teach pt about IV = when to call nurse, don't manipulate lines or pump, don't touch site

date tubing - check site q2h

aseptic technique

know s/s complications

match catheter size with pt needs

Dc'ing IV check that catheter is intact and document.

1. Fluid Overload leads to CHF & Pulmonary Edema caused by rapid infusion

s/s = crackles, edema, dyspnea

2. Air embolism leads to Shock & death caused by IV tubing changes, cutting tubing with scissors, cracked ports, separation of tubing at joints or ports

s/s = dyspnea, cyanosis, hypotension, weak rapid pulse

3. Sepsis caused by contamination of solution or the administration set

s/s = abrupt incr T, backache, HA, increase P & R, NVD, chills

1. Infiltration/Extravasation = diffusion of solution or medication into surrounding tissue.

2. Phlebitis = inflammation of vein r/t chemical, bacterial, or mechanical irritation.

3. Thrombophlebitis = presence of clot plus inflammation of vein.

4. Occlusion = caused by kinked tubing, empty bag, or failure to flush IV line after intermittent infusion.

verify order

consent form - explain procedure

 Take VS - if elevated T, hold & notify MD

Check right pt & right blood type

check blood for gass bubbles/cloudiness

Administer within 30 mins of removal from frig

* never piggyback blood with other IV fluids

1st 15min - admin no more than 5ml/hr, stay with pt, incr rate after 15min if no adverse reaction

Monitor VS q15min x 4, then q30min

complete whole blood admin within 4hrs

PRBCs within 2 hrs

platlets within 30-60mins

change tubing every 2 units of blood

Assessment

Interventions

Education

Evaluation

5 Rights of Drug Admin -

right pt

right time

right med

right dose

right route of admin

Acute hemolytic reaction - within first 15mins - life threatening - TX = stop transfusion, NS, notify MD, send blood & bag back to blood bank

Nonhemolytic febrile reaction = T elevation of 1 degree or more without any other explanation - TX same as above

Allergic reation = Itching, hives, flushing - TX same as above

Circulatory overload - rapid admin, poor kidney perfusion = s/s dyspnea, tachycardia, anxiety, JVD, crackles, incre BP = TX = stop infusion, raise HOB, notify MD

Bacterial Contamination - platlets at greatest risk, prevent by using aspetic technique during procurement, processing, and administration

Delayed hemolytic reaction - within 14 day of transfusion - usually requires no intervention.

Allergic response - monitor 30 mins after med is given especially PCN

Anaphylaxis - can occur within a few seconds up to 30 mins - TX is management of anaphylaxis = stop med, take to hospital, establish airway, give meds like benadryl, epinephrine, steroids

Superinfections - if pt develops diarrhea or recurrent fever. TX = stop drug or replace with another drug. culture suspected area.

what is Gentamicin?

aminoglycoside - bacterostatic

Peak & Trough ordered

usually reserved for life threatening infections

poorly absorbed in intestinal tract

Rapidly absorbed in IM or IV

can cause nephrotoxicity and ototoxicity

watch for overdose

opioid analgesics are habit forming

watch for resp depression, NV, & constipation

Narcan = narcotic antagonist which reverses resp depression.

Overdose s/s = cold, clammy, drowsy, dizzy, restless, confusion, decreased P & BP, decrease Resp

If Resp is <12 - hold narcotic

If Resp = 4 - call MD - narcan works in mins

Morphine causes increased ICP - watch in head injuries

Always:

Assess pain level

LOC

VS

Side rails up

evaluate effectiveness of pain med

Excess CO2 Retention

ph < 7.35

HCO3 > 26 (if compensating)

PaCO2 > 45 mm Hg

diaphoresis

HA

tachycardia

confusion

restlessness

apprehension

monitor resp rate

if < 12 = arouse & deep breathe

admin O2

ventilator

sodium bicarb

excess CO2 excretion

pH > 7.45

HCO3 < 22 mEq/L (if compensating)

PaCO2 < 35 mm Hg

Rapid, deep respirations

paresthesia

light-headedness

twitching

anxiety

fear

Paper bag - to rebreathe CO2

mask (same as above)

Sedation - calming

HCO3 loss - acid retention

pH < 7.35

HCO3 < 22 mEq/L

PaCO2 < 35 mm Hg (if compensating)

rapid - deep breathing

fruity breath

fatigue

HA

Lethargy

drowsiness

nausea

vomiting

arrhythmias or coma (if severe)

treatment for metabolic acidosis

correct the cause

check BG

insulin

Fluid & Electrolyte

watch elevated K & lowered Na

HCO3 retention - acid loss

ph > 7.45

HCO3 > 26 mEq/L

PaCO2 > 45 mm Hg (if compensating)

slow, shallow breathing

hypertonic muscles

restlessness

twitching

confusion

irritability, apathy, tetany

seizures

arrhythmias or coma (if severe)

correct cause

IV fluids

K

antiemetics (for NV)

Fluid & electrolytes

DC NG tube

nursing actions for hypocalcemia

check EKGs

diet = milk (lower in fat = higher in Ca)

sardines, salmon, green leafies

incr vit D (sun) and as a po supplement

Ca supplements - 30 mins before meals

Ca gluconate - emergency IV (1cc per/min) can cause necrosis

parathyroid hormone - increases renal absorption

put pt on seizure precautions

tetany

parathesias - hands & feet

laryngeal stridor - leads to spasm & arrest

cardiac arrhythmias - mental disturbances

seizures (incr CNS irritation)

trousseau's sign - carpal spasm when pressure applied to nerve of upper arm (BP cuff)

chvostek's sign - twitching of facial muscle after tap on facial nerve (located by zygomatic arch)

transport/storage of folate

metabolism of fatty acids/amino acids

animal sources

supplements

injection

Pernicious anemia - pt also has no intrinsic factor to enable GI system to absorb B12

weak

fatigue

mild diarrhea

parasthesia

smooth, sore red tongue

RBCs pale

Jaundice

loss of skin pigment

prematurely gray

injection of B12 IM daily

will see improvement of tongue & blood within weeks

safety precautions for confused

soft diet

5-6 small meals

unprocessed foods

fruits

vegetables

dairy products

meats

legumes

3 P's = polyuria, polydipsia, polyphagia

wt gain/wt loss

fatigue

weakness

sudden visual changes

tingling/numbness in hands & feet

dry skin

slow healing sores

recurrent infections

NV

abdominal pain

acetone breath (fruity)

dehydration

Kussmal's resp

sexual dysfunction

hypoglycemia/insulin reaction - prevent by consistent pattern of eating, administration of insulin/po meds, and exercise

Diabetic Ketoacidosis - prevent by monitoring BG & take insulin/po meds when needed - even when sick.

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) - no prevention - seek medical help

10-15g fast acting CHO

3-4 glucose tabs

4-6oz fruit juice/soda

6-10 lifesavers/candy

2-3 tsp sugar/honey/cake icing

4-6oz milk = best choice because it is a protein & sugar

recheck BG after 15 mins

>70-75 mg/dl = give snack (protein & starch)

<70-75 mg/dl = repeat CHO

1 mg Glucagon SQ or IM

pt should regain consciousness within 20 min, then give sample CHO and snack

unconscious pt in Emergency Room = 25-50 mL D50 IV

fluid replacement - 1/2NS or NS

Correct electrolyte imbalance - add K

*never IV push K

Insulin administration - add dextrose when BG drops to 250-300mg/dl

Treat until metabolic abnormals are corrected and neuro s/s resolve

"Logs" - such as Humalog

onset 10-15 mins

peak 1-2 hrs

duration 3 hrs

"R" - Regular such as Humulin R, Novolin R

onset 30min - 1 hr

peak 2-3 hrs

duration 4-6 hrs

"N" - such as Humulin N, Novolin N

onset 3-4 hrs

peak 4-12 hrs

duration 20-30 hrs

Humulin U

onset 6-8 hrs

peak 12-16 hrs

duration 20-30 hrs

Novolog Mix 70/30

Humalog Mix 75/25

Humulin 70/30

peak 30mins - 12 hrs

Levemir & Lantis

onset 1 hr

peak continuous

duration 24 hrs

local allergic reaction

systemic allergic reaction

lipodystrophy

resistance

morning hyperglycemia

syringe

insulin pen

jet injector

insulin pump

implantable & inhalant insulin

transplant of pancreas or islet cell

take BP before med

if <90 = hold & call MD

if significantly lower than pt norm = hold & call MD

remember 5 rights of med admin

watch for hazards of sudden cessation = rebound HTN

watch for possible side effects:

postural hypotension

hypokalemia with diruetics

sexual dysfunction

Loop diuretic blocks Na and H2O reabsorption

causes rapid volume depletion

take diuretics in the morning

loop diuretics increase uric acid

may cause gout

low potassium

thirst

skin rash

postural hypotension

NV

gout

given po

must be on 2 days before DC of heparin

must monitor PT (1-1.5 x control) or INR (2-4)

reversal agent = Vit K

given IV or SQ

(not given po because it would be destroyed by gastric enzymes)

must monitor aPTT frequently (1.5 x control)

reversal agent = Protamine Sulfate

stable

unstable

intractable

variant

silent ischemia

predictable, consistent.

occurs on exertion and is relieved by rest.

unpredictable, Chest pain while sitting or no activity.

progressive increase in frequency, intensity and duration of anginal attacks.

associated with increased risk of having MI within a few months

unpredictable, no precipitating factor - also accompanied by ST-segment elevation in EKG.

Associated with increased risk of having MI in few months

assess pain

assess VS & EKG

Assess cardiac status

Any precipitating or relieving factors

risk factor control

teaching

promote oxygenation of tissue

relieve pain

prevent further tissue damage

improve coronary circulation

prevent complications

MONA - morphine, oxygen, nitroglycerin, aspirin

relieve chest pain

O2

Bedrest w/HOB elevated

Quiet environment

TCDB

Nutrition = low fat, low salt, restrict caffeine, avoid extreme temp foods - hot or cold, small freq meals

emotional support & reduce anxiety

patient education & cardica rehab

elevate HOB

O2

call MD

oral iron = on empty stomach, 1 hr before or 2 hr after meals

no antacids, no dairy

liquid stains teeth - so drink w/straw & rinse mouth

IM = stains skin, Z-track method

year long compliance

side effect = constipation

decreased platelets

platlets are less than 50,000

pt bleeds a lot & bruises

GI hemorrage

treat underlying disease

platlet transfusion

watch platlet count

no aspirin or sharp objects

instruct w/meds that increase bleeding, wear protective clothing, and limit invasive procedures

note any abnormal bleeding, petechiae, GI hemmorrhage, excessive surgical bleed

hyperkalemia med

normal K 3.5-5.0 mEq/L

Na polystyrene sulfanate

only med that gets rid of K

exchanges Na for K in colon

usually given as an enema, can be given po

retention enema mix w/150cc H2O, then hold for 30-60min, then follow with a cleansing enema

constant pain

sudden incapacitating pain

LUQ but can radiate

pain is worse when supine,

 after meals, & after ETOH

NV

abdominal distention

ascites

low grade fever

dehydration

abdominal rigidity

jaundice

Grey Turner's sign (bruising of flanks)

Cullen's sign (bruise around umbillicus)

tremors, tetany, & convulsions

sterrohea

all are elevated except Ca and H&H

Serum Amylase - most significant test - rises within 24-48 hours of episode - normal is 80-150. Pancreatitis pt = 300-2000

Serum Lipase - high after 2 days - not used as much

Urinary Amylase - stays elevated longer than serum amylase

Coag profile = PT increased b/c no vit K

non-narcotic pain meds

avoid ETOH

avoid caffiene

low-fat bland diet - small freq meals

Cimetadine (tagamet) = to decrease inactivation of lipase by gastric acid thereby decreasing streatorrhea. * not a tx - decreases HCL

Pacreatic enzyme replacement - to treat malabsorption and streatorrhea

Pancrealypase, Pancreatinie - digests fat and protein - job of pancreatic hormones - must take with meals or snack - stools will turn norm when taking enough enzyme.  Monitor number & consistency of stool - monitor I&O to adjust dose.

NPO with NGT = #1 tx

IV fluids replace and correct F&E imbalance

Tagament, Zantac, Prevacid, Prilosec - lower HCL secretion

Antispasmodics (Pro-Banthine) and anticholergics to block stimulation of pancreatic secretions and to control pain (slows everything down)

Demerol - DRUG OF CHOICE - no morphine

Ca gluconate to combat tetany - keep at bedside

Bowel abx = neomycin or kanamycin to tx peritonitis

NSAIDS, Motrin for inflammation

drain abcess if present

Insulin may be given

High Fowler's, TCDB, peritoneal lavage (pull off fluid) - Don't palpate abdomen

1. non-narcotic pain medication - can lead to addiction

2. avoidance of ETOH - no caffiene or nicotine

3. low fat, bland diet - sm freq meals

low protein - high CHO  no spicy/rich foods

4. surgical interventions - pancreaticojejunostomy

5. DM is treated with diet, insulin, or oral hypoglycemic agaents

2-3g

limit/avoid salt preserved/smoked foods

salted foods, aged cheese, commercial PB

canned veg, baking soda/powder, shellfish

commercial breads, candies, OTC meds

1. assess color & T distal to graft q 1h x 12h, then q4h

2. assess peripheral pulse - sudden disappearance is usually thrombitis - call MD

3. assess VS, edema, sensation, and movement in distal limb

4. assess incision - redness, drainage, swelling

5. promote circulation

6. position change 2h, don't cross legs

7. footboard or overbed cradle, progressive activity

8. watch for bleeding (hep during surgery)

9. teach = avoid sharp flexion at graft site

smoking

age

ETOH

sedentary lifestyle

high stress

obesity

males > females

high fat diet

diabetics

family hx

black

Birth control pills

short acting for acute attacks

1/150 gr = most common dose

take at 5min intervals with a maximum dose of 3.

If no change in pain, call MD or go to ER

Nitroglycerin IV or translingual

long acting = prevention of angina

Nitrobid = sustained release

Nitrol ointment - squeeze on marked paper. Dose usually 1/2 to 2.5 inches. Given q4-6h.  Wear gloves.  Don't put on hairy part of body or distal part of extremity.  Remove old ointment.  May tape paper on.

Patches - already has med on it but basically use like ointment - can shower with patch.  Replace q18-24h. remove old, wear gloves, not on hairy part, etc.

Isosorbide dinitrate (Isordil, sorbitrate) - sublingual, chewable tab, or sustained release = to prevent or decrease number of anginal attacks

monitor response to med

pt should have med with them and take SL at first sign of attack.  Take 1 SL q5min til pain gone or up to 3 times. - if no response seek help.

Take BP and pulse before giving med. - if too low, hold & call MD

normal cholesterol <200

HDL norm 35-70

LDL norm <130

High cholesterol = animal fats, fried foods, eggs, liver, seafood, whole milk, beef, pork

Low cholesterol = veggies, chicken skin, freshwater fish, oatmeal, anything high in fiber helpw to lower cholesterol, veggie oils, and fruits

To lower cholesterol = exercise, high fiber/low cholesterol diet

ACE inhibitor

inhibits conversion of Angiotension 1 to Angiotension 2

watch for hypotension, dry cough, proteinuria

decreases risk of MI, CVA, CV death

has little effect on BP in non-HTN pt

increases O2 supply

decreases preload & afterload

decreases left ventricle mass

stabilizes plaque

nursing actions for Captopril

check BP and pulse before & after giving med

labs to watch = BUN, creatinine, K, & Na

can increase liver enzymes

used to treat CHF & supraventricular arrhythmias

increases force of contractions without increase in O2 demands

K, Ca, & Mg need to be monitored

Digibind is antidote for dig toxicity

anorexia (early sign)

NVD

halos

low K level will make pt more prone to dig toxicity

take pulse before giving - give for pulse of 65 or more.

increase in fiber diet decreases the effectiveness of digoxin

fluid is forced back into lungs =

crackles, wheezes, dyspnea, cough (pink, frothy sputum), fatigue, tachycardia, anxiety, orthopnea, paroxysmal nocturnal dyspnea, insomnia, tachypnea

if left side is not treated, it can result in right side failure

blood backs up to rest of organs =

dependent edema of lower extremities, weight gain, hepatomegaly with tenderness, ascites, anorexia, JVD, nausea, nocturia, weakness

EKG will show tachycardia, may have dysrhythmias and hypertrophy of muscles

nursing actions = small freq meals, set with arms and legs elevated, rest to decrease workload of heart

Fresh MI - EKG will show ST elevation and T wave inversion (ST segment shows signs of cardiac ischemia)

can have ventricular Bigeminy - every other beat is a PVC, enlarged Q

decreasing LOC is an early sign of IIP = slowing of speech, delay in response

Increased systolic pressure, widening pulse pressure, bradycardia, progressive pupil dilation (tends to be one eye)

(Brocca's area damage)

pt understands what is being said and knows what he wants to say

may be able to write message

can't produce sequence of movements necessary to verbalize

VERY frustrating for pt

more likely in Left CVA

poor comprehension

non-fluent speech

few intact language skills

consult with speech therapist

allow time for pt to speak and respond

face pt on unaffected side

repeat or rephrase if necessary

use short sentences, pause, see if pt understands

show acceptance - don't finish sentences

keep distractions to a minimum - involve family in care

be consistent - use same wording each time instructions are given

provide privacy

if aura - insert airway

do not force airway between clenched teeth

ease to floor & turn on side to drain secretions from mouth and prevent aspiration

protect from injury - pad head, extremities, body

don't restrain pt

loosen restrictive clothing

keep on side & reorient

no need to go to hospital unless =

1. no hx seizures

2. status epilepticus

3. injury

4. neuro deficits

antiepileptic drug

po or IV

300-400 mg/daily (divided or all at once)

drowsiness

Gingival hyperplasia

rash

leukopenia (sore throat)

Toxic =

nystagnum

tremor

visual difficulty

staggering gait

give with meals to prevent GI upset

good oral hygiene

q 3 months dental visits to prevent gingival hyperplasia (thickened red gums)

special considerations =

slow IV dose - more than 50mg/min can cause cardiac arrest

mix only with NS

irritating to veins

associated with decreased levels of dopamine due to destruction of neuronal cells.

This causes an imbalance of excitatory and inhibiting neurotransmitters.

Symptoms usually do not appear until dopamine levels are decreased by 80%.

Then, extrapyramidal tracts controlling complex body movements are affected giving you three cardinal signs.

1. tremors

2. rigidity

3. bradykinesia

caused by cerumen, OM, otosclerosis

results in inefficient transmission of sound by air to inner ear

sesorineural hearing loss

s/s of hearing loss

(conductive/sensorineural)

tinnitus

inability to hear in groups

high TV/radio volume

change in personality/attitude

decreased ability to communicate

decreased awareness of surroundings

disinterest/isolation

hearing loss test

bone conduction/lateralization test using a tuning fork on top of head

results =

if conductive loss = heard better in affected ear

if sensorineural loss = heard better in unaffected ear

hearing loss test

bone vs air

&

conductive vs sensorineural

results =

norm = air sound is greater than bone sound

conductive loss = bone sound is greater than air (neg Rinne)

sensorineural loss = air sound is greater than bone sound (pos Rinne)