NCLEX Key Concepts
- Medicine
- 159 pages
- Shared June 2025
Clinical care notes covering bladder irrigation, assistive ambulation devices (crutches, canes, walkers), dumping syndrome, Crohn’s disease, and ulcerative colitis—key interventions, symptoms, and patient education in concise bullet points.
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1 IMPORTANT NOTES Bladder 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 color O The initial voidingfollowing removal may be uncomfortable, red in collorand contain dots. The color of the urine should progress toward amber in 2 to 3 days. 0 On the fourth day the urine should be clear -4 t- day if you see blood this is NOT a good thing 0 If bright-red or ketchup-appearing (arterial) bleeding with clots is observed, the nurse should increase the rate • If the catheter becomes obstructed (bladder spasms, reduced irrigation outflow), turn off the CBI and irrigate with 50 mL of irrigation solution using a large piston syringe. 0 Contact the primary care provider if unable to dislodge the clot. • Record the amount of irrigating solution instilled {generally very large volumes) and the amount of return. The difference equals urine output • Instruct the client to not try to push pee 0 The catheter has a large balloon (30 to 45 mL) that is taped tightly to the leg. creating traction so that the balloon will apply firm pressure to the prostatic fossa to prevent bleeding. This makes the client feel a continuous need to urinate. O Tell 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) O Instruct the client that expected output is 150 to 200 mL every 3 to 4hr. The client should contact the provider if unable to void. • Need to watch out for blockage • Sodium can be absorbed through bladder irrigation • Avoid kinks in the tubing. • Complications Urethral trauma, urinary retention, bleeding, and infection are complications associated with TURP. Other complications include re-growth of prostate tissue and reoccurrence of bladder neck obstruction. Crutches • With crutches 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 the elbows flexed at 30°. • Position the crutches on the unaffected side when sitting or rising from a chair. Climbing the Stairs with Crutches • Upstairs - Good foot {good up to heaven) • Downstairs Bad (bad go down hell)
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2 Cane ■ Important to always have TWO CONTACT POINTS touching at all times - two points of support ■ Keep the cane on the STRONG SIDE of the body ■ When moving with the cane: support body weight on both legs, move the cane forward 6 to 10 inches, 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. Move cane up to 4 inches, ther WEAK LEG- strong leg. 0 Upstairs with Cane: (UP-STRONG/DOWN- STRONG) . Take first step with the strong leg Move the affected leg to the same step 0 Downsta irs 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 grasping the hand grips 0 Move walker up 6 to 8 inches & move the WEAK LEG & then bring the strong leg equal with the weak leg. WWS! • Crutches: Axillary crutch is more commonly used and must be measured to fit an individual. Crutch should be 2 fingers width from the axilla and 15 cm lateral to client's heel ■ The basic crutch stand is thetripod position the crutch is placed 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot. It improves a person's balance. The axilla should not bear weightand client assumes tripod position before crutch walking. Types of Crutch Gaits: • Four-point gait- {Alternating Gait) gives stability to client- requires weight bearing on both legs. Each eg 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 the weight 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 same time as the opposing leg. ■ Swing-through gait- (paraplegics wear weight supporting braces use this gait)With weight placed on both 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 occurring in response to food ingestion. Symptoms result from the rapid emptying of gastric contents into the small intestine.
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3 ■ Client Education- Dumping Syndrome Q Lay down after meal - because it will slow the movement of food within the intestines O Limit the amount of fluids ingested at one time ■ Eliminate liquids with meals and for 1 hr prior to and following a meal O Consume a high fat, high proteins, low to moderate carbs diet O Avoid milk, sweets, and sugars - because these can cause diarrhea O Small frequent meals rather than large meals O Pernicious anemia is common here- Give Vit B12 Crohn's Disease • Intermittent involvem ent of throughout the entire lower Gl tract, most commonly in the small intestine and the terminal ileum. • Inflammation and ulceration throughout the Gl tract - see sporadic lesions and fistulas are common • Diarrhea and colicky abdominal pain • Monitor for Megaloblastic (pernicious Janemia - Give VITAMIN B12 injection monthly for life • UTI - first sign in bowel/bladder fistula (Feces times seen in urine and vagina) • S/S: Abdominal pain/cramping: Often right-lower quadrant pain O Anorexia 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 abscess and fistulas- common in Crohn's disease ■ Low fibe r diet or NP O (seve re inflam mation) • Long term treatment is low fiber diet and medication Ulcerative colitis • TOXIN MEGACOLON - common in ulcerative colitis • More acute - see blood and mucus • Bloody a nd frequ ent d la rrhea and abd o minal pa in, te nesmus & rectaI b Ieedi ng • See in the DESCENDING COLON • Common to see joint pain/ arthritis (inflammation) • Antiinflammatory med: o Give sulfasalazine (Azulfidine) 1 May 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/TREAT WITH SITZ BATH OF WITCH HAZEL COMPRESSION • Medication- antibiotics: SULFASALAZINE (AZULFIDINE) - decrease inflammation of intestinal mucosa (can be given recta lly)
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4 Ulcerative 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 low in fiber may be used. • Monitor for an electrolyte imbalance, especially potassium. Diarrhea can cause a loss of fluids and electrolytes. ■ Monitor fluids and assess for dehydration. • Educate the client regarding the use of vitamin supplements and B12 injections, 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-High fiber diet & increase fluids- is very important in preventing future diverticulitis attacks but during EXACERBATION OF DIVERTICULITIS put patient on LOW fiber diet • Encourage walk daily for 30mins (for no constipation)- No strenuous exercises Acute Diverticulitis • Priority interven tion: N PO-BoweI rest. Example Q: Which of the following comments made by the patient indicates that additional instruction about the 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 area heals." Rationale: The appliance is changed every 4 to 7 days unless leakage occurs Heat and Cold Therapy • First 24hrs -cold 0 Prevents swelling, decreases inflammation, reduces bleeding, reduces fever, diminishes muscle spasms decreases pain by decreasing the velocity of nerve conduction • After 24 hrs - heat • Heat increases blood flow 0 Increases tissue metabolism 0 Relaxes muscles 0 Do not take long showers 0 Eases 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. 0 Avoid the use of heat applications over metal devices (pacemakers, prosthetic joints) to prevent deep tissue burns. 0 Do not apply heat to the abdomen of a pregnant woman to prevent harm to the fetus. 0 Do not place a heat application under an immobile client as this may increase the risk of burns
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5 Cold- Decreases inflammation • Prevents swelling • Reduces bleeding • Reduces fever • Diminishes muscle spasms • Decreases pain by decreasing the velocity of nerve conduction Avoid cold application for cold intolerance • Hyperthyroidism • Peripheral arterial disease • Raynaud s phenomenon Hot 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 and nutrients to the area, which will alleviate pain. Cold compresses cause vasoconstriction in the area and divert blood flow. Cognitive Disord ers/Alzheimer's • How do you promote hygiene/p roper care in pt with Alzheimer's? • Alzheimer's disease (AD) is a nonreversible type of dementia that progressively develops through seven stages over many years • AD is a type of dementia. Dementia is defined as multiple cognitive deficits that impair memory and can affect language, motor skills, and/or abstract thinking Nursing Care 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: f a m j|y pj C S i t i m e place and p e r s o n • Offer varied environmental stimulations such as walks, music, or craft activities. • Keep a structured environment and introduce change gradually (client's daily routine or a room change}. • Use a ca le ndar to assist with o rientatio n. • Use short directions when explaining an activity or care the client needs, such as a bath. • Use therapeutic touch • Place stop signs on the door. Have the client wear ID, Have client walk with supervision. Apply physical restraints only as a last resort. Provide Memory Training! • Reminisce with the client about the past.
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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 routine schedule. ■ Reality orientation (early stages) • Easily viewed clock and single day calendar • Pictures of fa mily an d 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 of daily living 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 the duodenum) 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 s sign) • Jaundice, clay-colored stools, steatorrhea (fatty stools), dark urine, and pruritus (accumulation of bile 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 of contrast. Diet: ■ Encourage a LOW-FAT diet (reduce dairy and avoid fried foods, chocolate, nuts, gravies). Promote weight 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
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7 • Tighten pelvic muscles for a count of 10, relax slowly for a count of 10 . and repeat in sequences of 15 in the lying-down, sitting and standing position 0 Perform four times a day • 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 of sleep and to feel rested. The person may have difficulty falling asleep, have difficulty staying asleep, awaken too early, or not get refreshing sleep Q Acute insomnia lasts for only a few days and may be due to personal stressors. O Chronic insomnia lasts a month or more. Some people experience intermittent insomnia, where they are able to sleep well for a few days and then experience insomnia for a few days. Women and 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 10 seconds/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 stay awake. It often happens at inappropriate times and can put the person at risk for injury. • Assessment/Data Collection: O Ask the client about sleep patterns, history, and if any changes have occurred. O Ask the client about sleep problems, which include O Type of problem, symptoms, timing, seriousness, related factors, how the lack of sleep has affected the client. 0 Use 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. O Assess 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). O Exercise - promotes sleep if done at least 2 hr before bedtime: otherwise, it can disrupt sleep O Sleep environment that is too light, the wrong temperature, or too noisy (children, pets, loud noise, snoring partner). • Amino acid in milk-TRYPTOPHAN- helps in sleep • MELATONIN-hormone-helps in sleep • Medications - may induce sleep but interfere with the restorative sleep cycles O Ask patient if they dream (REM SLEEP) O Loop diuretics should be avoided at night to prevent falls and will most likely interrupt the client's sleep Nonpharmacological Pain Therapy * TENS (Tran scuta neous Electrica I Ne rve Stimulation )
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8 • Therapeutic Touch • Pain Pathways - Gate Control Theory: The theory guided research toward the cognitive behavioral approaches to pain management. This theory helps to explain how interventions based on somatosensory (auditory, visual and tactile) stimulation such as friction, music therapy and distraction provide pain relief. 0 Two receptors for opioids o Nu and Kappa • Distraction-Includes ambulation, deep breathing, visitors, television, and music 0 Distraction therapy works best with children • Relaxation-Includes meditation, yoga, and progressive muscle relaxation • Imagery- Focusing on a pleasant thought to divert focus 0 Requires an ability to concentrate • Acupuncture - vibration or electrical stimulation via tiny needles inserted into the skin and subcutaneous tissues at specific points O Reduction of pain stimuli in the environment • Elevation of edematous extremities to promote venous return and decrease swelling Stump Pain after Amputation • Elevation for edema • Phantom pain O Treated as real pain O Patient says they have pain - give them pain meds Acute and Chronic Glomerulonephritis • Glomerulonephritis is an inflammation of the glomerular capillaries, usually following a Streptococcal Infection. It is an immune complex disease, not an infection of the kidney • Due to swelling and capillary cell death 0 Also get it from SLE, hypotension and diabetes mellitus • Patient will have a spontaneous recovery • Diet includes: O Fluid restriction (24 hr output +500 mL). 0 LOW SODIUM, LOW PROTEIN AND LOW POTASSIUM DIET O PROTEIN restriction {if Azotemia is present = increased BUN). • Important to watch BUN and creatinine levels • CARE after disch arge O Advise the client to maintain fluid and sodium restriction - a dietary consult may be necessary. • Client Education: Encourage the client to rest in order to conserve energy. O Maintain prescribed dietary restrictions. Acute Glorn eru al Nephritis • Strep infection • Ask pt. about sore throat • S/S: body edema, HTN & oliguria Renal Failure • Early symptoms of Acute Renal Failure:Oliguria (decreased urinary output)
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9 * BUN (10-20)- increased * Creatinine (0.8-1.2}- increased * Anuria: non-passage of urine End 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 factors Diet Teaching Uric Acid- to prevent hyperuricemia * Avoid -Red meat (beef, pork and lamb), fatty fish and seafood (tuna, shrimp, lobster and scallops shellfish 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 alco hoi & sugar * Choose low-fat o r f at-f ree dai ry prod ucts: Drinking skim o r low-fat miIk & yogurt * Choose complex carbohydrates: whole grains and fruits and vegetables Chronic 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 can affect mental status £ cause confusion Peritoneal dialysis * Therapeutic procedure for CKD utilizes the patient's abdominal cavity lining as a natural filter * Interventions: STERILE * Cl oudy Urine dia lysis: IM MEDIATE INTERVENTION * Abdominal cramping: SLOW THE INFUSION * Assess for infection -clean the pins with HYDROGEN PEROXIDE AND NS Kayexalate ■ Normal potassium level 3.5-5.0 * Therapy for elevated potassium (hyperkalemia) * Kayexalate - never give it to patient with PARALYTIC ILEUS AV Shunt * Assess:thrill and bruit (thrill is palpated £ bruit is heard) * Take BP on opposite arm of shunt Kosher Diet * Prohibits eating meat and dairy together. This separation includes not only the foods themselves, but the utensils, pots and pans with which they are cooked, the plates and flatware from which they are
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10 eaten, the dishwashers or dishpans in which they are cleaned, the sponges with which they are cleaned 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 for dairy. One must wait a significant amount of time between eating meat and dairy. Opinions differ, and vary from three to six hours after meat. This is because fatty residuesand meat particles tend to cling to the mouth. From dairy to meat, however, one need only rinse one's mouth and eat a neutral solid like 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 and vegetables are not kosher. Jehovah's Witnesses • Jehovah's Witnesses do NOT accept blood transfusions. • Clients avoid foods having or prepared with blood. • Can recommend an AUTOLOGOUS blood transfusion 0 When the patient goes in a couple of days before and donates their own blood Stoma Care ■ An ostomy is a surgical opening from the inside of the body to the outside. Ostomies can be permanent or temporary and are located in various parts of the body. • Jleostomy opening at the small intestine 0 See more fluids and more skin degeneration ■ Colostomy opening at the colon o See more solid ...change bag more often-% to VS full- change it! • Nursing Actions 0 Assess the type and fit of the ostomy appliance. 0 Monitor for leakage (risk to skin integrity). 0 Fit the ostomy appliance based on: ■ Type of ostomy. ■ Location of the ostomy. ■ Visual acuityandmanualdexterity of the client. 0 Visual acuity a n d m anuaI dexterity of the client. 0 Assess peristomal skin integrity and the appearance of the stoma. 0 The stoma should appear pink and moist. 0 Apply skin barriers and creams, such as stoma adhesive paste, when applying wafers to protect the peristomal skin. 0 Let the skin sealants dry before applying a new appliance. 0 Evaluate output from the stoma. Normal post -op output is less than 1000 ml/day. T O he higher up an ostomy is placed in the small intestine, the more liquid and acidic the output will be from the ostomy. O Assess for fluid and electrolyte imbalances, particularly with a new ileostomy. O Educate the client regarding dietary changes and ostomy appliances that can help manage flatus and odor. ■ Foods that can cause odor include fish, eggs, asparagus, garlic, beans, and dark green leafy vegetables.
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11 1 Foods that can cause gas include dark green leafy vegetables, beer, carbonated beverages, dairy products, and corn. Yogurt can be ingested to help decrease gas. • After an ostomy is placed involving the small intestine, the client should O Be instructed to avoid high-fiber foods for the first 2 months after surgery, chew food well, drink plenty of fluids 0 Evaluate for any evidence of blockage when slowly adding high-fiber foods. O Do not put anything in the bag to mask odor such as a mint. 0 Keep appliance clean and empty frequently to decrease odor. • Normal and Abnormal Findings O Immediate postoperative stoma should be reddish pink, moist, and may have a small amount of visible blood: report any evidence of stoma ischemia or necrosis 0 If some skin is hanging off post op that is a normal finding 0 Signs of stomal ischemia are pale pink or bluish/purple in color and dry in appearance. O If the stoma appears black or purple in color, this indicates a serious impairment of blood flow and requires immediate intervention. Spinal Cord Injury • Autonomic Dysreflexia • Stimulation of the sympathetic nervous system causes extreme hypertension, sudden severe headache, 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 parasympathetic nervous system is able to neutralize the sympathetic response. • Nursing Actions O Determine and treat the cause. O Sit the dient up (to decrease blood pressure secondary to postural hypotension). O Notify the provider. 0 Determine The Ca use . ■ DISTENDED BLADDER'S the most common cause (kinked or blocked urinary catheter, urinary retention, or urinary calculi) ■ Fecal impaction ■ Cold stress or drafts on lower part of the body ■ Tight clothing ■ Undiagnosed injury or illness (kidney infection or stone, lower extremity fracture) 0 Treat 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).
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12 0 Client Education: Instruct the client to space out fluid intake and increase frequency of intermittent catheterizations if fluid intake is temporarily increased. • Perineal Care 0 Development of a schedule as part of bladder and bowel training is critical for the establishment of a routine 0 Flaccid Neurogenic Bladder - Clients who have LOWER MOTOR NEURON INJURIES will develop a flaccid bladder. Bladder management options for males and females include intermittent catheterization and Crede's method (downward pressure placed on the bladder to manually express the urine). 0 Spastic Neurogenic Bladder - Clients who have UPPER MOTOR NEURON INJURIES will develop a spastic bladder after the spinal shock resolves. Bladder management options for male clients include condom catheters and stimulation of the micturition reflex by tugging on the pubic hair. Female clients will need to use an indwelling urinary catheter due to the un predictably of the release of urine. 0 Neurogenic bowel functioning does not differ a lot between upper and lower motor neuron injuries. O Daily use of stool softeners or bulk forming laxatives is recommended to keep the stool soft. A bowel 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 gloved and lubricated finger). ■ Docusate sodium (Colace) or polycarbophil (Fibercon) to prevent constipation and keep the stool soft. • A client who has a cervical spinal injury will also have an upper motor neuron injury, which will manifest itself by creating a spastic bladder. Since the bladder will empty on its own. a condom catheterisan appropriate method. • Develop a schedule as part of the bowel and bladder training. Pharmacology Leukotriene Modifiers: Montelukast (Singulair), Zileuton (Zyflo), Zafir lukast (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 prevent exercise-induced bronchospasm. • Take these drugs everyday- they are NOT rescue inhalers What group does Spiriva (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- prevents it overtime • Spiriva (tiotropum)- inhaled anticholinergic- blocks muscarenic receptors of the bronchi, resulting in bronchodilation. • Advair (Fluticasone propionate)- Glucocorticoids O These medications prevent inflammation, suppress airway mucus production, and promote responsiveness of beta2 receptors in the bronchial tree.
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13 Antibiotics * Antibiotics that affect theCELL WALL are 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)- 2 nd generation * Ceftriaxone (Rocephin), Cefotazime (Claforan). Cefoperazone (Cefobid)- 3rd generation * Cefepime (Maxipime)- 4 rh generation Carbapenems • Imipenem (Primaxin) • Meropenem (Merrem IV) Monobactams No cross-hypereensitivity reactions with penicillin but like penicillins can trigger seizures in patients with history of seizures. • Vancomycin (Vancocin) • Aztreonam (Azactam) • Fosfomycin (Monurol) • Penicillin-anaphylactic reaction of antibiotic that breaks the CELL WALL- also cephalosporin C Anaphylaxis: ■ Interview clients fo r prio r aIlergy. 1 Advise clients to wear an allergy identification bracelet. ■ Gentamicin- Interfere with PROTIEN SYNTHESIS 0 Can cause OTOTOXCICTY (ringing in the ears) and NEPROTOXCICTY 0 Most common IV medication 0 Dosage is reduced in the elderly due to decrease in renal clearance- after 65 kidneys function less 0 Side Effects/Adverse Effects: 1 Ototoxicity: Monitor clients for symptoms of TINNITUS (ringing in the ears), headache, hearing loss, nausea, dizziness and vertigo. STOP medication if this occurs. ■ Nephrotoxicity: Monitor l&O, BUN and Creatinine levels. Instruct client to report significant decrease in the amount of urine output. Medications That Cause Nephrotoxicity: • Amphoteracin B (antifungal) ■ Cyclosporins • ACE inhibitors ■ Cisplatin (cancer medication)
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14 • NSAIDs Lithium (Lithane, Eskalith**, and Lithonate): MOOD STABILIZER** * Effective in the treatment of bipolar I acute and recurrent manic and depressive episodes. • It usuai/y takes 7 to 14 days to reach therapeutic levels. ■ Antipsychotic or benzodiazepine can be used to prevent exhaustion, coronary collapse, and death until Lithium reaches therapeutic levels * METALLIC TASTE -telI patient to chew hard candy or use oral swabs • During initial treatment of manic episodes- levels 0.8-1.4 mEq/L * Instruct clients to monitor signs of toxicity and when to contact the provider.. Clients should stop taking medication and seek medical attention if experiencing diarrhea, vomiting, or excessive sweating. • Need to watch for HYPONATREMIA o Reduced serum sodium decreases lithium excretion, which can lead to toxicity. 0 Adequate fluid and sodium intake should be maintained. 0 If taking diuretics- risk for hypokalemia 0 Side effects: Polyuria and mild thirst 0 Intervention: Use a potassium-sparing diuretic, such as spironolactone (Aldactone). Pharmacological Interventions: • Lithium carbonate Therapeutic and toxic levels 0 Therapeutic blood level 0.8 to 1.2 mEq/L 0 Maintenance blood level 0.4 to 1.3 mEq/L o Toxic blood level: 1.5 to 2.0 mEq/L Lithium Toxicity: Symptoms of Li Toxicity • Levels 1.3 to 1.5 mEq/L -Fine hand tremors, nausea, vomiting, diarrhea, confusion, ataxia, slurred speech, lethargy, thirst and polyuria, muscle weakness. • Nursing Consideration: Medication should be withheld. Assess patient for toxicity symptoms, blood levels measured, and evaluate dosage. Dehydration should be addressed. • Levels 1.6 to 2.0Course hand tremors, Gl upset, mental confusion, muscle hyperirritability, incoordination, and sedation. • Nursing Consideration: Medication should be withheld, Assess patient for toxicity symptoms, blood levels measured, and evaluate dosage. Dehydration should be addressed. • Levels > 2.1 to 3.0 mEq/L- Ataxia, Confusion, blurred vision, hypotension, Profound CNS depression, arrythmias, seizures, coma, death due to pulmonary complications. • Nursing considerations: All of the above & administer emetic to alert the clients or administer gastric lavage. • Greater than 2.5 mEq/L- rapid progression of symptoms leading to coma & death-Nursing Considerations! All of the 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 4 days for them.
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15 • Someone can go toxic at anytime in treatment - even iff they have been taking it for years so it is important to teach patient to get routine blood work done. ■ Suddenly stopping lithium can lead to relapse and recurrence of MANIA. • Two major long-term risks of lithium therapy are HYPOTHYROIDISM and IMPAIRMENT of the KIDNEYS ability to CONCENTRATE URINE • Before starting therapy, you should assess: Renal Function, Thyroid Status, Dementia And Neurological Disorders. • Shouldn't be given to patients with cardiovascular disease, brain damage, renal disease, thyroid disease, or myasthenia gravis. • It can harm a fetus, shouldn't be used when breast feeding, and shouldn't be used for children under 12 years of age. • Lithium is a naturally occurring salt - but you need to teach the patient NOT to change their diet to one of low sodium - THEY NEED TO KEEP 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 an electrolyte imbalance that can lead to lithium toxicity ■ Lithium with an SSRI for a manic pt. can cause RAPID CYLING! Q: If a patient comes in with a lithium level of 1.6 what do you do? A: Assess the patient, hold the dose and then call the doctor. Digoxin: • Norma I lab va Iu e- 0.5 to 2.0 ng/m L • Watch for HYPOKALEMIA • Check apical pulse- if less than 60/min in an adult, less than 70/min in children, less than 90/min in infants- Hold Digoxin & notify provided • Instruct client to observe symptoms of toxicity: Anorexia, fatigue, weakness, nausea and vomiting • Man agement of toxicity: O Digoxin and potassium-sparing medication should be stopped immediately. O Monitor potassium levels. For levels less than 3.5 mEq/L, administer potassium intravenously. O If K+- levels greater than 5.0 mEq/L- Put pt. on a cardiac monitor. O Treat dysrhythmias with phenytoin (Dilantin} or Udocaine. O Treat bradycardia with atropine. O For overdose treat with: activated charcoal, cholestyramine or DIGIBIND can be used to bind digoxin and prevent absorption. • H ow it interferes with K+ O Thiazide diuretics, such as hydrochlorothiazide (HCTZ), and loop diuretics, such as furosemide (Lasix), may lead to HYPOKALEMIA- Increase the risk of DYSRHYTHMIAS! O Ace inhibitors and ARBS increase the risk of HYPERKALEMIA- leads to decreased therapeutic effects of digoxin. O Monitor k+ levels to maintain 3.5 to 5.0 mEq/L O Instruct client to report signs of hypokalemia (nausea, vomiting and weakness) 0 Teach clients to consume high potassium foods (Spiniach, bananas, potatoes). • Monitor Digoxin Levels O Signs of toxicity may appear less than 1.75 ng/mL 0 Teach clients to monitor apical pulse. The rate maybe irregular with early or extra beats noted.
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16 0 Clients with heart failure respond best to serum levels between 0.5- 0.8ng/mL 0 Nausea & Vomitins are significant toxic symptoms- 1 H sign 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 to HYPERTENSIVE CRISIS • Given SubQ • Adverse Effects: 0 Hypertension secondary to elevation in hematocrit levels 0 Monitor clients hemoglobin, hematocrit and BP, if elevated- give hypertensive medications 0 Increases risk for cardiovascular event (Ml, Stroke, Cardiac Arrest) with an increase in Hgb above 12 g/dL or more than 1 g In 2 weeks. 0 Decrease dosage when these limits are reached. • Nursing Interventions: □ Obtain client's baseline blood pressure. Clients with chronic renal failure- control hypertension before start of treatment. 0 Ad minister SubQ or IV bolus injection. 0 Do not agitate the vial of medication. Use each vial for one dose and do not put the needle back into the vial when withdrawing the medication. 0 Dosing is usually 3x/week, but maybe once a week with some types of chemotherapy. 0 Monitor client's iron levels- REC growth is dependent on adequate iron, folic acid and vitamin B12. 0 Monitor 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 results in diminished oxygen -carrying capacity and delivery to tissues and organs. • N ursing Actions for Anem i a 0 Monitor the client for fatigue, pallor, dizziness, and shortness of breath. 0 Help the client manage anemia-related fatigue by scheduling activities with rest periods in between and using energy saving measures (sitting during showers and ADLsj. 0 Administer erythropoietin medications such as erythropoietin aIfa ( Epogen) and antianemic medications such as ferrous sulfate (Feosol) as prescribed. 0 Monitor the client's Hgb to determine response to medications. Be prepared to administer blood if prescribed 0 Monitor 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 2 weeks). * Iron supplementation: 0 Stool will be black. 0 May cause gastrointestinal distress; take with food if this occurs. 0 Take with vitamin C to increase absorption.
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17 0 Take 2 hr before or after meal or antacids. 0 Increase fiber and fluids in diet to manage constipation. O Use 3 straw with liquid iron to avoid staining teeth . Anemia 0 Iron deficiency! food sources rich in IRON? - Absorption IRON better with Vit C but more GI difficulty 0 Foods sources rich in iron: Red meat. Egg yolks, Dark, leafy greens (spinach, col la rds),Dried fruit (prunes, raisins).Iron-enriched cerealsand grains (check the labels),Mollusks (oysters, dams, scallopsjTurkey or chicken giblets. Beans, lentils, chickpeas and soybeans. Liver, Artichokes 0 Megaloblastic: why do cells become bigger? B/c Vit B12 is low 0 Sickle cell: hydration!!! 0 Good sources of Vit B12-liver, beef, salmon, trout, breakfast cereals. Tuna, milk, cheese, ham, egg. roasted chicken 0 Anemia is an abnormally lov/ amount of circulating RBCs, Hgb concentration, or both. 0 Anemia results in diminished oxygen-carrying capacity and delivery to tissues and organs. 1 Nursing Considerations 0 Administer parenteral iron to a client using the Z-track method. 0 Instruct to have hemoglobin checked in 4 to 6 weeks to determine efficacy. 0 Vitamin C may increase oral iron absorption 0 Instruct the client to take iron supplements between meals to increase absorption, if tolerated. 0 Erythropoietin - Epoetin alfa (Epogen, Procrit) 0 A hematopoietic growth factor used to increase production of RBCs 0 Observe the client for an increase in blood pressure (Hypertension). 0 Monitor Hgb and Het twice a week 0 Monitor the client for cardiovascular event if Hgb increases too rapidly ( >lgm/dL in 2 weeks}. • Client Education 0 Reinforce the importance of having Hgb and Het evaluated on a twice-a week basis. 0 Vitamin B12 supplementation (Cyanocobalamin) 0 Vitamin B12 is necessary to convert folic acid from its inactive form to its active form. All cells rely on folic acid for DNA production. 0 Nursing Considerations 1 Give vitamin B12 according to appropriate route related to cause of Vitamin B12 anemia (parenteral versus oral}. 1 Administer parenteral forms of vitamin B12 intramuscularly or deep subcutaneous to decrease irritation. Do not mix 1 The 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 of the bone needs iron to make hemoglobin, the part of the red blood cell that transports oxygen to the body's organs. Without adequate iron, the body cannot produce enough hemoglobin for red blood cells. The result is iron-deficiency anemia.
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18 This 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 small intestine • Certain drugs, foods, and caffeinated drinks • Older adult clients most at risk for developing iron deficiency anemia, chronic blood loss, vitamin B12 and folate deficiencies. • Food Sources Rich in Iron - 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 artichokes Sicfde Cell Anemia PAIN MANAGEMENT AND HYDRATION IS REALLY IMPORTANT • An inherited disorder that affects African-Americans. Red blood cells become crescent-shaped because of a genetic defect. They break dovjn rapidly, so oxygen does not get to the body's organs, causing anemia. The crescent-shaped red blood cells also get stuck in tiny blood vessels, causing pain • The key interventions for a client in sickle cell crisis is to promote and maintain oxygenation and tissue perfusion, hydrate the client to prevent excessive sickling of the red blood cells, manage the client's pain, and promote neurological function. • Administer morphine, administer normal saline, assess hand -grip strength. • Clients with sickle cell anemia have problems with the shape of the red blood cells, not the number, so a blood transfusion would not be indicated. Microcytic Anemia: Vitamin B12 deficiency folic acid deficiency alcoholism. Anemia Caused by Efood Loss • Red blood cells can be lost through bleeding, which can occur slowly over a long period of time, and can often go undetected. This kind of chronic bleeding commonly results from the following: • Gastrointestinal conditions: ulcers, hemorrhoids, gastritis (inflammation of the 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 are multiple pregnancies Anemia Caused by Decreased or Faulty Red Efood Cell Production The body may produce too few blood cells or the blood cells may not function correctly. In either case, anemia can result. Red blood cells may be faulty or decreased due to abnormal red blood cells or the a lack of minerals and vitamins needed for red blood cells to work properly. Conditions associated with these causes of anemia include the following: • Sickle cell anemia * Bone marrow and stem cell problems • Iron deficiency anemia * Other health conditions • Vitamin deficiency Vita min-deficiency anemia may occur when vitamin B-12 and folate are deficient These two vitamins are needed to make red blood cells. Conditions leading to anemia caused by vitamin deficiency include: • Megaloblastic Anemia: Vitamin B-12 or folate or both are deficient C Cells will become bigger because B12 is low
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19 O Good 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, an intestinal 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 eating too few vegetables may cause a folate deficiency. ■ During early pregnancy, sufficie nt folic acid can prevent the fetus from developing neural tube defects such as spina bifida. Central Line • Important that you watch for INFECTION because 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) • Flush the line at least every 12 hr (3 mL for peripheral, 10 mL for central lines) to maintain patency. • Studies show that 0.9% sodium chloride is as effective as heparinized flush solutions to maintain catheter 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 a single- or double- lumen peripherally inserted central line (PICC). Magnesium Sulfate . CNS Depressant - USED FOR SEIZURES • Use in early onset of labor - t o Prevent Seizure and increase tolerance for seizure activity • Monitor reflexes (Deep Tendon Reflexes) and respirations • Low magnesium, heart rate goes up = TACHYCARDIA • Used in treatment of pregnancy induced hypertension and preeclampsia ■ Magnesium sulfate, lowers BP and depresses CNS - Monitor BP • Signs Of Toxicity absence of patellar deep tendon reflexes, urine output < 3 0 m l / h r , respirations <12/mi o Calcium gluconate-antidote for Magnesium toxicity Calcium Channel Blockers (CCB) • Nifedipine (Adalat, Procardia) * Amlodipine (Norvasc) • Verapamil (Calan) • Felodipine (Pkendil) • Diltiazem (Cardizem)- used to regulate HR- ■ Nicardipine (Cardene, Cleviprex) administer IV ■ Concurrent use of CCB &. Beta blockerscan lead to BRADYCARDIA and HEART FAILURE-space these meds- couple hours between • CCB cannot be taken with GRAPEFRUIT JUICE- LEAD TO TOXICITY * “When you send a patient home a good beta blocker to give for home management is: 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)
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20 O Monitor IV closely O Discontinue infusion at the first sign of irritation o Regitine is the antidote! TPN - Bag becomes empty give them 10% dextrose Nardil (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, sexual dysfunction, weight gain and hepatic necrosis • Indications"*: useful in ATYPICAL DEPRESSION (increased sleep/appetite, anxiety & rejection). * Adverse/toxic effects - Hypertensive Crisis(ifyou eat foods containing tyramine) * Inhibits the breakdown of norepinephrine, serotonin, dopamine, and tyramine - All of these are desired 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 FOODS such as avocados, soybean, figs, ripe bananas, fermented, smoked, or aged meats, sausages such as bologna, pepperoni, and salami, smoked fish, all cheeses, beers, red wine, soy sauce, and protein supplements. Qon the 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: O Atypical Depression, Bulimia, Obsessive compulsive Disorders * Side effects: Dizziness, headache, stiff neck, N/V, restlessness, insomnia, dry mouth, sexual dysfunction, weight gain.hypotension and hepatic necrosis. • Orthostatic Hypotension O Monitor BP O Hold medication O Instruct the client to change positions slowly * Other information for MAOI's: ❖ Monitor BP during the first 6 weeks of treatment. HYPERTENSIVE CRISIS may begin with a headache, stiff neck, palpitations, increased or decreased HR, nausea, vomiting, or pyrexia. Immediate medical attention is required. O Administer Phentolamine {Regitine)
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21 o Administer Calcium Channel Blocker- Nifedipine (Procardia), o Ice packs or hypothermic blankets can be used. •'Labs are done early in the morning before the morning dose of medications • Contraindications: 0 Use cautiously in clients with diabetes and seizure disorder or those taking Tricyclic Antidepressants- can lead to HYPERTENSIVE CRISIS. 0 Use with SSRI's can lead to SERTONIN CRISIS 0 Tyramine Rich Foods 0 Concurrent use of vasopressors (phenlethylamine, caffeine) may result in hypertension 0 Advise clients to avoid, tyramine foods, and foods that contain caffeine, chocolate, fava beans and ginseng. The BIG Deal with MAOI: • Food interaction! Pickled, fermented, smoked, or aged foods, such as red wine, preserved food, aged stinky cheese, which leads to hypertensive crises resulting in intracranial bleed. • Drug Interaction (Do not give with) > Other antid ep ressants > OTC cold and flu medications > Demerol Antidepressant Drugs: • T ricyclic Antidepressants (TCAs) 0 Amitriptyline (Elavil) 0 Imipramine (Tofranil) 0 Doxepin (Sinequan) 0 Nortriptyline {Aventyl) Q Amoxapine (Asendin) o Trimipramine (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 SEIZURES TCA Amitriptyline bide errects Nursing interventions Orthostatic Hypotension • Instruct clients about the signs of postural hypotension (lightheadedness, dizziness), if these occur, advise the client to sit or lie
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22 down. ■ Orthostatic hypotension can be minimized by getting up or changing positions slowly. ■ Monitor blood pressure and heart rate for clients in the hospital for orthostatic changes before administration and 1 hr after, if a significant decrease in blood pressure and/or increase in heart rate is noted, do not administer the medication, and notify the provider. • Instruct clients on ways to minimize anticholinergic effects. These include: 0 Chewing sugarless gum 0 Sipping on water 0 Wearing sunglasses when outdoors 0 Eating foods high in fiber 0 Participating in regular exercise 0 Increasing fluid intake to at least 2 to 3 L/day 0 Voiding just before taking medication ■ This effect usually diminishes over time. • Advise clients to avoid hazardous activities such as driving if sedation is excessive. • Advise clients to take medication at bedtime to minimize daytime sleepiness 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 -Tachycardia Sedation Fatal Arrhythmias! Toxicity resulting in cholinergic blockade and cardiac toxicity evidenced by dysrhythmias, mental confusion, and agitation, followed by seizures, coma, and possible death. Decrease seizure threshold Excessive Sweating • Monitor clients who have seizure disorders • inform clients of side effect. • Assist clients with frequent linen changes. Contra i ■ Pregnancy, those who have SEIZURE DISORDERS ■ Concurrent use of Mao's & St. John's wort may lead to SEROTONIN SYNDROME. * Selective Serotonin Reuptake Inhibitors (SSRIs)- Do not take with MAOI's > Fluoxetine (Prozac) > Sertraline (Zoloft) > Paroxetine (Paxil) > Citalopram (Celexa)
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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: O Dizziness, Nausea, Pins and needles O Zappers 0 Prozac does not cause discontinuation symptoms = 16 weeks half life > Possible Side Effects SSRI: 0 Gl upset: Nausea and Vomiting, Constipation 0 Nervousness, sleep disturbance. somnolence 0 Sexual dysfunction: libido and orgasm O Weight 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 MAO inhibitor. O Indicated for depression and diabetic peripheral neuropathy O Neuropathic pain= nerve injury or dysfunction O t serotonin and Norepinephrine Serotonin 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!ng Conventional Antipsychotic Medications EPS Side Effects: Acute dystonia: Anticholinergics 7 Involves bizarre and severe muscle contractions usually of the head and neck. Can be painful and frightening. Occurs within 48 hours of initiation of medication. Intervention: Treat with Cogentin or Benadryl or Symmetrel IM Akathisia: Anticholinergics-Descrlbed as feeling like jumping out of the skin. Inability to sit still, resultingin rocking, running, or agitated dancing. Regular rhythmic movements usually of lower limbs. Usually occurs after 3 or more weeks of treatment. Intervention: Treat w/Lo raze pam or Cogent in or Benadryl or Symmetrel IM Pseudo parkinsonism: Anticholinergics- Cogwheel rigidity, tremors at rest, rhythmic oscillations of the extremities, pill rolling movement of the fingers and bradykinesia. Usually occurs after 3 or more weeks of treatment. Intervention: Treat with Cogentin or Benadryl or Symmetrel IM Tardive Dyskinesia: Abnormal Involuntary Movement Scale (AIMS) - Characterized by abnormal involuntary
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24 movements lip smacking (Guppy like), tongue protrusion, foot tapping & facial tics. Usually occurs late in the course of long-term treatment. Avoid typical antipsychotics. Prophylactic use of vitamin E and Omega-3 FFA. Often irreversible. Intervention: Abnormal Involuntary Movement Scale {AIMS)- Brief test for detection of tardive dyskinesia Anti-Pa rkinson 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 • Urinary retention • Tachycardia • Photophobia Potentially Dangerous Responses to Antipsychotics: TOXICITY • Neuroleptic Malignant Syndrome (NMS) 0 Typically occurs in first 2 weeks of treatment or when the dose is increased 0 Caused by acute reduction of dopamine in the brain 0 Symptoms: Muscle rigidity, tachycardia, hyperpyrexia {elevated temp) altered consciousness (mental confusion), tremors and diaphoresis-lead to DEATH 0 Watch patient as soon as temperature spikes- if left untreated a person can die within 8 hours. 0 If pt. is diaphoretic, unable to respond & is motionless Hold the medication, notify the physician, and begin supportive treatments. O Mild cases can be treated with Parlodel (Bromocriptine) o Severe cases can be treated with Dan trium & ECT • Nursing Interventions: O Stop antipsychotic medications O Apply cooling blankets O Administer antipyretics O Administer diazepam (Valium) to control anxiety 0 Administer Dantrolene (Dantrium) to induce muscle relaxation Methergine - for uterine atony, excessive bleeding post partum ■ Monitor BP
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25 T racheostomy 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 a cannula • Provide tracheostomy care every 8 hr ■ Give frequent oral care , usually eve ry 2 hr. • Forcuffed tubes, keep the pressure below 20 mm Hg to reduce the risk of tracheal necrosis due to prolonged compression of tracheal capillaries. • Assess/Monitor □ Oxygenation and ventilation (respiratory rate, effort. SaO2) and vital signs hourly 0 Thickness, quantity, odor, and color of mucous secretions 0 Stoma and skin surrounding the stoma for signs of inflammation or infection (redness, swelling, drainage) 0 Provide adequate humidification and hydration to thin secretions and decrease risk of mucus plugging. O Do not suction routinely, because this may cause mucosal damage, bleeding, and bronchospasm. O Assess/monitor the need for suctioning: Suction on a PRN basis when assessment findings indicate it is needed (audible/noisy secretions, crackles, restlessness, tachypnea, tachycardia, mucus in the airway). • Suction: O Suction the tracheostomy tube if necessary, using sterile suctioning supplies. 0 Sterile procedure during suctioning, suction 10-15 seconds a t a time ■ Infant you only suction for 5 seco nds O Hyperoxygenate the client with oxygen before and after 0 You only suction when you are pulling out O Assess respiratory status every 1-2 hours 0 Never turn off the ventilator alarms. O There are three types of ventilator alarms: volume, pressure, and apnea alarms. ■ VOLUME (LOW PRESSURE) ALARMS: indicate a low exhaled volume due to a disconnection, cuff leak, and/or tube displacement. ■ PRESSURE (HIGH PRESSURE) ALARMS: indicate excess secretions, client biting the tubing, kinks in the tubing, client coughing, pulmonary edema, bronchos pas m, and/or pneumothorax or obstruction. ■ APNEA ALARMS: indicate that the ventilator does not detect spontaneous respiration in a preset time period. O Assess the cuff pressure at least every 8 hr. ■ Maintain the cuff pressure below 20mm Hg to reduce the risk of tracheal necrosis O Assessfor an air leak around the cuff (client speaking, air hissing, or decreasing SaO2). Inadequate cuff pressure can result in inadequate oxygenation and/or accidental extubation.
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25 Tracheostomy 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 a cannula ■ Provide tracheostomy care every 8 hr • Give frequent oral care, usu aIly eve ry 2 hr. • Forcuffed tubes, keep the pressure below 20 mm Hgto reduce the risk of tracheal necrosis due to prolonged compression of tracheal capillaries. • Assess/Monitor 0 Oxygenation and ventilation (respiratory rate, effort, SaO2) and vital signs hourly 0 Thickness, quantity, odor, and color of mucous secretions 0 Stoma and skin surrounding the stoma for signs of inflammation or infection (redness, swelling, drainage) 0 Provide adequate humidification and hydration to thin secretions and decrease risk of mucus plugging. 0 Do not suction routinely, because this may cause mucosal damage, bleeding, and bronchospasm. 0 Assess/monitor the need for suctioning: Suction on a PRN basis when assessment findings indicate it is needed (audible/noisy secretions, crackles, restlessness, tachypnea, tachycardia, mucus in the airway). ■ Suction: 0 Suction the tracheostomy tube if necessary, using sterile suctioning supplies. 0 Sterile procedure during suctioning, suction 10-15 seconds a t a time ■ Infant you only suction for 5 seconds 0 Hyperoxygenate the client with oxygen before and after 0 You only suction when you are pulling out 0 Assess respiratory status every 1-2 hours 0 Never turn off the ventilator alarms. 0 There are three types of ventilator alarms: volume, pressure, and apnea alarms. ■ VOLUME (LOW PRESSURE) ALARMS: indicate a low exhaled volume due to a disconnection, cuff leak, and/or tube displacement. ■ PRESSURE (HIGH PRESSURE) ALARMS: indicate excess secretions, client biting the tubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm, and/or pneumothorax or obstruction. ■ APNEA ALARMS: indicate that the ventilator does not detect spontaneous respiration in a preset time period. 0 Assess the cuff pressure at least every 8 hr. ■ Maintain the cuff pressure below 20mm Hgto reduce the risk of tracheal necrosis 0 Assess for an air leak around the cuff (client speaking, air hissing, or decreasing SaO2). Inadequate cuff pressure can result in inadequate oxygenation and/or accidental extubation.
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26 • Cha nging Tracheotomy 0 Remove old dressings and excess secretions. 0 Apply the oxygen source loosely if the client desaturates during the procedure. 0 Use cotton-tipped applicators and gauze pads to clean exposed outer cannula surfaces. 0 Begin with half-strength (mixed with sterile 0.9% NaCl) or full-strength hydrogen peroxide followed by 0.9% NaCl. Clean in a circular motion from the stoma site outward. 0 Use 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). 0 Replace the inner cannula if it is disposable. 0 Change 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 her chest to enable swallowing. Assess for aspiration Bioterrorism • Cutaneous Anthrax - Forms black scabs • Inhalational -Anthrax 0 S/S: Sore throat. Fever, Muscle aches, Severe dyspnea, Meningitis, Shock a TX: 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. • Lifting 0 Don't lift with your back - always use your knees 0 Use the major muscle groups to prevent back strain, and tighten the abdominal muscles to increase support to the back muscles. 0 Distribute the weight between the large muscles of the arms and legs to decrease the strain on any one muscle group and avoid strain on smaller muscles. 0 When liftingan object from the floor, flex the hips, knees, and back. Get the object to thigh level, keeping the knees bent and the back straightened. 0 Stand up while holding the object as close as possible to the body, bringing the load to the center of gravity to increase stability and decrease back strain. 0 Use assistive devices whenever possible, and seek assistance whenever it is needed. • When pushing or pulling a load: 0 Widen the base of support. 0 When opportunity allows, pull objects toward the center of gravity rather than pushing away. 0 If pushing, move the front foot forward, and if pulling, move the rear leg back to promote stability. 0 Face the direction of movement when moving a client. 0 Use own body as a counterweight when pushing or pulling to make the movement easier. 0 Sliding, rolling, and pushing require less energy than lifting and offer less risk for injury. 0 Avoid twisting the thoracic spine and bending the back w hile the hips and knees are straight.
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27 ■ Leading the blind- They need to hold onto you 0 Le a d them hold Ing o nto the eIbow PT. IN TRACTION- NEVER TAKE OFF THE WEIGHTS Buck Traction: (Hip Fractures) is a foam boot with Velcro straps applied to the lower leg to help immobilize 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 when using 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 CONSTANT TRACTION Bryant's traction is used in children under 3 years of age & has a fractured femur Skeletal 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: O Used continuously. The pulling force is applied directly to the bone by weights attached by rope directly 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 the provider. Assure that pulley ropes are free of knots. • Notify the provider if the client experiences severe pain from muscle spasms unrelieved with medications and/or repositioning. • Move the client in halo traction as a unit, without applying pressure to the rods. This will prevent loosening of the pins and pain • Routinely monitor skin integrity and document ■ Pin Site Care: O Pin care is done frequently throughout immobilization (skeletal traction and external fixation methods)
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28 0 Monitor 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 institution policy. ■ A primary concept of pin care is that one cotton-tip swab is designated for each pin to avoid 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 from bacteria. Skin T raction * Used for short term: Assess every 8 hrs - skin care dressing * Clean pins with NS or hydrogen peroxide Six 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 muscle traveling through compartment * Pressure: T in compartment * Pallor: coolness and loss of normal color of extremity * P ara lysis: Ioss of functio n * Pulselessness:diminished/absent peripheral pulses If Compartment Syndrome Then: * Extremity should NOT BE ELEVATED above heart level. 0 Elevation 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 to ensure adequate soft tissue decompression; risk for infection and delayed wound healing is a potential problem following fasciotomy If a patient has a surgery to repair fractured left tibia and cannot feel the surgical site by stating that it feels asleep, you should? * Neurovascular assessment of fractured extremity for any changes * Check peripheral pulses * Check for edema, color & te mperature * Notify HCP A 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.
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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: Check for patent airway, maintain clean oral hygiene, and adequate nutrition ■ 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 term rehabilitation 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 absorption pads. Nursing Management for Hip Replacement Surgery * ABDUCTION pillow between legs * Patient should never cross legs or twist to reach behind • Never bend down/Weight bearing exercises Example Q: In identifying people at risk for fractures, the nurse recognizes that the person at greatest risk for greenstick fractures is? a. A female client over 40 years old walking her dog b. A 21 year old male who plays basketball 6 times a week for 6 hours c. A 5 year old male playing at the playground d. A 90year old female with a history of falls Pelvic Fracture/Hip Replacement ■ Do not cross legs • No squatting or sitting down * Teaching is important here HIP REPLACEMENT SURGERY The Dos • Do keep the leg 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 ice to reduce pain and swelling, but remember that ice will diminish sensation. Don't apply ice 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 towel for 15 to 20 minutes. • Do cut back on your exercises if your muscles begin to ache, but don't stop doing them] The Don'ts * Don't cross 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 you sit down. • 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.
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30 • Don't bend at 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 to treat pain following a procedure, but may also be used for such things as pain caused by kidney stones, back pain, or cancer pain. • Belongs to a class of drugs called non steroid aI anti-inflammatory drugs. 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 limited to: 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, and excessive tiredness. • Kidney problems, including kidney failure • Fluid retention or unexplained weight gain Patient 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) If an IV is infiltrated, this could be a priority given the other options. • Stop the IV and monitor the site& place warm/hot compresses BPH Teaching • BPH is a benign enlargement of the prostate gland- usually men over 60 ■ Avoid: Caffe in e & Alcohol • The possible cause of this condition is thought to be attributed to the increased accumulation of dIhydrosytestosterone- Not Cance r • Decreased force of urinary stream, difficulty in urination. Double Voiding (stopping and starting stream 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 practice Kegal exercises for 10-20 mins daily
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31 • The nurse should know and teach patients to know that Anticholinergic (COGENTIN) should NOT be given to patients with BPH • Diagnostics: Digital Rectal Exam. PSA test > 4ng = Prostate Cancer. Urine test for Nitrates, Blood test for creatine & Transurethral ultrasound with Biopsy . BPH Medication: O PROSCAR (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 concerns BPH Teaching- Yearly Check • Kegel exercises 10-20 min daily • Saw palmetto(herb)can decrease prostate but can increase risk for BLEEDING • Proscar: INCREASE ORTHOSTATIC HYPOTENSION 50 risk for falls, not for pregnant women, decreases size of prostate. • Urine incontinence-dribbling- difficulty urinating is indicative if BPH • Cogentin (anticholinergics)should NOT be given to patients with BPH Trans-Urethral Resection of the Prostate (TURP): Prostate surrounds the urethra: the enlargement can squeeze 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 catheter Priorities for the most experienced nurses: Only give TURP to experienced nurses! • Don't give a new nurse a complex patient such as one with TURP. TURP- Transurethral Resection of the Prostate • Use of excision and cauterization to remove prostate tissue cytoscopically • A surgical treatment using a resectoscope inserted through the urethra • CONTINUOUS BLADDER IRRIGATION 0 Continuous bladder irrigation 3 lumen catheter ( 2000L)-increase flow rate if you see red blood 0 It is usually done for the first 24 hours to prevent obstruction from mucus and blood clots. 0 It is to PREVENT THE CLOTS, if there is a BRIGHT RED BLEEDING that means there is a clot stuck in there so you have the INCREASE THE FLOW rate of CBI Hand Hygiene • The No. 1 measure to reduce the growth and transmission of infectious agents is hand hygiene. The Centers for Disease Control and Prevention (CDC) states that "hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in health care
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32 settings. The term "hand hygiene" refers to both hand washing with an antimicrobial or plain soap and water as well as the use of alcohol based products such as gels, foams, and rinses." • The three essential components of hand washing include: 0 Soap O Water O Friction Transmission of Infectious Diseases • Reverse Isolation O Designed 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. O Protective modified reverse isolation is less restrictive but is not prolonged needlessly because the patient usually feels lonely and sensorial deprived. O Hand washing, gowning, gloving, sterilization, or disinfection of materials brought into the area and other details of housekeeping vary with the reason for the isolation and the usual practices of the hospital. • Rotavirus- Contact precaution O Protect visitors and caregivers against direct dient'environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, scabies, multidrug- resistant organisms). 0 Contact Precautions Require: ■ A private room ora room with other clients with the same infection ■ Gloves and gowns worn by the caregivers and visitors 1 Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag • Meningitis- Dropiet precaution O Isolate the client as soon as meningitis is suspected. 0 Maintain isolation precautions per hospital policy. O This should be DROPLET PRECAUTIONS which requires a private room or a room with cohorts, wearing of a surgical mask when within 3 feet of the client, appropriate hand hygiene, and the use of designated equipment, such as blood pressure cuff and thermometer. Continue until antibiotics have been administered for 24 hr. O Implement fever- reduction measures, such as a cooling blanket, if necessary. 0 Report meningococcal infections to the public health department. 0 Dec rease enviran m ental sti mu 11. O Provide a quiet environment. 0 Minimize exposure to bright light (natural and electric). O Maintain bed rest with the head of the bed elevated to 30°. O Maintain client safety, such as seizure precautions. Home Visit • Child safe home: 0 Aspiration: ■ Keep alI sm a11 o bjects out of reach.
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33 ■ Check toys for loose parts. ■ Do not feed the infa nt hard ca ndy, pea nuts, popcor n, or whole or si iced pieces of h ot dog. ■ 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. 0 Provide parents with information about prevention of lead poisoning electrical sockets, meds, locking cabinets, poison control center # 0 Suffocation: ■ Keep plastic bags out of reach. ■ Make sure crib mattress fits snugly and that crib slats are no more than 23/8 inches apart. 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 push up. ■ 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 for protective responses such as closing her mouth underwater. ■ Keep toilet lids down and bathroom doors closed 0 Poisoning : ■ Keep h ouse pla nts and cleaning agents out of reach. ■ Place poisons, paint, and gasoline in locked cabinet. ■ Keep m edicatio ns in chi d-p roof conta in ers a n d Iocked up. ■ Dispose of medications which are not longer used or are out of date. C Falls : ■ 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 le r sta rts to climb. 0 Motor vehicle/lnjury: ■ Use backward facing car seat until the infant/toddler is 1 year old and weighs at least 20 lb. ■ All car seats should be federally approved and be placed in the backseat 0 Burns: ■ 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 faucets Elderly safe home: falls 0 Modifications that can be made to improve home safety include: 0 Removing 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] furniture 0 Making sure that steps and sidewalks are in good repair
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34 0 Placing grab bars near the toilet and in the tub or shower and installing a stool riser 0 Using a non-skid matin the tub or shower & place a shower chair in the shower 0 Ensuring that lighting is adequate both inside and outside of the home • Red flag 0 Domestic violence, elder abuse, fall risk 0 Stages of healing of bruises or cuts O Malnutrition 0 Lice on children O Electrical sockets O Poisonous substances Respiratory 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 • Pulse Oximeter O Measures light absorption by oxygenated and deoxygenated Hgb in arterial blood. O SaO2 and SpO2 are used interchangeably © This is a noninvasive, indirect measurement of the oxygen saturation (SaO2) of the blood. The expected reference range is 95% to 100%, although acceptable levels for some clients range from 91% to 100%. 0 Less than 85% is abnormal 0 Additional reasons for low readings include hypothermia, poor peripheral blood flow, too much light (sun or infrared lamps), low Hgb levels, client movement, edema, and nail polish. 0 A SaO2 below 91% requires interventions to help the client regain acceptable 5aO2 levels. O A SaO2 below 86% is an emergency. 0 A SaO2 below 80% is life-threatening. 0 If you get a low reading - make sure that it is working • Ventilation: © HIGH PRESSURE ALARM: obstruction ex. Patient needs suctioning © LOW PRESSURE A L A R M : something has become disconnected ex. tubing disconnected Respiratory Drugs • Albuterol usually given in treatment • Give Zopinex to not increase HR as much as Albuterol • Mucomyst for breaking up secretions
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35 Cooling Blanket * Place thermal sensor first * ColIect vita Is more freq uently Acid 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% 0 Blood 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 cyanotic Respiratory 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 respirations Metabolic 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, flushed Metabolic 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-normal 0-0.1 (elevated) 0 Troponin is more im po rtant CKMB
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36 ■ Mis are classified based on: 0 The affected area of the heart (anterior, anterolateral). 0 The EKG changes produced ST ELEVATION 0 Most 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 • Associated S&S-dyspnea, sweating, weakness, n &v, severe anxiety. ■ Clinica I Maniterations of M I 0 Pain ■ Severe, immobilizing chest pain NOT relieved by rest, position change, or nitrate administration - The HALLMARK of an Ml 0 Nausea 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 stimulated ST Elevation = Ml ST Depression = Ischemia Planning for Chest Pain • Give them Nitroglycerine and Morphine • Emergency treatment chest pain (MONA) - Oxygen comes first] 0 Morphine sulfate if pain unrelieved O Oxygen O Nitroglycerine spray, or sublingual or IV if indicated O Aspirin 325 mg ■ 2 large gauge IV lines ■ Cardiac monitor, 12-lead ECG (gold standard) ■ Assess contraindications thrombolytic therapy I Recent Surgery, high BP, risk for embolism - DON'T DO ■ Send to cardiac cath lab within 30 minutes QUESTION: Patient arrives at an urgent care center complaining of substernal and epigastric pain and pressure for the last 12 hours. The nurse reviews the labs knowing that this point in time Ml would be indicated by peak levels or what? ANSWER: Troponin and CK-MB PeakT wave = Hyperkalemia U wave = Hypokalemia Other Drugs to Know - Other Uses
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37 Breast cancer drug = tomoxiphen Prostate cancer drug = lupron (can be given to women to stop bleeding) Pulmonary fibrosis = viagra Hyperkalemia = Calcium Gluconate Angiocardiogra phy Visualize the interior of the heart & adjacent great vessels Procedure: using sterile technique, vascular access is obtained 0 Catheter inserted that contains a guide wire & is advanced to the Rt atrium, guide wire removed & contrast material is injected. X-ray images are taken & stored 0 Nursing care-similar to conscious sedation, manual pressure for 5 min at insertion site, then pressure dressing; monitor for hemorrhage or hematoma formation, push fluids afterwards Pre procedure: 0 Patient needs to be NPO, informed consent, contrast (make sure that they are not allergic to the die) P conscious sedation (not putting to sleep), when you inject the die important to tell the patient there will be a FLUSHING SENSATION - so they don't get scared 0 Post procedure- Have to lay flat for 2 hours and on bed rest for 4-6 hours - CAN’T GET UP! O Important to check renal function before the test because of the contrast Intra procedure 0 Pt receives dye, anti-platelet medication - Aggrastat (don’t want to re-occlude the area) - be careful patient might bleed out!! O See occlusion they will suck it out and stent the area ■ Pt having stent might have to be on Plavix for one year - good potential that the patient might re-ocdude 0 If the patient is on Glucophage (Metformin) for diabetes it can be toxic to the kidneys - hold the GLUCOPHAGE (Metformin) for 43 hours post procedure O Pt receives contrast - monitor patient creatinine, blood sugars ■ If pt has kidney problems, history of diabetes, high blood sugars are high or GFR are low Can give them Mucomyst PO helps with binding with the irons from the contrast to get it out of the system Postprocedure 0 Your FIRST PRIORITY is to check circulation! Check distal pulse (dorsal pedal pulses) O Patient has no pulse post procedure - need to let someone know right away 0 Checking every 15 minutes!! O Loo k at col o r of the skin: pal e, cool or warm 0 Check for bleeding or hematoma at the puncture site 0 If the site has some bleeding - put pressure above site for 5 to 10 minutes then put a 10 pound sac on the area O Vital signs: monitor Q 5 minutes for an hour 0 Monitor for dysrhythmias O Watch for s/s of pulmonary emboli O Push fluids afterwards
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33 0 Bed rest for 4-6 hours, first two hours flat 0 If the patient wants to drink something 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? 0 Pull out - femoral artery is going to bleed 0 Have to put pressure ABOVE the puncture site 0 10 pound weight pressure - for about 10-15 minutes ■ Not a sandbag - has to be the nurse putting on pressure ■ Then later put sandbag 0 Two 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 cough 0 While holding down - have the other nurse check pulses to make sure that you aren't putting too much pressure □ See slight bleeding - put a weight on the incision patient - they MUST remain flat 0 Pulsation and pain to the site - it's an aneurysm and has to be fixed by surgery 0 Pt complaining of back pain - check for bleeding and BP QUESTION: A patient returns from the cardiac cath lab following a coronary angiogram which of the fol Iowing assessment 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 patient LASIX ■ What if the number is 5 - give them FLUIDS Normal 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 extubated Once you take the tube out: Priority- CHECK FOR STRIDOR & OXYGENATION • Give them Salmeterol or Albuterol Mental Health Depression • Depression is a mood (affective) disorder that is a widespread issue, ranking high among causes of disability. • Depression may be comorbid with the following: 0 Anxiety disorders ■ These disorders are comorbid with 7O9G of major depressive disorders, the combination of which makes a client's prognosis poorer, with a higher risk for suicide and disability. 0 Schizophrenia 0 Substance abuse
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39 ■ Clients often abuse substances in order to relieve symptoms and/or self-treat mental health disorders. 0 Eating disorders 0 Personality disorders ■ A client with depression may be at risk for suicide, especially if he has a family or personal history of suicide 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 (not associated with mood swings from major depression to mania) resulting in a significant change in a client's normal functioning (social, occupational, self-care) accompanied by at least five of the following specific symptoms, which must occur almost every day for a minimum of 2 weeks, and last most of the day: 0 Depressed mood 0 Difficulty sleeping or excessive sleeping 0 Indecisiveness 0 Deere ased a bility to co nee ntrate 0 Suicidal ideation 0 In crease o r d ecre ase in m otor a cthrity O Inability to feel pleasure O Increase or decrease in weight of more than 5% of total body weight over 1 month Anxiety ■ Anxiety is a response to stress. Higher levels of anxiety result in behavior changes. Anxiety tends to be persistent and is often disabling. • Anxiety levelscan be mild (restlessness, increased motivation, irritability), moderate (agitation, muscle tightness), severe (inability to function, ritualistic behavior, unresponsive), or panic (distorted perception, 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 assistance with working through traumatic events or losses to reach an acceptance of what has happened • Encouraging group therapy Panic Disorder • Episodes typically last 15 to 30 min. • Four or more of the following symptoms are present: 0 PaIpitations & Shortness of breath O Choking or smothering sensation O Chest pain © Nausea © Feelings of depersonalization O Fear of dying o r in sa nity
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40 0 Chills or hot flashes ■ The client may experience behavior changes and/or persistent worries about when the next attack will occur. ■ The client may begin to experience agoraphobia due to a fear of being in places where previous panic attacks occurred. For example, if previous attacks occurred while driving, the client may stop driving. If attacks continue while walking or taking alternative transportation, the client may remain at home • Levels of Anxiety 0 Mild: -restlessness, increased motivation, irritability (its good- 0 Moderate:-agitation n muscle tightness 0 Severe: inability to function, ritualistic behavior, unresponsive 0 Panic: Distorts perception, loss of rational thought, immobility Personality Disorders • All Personality Disorders Share Four Common Characteristics: 0 Inflexibility/maladaptive responses to stress 0 Disability in social and professional relationships 0 Tendency to provoke interpersonal conflict 0 Ability 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 - ge n erally described as a nxious or fearfuI • Cluster A (od d o r eccentric disord ers) 0 Paranoid personality disorder : characterized by irrational suspicions and mistrust of others. 0 Schizoid personality disorder lack of interest in social relationships, seeing no point in sharing time with others, anhedonia, introspection. 0 Schizotypal personality disorder): characterized by odd behavior or thinking. • Cluster B (dramatic, emotional or erratic disorders) 0 Antisocial Personality Disorder: a pervasive disregard for the law and the rights of others. 0 Borderiine Personality Disorder: extreme "black and white thinking, instability in relationships, self-image, identity and behavioroften leading to self-harm and impulsivity. Borderline personality disorder is diagnosed in three times as many females as males. 0 Histrionic Personality Disorder: pervasive attention-seeking behavior including inappropriately seductive behavior and shallow or exaggerated emotions. 0 Narcissistic Personality Disorder: a pervasive pattern of grandiosity, need for admiration, and a lack of empathy. • Cluster C (a nxious or fea rf uI diso rders) 0 Avoidant Personality Disorder social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction. 0 Dependent Personality Disorder: pervasive psychological dependence on other people. 0 Obsessive-Compulsive Personality Disorder: {not the same as obsessive-compulsive disorder) characterized by rigid conformity to rules, moral codes and excessive orderliness.
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Bipolar • Recognize s/s of manic episode of bipolar disorder • Mania - an abnormally elevated mood, which may also be described as expansive or irritable; usually requires inpatient treatment • S/S: 0 Persistent elevated mood (EUPHORIA) O Agitation and irritability 0 Dislike of interference and intolerance of criticism 0 Increase in talking and activities 0 Flight of ideas - rapid, continuous speech with sudden and frequent topic change O Grandiose view of self and abilities (grandiosity) O Impulsivity: spending money, giving away money or possessions 0 Demanding and manipulative behavior 0 Distractibility 0 Poor judgment 0 Attention-seeking behavior: flashy dress and makeup, inappropriate behavior 0 Impairment in social and occupational functioning 0 Decreased sleep 0 Neglect of ADLs, including nutrition and hydration 0 Possible presence of delusions and hallucinations O Denial of illness 0 Giving away things, spending a lot of money 0 Being extremely sexual Anger Management • Howto manage aggressive and angry client Nursing Care: • Provide a safe environment not only for the client who is aggressive, but also for the other clients and staff on the unit. • Follow policies of the mental health setting when working with clients who demonstrate aggression. • Assess fo r tri gge rsorpreconditionsthatescalateclientemotion. • 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 • Setti ng limits for the die nt: 0 Tell the client calmly and directly what he must do in a particular situation, such as, "I need you to stop yelling and walk with me to the day room where we can talk." 0 Use physical activity, such as walking, to de-escalate anger and behaviors.
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0 Inform the client of the consequences of his behavior, such as loss of privileges. O Use pharmacological interventions if the client does not respond to calm limit setting. O Plan for four to six staff members to be available and in sight of the client as a "show of force" if appropriate. * Following an aggressive/violent episode: O Discuss ways for the client to keep control during the aggression cycle. O Encourage the client to talk about the incident and what triggered and escalated the aggression from the client's perspective. O Debrief the staff to evaluate the effectiveness of actions. 0 Document the entire incident completely 1 Medications: Haloperidol (Haldol) • Haloperidol is am antipsychotic agent used to control aggressive and impulsive behavior. Nutrition - Albumin Levels: 3.5-5.0G/DI Caring For a Dying Patient * Normal grief O This grief is considered uncomplicated. O Emotions may be negative loss, such as anger, resentment, withdrawal, hopelessness, and guilt but should change to acceptance with time. O Some acceptance should be evident by 6 months after the loss. 0 Somatic complaints may include chest pain, palpitations, headaches, nausea, changes in sleep patterns, or fatigue. * Anticipatory grief O This grief implies the "letting go" of an object or person before the loss, as in the case of a terminal illness. 0 Individuals have the opportunity to grieve before the actual loss. * Dysfunctional grief O This grief involves difficult progression through the expected stages of the grieving process. 0 Usually the work of grief is prolonged, the symptoms are more severe, and they may result in depression or exacerbation of a preexisting disorder. O The client may develop suicidal ideation, intense feelings of guilt, and lowered self-esteem. O Somatic complaints persist for an extended period of time. ■ Disenfranchised grief O This grief entails an experienced loss that cannot be publicly shared or is not socially acceptable, such as the loss of a loved one through suicide. * Nursing Interventions O Promote continuity of care and communication by limiting assigned staff changes. O Assist the client and family to set priorities for end-of-life care. O Give priority to the control of symptoms. O Administer medications that manage pain, air hunger, and anxiety. O Perform ongoing assessment to determine effectiveness of treatment and need for modifications of treatment plan, such as lower or higherdosesof medications.
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0 Manage side effects of medications 0 Reposition the client to maintain airway and comfort. 0 Maintain integrity of skin and mucous membranes. 0 Provide an environm ent tha t prom otes dignity and self-estee m. 0 Remove products of elimination as soon as possible to maintain a dean and odor free environment. 0 Offer comfortable clothing. 0 Provide grooming for hair, nails, and skin 0 Encourage family members to bring in comforting possessions to make the client feel at home 0 Encourage use of relaxation techniques, such as guided imagery and music. 0 Promote decision making in food selection, activities, and health care to permit the client as much control as possible. • Support for the Grieving Family 0 Suggest that family members plan visits in a manner that promotes client rest. 0 Ensure that the family receives appropriate information as the treatment plan changes. 0 Provide privacy so family members have the opportunity to communicate and express feelings among themselves without including the client. 0 Determine family members' desire to provide physical care. Provide instruction as necessary. 0 Educate the family about physical changes to expect as the client moves closer to death. Stages of Grief (Kiib I er Ross Stages} * Denial, Anger, Bargaining. Depression, Acceptance Palliative Care * Family and pt education-Palliative care improves the quality of life of clientsand their families facing end-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 among themselves 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 Care 0 Give priority to controlling symptoms. 0 Administer medications that manage pain, air hunger, and anxiety. 0 Perform ongoing assessment to determine the effectiveness of treatment and the need for modifications of the treatment plan, such as lower or higher doses of medications. 0 Manage adverse/side effects of medications. 0 Reposition the client to maintain airway patency and comfort. 0 Maintain the integrity of skin and mucous membranes.
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□ Provide an environment that promotes dignity and self-esteem. 0 Remove products of elimination as soon as possible to maintain a clean and odor free environment 0 Offer comfortable clothing O Morphine is given for comfort' o If Patient taking morphine and see respiratory depression - GIVE NARCAN 0 Oxygen is a comfort measure Body Image • Could be due to burns, stoma, scoliosis O Scoliosis: have to wear the back brace 24 hours a day for a year except for the shower - need to 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 management strategies * Nursing Actions O Help client develop a safety plan, identify behaviors and situations that might trigger violence and provide information regarding safe places to live. O Encourage participation in support groups. O Use case management to coordinate community, medical, criminal justice, and social services. O Use crisis Intervention techniques to help resolve family or community situations where violence has been devastating • Nursing Intervention: O Must be culturally sensitive. O Counseling is an important nursing intervention for all types of violence O Case management is needed to coordinate services. O Nurses have a legal responsibility and are mandated to report suspected or actual cases of child or elder abuse. • Nursing Interventions for domestic partner violence: O Make a safety plan for fast escape when violence occurs. O Teaching empowerment skills to client. O Teaching the client to recognize behaviors and situations that might trigger violence. * Nursing Interventions for family violence: O Stabilizing the home situation. 0 Maintaining an environment without violence and a higher quality of life for all family members. 0 Empoweringthe vulnerable members and promoting the growth and development of all family members. Teaching and promoting normal growth and development O Teaching strategies to manage stress.
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Psychosis * Verify are they hearing voices, what are their voices telling them- Ask patient about hallucinations * Agoraphobia- fear of crowded places and being in public places- with no escape * Flight of ideas: describes excessive speech at a rapid rate that involves fragmented or unrelated ideas * Abstra ct th i nking telI someone a cat has nine lives - a nd they wilI kilI the cat a n d wa it fo r it to co me back to life Must Know Definitions Negative Symptoms: Positive Symptoms: Affect-flat or blunted (Facial expression never changes) Alogia- poverty of thought or speech- mumble Avolition- (lack of motivation) lack of motivation in activities and hygiene Anhedonia- lack of pleasure or joy Anergia- lack of energy Apathy- indifference Social isolation Chronic low self-esteem Neologisms-are made up words Echolalia- repeating another’s words Echopraxia - mimicking of movements Clang associations- rhyming words "on the track...have a big Mac" Word salad- jumble of words that are meaningless to the listener Loose Association- Pattern of thinking is illogical & connections in thought are interrupted. Delusions- false fixed beliefs that's held to be true Hallucinations-a sense of perception- tactile, gustatory, auditory, olfactory and visual. Disturbed thought processes Bizarre behavior- such as walking backward Imipramine Tofranil (TCA) antidepressant is used to treat clients with agoraphobia and those under detoxification of cocaine! Chronic Emphysema • What kind of acid base balance? Respiratory acidosis and compensatory metabolic alkalosis • Chronic means compensated Burns • Priority intervention is airway • Also important hydration, infection control, and a high calorie diet Care of Skin Cancer • SPF cream-sun protection -Hours of day to avoid: 10-2pm • Hours of day to not go out to prevent mosquito bites: during dusk and dawn Pulmonary 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 ventricle Umbilical Cord Prolapse • The greatest risk to the client and fetus is umbilical cord prolapse leading to fetal distress
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* During cord prolapse Fetal bradycardia (FHR d l O / m i n for 10 min or more) * When there is suspected rupture of membranes the nurse should first assess the FHR to assure there is no fetal distress from possible umbilical cord prolapse, which can occur with the gush of amniotic fluid. * In Amniotomy the client is at increased risk for cord prolapse. 0 In Amniotomy Assure that the presenting part of the fetus is engaged prior to an amniotomy to prevent cord prolapse. * Intervention 0 Lower the head of the bed and elevate the client's hips on a pillow, or place the client in the knee-chest position to minimize pressure from the cord. 0 Place pt in a Trendelenburg position or Knee chest position Using gravity to shift the baby off the pelvis 0 Lift the cord upward Umbilical Cord Prolapse Intervention * 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 part up until delivery * Maternal hip are elevated on two pillows * The knee to chest position See Decelerations on the FHR Monitor - Indication of an Umbilical Cord Prolapsed * Early Dece le rations: fetaI HEAD COMPRESSION, fun dal pressure 0 Interventions: Nothing * Variable Decelerations:CORD COMPRESSION, Oligohydraminos (not enough amniotic fluids) * Late Decelerations: UTEROPLACENTAL INSUFFICIENCY, maternal hypotension 0 Interventi o ns for varia ble and late: ■ Discontinue Oxytocin (Pitocin ) if it is being infused. ■ Help the client into aside-lying position or to a hands and knees position to take the pressure off the umbilical cord ■ Administer oxygen (8 to 10 L/min by mask). ■ Start an IV line if one is not in place. ■ Administer a tocolytic medication as prescribed. ■ Stimulate the fetal scalp. ■ Notify the primary care provider. * Fetal kick counts 0 Pt is instructed to lie on her side & count the number of times she feels the fetus moves 0 1 E method: She counts and records 10 fetal movements in a period of 2 hours 0 2 nd method: She counts fetal movements for 1 hour three times/week- count is reassuring if it equals or exceeds the established baseline * Assessment of Fetal Well-Being C Dopp I er uItrasound (see und er uItrasound )
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0 Fetal Biophysical Profile ■ Noninvasive fetal physical assessment ■ Involves fetaI heart rate m on itor a nd uItrasound ■ BPP (biophysical profile): uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observes for fetal biophysical responses to stimuli. ■ It measures 5 va ri a b les with a score of 2 for e ach n orm aI fi nding a nd 0 for each abnormal finding: 4 Reactive FHR (from reactive NST), 4 Fetal breathing movements (at least 1 episode of 30 sec in 30 min is a normal response) 4 Gross body movements (at least 3 body or limb extensions with return to flexion in 30 min is a normal response) 4 Fetal tone (at least 1 episode of extension with return to flexion is a normal reaction} 4 Amniotic fluid volume (at least 1 pockets of fluid that measures at least 1cm in 2 perpendicular planes is a normal reaction). 4 Total score of 3-10 is normal, less than 4 is abnormal. Non-Stress Test • Noninvasive procedure performed during the third trimester to monitor fetal movements • Assess for an intact fetal CNS • NST (nonstress test}: is most widely used technique for antepartum evaluation of fetal wellbeing performed during the third trimester. • It is a noninvasive procedure that monitors response of the FHR to fetal movement. • A Doppler transducer, used to monitor the FHR and a tocotransducer, used to monitor uterine contractions, is attached externally to a client's abdomen to obtain paper tracing strips. ■ The client pushes a button attached to the monitor whenever she feels a fetal movement, which is then noted on the paper tracing. This allows a nurse to assess the FHR in relationship to the fetal movement. ■ This is indicated for assessing an intact fetal CNS during the third trimester, ruling out the risk for fetal death in clients who have diabetes mellitus used twice a week or until after 28 weeks of gestation. ■ NST is REACTIVE if the FHR is a normal baseline rate with moderate variability, accelerates to 15 beats/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 assessed with a contraction stress test (CST) or biophysical profile (BPP) • Procedure O Position at semi-Fowler's or left lateral position O Client presses the button when fetus moves O If there is no movement Vibroacoustic stimulation is activated
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