant toxic symptoms-1Hsign of toxicity!Epogen- Used for Chronic Anemia (Kidney Failure)- Kidney's can't produce erythropoietin•It s working if Hematocrit goes up•Watch HCT if it goes up too much- BP could increase and lead toHYPERTENSIVE CRISIS•Given SubQ•Adverse Effects:0Hypertension secondary to elevation in hematocrit levels0Monitor clients hemoglobin, hematocrit and BP, if elevated- give hypertensive medications0Increases risk for cardiovascular event (Ml, Stroke, Cardiac Arrest) with an increase in Hgbabove 12 g/dL or more than 1 g In 2 weeks.0Decrease dosage when these limits are reached.•Nursing Interventions:□Obtain client's baseline blood pressure. Clients with chronic renal failure- control hypertensionbefore start of treatment.0Administer SubQ or IV bolus injection.0Do not agitate the vial of medication. Use each vial for one dose and do not put the needleback into the vial when withdrawing the medication.0Dosing is usually 3x/week, but maybe once a week with some types of chemotherapy.0Monitor client's iron levels- REC growth is dependent on adequate iron, folic acid and vitaminB12.0Monitor Hgb and Het twice a week until target range is reached.Anemia•Anemia is an abnormally low amount of circulating RBCs, Hgb concentration, or both.•Anemia resultsindiminished oxygen-carrying capacity and deliverytotissues and organs.•N ursing ActionsforAnemia0Monitor the client for fatigue, pallor, dizziness, and shortness of breath.0Help the client manage anemia-related fatigue by scheduling activities with rest periods inbetween and using energy saving measures (sitting during showers and ADLsj.0Administer erythropoietin medications such as erythropoietin aIfa (Epogen)and antianemicmedications such as ferrous sulfate (Feosol) as prescribed.0Monitor the client's Hgb to determine response to medications. Be prepared to administerblood if prescribed0Monitor Hgb and Het closely because you do not want it to rise too quickly = Hypertension■Should not grow by 4 in two weeks■Monitor the client for cardiovascular event if Hgb increases too rapidly ( >lgm/dL in 2weeks).*Iron supplementation:0Stool will be black.0May cause gastrointestinal distress; take with food if this occurs.0Take with vitamin C to increase absorption.

Loading page image...

170Take 2 hr before or after meal or antacids.0Increase fiber and fluids in diet to manage constipation.OUse 3 straw with liquid iron to avoid staining teeth.Anemia0Iron deficiency! food sources rich in IRON?- Absorption IRON better with Vit C but more GIdifficulty0Foods sources richin iron:Red meat. Egg yolks, Dark, leafy greens (spinach, collards),Dried fruit(prunes, raisins).Iron-enriched cerealsand grains (check the labels),Mollusks (oysters, dams,scallopsjTurkey or chicken giblets. Beans, lentils, chickpeas and soybeans. Liver, Artichokes0Megaloblastic: why do cells become bigger? B/c Vit B12 is low0Sickle cell:hydration!!!0Good sources of Vit B12-liver, beef, salmon, trout, breakfast cereals.Tuna, milk, cheese, ham, egg. roasted chicken0Anemia is an abnormally lov/ amount of circulating RBCs, Hgb concentration, or both.0Anemia results in diminished oxygen-carrying capacity and delivery to tissues and organs.1Nursing Considerations0Administer parenteral iron to a client using the Z-track method.0Instruct to havehemoglobin checked in 4to6 weeksto determine efficacy.0Vitamin C may increase oral iron absorption0Instruct the client to take iron supplements between meals to increase absorption, if tolerated.0Erythropoietin -Epoetin alfa (Epogen, Procrit)0A hematopoietic growth factor used to increase production of RBCs0Observe the client for an increase in blood pressure (Hypertension).0Monitor Hgb and Het twice a week0Monitor the client for cardiovascular event if Hgb increases too rapidly ( >lgm/dL in 2 weeks}.•Client Education0Reinforce the importance of having Hgb and Het evaluated on a twice-a week basis.0Vitamin B12 supplementation (Cyanocobalamin)0Vitamin B12 is necessary to convert folic acid from its inactive form to its active form. All cellsrely on folic acid for DNA production.0NursingConsiderations1Give vitamin B12 according to appropriate route related to cause of Vitamin B12 anemia(parenteral versus oral}.1Administer parenteral forms of vitamin B12 intramuscularly or deep subcutaneous todecrease irritation. Do not mix1The goal of treatment is to restore and maintain adequate tissue oxygenation.Iron deficiency anemia occurs because of a lack of the mineral iron in the body. Bone marrow in the center ofthe bone needs iron to make hemoglobin, the part of the red blood cell that transports oxygen to the body'sorgans. Without adequate iron, the body cannot produce enough hemoglobin for red blood cells. The result isiron-deficiency anemia.

Loading page image...

18This type of anemia can be caused by:•An iron-poor diet, especially in infants, children, teensi vegans, and vegetarians•The metabolic demands of pregnancy and breastfee ding that deplete a woman's iron stores•Menstruation, frequent blood donation and endurance training.•Digestive conditions such as Crohn's disease or surgical removal of part of the stomach or smallintestine•Certain drugs, foods, and caffeinated drinks•Older adult clients most at risk for developing iron deficiency anemia, chronic blood loss, vitamin B12and folate deficiencies.•Food Sources RichinIron - red meat, egg yolks, dark, leafy greens (spinach, collards), dried fruit{prunes, raisins). Iron-enriched cereals and grains (check the labels), mollusks (oysters, clams, scallops),turkey or chicken giblets, beans, lentils, chick peas and soybeans, liver, and artichokesSicfdeCell Anemia PAIN MANAGEMENT AND HYDRATION IS REALLY IMPORTANT•An inherited disorder that affects African-Americans. Red blood cells become crescent-shaped becauseof a genetic defect. They break dovjn rapidly, so oxygen does not get to the body's organs, causinganemia. The crescent-shaped red blood cells also get stuck intinyblood vessels, causing pain•The key interventions for a client in sickle cell crisisis to promote and maintain oxygenation andtissue perfusion, hydrate the client to prevent excessive sickling of the red blood cells, manage theclient's pain, and promote neurological function.•Administermorphine,administer normal saline, assess hand -grip strength.•Clients with sickle cell anemia have problems with the shape ofthered blood cells, notthenumber, soa blood transfusion would not be indicated.Microcytic Anemia:Vitamin B12 deficiency folic acid deficiency alcoholism.Anemia Causedby Efood Loss•Red blood cells can be lost through bleeding, which can occur slowly over a long period of time, andcan often go undetected. This kind of chronic bleeding commonly results from the following:•Gastrointestinal conditions:ulcers, hemorrhoids, gastritis (inflammationofthe stomach) & cancer•Use of nonsteroidal anti-inflammatory drugs (NSAID5) such as aspirin or ibuprofen•Menstruation and childbirth in women, especially if menstrual bleeding is excessive and if there aremultiple pregnanciesAnemia Causedby Decreased or Faulty Red Efood Cell ProductionThe body may produce too few blood cells or the blood cells may not function correctly.Ineither case, anemiacan result. Red blood cells may be faulty or decreased due to abnormal red blood cells or the a lack of mineralsand vitamins needed for red blood cells to work properly.Conditions associated with these causes of anemia include the following:•Sicklecellanemia*Bone marrow and stem cell problems•Iron deficiency anemia*Other health conditions•Vitamin deficiencyVitamin-deficiency anemiamay occurwhen vitamin B-12 and folate are deficientThese two vitamins areneeded to make red blood cells. Conditions leading to anemia caused by vitamin deficiency include:•Megaloblastic Anemia:Vitamin B-12 or folate or both are deficientCCells will become bigger because B12 is low

Loading page image...

19OGood sources ofVit B12-liver, beef, salmon, trout, breakfast cereals, tuna, milk, cheese, ham,egg, roasted chicken*Pernicious anemia:Poor vitamin B-12 absorption caused by conditions such as Crohn's disease, anintestinal parasite infection, surgical removal of part of the stomach or intestine, or infection with HIV*Dietary deficiency:Eating little or no meat may cause a lack vitamin B-12, while overcooking or eatingtoo few vegetables may cause a folate deficiency.■During early pregnancy, sufficient folic acid can prevent the fetus from developing neural tube defectssuch as spina bifida.Central Line•Important that you watch forINFECTIONbecause it is a line straight to the heart•Observe the central line insertion site frequently for local infection (erythema, tenderness, exudate).•Change the sterile dressing on a central line per protocol (typically every 72 hrs)•Flushtheline at least every 12 hr (3 mL for peripheral, 10 mL for central lines)tomaintain patency.•Studies show that 0.9% sodium chloride is as effective as heparinized flush solutions to maintaincatheter patency. Follow facility policy. Leave central lines clamped when not in use.•TPN administration is usually through a central line , such as a non-tunneled triple lumen catheter or asingle- or double-lumen peripherally inserted central line (PICC).Magnesium Sulfate.CNS Depressant - USED FOR SEIZURES•Use in early onset of labor - t oPrevent Seizure and increase tolerance for seizure activity•Monitor reflexes (Deep Tendon Reflexes) and respirations•Lowmagnesium,heart rate goes up= TACHYCARDIA•Usedintreatment ofpregnancyinducedhypertension and preeclampsia■Magnesium sulfate,lowers BP anddepressesCNS -Monitor BP•SignsOf Toxicity absence of patellar deep tendon reflexes, urineoutput <3 0 m l / h r , respirations <12/mioCalcium gluconate-antidote for Magnesium toxicityCalcium Channel Blockers (CCB)•Nifedipine (Adalat, Procardia)*Amlodipine (Norvasc)•Verapamil (Calan)•Felodipine (Pkendil)•Diltiazem (Cardizem)- usedtoregulateHR-■Nicardipine (Cardene, Cleviprex)administer IV■Concurrent use of CCB &. Beta blockerscan leadto BRADYCARDIA and HEART FAILURE-space thesemeds- couple hours between•CCB cannot be taken with GRAPEFRUIT JUICE- LEAD TO TOXICITY* “When you sendapatient home a good betablocker togive for home managementis:Coreg**Dopamine - you will see drug calculations and drip rates•Used to treat shock and heart failure•It's a vasoconstrictor•For critical care- in cardiac care•Increase BP- worry about EXTRVASTION (LEAKING OUT OF IV = NECROSIS)

Loading page image...

20OMonitor IV closelyODiscontinue infusionatthe first signofirritationoRegitineis the antidote!TPN -Bag becomes empty give them 10%dextroseNardil (Phenelzine) -MAOI's -> interacts with food (containing TYRAMINE).Monoamine Oxidase Inhibitors (MAOI):•Phenelzine - Nardil (7.5 - 90 mg/d)•Tranylcypromine - Parnate (10 - 60 mg/d)•Isocarboxazid - Marplan (20 - 60 mg/d*Selegiline - Emsam (Patch) 6mg - 12mg/d•Moclobemide - Manerix (Canada)*St. John's Wort•Side effects: Dizziness, headache, stiff neck, N/V, restlessness, insomnia, dry mouth, sexualdysfunction, weight gain and hepatic necrosis•Indications"*: useful in ATYPICAL DEPRESSION (increased sleep/appetite, anxiety & rejection).*Adverse/toxiceffects-Hypertensive Crisis(ifyoueat foods containing tyramine)*Inhibits the breakdown of norepinephrine, serotonin, dopamine, and tyramine-All of these aredesired except for the inhibition of breaking down tyramine.*High tyramine levels can cause high BP, hypertensive crisis, and CVA•Rarely used because of the problems with food interactions*Emsam is a patch & causes severe increase in blood pressure•Food interaction:This will be a question on the test!MUST AVOID FOODSsuch as avocados, soybean, figs, ripe bananas, fermented, smoked, oraged meats, sausages such as bologna, pepperoni, and salami, smoked fish,allcheeses, beers,red wine, soy sauce, and protein supplements.Qonthe test: Why do you teach a patient to avoid these things like tyramine?A: Because it can result in high blood pressure and intracranial bleeding.■Drug interaction-DON'T ADMINISTER WITH:*> Other antidepressants (SSRIs, SNRI's, TCA's), OTC cold & flu medications and DEMEROL.*Therapeutic uses:OAtypicalDepression,Bulimia, ObsessivecompulsiveDisorders*Side effects:Dizziness, headache, stiff neck, N/V, restlessness, insomnia, dry mouth, sexualdysfunction, weight gain.hypotension and hepatic necrosis.•Orthostatic HypotensionOMonitor BPOHold medicationOInstruct the client to changepositionsslowly*Other information for MAOI's:❖Monitor BP during the first6weeks oftreatment.HYPERTENSIVE CRISISmay begin with a headache, stiff neck, palpitations, increased ordecreasedHR,nausea, vomiting, or pyrexia. Immediate medicalattention isrequired.OAdministerPhentolamine{Regitine)

Loading page image...

21oAdminister Calcium Channel Blocker- Nifedipine (Procardia),oIce packs or hypothermic blankets can be used.•'Labs are done early in the morning before the morning dose of medications•Contraindications:0Use cautiously in clients with diabetes and seizure disorder or those takingTricyclicAntidepressants-can lead toHYPERTENSIVE CRISIS.0Use withSSRI'scan lead toSERTONIN CRISIS0Tyramine Rich Foods0Concurrent use of vasopressors (phenlethylamine, caffeine) may result in hypertension0Advise clients to avoid, tyramine foods, and foods that contain caffeine, chocolate, fava beansand ginseng.The BIG Deal with MAOI:•Food interaction! Pickled, fermented, smoked, or aged foods, such as red wine, preserved food, agedstinky cheese, which leads to hypertensive crises resulting in intracranial bleed.•Drug Interaction (Do not give with)>Other antid epressants>OTC cold and flu medications>DemerolAntidepressant Drugs:•TricyclicAntidepressants (TCAs)0Amitriptyline (Elavil)0Imipramine (Tofranil)0Doxepin (Sinequan)0Nortriptyline {Aventyl)QAmoxapine (Asendin)oTrimipramine (Surmontil)>Amitriptyline (Elavil)- Do not use with MAOI's■Have more side effects■Take longer to reach optimal dose"FAR MORE LETHAL IN OD■Contraindicated for clients with SEIZURESTCA Amitriptylinebide errectsNursing interventionsOrthostatic Hypotension•Instruct clients about the signs of postural hypotension(lightheadedness, dizziness), if these occur, advise the client to sit or lie

Loading page image...

22down.■Orthostatic hypotension can be minimized by getting up or changingpositions slowly.■Monitor blood pressure and heart rate for clients in the hospital fororthostatic changes before administration and 1 hr after, if a significantdecrease in blood pressure and/or increase in heart rate is noted, do notadminister the medication, and notify the provider.•Instruct clients on ways to minimize anticholinergic effects. Theseinclude:0Chewing sugarless gum0Sipping on water0Wearing sunglasses when outdoors0Eating foods high in fiber0Participating in regular exercise0Increasing fluid intake to at least 2 to 3 L/day0Voiding just before taking medication■This effect usually diminishes over time.• Advise clients to avoid hazardous activities such as driving if sedation isexcessive.•Advise clients to take medication at bedtime to minimize daytimesleepiness and to promote sleep.•Give a 1-week supply of medication to clients who are acutely iil.•Obtain the client's baseline ECG.•Monitor vital signs frequently.•Monitor clients for signs of toxicity.•Notify the provider if signs of toxicity occur.Anticholinergic Effects-Dry mouth-Blurred Vision-Photophobia-Urinary hesitancy, retention-Constipation-TachycardiaSedationFatal Arrhythmias!Toxicity resulting in cholinergicblockade and cardiac toxicityevidenced by dysrhythmias,mental confusion, and agitation,followed by seizures, coma, andpossible death.Decrease seizure thresholdExcessive Sweating•Monitor clients who have seizure disorders•inform clients of side effect.•Assist clients with frequent linen changes.Contrai■Pregnancy, those who have SEIZURE DISORDERS■Concurrent use of Mao's & St. John's wort may lead toSEROTONIN SYNDROME.*Selective Serotonin Reuptake Inhibitors (SSRIs)- Do not take with MAOI's>Fluoxetine (Prozac)>Sertraline (Zoloft)>Paroxetine (Paxil)>Citalopram (Celexa)

Loading page image...

23>Do not take SSRI with pimozide (Orap), thioridazine (Mellaril), or a monoamine oxidase inhibitor(MACH) such as furazolidone (Furoxone), isocarboxazid (Marplan), phenelzine (Nardil)>Issues with SSRIs:ODizziness, Nausea, Pins and needlesOZappers0Prozac does not cause discontinuation symptoms=16 weeks half life>Possible Side Effects SSRI:0Gl upset: Nausea and Vomiting, Constipation0Nervousness, sleep disturbance.somnolence0Sexual dysfunction:libido and orgasmOWeight gain & Cognitive problems:WORD FINDING•Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)-Do not use with MAOI's>Venlafaxine (Effexor)>Duloxetine (Cymbalta) - Do not use Cymbalta together with thioridazine (Mellaril), or an MAOinhibitor.OIndicated for depression and diabetic peripheral neuropathyONeuropathic pain= nerve injury or dysfunctionOtserotonin and NorepinephrineSerotonin Syndrome:•Mild in most people, recovery within 24 - 72 hours, although it can cause death under circumstances•Seen in people taking two or more medications that increase levels of serotonin in the CN5•Symptoms:3 of the follow!ngConventional Antipsychotic Medications EPS Side Effects:Acute dystonia: Anticholinergics7Involves bizarre and severe muscle contractions usually of the head andneck. Can be painful and frightening. Occurs within 48 hours of initiation of medication.Intervention:TreatwithCogentin or Benadryl or Symmetrel IMAkathisia:Anticholinergics-Descrlbed as feeling like jumping out oftheskin. Inability to sit still, resultinginrocking, running, or agitated dancing. Regular rhythmic movements usually of lower limbs. Usually occursafter 3 or more weeks of treatment.Intervention:Treat w/Lorazepam or Cogentin or Benadryl or Symmetrel IMPseudoparkinsonism: Anticholinergics- Cogwheel rigidity, tremors at rest, rhythmic oscillations of theextremities, pill rolling movement of the fingers and bradykinesia. Usually occurs after 3 or more weeks oftreatment.Intervention:TreatwithCogentin or Benadryl or Symmetrel IMTardive Dyskinesia:Abnormal Involuntary Movement Scale (AIMS) - Characterized by abnormal involuntary

Loading page image...

24movements lip smacking (Guppy like), tongue protrusion, foot tapping & facial tics. Usually occurs late inthe course of long-term treatment. Avoid typical antipsychotics. Prophylactic use of vitamin E and Omega-3FFA. Often irreversible.Intervention:Abnormal Involuntary Movement Scale {AIMS)- Brief test for detection of tardive dyskinesiaAnti-Parkinson medications: (to relieve EPS Parkinson side effects)•Trihexyphenidyl (Artane)•Diphenhydramine (Benadryl)•Benztropine (Cogentin)•Amantadine (Symmetrel)Anticholinergic Side Effects: Occur with Typical (Conventional) Antipsychotics•Dry mouth■Blurred vision•Constipation•Urinaryretention•Tachycardia•PhotophobiaPotentially Dangerous Responses to Antipsychotics: TOXICITY•Neuroleptic Malignant Syndrome (NMS)0Typically occurs in first 2 weeks of treatment or when the dose is increased0Caused by acute reductionofdopamine in the brain0Symptoms:Muscle rigidity, tachycardia, hyperpyrexia {elevated temp) altered consciousness(mental confusion), tremors and diaphoresis-lead to DEATH0Watch patient as soon as temperature spikes- if left untreated a person can die within 8 hours.0If pt. is diaphoretic, unable to respond & is motionlessHold the medication, notify thephysician, and begin supportive treatments.OMild cases can be treated with Parlodel (Bromocriptine)oSevere cases can be treated withDan trium & ECT•NursingInterventions:OStop antipsychotic medicationsOApply cooling blanketsOAdminister antipyreticsOAdminister diazepam (Valium) to control anxiety0Administer Dantrolene (Dantrium) to induce muscle relaxationMethergine -for uterine atony, excessive bleeding post partum■Monitor BP

Loading page image...

25Tracheostomy Care■Tracheotomy is a sterile surgicalincisioninto the trachea for establishing an airway•Tracheostomy is the stoma that results from tracheotomy and the insertion and maintenance of acannula•Provide tracheostomy care every 8 hr■Give frequent oral care, usually every 2 hr.•Forcuffed tubes, keep the pressurebelow20mm Hgto reduce the risk of tracheal necrosis due toprolonged compression of tracheal capillaries.•Assess/Monitor□Oxygenation and ventilation (respiratory rate, effort. SaO2) and vital signs hourly0Thickness, quantity, odor, and color of mucous secretions0Stoma and skin surrounding the stoma for signs of inflammation or infection (redness, swelling,drainage)0Provide adequate humidification and hydration to thin secretions and decrease risk of mucusplugging.ODo not suction routinely, because this may cause mucosal damage, bleeding, andbronchospasm.OAssess/monitor the need for suctioning:Suction on a PRN basis when assessment findingsindicate it is needed (audible/noisy secretions, crackles, restlessness, tachypnea, tachycardia,mucus in the airway).•Suction:OSuction the tracheostomy tube if necessary, usingsterilesuctioning supplies.0Sterile procedure during suctioning, suction 10-15 seconds a t a time■Infant you only suction for 5 secondsOHyperoxygenate the client with oxygen before and after0You only suction when you are pulling outOAssess respiratory status every 1-2 hours0Never turn off the ventilator alarms.OThereare three types of ventilator alarms: volume, pressure, and apnea alarms.■VOLUME (LOW PRESSURE) ALARMS:indicate a low exhaled volume due to adisconnection, cuff leak, and/or tube displacement.■PRESSURE (HIGH PRESSURE) ALARMS:indicate excess secretions, client biting thetubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm, and/orpneumothorax or obstruction.■APNEA ALARMS:indicate that the ventilator does not detect spontaneous respiration ina preset time period.OAssess the cuff pressure at least every 8 hr.■Maintain the cuff pressure below20mmHg to reduce the risk of tracheal necrosisOAssessforan airleakaround the cuff(client speaking, air hissing, or decreasing SaO2).Inadequate cuff pressure can result in inadequate oxygenation and/or accidental extubation.

Loading page image...

25Tracheostomy Care•Tracheotomy is a sterile surgical incision into the trachea for establishing an airway•Tracheostomy is the stoma that results from tracheotomy and the insertion and maintenance of acannula■Provide tracheostomy care every 8 hr•Give frequent oral care, usuaIly every 2 hr.•Forcuffed tubes, keep the pressurebelow 20 mm Hgto reduce the risk of tracheal necrosis due toprolonged compression of tracheal capillaries.•Assess/Monitor0Oxygenation and ventilation (respiratory rate, effort, SaO2) and vital signs hourly0Thickness, quantity, odor, and color of mucous secretions0Stoma and skin surrounding the stoma for signs of inflammation or infection (redness,swelling,drainage)0Provide adequate humidification and hydration to thin secretions and decrease risk of mucusplugging.0Do not suction routinely, because this may cause mucosal damage, bleeding, andbronchospasm.0Assess/monitor the need for suctioning: Suction on a PRN basis when assessment findingsindicate it is needed (audible/noisy secretions, crackles, restlessness, tachypnea, tachycardia,mucus in the airway).■Suction:0Suction the tracheostomy tube if necessary, using sterilesuctioning supplies.0Sterile procedure during suctioning, suction 10-15 seconds a t a time■Infant you only suction for 5 seconds0Hyperoxygenate the client with oxygen before and after0You only suction when you are pulling out0Assess respiratory status every 1-2 hours0Never turn off the ventilator alarms.0There are three types of ventilator alarms: volume, pressure, and apnea alarms.■VOLUME (LOW PRESSURE) ALARMS: indicate a low exhaled volume due to adisconnection, cuff leak, and/or tube displacement.■PRESSURE (HIGH PRESSURE) ALARMS: indicate excess secretions, client biting thetubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm, and/orpneumothorax or obstruction.■APNEA ALARMS: indicate that the ventilator does not detect spontaneous respiration ina preset time period.0Assess the cuff pressure at least every 8 hr.■Maintain the cuff pressure below 20mm Hgto reduce the risk of tracheal necrosis0Assess for an air leak around the cuff (client speaking, air hissing, or decreasingSaO2).Inadequate cuff pressure can result in inadequate oxygenation and/or accidental extubation.

Loading page image...

26•Changing Tracheotomy0Remove old dressings and excess secretions.0Apply the oxygen source looselyifthe client desaturates during the procedure.0Use cotton-tipped applicators and gauze pads to clean exposed outer cannula surfaces.0Begin with half-strength (mixed with sterile 0.9% NaCl) or full-strength hydrogen peroxidefollowed by 0.9% NaCl. Clean in a circular motion from the stoma site outward.0Use surgical aseptic technique to remove and clean the inner cannula (use half-strength or full-strength hydrogen peroxide solution to clean the cannula and sterile 0.9% NaCl to rinse it).0Replace the inner cannula if it is disposable.0Change non-disposable tracheostomy tubes every 6 to 3 weeks or per protocol.■Reposition the client every 2 hr to prevent atelectasis and pneumonia.■Minimize dust in the client's room: DO NOT SHAKE BEDDING■If the client is permitted to eat, position the client in an upright position and tip the client's chin to herchest to enable swallowing. Assess for aspirationBioterrorism•Cutaneous Anthrax - Forms black scabs•Inhalational -Anthrax0S/S:Sore throat. Fever, Muscle aches, Severe dyspnea, Meningitis,ShockaTX:IV ciprofloxacin(Cipro)Ergonomic Principles•Assess the client’s ability to balance, transfer, and use assistive devices prior to planning care.•The closer the line of gravity is to the center of the base of support, the more stable the individual is.•To lower the center of gravity, bend the hips and knees.•Lifting0Don't lift with your back - always use your knees0Use the major muscle groups to prevent back strain, and tighten the abdominal muscles toincrease support to the back muscles.0Distribute the weight between the large muscles of the arms and legs to decrease the strain onany one muscle group and avoid strain on smaller muscles.0When liftingan object from the floor, flex the hips, knees, and back. Get the object to thighlevel, keeping the knees bent and the back straightened.0Stand up while holding the object as close as possible to the body, bringing the load to thecenter of gravity to increase stability and decrease back strain.0Use assistive devices whenever possible, and seek assistance whenever it is needed.•When pushing or pulling a load:0Widen the base of support.0When opportunity allows, pull objects toward the center of gravity rather than pushing away.0If pushing, move the front foot forward, and if pulling, move the rear leg back to promotestability.0Face the direction of movement when moving a client.0Use own body as a counterweight when pushing or pulling to make the movement easier.0Sliding, rolling, and pushing require less energy than lifting and offer less risk for injury.0Avoid twisting the thoracic spine and bending the back w hile the hips and knees are straight.

Loading page image...

27■Leading the blind- They need to hold onto you0Lead them hold Ing o nto the eIbowPT. IN TRACTION- NEVER TAKE OFF THE WEIGHTSBuck Traction: (Hip Fractures)is a foam boot with Velcro straps applied to the lower leg to helpimmobilize and relieve pain in clients with fractured hip!■To decrease muscle spasms- Placed for longer periods•If patient is SOB/Cyanotic: Give 02 before notifying HCP■Superficial perineal nerve compression can result if the straps are too tight.•Frequent release of straps prevents this complication.■Buck traction: 5 - 10 LBs- must NOT be sitting on the floor•Keep proper body alignment and change positions slowly with the assistance of unaffected side whenusing BUCK'S traction•Boot should be removed 3 times a day for inspection of skin•Assist client with foot exercises throughout the day to prevent DVT■NEVER PLACE WEIGHTS ON THE FLOOR- WEIGHTS MUST HANG FREELY TO PROVIDE CONSTANTTRACTIONBryant's traction is used in children under 3 years of age & has a fractured femurSkeletal Traction•Applied directly to the bone to reduce a fracture or to maintain bone alignment■Pins & wires are inserted through the skin and soft tissue and into the bone•Balanced suspension is uses splints and slings to support the extremity and weights for countertraction■Skeletal:OUsed continuously. The pulling force is applied directly to the bone by weights attached by ropedirectly to a rod/screw placed through the bone.•Examples include skeletal tongs (Gardner-Wells) and femoral or tibial pins (Steinmann pin).■Weights up to 25 pounds can be applied as needed•Maintain body alignment and realign if the client seems uncomfortable or reports pain.■Avoid lifting or removing weights.•Assure that weights hang freely,•If the weights are accidentally displaced, replace the weights. If the problem is not corrected, notify theprovider. Assure that pulley ropes are free of knots.•Notify the provider if the client experiences severe pain from muscle spasms unrelieved withmedications and/or repositioning.•Move the client in halo traction as a unit, without applying pressure to the rods. This will preventloosening of the pins and pain•Routinely monitor skin integrity and document■Pin Site Care:OPin care is done frequently throughout immobilization (skeletal traction and external fixationmethods)

Loading page image...

280Monitor for signs of infection including:■Drainage (color, amount, odor).■Loosening of pins.■Tenting of skin at pin site (skin rising up pin).■Pin care protocols (Chlorhexidine) are based on provider preference and institutionpolicy.■A primary concept of pin care is that one cotton-tip swab is designated for each pin toavoid cross-contamination.■Pin care is provided three times a day or per facility protocol.■Crusting at the pin site should not be removed as this provides a natural barrier frombacteria.Skin Traction*Used for short term: Assess every 8 hrs - skin care dressing*Clean pins with NS or hydrogen peroxideSix Ps Are Characteristic of Impending Compartment Syndrome*Paresthesia: numbness and tingling*Pain: distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscletraveling through compartment*Pressure: T in compartment*Pallor: coolness and loss of normal color of extremity*Paralysis: Ioss of functio n*Pulselessness:diminished/absent peripheral pulsesIf Compartment Syndrome Then:*Extremity should NOT BE ELEVATED above heart level.0Elevation may raise venous pressure and slow arterial perfusion.*Application ofcold compresses may result in vasoconstriction and may exacerbate (make worse)compartment syndrome.*May be necessary to remove or loosen bandage*Reduction infraction weight may J- external circumferential pressures.*Surgical decompression may be necessary.fFasciotomy-surgical site left open for several days toensure adequate soft tissue decompression; risk for infection and delayed wound healing is a potentialproblem following fasciotomyIf a patient has a surgery to repair fractured left tibia and cannot feel the surgical site by stating that it feelsasleep, you should?*Neurovascular assessment of fractured extremity for any changes*Check peripheral pulses*Check for edema, color & te mperature*Notify HCPA patient post-operative walking with a limp could indicate that the HIP IS DISLODGED.If a patient had a hip replacement, you should place an ABDUCTION PILLOW between the legs.Nursing Implementation for Fractures:*Neurovascular assessment of fractured extremity for any changes.

Loading page image...

29*Check pulse, for edema, color, temperature.*Minimize pain by proper alignment, support of extremity, and positioning of patient•Keep extremity elevated above heart.*Monitor for bleeding and look over bony prominences for skin integrity.•Fractured mandible:Checkfor patent airway, maintain clean oral hygiene, and adequatenutrition■Because of limited movement, to prevent constipation, maintain a high fluid intake and fibrous foods.*Assist patient with ambulation to help determine the patient's abilities. Give referrals to long termrehabilitation programs.*Fractured hip: keep hip in neutral position when sitting, walking, or laying down.•Fractured humerus:Protect the axilla of skin breakdown due to constant sweating with absorptionpads.Nursing Management forHip ReplacementSurgery*ABDUCTIONpillow between legs*Patient should never cross legs or twist to reach behind•Never bend down/Weight bearing exercisesExample Q: In identifying people at risk for fractures, the nurse recognizes that the person at greatest risk forgreenstick fractures is?a.A female client over 40 years old walking her dogb.A 21 year old male who plays basketball 6 times a week for 6 hoursc.A 5 year old male playing at the playgroundd.A 90year old female with a history of fallsPelvicFracture/HipReplacement■Donot cross legs•No squatting or sitting down*Teaching is important hereHIP REPLACEMENT SURGERYTheDos•Dokeeptheleg facing forward.•Do keep the affected leg in front as you sit or stand.*Do use a high kitchen or barstool in the kitchen.•Do knee on the knee on the operated leg (the bad side).•Do use icetoreducepainand swelling,butremember that ice will diminish sensation. Don'tapplyice directly to the skin: use an ice pack or wrap it in a damp towel.*Do apply heat before exercising to assist with range of motion. Use a heating pad or hot, damp towelfor 15 to 20 minutes.•Do cut back on your exercises if your muscles begin to ache, but don't stop doing them]TheDon'ts*Don'tcross your legs at the knees for at least 8 weeks.•Don't bring your knee up higher than your hip.*Don't lean forward while sitting or as yousitdown.•Don't try to pick up something on the floor while you are sitting.*Don't turn your feet excessively inward or outward when you bend down.•Don't reach down to pull up blankets when lying in bed.

Loading page image...

30•Don't bendat the waist beyond 90°.•Don't stand pigeon-toed.■Don't kneel on the knee of the unoperated leg (the good side).•Don't use pain as a guide for what you may or may not do.Toradol (NSAID)•The medication is most often used totreat pain following a procedure, butmay also be used for suchthings as pain caused by kidney stones, back pain, or cancer pain.•Belongs to a class of drugs called non steroidaI anti-inflammatorydrugs.Toradol Side Effects Include:•Headache. Abdominal pain (or stomach pain) & Nausea•Heartburn or indigestion•Diarrhea, Dizziness, Drowsiness & Swelling•Other side effects with Toradol occurring in more than 1 percent of people include but are not limitedto: High blood pressure (hypertension), Itching, Unexplained rash, Gas. Constipation,Vomiting,Sweating Pain at the injection site if injection.Toradol - Serious Side Effects:•Allergic reactions•Stomach or intestinal problems, including bleeding, ulcers (known as a perforation).•Liver damage, which can cause nausea, fatigue, yellowing of the skin or whites of the eyes, andexcessive tiredness.•Kidney problems, including kidney failure•Fluid retentionorunexplained weight gainPatient has thick sputum that cannot be expelled by coughing. First thing you should do is provide•Water to loosen up the secretions.* “Sputum Specimens are best taken in the morning- have client drink some water. (TB testing)Ifan IVis infiltrated, this could be a priority given the other options.•StoptheIVand monitor the site& place warm/hot compressesBPH Teaching•BPH is a benign enlargement oftheprostate gland- usually men over 60■Avoid:Caffeine & Alcohol•The possible cause of this condition is thought to be attributed to the increased accumulation ofdIhydrosytestosterone-Not Cancer•Decreased force of urinary stream, difficulty in urination. Double Voiding (stopping and startingstream several times while voiding and dribbling at the end of the voiding) is an indication of BPH•S/S:FREQUENCY, URGENCY, NOCTURIA & HESITANCY•Teach the patient to practiceKegal exercisesfor 10-20 mins daily

Loading page image...

31•The nurse should know and teach patients to know that Anticholinergic (COGENTIN) should NOT begiven to patients with BPH•Diagnostics: Digital Rectal Exam. PSA test > 4ng = Prostate Cancer.Urinetest for Nitrates, Blood testfor creatine & Transurethral ultrasound with Biopsy.BPH Medication:OPROSCAR (FINASTERIDE) 5- alpha reductase inhibitor■Cause Orthostatic Hypotension■Slows the growth of the prostate■Can cause ERECTILE DYSFUNCTION■Patient teaching:Sexual activity will decreases-Discuss sexual concernsBPH Teaching- Yearly Check•Kegel exercises 10-20 min daily•Saw palmetto(herb)candecrease prostate but can increase risk for BLEEDING•Proscar: INCREASE ORTHOSTATIC HYPOTENSION50 risk for falls, not for pregnant women, decreasessize of prostate.•Urine incontinence-dribbling- difficulty urinating is indicative if BPH•Cogentin (anticholinergics)should NOT be given to patients with BPHTrans-Urethral Resection of the Prostate (TURP): Prostate surrounds the urethra: the enlargement cansqueeze the urethra making it difficult to pass urine. This may lead to symptoms that can include:•Weak flow of urine•Needing to strain to pass urine•Not being able to empty the bladder completely, so needing to use the toilet day and night.•To relieve the above symptoms of an enlarged prostate - TURP is carried out•TURP:For males- always check catheters, will be a Foley catheter but a 3-way, so always check.•If the catheter caused infection then change the catheterPriorities for the most experienced nurses: Only give TURP to experienced nurses!•Don'tgive a new nurse a complex patient such as one with TURP.TURP-Transurethral Resection oftheProstate•Use of excision and cauterization to remove prostate tissue cytoscopically•A surgical treatment using a resectoscope inserted through the urethra•CONTINUOUS BLADDER IRRIGATION0Continuous bladder irrigation 3 lumen catheter ( 2000L)-increase flow rate if you see red blood0It is usually done for the first 24 hours to prevent obstruction from mucus and blood clots.0It is to PREVENT THECLOTS, if there is a BRIGHT RED BLEEDING that means there is a clot stuckin there so you have the INCREASE THE FLOW rate of CBIHand Hygiene•The No. 1 measure to reduce the growth and transmission of infectious agents is hand hygiene. TheCenters for Disease Control and Prevention (CDC) states that "hand hygiene has been cited frequentlyas the single most important practice to reduce the transmission of infectious agents in health care

Loading page image...

32settings. The term "hand hygiene" refers to both hand washing with an antimicrobial or plain soap andwater as well as the use of alcohol based products such as gels, foams, and rinses."•The three essential componentsofhand washinginclude:0SoapOWaterOFrictionTransmission of Infectious Diseases•Reverse IsolationODesigned to protect a patient from infectious organisms that might be carried by the staff,other patients, or visitors or on droplets in the air or on equipment or materials.OProtective modified reverse isolation is less restrictive but is not prolonged needlessly becausethe patient usually feels lonely and sensorial deprived.OHand washing,gowning, gloving, sterilization, or disinfection of materials brought into the areaand other detailsofhousekeeping vary with the reason fortheisolation and the usual practicesof the hospital.•Rotavirus- Contact precautionOProtect visitorsand caregivers against directdient'environmentalcontact infections(respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, woundinfections, herpes simplex, scabies, multidrug-resistant organisms).0Contact Precautions Require:■A private room ora room with other clients with the same infection■Gloves and gowns worn by the caregivers and visitors1Disposal of infectious dressing material into a single, nonporous bag without touchingthe outside of the bag•Meningitis- Dropiet precautionOIsolate the client as soon as meningitis is suspected.0Maintain isolation precautions per hospital policy.OThis should be DROPLET PRECAUTIONS which requires a private room or a room with cohorts,wearing of a surgical maskwhen within3feetof theclient,appropriate hand hygiene, and theuse of designated equipment, such as blood pressure cuff and thermometer. Continue untilantibiotics have been administered for24hr.OImplement fever- reduction measures, such as a coolingblanket,if necessary.0Report meningococcal infections to the public health department.0Decreaseenviranm ental stimu11.OProvide a quiet environment.0Minimize exposure to bright light (natural and electric).OMaintainbed rest with the headofthe bed elevated to 30°.OMaintain client safety, such as seizure precautions.Home Visit•Child safe home:0Aspiration:■Keep alI sma11objectsout ofreach.

Loading page image...

33■Check toys for loose parts.■Do not feed the infant hard candy, peanuts, popcor n, or whole or siiced pieces of h otdog.■Do not place the infant in the supine position while feeding or prop the infant's bottle.■A pacifier (if used) should be constructed of one piece.0Provide parents with information about prevention of lead poisoning electrical sockets, meds,locking cabinets, poison control center #0Suffocation:■Keep plastic bags out of reach.■Make sure crib mattress fits snugly and that crib slats are no more than 23/8 inchesapart. Never leave an infant or toddler alone while in the bathtub.■Remove crib toys such as mobiles from over the bed as soon as the infant begins to pushup.■Keep latex balloons away from infants and toddlers.■Fence swimming pools and use a locked gate.•Begin swimming lessons when the child's developmental status allows forprotective responses such as closing her mouth underwater.■Keep toilet lids down and bathroom doors closed0Poisoning :■Keep h ouse pla nts and cleaning agents out of reach.■Place poisons, paint, and gasolineinlocked cabinet.■Keep m edications in chi d-proof conta iners and Iocked up.■Dispose of medications which are not longer used or are out of date.CFalls :■Keep crib and playpen rails up.■Never leave the infant unattended on a changing table or other high surface■Restrain when in high chair, swing, stroller, etc■Place in a low bed wh en todd ler sta rts to climb.0Motor vehicle/lnjury:■Use backward facing car seat until the infant/toddler is 1 year old and weighs at least 20lb.■All car seats should be federally approved and be placed in the backseat0Burns:■Test the temperature of formula and bath water.■Place pots on back burner and turn handle away from front of stove.■Supervise the use of faucetsElderly safe home: falls0Modifications that can be made to improve home safety include:0Removing items that could cause the dient to trip, such as throw rugs and loose carpets□Placing electrical cords and extension cords that against a wall behind] furniture0Making sure that steps and sidewalks are in good repair

Loading page image...

340Placing grab bars near the toilet and in the tub or shower and installing a stool riser0Using a non-skid matin the tub or shower & place a shower chair in the shower0Ensuring that lighting is adequate both inside and outside of the home•Red flag0Domestic violence, elder abuse, fall risk0Stages of healing of bruises or cutsOMalnutrition0Lice on childrenOElectrical socketsOPoisonous substancesRespiratory Therapy- Oxygen therapy•21% 02 in air - the rest is nitrogen.Humidified over 4L (do not use on patient with a nose bleed),High volume & most precise = VENTURI MASK■40% nasal cannula•60-80%-mask•100%-nonreabreather•PulseOximeterOMeasures light absorption by oxygenated and deoxygenated Hgb in arterial blood.OSaO2 and SpO2 are used interchangeably©This is a noninvasive, indirect measurement of the oxygen saturation (SaO2) of the blood. Theexpected reference range is 95% to 100%, although acceptable levels for some clients rangefrom 91% to 100%.0Less than 85% is abnormal0Additional reasons for low readings include hypothermia, poor peripheral blood flow, toomuch light (sun or infrared lamps), low Hgb levels, client movement, edema, and nail polish.0A SaO2 below 91% requires interventions to help the client regain acceptable 5aO2 levels.OA SaO2 below 86% is an emergency.0A SaO2 below 80% is life-threatening.0If you get a low reading - make sure that it is working•Ventilation:©HIGHPRESSURE ALARM: obstruction ex. Patient needs suctioning©LOWPRESSURE A L A R M : something has become disconnected ex. tubing disconnectedRespiratory Drugs•Albuterol usually given in treatment•Give Zopinex to not increase HR as much as Albuterol•Mucomyst for breaking up secretions

Loading page image...

35CoolingBlanket*Place thermal sensor first*ColIect vita Is more freq uentlyAcid Base Imbalances■pH 7.35 to 7.45*PaO2 SO to 100 mm Hg*PaC02 35 to 45 mm Hg*HCO3- 22 to 26 mEq/L*SaO2 95 to 100%0Blood pH levels below 7.35 reflect acidosis, while levels above 7.45 reflect alkalosis.Respiratory Acidosis - Hypoventilation*Change in PaCO2, pH below 7.35*Vital signs: Tachycardia (severe acidosis may lead to bradycardia), tachypnea & dysrhythmias*Neurological: Anxiety, irritability, confusion, coma*Respiratory: Ineffective, shallow, rapid breathing*Skin:Pale or cyanoticRespiratory Alkalosis - Hyperventilation•Change in PaCO2, pH above 7.45•Vital Signs: Tachypnea•Neurological: Anxiety, tetany, convulsions, tingling, numbness•CV: Palpitations, chest pain, dysrhythmias•Respiratory: Rapid, deep respirationsMetabolic Acidosis - DIARRHEA•Change in HCO3, ph below 7.35•DM = metabolic Acidosis- Non-ketotic if blood sugar is over 600•Vital Signs: Bradycardia, weak peripheral pulses, hypotension, tachypnea and dysrhythmias•Neurological: Muscle weakness, Hyporeflexia, flaccid paralysis, fatigue, confusion•Respiratory: Rapid, deep respirations (Kussmaul's respirations)•Skin: Warm, dry, flushedMetabolic Aika/osis - VOMITING•Change in HCOS, ph above 7.45•Vital Signs: Tachycardia, normotensive or hypotensive, dysrhythmias•Neurological: Numbness, tingling, tetany, muscle weakness. Hyperreflexia, confusion, convulsion•Respiratory: Depressed skeletal muscles resulting in ineffective breathing•* "anything chronic you will always see compensation***Myocardial Infarction•Troponin levels-normal0-0.1(elevated)0Troponin is more im portant CKMB

Loading page image...

36■Mis are classified based on:0The affected area of the heart (anterior, anterolateral).0The EKG changes produced STELEVATION0Most Ml tend involve the left ventricle (LV)Myocardial Infarction (Ml)■Location-precordial, substernal: radiates•Quality-heaviness, crushing pressure, burning■Quantity-severe, sometimes mild•Timing -sudden onset, lasting > 15 min•Aggravating & relieving factors- UNRELIEVED•AssociatedS&S-dyspnea, sweating, weakness, n &v, severe anxiety.■ClinicaI Maniterations of M I0Pain■Severe, immobilizing chest pain NOT relieved by rest, position change, or nitrateadministration-The HALLMARK of an Ml0Nausea and vomiting■Can result from reflex stimulation of the vomiting center by the severe pain■Patient in so much pain - reflex stimulation in the brain is stimulatedST Elevation = MlST Depression = IschemiaPlanning for Chest Pain•Give themNitroglycerine and Morphine•Emergency treatment chest pain (MONA) - Oxygen comes first]0Morphine sulfate if pain unrelievedOOxygenONitroglycerine spray, or sublingual or IV if indicatedOAspirin 325mg■2large gauge IV lines■Cardiac monitor, 12-lead ECG (gold standard)■Assess contraindications thrombolytic therapyIRecent Surgery, high BP, risk for embolism - DON'T DO■Send tocardiac cathlabwithin 30minutesQUESTION:Patient arrives at an urgent care center complaining of substernal and epigastric pain and pressurefor the last 12 hours. The nurse reviews the labs knowing that this point in time Ml would be indicated bypeak levels or what?ANSWER: Troponin and CK-MBPeakT wave= HyperkalemiaU wave = HypokalemiaOther Drugs to Know - Other Uses

Loading page image...

37Breast cancer drug = tomoxiphenProstate cancer drug = lupron (can be given to women to stop bleeding)Pulmonary fibrosis = viagraHyperkalemia = Calcium GluconateAngiocardiographyVisualize the interior of the heart & adjacent great vesselsProcedure:using sterile technique, vascular access is obtained0Catheter inserted that contains a guide wire & is advanced to theRtatrium, guide wire removed &contrast material is injected. X-ray images are taken & stored0Nursing care-similar to conscious sedation, manual pressure for 5 min at insertion site, thenpressure dressing; monitor for hemorrhage or hematoma formation, push fluids afterwardsPreprocedure:0Patient needs to be NPO, informed consent, contrast (make sure that they are not allergic tothe die)Pconscious sedation (not putting to sleep), when you inject the die important to tell thepatient there will be a FLUSHINGSENSATION-so they don't get scared0Post procedure- Have to layflatfor 2hoursand on bed rest for4-6 hours -CAN’T GET UP!OImportant to check renal function before the test because of the contrastIntra procedure0Pt receives dye, anti-platelet medication - Aggrastat(don’t want to re-occludethearea)- becareful patient might bleed out!!OSee occlusion they will suck it out and stent the area■Pt having stent might have to be onPlavix forone year - good potential that the patientmight re-ocdude0If the patient is onGlucophage (Metformin) fordiabetes it can betoxic to the kidneys - holdthe GLUCOPHAGE (Metformin) for 43 hours post procedureOPt receives contrast - monitor patient creatinine, blood sugars■If pt has kidney problems, history of diabetes, high blood sugars are high or GFR are lowCan give themMucomystPO helps with binding with the irons from the contrastto get it out of the systemPostprocedure0Your FIRST PRIORITY is to check circulation! Check distal pulse (dorsal pedal pulses)OPatient has no pulse post procedure - need to let someone know right away0Checking every 15 minutes!!OLook at col or of the skin: pal e, cool or warm0Check for bleeding or hematoma at the puncture site0If the site has some bleeding -put pressureabovesitefor5to10minutes thenputa 10poundsacon theareaOVitalsigns: monitor Q 5 minutes for an hour0Monitor for dysrhythmiasOWatch for s/s of pulmonary emboliOPush fluids afterwards

Loading page image...

330Bed rest for 4-6 hours, first two hours flat0If the patient wants todrinksomething put them in REVERSE TRENDELENBURG position -head of the bed lower than the feet - not bending the torso■How Do You Take The Catheter Out?0Pull out - femoral artery is going to bleed0Have to put pressure ABOVE the puncture site010 pound weight pressure - for about 10-15 minutes■Not a sandbag - has to be the nurse putting on pressure■Then later put sandbag0Two people should be in the room - patient can have a vasovtrgo/ reaction■Bradycardia and the blood vessels dilate■Tell patient to hear down and not to cough0While holding down - have the other nurse check pulses to make sure that you aren't puttingtoo much pressure□See slight bleeding - put a weight on the incision patient - theyMUST remain flat0Pulsation and pain to the site - it's an aneurysm and has to be fixed by surgery0Pt complaining of back pain - check for bleeding and BPQUESTION: A patient returns from the cardiac cath lab following a coronary angiogram which of the fol Iowingassessment would require immediate action?ANSWER: ST Segment Elevation (Infarction)PAWP- Measures the pressures in the LEFT Ventricle via the pulmonary artery■Normal level (PAWP): 6-12■What if the number is 20 - too much volume- give the patientLASIX■What if the number is 5 - give them FLUIDSNormal CVP: 2-3■What if the patient's CVP is 15 - what should you do? Give the patient's lasix•What if the patient's CVP is 0 - give them fluids - anticipate that the patient's BP is going to drop* ““If stabilizations of ABG is good - patient can be extubatedOnce you take the tube out: Priority-CHECKFORSTRIDOR & OXYGENATION•Give them Salmeterol orAlbuterolMental HealthDepression•Depression is a mood (affective) disorder that is a widespread issue, ranking high among causes ofdisability.•Depression may be comorbid with the following:0Anxiety disorders■These disorders are comorbid with 7O9G of major depressive disorders, the combinationof which makes a client's prognosis poorer, with a higher risk for suicide and disability.0Schizophrenia0Substance abuse

Loading page image...

39■Clients often abuse substances in order to relieve symptoms and/or self-treat mentalhealth disorders.0Eating disorders0Personality disorders■A client with depression may be at risk for suicide, especially if he has a family or personal history ofsuicide attempts, co morbid anxiety disorder or panic attacks, comorbid substance abuse or psychosis,poor self-esteem, a lack of social support, or a chronic medical condition*Major depressive disorder (MDD) is a single episode or recurrent episodes of unipolar depression (notassociated with mood swings from major depression to mania) resulting in a significant change in aclient's normal functioning (social, occupational, self-care) accompanied by at least five of thefollowing specific symptoms, which must occur almost every day for a minimum of 2 weeks, and lastmost of the day:0Depressed mood0Difficulty sleeping or excessive sleeping0Indecisiveness0Deereased ability to coneentrate0Suicidal ideation0Increase or decre ase in m otor acthrityOInability to feel pleasureOIncrease or decrease in weight of more than 5% of total body weight over 1 monthAnxiety■Anxiety is a response to stress. Higher levels of anxiety result in behavior changes. Anxiety tends to bepersistent and is often disabling.•Anxiety levelscan be mild (restlessness, increased motivation, irritability), moderate (agitation, muscletightness), severe (inability to function, ritualistic behavior, unresponsive), or panic (distortedperception, loss of rational thought, immobility)•Interventions for anxiety disorders include:■Providing emotional support that is accepting of regression and other defense mechanisms•Offering protection during panic levels of anxiety by providing for needs■Implementing methods to increase client self-esteem and feelings of achievement•Providing assistancewithworking through traumatic events or losses to reach an acceptance of whathas happened•Encouraging group therapyPanic Disorder•Episodes typically last 15 to 30 min.•Four or more of the following symptoms are present:0PaIpitations & Shortness of breathOChoking or smothering sensationOChest pain©Nausea©Feelings of depersonalizationOFear of dying or insanity

Loading page image...

400Chills or hot flashes■The client may experience behavior changes and/or persistent worries about when the next attack willoccur.■The client may begin to experience agoraphobia due to a fear of being in places where previous panicattacks occurred. For example, if previous attacks occurred while driving, the client may stop driving. Ifattacks continue while walking or taking alternative transportation, the client may remain at home•Levels of Anxiety0Mild:-restlessness, increased motivation, irritability (its good-0Moderate:-agitationnmuscle tightness0Severe: inability to function, ritualistic behavior, unresponsive0Panic: Distorts perception, loss of rational thought, immobilityPersonality Disorders•All Personality Disorders Share Four Common Characteristics:0Inflexibility/maladaptive responses to stress0Disability in social and professional relationships0Tendency to provoke interpersonal conflict0Ability to merge personal boundaries with others•Cluster A- generally described as odd or eccentric•Cluster B- generally described as dramatic, emotional, or erratic•Cluster C - generally described as anxious or fearfuI•Cluster A (od d or eccentric disord ers)0Paranoid personality disorder : characterized by irrational suspicions and mistrust of others.0Schizoid personality disorder lack of interest in social relationships, seeing no point in sharingtime with others, anhedonia, introspection.0Schizotypal personality disorder): characterized by odd behavior or thinking.•Cluster B (dramatic, emotional or erratic disorders)0Antisocial Personality Disorder:a pervasive disregard for the law and the rights of others.0Borderiine Personality Disorder:extreme "black and whitethinking, instability inrelationships, self-image, identity and behavioroften leading to self-harm and impulsivity.Borderline personality disorder is diagnosed in three times as many females as males.0Histrionic PersonalityDisorder: pervasive attention-seeking behavior including inappropriatelyseductive behavior and shallow or exaggerated emotions.0NarcissisticPersonality Disorder:a pervasive pattern of grandiosity, need for admiration,andalack of empathy.•Cluster C (anxious or fearf uI disorders)0Avoidant Personality Disorder social inhibition,feelingsofinadequacy, extreme sensitivity tonegative evaluation and avoidance of social interaction.0Dependent Personality Disorder:pervasive psychological dependence on other people.0Obsessive-Compulsive Personality Disorder: {not the same as obsessive-compulsive disorder)characterized by rigid conformity to rules, moral codes and excessive orderliness.

Loading page image...

Bipolar•Recognize s/s of manic episode of bipolar disorder•Mania -an abnormally elevated mood, which may also be described as expansive or irritable; usuallyrequires inpatient treatment•S/S:0Persistent elevated mood (EUPHORIA)OAgitation and irritability0Dislikeofinterference and intolerance of criticism0Increase in talking and activities0Flight of ideas- rapid, continuous speech with sudden and frequent topic changeOGrandiose view of selfandabilities (grandiosity)OImpulsivity: spending money, giving away money or possessions0Demandingandmanipulative behavior0Distractibility0Poor judgment0Attention-seeking behavior:flashy dress and makeup, inappropriate behavior0Impairment in social and occupational functioning0Decreased sleep0Neglect of ADLs, including nutrition and hydration0Possible presence of delusions and hallucinationsODenial of illness0Giving away things, spending a lot of money0Being extremely sexualAnger Management•Howto manage aggressive and angry clientNursing Care:•Provide a safe environment not only for the client who is aggressive, but also for the other clients andstaff on the unit.•Follow policies of the mental health setting when working with clients who demonstrate aggression.•Assess fo r tri ggersorpreconditionsthatescalateclientemotion.•Steps to handle aggressive and/or escalating behavior in a mental health setting include:•Responding quickly•Remaining calm and in control•Encouraging the client to express feelings verbally, using therapeutic communication techniques(reflective techniques, silence, active listening•Allowingthe client as much personal space as possible•Maintaining eye contact and sitting or standing at the same level as the client•Communicating with honesty, sincerity, and nonaggressive stance•Avoiding accusatory or threatening statements•Describing options clearly and offering the client choice•Reassuring the client that staff are present to help prevent loss of control•Setting limitsforthe die nt:0Tell the client calmly and directly what he must do in a particular situation, such as, "I need youto stop yellingandwalkwith me tothe day room where we can talk."0Use physical activity, such as walking, to de-escalate anger and behaviors.

Loading page image...

0Inform the client of the consequences of his behavior, such as loss of privileges.OUse pharmacological interventions if the client does not respond to calm limit setting.OPlan for four to six staff members to be available and in sight of the client as a "show of force" ifappropriate.*Following an aggressive/violent episode:ODiscuss ways for the client to keep control during the aggression cycle.OEncourage the client to talk about the incident and what triggered and escalated the aggressionfrom the client's perspective.ODebrief the staff to evaluate the effectiveness of actions.0Document the entire incident completely1Medications:Haloperidol (Haldol)•Haloperidol is amantipsychotic agent used to control aggressive and impulsive behavior.Nutrition - Albumin Levels: 3.5-5.0G/DICaring For a Dying Patient*Normal griefOThis grief is considered uncomplicated.OEmotions may be negative loss, such as anger, resentment, withdrawal, hopelessness, and guiltbut should change to acceptance with time.OSome acceptance should be evident by 6 months after the loss.0Somatic complaints may include chest pain, palpitations, headaches, nausea, changes in sleeppatterns, or fatigue.*Anticipatory griefOThis grief impliesthe"letting go" of an object or person before the loss, as in the case of aterminal illness.0Individuals have the opportunity to grieve before the actual loss.*Dysfunctional griefOThis grief involves difficult progression through the expected stages of the grieving process.0Usually the work of grief is prolonged, the symptoms are more severe, and they may resultindepression or exacerbation of a preexisting disorder.OThe client may develop suicidal ideation, intense feelings of guilt, and lowered self-esteem.OSomatic complaints persist for an extended period of time.■Disenfranchised griefOThis grief entails an experienced loss that cannot be publicly shared or is not sociallyacceptable, such as the loss of a loved one through suicide.*Nursing InterventionsOPromote continuity of care and communication bylimitingassigned staff changes.OAssist the client and family to set priorities for end-of-life care.OGive priority to the control of symptoms.OAdminister medications that manage pain, air hunger, and anxiety.OPerform ongoing assessment to determine effectiveness of treatment and need formodifications of treatment plan, such as lower or higherdosesof medications.

Loading page image...

0Manage side effects of medications0Reposition the client to maintain airway and comfort.0Maintain integrity of skin and mucous membranes.0Provide an environment tha t prom otes dignity and self-esteem.0Remove products of elimination as soon as possible to maintain a dean and odor freeenvironment.0Offer comfortable clothing.0Provide grooming for hair, nails, and skin0Encourage family members to bring in comforting possessionstomake the client feel at home0Encourage use of relaxation techniques, such as guided imagery and music.0Promote decision making in food selection, activities, andhealthcare to permit the client asmuch control as possible.•Support for the Grieving Family0Suggest that family members plan visits in a manner that promotes client rest.0Ensure that the family receives appropriate information as the treatment plan changes.0Provide privacy so family members have the opportunity to communicate and express feelingsamong themselves without including the client.0Determine family members' desire to provide physical care. Provide instruction as necessary.0Educate the family about physical changes to expect as the client moves closer to death.Stages of Grief (Kiib Ier Ross Stages}*Denial, Anger, Bargaining. Depression, AcceptancePalliativeCare*Family and pt education-Palliative care improves the quality of life of clientsand their families facingend-of-life•Determine family members' desire to provide physical care. Provide instruction as necessary.■Educate the family about physical changes to expect as the client moves closer to•Suggest that family members plan visits to promote the client's rest.*Ensure that the family receives appropriate information as the treatment plan changes.•Provide privacy so family members have the opportunity to communicate and express feelings amongthemselves without including the client•Promote continuity of care and communication by limiting assigned staff changes.■Assist the client and family to set priorities for end-of-life care.*Physical Care0Give priority to controlling symptoms.0Administer medications that manage pain, air hunger, and anxiety.0Perform ongoing assessment to determine the effectiveness of treatment and the need formodifications of the treatment plan, such as lower or higher doses of medications.0Manage adverse/side effects of medications.0Reposition the client to maintain airway patency and comfort.0Maintain the integrity of skin and mucous membranes.

Loading page image...

□Provide an environment that promotes dignity and self-esteem.0Remove products of elimination as soon as possible to maintain a clean and odor freeenvironment0Offer comfortable clothingOMorphineisgiven forcomfort'oIfPatient taking morphine and see respiratory depression -GIVE NARCAN0Oxygen is a comfort measureBody Image•Could be due to burns, stoma, scoliosisOScoliosis:have to wear the back brace 24 hours a day for a year except for the shower - needto give her clothes that she can wear over the brace■Support the client who is experiencing disturbed body image.Domestic Violence*Counseling is very important*Family therapy-maybe useful if the violent episode was recent and if both partners agree to take part.•The perpetrator must first take steps to control violence, such as learning anger managementstrategies*Nursing ActionsOHelp client develop a safety plan, identify behaviors and situations that might trigger violenceand provide information regarding safe places to live.OEncourage participation in support groups.OUse case management to coordinate community, medical, criminal justice, and social services.OUse crisis Intervention techniques to help resolve family or community situations whereviolence has been devastating•Nursing Intervention:OMust be culturally sensitive.OCounseling is an important nursing intervention for all types of violenceOCase management is needed to coordinate services.ONurses have a legal responsibility and are mandated to report suspected or actual cases of childor elder abuse.•Nursing Interventions for domestic partner violence:OMake a safety plan for fast escape when violence occurs.OTeaching empowerment skills to client.OTeaching the client to recognize behaviors and situations that might trigger violence.*Nursing Interventions for family violence:OStabilizing the home situation.0Maintaining an environment without violence and a higher quality of life for all family members.0Empoweringthe vulnerable members and promoting the growth and development of all familymembers. Teaching and promoting normal growth and developmentOTeaching strategies to manage stress.

Loading page image...

Psychosis*Verify are they hearing voices, what are their voices telling them- Askpatient about hallucinations*Agoraphobia-fear of crowded places and being in public places- with no escape*Flight ofideas: describes excessive speech at a rapid rate that involves fragmented or unrelated ideas*Abstract thinkingtelI someone a cat hasninelives - and theywilI kilIthecat and wait for it to comeback to lifeMust Know DefinitionsNegative Symptoms:Positive Symptoms:Affect-flat or blunted (Facial expression neverchanges)Alogia- poverty of thought or speech- mumbleAvolition- (lack of motivation) lack of motivationin activities and hygieneAnhedonia- lack of pleasure or joyAnergia- lack of energyApathy- indifferenceSocial isolationChronic low self-esteemNeologisms-are made up wordsEcholalia- repeating another’s wordsEchopraxia - mimicking of movementsClang associations- rhyming words "on thetrack...have a big Mac"Word salad- jumble of words that aremeaningless to the listenerLoose Association- Pattern of thinking isillogical & connections in thought areinterrupted.Delusions- false fixed beliefs that's held tobe trueHallucinations-a sense of perception- tactile,gustatory, auditory, olfactory and visual.Disturbed thought processesBizarre behavior- such as walking backwardImipramine Tofranil (TCA) antidepressant is used to treat clients with agoraphobia and those underdetoxification of cocaine!Chronic Emphysema•What kind of acid base balance? Respiratory acidosis and compensatory metabolic alkalosis•Chronic means compensatedBurns•Priority intervention is airway•Also important hydration, infection control, and a high calorie dietCare ofSkinCancer•SPFcream-sun protection -Hours of day to avoid:10-2pm•Hours of day to not go out to prevent mosquito bites: during dusk and dawnPulmonary Artery Wedge Pressure•To see how much blood is going to lungs - determine how much gas exchange•PAWP 4-12/ left heart (preload)•Swan Catheter - inflate balloon {nurse does hOT inflate balloon)•Can't keep balloon inflated cause it can rupture and damage left ventricleUmbilical Cord Prolapse•The greatest risk to the client and fetus is umbilical cord prolapse leading to fetal distress

Loading page image...

*During cord prolapseFetalbradycardia (FHR d l O / m i nfor10 min or more)*When there is suspected rupture of membranes the nurse should first assess the FHR to assure there isno fetal distress from possible umbilical cord prolapse, which can occur with the gush of amniotic fluid.*In Amniotomythe client is at increased risk for cord prolapse.0In Amniotomy Assure that the presenting part of the fetus is engaged prior to an amniotomy toprevent cord prolapse.*Intervention0Lower the head of the bed and elevate the client's hips on a pillow, or place the client in theknee-chest position to minimize pressure from the cord.0Place pt in a Trendelenburg positionorKnee chest position Using gravity to shift the baby offthe pelvis0Lift thecord upwardUmbilicalCordProlapseIntervention*Loop of the cord slips down the presenting part of the fetus and is pulsating■Frank is visible cord*Gloved hand is to hold the presenting partupuntil delivery*Maternal hip are elevated on two pillows*The knee to chest positionSee Decelerations on the FHR Monitor - Indicationof an Umbilical Cord Prolapsed*Early Decelerations:fetaIHEADCOMPRESSION, fundal pressure0Interventions: Nothing*Variable Decelerations:CORDCOMPRESSION,Oligohydraminos (not enough amniotic fluids)*Late Decelerations:UTEROPLACENTAL INSUFFICIENCY, maternal hypotension0Interventions for variable and late:■Discontinue Oxytocin (Pitocin) if it is beinginfused.■Help the client into aside-lyingpositionor to a hands and knees position to take thepressure off the umbilical cord■Administer oxygen (8 to 10 L/min by mask).■Start anIVline if one is notinplace.■Administer a tocolytic medication as prescribed.■Stimulate the fetal scalp.■Notify the primary care provider.*Fetal kick counts0Pt is instructed to lie on her side & count the number of times she feels the fetus moves01Emethod:She counts and records 10 fetal movements in a period of 2 hours02ndmethod:She counts fetal movements for 1 hour three times/week- count is reassuringif itequals or exceeds the established baseline*Assessment of Fetal Well-BeingCDoppIer uItrasound (see under uItrasound)

Loading page image...

0Fetal Biophysical Profile■Noninvasive fetal physical assessment■Involves fetaI heart rate m onitor and uItrasound■BPP (biophysical profile):uses a real time ultrasound to visualize physical andphysiological characteristics of the fetus and observes for fetal biophysical responses tostimuli.■It measures 5 vari ables with a score of 2 for each n orm aI fi nding and 0 for eachabnormal finding:4Reactive FHR (from reactive NST),4Fetalbreathing movements (at least 1 episode of 30 sec in 30 min is a normalresponse)4Gross body movements (at least 3 body or limb extensions with return to flexionin 30 min is a normal response)4Fetal tone(at least 1 episode of extension with return to flexion is a normalreaction}4Amniotic fluid volume (at least 1 pockets of fluid that measures at least 1cm in 2perpendicular planes is a normal reaction).4Total score of 3-10 is normal, less than 4 is abnormal.Non-Stress Test•Noninvasive procedure performed during thethird trimester tomonitorfetal movements•Assess for an intact fetal CNS•NST (nonstress test}: is most widely used technique for antepartum evaluation of fetal wellbeingperformed during the thirdtrimester.•It is a noninvasive procedure that monitors response oftheFHR to fetal movement.•A Dopplertransducer, used to monitor the FHR and a tocotransducer, used to monitor uterinecontractions, is attached externally to a client's abdomen to obtain papertracingstrips.■Theclientpushes a button attached to themonitorwhenever she feels a fetal movement,whichis then notedonthepapertracing. This allows a nurse to assess the FHR in relationshipto the fetal movement.■This is indicated for assessing an intact fetal CNS during the third trimester, ruling out the riskfor fetal death in clients who have diabetes mellitus used twice a week or until after 28 weeksof gestation.■NST is REACTIVEif the FHR isanormal baseline rate with moderate variability, accelerates to 15beats/min for at least 15 seconds and occurs two or more times during a 20 min period.■If this doesn't happen after 40 minutes, it is considered NONREACTIVE, it is further assessedwith a contraction stress test (CST) or biophysical profile (BPP)•ProcedureOPosition at semi-Fowler'sorleft lateral positionOClient presses the button when fetus movesOIf there is no movement Vibroacoustic stimulation is activated

Preview Mode

This document has 159 pages. Sign in to access the full document!

Report

Study Now!

Document Details

Related Documents

PETH 410 Midterm

EPI Notes

Understanding Hemodialysis Patient Guide and Meal

Newborn Assessment Critical Thinking Map

Maternal Health Theory and Applications

Gynecological Exam

Navigating the Difficulties of Addressing Intricat

Cardiovascular 2 Handout

Understanding EKG Rhythms and Pacemaker Care NCLEX

SkillGrp4Program Software

Company

Explore

Study Tools