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PRETEST: BASIC CARE AND COMFORT




PRETEST: BASIC CARE AND COMFORT






PRETEST: BASIC CARE AND COMFORT





PRETEST: COORDINATED OF CARE



PRETEST: COORDINATED OF CARE






PRETEST: COORDINATED OF CARE





PRETEST: COORDINATED OF CARE




PRETEST: COORDINATED OF CARE

















PRETEST: HEALTH PROMOTION AND MAINTENANCE





PRETEST: HEALTH PROMOTION AND MAINTENANCE







PRETEST: SAFETY AND INFECTION CONTROL






PRETEST: SAFETY AND INFECTION CONTROL






PRETEST: SAFETY AND INFECTION CONTROL



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I. Concepts of Management and Supervision


A.
Review standards/position statements of the following agencies before delegating any nursing tasks


1. State board of nursing

2. National Council of State Boards of Nursing (NCSBN)

3. Nursing organizations - publish position statements and define standards of practice

a. American Nurses Association (ANA) - interpretations or position statements

b. National league for Nursing (NLN)

c. National Federation of Licensed Practical Nurses (NFLPN)



4. Health care institutions






B. Nurses must understand the legal aspects of the nursing profession

1. Provide safe competent care

2. Advocate client's rights

3. Provide care that is within their scope of practice

4. Provide care that is consistent with established standards of care

C. Establishing priorities

1. Prioritizing involves decisions of which needs or problems require immediate attention or action and which
ones can be delayed until a later time if they are not urgent

2. Needs that are life-threatening or could result in harm to the client if left untreated are high priorities

3. Actual problems or needs have higher priority than potential problems or needs

4. Problems or needs identified by client are of a higher priority

5. Consider Maslow's principles (hierarchy of needs) or the ABCs (airway, breathing, circulation) of
emergency care to guide decisions

6. Mutual decision-making for priorities may be made with the client based on the client's physiologic needs,
desires, and safety.



D. Communication skills and conflict resolution


1. Communication

a. involves perception to receive a message

b. involves expectation - the unexpected may be ignore

c. makes demands on nurses to think and respond

d. is different than information







Don't Confuse these!
Scope of Practice - determined by a state's Nurse Practice Act
Standards of Practice - established by the nursing profession, i.e., the American Nurses
Association
Standard of Care - institutional policy and procedure documents
2




3. Causes of conflict

a. Inadequate communication

b. incorrect facts


c. unstable leadership or inadequate action plans

d. misunderstood roles or responsibilities

e. receiving directions from two or more delegators

f. lack of or limited staff input into decisions

g. inability to accept change

h. power issues



4. Prevention of conflict includes

a. allocating resources fairly

b. avoiding unexplained changes

c. clearly stating expectations

d. addressing staff fears



5. Dealing with conflict

a. take prompt action


b. help parties resolve conflict among themselves (communicate trust that
parties can accomplish resolution)

c. maintain an objective approach

d. avoid criticism


e. use problem solving approach

f. provide privacy for sensitive issues

g. negotiate for agreements- not winning or losing

h. focus on patient care interests

i. avoid emotional outbursts

j. include a third party when mediation seems the best choice


2. Types of communication

a. downward - used to relate organizational policy such as position
description and rules and regulations

b. upward - include such things as staff meetings

c. lateral - between staff members, i.e. to coordinate activities

d. diagonal - staff from different levels work together on a
project

3

E. Communication and collaboration techniques

1. SBAR technique - provides a standardized framework for communication between
members of the health care team

a. S =situation (a concise statement of the problem)

b. B =background (pertinent and brief information related to the situation)

c. A =assessment (analysis and considerations of options - what you
found/think)


d. R =recommendation (action requested/recommended - what you want)



2. "I PASS the BATON" - used to improve "handoffs" and transitions in health care, with
opportunities to ask questions, clarify, and confirm

a. I =introduction (introduce yourself and your role/job)

b. P =patient (name, identifiers, age, gender, location)

c. A =assessment (presenting chief complaint, vital signs and symptoms and
diagnosis)


d. S =situation (current status/circumstances, including code status, recent
changes, response to treatment)

e. S =safety concerns (critical lab values/reports, socio-economic factors,
allergies, alerts such as falls, isolation, etc.)

f. B =background (co-morbidities, previous episodes, current medications,
family history)


g. A =actions (what actions were taken or are required and provide brief
rationale)


h. T =timing (level of urgency and explicit timing, prioritization of actions)

i. O =ownership (who is responsible - nurse/doctor/team and
patient/family responsibilities)

j. N =next (what will happen next? anticipated change? what is the PLAN? what
is the contingency plan?)

3.

CUS - a process used to more effectively advocate for clients when there is a
concern

a. C =concern ("I am concerned...")

b. U =uncomfortable ("I am uncomfortable...")

c. S =safety ("this is unsafe...")


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II. Delegation


A. Definitions


1. Delegation: a process by which responsibility and authority for performing tasks are transferred from
one individual to another who accepts that authority and responsibility

2. Delegation involves

a. responsibility: an obligation to accomplish a task

b. accountability: accepting ownership for the results or lack of

c. authority: right to act or empower over others



B. Delegation overview

1. A nurse can only delegate those tasks for which that nurse is responsible (as outlined in the
state's Nurse Practice Act)

2. The delegator remains accountable for the task

3. Along with responsibility for a task, the nurse who delegates must also transfer the authority
necessary to complete the task

4. The delegator knows how to perform the task being delegated

5. Delegation is a contractual agreement that is entered into voluntarily

6. Nursing tasks that may not be delegated include client assessment, professional nursing
judgement, planning of nursing care or the evaluation of the client's response, health teaching
or counseling





7.

Consider the scope of practice of nursing personnel (as determined by a state's Nurse Practice Act)


a. Registered Nurses (RNs):

i. baccalaureate prepared nurses are equipped to care for
individuals, families, groups and communities in both structured
and unstructured health settings
ii
.
associate degree prepared nurses are equipped to care for
individuals in a structured health care environment


b.
Licensed Practical or Vocational Nurses (LPN/VN)

i. assist in implementing a defined plan of care and to perform
procedures according to protocol
ii. assessment skills involve collecting data and are directed at
differentiating normal from abnormal
iii. may reinforce information that has been
given to the client by the RN
iv. competence to care for physiologically stable clients
with predictable conditions




c. Unlicensed Assistive Personnel (UAP)

i. because they are unlicensed, they have no scope of practice
ii. in general, nursing tasks that may be delegated include non-invasive and non-
sterile treatments
>
assist in a variety of direct client care activities or tasks,
e.g., bathing, transferring, ambulating, feeding, toileting,
and obtaining measurements (vital signs, height, weight,
intake and output, blood glucose levels)
>
perform indirect activities such as housekeeping,
transporting people and stocking supplies
iii. some states allow for the practice of medication administration in specific
settings by medication aides - refer to your state's Nurse Practice Act for
specific information










5








C. Steps of delegation - if allowed by your state's Nurse Practice Act

1. Right task - define the task and determine if it can be safely delegated

a. match the delegatee to the task

b. determine if the task is within the scope of practice for the delegatee

c. determine agency policies, procedures, and standards

d. understand standards of practice, e.g., the ANA or NAPNES Standards of Practice

e. remember - nursing tasks that be delegated to unlicensed assistive personnel (UAP) are intended to assist,
but not replace, the nurse


2. Right circumstances

a. determine if there is anything about the client's condition or the environment which would preclude this delegatee from
performing the task as delegated

b. determine if staff members have the resources, equipment, and supervision needed to work safely


3. Right person - is the right person delegating the right task to the right person to be performed on the right patient?

a. determine if staff members have the necessary knowledge, skills, and abilities (KSA) to perform the delegated tasks and if this
information is documented

b. determine if the client's condition is stable with predictable outcomes prior to delegating care



4. Right direction/communication - clearly communicate the specific steps of the task, expectation about performance, reporting, and
documentation of the task

a. potential problems and solutions are discussed

b. the nurse intervenes if necessary

c. staff members must be able to decline without jeopardizing their jobs


5. Right supervision/evaluation - appropriate monitoring, intervention, evaluation, and ongoing feedback

a. the nurse must have the appropriate skills to assist, teach and guide the individual who is completing the task

b. the nurse will determine if client needs were met

c. the nurse can continue or withdraw the delegation

d. problems, particularly and sentinel events, are clarified or reported to supervisors


D. Client care assignments

1. Assign the right task

2. Assign the task to the right person

3. The LPN may assign tasks to the unlicensed assistive personnel or nursing assistants (if allowed by that state's Nurse Practice
Act)


4. Unlicensed assistive persons (UAP) or nursing assistants cannot delegate to other UAPs or nursing assistants





Five Rights of Delegation

Right Task
Right Circumstances
Right Person
Right Direction/Communication
Right Supervision/Evaluation

The 4 C's of Communication
1. Clear - Does the team member understand what I am saying?
2. Concise - Have I confused the direction by giving too much unnecessary information?
3. Correct - Is the direction given according to policy, procedures, job description, and the law?
4. Complete - Does the delegatee have all the information necessary to complete the task?

6


III.Performance Improvement (Quality Assurance)


A. Quality: the degree to which client care services increase the probability of desired outcomes and reduce the probability of
undesired outcomes given the current state of knowledge

B. Performance improvement/assurance: the process of attaining a new level of performance or quality that is superior to any
previous one

C. Total quality Management: a philosophy that emphasizes a commitment to excellence throughout the organization

D. Six characteristics of total quality management

1. Focus on the customer, i.e., the client

2. Focus on outcomes

3. Total organizational involvement

4. Multi-professional approach

5. Use of quality tools and statistics for measurement

6. Identification of key areas for improvement with an emphasis on SAFETY



E. Mandated by The J oint Commission


IV. Nursing Care Delivery Systems

A. Functional nursing (task nursing)
1. Needs of patients are broken down into tasks
2. Tasks are assigned to various levels of health care workers according to licensure and skill
3. Example: LPN/VNs give medications and UAP (or nursing assistants) give bed baths for one group of patients

B. Team nursing
1. Most common nursing-care delivery system
2. A team of nursing personnel provides total patient care to a group of patients
3. Team leaders supervise client-care teams, which usually consist of an RN, PN, and an unlicensed assistive personnel (UAP)
4. Team leader reviews clients' plans of care and progress with team members during team conference

C. Total care (case method)
1. A registered nurse is responsible for all aspects of care of one or more patients
2. The LPN/VN may be assigned to assist the RN
3. This type of care is usually provided in areas requiring high level of nursing expertise, such as the critical care unit (CCU) or
the post-anesthesia recovery unit (PACU)

D. Primary nursing
1. The registered nurse is responsible for a work load of consistent clients
2. The primary nurse designs, implements and is accountable for the nursing care of those clients during their entire stay on the
unit

E. Practice partnerships
1. An RN and an assistant (UAP, PN, less-experienced RN, graduate nurse, or nurse intern) agree to be practice partners
2. Partners work together on same schedule with same group of clients
3. Senior partner directs the work of the junior partner within the scope of each partner's practice









Remember the steps in the Nursing Process - A Delicious PIE

A=Assessment
D=Diagnosis
P=Planning
I=Implementation
E=Evaluation

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F. Case management
1. Model for identifying, coordinating, and monitoring the implementation of services needed to achieve desired client outcomes
within a specified period of time
2. Organizes client care by major diagnoses or diagnostic-related groups (DRGs)
3. A collaborative practice team defines the expected outcomes of care and care strategies for a client population by defining
critical paths.
4. A registered nurse manager is assigned to coordinate, communicate, collaborate, problem solve, facilitate and evaluate client
care for a group of clients
5. Case manager usually does not provide direct client care but supervises care provided by licensed and unlicensed nursing
personnel according to a critical path

6. Critical pathways are plans for providing care to the client and family
a) identify desired outcomes
b) state expected amount of time and resources to be used
c) focus on specific diagnoses or procedures that are high volume and or high resource use (and therefore costly)
d) promote collaboration among disciplines (health care professionals)

7. The essential components of case management include
a) collaboration of all health care team members
b) identification of expected patient outcomes with time frames
c) use of principles of continuous quality improvement (CQI) with variance analysis
d) promotion of professional practice

8. Client involvement and participation is key to successful case management

G. Differentiated practice
1. Identifies distinct levels of nursing practice based on defined abilities that are incorporated into job descriptions
2. Structures nursing roles according to education, experience, and competency

H. Client-centered care
1. Registered nurse coordinates a team of multi-functional unit-based caregivers
2. All patient care services are unit-based, including admission, discharge, diagnostic testing and support services
3. Uses unlicensed assistive personnel to perform delegated client care tasks

V. Information & Documentation

A. Types of patient records
1. Problem-oriented medical record (POMR)

a) a decision is made on the nature of the client's problem or problems and these problems are assessed regularly
b) recorded using a standardized format, by narrative notes in the S.O.A.P. format or by flow sheets
c) discharge summary relates the overall assessment of progress during treatment and plans for follow-up care, encouraging
continuity of care .
d) four parts
I. data base: the client's present health status
II. problem list: numbered list of health problem(s)
III. initial plan: plan to help overcome health problem(s)
IV. progress notes: all disciplines chart on the same page

2. Source-oriented
a) most traditional type of charting, with different disciplines charting on separate forms
b) drawback: records become very bulky, very quickly









Documentation has six key components (CO-ACTS)

Confidential
Organized (chronologically)
Accurate
Complete
Timely
Subjective and objective data

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B. Methods (styles) of charting
1. Narrative charting
a. the nurse records observations, data (including reactions from the client) in a sequential and chronological order
b. baseline charted every shift
c. source-oriented

2. S-O-A-P: problem-oriented charting; comes from a medical model
a. S =subjective; what client tells you
b. O =objective; what you observe, see, etc.
c. A =assessment; what you think is going on based on the data
d. P =plan; what you are going to do

3. D-A-R
a. D =data - collecting information about a problem
b. A =action - the task to be completed about the problem
c. R =response - the client's response to the problem

4. Focus charting
a. charting on an acute condition, a potential problem, a treatment or procedure, or a client behavior
b. components of this type of charting include: information about the condition/problem, action, and client's responses

5. A P-I-E charting - uses the nursing process
a. A =assessment
b. P =problem
c. I =intervention
d. E =evaluation

6. Charting by exception
a. uses flowsheets
b. emphasis on abnormal (or what is abnormal for this particular client); normal routine is presumed as having been done,
without any problems

C. Documentation guidelines
1. General
A. Check that you have the correct chart
B. Record the facts as accurately as possible
C. Chart as you go
D. Never chart for another person
E. Do not mention incident reports
F. Avoid the use of abbreviations - when in doubt, write it out!

I. All health care institutions have a list of accepted abbreviations
II. Refer to the J oint Commission's official "Do Not Use" list of abbreviations

A. Never alter a client's record (altering a client chart is a criminal offense)
B. Six things that nurses must document

I. Assessment
II. Nursing diagnosis and client needs
III. Interventions
IV. Care provided
V. Client response to care
VI. Client's ability to manage continuing care after discharge

2. Legal guidelines for charting
A. electronic health record (EHR) charting
i. never share access or password with another person
ii. change your password frequently
iii. maintain confidentiality of documented information printed from the computer
iv. carefully check your information before you press enter
v. access information for clients under your care only
vi. log off when you are finished
vii. date and time are automatically recorded

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B. paper-ink
i. DO
write in chronological order
use permanent black ink
chart the time and date for each entry
include consent for or refusal of treatment, client responses to interventions, calls made to other health care professionals
write legibly
cross through the error once, date and initial the change
correct any errors in a timely manner

ii. DO NOT
erase, scratch out or use correction fluid (Liquid Paper or Wite-Out)
document for others or change documentation by others
leave blank spaces
recopy any charting form
make photocopies without permission

VI. Legal Responsibilities
A. Sources of law
1. Federal Regulations
a. The Health Insurance Portability and Accountability Act (HIPAA)
b. The Americans with Disabilities Act (ADA)
c. The Mental Health Parity Act (MHPA)
d. The Patient Self-Determination Act (PSDA)
e. The Uniform Anatomical Gift Act and the National Organ Transplant Act

2. State law - Nurse Practice Act
a. passed by each state legislature to regulate the practice of nursing in that state
b. administered by the board of nursing in each state or jurisdiction
c. scope and responsibilities vary state-to-state, therefore nurses are responsible for knowing regulatory
requirements for nursing in each state where they are practicing
d. Nurse Practice Acts define
i. scope of practice (what the nurse is allowed to do)
ii. nursing titles that are allowed to be used
iii. qualifications for licensure
iv. actions that can or will happen if a nurse does not follow the nursing law

B. Types of law
1. Criminal Law
a. deals with acts of intentional harm to individuals and society as a whole
b. categorized as a felony or misdemeanor
c. the defendant is either guilty or not guilty
d. the burden of proof is "beyond a reasonable doubt"







2. Civil Law
a. deals with disputes between parties or negligent acts that cause harm to others protects the individual rights of people
b. deals with tort law - unintentional, quasi-intentional or intentional torts
c. the burden of proof is "preponderance of the evidence"
d. negligence and malpractice are examples of unintentional torts
i. negligence: a breach of the duty to provide nursing care to the client
ii. malpractice is professional negligence; the unintentional failure of an individual to perform or not perform an act that a
reasonable person would or would not perform in a similar set of circumstances
iii. negligence involves four legal concepts
REMEMBER IT!
A former client sues a nurse for negligence. The client must prove that the nurse
not only committed a breach of duty but that this breach of duty was the
proximate cause of any damages incurred by the client.

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duty: nurses have a legal obligation to provide nursing care to clients
must meet a reasonable and prudent standard of care under the circumstances
must deliver care as any other reasonable and prudent nurse of similar education and experience would, under similar
circumstances

breach of duty: failure to provide expected, reasonable standard of care under the circumstances (includes errors of omission or
commission)
proximate cause
relationship between the breach of duty and the resulting injury
the injured party must prove that the nurse's action or omission led to the injury

damages: the injury and the monetary award to the plaintiff

VII. Professional Misconduct
A. The impaired professional
1. Remember that the impaired nurse is compromising client care
2. Be sure that the problem exists and can be proven
3. Communicate specific concerns to appropriate persons such as nurse manager or risk manager
4. Document incidents in terms of behaviors, specific times, dates - be objective
5. File a report according to the policies and procedures of the institution

B. Boundary violations
1. Definition: Actions that overstep established interpersonal boundaries to meet the needs of the nurse
2. Guiding principles in determining professional boundaries
a. nurse is responsible for setting and keeping boundaries
b. nurse must avoid simultaneous professional and personal relationship with same person
c. nurse must avoid flirtation

C. Consequence of professional misconduct
1. A board of nursing must protect the public and is required to take action against the licenses of nurses who have exhibited
unsafe nursing practice.
2. A state board of nursing may imposes penalties for professional misconduct, ranging from probation, censure, and
reprimand, to suspension or even revocation of licensure.

VIII. Client Rights
A. Privacy
1. Confidential information may only be released by signed consent of the client
2. Unauthorized release of client data may be an invasion of privacy
3. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
a. provides individuals with access to their medical records and more control over how their personal health information is used
b. provides privacy protection for consumers of health care

4. Health care workers must release information when a court orders it or when statutes require it (as in child abuse or communicable
diseases)
5. Special regulations apply to release of information about psychiatric illness or HIV

B. Advance directives
1. As part of the Omnibus Budget Reconciliation Act (OBRA) of 1990, Congress established the Patient Self-Determination (PSDA);
this requires states to provide written information to clients outlining their rights to make health care decisions

2. These rights include:
a. the right to refuse or accept treatment
b. the right to formulate advance directives

3. Nurses and other members of the health care team are required to
a. assess the clients knowledge of advance directives and their status regarding the advance directive process
b. provide information and assistance to the client in developing advance directives
c. plan care that incorporates the clients decisions regarding advance directives Three common advance directives are:
i. living will - identifies what a client wishes for his care should he become unable to communicate these wishes
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ii. durable power of attorney for health care decisions - the client has appointed a person to make decisions about their
care if they are unable to do so.
iii. do not resuscitate (DNR) status - this has been expanded to include identification of medications that may be given
without any defibrillation attempts (comfort measures only)
Follow the facility policy on obtaining and implementing DNR orders
Generally, the order must be written by a physician; some facilities may have a policy to allow verbal orders under
specific conditions
The order must be communicated clearly to all personnel caring for the client
The client or her or his health care proxy can withdraw the order at any time
A nurse who attempts to resuscitate a client with a valid DNR order may be committing battery

C. Refusal of treatment - competent clients may refuse treatment, even life-sustaining treatment

D. Freedom from protective devices (restraints)
1. Physical restraints/safety devices require a signed, dated health care provider's order specifying the type of restraint and a
time limit

2. Types of protective devices
a. Chemical - central nervous system depressants, paralytics
b. Physical - vests restraints, side rails

3. Use the least restrictive form of restraint/safety device
4. Know agency guidelines for use of restraints
5. You must document three factors
a. Why restraints/safety devices were used
b. How the client responded
c. Whether the client needs continued protective device

6. Restraining clients without consent or sufficient justification may be interpreted as false imprisonment

E. Informed consent
1. Basic requirements
a. Capacity
b. Voluntariness
c. Information
i. health care provider is legally obligated to provide a complete description of the treatment/procedure, description of the
potential harm, pain, and discomfort that may occur, options for other treatments, and the right to refuse treatment

ii. the nurse should verify client comprehends and consents to care

2. The client must understand
a. Purpose of the procedure and expected results
b. Anticipated risks and discomforts
c. Potential benefits
d. Any reasonable alternatives
e. That consent may be withdrawn at any time

3. Requirements for signing an informed consent form
a. Must be signed by a competent adult
b. Individual who is signing must be able to understand the information given by the health care professional (if the person is
unable to understand the information due to language barrier or hearing impairment, a trained medical interpreter must be present)

F. Transition planning - recognizes that clients are not discharged from care but moved across the continuum to another level of care

IX. Ethical Practice
A. Ethics
1. A theory or system of moral values, based on the ideas of right and wrong, good and bad
2. It governs our relationships with others
3. Influenced by our personal beliefs and values

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B. Ethical principles
1. Respect for others: The right of the individual to make their own decision
2. Autonomy: Respect for an individuals right to self determination
3. Nonmaleficence: the principle of "do no harm"
4. Beneficence: do good and avoid evil
5. J ustice: the principle of fairness
6. Veracity: the ethical duty to tell the truth
7. Confidentiality: the respect for individual privacy
8. Fidelity: loyalty, faithfulness and honoring commitments





























QUIZ 1

Nurses have a legal duty to account for every task that they delegate. True False

Nurses have a legal duty to carry out the provider's written orders, whether they agree with them or not. True False

A nurse has a legal duty to report a co-worker who is violating a client's privacy. True False

A nurse has a legal duty to provide nursing care to the client, within the scope of the nurse's education and experience. True False

A nurse has a legal duty to abide by the scope of practice in the state's nurse practice act. True False

A nurse has a legal duty to meet a reasonable and prudent standard of care under the circumstances. True False

A nurse has a legal duty to provide Good Samaritan care at the site of a traffic accident. True False

A nurse has a legal duty to avoid negligence by either omission or commission. True False

A nurse has a legal duty to avoid professional misconduct. True False

A nurse has a legal duty to decide whether a client may or may not be restrained. True False

A nurse has a legal duty to prove that he or she was not the "proximate cause" of damage to a client. True False

A nurse has a legal duty to encourage the client to sign the consent form if the nurse believes the procedure will really benefit the client. True False

A nurse has a legal duty to explain (or verify that someone has explained) risks, consequences, and benefits to the client. True False

A nurse has a legal duty to advocate for the client and protect the client's autonomy as far as possible. True False

A nurse has a legal duty to use the most secure form of restraint if the provider orders restraints. True False



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1. A client is diagnosed with confusion and anemia. While caring for this client, which task should the practical nurse assign to an
unlicensed assistive person (UAP)?
A. Test stool for occult blood
B. Assess mental status
C. Check for skin color changes
D. Assist client to select foods high in iron from the menu

2. A practical nurse (PN) is having difficulty reading a health care provider's written order from the prior shift. What action should the nurse
take?
A. leave the order for the oncoming staff to follow-up or interpret
B. call the pharmacy for assistance in the interpretation
C. ask the registered nurse (RN) to notify the health care provider for written clarification
D. contact the manager to report the problem with the legibility of the order

3. The nurse manager requests that the practical nurse (PN) staff form a task force to investigate and develop potential solutions to this
problem: excessive documentation with resultant overtime. The PN staff are to present a report on solutions at the next staff meeting.
This nurse manager's leadership style would be described as autocratic
A. autocratic
B. participative
C. laissez-faire
D. group

4. Which of these clients should a nurse assign to an unlicensed assistive personnel (UAP)?
A. a client diagnosed with peripheral vascular disease and an ulceration of the lower leg a new
B. admission with a history of diagnoses of transient ischemic attacks and dizziness
C. an older adult client with hypertension and a self-report of non-compliance
D. a preoperative client with a history of asthma awaiting surgery for an adrenalectomy

5. A nursing student is discussing the delegation of tasks to an unlicensed assistive personnel (UAP) with a preceptor. Which task
assigned to the UAP by the student indicates that the student is confused about delegation and needs help?
A. collect a sputum specimen before breakfast
B. provide discharge teaching
C. assist a client to ambulate after lunch
D. feed a two year-old in traction

6. A manager makes all decisions and rarely asks for staff input. The best description of this nurse manager's leadership style is
A. autocratic or authoritarian
B. ultraliberal or communicative
C. laissez faire or permissive
D. participative or democratic

7. Which one of these tasks should be assigned to the certified nursing assistant (CNA) by the practical nurse (PN)?
A. giving enemas until clear to a middle-aged man scheduled for a colonoscopy
B. assisting a client with colostomy care within 24 hours after surgery
C. performing a first time post-op dressing change on the abdomen
D. feeding a client who has difficulty swallowing within the initial 24 hours after a stroke

8. A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which of these clients might the PN offer to be
assigned to provide care?
A. a young adult client who is in skeletal traction after a motor vehicle accident
B. a new admission of a young adult who reports left sided weakness from a probable stroke
C. a middle-aged client diagnosed with a possible myocardial infarction
D. a client diagnosed with multitrauma and with a history of a newly implanted pacemaker

9. A client diagnosed with head trauma is in a nonresponsive state. Vital signs are stable and breathing is regular and spontaneous. Which
documentation accurately describes the client's condition?
A. comatose, breathing unlabored
B. Glasgow Coma Scale 8, respirations regular
C. Glasgow Coma Scale 13, no ventilator required
D. appears to be sleeping, vital signs stable

14





























































10. A client exhibiting confusion has been placed in extremity restraints by an order of the health care provider. Which care task for this client
should a nurse assign to an unlicensed assistive personnel (UAP)?
A. monitor circulation to hands and feet
B. identify basic comfort needs during the shift
C. evaluate the client for safety issues
D. assist with activities of daily living

11. Upon completing a review of the admission documents, a nurse identifies that an 87 year-old client does not have an advance directive. What
action should the nurse take?
A. give information about advance directives
B. refer this issue to social services department
C. assume that the client wishes a full code
D. record this information on the chart

12. The practical nurse (PN) is caring for a client in isolation. Which task should the PN assign to an unlicensed assistive personnel (UAP)?
A. reinforce isolation precautions to any visitors
B. observe of the client's reaction to the isolation environment
C. monitor the client's thoughts about being in isolation
D. evaluate the visitors compliance with isolation measures

13. An unlicensed assistive personnel (UAP), who usually works on a medical-surgical unit, is assigned to work on an ortho-neuro unit. Which of
these questions should the UAP be asked by the nurse prior to making any assignments?
A. "How long have you been a UAP?
B. "Do you have your competency checklist for review?
C. "What type of care did you give on the medical-surgical unit?
D. "Are you comfortable caring for adults with broken bones?

14. A nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg
splint. Which activity should the UAP be involved with?
A. assist the client to transfer from a bed to a chair
B. screen for findings of redness overlying joints
C. encourage independence in self-care
D. monitor the client's response to activity

15. Which of these clients would be most appropriate for a practical nurse (PN) who has been reassigned to a different acute care unit to accept?
A. A client, admitted for a possible stroke, has unstable neurological findings
B. A confused client whose family complains about the nursing care given after the clients surgery
C. An older adult client diagnosed with cystitis has an indwelling urethral catheter
D. A trauma victim with multiple lacerations requiring complex dressings

16. When walking past a clients room, a nurse hears an unlicensed assistive personnel (UAP) talking to another UAP. Which one of these
statements requires further intervention by the nurse?
A. "Ill come back and make the bed after I go to the lab."
B. "If we work together we can get all of the client care completed."
C. "This client seems confused, we need to watch the client closely."
D. "Since I am late for lunch, would you do my client's accucheck glucose test?"

17. A nurse has been assigned to four residents. Which client should be seen first on the initial shift rounds?
A. an 86 year-old male diagnosed with hypertension has a reported BP of 180/90 after learning that a close friend had to be hospitalized
B. an 81 year-old female with a history of coronary artery disease (CAD) reported to have had dyspnea, nausea, and unusual discomfort in
the upper back
C. a 70 year-old male with history of heart failure (HF) reported going to the bathroom too much after taking a water pill
D. a 94 year-old female diagnosed with peripheral artery disease (PAD) cramp-like pains in both calf muscles during activities in physical
therapy


15























POINTS TO REMEMBER

Nursing practice is governed by legal restrictions and professional standards.
What a nurse can do depends on the nurse practice act in the state in which the nurse is licensed.
Each state defines what constitutes professional misconduct.
The state board of nursing has the authority to impose a penalty for professional misconduct.
Penalties include probation, censure, reprimand, suspension or revocation of the license.
Standards of nursing practice apply to all nurses in all practice settings.
Standards of care are based on facility policy and procedure, nursing education, experience, and publications of professional
nursing associations and accrediting groups.
To avoid negligence:
Know the standard of care
Deliver care that meets the standard and follows the facility's policies and procedures
Document care accurately and in a timely manner
The only employee of a health care organization who may be the legal witness to the signing of an advance directive is a clinical
social worker. It is at the discretion of each health care facility as to whether or not this is done. Always check the policy of your
facility. A relative or heir to the estate should never be the witness to the signing of an advance directive.
Ethics guide the nurse toward client advocacy and the development of a therapeutic relationship.
Ethical dilemmas result from conflicts in values.
An effective leader modifies his/her style according to the situational requirements.
Final responsibility for any delegated task resides with the registered nurse or the PN if the PN delegates to the UAP.
The registered nurse must monitor delegated tasks and evaluate the outcomes.
The practical nurse is responsible for client care assignments to be completed in a timely manner

18. To whom should the measurement and documentation of vital signs in a long-term care facility be assigned?
A. volunteer
B. registered nurse (RN)
C. practical nurse (PN)
D. unlicensed assistive personnel (UAP)

19. Which task for an older adult client who has a diagnosis of hyperglycemia should the nurse assign to an unlicensed assistive
personnel (UAP)?
A. check sensation in the extremities when in the room
B. observe for mental status changes every 4 hours
C. reinforce findings of hyperglycemia as the client asks
D. test blood sugar by peripheral sticks every 2 hours

20. Which newly admitted client would be appropriate for an assignment to an unlicensed assistive personnel (UAP)?
A. a client diagnosed with severe depression
B. a known heroin addict who exhibits findings of the withdrawal process
C. a client with a history of chronic peripheral vascular disease
D. a client with diagnoses of dehydration and anorexia

16



I. Safety

A. The Quality and Education for Safety in Nursing (QSEN) project

1. QSEN's goal: meet the challenge of preparing future nurses who will have the knowledge, skills
and attitudes (KSAs) necessary to continuously improve the quality and safety of the
healthcare systems within which they work

2. KSA for Safety: minimize the risk of harm to patients and providers through both system
effectiveness and individual performance

3. Safety is the primary concern when caring for clients




B. Fire, electrical and radiation safety

1. Fire safety

a. prevention

b. types of fire extinguishers and their uses

c. response to fire

d. examples of facility rescue plans:

i. P-R-C

Protect clients from injury

Report the fire

Contain the fire


ii. A-R-C-E

Activate fire alarm system

Rescue or remove clients

Contain fire by closing doors and windows

Extinguish flames with fire extinguishers

If there is a fire, remember R-A-C-E:
R=Rescue or remove clients
A=Activate fire alarm system
C=Contain fire by closing windows and doors
E=Extinguish flames (with fire extinguishers)


2. Electrical safety

3. Chemical safety: for all health care institutions, the Occupational Safety and Health
Administration (OSHA) suggests following its Material Safety Data Sheets (MSDS)

4. Radiation safety



C. Poison control

1. High risk groups are young children and older adults with impaired eyesight and diminished
memory
Caution! Do not induce vomiting if the poison contains alkaline or acid agents. Such poisons
include lye, household cleaners, oven cleaner, furniture polish, metal cleaners, battery acids, or
17

petroleum products.

2. Goals of therapies

a. before the body absorbs poison, either remove it, (either through vomiting or gastric lavage)
or neutralize it (using activated charcoal, for example)

b. give supportive care (manage shock, seizures, aspiration)

c. give the correct antidote to neutralize poison

d. speed the elimination of any absorbed poison




D. Fall & injury prevention

1. Assesses client for risk factors
Use the mnemonic FRAIL MOM & DAD for assessing the geriatric client in the primary care
setting:
Falls
Relative or caregiver strain
Activities of daily living
Incontinence
Living situation

Memory Impairment
Oculo-otic impairment (visual and auditory problems)
Malnutrition

Drugs
Advance directives
Depression

2. Guidelines to prevent client falls

3.
Assess age-specific safety risk factors




4. Safe patient-handling and movement

a. principles of manual client handling (to be used in conjunction with "safe patient handling"
techniques when handling and moving clients)

i. widen the base of support, keeping feet apart

ii. place bed at correct height (waist level)

iii. keep work directly in front of you (to avoid twisting the spine)

iv. keep client as close to your body as possible to minimize reaching


b. "safe patient handling"

i. use principles of body mechanics (above)

ii. know how the equipment works and match to the needs of the client and limitations of the
room/area



5. Sharps injuries
If you are stuck by a needle or other sharp object or get blood or other potentially infectious
materials in your eyes, nose, mouth, or on broken skin, you should immediately flood the exposed
area with water and then clean any wound with soap and water or available skin disinfectant.
18

Report the incident to your employer and seek medical attention right away

6. Biohazards

a. examples of biohazards in the workplace include chemotherapeutic agents, exposure to latex,
bloodborne pathogens

b. refer to OSHA for guidelines on handling and disposing of hazardous materials



E. Security plan

1. Required by the Joint Commission

2. Purpose

a. to manage the physical and personal security of clients, staff (including
addressing the risks of violence in the workplace) and individuals coming
to the organization's facilities

b. security of the established environment, equipment, supplies, and
information


II. Infection

A. Types of infections

1. Community acquired (CAI) - if the client develops an infection outside a health care
facility, e.g., a football player develops a staph infection following use of improperly
cleaned sports equipment

2. Health-care Acquired (HAI) - the client develops an infection while admitted to a health
care facility, e.g., a client develops a urinary tract infection following urinary
catheterization


Infection Type Examples
central nervous system infections meningitis, encephalitis
childhood & vaccine-preventable
infections
Varicella (chicken pox), diphtheria, tetanus, mumps
(infectious parotitis), pertussis (whooping
cough), poliomyelitis, rubella (German
measles), rubeola (measles)
gastrointestinal infections staphylococcal food poisoning, botulism
acute bacterial, viral gastroenteritis salmonella, gastroenteritis, viral hepatitis, Clostridium difficile
hemolymphatic infections mononucleosis, cytomegalovirus,
toxoplasmosis
respiratory infections influenza, tuberculosis, histoplasmosis, pharyngitis, scarlet fever,
rheumatic fever, pneumonia
sexually transmitted infections gonorrhea, chlamydia, syphilis, genital herpes, chancroid, AIDS,
genital warts
urinary tract infections
cystitis, pyelonephritis
19


B. Stages of an infectious process

1. Incubation period

2. Prodromal period

3. Illness period

4. Convalescent period


C. Complications of infection

1. Relapse - some infections may reactivate, often because they were not treated thoroughly or the
client did not comply

2. Local complications - local infections may form abscesses

3. Systemic complications - pathogen may enter bloodstream and cause septicemia



D. Chain of infection

1. Causative agent (pathogen)

2. Reservoir

3. Portal of exit - way to get out of host

4. Transmission route - way to reach new host

5. Portal of entry - way to gain entrance

6. Susceptible host

7. After the pathogen enters the host, illness depends on 4 factors

a. number of pathogen organisms

b. duration of the exposure

c. health status of host, including age, physical, mental, and emotional health

d. genetic status of host's immune system




III. Infection Control

A. Medical and surgical asepsis

1. Medical asepsis (or "clean technique")

2. Surgical asepsis

20


B. Precaution types

1. Standard precautions

a. used for care of all clients

b. used to prevent the spread of microorganisms

c. synthesize the major features of universal precaution and body substance isolation

i. universal (blood and body fluid) precautions - designed to reduce the risk of
transmission of bloodborne pathogens

ii. body substance or contact precautions - designed to reduce the risk of transmission of
pathogens from moist body substances


d. apply to

i. blood

ii. all body fluids, secretions, and excretions, except sweat, regardless of whether or not
they contain visible blood

iii. non-intact skin

iv. mucous membranes


e. designed to reduce the risk of transmission of microorganisms from both recognized and
unrecognized sources of infection in hospitals

f. personal protective equipment (PPE) - designed to reduce the risk of transmission of
microorganisms from both recognized and unrecognized sources of infection in health care
settings

i. gloves

ii. masks

iii. gowns

iv. protective eyewear

v. head coverings






2. Transmission-based precautions

a. (direct and indirect) contact precautions

i. direct contact transmission: microorganisms are transferred from one infected person
to another person without a contaminated intermediate object or person

ii. indirect contact transmission: transfer of an infectious agent through a contaminated
intermediate object or person (especially contaminated hands of health care workers)

iii. gown and gloves are required for all contact

iv. epidemiologically important organisms for contact transmission, e.g., VRE
(vancomycin resistant enterococcus); Clostridium Difficile (C. Diff.) infection, excessive
wound drainage; fecal incontinence
With Clostridium difficile (C. diff) infections, you must wash your hands with soap and water because
alcohol-based hand sanitizer does not kill the C. difficile spores.


b. droplet precautions - transmission involves contact of the conjunctivae or the mucous
membranes of the nose or mouth of a susceptible person with large particle droplets
containing microorganisms generated from someone who either exhibits a disease or
who is a carrier of the microorganism
21


i. respiratory droplets are generated when an infected person coughs, sneezes, or talks,
or during procedures such as suctioning, endotracheal intubation, cough induction by
chest physiotherapy and cardiopulmonary resuscitation

ii. when close contact (typically within 3 feet or less) between the source client and a
susceptible person is required, the use of a standard surgical mask is required

iii. epidemiologically important organisms for infectious agents transmitted through the
droplet route include group A streptococcus (for the first 24 hours of antimicrobial
therapy), adenovirus, rhinovirus, Neisseria meningitis, pertussis, influenza virus


c. airborne precautions - used when microorganisms dispersed through the air over long
distances remain infective over time and distance

i. preventing the spread of airborne pathogens requires

use of special air handling and ventilation systems

wearing respiratory protection with NIOSH-certified N95 or higher level respirator for
all healthcare workers


ii. epidemiologically important organisms for infectious agents transmitted through the
airborne route include rubeola virus (measles), varicella-zoster virus (chickenpox),
Mycobacterium tuberculosis


d. neutropenic precautions - used to prevent infection in clients who have neutropenia (low
white blood cell counts) or are immunocompromised

i. health care workers will wear gowns, masks, gloves when providing care

ii. strict hand washing

iii. client is in a private room

iv. visitors are restricted

v. no raw vegetables or fruits

vi. client should be instructed to bathe daily



C. Immunization - raises host resistance, defenses, and immunity

1. Acquired immunity

a. any form of immunity that is not innate

b. obtained during life

c. natural or artificial

i. naturally acquired immunity is obtained by

the development of antibodies resulting from an attack of infectious disease

the transmission of antibodies from the mother through the placenta to the fetus
or to the infant through the colostrum


ii. artificially acquired immunity is obtained by

vaccination

injection of an antiserum, also called an immune globulin such as a hepatitis
immune globulin, after hepatitis exposure


22


d. passive or active

i. passive immunity results from antibodies that are transmitted through

the placenta to the fetus

the colostrum to an infant

injection of antiserum (immune globulin) for treatment or prophylaxis


ii. passive immunity is not permanent and does not last as long as active immunity

iii. active immunity is when the body produces its own antibodies as a reaction to
exposure to an antigen






D. Disease reporting

1. Reporting of nationally notifiable diseases

a. voluntary - to the Centers for Disease Control and Prevention

b. mandated (by legislation or regulation) - at the state level


2. The list of notifiable diseases varies from state-to-state, but internationally quarantinable
diseases, e.g., cholera, plague, yellow fever, are reported in compliance with the World
Health Organization's International Health Regulations


IV. Emergency Preparedness and Response

A. Overview of emergency preparedness and response

1. An emergency can be brought on by a disaster, which is any event initiated by a
person or by nature, or a combination of both

2. A formal emergency preparedness plan of action is required to respond to a disaster

a. personal and family preparedness plan

b. formal institutional plan

i. internal disasters: events that occur within the healthcare facility, e.g., fire or
chemical spill

ii. external disasters: natural or man-made events that occur outside the
healthcare facility, e.g., tornado or airplane crash



3. The Federal Emergency Management Agency (FEMA) identifies

a. four disaster management phases:

i. mitigation

ii. preparedness

iii. response

iv. recovery


b. three levels of disaster, ranging from minor (Level III) to major (Level I)

i. Level I Disaster - requires state or federal assistance due to massive levels and
breadth of damage

ii. A Level II disaster - requires regional efforts and mutual aid from surrounding
communities

iii. Level III disaster - involves minor to average levels of damage; local emergency
response personnel and organizations are able to contain and deal effectively
23

with the disaster and its aftermath



4. Specific hazards associated with disasters

a. bioterrorism

b. chemical emergencies

c. radiation emergencies

d. mass casualties

e. natural disasters and severe weather

f. recent outbreaks and incidents, e.g., salmonella




B. Triage

1. In the community setting, for a disaster or war situation

a. brief assessment of victims, classifying them according to:

i. the severity of the injury

ii. urgency of treatment

iii. place for treatment


b. various rating systems exist and nurses should know and understand the rating
systems

i. treated first: individuals who have life-threatening injuries that are readily
correctable

ii. treated last: individuals who have no injuries, or noncritical injuries, and who are
ambulatory, as well as individuals who are dying or are dead



2. In the health care agency - emergency department triage involves dividing those who
need care into one of the following three categories:

a. emergent individuals who have life-threatening injuries and need immediate
attention are given the highest priority

b. urgent individuals with non-life-threatening injuries

c. nonurgent individuals with no immediate complications and who can wait for
treatment



Biological weapons, which include any organism or toxin found in nature that can be used to
incapacitate or kill an adversary, can be characterized by the following attributes: low visibility; high
potency; accessibility; and easy delivery.

C. Bacterial agents

1. Anthrax


a. causative agent: Bacillus anthracis
24


b. exposure:

i. integumentary system (most common): direct skin contact with spores; in nature, contact with
infected animals or animal products

ii. respiratory tract: inhalation

iii. gastrointestinal system: eating undercooked or raw infected dairy products

iv. oropharyngeal


c. exposed individuals do not spread infection

d. clinical indicators of anthrax infection: symptoms can appear within 7 days of coming in contact with the
bacterium for all types of anthrax

i. skin: localized itching followed by papular lesions that turns vesicular; becomes black eschar after 7 to 10
days

ii. inhalation: initially low-grade fever, cough, malaise, fatigue, myalgias, sweating, and chest discomfort
but progressing to high fever, respiratory distress, shock and death within 24 to 36 hours


e. treatment

i. decontamination

remove clothing; do not pull anything over the head

decontaminate in area outside of treatment area: using large amounts of water,
shower with soap or wash with soap and running water; flush eyes with running
water for 15 minutes


ii. antibiotics

ciprofloxacin hydrochloride (Cipro), drug of choice

penicillin G procaine (Wycillin)

doxycycline (Vibramycin)

note: do not use extended-spectrum cephalosporins or
trimethoprim/sulfamethoxazole due to resistance of anthrax to these drugs



f. vaccine available, but not to the general public



2. Plague

a. causative agent: Yersinia pestis

i. zoonotic infection carried on rodents and their fleas

ii. Y. pestis destroyed by sunlight and dryness, although bacterium can survive for 1 hour after release


b. exposed individuals can spread infection

c. disease states: bubonic plague, pneumonic plague and septicemic plague

d. clinical indicators of pneumonic plague

i. rapidly deteriorating pneumonia

ii. fever, chest pain, bloody or watery sputum


e. treatment: individuals with the plague need immediate treatment or death will occur within 24 hours after the
first symptoms

i. isolate exposed individuals

ii. treat with antibiotics
25


streptomycin

gentamycin (Garamycin)

doxycycline (Vibramycin)

ciprofloxacin hydrochloride (Cipro)


iii. supportive treatment: oxygen, IV fluids and respiratory support are usually needed


f. vaccine: not available


D. Viral agents

1. Smallpox


a. causative agent: variola virus

b. exposed individuals can spread infection via direct contact or prolonged face to face contact

c. clinical indicators of smallpox disease

i. initially (sometimes contagious): high fever (101 to 104 degrees Fahrenheit), malaise, head and body
aches

ii. rash (most contagious): start as small, red spots on the tongue and mouth; the spots become open
sores and, then, spread to the rest of the body becoming pustules that crust and scab-over

iii. individuals are contagious until all scabs have fallen off


d. treatment

i. no specific drug treatment or cure

ii. if the smallpox vaccine is given with 1 to 4 days after exposure to the disease, illness may be prevented
or be less severe

iii. individuals diagnosed with smallpox and everyone they have had close contact with will need to be
isolated


e. vaccine:

i. has not been given routinely in the U.S. since 1972

ii. it is unknown how long immunity lasts after immunization




2. Viral hemorrhagic fever (VHF)

a. used to describe a severe multisystem syndrome caused by four different families of viruses, including
arenaviruses, filoviruses, bunyaviruses, and flaviviruses

i. the vascular system is damaged and the bodys ability to regulate itself is impaired

ii. usually accompanied by hemorrhage, but this is not the life-threatening aspect of these diseases


b. disease states include: Ebola, Marburg, yellow fever, Argentine hemorrhagic fever
26



c. the viruses are zoonotic, residing in and totally dependent on their animal hosts

i. an animal reservoir host, e.g., rodents

ii. arthropod vector, e.g., ticks, mosquitoes


d. clinical indications of VHF

i. initially: high fever, muscle aches, weakness

ii. severe disease: subcutaneous and internal bleeding, bleeding from body orifices; shock, delirium, seizures,
and coma


e. treatment:

i. supportive therapy

ii. no effective treatment or cure


f. vaccine: vaccines only for yellow fever and Argentine hemorrhagic fever



E. Biological toxins ( chemical agents )

1. Sulfur mustard or mustard gas (H, HD, or HT): a blister agent/vesicant

a. human-made chemical warfare agent

i. powerful irritant and blistering agent that damages the skin, eyes, and respiratory tract

ii. damages DNA

iii. may smell like garlic, onions, or mustard

iv. effects of sulfur mustard usually last 1 to 2 days in environment, but can be present for
weeks to months in a cold climate

v. rarely fatal but potentially long term health effects


b. exposure to a vapor (released into the air), an oily-textured liquid (released into the water), or
to a solid form

c. clinical indications of exposure

i. skin: redness and itching immediately after exposure eventually resulting in yellow blistering

ii. eyes: irritation, pain, swelling, and tearing with mild to moderate exposure; severe
exposure can cause light sensitivity, pain, or blindness lasting up to 10 days

iii. respiratory tract: runny nose, sneezing, hoarseness, bloody nose, sinus pain, shortness of
breath, and cough

iv. digestive tract: abdominal pain, diarrhea, fever, nausea, vomiting


d. post exposure treatment: remove sulfur mustard from the body

i. antidote: none
27


ii. shower with soap or wash with soap and running water thoroughly; flush eyes with running
water for 15 minutes but do not cover eyes with bandages

iii. inhalation: leave area of exposure; get fresh air, provide oxygen, and support breathing





2. Sarin (GB) nerve gas

a. human-made chemical warfare agent

i. clear, colorless, tasteless liquid that can evaporate into a odorless gas

ii. extremely toxic, acts very quickly

iii. breaks down the enzyme acetylcholinesterase, which results in excessive concentrations of
acetylcholine in nerve synapses and leads to overstimulation of parasympathetic nerves in the
smooth muscles

iv. impairs normal functioning of nervous system

v. can cause seizures, loss of consciousness, and respiratory failure in minutes


b. exposure via inhalation, ingestion, and/or absorption through eyes and skin

c. clinical indications of exposure

i. low to moderate doses: runny nose, watery eyes, blurred vision, drooling, cough and chest
tightness, diarrhea, drowsiness, weakness, headache, changes in heart rate and blood pressure

ii. large doses: loss of consciousness, seizures, paralysis, respiratory failure


d. post-exposure treatment

i. antidotes: soldiers typically have a antidote kit containing these two medications

atropine (Atropine): binds to one type of acetylcholine receptor on the post-synaptic nerve

pralidoxime chloride (2-PAM chloride): blocks sarin from binding to any free
acetylcholinesterase


ii. decontaminate before transport to treatment facility

flush eyes first for 15 minutes

remove clothing (without pulling over the head) and shower with soap and large amounts of
water or 0.5 % solution of sodium hypochlorite (bleach), or use absorbent powders such as
flour or talcum powder


iii. do not induce vomiting if swallowed; administer activated charcoal

iv. note: can contaminate rescuers by direct contact or off-gassing vapor of contaminated skin or
clothing

v. supportive measures: maintain airway, assist ventilation, and protect client; administer
diazepam for seizure activity




3. Strychnine

a. the primary natural source: the plant Strychnos nux vomica

i. a strong poison; typically used to kill rats

ii. white, odorless, bitter crystalline powder

iii. very small amount able to cause extremely serious adverse effects

v. impairs functioning of neurotransmitters resulting in severe, painful muscle spasms without
28

affecting consciousness


b. exposure

i. injection (mixed with street drugs)

ii. ingestion (food or water contamination)

iii. inhalation (release into air, smoked or snorted in street drugs)


c. clinical indications of strychnine poisoning

i. initially or with low level exposure:

apprehension, agitation, painful muscle spasms

the client is conscious and in extreme pain


ii. later findings or high level exposure: uncontrollable arching of back and neck, hyperreflexia
and muscle twitches, rigid extremities, seizures, difficulty breathing, brain death


d. post exposure treatment: most victims die of asphyxia before reaching the hospital

i. no specific antidote exits

ii. decontaminate in area outside of treatment area

remove clothing; do not pull anything over the head to remove

using large amounts of water, shower with soap or wash with soap and running water

flush eyes with running water for 15 minutes


iii. do not induce vomiting or give fluids to drink

iv. supportive care

IV fluid resuscitation

cooling therapy for fever

anticonvulsants (diazepam, phenytoin, Phenobarbital), antispasmodic agents and muscle
relaxants




4. Ricin

a. a plant protein toxin derived from the beans of the castor plant

b. exposure: through air, food or water

i. in the form of a powder, a mist, a pellet

ii. may also be dissolved in water or weak acid


c. clinical indications: effects depend on whether it was inhaled, ingested, or injected; death can
occur within 36 to 72 hours of exposure

i. inhalation: respiratory distress, fever, cough, nausea, chest tightness; pulmonary edema

ii. ingestion: vomiting and diarrhea that may become bloody; dehydration; low blood pressure;
may include hallucinations, seizures and multi-system failure

iii. skin and eye exposure: redness and pain


d. post exposure treatment

e. treatment: get ricin off or out of the body as quickly as possible

i. no available antidote

ii. decontamination

shower with soap or wash with soap and running water thoroughly
29


flush eyes with running water for 15 minutes


iii. inhalation:

leave area of exposure to get fresh air

provide oxygen and support breathing


iv. ingestion

do not induce vomiting; remain NPO

administer large dose of activated charcoal

gastric lavage

aggressive fluid resuscitation and electrolyte repletion

if necessary, medicate to control seizures and treat hypotension




F. Radiation emergencies

1. Causes of radiation emergencies

a. radioactive material contaminates food/water

b. a bombing or destruction of a nuclear reactor

c. exploding a nuclear weapon

d. nuclear weapon attack

e. radiation dispersal device (dirty bomb)


2. Contamination via

a. wounds

b. ingestion

c. inhalation


3. Severity of signs and symptoms of radiation sickness depends on how much radiation has been
absorbed

a. mild radiation sickness (absorbed dose of 1-2 Gy): nausea and vomiting, headache, fatigue,
weakness within 24 to 48 hours after exposure

b. very severe radiation sickness (absorbed dose of 3.5-5.5 Gy): nausea and vomiting less than 30
minutes after exposure to radiation, dizziness, disorientation, hypotension; usually fatal


4. Treatment

a. get inside and stay in an undamaged building

b. decontamination

i. remove clothing and shoes

ii. gently washing with soap and water


c. for damaged bone marrow:

i. filgrastim (Neupogen): a protein-based medication which promotes the growth of white
blood cells

ii. pegfilgrastim (Neulasta): also increases white blood cells and prevents subsequent
infections


d. for internal contamination (chelating agents)

i. potassium iodide (KI): used to prevent absorption of radioiodine in the thyroid gland
30


ii. Prussian blue: a type of dye that binds to particles of radioactive elements (cesium and
thallium)

iii. diethylenetriaminepentaacetic acid (DTPA): binds to particles of the radioactive elements
plutonium, americium and curium


e. supportive treatment for infections, headache, fever, diarrhea, dehydration; end-of-life care



G. Mass casualties

1. Explosions or blasts can cause unique patterns of injury

a. primary: injury from over-pressurization force impact

b. secondary: injury from projectiles

c. tertiary: injury from displacement of victim by the blast wind

d. quaternary: all other injuries, i.e., burns, toxic exposures


2. Predominant injuries involve multiple penetrating injuries and blunt trauma

3. All bomb events have the potential for chemical and/or radiological contamination

4. Treatment

a. lung injuries

i. high flow oxygen sufficient to prevent hypoxemia via non-rebreather mask, CPAP or ET tube

ii. ensure tissue perfusion but avoid volume overload

iii. prompt decompression for clinical evidence of pneumothorax or hemothorax


b. abdominal injury: clinical signs can be subtle at first; observe for acute abdomen or sepsis

c. ear injuries: tinnitus or deafness will warrant written communication

d. admit 2
nd
and 3
rd
trimester pregnancies for monitoring

e. crush injuries: sudden release of a crushed extremity may result in reperfusion syndrome
(acute hypovolemia, renal failure, metabolic abnormalities)

i. IV fluid replacement (up to 1.5L/hour)

ii. to help prevent renal failure: mannitol to maintain diuresis at at least 30 mL/hour; dialysis
may be needed

iii. to treat acidosis: IV sodium bicarbonate until urine pH reaches 6.5 (to prevent myoglobin
and uric acid deposition in the kidneys)

iv. to treat hyperkalemia/hypocalcemia: calcium gluconate 10% 10 mL or calcium chloride
10% 5 mL IV over 2 minutes; sodium bicarbonate 1 mEq/kg IV push (slowly); regular insulin
5-10 unites and D5O 1-2 ampules IV bolus; kayexalate 25-50g with sorbitol 20% 100 mL PO
or PR

v. monitor injured areas for the 5 Ps: pain, paresthesia, paralysis, pulse, pallor

vi. monitor for sepsis


f. injuries resulting in non-intact skin or mucous membrane exposure

i. hepatitis B immunization (within 7 days)

ii. tetanus toxoid vaccine




H. Natural disasters and severe weather

1. Clustered under this category are: earthquakes, extreme heat, floods, hurricanes, tornadoes,
31

tsunamis, volcanoes, wildfires, landslides/mudslides, winter weather

2. Traumatic events following natural disasters are characterized by a sense of horror, helplessness,
serious injury, or the threat of serious injury or death

3. Emergency preparedness includes being ready for any type of hazard


A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor
and experiences a seizure while in the classroom, the most important action to take during the seizure would be which action?

Provide privacy as much as possible to minimize frightening the other children
Move any chairs or desks at least three feet away from the child
Place the hands or a folded blanket under the head of the child
Note the sequence of movements with the time lapse of the event

The priority during seizure activity is to protect the child from physical injury. Place a pillow, folded blanket or the hands under the child's
head to prevent concussion or further head trauma. The other body parts are at less risk for injury.

A child is admitted with a diagnosis of suspected meningococcal meningitis. Which admission orders should a nurse implement first?

Institute seizure precautions
Notify of changes in neurologic status
Place on droplet precautions
Monitor vital signs every 30 minutes

Meningococcal meningitis is a bacterial infection that can be communicated to others. The initial therapeutic management of acute bacterial
meningitis includes use of respiratory/secretions droplet precautions, initiation of antimicrobial therapy, monitor neurological status along
with vital signs, institute seizure precautions, and lastly maintain optimum hydration. The first action for nurses to take is initiate necessary
droplet precautions to protect themselves and others from the possible infection. Viral meningitis, on the other hand, usually does not
require protective measures of isolation.


The nurse is attending an inservice about healthcare-associated infections (HAIs). Which factor is identified as the most common cause of HAIs
in the acute care setting?

Presence of an indwelling urinary catheter
Decreased mobility for a week or longer
Inadequate fluid intake over 72 hours
Existence of an intravenous access device

Catheter-associated urinary tract infections is the most common HAI in the acute care hospital setting. Surgical site infections, bloodstream
infections and pneumonia are the other categories of infections.

Which nursing action is a priority for a client during a seizure?

observe the sequence of movements
protect the client from injury
suction the oropharynx
loose restrictive clothing

The priority during a seizure is to protect the client. Next, it is a priority to observe, and then record what movements are seen during a
seizure. The diagnosis and subsequent treatment often rests on the seizure description. Suctioning may be done after seizure activity, as well
as loosening clothing.

Parents call the emergency department to report that their toddler has swallowed a granular drain cleaner. The triage nurse instructs them to
call for emergency transport to the hospital. The practical nurse anticipates that the triage nurse suggested giving the toddler sips of which
substance while waiting for an ambulance?

Lemonade
Tea
Coca-Cola or other similar beverage
Water

Small amounts of water (or milk) will dilute a granular material if performed within 30 minutes after ingestion. The other substances have
the potential to cause a reaction with the drain cleaner, which would result in more damage.
Test-taking Tips: Remember that safety always takes priority when it is an option and the question is about the priority.

32


There is an external disaster situation and an overflow of victims is being sent to an urgent care facility. The licensed
practical nurse understands that the registered nurse will use which type of leadership skill to manage this situation?

A. Share decision-making with others
B. Assume a decision-making role
C. Use a laissez-faire approach
D. Seek input from staff

Authoritarian (or autocratic) leadership assumes that decision-making is the role of the leader, with little input by subordinates. This
leadership style is very efficient and best used in emergency and crisis situations.


A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). What type of transmission-based
precautions should a nurse institute?

A. Airborne
B. Standard
C. Droplet
D. Contact

Airborne precautions include an OSHA mandated/NIOSH certified respirator, negative pressure in a private room with the door closed or a
semiprivate room with both clients diagnosed with the same disease (called cohorts), and limited movements or transport of the client. If
these clients have to leave the room, they must wear a mask. A tight fitting, high-efficiency mask such as the particulate HEPA filtered
respirator mask is required when caring for clients who have suspected communicable disease of the airborne variety. Active TB, measles
and chicken pox require airborne precautions. Droplet precautions are used for influenza, whooping cough and mumps. Contact precautions
are for active HSV lesions, VRE, MRSA, lice, scabies, RSV and impetigo.


When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event that these do not
match, what is the priority action of the nurse?

A. Change whichever item is incorrect to the correct information
B. Notify the admissions office and wait to apply the bracelet
C. Make a corrected identification bracelet on the unit for the client
D. Use the bracelet and admission form until a replacement is supplied

The admissions office has the responsibility to verify the clients identity and keep all the records in the system consistent. Changes made by
the nurse put the client at risk for misidentification. Using an incorrect or unofficial identification bracelet is unsafe. Making a new bracelet
on the unit is usually inappropriate.


When a client is diagnosed with active tuberculosis, the public health department is to be notified for what reason?

A. Contacts need to be traced and screened
B. Follow-up with additional tests is
C. The incidence of tuberculosis is tracked correct response
D. Disease statistics need to be maintained

Active tuberculosis is a reportable disease because persons who had contact with the client must be traced, evaluated for the disease and
possibly treated prophalactally. Statistics are kept; however, that is not the reason for required reporting.

The 75 year-old client has an appointment for a screening scan for osteoporosis. The nurse understands that which finding is a risk factor for
osteoporosis?

A. Drinks two ounces of red wine daily
B. Has used steroids for arthritis for more than two years
C. Reports late menarche and menopause
D. Walks two miles every other day

A dual energy x-ray absorptiometry (DXA) scan is used to screen for osteoporosis. While there are many causes of osteoporosis, the use of
steroids over time increases the risk for osteoporosis. Other risk factors include low bone mass, poor calcium absorption, lack of weight-
bearing exercise, and moderate to high alcohol ingestion. A late menopause would have increased the client's supply of estrogen, which
would help prevent osteoporosis.





33

Which bed position is preferred to use with a client who is on a fall risk prevention protocol in an extended care facility? .

A. lower side rails up with the bed placed facing the doorway and against the wall
B. head slightly elevated, and the bed height in the lowest position
C. bed height in the lowest position, wheels locked, and the bed placed against the wall
D. all four side rails up and the wheels locked with assignment of the bed closest to door

It is no longer advisable to use or have both lower side rails on a bed. Placement of the bed against the wall permits getting out of bed on
only one side. Locking the wheels keeps the bed from sliding. Keeping the bed in the lowest position provides a shorter distance to the
ground if the client chooses to get out of bed. If using side rails, the two top rails and one bottom rail pulled up is acceptable. If all 4 are
pulled up, an order for protective restraints is needed and usually has to be renewed every 48 to 72 hours, along with more frequent and
specific documentation.

Which type of transmission-based precaution is appropriate to use when the nurse is performing postmortem care on a deceased client who
was diagnosed with methicillin resistant staphylococcus aureus (MRSA)?

A. Airborne
B. Droplet
C. Compromised host
D. Contact

The resistant bacteria of MRSA remain alive for up to three days after death. Therefore, contact precautions must still be implemented. Also,
the deceased body needs to be labeled so that the funeral home staff can protect themselves as well. Gown and gloves are required, and
masks if splashes are anticipated.


The nurse is reviewing discharge orders for a client who has been prescribed daily warfarin (Coumadin) for the next six months. Which of these
points should be emphasized during the discharge instructions?

A. Report any changes in the color of your stools and urine
B. Use a nonsteroidal antiinflammatory drug for headache pain
C. Use a soft toothbrush
D. Eliminate all dark green leafy vegetables from your diet

The client should notify the health care provider for color changes to stool or urine; blood will make the stool dark brown or black and the
urine more of a rusty red color. The client should use a soft-bristled toothbrush to avoid irritating the gums. Dark green leafy vegetables
contain vitamin K, which plays a major role in blood clotting; the client should restrict, but not eliminate these foods from the diet. Taking
NSAIDs with warfarin can greatly increase the risk of bleeding; alternative pain medications should be discussed with the health care
provider.

A client who has an infected leg wound from a motorcycle accident, has returned home from the hospital. The client was ordered to keep the
affected leg elevated and is on contact precautions. The client asks a home health nurse Can my friends come to visit me? The appropriate
response from the nurse should be which of these?

A. There are no special requirements for your visitors.
B. Visitors must wear a mask and a gown.
C. Visitors should wash their hands before and after touching you anywhere.
D. Gloves should be worn if visitors touch you.

Gown and gloves are worn by persons coming in contact with the wounds or infected equipment. Visitors should wash their hands before
and after touching the client.

A nurse is assigned to a client with human immunodeficiency virus (HIV) infection. The client also has a secondary herpes simplex 1 (HSV 1)
infection. The nurse should care for the client based on knowledge that which of the following options is the most likely cause of the HSV 1
infection?

A. Emotional stress caused by the chronic diseases
B. Poor oral hygiene often associated with such infections
C. Reaction to the multiple prescribed medications
D. Immunosuppression caused by the hiv infection

Associate HIV with the word "immunosuppression." The person's weakened immune system results in frequent secondary infections, like
herpes simplex virus 1 (HSV 1), candidiasis, cytomegalovirus (CMV) and pneumocystis carinii pneumonia (PCP). Poor oral hygiene would not
cause HSV, nor would medications.





34

A nurse is stuck in the hand by an exposed needle left in a client's bed linen. What immediate action should the nurse take?

A. Immediately wash hands with
B. Notify the supervisor and risk management
C. Look up the policy on needle sticks
D. Contact employee health services

The immediate action of vigorously washing the hands will help remove possible contamination. If the site bleeds it will help cleanse the
contaminate. Then, the sequence of actions would be options "notify", "look up", and "contact."

A health care provider has written an order for a nurse to change the dressings and clean the incision on a postsurgical client. Which process
should a nurse use to clean the surgical incision?

A. Scrub lightly around the incision without touching the incision itself
B. Clean from the top to the bottom of the incision using slow downward strokes
C. Start at the incision and clean in an outward direction from the incision
D. Use a circular motion to clean from the bottom to the top of the incision

In order to prevent the introduction of microorganisms into the surgical incision during cleaning, follow the principle to clean from the area
of least contaminated to most contaminated. Recall tip: clean to dirty.

The nurse is working on a medical-surgical unit. The nurse understands that contact precautions, in addition to standard precautions, should be
implemented for a client with which of these health concerns?

A. Mononucleosis
B. Herpes simplex virus (HSV)
C. Scarlet fever
D. Viral pneumonia

Health care workers should use standard precautions with all clients. Contact precautions are required to protect against either direct or
indirect transmission of an illness. Clients with the viral infection HSV should be placed on contact precautions until the lesions have crusted
over. Mononucleosis and viral pneumonia require only standard precautions. Clients diagnosed with scarlet fever will be placed on droplet
precautions for about 24 hours.


The nurse is teaching a new nurse about techniques used to protect clients. In response to a question, the nurse clarifies that surgical asepsis
differs from medical asepsis in that surgical asepsis requires staff?

A. Wash hands prior to applying a clean dressing
B. Wear gloves when giving parenteral medications
C. Double bag soiled linens removed from the room
D. Maintain sterility during intravenous catheter insertion

All invasive procedures or entry into a bodily orifice or vessel require sterile technique, which is a part of surgical asepsis. Three options are
actions related to medical asepsis.

During the collection of data about the home care for a client with Alzheimer's disease, a priority for a nurse to document is which piece of
information?

A. Any nutritional intake changes
B. The use of over the counter medications
C. The presence of environmental hazards
D. The familys use of respite care

A safe environment for the client with increasing memory loss is a priority focus of home care. Note that the other options would be included
in the documentation with importance being in this order: "environmental hazards", "over the counter medications", "intake changes" and
then "respite care." The question is asking the reader to prioritize.







35

Points to Remember
Safety

Safety is the primary concern when caring for clients.

The goal of the Quality and Education for Safety in Nursing (QSEN) project is to meet the challenge of preparing future nurses
who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the
healthcare systems within which they work.

Falls are the most frequent cause of injury for elderly clients in acute care.

Know the institution's plan for fire drills and evacuation.

Know the emergency phone number for reporting fire.

Know locations of all fire alarms, exits, and extinguishers.

ARCE, RACE, or PRC - find out which one is the procedure suggested by your institution.

Turn off all oxygen supplies in the area of the fire.

In a fire, never use an elevator - use the stairs.

In a fire, close all doors and windows.

Only certain electrical outlets access the emergency generators in a power failure; know which ones they are.

Know your agency's policy for cleaning up a biohazardous spill.

Safety devices, such as restraints, are used only as a last resort.

Use the least restrictive immobilizing device possible for the situation.

Poisons

Never induce vomiting unless instructed to do so by a poison center or health care provider.

If you suspect someone has taken poison, take the poisonous substance with you to the emergency room.

Call the local poison control center to determine appropriate treatment for the specific poison.

Infection

Infection control with the use of standard precautions, transmission precautions and medical and surgical asepsis decreases
the spread of infection.

The major sites for healthcare acquired infections (HAI) are urinary and respiratory tracts, blood, and wounds.

All healthcare acquired (HAI) infections that occur in hospitals must be tracked and recorded by risk management.

Hand washing is the most effective method of preventing infection; friction is the most important variable.

Standard precautions are used for contact with all body fluids (except sweat).

Standard precautions are used for all clients and transmission precautions are used for all clients with transmittable organisms.

Special (N95) respirator masks are necessary to care for clients under airborne precautions who have tuberculosis or other
airborne infectious conditions.

Protective (neutropenic) isolation is used for clients with immunosuppression and low white blood counts.

Disease reporting of "notifiable diseases" is mandated at the state level (through legislation or regulation).

Emergency Preparedness and Response

Triage in a health care setting is different from that in a community or field setting.

Specific hazards associated with disasters include

bioterrorism, e.g., anthrax, plague (bacterial agents): smallpox, viral hemorrhagic fever (viral agents)

chemical emergencies

radiation emergencies

mass casualties

natural disasters and severe weather

recent outbreaks and incidents, e.g., salmonella, E. coli, H1N1 (influenza), melamine (in food products)


36



I. Family Planning

A. Contraception - the voluntary prevention of pregnancy

1. Attitudes toward contraception

a. shaped by religious beliefs and culture

b. influenced by family or social attitudes

c. affected by socioeconomic status


2. Contraception only works if the user

a. accepts the method

b. understands it

c. is motivated to use it correctly


3. Practical nurse's role in family planning

a. reinforce teaching by health care providers on methods of contraception

b. encourage questions

c. provide opportunity for woman (and partner) to discuss feelings about contraception

d. have user explain chosen method ("say back")

e. clarify any misunderstandings





B. Sterilization

1. Surgical procedures intended to render the person infertile

2. Most states prohibit sterilization of minors or mentally incompetent persons

3. Methods

a. male: vasectomy


b. female: removal of ovaries or uterus, tubal ligation



4. Informed consent by a health care provider must include:

a. an explanation of risks, benefits, and alternatives

b. a statement that sterilization is meant to be permanent and irreversible

c. a mandatory 30-day waiting period from the time the consent is signed until surgery may occur

d. wording in person's native language or interpreter must be provided



37

C. Interruption of pregnancy (abortion)

1. Types

a. therapeutic: medical indications; physical or psychiatric reasons

b. elective (voluntary): nonmedical indications

c.
spontaneous (involuntary): initially occurs without medical intervention

i. 1 in 4 pregnancies ends in "miscarriage"


ii.
bleeding and loss of the pregnancy = loss of a hoped for, dreamed of baby

provide information and support women and their families experiencing a perinatal
loss

nurses offer supportive statements, such as "I am sorry for your loss" or "I am sorry
this is happening to you"





2. Methods

a. first trimester: menstrual extraction; dilation and curettage (D&C); suction or vacuum aspiration;
mifepristone (RU-486) and misoprostol (Cytotec) - when 8 weeks pregnant or less

b. second trimester: dilation and evacuation (D&E); saline injection; prostaglandins (vaginal)


3. Possible complications

a. most common: infection; retained products of conception or intrauterine blood clots; continuing
pregnancy; cervical or uterine trauma; and excessive bleeding; disseminated intravascular coagulation
(DIC)

b. D&C - may perforate uterus

c. suction - may invert uterus

d. saline injection - fluid and electrolyte imbalance and cardiac dysrhythmias


4. Legal issues: laws vary regarding abortion in each state of practice


II. Uncomplicated Pregnancy

A. Preconception health - reinforce teaching regarding

1. Lifestyle for optimal health

2.
Balanced diet, including folic acid (which is critical prior to pregnancy and during the first trimester)

a. recommendation: women of childbearing age should have a daily intake of 400 mcg

b. if there is iron deficiency anemia, then the daily dose of folic acid is 1 mg/day


3. Fertility awareness

4. Stress management

5. Avoidance of harmful or teratogenic substances

6. Safe sex

7. Risk awareness - tobacco, alcohol and drug use, lifestyle, home remedies

8. Parenting responsibilities - environmental, social, work, financial


B. Conception

1. Factors influencing conception

a. hormone cycles

b. cervical mucus

c. sperm number and motility

d. ovulation
38


e. general health of both partners


2. Occurs when ovum is penetrated by sperm to result in fertilization

3. Male gamete determines sex of child at fertilization

4. Fertilization typically occurs in outer third of the fallopian tube

5. Single or multiple fertilizations are possible



C. Implantation

1. Usually occurs 7 to 10 days after fertilization

2. Trophoblast secretes enzymes which enable it to burrow into endometrium

3. Trophoblast develops chorionic villi which secrete human chorionic gonadotropin (HCG)

a. hCG inhibits further ovulation by stimulating secretion of estrogen and progesterone

b. nausea, vomiting, "morning sickness" in first trimester is attributed to hCG

c. hCG is detected by lab tests for pregnancy as early as 6 days after conception in blood and 26 days
after conception in urine

i. over-the-counter pregnancy kits give varying results

ii. women should be advised to seek advice from health care provider early in the event of an ectopic
pregnancy (which will result in a positive reading)




D. Fetal development

1. Embryo

a. most critical developmental period

b. developing areas most vulnerable to teratogens

c. the basic structure of all major body organs and main external features are all formed


2. Fetal development

3. Fetal-placental unit

a. oxygenation

b. nutrition

c. hCG levels

d. screening for fetal problems

i. daily count of fetal movements

ii. non stress test

iii. basic ultrasound screening






39


E. Maternal health in pregnancy

1. All physiological systems must adapt in pregnancy

2. Psychologic adaptations

a. maternal emotional responses

b. paternal emotional responses

c. maternal role tasks of pregnancy

d. other factors that affect adaptation

i. support systems - grandparents, siblings, others in household, partners

ii. cultural influences

iii. religious beliefs

iv. developmental needs of family and parents

v. previous experience with pregnancy

vi. health beliefs

vii. economic factors

viii. stress management or coping resources

ix. socioeconomics - housing, transportation, finances, proximity to health care agencies




F. First trimester - data collection

1. Initial history

a. general health

b. family health/partner's health history

c. current health status

d. reproductive summary (gravida, parity)

i. past pregnancies

ii. current pregnancy (subjective findings)


e. social factors - housing, transportation, finances, proximity to health care facility

f. lifestyle, including risky behaviors

g. nutritional intake - foods, beverages, amounts, times eaten

h. cultural and religious practices

i. risk factors of pregnancy



40


2.
Initial physical exam

a. baseline vital signs and weight/height - by PN

b. head-to-toe assessment/general well-being assessment - parts by PN

c. breast examination - by health care provider

d. abdominal examination - by health care provider

e. pelvic exam/pap smear/cultures as indicated by health care provider


g. PN role is to obtain, document, and report client stated findings
f. findings of pregnancy

i. presumptive/possible

subjective findings and objective signs reported by woman, including amenorrhea, fatigue, nausea
and vomiting, breast changes, elevation of basal body temperature, skin changes

findings may be caused by conditions other than pregnancy


ii. probable: changes observed by examiner

Chadwick's sign: increased vaginal vascularity contributes to bluish purple hue of the cervix, vagina
and vulva

Hegar's sign: increased vascularity and softening of uterine isthmus

Goodell's sign: cervical softening caused by stimulation from estrogen and progesterone


iii. positive: signs attributed only to presence of fetus, e.g., fetal heart tones, visualization of fetus,
palpating fetal movements



3. Laboratory tests

a. urinalysis for glucose, protein, blood, and bacteria

b. urine or blood hCG levels

c. complete blood count

d. blood types and Rh factor

e. rubella titer

f. screening for syphilis

g. cervical culture for Chlamydia and gonorrhea

h. hepatitis B surface antigen (HBsAG)

i. hepatitis B surface antibody (HBsAB)

j. Pap smear

k. tuberculin skin test

l. HIV antibody (with client permission)


Blood Types Rh Factor


41


4. Psychological assessment

i. emotional response to pregnancy - ambivalence is a normal expectation during first trimester

ii. family relationships - with partner, parents, other children

iii. support systems

iv. developmental tasks/maternal tasks

v. learning needs


5. Gestational assessment performed by health care provider

i. ultrasound to confirm (dates versus measurements/crown-rump length)

ii. best determined in the first trimester scan (most accurate +/- one week)

iii. confirms viability

iv. identifies multiple gestation


6. Nursing care

i. build rapport

ii. discuss pregnancy confirmation

iii. calculate due date: Naegele's Rule (when first day of last normal period = N, then due date is N plus 7 days,
minus 3 months, plus 1 year)
Example: If June 10, 2012 = first day of last menstrual period
6 10 2012
-3 +7 +1
3 17 2013
Then estimated date of birth (EDB) = March 17, 2013



iv. discuss maternal physical changes

v. review development of embryo and fetus

vi. return scheduling - plan antepartal schedule of visits

vii. review and reinforce - identify learning needs, refer as needed


viii. risk assessment, with recommendations

ix. recommend prenatal multivitamins, as well as folic acid and iron supplements (first trimester may have
tolerance problems due to "morning sickness")

x. review anticipatory guidance

discomforts and remedies

breast tenderness - wear firm, supportive bra

fatigue - frequent periods of rest; balanced diet and iron supplements to prevent
anemia, dry toast for morning sickness

nausea - small, frequent meals including dry crackers and/or toast with tea; avoid
greasy, fried foods

rest and exercise (including Kegel exercise)
42


diet and fluid intake

medications - avoid tobacco, alcohol, other substances

safety - avoid hot tubs, virus exposure, contagious diseases

referrals - to childbirth or other classes

warning signs of problems during pregnancy




7. Role of expectant woman and partner

i. keep appointment schedule (usually monthly visits unless complications arise)

ii. maintain healthy lifestyle

iii. follow diet and take recommended vitamins

iv. cope safely with discomforts

v. discuss sexual feelings and needs

vi. promptly report warning signs in pregnancy



8. Second trimester - routine monthly data collection

a. report of current findings

b. visualize fetal outline

c. palpate fetal outline using Leopold maneuvers (performed by RN and health care provider)

d. fetus

i. activity (date of quickening)

ii. heart rate


e. gestational age assessment - PN to have knowledge of these but not necessarily perform

i. estimated after duration of pregnancy and estimated date of birth (EDB) are determined

ii. determined by

first uterine size estimate

fetal heart first heard

date of quickening

current fundal height

current week of gestation

ultrasound

reliability of dates



f. physical exam by health care provider

i. compare weight, vital signs to baseline

ii. fundal height
uterus becomes an abdominal organ
height of fundus in centimeters is approximately same as number of weeks gestation




g. laboratory tests

i. urinalysis for protein, glucose and ketones

ii. quad screen at 16 to 18 weeks gestation - to test for chromosomal and congenital malformations

human chorionic gonadotropin (hCG)

alpha-fetoprotein (AFP)

estradiol (E2)
43


inhibin A


iii. gestational diabetes screening (24 to 28 weeks gestation)

non-fasting 1 hour (50 g) glucola screening performed; if greater than 140 mg/dL then next
step is 3 hour oral glucose tolerance test (OGTT)

OGTT - diagnostic for GDM when (2) out of the (4) values meet or exceed normal limits


iv. viral screening for HIV, hepatitis, etc., if indicated

v. tuberculin test (can be done in first or second trimester only)

vi. possible amniocentesis - usually scheduled between the 15th and 18th week of pregnancy


h. psychological data collection

i. interest turns to fetus and its well-being

ii. emotional response

iii. start initial birthing classes


i. nursing care

i. discuss birth plan

ii. offer anticipatory guidance related to

adapting employment to motherhood

safety

discomforts and remedies

travel, exercise, nutrition

sexual relations

childbirth education

body image changes

problems presented by woman or partner



j. role of expectant woman and partner

i. keep appointments (monthly)

ii. verbalize concerns

iii. modify lifestyle as needed; eat balanced diet

iv. use safe remedies, such as small, low-fat meals for heartburn

v. discuss emotional responses and birth plan

vi. enroll in and attend childbirth education

vii. develop prenatal attachment, prepare other children for new siblings

viii. report warning signs



9. Third trimester - regular data collection

a. current health status

b. comfort and mobility

c. physical examination

i. comparison to baseline

weight gain pattern

vital signs


ii. fundal growth
44


iii. fetal assessment

kick counts

fetal heart rate

assessing the passenger , including presentation, position and size of fetus


iv. pelvic examination

v. observe for fluid retention (indicating preeclampsia, also called pregnancy-induced hypertension)

vi. test maternal deep tendon reflexes of the extremities



REMEMBER IT
The delivery process is described in these terms:

Fetal Station: the relationship between the presenting part of the baby with the mother's pelvis
Fetal Lie: the relationship between the head to tailbone axis for both the fetus and the mother
Fetal Attitude: the relationship of the fetal body parts to one another
Fetal Presentation: portion of the fetus that enters the pelvic inlet first (cephalic, breech, shoulder)


d. laboratory tests

i. urinalysis for protein, glucose, ketones

ii. antibody screen at 28 weeks gestation if client is Rh-negative

iii. cervical culture for group B streptococcus at 34 to 36 gestation

iv. hemoglobin and hematocrit


e. psychological data collection

i. partner supports in childbirth classes

ii. anticipatory excitation of birth

iii. coping with third trimester physical discomforts


f. nursing care

i. reinforcing information and education presented by RN, physician and/or certified nurse midwife

ii. administer Rh immune globulin to Rh-negative woman (24 to 28 weeks) to prevent erythroblastosis
fetalis

iii. offer anticipatory guidance related to

discomforts and remedies

body mechanics and safety

birth options, feeding choices, plans for newborn care

recognizing onset of labor

reportable warning signs



g. role of expectant woman and partner

i. keep appointments (visits scheduled every two weeks or weekly)

ii. prepare for role change; support each other; discuss sexual needs

iii. use safe remedies for discomforts (such as lateral posture for sleep)

iv. practice relaxation and breathing techniques; perform fetal movement count daily

v. follow dietary and fluid advice

vi. maintain safety in daily activities

vii. meet psychological tasks
45


viii. arrange hospital or home birth, plan newborn feeding; learn newborn needs

ix. recognize signs of labor with proper actions

x. report warning signs



III. Uncomplicated Labor and Birth

A. Processes of labor

1. Factors affecting labor include the five P's: passageway, passenger, powers, position and psyche

a. passageway, i.e., bony pelvis and soft tissues of cervix, pelvic floor, vagina, and introitus

i. inlet

ii. outlet

iii. size

iv. types


b. passenger (fetus)

i. fetal head diameter

ii. position

iii. presentation

iv. station


c. powers

i. primary

uterine contractions
frequency
duration
intensity
rest phase

responsible for effacement and dilation of cervix


ii. secondary (bearing down efforts)

aids in expelling fetus

diaphragm and abdominal muscles



d. position of laboring woman

i. for comfort and safety

ii. fetus has better oxygenation if mother lies on her side

iii. determined by woman's preference

iv. constrained by condition of woman and fetus, environment, and health provider's
confidence in assisting birth in a specific condition or position


e. psychology of birth





2. Early signs of labor versus true labor

3. Duration of stages and phases varies with parity, fetal presentation, position and station

4. Maternal systems adaptations

a. reproductive

i. effacement

vaginal part of cervix progressively shortens and its walls thin
46


effacement is noted as a percentage from 0% (non-effaced) to 100% (fully effaced)


ii. cervical dilation: progressive enlargement of the cervical os from less than 1 centimeter to 10
centimeters (dilation complete at 10 centimeters)


b. cardiovascular

i. as labor progresses, cardiac output increases between contractions

ii. BP rises with contractions and with voluntary bearing down

iii. BP can vary with mother's position, anxiety and pain

iv. pulse rate rises slowly and progressively


c. respiratory

i. mother consumes more oxygen

ii. pain or anxiety can cause hyperventilation

iii. respiratory alkalosis, hypoxia or hypocapnia can occur


d. renal

i. uterus may squeeze ureters and impede urine flow

ii. trace amounts of protein in urine are common


e. gastrointestinal

i. decreased peristalsis and absorption

ii. stomach is slower to empty (gastric emptying is delayed)

iii. nausea and vomiting are common, expected


f. musculoskeletal

i. diaphoresis, fatigue, proteinuria and possible increased temperature cause marked increase in
muscle activity

ii. backache, joint aches

iii. leg cramps


g. endocrine - progestin levels drop and as a result the labor process begins



5. Laboring mother's behavioral changes are affected by

a. stage and phase of labor

b. psychological responses to pain

c. preparation for labor

d. presence of support person

e. coping style

f. culture

g. previous childbirth experience

h. feelings about this pregnancy



6. Fetal adaptations



a. mechanisms of labor (cardinal movements)
i. engagement

ii. descent

iii. flexion
47


iv. internal rotation

v. extension

vi. external rotation

vii. expulsion



b. fetal circulation

i. decreases when uterus contracts

ii. maximum oxygenation during rest phase between contractions

iii. fetal monitoring




B. Labor and Birth (intrapartum)

1. First stage of labor: latent phase - lasts approximately 8 hours for the primipara and 4 to 5 hours for
the multipara

a. data collection

i. history

ii. critical data
due date
onset, frequency and duration of contractions
membranes intact or leaking
gravida and parity


iii. general health history

iv. reproductive history

v. prenatal care

vi. social history

vii. lifestyle - risky behaviors

viii. allergies - medications, foods, environment

ix. family history

x. childbirth preparation

xi. risk factors including

problems identified on antepartal record

preterm labor - effective, ineffective actions

reduced or absent fetal activity - first noticed

prolonged ruptured membranes - the longer the membranes have been ruptured,
the greater the possibility for infection

acute health problems - respiratory, circulatory
48


infection - acute/chronic

bleeding with pain (risk abruptio placenta)

bleeding without pain (risk placenta previa)

substance abuse - type, frequency, history





b. physical examination

i. baseline vital signs compared to antepartal chart

ii. weight (do not accept a verbal weight)

iii. intake and output within last 8 to 24 hours

iv. contractions - mild and irregular, more than 10 minutes apart lasting about 30 seconds


v. Leopold's maneuvers - by RN, certified nurse midwife or physician/health care provider

vi. fetal activity and heart rate

vii. pelvic exam - by health care provider

confirm true labor

identify fetal position, presentation, station

membranes - may be intact or ruptured


viii. head-to-toe assessment - by health care provider



c. laboratory tests - compare values to antepartal records

i. complete blood count (CBC)

ii. blood type and Rh factor

iii. urinalysis for protein



d. psychological data

i. response of client to mild irregular contractions

ii. expectation and knowledge about birth and labor process

iii. learning needs

iv. developmental level

v. support systems available during labor

vi. cultural influences on labor and care

vii. behavioral responses, i.e., excited, talkative

viii. strategies used to cope with pain of labor



e. nursing care: role of PN is assisting the registered nurse (RN), certified midwife and physician

i. promote comfort through ambulation, position changes, shower, whirlpool

ii. reinforce information about learning needs for labor and birth

iii. review birth plan
49


iv. understand information about intermittent/continuous electronic fetal monitoring



f. role of mother and/or support person, which may include a doula

discuss questions and concerns

use appropriate relaxation methods for early labor

adapt the environment to cultural beliefs

mother to empty bladder frequently

report physical changes promptly

participate in the labor process



2. First stage of labor: active phase - lasts approximately 4 hours for the primapara and 2 hours for the
multipara

a. data collection

i. physical

compare current vital signs to baseline; check hourly

monitor contractions: increased intensity, moderate to strong by palpation, more
regular about 3 to 5 minutes apart lasting 45 seconds

observe membranes: intact or ruptured

measure fetal heart rate every 15 to 30 minutes (or continuously)



ii. psychological: emotional response to increasing frequency, duration and intensity of
contractions


iii. behavioral changes
inwardly-focused
limits interactions with others
absorbed in the work of labor



b. nursing care: role of PN is to assist the RN, certified nurse midwife and physician/health care
provider

i. encourage ambulation or position changes until membranes rupture

ii. promote drug-free comfort measures, e.g., effleurage, massage, hydrotherapy, relaxation and
paced breathing, labor support

iii. parenteral analgesia (meperidine [Demerol], fentanyl [Sublimaze], butorphanol [Stadol],
nalbuphine [Nubain]) - birth should occur less than 1 hour or more than 4 hours after
administration of opioids (to decrease chance of CNS depression in newborn)

iv. support laboring client's decision for regional anesthesia (pudendal block, epidural block, spinal
block or paracervical nerve block)
50




c. role of mother and/or support person

i. continue effective breathing and relaxation techniques

ii. alter mother's position for comfort

iii. maintain bed rest (lateral position preferred) after membranes rupture; lateral position
promotes optimal uteroplacental and renal blood flow and increases oxygen saturation

iv. communicate questions and concerns

v. report physical changes promptly




3. First stage of labor: transitional phase - approximately 10 to 15 minutes in length

a.
data collection

i. physical

health care provider performs pelvic exam

dilation 8 to 10 centimeters

membranes ruptured; check character of amniotic fluid

fetal descent and station

monitor vital signs every 15 to 30 minutes, compare with baseline

monitor contractions: strong palpation, more painful, every 1.5 to 2 minutes, lasting 60
to 90 seconds

measure fetal heart rate every 15 minutes

findings of approaching delivery:
perineum will bulge with contractions
nausea and vomiting
trembling
strong urge to push and a feeling of need to defecate
diaphoresis
increasing bloody show



ii. psychological and emotional responses

emotional response to increased pressure and contraction intensity

irritability, tension, loss of control

amnesia between contractions

feelings of loss of control;


iii. behavioral responses

loss of control

inability to follow directions during contractions

irritability and tension



b.
nursing care: role of PN is to assist the RN, certified nurse midwife and physician/health care
51

provider

i. maintain safety, e.g., side rails up and in lateral position

ii. follow standard precautions

iii. monitor for urge to bear down - suggest open-glottal breathing with contractions to avoid a
bearing-down effort

iv. minimize hyperventilation

v. promote rest and relaxation techniques between contractions



c. role of mother and/or support person:

i. communicate physical changes promptly

ii. continue effective breathing techniques

iii. maintain lateral position as much as possible

iv. participate in the labor process




4. Second stage of labor: complete dilation through birth - approximately 30 to 50 minutes for the
primipara and 20 minutes for the multipara

a. data collection and observation

i. physical

fetal crowning


increased bloody show

mother pushes involuntarily - open glottis pushing is recommended

fetal heart rate response to contractions and pushing (expected decrease), check every
5 to 15 minutes

strong contractions to palpation every 2 to 3 minutes lasting 60 to 90 seconds



ii. psychological

emotional response to perineal pressure

relief at labor's end


iii. behavioral responses

irritable, apprehensive in early second stage

excited

responsive

focused on newborn
52


more in control after birth



b. nursing care: role of PN is to assist the RN, certified nurse midwife and physician/health care
provider

i. pushing can either follow the mother's spontaneous urge or be directed by health care provider
(physician or certified nurse midwife)

ii. position mother to aid delivery

iii. assist with delivery of the newborn

clear newborn airway - first priority; newborns are nasal breathers

dry newborn skin - wrap in warm blanket to maintain warmth

place newborn with mother as appropriate - usually over mother's chest or upper
abdomen

inform the couple of the newborn's gender and condition

reinforce any information on the repair of episiotomy or lacerations


iv. monitor uterine contraction; fundus should be firm post-delivery

v. follow Standard Precautions


c. role of mother and/or support person

i. breathe effectively

ii. push with and relax after contractions - contractions occur every 2 to 3 minutes and last 60 to 90
seconds

iii. follow directions to stop pushing

iv. hold and bond with newborn




5. Third stage of labor: placental separation and expulsion - lasts approximately 5 to 30 minutes

a. data collection

i. physical

sudden trickle or gush of blood from vaginal opening

umbilical cord lengthens

uterine contractions continue


ii. psychological

emotional response to newborn's birth

concern for condition of newborn


iii. behavioral responses

continues to focus on newborn

may ask support person to assist in needs



b. nursing care: role of PN is to assist the RN, certified nurse midwife and physician/health care
provider

i. monitor maternal vital signs

ii. monitor effects of oxytocic drugs

iii. document promptly and accurately


c. role of mother and/or support person

i. refrain from pushing during placental stage
53



ii. hold and talk to newborn

iii. initiate lactation if planned




6. Fourth stage of labor: maternal mother (1 to 2 hours after birth)

a. data collection

i. physical

monitor vital signs (every 15 minutes) for comparison to intrapartal data

observe for:

uterine contraction, reflected in firm fundus

vaginal bleeding: lochia, number and percent saturation of pads

trembling or chills - expected and normal

bladder distention - relieve quickly if present

fundal height - midline and above umbilicus is normal

venous thrombosis

observe episiotomy or repaired lacerations


ii. psychological

emotional response to birth

early interaction with newborn

sense of peace and excitement


iii. behavioral response

family interaction is increased; talkative

notification of others about newborn

may report varying degrees of fatigue or simply sleep

may report uterine cramp-like discomfort

attachment process begins with the newborn



b. nursing care: role of PN is assisting the registered nurse (RN), certified midwife and physician

i. assist to void, monitor urinary output, avoid bladder distension

ii. massage the fundus if soft or flabby

iii. monitor bleeding and clots

iv. inspect the perineum for bruises, swelling

v. help with hygiene, perineal care

vi. monitor oxytocic drugs or IV fluids

vii. offer food and fluids

viii. help with ambulation

ix. monitor recovery from regional anesthesia
54


x. administer pain medication as prescribed

xi. facilitate first breast feeding if indicated

xii. administer rubella vaccination or Rh immune globulin (RhoGAM) if indicated


c. role of mother and/or support person

i. verbalize questions and concerns

ii. report physical changes promptly

iii. ask for pain relief as necessary

iv. bond, hold, talk with the newborn




IV. Normal Postpartum

A. Maternal adaptations: birth (before discharge from hospital) to 6 weeks (puerperium)

1. Systems adaptations

a. reproductive

i. uterine contraction with fundus moving downward

ii. lochia with minimal clots (rubra)

iii. perineal healing - approximation of any wound edges


b. cardiovascular - vital signs return to base line with decrease circulating blood volume

c. respiratory - less strain and dyspnea

d. renal - improved blood flow

e. gastrointestinal - less indigestion

f. integumentary - pigmentation changes fade

g. endocrine

i. estrogen - drops at birth; lowest one week postpartum

ii. progesterone - drops at birth; undetectable 72 hours postpartum

iii. oxytocin - stimulates uterine contraction and milk letdown reflex

iv. prolactin - stimulates milk production when nipples stimulated



2. Psychological adaptations

a. emotional responses

i. taking-in phase 24 to 48 hours

ii. taking-hold phase 48 to 72 hours


b. interaction with newborn

c. family dynamics and bonding

d. role change in first 24 hours





3. Initial postpartum history - assist RN collect data

a. labor and birth information

b. present findings

c. health history

d. reproductive summary

e. social factors

f. cultural and religious practices
55


g. lifestyle

h. diet history

i. risk factors

i. identified in pregnancy

ii. related to labor or birth

iii. adolescent parenting

iv. substance abuse

v. nutritional alterations

vi. family relationships

vii. economic strain such as poverty, single parenthood

viii. disability

ix. transportation and distance to health care services



4. Laboratory data

a. hemoglobin and hematocrit

b. rubella titer

c. blood type and Rh factor

d. cultures if indicated



5. Data collection

a. physical examination - B.U.B.B.L.E. assessment

i. monitor vital signs and compare to intrapartal data

ii. assist with head-to-toe assessment

iii. observe examination of fundal height

at umbilicus (size and consistency of firm grapefruit) after birth

1 finger above the level of the umbilicus on day 1 (first 12 hours)

nonpalpable and behind symphysis pubis by day 10


iv. observe lochia

i. rubra (red) on days 1 to 3

ii. serosa (pink to brown) on days 3 to 7

iii. alba (creamy white) on or around day 10


v. observe perineum and repaired episiotomy or lacerations

vi. observe legs for edema, Homan's sign

vii. check for common problems

i. breast engorgement; sore nipples

ii. afterpains

iii. bladder distention; altered bowel function; hemorrhoids

iv. swelling and discomfort from episiotomy



b. psychological

a. initial emotional response to labor/birth

b. response to pain

c. early interactions with newborn
56


d. family support and interactions

e. cultural and/or religious practices



REMEMBER IT
Postpartum assessment: BUBBLE

B=Breasts
U=Uterus
B=Bowels
B=Bladder
L=Lochia
E=Episiotomy/C-section incision

E---can also stand for maternal emotions about the
outcomes of the birth and the new baby



6. Nursing care: role of PN is assisting RN as a provider of care

a. maintain a caring relationship

b. reinforce with mother the physical changes and expected findings

c. respond to questions and concerns

d. promote physical comfort and rest

e. offer analgesics for pain relief

f. reinforce information of specifics for fundal massage

g. encourage frequent emptying of bladder

h. reinforce perineal hygiene and care

i. encourage ambulation

j. help with initial lactation if indicated

k. offer food and fluids

l. identify and report problems promptly

m. document data and care


7. Role of mother and/or support person

a. express questions and concerns

b. hold and interact with the newborn and each other

c. participate with rooming-in if indicated

d. report physical or emotional changes promptly



B. Postpartum discharge planning and reinforcement of initial teaching (24 to 48 hours)

1. Data collection based on adaptations

a. self-assessment by mother

b. reportable findings



2. Nursing care: role of PN is assisting the RN as a provider of care

a. report mother's learning needs

b. anticipatory guidance: self care
57


i. episiotomy/perineal care

ii. vaginal discharge

iii. balanced diet for health and lactation

iv. activity and rest

v. breast and nipple care

vi. resources for questions and concerns

vii. family involvement at home

viii. return of menses

ix. sexual needs

x. family planning options

xi. reportable conditions (mother and baby)

xii. adjustment to parenthood



c. anticipatory guidance: lactation

i. early and frequent nursing

ii. positions for comfort

iii. pumping and storing milk


d. administer prophylaxis for Rh negative mother

e. reinforce for mother to keep using multivitamins and iron for at least 6 to 8 weeks postpartum


3. role of mother and/or family

a. seek answers to questions and concerns

b. report physical or emotional problems promptly

c. use resources as needed

d. increase activities gradually

e. integrate newborn into family




C. Follow-up home visit (2 to 4 days after discharge)

1. Data collection

a. self-assessment by mother

b. physical

i. vital signs

temperature greater than 100.4 F (38 C) in the first 24 hours after delivery may indicate
dehydration

temperature greater than 100.4 F (38 C) hours apart after the first 24 hours after delivery
for 2 consecutive days may indicate a postpartum infection


ii. breasts filling - engorgement

iii. nipples intact

iv. uterine contraction and descent- fundus should be firm

v. lochia serosa

vi. perineal healing

vii. lower extremities - edema diminishing
58


viii. comfort

ix. elimination - bowel movement and voiding difficulties

x. fatigue/energy level/sleep pattern


c. psychological and social

i. emotional responses and coping; evaluate depression or "baby blues" days

ii. taking- hold phase

iii. parent-newborn interaction

iv. family dynamics

v. financial concerns

vi. health care follow-up concerns

vii. support network




2. Nursing care: role of PN is to assist the RN as a provider of care

a. continue caring relationship

b. respond to questions and concerns

c. show interest in newborn and siblings

d. evaluate safety in newborn care

e. reinforce nurturing behaviors

f. identify problems or risky behaviors (mother and baby) - report promptly

g. remind mother of follow-up visit date


3. Role of mother and family

a. verbalize questions and concerns

b. report physical changes/problems promptly

c. demonstrate safe newborn care



D. Follow-up clinic or office visit (3 to 6 weeks postpartum)

1. Data collection

a. involution of uterus is complete

b. letting-go behaviors expected

c. lactation established if selected this option

d. check vital signs and weight


2. Nursing care: role of PN is to assist the RN as a provider of care

a. review health maintenance and promotion teaching

b. reinforce teaching of self and newborn care

c. respond to questions and concerns

d. refer to resources

i. supplement teaching with tools appropriate to level of education

ii. refer needs related to fertility awareness and birth control



3. Role of mother and/or family

a. incorporate newborn into the family unit

b. follow suggestions for a healthy lifestyle to eliminate risky behaviors

c. report reproductive health problems promptly
59


d. schedule regular health care visits for self and newborn

e. demonstrate safe self care and newborn care




V. Normal Newborn

A. Immediate care - birth to 2 hours after delivery

1. Systems adaptations

a. fetal to newborn circulation

b. approach newborn care with the focus that all systems are immature initially

c. reflexes are present to protect infant until systems mature

d. reflexes disappear in a cephalocaudal (head-to-toe) manner


2. Data collection

a. respirations - determine respiratory effort, rate and pattern

b. Apgar Score


c. appearance


d. body temperature - risk of cold stress

e. umbilical cord - clamped without bleeding/drainage


3. Management actions by provider of care - PN may assist as directed

a. maintaining open airway

b. maintain body heat- dry the skin, wrap, put cap on baby or place in radiant warmer

c. ensuring safety

d. clamping the cord

e. take blood samples

f. identify mother and newborn

g. instilling prophylactic eye treatment

h. support and foster parent contact

i. document assessments and care





60


B. Newborn care - birth until discharge

1. Data collection

a. history

i. antepartal data

ii. labor and birth information

iii. risk factors - before, during, and after birth


b. physical examination of newborn

i. axillary temperature (97.9 - 99.7 F [36.6 - 37.7 C])

ii. apical heart rate (110 to 160 beats per minute; 110 beats per minute at rest or sleep)

iii. blood pressure (50 to 75 mm Hg)

iv. respirations (30 to 60 per minute)

v. pain assessment - Neonatal Pain and Sedation Scale (NPASS)

vi. weight

vii. measurements of length and head, chest and abdominal circumference

viii. head-to-toe assessment

ix. reflexes

x. growth and gestational age assessment (using Ballard Maturational Assessment of
Gestational Age tool)


c. normal characteristics and common variations

i. caput succedaneum

ii. cephalohematoma

iii. molding


d. sensory responses

i. startle reflex

ii. fencing reflex

iii. extrusion reflex


e. behavioral responses - sleep state, quiet but alert state, crying state

f. elimination - first meconium stool within 24 hours, then continues to occur for up to 72 hours

g. laboratory data

i. complete blood count

hemoglobin should be between 14.5 - 22 g/dL

hematocrit should be between 44 - 72%


ii. blood type and Rh factor

iii. direct Coombs' antibody test (infant)

iv. glucose level (40 - 60 mg/dL iif newborn is symptomatic of IgA)

v. urinalysis for urine culture if indicated

vi. screening as indicated, e.g., sickle cell screening, Tay Sachs disease

vii. bilirubin levels 0-1 mg/dL

appearance of jaundice during the first day of life indicates a pathological process

evaluation is indicated with hyperbilirubinemia (15 mg/dL or greater for term infant, 10
mg/dL or greater for preterm infant)


viii. thyroid screen
61


ix. hearing screening






2. nursing care: role of PN is assisting the RN as a provider of care

a. report any vital signs outside normal range

b. keep the baby warm

c. clear the baby's airway as needed, especially nares, since newborns are obligate nasal breathers

d. position baby (on back or side)

e. document findings

f. share findings with parents as appropriate

g. report problems to RN

h. administer vitamin K and hepatitis B vaccine as prescribed

i. observe behavioral and neurological changes

j. note first void and stool within 24 hours

k. assist with feedings

l. screening for phenylketonuria (PKU) after initial 24 to 48 hours and after adequate protein (milk)
intake (test is invalid with inadequate protein intake)

m. routine cord care with every diaper change




3. reinforcing teaching of parents

a. nurturing behaviors

b. newborn care

i. safety

use of car seat

fall prevention while carrying infant

suffocation prevention

sleep position on back


ii. feedings

iii. hygiene

iv. cord care - keep cord clean and dry; usually falls off by postpartum day 10

v. circumcision care


c. elimination patterns

d. mother's initial weight loss - 12 to 15 pounds after delivery; additional five pounds within the first
week and ten pounds in the next six weeks
62


e. newborn's weight loss - up to ten percent loss of initial weight within the first ten days of life is
expected

f. newborn stimulation

g. positioning and holding during and after feedings


4. role: mother and family should

a. express questions and concerns

b. bond and attach to newborn

c. recognize newborn as a separate person

i. call baby by name

ii. note unique things about baby


d. describe and implement cultural or religious beliefs

e. demonstrate caregiving skills

f. introduce siblings to newborn


C. Discharge instructions - reinforce information provided by RN and health care team

1. Expected findings discussed by provider of care

2. Follow-up laboratory tests

i. phenylketonuria (PKU)

ii. bilirubin test


3. Reportable signs

a. fever - any elevation is a concern for infection or dehydration

b. vomiting

i. frequency, color, force it projectile?

ii. how it differs from normal 'spitting up'


c. stool changes; diarrhea

i. for frequency, color, smell

ii. lack of stool or ribbon-like or mucoid


d. behavioral changes - irritability or inability to awaken

e. feeding problems - retention or intake; new versus present at birth

f. skin

i. rash - newly developed versus present from birth

ii. jaundice - expected from 48 to 72 hours after birth



4. Resources

a. newborn nursery staff, well baby clinic staff

b. pediatrician

c. infant CPR courses

d. family members

e. support groups, such as La Leche League, church, or other local

f. telephone numbers, such as Poison Control Center, clinic, abuse hot lines






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D. Follow-up home visit

1. Mother's adaptation (compare to hospital records)

2. Physical findings of newborn (compare to hospital records)

a. vital signs

b. weight

c. head-to-toe examination

d. reflexes

e. behavior

f. sensory responses

g. elimination patterns

h. contentment and sleep

i. feeding

j. hygiene


3. Home environment

4. Psychological and social findings

a. interaction between family and newborn

b. emotional responses of family to newborn and each other

c. responses to newborn cues



5. Nursing care - role of PN is assisting the RN as a provider of care

a. establish caring relationship

b. display interest in the newborn

c. encourage questions

d. respond to concerns and questions

e. share data collection findings with family

f. demonstrate care giving skills as needed

g. review newborn feeding needs, patterns, common problems

h. reinforce parenting behaviors

i. remind parents about well-baby schedule and immunizations

j. review postpartum reportable findings for mother

k. review reportable signs for infant


6. Role of family

a. express questions and concerns

b. incorporate newborn into family

c. provide safe, nurturing care

d. recognize reportable signs

e. plan/implement well baby follow-up care








64

Fetal movement count during the third trimester should be at least 5 movements per day. True False

The fourth stage of labor is placental separation and expulsion. True False

When the fetus is active, its heart rate should increase by about 15 beats per minute. True False

Most pregnancy tests measure the level of estrogen in the woman's blood. True False

One of the first signs of pregnancy is Chadwick's sign, which is the softening of the cervix. True False

The nurse will give Rh immune globulin (RhoGAM) to a Rh negative women after a miscarriage (spontaneous abortion). True False

Chloasma is the first milk the new mother produces. True False

The fetus receives more oxygenated blood when the laboring mother lies on her side. True False

A gravida 3, para 3 woman should be rushed to the delivery room once engagement has occurred. True False

An APGAR score of 2 for appearance means the newborn's fingers and toes are bluish in color. True False

A baby tapped briskly on the bridge of the nose will close both eyes. True False

About 5 days after delivery, lochia is pink-brown in color. True False

Common issues on the first postpartum day include after pains and episiotomy discomfort and swelling. True False

A woman cannot become pregnant when she is breastfeeding. True False

The safest time for the fetus is to give the mother analgesia when her cervix is dilated 8 to 10 centimeters. True False


VI. Growth and Development: Infant Through Older Adult

A. Growth and development - an overview

1. Patterns of growth and development

a. cephalocaudal development: head to feet, occurs first two years of life

b. proximodistal development: near to far, or central to peripheral

c. differentiation: from simple operations to more complex activities and functions, i.e.,
concrete to abstract thinking, gross to fine motor skills


2. Growth measures

a. height

b. weight

c. frontal-occipital circumference


3. Theories of development

a. Piaget's theory of cognitive development

b. Erikson's theory of psychosocial development

c. Kohlberg's theory of moral development


d. language development


4. Assessment of growth and development: Denver II developmental screening test

a. role of PN is to assist in process

b. screens children from birth through six years

c. assesses four skills

i. personal-social

ii. fine motor adaptive

iii. language
65


iv. gross motor






B. Infancy (up to 12 months)

1. Growth

a. period of very rapid growth

b. doubles birth weight at 6 months, triples at 1 year

c. by 1 year birth length has increased by almost 50% (occurs mainly in trunk)

d. by 1 year head circumference equals chest circumference

e. posterior fontanel closes at 6 to 8 weeks of age

f. anterior fontanel closes at 12 to 18 months of age

g. tooth eruption begins at 5 to 6 months

h. 6 to 8 teeth by one year



2. Motor development

a. sits without support at 6 to 8 months of age

b. rolls completely over at 6 months

c. vocalization at 8 months of age

d. pincer grasp at 9 to 11 months of age

e. crawling or creeping 6 to 7 months

f. stands alone 10 to 12 months

g. cruises (walks holding on) 10 to 12 months

h. walks independently at 12 to 15 months of age

i. begin feeding self at 11 months


3. Cognitive: Piaget's sensorimotor period

4.
Psychological: Erikson's developmental task of trust vs. mistrust

a. lays foundation for other developmental tasks

b. stranger anxiety/separation anxiety begin


5. Language development

a. cries, smiles, coos by 3 months

b. produces chained syllables by 6 months

c. says two or more words by 1 year

d. understands meaning of "no" by 11 months

e. can follow simple directions at 1 year

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6. Play is solitary

a. initially with rattles or mobiles

b. game playing such as peek-a-boo and pat-a-cake by ten months


7. Common fears

a. from birth to 3 months - fears sudden movements, loud noises, and loss of physical support

b. from 4 to 12 months - fears strangers, strange objects, heights, and anticipation of previous
uncomfortable situations


8. Suggested toys

a. birth to 6 months - mobiles, unbreakable mirrors, music boxes, rattles

b. 6 to 12 months - blocks, nesting boxes or cups, simple take apart toys, large ball, large puzzles,
jack in the box, floating toys, teething toys, activity box, push-pull toys





C. Toddlerhood (1 to 3 years)

1. Growth

a. gains 1.8 to 2.7 kilograms (4 to 6 pounds) per year

b. grows 7.5 centimeters (3 inches) per year (occurs mainly in legs)

c. lordosis and potbelly are characteristic

d. head circumference usually equal to chest circumference by one-two years of age

e. primary dentition complete by 30 months



2. Motor development

a. walking improves

b. runs

c. begins to climb and walk up and down stairs with help

d. builds tower of six blocks by age 2 years and eight blocks by age 3 years

e. by end of toddlerhood can copy a circle on paper

f. dresses self in simple clothing

g. begin potty training - bladder control is often more difficult to attain than bowel control


3. Cognitive: Piaget's period of preoperational thought

4. Psychological: Erikson's developmental task of autonomy vs shame and doubt

a. separation anxiety peaks during toddlerhood

b. toilet training begins

c. discipline becomes necessary

d. ritualistic: need to maintain sameness and reliability

e. negativism: persistent negative response to requests - "no"

f. frustration may result in temper tantrums or regression

g. imitation of parents / caretakers - walks in parents' shoes

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5. Moral development: Kohlberg's preconventional or premoral level

6. Language development

a. vocabulary grows from four to six words at 15 months to over 300 words by age 2

b. "no!", "me", and "mine!" are key words

c. ability to understand speech is much greater than the number of words the child can say

d. uses multi-word sentences by age two


7. Play is parallel - child plays next to others with no interaction with others

8. Common fears include the dark, being alone, separation from parents, some animals, and loud
machines

9. Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls, blocks, puzzles, simple
tape recorder, housekeeping toys, puppets, cloth picture books, large beads to string, toy
telephone, water toys, sand box, play dough or clay, chalk and chalkboard



D. Preschool age (3 to 6 years)

1. Growth

a. average weight gain about 2 to 3 kilograms (5 pounds) per year

b. height: increase of 6.75 to 7.5 centimeters (2.5 to 3 inches) per year (occurs in legs)



2. Motor development

a. very active

b. can hop on one foot

c. pedals tricycle

d. refinement of previous learned motor skills - gross and fine motor

e. draws a person with one body part/year

f. consistent day and night dryness (bowel and bladder control) should by achieved by 5 years of
age or further evaluation is warranted


3. Cognitive: Piaget's period of preoperational thought

4. Psychological: Erikson's developmental task of initiative vs. guilt

a. sexual curiosity

b. imitation of adult roles or make believe characters with dress-up games

c. magical thinking

d. makes up rules when playing games


5. Moral development - Kohlberg

a. 2 to 4 years: punishment and obedience

b. 4 to 7 years: naive instrumental orientation


6. Language development

a. by age 5, has vocabulary of 2,100 words
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b. knows name and address

c. asks questions constantly

d. uses fantasy in stories

e. "Why?" is favorite word


7. Preschool play is associative and cooperative - child interacts with others

a. dress-up in costumes or uses items to make a costume

b. fantasy play

c. imaginary playmates

d. little interest in following rules when playing games


8. Common fears of preschool child include body mutilation, animals, supernatural beings, monsters,
ghosts, unfamiliar routines, separation from trusted adults, and abandonment, annihilation

9. Suggested toys: tricycle, gym and sports equipment, sandboxes, blocks, books, puzzles, computer
games, dress-up clothes, blunt scissors, picture games, construction sets, musical instruments, cash
registers, simple carpentry tools


E. School age (6 to 12 years)

1. Growth

a. growth is slow and steady until growth spurt of adolescence

b. weight gain an average of 2 to 3 kilograms (4.5 to 6.5 pounds) per year

c. brain fully developed in size

d. height: average growth of 5 centimeters (2 inches) per year

e. loss of deciduous teeth and acquisition of permanent teeth in early school age years, usually by 8
years of age

f. child is usually lean, but some may become overweight depending on eating habits and activity

g. eyesight maximally developed by 8 years of age; common to establish a need for glasses in the
mid-school-age years



2. Motor development

a. full of energy

b. rides bicycle and plays active games

c. most enjoy physical activity

d. writes in cursive

e. more awkward as adolescence approaches

3. Cognitive: Piaget's period of concrete operations

4. Psychological: Erikson's developmental task of industry vs. inferiority

a. develops a sense of accomplishment through completion of tasks

b. joins clubs
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c. has same-sex friends

d. peer approval is strong motivating power



5. Moral development - Kohlberg

a. develops a moral code and social rules

b. views rules as necessary principles of life, not just as dictates from authority by age 12

c. can judge flexibly and decide if rules apply to a given situation by age 12


6. Language development

a. vocabulary of approximately 14,000 words

b. reading skills improve dramatically



7. Play is cooperative with a focus and concern about the rules of a game

a. sports and games with rules

b. fantasy play in early school-age years

c. clubs

d. hero worship

e. cheating may begin in later school-age years



8. Suggested toys and activities: board or computer games, books, initiated collections, scrapbooks,
sewing, cooking, carpentry, gardening, painting



F. Adolescence (age 13 to 19)

1. Growth

a. boys increase in muscle mass; girls increase in fat deposits

b. may experience growth spurts; most aggressive growth period in lifetime

c. Tanner Stages and pubertal changes - development of primary and secondary sex
characteristics

d. dentition is complete - all permanent teeth


2. Motor development

a. increase in gross and fine motor abilities

b. increase in risk-taking behaviors


3. Cognitive: Piaget's period of preoperational thought


4. Psychological: Erikson's developmental task of identity vs. role confusion

a. begins to develop a sense of "I"

b. peers become most significant group

c. separates from parents



5. Moral development - Kohlberg

a. healthy adolescents consolidate moral development

b. understand that rules are not absolutes, but cooperative agreements that can be changed to fit
the situation

c. judge themselves by internalized ideals
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d. group values become less significant in later adolescence

e. sense of right and wrong develops from applying values to daily decisions

6. Language development - increases as cognitive skills increase


7. Play and recreation

a. centers around social interactions: expanding peer life

b. sporting and cultural activities

c. small group activities




G. Early adulthood (post-adolescence through age 40)

1. Physical development

a. period of optimal physical function

b. typically free of acute or chronic illness

c. effects of aging begin around age 20

d. musculoskeletal system

i. growth completed about age 25

ii. well-developed and coordinated


e. cardiovascular system

i. strength peaks about age 30

ii. men more likely to have higher cholesterol levels

iii. blood pressure changes noted by race, sex and weight


f. gastrointestinal system

i. after age 30, digestive juices decrease

ii. wisdom teeth emerge

iii. weight may change as a result of environment, diet and exercise


g. reproductive system

i. fully mature in 20s

ii. optimal reproductive time between 20 and 30 years of age for women




2. Psychosocial development

a. Erikson's developmental task of intimacy vs. isolation

b. become more self-directive in the twenties

c. may question previous life choices

d. adult roles emerge, i.e., work, intimacy, parenting, social purpose

e. developmental and situational stressors are great


3. Cognitive development

a. development of brain cells peaks during twenties

b. continue to develop a higher level of cognitive functioning

c. can think abstractly

d. now can perceive many different points of view

e. more realistic and objective

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4. Health risks

a. emotional stress - peer pressure to engage in risky behaviors

b. injuries - leading cause of death

i. motor vehicle accidents

ii. firearm-related homicides

iii. suicides

iv. intimate partner violence


c. sexually transmitted infections - multiple sex partners

d. substance abuse - tobacco, alcohol, illegal drugs

e. nutrition



5. Psychosocial development

a. Erikson's developmental task of intimacy vs. isolation

b. become more self-directive in the twenties

c. may question previous life choices

d. adult roles emerge, i.e., work, intimacy, parenting, social purpose

e. developmental and situational stressors are great


6. Cognitive development

a. development of brain cells peaks during twenties

b. continue to develop a higher level of cognitive functioning

c. can think abstractly

d. now can perceive many different points of view

e. more realistic and objective


7. Health risks

a. emotional stress - peer pressure to engage in risky behaviors

b. injuries - leading cause of death

i. motor vehicle accidents

ii. firearm-related homicides

iii. suicides

iv. intimate partner violence


c. sexually transmitted infections - multiple sex partners

d. substance abuse - tobacco, alcohol, illegal drugs

e. nutrition


8. Health promotion

a. routine health tests and screenings

b. safety

c. nutrition, exercise, elimination

d. social interactions, goal setting



H. Middle adulthood (40 to 65 years)

1. Physical development

a. signs of normal aging begin to show; pattern of aging is unique in each person but with similar
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elements

b. subtle but gradual decline in most body systems

c. integumentary system

i. redistribution of pigment in hands ("age spots")

ii. graying of hair

iii. progressive decrease in skin turgor


d. respiratory system

i. anteroposterior diameter of chest increases

ii. respiratory rate 16 to 20 breaths per minute

iii. normal breath sounds


e. cardiovascular system

i. normal heart sounds

ii. pulse 60 to 100 beats per minute

iii. blood pressure:

systolic 95 to 135 mm Hg

diastolic 60 to 85 mm Hg



f. sensory

i. visual acuity decreases

ii. presbyopia




g. reproductive system and sexuality - sexual interest in later life reflects life-long patterns

i. female

ovaries gradually atrophy causing a drop in estrogen

results in gradual changes in menstrual cycle and flow

perimenopause: time period prior to menopause when periods become variable;
ranges from one to ten years

menopause: no menstrual periods for 12 months

diminished estrogen production results in: hot flashes, headache, palpitations, mood
swings, and vaginal dryness and atrophy resulting in itching, burning, and/or painful
intercourse, insomnia, frequent urinary tract infections and urinary urgency

actions to minimize findings: balanced diet, exercise (at least 30 minutes per day),
estrogen replacement therapy and complementary and alternative therapies (CAT)
including herbs, vitamin E

may gain a new sexual interest

complications

osteoporosis

cystocele or rectocele
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uterine prolapse

heart disease risk




ii. male

libido remains consistent

sperm count reduced

slower to achieve erection and ejaculation

prostatic enlargement common (benign)

andropause - decreased androgen levels with no physical findings; symptoms include
insomnia, fatigue, and circulatory problems



2. Cognitive

a. peak of intellectual development

b. no longer views self as invincible

c. chooses conflicts and battles to fight or get involved in


3. Psychosocial development

a. Erikson's developmental task of generativity vs. stagnation

b. midlife transition: time for assessing one's life structure

c. community involvement peaks

d. role reversal takes place with parents

e. awareness of one's own mortality


4. Threats to health and safety - depends on lifestyle choices and aging process

I. Older adult (over age 60)

1. Biological theories of aging - no two individuals age identically

a. Cross-Linking theory (also called the Glycosylation Theory of Aging)

b. immunological theory

c. free radical theory

d. stress theory

e. error theory (genetic mutations)

f. biological clock or genetic programming


2. Psychosocial theories of aging

a. disengagement theory

b. activity theory

c. continuity theory


3. Developmental tasks of elderly adult
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a. Erikson's developmental task of ego integrity vs. despair

b. accept self as an aging person; coping with physiological changes

c. adjust to decreasing physical abilities

d. adjust to retirement and with potential reduced income

e. adjust to death of spouse; redefining relationships with children

f. maintain satisfactory living arrangements, and quality of life



4. Physical systems

a. integumentary system

i. dry, thin, scaly skin

ii. decreased perspiration

iii. decreased elasticity and subcutaneous layer

iv. senile purpura

v. spotty pigmentation

vi. slower healing


b. respiratory system

i. reduced vital capacity

ii. increased airway resistance

iii. kyphosis may cramp lung expansion

iv. decreased lung expansion


c. cardiovascular system

i. decreased cardiac output and reserve

ii. baseline systolic blood pressure may rise

iii. peripheral pulses may be weaker


d. gastrointestinal system

i. abdominal muscle tone decreases

ii. less saliva; decreased thirst perception

iii. less gastric motility, less gastric juices, with less absorption - potential for malnutrition and
indigestion

iv. food appeals less secondary to decreases taste perception; slower gastric emptying

v. decreased peristalsis - constipation common

vi. decreased hepatic clearance of drugs and other substances



e. urinary system

i. decreased renal filtration

ii. decreased bladder capacity

iii. female

urgency

stress incontinence

menopause


iv. male

urinary frequency
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benign prostatic hypertrophy contributes to urine retention

andropause


v. sexual function depends on general health, psychological health, types of medication and a partner


f. musculoskeletal system

i. reduced muscle mass and strength

ii. decreased joint mobility and decreased range of motion

iii. decreased endurance

iv. postmenopausal women - bone demineralization


g. nervous system

i. decreased rate of voluntary or automatic reflexes, decreased nerve conduction velocity

ii. sleep cycle changes, frequent awakening, decreased deep sleep

iii. impaired thermoregulation

iv. decreased balance and spatial orientation


h. sensory changes

i. decreased visual acuity

ii. decreased accommodation

iii. presbyopia

iv. decreased hearing acuity (presbycusis)

v. decreased pitch discrimination - minimal ability to hear high-pitched sounds

vi. taste buds atrophy

vii. decreased sense of smell

viii. decreased heat, cold, touch, pressure perception


i. immune system

i. lower base line temperature

ii. decreased immune response - increased infection risk


5. Cognitive changes

a. expected: gradual decrease short-term memory, narrowed interests

b. unexpected: occur when cerebral dysfunction, trauma, or hypoxia is present

c. intelligence does not decrease


6. Psychosocial

a. Erikson's developmental theory of ego integrity vs. despair

b. personality, creativity, values, and adaptability remain constant

c. retirement: change in occupational and social roles; economic changes

d. facing multiple losses and grief response

e. isolation: social, attitudinal, behavioral, geographic


7. Sexual function will depend on general health, psychological health, medications

8. Threats to health and safety

9. Housing - safety is the priority and functional needs met

a. home: single family, apartment, and retirement community

b. assisted living

c. day care
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d. respite care

e. long-term care


VII. Health & Health Promotion

A. Definitions

1. Health

a. Traditional Western model: "freedom from disease"

b. World Health Organization (1958): a "state of complete physical, mental and social
wellbeing and not merely the absence of disease and infirmity"


2. Wellness: a multidimensional state of being; functioning at maximum potential, regardless of
state of health

3. Health promotion behavior: behavior in which the client views health as a goal and engages in
behaviors designed to achieve or maintain that goal

4. Health care: includes prevention, early detection, treatment and rehabilitation for clients with
potential for or existing illness or disability

5. Health belief model

a. Psychological and behavioral theory

b. Attempts to explain individual health behaviors

c. Health behaviors are based on three factors

i. the individual's perception of susceptibility of illness

ii. the individual's perception of seriousness of the illness

iii. the likelihood that the person will take preventive action


d. Modifying factors

i. cultural beliefs

ii. economics

iii. political factors

iv. social factors

v. personal beliefs





B. Healthy People 2020

1. The US Department of Health and Human Services originally released Healthy People in 1990

2. Statement of national health objectives designed to identify the most significant preventable
threats to health and to establish national goals to reduce these threats

3. The goals of the project

a. increase quality and years of healthy life

b. eliminate health disparities



C. The Patient Protection and Affordable Care Act (Public Law 111-148) - also known as "Obamacare"
(2010):

1. Provides for quality and affordable health care for all Americans

2. 10 titles or sections, including the following provisions:

a. Title II: expands Medicaid coverage

b. Title III: closes the gap in prescription drug coverage in Medicare (Part D)

c. Title IV: establishes the National Prevention, Health Promotion, and Public Health Council - for
supporting preventative health care

d. Title VIII: establishes the Community Living Assistance Services and Supports (CLASS Act) - for
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support for people with disabilities



D. Health promotion model

1. Developed by Nola Pender (1982; revised 1996)

2. Health promotion depends on seven factors of cognition-perception

a. importance of health to the person

b. perceived control of health

c. perceived self-efficacy

d. definition of health

e. perceived health status

f. perceived health benefits from the health-promoting behavior

g. perceived barriers to the health-promoting behavior



E. Disease prevention behaviors: behaviors designed to decrease the likelihood/risk of illness

1. Primary prevention

a. health promotion and disease prevention

b. applied to clients considered physically and emotionally healthy

c. example: exercise programs, healthy diet


2. Secondary prevention

a. early detection of illness

b. focuses on individuals who are experiencing health problems and illnesses and who are at risk
for complications

c. activities are directed at diagnosis and prompt treatment

d. example: breast self examination, cholesterol screening


3. Tertiary prevention

a. prevention of further deterioration in disease or disability

b. occurs when a defect or disability is permanent and irreversible

c. activities are directed at rehabilitation

d. example: alcoholics anonymous



F. Health screening risk appraisal

1. Used to analyze all that is known about a person's entire life situation, including personal and family
medical history, occupation, and social environment in order to estimate his or her risk of disability
or death as compared with the national averages

2. Can prevent or minimize illness and disability


REMEMBER IT
Primary - Prevent
Secondary - Screen
Tertiary - Treat


G. Risk factors - probability of acquiring a particular health problem

1. Varies with age, race, ethnicity, gender

2. Risk increases with certain lifestyle choices, such as smoking, occupation, diet, environment

3. Modifiable risk factors include such things as occupation, work stress, and diet

4. Non-modifiable risk factors include race, age and gender
78


5. Examples: risk factors are important in

a. coronary artery disease

i. history of smoking

ii. history of high cholesterol

iii. genetic predisposition

iv. obesity


b. cancer (general)

i. high consumption of caffeine

ii. genetic predisposition

iii. environmental exposure to carcinogens


c. colon cancer

i. over 50 years of age

ii. family history of colon polyps or cancer

iii. urban living

iv. diet high in fats and low in fiber


d. tuberculosis

i. history of exposure to someone with tuberculosis (TB)

ii. history of travel or living outside United States

iii. history of prison time

iv. HIV infection

v. cancer chemotherapy

vi. malnutrition

vii. homelessness

viii. history of intravenous drug use

ix. medical workers



e. diabetes: candidates for screening

i. strong family history of diabetes mellitus

ii. markedly obese

iii. obstetrical history of babies weighing over nine pounds at birth

iv. obstetrical history of miscarriage or fetal death

v. pregnant women between 24 to 28 weeks gestation

vi. history of gestational diabetes





H. Risky behaviors - behaviors that impact the health of individuals

1. Adolescence (12 to 19 years)

a. eating disorders

i. anorexia nervosa - restrictive eating

ii. bulimia nervosa - binge eating followed by purging


b. injury prevention

i. wearing of seat belts
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ii. wearing of helmets

iii. sports injuries

iv. homicide and suicide


c. substance abuse

i. tobacco

ii. underage drinking

iii. illicit drug use


d. sexual behavior

i. number of sex partners

ii. use of contraception

iii. unintended pregnancy

iv. exposure to sexually transmitted infections - use of condoms



2. Young adult (post-adolescence through age 40)

a. eating disorders - onset of obesity

b. injury prevention

i. motor vehicle accidents

ii. occupational hazards

iii. homicide and suicide


c. substance abuse

i. tobacco

ii. alcohol use

iii. illicit drug use


d. sexual behavior

i. sexually transmitted disease - use of condoms

ii. unintended pregnancy


e. stress

i. changing roles

marriage

beginning a new family

starting a new job


ii. depression



3. Middle adult (40 to 65 years)

a. obesity

b. lack of exercise

c. substance abuse

i. tobacco

ii. alcoholism

iii. illicit drug use


d. lack of preventative health care

e. stress
80


i. job

ii. family / divorce

iii. acceptance of aging



4. Older adult (age 65 and older)

a. obesity

b. lack of exercise

c. substance abuse

i. tobacco

ii. alcoholism

iii. illicit drug use


d. injury prevention

i. falls

ii. seat belts

iii. suicide

iv. multiple medications




I. Screening recommendations for the average American

1. For everyone

a. Cholesterol - baseline at age 20; every 5 years if normal

b. Blood pressure screening ( measuring blood pressure )

c. Colonoscopy (visualization of the entire colon) - once every 10 years after turning 50 (unless
there is a family history)

d. Guaiac test for occult blood every year after the age of 50

e. Tuberculosis skin test (intradermal injection of antigen), followed by chest x-ray if positive results

f. Diabetes - fasting plasma glucose (ideally 8 to 12 hours fasting)

g. Vision - regular check-ups

h. Dental - regular check-ups and cleanings should be performed every six months

i. Hearing - recommended every 10 years; every 3 years after age 50

j. Well child care - birth to age 6

k. Physical exam - every 1 to 5 years depending on risk factors and health concerns

l. Scoliosis screening - onset of adolescence

m. Immunizations (non-childhood) - tetanus booster (every 10 years), influenza, pneumococcal and
Zostavax (for shingles) vaccines


2. Women

a. mammography

b. clinical breast exam

c. monthly breast self exam

d. Papanicolaou test (or Pap smear) - no later than age 21


3. Men

a. prostate-specific antigen (PSA) test - routine screening no longer recommended

b. digital rectal exam

c. testicular self-exam - starting at age 15


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J. Compliance

1. Definition: adherence to therapeutic recommendations

2. Factors influencing compliance

a. personal meaning and perceptions: knowledge, values, beliefs, outcome expectations

b. social factors: environmental context, social relationships, social support, societal norms,
economic resources

c. deficiencies in the health care system: access, costs, wait time, monolingual services



K. Noncompliance

1. An individual's informed decision not to initiate or adhere to a therapeutic recommendation

2. An individual is unable or unwilling to alter habitual behaviors or adopt new behaviors necessary to
a prescribed therapeutic regime


VIII. Health Data Collection

A. Purposes

1. Data collection

2. Supplement, confirm or refute historical data

3. Identify changes in client's status

4. Instruct about healthy behaviors, health risks, and health promotion

5. Report results to health care provider


B. Types - comprehensive, problem-centered, follow-up, emergency

C. History

1. Present health/history of present illness

a. onset

b. location of symptoms (or pain)

c. quality of discomfort

d. precipitating or aggravating factors

e. duration of symptoms

f. associated symptoms


2. General health status (as perceived by the individual)

3. Medical and surgical history - events, treatment and outcomes, allergies, immunization status

4. Family history and risk factors - lifestyle, genetic

5. Social history

6. Occupation

7. Leisure activities and exercise regimen

8. Sleep patterns

9. Nutrition

10. Medications, including prescription, over-the-counter, substance use/abuse, tobacco use

11. complementary and alternative therapies (CAT)

12. psychosocial factors and support systems



D. Physical exam

1. Recommended equipment

2. Assist client into position
82


a. Fowler's - anterior, posterior for breath sounds

b. supine and dorsal recumbent (for abdominal assessment)


3. Ensure privacy

4. Collect data about general appearance and behaviors

a. gender and race

b. age

c. obvious signs of distress

d. body type

e. posture

f. gait

g. body movements

h. hygiene

i. dress

j. affect and mood

k. speech


5. Measure vital signs

a. pulse: rate, rhythm, force or strength

b. respiration: rate, rhythm, quality

c. body temperature

i. oral range: 97.5 - 99.5 F (36.4 - 37.5 C)

ii. measure core temperature: rectal, tympanic, esophageal, temporal artery, gastrointestinal
radio pill, urinary bladder

iii. measure surface temperature: skin, axilla, or mouth

iv. body temperature normally varies with age, exercise, hormone levels, circadian rhythm (time
of day), stress, the environment



6. Measure height and weight

a. height-for-age reference charts

b. measuring height with client standing or lying down; proxy measurements such as arm span may
also be used



E. Physical exam techniques

1. Inspection

a. process of observing the differences between normal physical findings and deviations

b. requires knowledge of normal physical findings throughout the lifespan

c. principles of inspection

i. in good lighting and with whole body part visible

ii. observe each area for size, shape, color, and position

iii. compare body parts bilaterally for symmetry



2. Palpation

a. use touch to assess rigidity, resilience, texture, temperature, moisture, vibration, pulsation,
location and size, crepitations, masses, tenderness and mobility

b. palpation may be either light or deep in pressure

i. use light palpation to determine surface characteristics
83


ii. deep palpation usually depresses the area by 1 to 2 inches; use it to examine specific organs


c. use palmar surface of fingers to determine position, texture, size, consistency, and pulsation;
also presence and shape of mass

d. use back of hand or inner aspect of wrist to test temperature

e. use palm of hand to sense vibration


3. Percussion

a. tap the body with fingertips to detect fluid, or to assess location, size, density (air, fluid, solid) of
a structure and borders of organs

b. tapping the body penetrates produces vibration and sound waves which are heard as percussion
tones

c. methods

i. direct: striking the body surface with two fingers

ii. indirect: striking the middle finger of the stationary hand on the back surface with the
dominant hand, rather than the body surface, while keeping the palm and remaining fingers
off the body


d. character of percussion sounds depends on the density of the tissue being percussed


4. Auscultation

a. listening (with unassisted ear or stethoscope) to sounds made by the body

b. stethoscope

i. bell - low pitched sounds

ii. diaphragm - high pitched sounds


c. assess presence of sounds and their character

i. frequency (high or low pitch)

ii. loudness (loud or soft)

iii. quality (blowing, gurgling, booming, muffled thud, hollow, flat, absolute dullness)

iv. duration (short, moderate, long)



5. Olfaction: use of sense of smell to differentiate common body odors from abnormal ones



IX. Health Data Collection by Body Part

A. Eye

1. History

a. presenting problem or injury

b. presence of visual changes

c. night blindness

d. associated findings - pain, redness, swelling, discharge

e. onset

f. precipitating factors

g. aggravating or alleviating factors

h. past history

i. family history

j. lifestyle factors: occupational exposure to irritating substances, sun exposure

k. medications - specifically for eyes or any that may have ocular side effects
84


l. self-care abilities

m. use of corrective lenses



2. Vision tests

a. distant vision - Snellen E chart

b. near vision - Rosenbaum chart held at "reading" distance (or 12 to 14 inches from eyes)

c. visual fields


3. Extraocular muscle function: six cardinal fields of gaze

a. corneal light reflex

b. cover test

c. positions test


4. External eye structures: inspection

a. symmetry

b. eyelids and eyelashes

c. eyeball position

d. bulbar conjunctiva and sclera

e. lacrimal apparatus

f. cornea and lens

g. iris and pupil

h. papillary reaction to light

i. accommodation of pupils


5. Internal eye structures and red reflex

a. using ophthalmoscope, inspect internal eye

b. observe red reflex

c. inspect retinal vessels and background color


6. Older adult considerations

a arcus senilis

b. pupils often miotic (smaller) with slower dilation and adaptation to dark

c. iris and retina may appear paler

d. decrease tear production resulting in dryness

e. disc may be slightly smaller and more opaque

f. presbyopia

g. color perception diminished and cool color distortion




B. Ear

1. History

a. presenting problem or injury
85


b. presence of hearing loss

c. use of hearing assistance

d. associated findings - earache, discharge, tinnitus, vertigo

e. onset

f. precipitating factors

g. aggravating and alleviating factors

h. lifestyle factors: swimming, musician, occupation, environmental noise exposure

i. medical history

j. family history of allergy or hearing disease

k. medications


l. self-care behaviors



2. Inspection - external ear

a. observe size, shape and symmetry of both ears

b. auricles are normally level with each other, and upper point of attachment is in a straight line
with the lateral canthus of the eye

c. inspect ear skin for color, lesions, rash and scaling

d. inspect area behind auricle for tophus


3. Palpation

a. palpate auricle, tragus and mastoid area for tenderness and elevated local temperature

b. normal findings: auricle is normally smooth without lesions

c. estimate size of external auditory meatus


4. Inspection - ear canal

a. adult: grasp auricle and pull up and back to straighten external ear canal before inserting
otoscope or light

b. child: grasp auricle and pull down and back

c. inspect ear canal for redness, swelling, discharge, crusting and foreign bodies

d. expect cerumen (ear wax) - genetically determined

i. dry and flaky (frequently Asians and American Indians)

ii. wet - honey to dark brown (frequently Blacks and Caucasians)
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5. Hearing acuity

a. gross hearing is tested by client's response to normal conversation

b. whispered word or ticking watch test

c. health care practitioner tests

i. Weber test - hearing test using a vibrating tuning fork that is held at various points along the
midline of the skull and face (bone conduction only); used to detect hearing loss

ii. Rinne test - compares sound conduction of air versus bone; normally air conduction (AC) is
greater than bone conduction (BC)



6. Older adult considerations

a. ear lobes may appear pendulous

b. presbycusis - starting at age 50, slowly progressive

c. cerumen dries and accumulates, reducing acuity


C. Mouth and pharynx

1. Inspection - normal findings

a. temporomandibular joint - smooth jaw excursion; easy mobility

b. lips and buccal mucosa - symmetrical, pink; smooth and moist

c. teeth and gums - 32 adult teeth; pink gums

d. tongue - symmetry; pink; moist; papilla present

e. hard and soft palate - hard palate is pale, immovable with transverse rugae; soft palate is pink
and movable

f. oropharynx - symmetrical; midline uvula, tonsils may be present on either side



2. Older adult considerations

a. mucosa drier, decreased saliva

b. soft tissue atrophy (tongue), smoother, loss of taste buds, sense of taste may be diminished

c. teeth may appear longer, yellowed, surface abraded
87


d. tooth loss may occur with osteoporosis



D. Skin

1. General appearance - inspection is integrated throughout the head-to-toe exam

a. color

i. varies with body part, and from person to person

ii. color ranges

"white" skin: ivory or light pink to ruddy pink

dark skin: light to dark brown or olive


iii. alterations in skin color

hyperpigmentation

hypopigmentation

cyanosis

jaundice

erythema

pale or pasty

mottled




b. moisture

c. temperature

d. texture: varies from part to part

i. smooth or rough

ii. supple or tight

iii. indurated



e. turgor

i. decreases with normal aging in older adults

ii. check turgor over forehead or sternum (use of hand or forearm is inaccurate) and note how
quickly it returns to its previous state

iii. decreased in dehydration

iv. usually unable to check in toddlers and infants


f. vascularity

i. in older adults - capillaries are more fragile (senile purpura)

ii. petechiae: flat red or purple freckles


g. edema
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i. peripheral

ii. generalized (anasarca)

iii. ascites (around abdomen)

iv. pitting (grading scale +1, +2, +3, +4) or non-pitting




h. lesions

i. normal finding: free of lesions

ii. primary lesions

macule

papule

patch

plaque

vesicle

bulla

pustule

nodule


iii. secondary lesions (arise from primary)

scale

crust

lichenification

scar

excoriation

ulcer

fissure

keloid

erosion



iv. note: color, drainage (exudates), texture, size, shape, type, grouping, location and distribution



i. hair

i. hirsutism

ii. alopecia


j. nails - normal capillary refill is less than three seconds

k. factors affecting skin condition

i. hygiene

ii. nutritional status

iii. underlying disorders



89

2. Older adult considerations

a. thinner skin and subcutaneous tissue

b. "liver spots" - small, flat, brown macules

c. hypopigmented patches

d. skin is drier, especially on lower extremities

e. less perspiration

f. all skin becomes less elastic and more sagging

g. toenails may be thick, distorted, and yellowish

h. lesions: cherry angiomas, senile keratosis, atrophic warts

i. graying, thinning hair



E. Heart

1. Assess the heart through the anterior thorax (front chest)



2. Inspection and palpation

a. client in supine position or with head elevated at 35 to 45 degrees

b. apical impulse

i. fourth or fifth left intercostal space, mid-clavicular line

ii. may or may not be seen

iii. normally a short, gentle tap


c. pulse deficit: take and compare apical and radial pulse

d. anatomical landmarks of the heart

i. second right intercostal space - aortic area

ii. second left intercostal space - pulmonic area

iii. third left intercostal space - Erb's point

iv. fourth left intercostal space - tricuspid area

v. fifth left intercostal space - mitral (apical) area

vi. epigastric area at tip of sternum





F. Vasculature

1. Blood pressure

a. reflects relationship between cardiac output, peripheral vascular resistance, blood volume and
viscosity, and arterial elasticity
90




b. factors influencing blood pressure

i. age

ii. stress

iii. race

iv. drugs

v. diurnal (day-night) variations

vi. gender

vii. weight

viii. hydration status

ix. skill of person assessing blood pressure


c. alterations in blood pressure

i. hypertension: blood pressure (BP) greater than 140/90 mm Hg

ii. hypotension: systolic BP less than 100 mm Hg

iii. range of normal blood pressure

child under age 2, weighing at least 2700 g: use flush technique, 30 to 60 mg Hg

child over age 2 years-old: 85 to 95/50 to 65 mm Hg

school age: 100 to 110/50 to 65 mm Hg

adolescent: 110 to 120/65 to 85 mm Hg

adult: < 130 mm Hg Systolic / < 85 mm Hg diastolic





2. Internal carotid arteries in neck


a. palpate each separately along margin of sternocleidomastoid

b. normal findings: strong thrusting pulse

c. auscultate both sides

d. normal findings: no sound heard

e. constriction causes bruit

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3. Jugular veins

a. client in supine position with head elevated at 35 to 45 degrees

b. normal findings: pulsations not evident

c. jugular venous distension (JVD): bulging, distension, or protrusion at 45 degrees


4. Peripheral arteries and veins

a. pulse

i. locations

ii. normal range of peripheral pulses

infants: 120 to 160 beats per minute; as low as 110 beats per minute at rest

toddlers: 90 to 140 beats per minute

preschool and school age: 75 to 110 beats per minute

adolescent and adult: 60 to 100 beats per minute


iii. factors affecting rate

exercise

body temperature - each degree (Fahrenheit) elevation above normal causes an increase of 7
to 10 beats per minute

stress, emotions

drugs

hemorrhage - less blood in the body requires more pumping per minute

postural changes

pulmonary conditions causing poor oxygenation

hydration status

environmental temperature


iv. rhythm - regular (normal) or irregular

v. strength

reflects volume of blood ejected with each beat

grading system


vi. equality

vii. alterations, e.g., heart murmurs

viii. dysrhythmias - extra or skipped beats


b. tissue perfusion

i. temperature, movement, sensation

ii. color: pale, cyanosis

iii. clubbing - indicates chronic hypoxia
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iv. edema

v. skin and nail texture

vi. hair distribution on lower extremities - absence suggests arterial insufficiency

vii. presence of ulcers

toe location - arterial insufficiency; gangrene risk

ankle location - venous insufficiency




G. Lymphatics

1. Retrieves excess fluid from tissue spaces and returns it to the bloodstream

a. conserves fluid and plasma proteins

b. is a major component of the immune system

c. absorbs lipids from the intestinal track

d. without lymphatic drainage, fluid remains in the interstitial spaces and produces edema


2. Two major trunks

a. right lymphatic duct empties into right subclavian vein

b. thoracic duct - drains remaining body


3. Lymph nodes


a. cervical - drains the head

b. axillary - drains the breast and upper arm

c. epitrochlear - in the antecubital fossa and drains the hand and lower arm

d. inguinal - in the groin and drains the lower extremities, external genitalia, and abdominal wall


4.
Head and Neck

a. preauricular - in front of the ear

b. posterior auricular (mastoid)

c. occipital - base of skull

d. submental - midline, behind tip of mandible

e. submandibular - halfway between angle and tip of mandible

f. superficial cervical - overlying the sternomastoid muscle

g. deep cervical - deep under the sternomastoid muscle

h. posterior cervical - in posterior triangle along edge of trapezius

i. supraclavicular - just above and behind the clavicle


5. Related organs

a. tonsils

b. thymus

c. spleen


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H. Lungs

1. History - smoking, infections, pain, discomfort, dyspnea with or without activity, fever - spike, low-
grade


2. Inspection

a. general appearance

i. respiratory effort - breathing should be quiet and easy

ii. depth - normal, deep, shallow


b. normal rates of respiration at rest

i. newborn: 30 to 60 breaths per minute

ii. infant: 30 to 50 breaths per minute

iii. toddler: 25 to 35 breaths per minute

iv. school age: 20 to 30 breaths per minute

v. adolescent & young adult: 14 to 20 breaths per minute

vi. older adult: 12 to 20 breaths per minute


c. respiration involves ventilation, diffusion, and perfusion of gases


d. factors influencing respirations

i. anxiety

ii. pain

iii. stress

iv. anemia

v. posture

vi. exercise

vii. drugs: narcotics, amphetamines, neuroleptics, antidepressants


e. rhythm: regular, irregular; normal finding: regular

f. skin color: pink, pale, cyanosis; in dark skinned person check oral mucosa

g. chest wall

i. normal findings: symmetrical with bilateral muscle development

ii. anterior-posterior (A-P) to transverse ratio; increases with normal aging

iii. barrel chest - suggests chronic lung disease




3. Palpation

a. feel for abnormalities such as masses, lesions, scars, swelling, crepitus, asymmetry

b. crepitus indicates air in subcutaneous tissue usually due to pneumothorax
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c. tactile (vocal) fremitus: ask client to repeat "99"

i. symmetrical vibration felt when patient speaks

ii. increased over areas of consolidation



4. Percussion - normal findings: resonance heard throughout lung fields

5. Auscultation with stethoscope

a. normal findings: clear breath throughout all lung fields

b. whispered pectoriloquy

i. client whispers "one, two, three"

ii. over normal areas of the lung, only muffled faint sounds are heard

iii. over consolidated areas, the words are more distinct


c. egophony

i. client says "E"

ii. over consolidated areas, the sound is a nasal "A"



6. Alterations in lung function

a. cough - productive/nonproductive

b. expectoration

c. dyspnea

d. bradypnea

e. tachypnea

f. hyperpnea

g. apnea

h. Cheyne-Stokes respiration

i. Kussmaul's breathing

j. Biot's breathing

k. grunting

l. retractions

m. hemoptysis

n. pleural pain

o. accessory muscle use

p. cyanosis

q. adventitious sounds

i. crackles Listen

ii. pleural friction rub

iii. rhonchi

iv. stridor Listen

v. wheeze Listen

vi. whispered pectoriloquy Listen


r. pursed-lip breathing
i. prolonged exhalation
95


ii. breathing out through puckered lips



7. Pediatric variations

a. increased risk of obstruction from mucus, edema, or foreign body due to the following:

i. smaller, shorter, more pliable airways

ii. underdeveloped supporting cartilage


b. flexible larynx more susceptible to spasm

c. immature immune system

d. incomplete myelinization

e. increased basal metabolic rate

f. decreased ability to mobilize secretions

g. less forceful cough


I. Breasts

1. Inspection (performed with client in lying, sitting, or standing position)

a. size - vary from convex to pendulous


b. symmetry (the left breast is commonly larger than the other)

c. skin - smooth even color, venous pattern, possibly a few hairs around areola

d. alterations

i. retraction of nipples

ii. dimpling of breast tissue

iii. lesions

iv. edema

v. inflammation

vi. pregnancy and lactation

enlargement of breasts bilaterally

soreness of nipples during lactation

possible striae



e. nipple and areola

i. size - varies with individuals

ii. color - ranges from pink to brown

iii. shape symmetrical

areola - round or oval

nipples - usually protrude


iv. symmetry - normally symmetrical
96


v. direction - normally nipples point in same direction

vi. alterations

discharge

inverted nipples - unilateral more of a concern than bilateral

bleeding





2. Palpation - breast

a. lymph nodes - normal findings: not palpable

b. breast tissue

i. client in supine position with hands placed behind neck

ii. methods of examining breast tissue

clockwise or counterclockwise circling breast from nipple outward

back and forth with fingers moving up and down each breast (recommended method)

cover entire thoracic area, including axillary area


iii. consistency

varies widely from person to person

normal findings: dense, firm and elastic


iv. alteration - fibrocystic disease of the breast


v. older adult considerations

relaxed breasts

may appear elongated or pendulous

decrease in glandular tissue




J. Abdomen

1. History

a. pain (location), bowel habits, dietary problems, weight change, difficulty swallowing, flatulence,
belching, heartburn, anorexia, nausea, vomiting, cramping, hemorrhoids

b. changes in micturition including: change in amount and color of urine, irritation of the lower
urinary tract, obstruction of the urinary tract, urinary incontinence, urinary tract pain with
voiding or bladder spasms

c. medications


2. Inspection

a. landmarks

i. xiphoid process - marks upper boundary

ii. symphysis pubis - marks lower boundary

iii. abdomen divided into four quadrants: RUQ, RLQ, LUQ, LLQ
97




b. normal findings
i. skin texture and color should be consistent with rest of body

ii. striae may be present

iii. umbilicus is normally flat or inverted midway between xiphoid and symphysis pubis

iv. abdomen may be flat, rounded or concave; all three are normal if there is symmetry

v. may note peristalsis movement or aortic pulse normally

vi. voiding: steady, straight stream with no pain or post void dribble




3. Auscultation - perform before percussion and palpation to obtain baseline bowel sounds

a. bowel motility (normal findings) - bowel sounds audible in all quadrants, about 5 to 30 times per
minute

i. start in right lower quadrant (RLQ)

ii. if bowel sounds are present in the RLQ, indicates no obstruction above in the large intestine


b. vascular sounds - normal findings

i. no vascular sounds over aorta, femoral or iliac arteries

ii. renal artery bruits may be heard



4. Percussion - normal findings:

a. tympany over stomach and intestines

b. dullness over liver, spleen, pancreas, kidneys and distended (greater than 150 mL) bladder


5. Palpation

a. light palpation - gently depress 1 centimeter, moving to each quadrant

b. deep palpation - depress 5 to 8 centimeters; use one hand over another (bimanual) for obese
abdomen

c. normal findings - soft with no palpable masses, no tenderness or rigidity

d. bladder noted as a bulge in abdomen at the suprapubic area when filled with more than 500 mL of
urine


6. Alterations

a. distention

b. ascites

c. paralytic ileus

d. borborygmus

e. guarding

f. tenderness
98


g. pain


7. Older adult considerations

a. increased fat deposits over abdominal area

b. abdominal muscle tone more lax


K. Female reproductive system

1. History: sexual activity, sexually transmitted infection, vaginal discharge, menstrual history,
obstetrical history, contraception, self-care behaviors


2. Inspection - normal findings

a. hair distribution - variable; usually inverted triangle starting at symphysis pubis

b. skin of perineum smooth, clean, slightly darker than other skin, no lesions

c. labia majora may be closed or gaping

d. clitoris - about 2 centimeters in length and 0.5 centimeters in width

e. urethral orifice intact, pink without irritation, midline

f. vaginal orifice ranges from thin, vertical slit to large orifice with moist tissue

g. anus moist and hairless; skin more darkly pigmented


3. Older adult considerations

a. labial folds flatten

b. perineum paler

c. meatus usually more posterior

d. natural lubrication decreased

e. vagina shortens with age

f. uterus diminishes in size

g. ovaries atrophy with age

h. pubic hair decreases



L. Male reproductive system


1. History: sexual activity, sexual history, sexually transmitted infection, contraception, surgery,
associated urinary problems, self-care behaviors
99




2. Inspection

a. external genitalia

i. hair distribution varies; usually diamond shaped, extends from base of penis over symphysis
pubis up to umbilicus; coarse and curly

ii. penis shaft, corona, prepuce, glans

iii. urethral meatus is slit like opening positioned on ventral surface, millimeters from tip of
glans; opening should be glistening and pink

iv. scrotum

skin more darkly pigmented; more wrinkled; usually loose

symmetry - left testicle is lower than right

size - changes with temperature


v. inguinal canal (normal finding) - no bulging



3. Palpation

a. penis

i. smooth without lesions

ii. foreskin, if uncircumcised, should retract easily

iii. small amount of thick white secretion (smegma) between glans and foreskin is normal


b. testicle - ovoid; ranges from 2 to 4 centimeters in diameter, smooth and rubbery; non-tender;
rope-like structure posteriorly is the epididymis

c. scrotum - without lesions; spermatic cords smooth and non-tender

d. inguinal area - inguinal lymph nodes not palpable, no bulges


4. Older adult considerations

a. pubic hair - thinning, grey

b. penis - decrease in size

c. testes - decrease in size and less firm

d. scrotal sac - pendulous

e. increased bogginess of prostate gland



M. Rectum and anus - male and female


1. History: usual bowel routine, changes in routine, medication use, rectal bleeding, rectal concerns
or pain, family history, self-care behaviors

2. Inspection of perianal areas

a. skin - smooth and uninterrupted
100


b. anal tissues - normally moist and hairless


3. Palpation: rectal tone, presence of stool

4. Alterations

a. hemorrhoids

b. fissures

c. fistulas

d. polyps

e. pain with or without defecation



N. Musculoskeletal


1. History: participation in sports, injuries, surgeries, risk factors for osteoporosis, impact of current
problem on activities of daily living, falls, pain, self-care behaviors

2. Inspection - normal findings

a. gait - client walks with arms swinging freely at sides; coordinated and smooth; rhythmic with
push off and swing through

b. posture and balance

i. upright stance with parallel alignment of hips and shoulders

ii. feet aligned; toes pointing straight ahead

iii. convex curve to thoracic spine

iv. concave curve to lumbar spine

v. can stand still without swaying or tilting


c. extremities - bilateral symmetry in length, circumference, alignment, position and number of
skin folds



3. Palpation

a. joints

b. muscles

c. normal findings: non-tender, no swelling or warmth to touch


4. Range of motion (normal findings) - able to move joints through required range of motion

a. abduction

b. adduction

c. dorsiflexion

d. eversion

e. extension

f. flexion

g. hyperextension

h. inversion

i. plantar flexion

j. pronation

k. supination


5. Muscle strength and symmetry (normal findings) - arm on dominant side generally stronger

6. Alterations
101


a. kyphosis

b. lordosis

c. scoliosis

d. pain



7. Older adult considerations

a. stance less upright with head and neck forward

b. lumbar curvature less pronounced

c. height decreased

d. gait slower to initiate and stop

e. less knee and ankle lifts

f. steps may be shorter and more rapid

g. less coordination and balance

h. muscles atrophy with disuse

i. weaker grip
j. active range of motion may be slower and limited in one or more joints

k. joints appear larger than surrounding tissue; may be stiff



O. Neurological system



1. History: difficulties with memory, communication, sensory data, usual intellectual functioning,
headaches, seizures, dizziness, lightheadedness

2. Mental status - Mini-Mental State Examination (MMSE)

3. Emotional status (normal findings) - affect matches speech

4. Cranial nerve function

5. Level of consciousness (LOC) - normal findings

a. alert

b. orientation to person, place, time, situation

c. responds appropriately to visual, auditory, tactile and painful stimuli

d. able to carry out simple commands
102


e. Glasgow coma scale

f. alterations in LOC



REMEMBER IT
There are a lot of mnemonics to remember the names of the 12
cranial nerves; here's one of the "cleaner" versions: On Old
Olympus Towering Tops A Fin And German Viewed Some Hops

Here's a version to help remember which of the cranial nerves
carry sensory, motor, or both types of impulses (S=sensory,
M=motor, B=both): Some Say Marry Money But My Brother
Says Big Business Makes Money



6. sensory nerve function (normal findings)

a. visual - recognizes objects

b. auditory - identifies sounds

c. tactile - identifies objects through blind touch; perceives pain, hot and cold and vibration; two-point
discrimination

d. olfactory - identifies familiar smells

e. taste - intact

7. Cerebellar function - position and balance

8. Speech and language (normal findings)

a. smooth flowing speech

b. able to formulate words without difficulty

c. varied inflection

d. able to write letters and numbers to dictation

e. vocabulary appropriate to educational level


9. Intellectual (normal findings)

a. memory: immediate recall and remote recall

b. able to abstract

c. demonstrates consistent insight and perception of self


10. Reflexes - newborn assessment

11. Older adult considerations

a. longer response time to sensory stimulation

b. tactile sensation diminishes

c. senile tremor

d. kinesthesia diminishes

e. superficial and deep reflexes may be diminished or absent

When you examine the mouth, you see that the soft palate is moist and pink with whitish spots. Alternation Normal
The client is able to stand on one foot, with eyes shut, for five seconds. Alternation Normal
This 42 year-old client breathes 30 times per minute. Alternation Normal
You examine this client's breast and see a cluster of very tiny dimples near one nipple Alternation Normal
Auscultation reveals bowel sounds in two of the four abdominal quadrants. Alternation Normal
In this 60 year-old man, the left scrotal sac is slightly lower than the right. Alternation Normal
This client can tell you her name, but does not know the day of the week. Alternation Normal
103




X. Client and Family Education

A. Adult learning theory characteristics

1. Self-directed

2. Reservoir of experience

3. Mutual planning and goal setting preferred

4. Internally motivated

5. Established orientation to learning

6. Educator viewed as facilitator of learning

7. Experiential rather than didactic focus

8. Must be immediately applicable to situations


B. Teaching/learning process

1. Data collection - identification of learning needs related to health promotion

2. Communication of identified client needs to RN

3. Reinforce actions for outcomes or goals

4. Review educational offerings

5. Reinforce instructions about healthy behaviors, health risks, and health promotion such as risky
behaviors, breast and/or testicular cancer self-exams


C. Learning styles

1. Vary with individuals

2. Types are

a. visual

b. auditory

c. tactile - learn through touch and "hands on"

d. kinesthetic - learn through movement



D. Teaching strategies

1. Demonstration and return demonstration - individual

2. Programmed instruction - self-paced

3. Role playing - group work

4. Simulation - group work

5. Case study analysis - individual or group work



E. Legal implications

1. American Hospital Association (AHA) issued the Patients' Bill of Rights (1973): guarantees a person's
right to information necessary to give informed consent before treatment begins

2. Patient Care Partnership (2008): describes the rights and responsibilities of individuals who are
hospitalized (replaced the Patients' Bill of Rights)

3. All teaching must be individualized and documented in client's chart

4. Older adult considerations

a. make sure client has glasses or hearing aid, if indicated

b. face the client and use a lower pitched voice

c. supplement oral presentation with print materials
104


d. use large print

e. provide bright lighting

f. some clients have a hard time seeing color; use black ink on white or yellow paper

g. keep sessions short, 15 to 30 minutes, and work with critical information initially

h. repeat, as necessary

i. break down learning into small steps

j. use specific, step-by-step directions and have the client redemonstrate them in the same manner

k. get frequent feedback on client's level of understanding



5. Health Insurance Portability and Accountability Act (HIPAA)

a. signed into law in 1996

b. requires employer-sponsored group health plans, insurance companies, and health maintenance
organizations (HMOs) to

i. limit exclusions for preexisting conditions

ii. prohibit discrimination against employees and dependents based on their health status

iii. guarantee renewability of health coverage to certain employers and individuals

iv. protect many workers who lose health coverage by providing better access to individual health
insurance coverage


c. revised in 2003

i. provides patients with access to their medical records and more control over how their personal
health information is used and disclosed

ii. key provisions

access to medical records

notice of privacy practices

limits on use of personal medical information

prohibition on marketing

stronger state laws

confidential communications

complaints




Points to Remember - OB
Before Birth

Early and regular antepartal (before-birth) care is critical. First trimester health and nutrition directly influences the
development of organs in embryo and fetus.

To identify risks, nurses need both subjective (client's) and objective (the nurse's own) data.

Prescribed medications, over-the-counter drugs, alcohol, street drugs, and tobacco may lead to problems for the fetus
and mother.

Pregnancy diet must include increased calcium, protein, iron and folic acid, which is most critical the first trimester.

If the mother's situation warrants, suggest ways to adapt activity, employment, and travel.

It is helpful if the mother can have the same support person throughout pregnancy, birthing classes, and the labor and
delivery process.

A doula gives prenatal, labor, birth and postpartum support for mothers and families.

Labor

Normal active labor progresses 1.2 centimeters per hour for primiparas and 1.5 centimeters per hour for multiparas.

Maintain safety and medical asepsis through the labor and birth process to reduce risks to mother and fetus/newborn.

Ideally, the same caregivers should stay through all stages of labor.

Reinforce the childbirth preparation techniques practiced by the couple during pregnancy but be flexible since woman
105

will have shorter attention span, increased discomfort, and experience a fluctuation of emotions during labor.

Respect the cultural and religious beliefs of the woman and partner.

Involve the family in the birth process as noted in their birth plan or special requests.

Document ongoing assessments, changes in condition and care.

Pain and anxiety can impede progress of labor.

Safest time for the fetus is to administer analgesics is when the woman is dilated between 4 to 7 centimeters.

Be prepared to assist newborn transition to extrauterine environment.


Points to Remember - OB 2
Postpartum

Reinforce teaching (by demonstration and praise) self assessment and care soon after newborn's birth.

Postpartum physical assessment can be remembered using the acronym: B.U.B.B.L.E. (for breasts, uterus, bowels,
bladder, lochia and episiotomy or C-section incision)

Perform Coombs' tests to detect antibodies after the birth of each Rh positive newborn

direct Coombs' test on newborn using neonatal cord blood

indirect Coombs' test and antibody screen on the mother

Share your findings and plans with the parents; welcome their input.

Respect culture and religious beliefs of the family.

Praise the parents' skills.

Media and pamphlets are useful teaching aids if the parents have a chance to discuss them; be mindful of the level of
education.

Mothers are discharged within 24 to 48 hours; reinforce teaching accordingly.

Home visits and follow-up telephone calls enhance discussions about adaptations, questions and concerns.

Women's health promotion should be emphasized in postpartum period.

The adolescent mother benefits from developmentally appropriate teaching and referral to community resources,
including parenting classes.

Receptiveness to teaching peaks about 3 to 7 days after delivery.

Points to Remember - Growth & Development
General Concepts

Both growth and development normally proceed in a regular fashion from simple to complex and in a cephalocaudal
and proximodistal pattern.

Growth and development are impacted by genetics, environment, health status, nutrition, culture, and family
structures and practices.

Growth should be measured and evaluated at regular intervals throughout childhood; deviations from normal growth
and development should be thoroughly investigated and treated as quickly as possible.

Development occurs through conflict and adaptation.

Children

In the care of children, key concepts are anticipatory guidance and disease prevention.

Major developmental tasks of infancy are: increase in mobility, separation, and establishment of trusting relationships

In both toddlerhood and adolescence, hallmarks are development of independence and further separation.

Children and adolescents have rapid growth patterns, so nurses must stress optimum nutrition and give anticipatory
guidance related to nutrition.

Leading causes of death

Ages 0 to 1 year: developmental and genetic conditions that were present at birth, sudden infant death syndrome
(SIDS), all conditions associated with prematurity and low birth weight.

Ages 1 to 4 years: accidents, developmental and genetic conditions present at birth, cancer

Ages 5 to 14 years: accidents, cancer, homicide

Ages 15 to 24 years: accidents, homicide, suicide


Points to Remember - Growth & Development 2
Older Adults
106


Older adults must adjust to changing physical and cognitive abilities; a majority of older adults have at least one
chronic disease.

When older adults experience cognitive changes, check for possible substance abuse or polypharmacy.

Cognitive impairment can be acute and reversible, or it can be chronic and irreversible.

Many older adults have some impairment in performance of activities of daily living.

Some physiologic changes are a normal part of the aging process and do not signal disease, e.g., decreased cardiac and
respiratory reserves.

Older adults usually need more time to complete psychomotor tasks.

Age is a weak predictor of survival in traumatic injury and critical illness.

Major health problems typically include cardiovascular, cerebrovascular, and respiratory diseases; diabetes; and
cancer.

The older adult will change social roles, and these changes may affect psychological health, leading to depression.

Older adults need the same nutrition as other adults, but need more bulk and fiber, and a more nutrient dense diet
containing fewer calories.

Older adults clear drugs from kidney and liver more slowly; medications have longer half-lives, causing side effects
and toxicity at lower doses (Rule: start low [dose], go slow [increasing the dose]).

Older adults with low protein levels may have increased risks of drug toxicity for drugs that are protein-binding.

Points to Remember - Health Promotion
Data Collection

Check equipment prior to exam for proper functioning.

Take vital signs after the client is at rest for 5 to 10 minutes..

Compare both sides of the body for symmetry.

Collect data for the systems related to the client's major complaint first.

Offer rest periods if client becomes tired.

Note if culture and religious beliefs might play a role in observed differences.

Warm hands and equipment such as stethoscope before touching client.

Tell client what is going to be done before touching client.

Keep in mind that normal variations exist among clients with a range of normalcy for physical findings.

Maintain the client's privacy throughout the process.

Control for environmental factors which may distort findings - lights, sounds.

Consider growth and developmental needs when working with specific age groups.

Integrate health teaching or reinforcement throughout the process.

Cardiovascular

Compare blood pressure in both arms.

Compare blood pressure with client lying, sitting with feet in a dangling position, and standing.


Points to Remember - Health Promotion 2
Lungs

Anemic patients seldom become cyanotic (and are more commonly a dusky-ashen color when hypoxic).

Polycythemic clients may be cyanotic, even when oxygenation is normal.

Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology.

Cyanosis, either peripheral (hands, feet) or central (circumoral) in origin, is one of the last signs of decreased available
oxygen.

Wheezes indicates narrowing/inflammatory process of lower airways, such as bronchioles.

Stridor is a harsh sound produced near the larynx by a vibration of structures in upper airway with a classic "barky
cough."

Crackles or rales are adventitious sounds, usually heard on inspiration, and can be described as "moist," "dry," "fine,"
and "coarse."

Breasts

Breast tissue shrinks with menopause
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Teach client breast self examination

Abdomen

Remember that tightening of abdominal muscles hinders accuracy of palpation and auscultation; position is dorsal
recumbent for abdominal evaluation

Warm hands before touching client's abdomen.

Note that men breathe abdominally; women breathe costally.

Auscultate all four quadrants for bowel sounds, starting in the lower right quadrant.

Auscultate abdomen between meals if possible.

Auscultate the abdomen before performing percussion or palpation to avoid altering the pattern of bowel sounds

Points to Remember - Health Promotion 3
Musculoskeletal

Older adults walk with smaller steps and need a wider base of support.

Adolescents should be screened for scoliosis.

Neurological

Glasgow coma score

not valid in clients who have used alcohol or other mind-altering drugs.

possibly not valid in clients who are hypoglycemic, in shock, or hypothermic (below 93 F [33.9]).

Reflexes are normally less brisk or even absent in some areas in elderly clients.

Reflex response diminishes in the lower extremities before the upper extremities are affected.

Absent reflexes may indicate a neuropathy or a lower motor neuron disorder, resulting in flaccidity.

Hyperactive reflexes suggest an upper motor neuron disorder, resulting in spasticity.


Reinforcement of Health Care Team Teaching

The teaching-learning process mirrors the nursing process.

Teaching strategies are to be compatible with the client's learning style, age, culture, level of education.

Client teaching should be multi-sensory - tell (auditory), show (visual), have them demonstrate (tactile).

The client's learning style is determined and teaching methods geared to using that style.

The client's understanding is to be validated and documented.

Teaching must be geared to the educational level and interest of the learner - most written materials are written at the
sixth to eighth grade level.

Repeat key information and summarize main points at intervals.

Medical terminology should be stated in lay terms.

Information should be sequenced the way the client will use it.

Be concrete and use the simplest words and the shortest sentences when teaching low literacy clients or any client
under stress.


















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Questions
A nurse is preparing to take a toddler's blood pressure for the first time. Which action should the nurse perform first?
A. permit handling the equipment before putting the cuff in place
B. explain that the blood pressure checks the heart pump
C. explain that the procedure will help the child to get well
D. show a cartoon character with a blood pressure cuff

A practical nurse (PN) is collecting data on a healthy child at the two year check up. Which finding should the nurse report immediately to the registered nurse
(RN)?
A. the growth pattern appears to have slowed
B. the height and weight percentiles vary widely
C. the short term weight changes are uneven
D. the recumbent and standing height are different

A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if
it occurs within 24 to 48 hours after a routine immunization?
A. Some irritability and fussiness
B. Localized tenderness at the injection site
C. Swelling at the injection site
D. Tympanic temperature of 104 F (40 C)

A nurse who works in a public high school is reinforcing information with a class of unwed pregnant students. What is the most important action the nurse
should stress that each girl can take to deliver a healthy child?
A. maintain good nutrition
B. stay in school to keep normal activities
C. keep in contact with the child's father
D. get adequate sleep and frequent rest

During the reinforcement of actions to prevent sudden infant death syndrome (SIDS) with new parents what is the the most important guideline a nurse
should emphasize?
A. place the infant in a supine position for sleep
B. be sure to check the infant hourly during the night
C. follow the recommended immunization schedule
D. do not allow anyone to smoke in the home

A nurse plans to administer liquid medicine to a nine month-old child. Which method is appropriate for the nurse to use?
A. administer the medication with a syringe next to the tongue
B. mix the medication with the infant's formula in the bottle
C. hold the child upright and administer the medicine by spoon
D. allow the infant to drink the liquid from a medicine cup

A nurse measures the head and chest circumferences of a 20 month-old infant. After comparing these measurements, the nurse finds that they are
approximately the same. What action should the nurse take?
A. record these as normal findings
B. listen to breath sounds
C. notify the charge nurse
D. check the anterior fontanel

Prior to giving immunizations, a nurse should check children for possible contraindications which would include which finding?
A. depressed immune system
B. mild cold symptoms
C. low-grade fever
D. chronic asthma

A nurse is preparing to perform parts of a physical examination on an eight month-old who is sitting contentedly on the mother's lap. Which action should the
nurse perform first?
A. examine the skin
B. auscultate the lung sounds
C. measure height and weight
D. examine the external ears

A nurse is discussing the appropriate amount of milk intake with the parents of an 18 month-old child. The nurse should include in the response which
information about the child?
A. can have milk mixed with other foods
B. should have a daily limit of 3 to 4 cups of milk
C. will benefit from fat free cow's milk
D. may drink as much milk as desired

A 14 year-old boy with a history of severe hemophilia A was admitted after a fall while playing basketball. In understanding his behavior and assisting in
planning care for this client, a nurse should recognize that adolescents with hemophilia
A. need to have structured activities
B. often take part in active sports
C. avoid physical risks after bleeding episodes
D. explain any limitations to peers


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A nurse should remember that a toddler's tendency to say "no" to almost everything is an indication of
A. rejection of parents
B. stubborn behavior
C. frustration with adults
D. assertion of control

When the vital signs are taken in children, a nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about
which age (in years)?
A. two
B. four
C. three
D. one


A nurse is reinforcing information about adding table foods with parents of an 11 month-old. Which item should the nurse review as an appropriate finger
food?
A. popcorn
B. sliced bananas cut long wise
C. whole grapes
D. hot dog pieces cut into medallions

A client with heart failure is newly referred to a home health care agency. A nurse identifies that the client has not been following the prescribed diet. It would
be most appropriate for the nurse to take which action at this time?
A. notify the health care provider of the client's failure to follow the prescribed diet
B. recommend a release from home health care related to noncompliance
C. make a referral to Meal-on-Wheels for delivery of one meal three times a week
D. discuss the diet with client to learn the reasons for not following the diet

In reviewing the growth of a 12 month-old child, a nurse expects to find that the infant has which characteristic?
A. increased 10% in height
B. tripled the birth weight
C. two deciduous teeth
D. equal head and chest circumferences

A nurse is planning to give a three year-old child a dose of oral liquid digoxin. Which approach should the nurse plan to use?
A. "Would you like to take your medicine from a spoon or a cup?"
B. "This is your medicine, and you must take it all right now."
C. "Do you want to take this pretty red medicine?"
D. "You will feel better if you take your medicine."

A nurse is checking a two year-old client with a possible diagnosis of congenital heart disease. Which finding is most likely associated with this diagnosis?
A. changes in appetite over the past four to six months
B. weight and height in 10th percentile since birth
C. takes an unusual number of rest periods while playing
D. several otitis media episodes in the last year

While caring for a hospitalized toddler, a nurse reinforces information about the expected developmental changes for this childs age group to the parents.
Which statement by the mother shows that she understands the child's developmental needs?
A. "I understand the need of my child to use new skills."
B. "I intend to keep control over my child."
C. "I will set limits on my childs exploration of the house."
D. "I want to protect my child from any falls."

Which behavior should be of the greatest concern to the nurse when caring for a preschool-aged child?
A. identifies with a family member
B. expresses shame
C. explores the playroom
D. plays imaginatively


110




I. Concepts of Mental Health and Mental Illness

A. Biochemical research

1. Study of the brain and its functioning has helped researchers understand which parts of the brain are involved
in each mental illness

2. Medications are now more effective as a result of a better understanding of neurotransmitters and their
functioning

3. Major neurotransmitters include: norepinephrine, dopamine, serotonin, and gamma-aminobutyric acid (GABA)

4. Neuroimaging through positron emission tomography (PET scan) or the computed tomography (CT scan) and
magnetic resonance imaging (MRI scan) allow researchers and diagnosticians to study the brain without
surgery



B. Genetic research

1. Currently, no type of genetic testing can tell whether a person will develop mental illnesses; not enough is
known about which gene variations contribute to them or the degree to which other factors contribute

2. Familial and genetic factors are part of many major psychiatric illnesses, including bipolar disorder and
schizophrenia


C. Psychological theories

1. Psychoanalytic theory

a. developed by Sigmund Freud

b. introduced concept of the mind as a structure incorporating the id, ego and superego

c. part of each persona's mental functioning is conscious and part unconscious

d. treatment includes helping make the unconscious conscious

e. defense mechanisms are used to defend the ego from conflicts between the id and superego




2. Interpersonal theory

a. originally developed by Harry Stack Sullivan

b. personality develops according to the client's perception of how others view them

c. a healthy personality is the result of healthy relationships

d. Hildegard Peplau, who is considered to be the "mother of psychiatric nursing", was influenced by this theory

i. she wrote Interpersonal Relations in Nursing, which became the foundation for the nurse-client relationship

ii. according to Peplau, the nurse-client relationship is one in which

the client receives unconditional acceptance

the relationship between nurse and client is client-centered

the relationship is developed according to the client's perceived readiness




3. Psychosocial developmental theory

a. developed by Erik Erikson

b. describes eight psychosocial stages of development in the human life cycle

c. development is successful if the person is able to resolve the conflict that arises during each stage

d. if the person does not effectively resolve the conflict, then development is arrested at that stage



4. Cognitive behavioral theory (CBT)

a. focuses on the premise that a person's thoughts control their behavior
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b. if a client is feeling or behaving in an unwanted way, then it is important to identify the thoughts that are causing
these feelings or behaviors

c. the treatment is for the client to replace the current thoughts with ones that produce a more desirable outcome

d. CBT is used to help clients manage symptoms of their illness and live a fuller life


5. Behavioral theory

a. symptoms of mental illness are the result of learned behavior

b. through the use of positive and negative reinforcement unacceptable learned behavior can be replaced by a more
desired behavior

c. symptoms of phobias, sexual dysfunction, and eating disorders are some of the mental illnesses currently treated
using behavioral therapy

d. assertiveness training and desensitization are commonly used behavioral techniques


D. Religious and Spiritual Influences

1. Develop cultural self-awareness - respect the beliefs that are different from those of the nurse

a. Religion - an organized system of beliefs about a higher power

b. Spirituality - beliefs about the essence of being


2. Be familiar with common practices of common religions including value systems, diet, beliefs surrounding death.

a. Catholic

b. Protestant

c. Jewish

d. Muslim

e. Hindu

f. Buddhist

g. Mormon

h. Christian Scientist

i. Jehovah Witness


3. Seek personal spiritual support for clients who are in distress

a. Use of chaplain service

b. Consider HIPAA and client's wishes


4. Recognize that research supports the importance of spiritual support; several studies indicate that prayer
improves health status


E. Cultural Awareness and Cultural Competence

1. Nurse develops cultural self-awareness - respect cultural differences of others

a. Consider culture as different from race or ethnicity alone

b. Determine the cultural beliefs of the client especially related to health practices


2. Be familiar with various cultural practices

a. Folk healing of rural populations

b. Native American practices

c. Integration of Eastern healing or complementary and alternative therapies







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3. Determine any healing practices the client uses, prescribed or unprescribed

a. Use non-judgmental approach

b. Observe for positive or negative interactions of traditional (allopathic) therapy with complementary
alternative therapies (CAT)

c. Document all practices and therapies



F. Grief & Loss

1. Loss

a. a universal phenomenon, occurring across the lifespan

b. types of loss

i. loss of external objects

ii. loss of significant others through death or divorce

iii. loss of environment by relocating, accepting a new job, hospitalization

iv. loss of an aspect of self, which may include a body part (amputation of a limb), physiologic, or psychologic
function

v. perceived loss - felt by the person but intangible to others, e.g., youth

vi. situational loss - the result of an unpredictable event, e.g., natural disaster


c. response to loss depends on

i. personality

ii. culture

iii. previous experience with loss

iv. one's values

v. perceived value of loss

vi. support system




2. Types of grief

a. anticipatory grief: person learns of impending loss and responds with processes of mourning, coping, interaction,
planning, and psychosocial reorganization

b. disenfranchised grief: person experiences a loss that is not or cannot be openly acknowledged, publicly mourned,
or socially supported

c. complicated grief: a result of a sudden loss


3. Mourning: process used to resolve grief

4. Bereavement: a state of grieving

5. Models (or theories) of grief

6. Nursing interventions in grief

a. support client's effective coping mechanisms

b. don't take client's responses personally

c. listen attentively

d. help client with problem-solving and decision-making as indicated

e. encourage the client and/or significant others to express their feelings and concerns

f. utilize therapeutic touch as appropriate

g. assist in discussions of future plans as appropriate



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REMEMBER IT
Tasks of mourning (common to the models of grief): R E A L

Real - accept that the loss is real
Experience the emotions associated with the loss
Adjust or re-adjust to life and activities
Let go and move on with one's own life

II. Therapeutic Interventions

A. Therapeutic relationship

1. Definition: a relationship that is established between a health care professional and a client for the purpose of
assisting the client with problem solving, grief counseling, teaching regarding illness or situation

2. Relationship consists of

a. a nurse who possesses the skills and ability to provide counseling, crisis intervention, health teaching, etc.

b. the client who seeks help for some problem



B. Phases of the nurse-client relationship

C. Five characteristics of nurse-client relationship

1. Mutual definition - the nurse and client define the relationship together

2. Goal direction - purpose, time, and place are specific

3. Specified boundaries - in time, space, content, and confidentiality

4. Therapeutic communication - nurse creates trust and open communication by these interpersonal techniques

5. Nurse helps client toward resolution


D. Types of therapeutic interventions

1. Individual (or one-on-one) therapy

2. Group therapy

3. Family therapy

4. Milieu therapy

5. Occupational therapy



E. The non-compliant client

1. Behavior characteristics - does not cooperate with the treatment plan

a. does not take prescribed medication

b. continues activities restricted by provider of care, such as smoking, drinking, gambling, risk taking behaviors

c. does not follow prescribed activities, such as exercise, adequate rest, healthy diet



2. Nursing interventions

a. explore the reasons for non-compliance

i. lack of understanding - reinforce teaching

ii. lack of family support - involve family and support groups

iii. medication side effects - refer to provider of care

iv. finances and access - refer to Social Services

v. negative attitude toward treatment - encourage expression


b. express genuine concern for client

c. discuss improvement potential


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F. Stress management

1. Stress: a universal phenomenon; requires change or adaptation so that the person can maintain equilibrium

2. Stress can be internal or external

3. Nature of stressor involves

a. intensity

b. scope

c. duration

d. other stressors - their number and nature


4. Categories of stressors - and examples

a. physical - drugs or alcohol

b. psychological - such as adolescent emotional upheaval, or unexpressed anger

c. social - isolation, interpersonal loss

d. cultural - ideal body image

e. microbiologic - infection


5. The greater the stressor as perceived by the client, the greater the stress response

6. Stress response involves both localized and general adaptation

REMEMBER IT
PANIC episode:
Palpitations
Abdominal distress
Nausea
Increased perspiration
Chest pain, chills, choking


7. Factors affecting stress response

a. personal - heredity, gender, race, age, personality, cognitive ability

b. sociocultural - finances, support systems

c. interpersonal - self-esteem, prior coping mechanisms

d. spiritual or belief system

e. environmental - crowding, pollution, climate

f. occupational - work overload, conflict, risk


8. Physiologic indicators of stress (stress response)

9. Emotional and/or behavioral indicators of stress

10. Stress can cause a variety of emotional and physical disorders

11. Stress management strategies



G. Crisis intervention

1. Definition: an acute, temporary state of severe personality disorganization with an extreme state of emotional
turmoil; usual coping mechanisms and resources fail

2. Types

a. acute crisis: client temporarily loses control; panic state

i. emotional reactions are overwhelming
115


ii. decision making and problem solving abilities are inoperative

iii. thinking is scattered

iv. social isolation

v. immobilization (unable to act)


b. exhaustion crisis

i. under emergency conditions

ii. person has lost effective coping

iii. cannot continue to function


c. shock crisis

i. sudden external change

ii. causes release of emotions

iii. overwhelms client



3. (Four) phases of crisis response - average crisis is four to six weeks (may vary widely)

a. vulnerable state

b. precipitating event

i. developmental change - maturational crisis

ii. a life change - situational crisis

iii. loss of loved one or job - situational crisis

iv. environmental disaster or war - adventitious crisis


c. acute crisis

d. reorganization



4. Findings

a. mild to severe anxiety

b. anger

c. crying, social isolation, helplessness

d. impaired cognitive processes; inability to concentrate; confusion

e. insomnia

f. regression

g. nausea and vomiting


5. Treatment - brief supportive interventions focused on the phase of crisis

a. objective: to help the client through the current crisis

b. allow free discharge of emotions

c. enhance client's cognitive processes

d. pharmacologic: trazodone (Desyrel), alprazolam (Xanax)

e. therapies: occupational and recreational


6. Nursing interventions in crisis

a. provide a quiet, restful environment

b. empower the client to solve problems

c. allow the client to express feelings and emotions

d. determine and correct any misperceptions about the crisis the client may have
116


e. help the client to identify support systems and alternative solutions

f. help the client to deal with long term impact of crisis

g. encourage relaxation strategies, e.g., deep breathing, imagery

h. assist the client in the development of new coping skills

i. cognitive behavior therapy

j. administer medications as ordered

k. nursing response to violent situations

i. set consistent limits

ii. inform of consequences

iii. use seclusion and restraints, as indicated

iv. get support and assistance

v. position self for an escape path



H. Suicide Precautions

1. Definition

a. suicide is a self-harming act intended to produce death

b. degrees

i. completed suicide: life ends

ii. attempted suicide: failed self-destructive act

iii. suicide ideation: thoughts of ending one's life

iv. violence can be spontaneous or planned



2. Risk factors for suicide

a. depression/bipolar

b. delusions/hallucinations in psychotic clients - protect from harm

c. hopelessness

d. environmental factors - relationship, social, work and financial loss

e. substance abuse

f. isolation

g. previous suicide attempt

h. unwillingness to seek help


3. Findings - suicide warning signs

a. statements about suicide or violence - verbal or written

b. often exhibit stillness or calmness prior to the act

c. negative feelings, e.g., anger, sadness, hopelessness, negative view of future

d. recent loss of job, loved one, possessions

e. perceived lack of any support system

f. self-mutilation or other destructive behaviors



4. Treatment for suicidal thoughts and behaviors

a. objective - to treat the condition that underlies the suicidal thoughts

b. medications, including antidepressants, antianxiety, and/or antipsychotics

c. Suicide precautions

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5. Nursing care for clients at risk for suicide

a. goal - to assess the client's safety and toto protect client and others

b. establish trusting relationship; use therapeutic communication to encourage negative of feelings, thoughts, plans

c. monitor for verbal or clues such as giving away valuable possessions

d. administer medications as ordered

e. institute suicide precautions, as indicated by data

f. encourage relaxation strategies

g. notify appropriate health care provider


I. Abuse, Maltreatment and Neglect

1. Definitions: any recent act or failure to act that results in death, serious physical or emotional harm, sexual abuse
or exploitation; or an act or failure to act which presents an imminent risk of serious harm

a. types

i. abuse and neglect: child physical abuse, child sexual abuse, child neglect, child psychological abuse

ii. adult maltreatment and neglect: spouse or partner violence (physical or sexual), spouse or partner neglect,
spouse of partner abuse (psychological), adult abuse by nonspouse or nonpartner


b. abuse may be physical, sexual, emotional (or psychological); abandonment of children; substance abuse


2. Etiology

a. biological theories: neurophysiological, biochemical, genetic influences; disorders of the brain

b. psychological theories: psychodynamic theory and learning theory

c. sociocultural theories


3. Findings

a. abusers: blame the victim, are jealous and controlling, demonstrate poor impulse control; low self-esteem;
have unrealistic expectations; are frequently victims of abuse themselves and have a history of past battering

b. person suffering from abuse

i. battered women: low self-esteem, accept the blame; feelings of guilt, anger, fear, shame; isolated from
family and support systems

ii. specific symptoms of abuse: physical (broken bones or dislocations, welts and/or bruises, burns,
inappropriate bald spots; signs of being restrained); sexual (bruising or bleeding in genital or anal area; pain
or itching in genital area; genitourinary infection; evidence of sexual intercourse) and emotional (rocking,
sucking, or mumbling)

iii. symptoms of neglect: malnutrition; extremes in behavior and learning disorders in child; social isolation;
unattended medical problems; unwashed; inappropriately dressed; has attempted suicide


c. cycle of abuse

i. phase I: the tension-building phase

ii. phase II: the acute battering incident

iii. phase III: the "honeymoon" phase (calm, loving, respite)




4. Treatment

a. crisis intervention: remove victim from source of abuse, contact protective services, report to appropriate state
entity

b. family therapy


5. Nursing care

a. ensure privacy

b. limit the number of different health care workers
118


c. provide information about any procedure before beginning

d. offer support

e. stress the importance of safety

f. assist with filing collecting data and filing appropriate reports


III. Therapeutic Communication

A. Overview

1. Consider the developmental level, culture, spiritual and emotional aspects, and physical condition of the
client

2. Focus on actual objective behaviors, not on subjective inferences

3. Focus on description, not on judgment

4. Share information and explore alternatives, instead of offering advice and solutions

5. Focus on how and what and not "why"

6. For confused or disoriented clients, focus on reality orientation

7. Ask open-ended questions and seek information

8. Focus on nursing interventions


B. Therapeutic communication techniques to use

C. Nontherapeutic communication to avoid


D. Cross-cultural Communication

1. Findings of nontherapeutic communication

a. efforts to change the subject - client may not understand what the nurse is saying

b. lack of questions - client may not understand what was said

c. nonverbal cues - blank expression, lack of eye contact


2. Nursing interventions and therapeutic communication

a. use simple sentence structure and gestures while talking

b. use visual aids

c. discuss one topic at a time

i. use the same words when you repeat a topic

ii. go from simple to complex, or familiar to unfamiliar


d. use any words you know in the client's language

e. use a medical interpreter service for verbal communication - avoid using family members as interpreters

f. obtain phrase books or use flash cards

g. ask open-ended questions


3. Cultural interpretations

a. silence

b. (appropriate and therapeutic) touch

c. (culturally-appropriate) eye contact



E. Clients with Hearing Loss

1. Findings of hearing loss

a. speech deterioration

b. indifference
119


c. social withdrawal

d. suspicion

e. tendency to dominate conversation

f. misinterpretation of what is said

g. lack of response to direct questioning


2. Nursing interventions

a. speak slowly and distinctly; do not shout

b. face client directly

c. make sure your face is clearly visible

d. before the discussion, tell client the topic you are going to discuss

e. insure that client has access to hearing aid and that it is functional

f. keep sentences short and simple

g. use written information to enhance spoken word

h. use lower tone of voice



F. Clients with Aphasia

1. Injured cerebral cortex blocks some language-related functions

2. Types of aphasia

a. global aphasia - the most severe form of aphasia where individuals cannot read, write, or understand speech

b. Broca's aphasia ("non-fluent" aphasia) - speech is limited mainly to short utterances of less than four words;
the client may understand speech and be able to read but has limited writing ability

c. Wernicke's aphasia ("fluent" aphasia) - inability to understand the meaning of spoken words and reading and
writing is impaired; able to speak but sentences do not hang together and speech may consist of mostly jargon


3. Nursing interventions

a. face client and establish eye contact

b. avoid completing client's statements

c. use gestures, pictures, and communication boards

d. limit conversation to practical matters

e. use the same words and gestures for objects

f. keep background noise to a minimum and turn off competing sounds, e.g., radio, television

g. do not shout or speak loudly

h. give the client time to understand and respond

i. if client has problems speaking, ask "yes" or "no" questions



120

G. Clients Post-CVA

1. Approach client from side of intact field of vision

2. Remind client to turn head in direction of visual loss to compensate for loss of visual field

3. Explain location of object when placing it near the client

4. Always put client care items in same places

5. Put objects within client's reach and on unaffected side

6. Encourage client to repeat sounds of the alphabet

7. Speak slowly and clearly

8. Use simple sentences with gestures or pictures

9. Reorient client to time, place, and situation

10. Provide familiar objects

11. Minimize distractions

12. Repeat and reinforce instructions


H. Clients with Dementia

1. Be calm and unhurried

2. Keep conversations short and focused

3. Do not ask the client to make decisions

4. Use "yes" or "no" questions

5. Be consistent

6. Avoid distractions

7. Use reality orientation techniques

REMEMBER IT
Communication with individuals with
aphasia or dementia is enhanced if you
remember the K.I.S.S. technique:
Keep It Short and Simple!

The nurse-client relationship is a mutually defined, social relationship. True False

Peplau is considered to be the mother of psychiatric nursing. True False

Grieving over the loss of a loved one lasts for approximately one year. True False

Primitive defense mechanisms are very effective for long-term use. True False

Stress mobilizes the parasympathetic nervous system. True False

Liquid medications are best for clients who are on suicide precautions. True False

A person under stress has pinpoint pupils and feels an urge to urinate. True False

The nurse should write everything down for the client with Wernicke's aphasia. True False

Be sure to look directly at clients before starting to speak. True False

Religious beliefs influence decisions about health. True False




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IV. Mental Disorders

A. Anxiety Disorders

1. Definition: a condition in which a person has excessive fear and anxiety and related behavioral disturbances

a. types: separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic
disorder, agoraphobia, generalized anxiety disorder (GAD)

b. depression and substance abuse may occur with an anxiety disorder


2. Etiology

i. not known; may have a genetic link

ii. stress may contribute to the development of GAD


3. Findings

a. main symptom is frequent worry or tension for at least 6 months, even when there is little or no clear
cause; usually related to family, other relationships, work, school, money, health

b. even when aware that worries or fears are stronger than appropriate for the situation, a person with GAD
still has difficulty controlling them

c. other symptoms: problem concentrating; fatigue; irritability; problems falling or staying asleep or restless
sleep; restlessness when awake; upset stomach; sweating; difficulty breathing; muscle tension.



Generalized Anxiety Disorder Panic Disorder




4. Diagnostics

i. physical exam and mental health assessment

ii. laboratory tests to rule out other conditions that may cause similar symptoms


5. Treatment

a. talk therapy

b. medications

i. antidepressants

SSRIs: fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), citalopram (Celexa)

SNRI: venlafaxine (Effexor) is commonly used to treat GAD

bupropion (Wellbutrin)

tricyclic antidepressants: imipramine (Tofranil) is prescribed for panic disorder and GAD

MAOIs: phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan)


ii. anti-anxiety: buspirone (Buspar) for GAD

iii. beta-blockers: propranolol (Inderal)

iv. benzodiazepines: clonazepam (Klonopin) for social phobia and GAD, lorazepam (Ativan) for panic disorder,
alprazolam (Xanax) for panic disorder and GAD


c. stress and relaxation techniques, yoga, acupuncture; kava


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6. Nursing care

a. provide non-demanding environment

b. acknowledge clients feelings

c. do not force contact with feared item or situation

d. provide distracting activities

e. use relaxation techniques

f. identify triggers

g. encourage client to take responsibility for self-care

h. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management

stress management strategies

teach ways to interrupt escalating anxiety


iii. support services, including crisis hotline, support groups, individual psychotherapy




B. Bipolar & Related Disorders

1. Definition: a condition in which a person has episodes of depression and periods of being extremely happy or
being cross and irritable; it includes changes in activity and energy as well as mood

a. types of disorders: bipolar I, bipolar II, cyclothymic

b. cycle: episodes of depression are more common than episodes of mania


2. Etiology: not known; but it occurs more often in relatives of people with bipolar disorder

a. affects men and women equally

b. usually starts between ages 15 and 25

c. common triggers of a manic episode: childbirth, medications (antidepressants or steroids), insomnia,
recreational drug use


3. Findings

a. manic phase may last days to months: easily distracted, little need for sleep, poor judgment, poor temper
control, reckless behavior and lack of control (such as excessive drinking, drug use, sex with many partners,
spending sprees), expansive or irritable mood (racing thought, talking a lot, false beliefs about self or abilities),
very involved in activities

b. depressive episodes are more common than mania and may include: daily low mood or sadness, difficulty
concentrating, remembering or making decisions, eating problems (loss of appetite and weight loss or
overeating and weight gain), fatigue or lack of energy, feeling worthless, hopeless or guilty, loss of pleasure in
activities once enjoyed, loss of self-esteem, thoughts of death or suicide, trouble of getting to sleep or sleeping
too much, pulling away from friends or activities that were once enjoyed


4. Diagnostics: physical exam and mental health assessment


5. Treatment

a. medications

i. mood stabilizers

lithium

anticonvulsants: valproic acid (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), oxcarbazepine
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(Trileptal)


ii. antidepressants (SSRIs): fluoxetine (Prozac), sertraline (Zoloft)

iii. atypical antipsychotics: olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal), ziprasidone
(Geodon), clozapine (Clorazil), lurasidone (Latuda)


b. electroconvulsive therapy (ECT)

c. support programs and talk therapy

d. hospitalization for severe manic or depressive episode


6. Nursing care

a. prevent self-injury and suicide ( Suicide Precautions )

b. mania:

i. offer high protein, high calorie finger foods, supplements for weight loss/malnutrition

ii. set limits on manipulative behavior

iii. positive reinforcement for appropriate behavior

iv. reduce stimuli


c. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

causes of bipolar disorder

cyclic nature of the illness

symptoms of depression and mania


ii. management of the illness

medication management

lithium: symptoms of toxicity, importance of regular blood tests

side effects

adverse effects

importance of not stopping medication

assertive techniques

anger management

electroconvulsive therapy


iii. support services, including crisis hotline, support groups, individual psychotherapy; legal and/or financial
assistance



C. Depressive Disorders

1. Definition: characterized by the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive
changes that significantly affect the individuals capacity to function for weeks or longer; types include disruptive
mood dysregulation, major depressive disorder, persistent depressive disorder (formerly called dysthymia),
premenstrual dysphoric disorder

2. Etiology

a. exact cause is not known; most likely it's due to a combination of genetic, biological, environmental and
psychological factors

b. alcohol or drug abuse, hypothyroidism or chronic pain, medications (steroids), sleeping problems, and
stressful life events are associated with depression


3. Findings

a. agitation, restlessness, and irritability, anger; becoming withdrawn or isolated, fatigue and lack of energy,
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feeling hopeless and helpless, worthless, guilty, self-hate; loss of interest or pleasure in activities that were
once enjoyed; sudden change in appetite, thoughts of death or suicide; trouble concentrating; trouble sleeping
or sleeping too much

b. severe depression can also be accompanied by hallucinations and delusions






4. Diagnostics

i. physical exam and mental health assessment

ii. blood and urine test to rule out other medical conditions with symptoms similar to depression


5. Treatment

a. medications - antidepressants

i. SSRIs: fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), paroxetine (Paxil), escitalopram (Lexapro)

ii. SNRIs: venlafaxine (Effexor) and duloxetine (Cymbalta)

iii. bupropion (Wellbutrin)

iv. tricyclics, tetracyclics, and MAOIs may also be used


b. talk therapy

i. cognitive behavioral therapy - to teach hot to fight off negative thoughts

ii. psychotherapy - to help to understand the issues that may be behind thoughts and feelings

iii. group therapy - to share with other who have like problems


c. electroconvulsive therapy (ECT)

d. light therapy - to relieve symptoms in the winter time (seasonal affective disorder or SAD)

e. acupuncture, stress and relaxation techniques, massage, meditation, yoga, Tai Chi, Qigong, SAMe

Due to its short half-life (and few drug interactions), Zoloft is the drug of choice for treating depression in the elderly.
Conversely, due to its long half life, PROzac is a better choice for children.


6. Nursing care

a. watch for suicidal behavior in children, teens, young adults ( suicide warning signs and suicide precautions )

b. encourage participation in goal setting and decision-making for own care

c. encourage client to explore and verbalize feelings and perceptions

d. monitor sleep, eating and self-care activities

e. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management
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side effects to report to the health care provider

importance of taking medications regularly

length of time to take effect

diet (specifically for MAOIs)

AVOID concurrent use of natural remedies (St. John's wort and certain antidepressants can lead to
serotonin syndrome)

assertiveness techniques

stress management strategies

way to increase self-esteem

electroconvulsive therapy (ECT)


iii. support services, including suicide hotline number; support groups; legal and financial assistance



D. Feeding & Eating Disorders

1. Definition: characterized by a persistent disturbance of eating or eating-related behavior that results in the
altered consumption or absorption of food and that significantly impairs physical health or psychosocial
functioning

a. types: pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa,
binge-eating disorder

b. serious medical complications can develop over time

i. anorexia - severe malnutrition, low potassium levels, heart problems, confusion

ii. bulimia nervosa - constipation, dehydration, dental cavities, electrolyte imbalances, hemorrhoids,
pancreatitis, swelling of the throat, tears of the esophagus



2. Etiology

a. not known

b. risk factors for anorexia include having an anxiety disorder as a child; having a negative self-image; having
certain social or cultural ideas about health and beauty; trying to be perfect or overly focused on rules


3. Findings

a. anorexia nervosa - severely limiting food intake; cutting food into small pieces and moving around the plate;
refusing to eat around other people; exercising all the time; using diuretics, enemas and laxatives and diet
pills; blotchy or yellow, dry skin covered with fine hair; depression, dry mouth; extreme sensitivity to cold; loss
of bone strength; muscle wasting and loss of body fat

b. bulimia nervosa - eat large amounts of high-calorie foods, usually in secret; forced vomiting; cavities or
gingivitis and enamel of teeth may be worn away or pitted due; excessive exercise; broken blood vessels in the
eyes; dry mouth; using laxatives, enemas or diuretics; small cuts and calluses across the tops of the finger
joints (from forcing oneself to vomit) known as Russells sign



4. Diagnostics

a. anorexia nervosa - laboratory tests to help find the cause of weight loss or to determine damage done by weight
loss including albumin, bone density test, CBC, ECG, electrolytes, kidney function tests, liver function tests, total
protein, thyroid function tests, urinalysis

b. bulimia nervosa - dental exam

c. general

i. physician exam and mental health assessment, including family history

ii. clinician-administered tests, such as Eating Disorder Examination (EDE), Yale-Brown-Cornell Eating Disorder
Scale (YBC-EDS)

iii. self-reports, such as Diagnostic Survey for Eating Disorders (DESD), Eating Attitudes Test (EAT), Eating
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Disorders Questionnaire (EDQ) and many others



5. Treatment

a. anorexia

i. hospitalization may be needed; follow-up with day treatment program

ii. increasing social activity, reducing the amount of physical activity, using schedules for eating (nutritional
rehabilitation)

iii. refeeding programs

iv. medications: antidepressants such as the SSRI fluoxetine (Prozac) (regardless of whether or not the client is
depressed)

v. talk therapy, including cognitive behavioral therapy, group therapy, and family therapy; support groups



b. bulimia

i. a stepped approach, including support groups, cognitive behavioral therapy, and nutritional therapy

ii. medications: antidepressants such as the SSRI fluoxetine (Prozac)

iii. support groups, such as Overeaters Anonymous and American Anorexia/Bulimia Association



6. Nursing care

a. establish adequate/appropriate nutritional intake

b. correct fluid and electrolyte imbalance

c. assist client to develop realistic body image and to improve self-esteem

d. provide support and involve significant others (including family) in treatment program

e. participate in total treatment program with other disciplines

f. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

symptoms of the illness

causes of eating disorder

effects of the illness or condition on the body


ii. management of the illness

principles of nutrition

importance of expressing fears and feelings

alternative coping strategies, relaxation techniques, problem-solving skills

correct administration of prescribed medications

indication for and side effects of medications

when to contact health care provider


iii. support services, such as Overeaters Anonymous, National Association of Anorexia Nervosa and Associated
Disorders (ANAD), the American Anorexia/Bulimia Association, Inc.



E. Neurodevelopmental Disorders

1. Definition: characterized by developmental deficits that produce impairments of personal, social, academic, or
occupational functioning; typically manifested before a child enters grade school

a. types: intellectual disability (intellectual developmental disorder), global developmental delay, language
disorders (including stuttering), autism spectrum disorder, attention-deficit/hyperactivity disorder, learning
disorder, tic disorder

b. requires assessing both cognitive capacity (IQ) and adaptive functioning


2. Etiology
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a. autism spectrum disorder: exact causes are not known

i. linked to abnormal biology and chemistry in the brain

ii. diet, digestive tract changes, mercury poisoning are also considered

iii. can be associated with other disorders of the brain, such as fragile X syndrome, tuberous sclerosis


b. attention deficit hyperactivity disorder (ADHD): not known; probably due to a combination of genetics and
environmental factors


3. Findings

a. autism spectrum disorder

i. difficulties in pretend play, social interactions, verbal and nonverbal communication

ii. overly sensitive in sight, hearing, touch, smell, or taste

iii. have unusual distress when routines are changed, perform repeated body movements, show unusual
attachments to objects


b. attention deficit hyperactivity disorder (ADHD): symptoms fall into 3 groups

i. inattentiveness

ii. hyperactivity

iii. impulsivity




4. Diagnostics

a. autism spectrum disorder

i. complete physical and neurologic exam

ii. hearing evaluation (for delay in language milestones)

iii. blood lead test

iv. genetic testing (for chromosome abnormalities)

v. metabolic testing

vi. screening tests, such as the Checklist for Autism in Toddlers [CHAT] or Autism Screening Questionnaire) and
evaluation of autism (using the Autism Diagnostic Interview-revised (ADI-R); Autism Diagnostic Observation
Schedule (ADOS); Childhood Autism Rating Scale (CARS); Gilliam Autism Rating Scale; pervasive
Developmental Disorders Screening Test-Stage 3


b. attention deficit hyperactivity disorder (ADHD)

i. complete physical and neurologic exam

ii. diagnosis is based on a pattern of the symptoms

iii. many children have at least one other developmental or mental health problem such as a mood, anxiety or
substance use disorder, a learning disability, or a tic disorder



5. Treatment

a. autism spectrum disorder - treatment is most successful when it is geared toward the child's particular needs

i. applied behavior analysis (ABA)

ii. medications - to treat aggression, anxiety, attention problems, extreme compulsions; hyperactivity,
impulsiveness, irritability, mood swings, sleep difficulties, tantrums

risperidone (Risperdal) - an antipsychotic approved to treat children ages 5-16 for irritability and aggression

SSRIs

divalproex (Depakote) - an anticonvulsant also used to treat the manic phase of bipolar disorder

mood stabilizers

stimulants, such as methylphenidate (Ritalin, Concerta)

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iii. diet - some children respond to gluten-free or casein-free diet

iv. various therapies, including occupational therapy, physical therapy, speech-language therapy, vision therapy
and sensory integration therapy

v. support groups


b. attention deficit hyperactivity disorder (ADHD) - partnership between health care provider and client; if client is a
child, then parents and teachers are involved

i. set specific appropriate goals

ii. medication: psychostimulants (stimulants), including methylphenidate(Ritalin, Concerta), amphetamine
(Adderall), dextroamphetamine (Dexedrine), lisdexamfetamine dimesylate (Vyvanse)

iii. various therapies, including talk therapy, behavioral therapy (to teach healthy behaviors and how to manage
disruptive behaviors)

iv. support groups



6. Nursing care

a. consistent daily schedule

b. limit distractions

c. clear and consistent rules for child

d. encourage, praise and reward independent achievement

e. assess the clients mental status

f. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management

side effects

length of time to take effect

what to expect from the medication

explain drug "holiday" (for ADHD)

AVOID over-the-counter medication

importance of not stopping medication

importance of sleep

importance of good nutrition

problem-solving skills


iii. support services, including support groups; legal and financial assistance



F. Obsessive-compulsive and related disorders

1. Definition: an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations
(obsessions), or behaviors that make them feel driven to do something (compulsions)

a. types: obsessive-compulsive disorder (OCD), body dysmorphic disorder, hoarding, trichotillomania disorder
(hair pulling), excoriation disorder (skin-picking)

b. OCD does not usually progress into another disease but there can be long-term complications, such as
excessive hand washing can cause skin breakdown and compulsive hair pulling can lead to hair loss


2. Etiology: not known; however, factors that may play a role include head injury, infections and abnormal brain
function

3. Findings

a. obsessions or compulsions that are not due to medical illness or drug use
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b. obsessions or compulsions cause major distress or interfere with everyday life; not doing the obsessive rituals
can cause great anxiety; the person recognizes the behavior is excessive and unreasonable

c. many people with OCD may have other psychiatric comorbid disorders, including mood and anxiety disorders,
eating disorders, ADHD


4. Diagnostics

a. physical exam and mental health assessment

b. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to define range and severity of symptoms



5. Treatment

a. medications

i. antidepressants

tricyclic: clomipramine (Anafranil) is used to treat OCD

SSRIs: such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and
citalopram (Celexa)


ii. antipsychotics: olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal)

iii. mood stabilizers: carbamazepine (Tegretol), divalproex (Depakote), lamotrigine (Lamictal)


b. cognitive behavior therapy (exposure and response prevention or ERP)

c. deep brain stimulation (when OCD does not respond to other treatments)


6. Nursing care

a. promote a predictable, structured schedule

b. avoid engaging in power struggles

c. identify triggers to ritualistic behaviors

d. initially allow time for rituals and then begin to limit

e. provide positive reinforcement for non-ritualistic behavior

f. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management, including side effects, length of time to take effect and what to expect

stress management strategies

teach ways to interrupt escalating anxiety


iii. support services, including crisis hotline, support groups, individual psychotherapy; legal and/or financial
assistance



G. Personality disorders

1. Definition: an enduring pattern of inner experience and behavior that deviates markedly from the expectations of
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the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over
time, and leads to distress or impairment

a. types: general personality, paranoid personality, schizoid personality, schizotypal personality, antisocial
personality, borderline personality, histrionic personality, narcissistic personality, avoidant personality,
dependent personality, obsessive-compulsive personality

b. complications include imprisonment, drug abuse, violence, suicide


2. Etiology: not known

a. may be related to genetic factors and environmental factors, for example, subjected as a child to abuse,
alcoholic parents, etc.

b. more men than women are affected

c. fire-setting and cruelty to animals during childhood are linked to the development of antisocial personality



3. Findings: may be able to act witty and charming; be good at flattery and manipulating other peoples emotions;
break the law repeatedly; disregard the safety of self and others; have problems with substance abuse; lie, steal
and fight often; show no guilt or remorse; are often angry or arrogant

4. Diagnostics: psychological evaluation to assess history and severity of symptoms


5. Treatment: difficult to treat; people usually start treatment when required by court action

a. behavioral treatment

b. talk therapy

c. medication can be used to treat symptoms of anxiety, anger, impulsiveness



6. Nursing care

a. protect client and others from harm

b. provide low environmental stimuli

c. observe behavior

d. set limits and provide structured environment

e. gradually encourage appropriate expression of anger

f. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management, including side effects

relaxation techniques

participation in therapy


iii. support services, including financial and legal assistance



H. Schizophrenia Spectrum & Other Psychotic Disorders

1. Definition: a lifelong condition that makes it hard to think clearly, to tell the difference between what is real and
not real, to have normal emotional responses and to act normally in social situations

a. types: schizophrenia, psychotic disorders, schizotypal (personality) disorder

b. defined by abnormalities in one or more of the following: delusions, hallucinations, disorganized speech

c. complications: having schizophrenia increases the risk of developing problems with drugs or alcohol, physical
illness (due to inactive lifestyle and medication side effects), suicide


2. Etiology: not known; there may be a genetic factor

a. affects about 1% of the world population

b. usually first diagnosed in late teens to early 20s

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3. Findings: symptoms develop slowly over months or years

a. early symptoms: may include irritable or tense feelings, trouble concentrating, trouble sleeping

b. later symptoms: involve thinking, emotions, and behavior, including: bizarre behaviors, hallucinations,
isolation, reduced emotion, problems paying attention, delusions, loose associations



4. Diagnostics

a. physical exam and mental health assessment

b. brain scans (CT or MRI)

c. laboratory tests to rule out other conditions with similar symptoms


5. Treatment

a. hospitalization during acute episodes

b. medications

i. antipsychotics

typical: chlorpromazine (Thorazine), haloperidol (Haldol), perphenazine, fluphenazine

atypical: clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone
(Geodon), aripiprazole (Ability), paliperidone (Invega), lurasidone (Latuda)


ii. antiparkinsonism agents: used to counteract the extrapyramidal side effects (tardive dyskinesia) of many
antipsychotic medications


c. support programs, including family therapy

d. behavioral techniques, such as social skills training, job training


6. Nursing care

a. establish therapeutic relationship - build trust, be honest and dependable

b. avoid touching the client without warning

c. observe for signs of hallucinations but do not reinforce hallucinations - orient client to reality

d. encourage independence in ADLs but intervene as needed

e. give recognition and positive reinforcement for appropriate interactions with others

f. prevent injury to others, self-injury and suicide ( suicide precautions )

g. monitor for side effects of medications

h. assist with setting realistic goals

i. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management

medication side effects

importance of not stopping medications
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when to contact health care provider

relaxation techniques and stress management strategies

skills training, such as social skills training and daily living skills training


iii. support services, including financial and legal assistance; support groups; respite care



I. Substance-related and Addictive Disorders

1. Definition: substance use disorder is a maladaptive pattern of substance use leading to clinical significant
impairment or distress; characterized by addiction, craving, tolerance, withdrawal

a. many different classes of drugs including cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics and
anxiolytics, stimulants

b. often co-occurring mental illness and substance abuse

c. potential complications include bacterial endocarditis, depression, overdose, cancer (mouth and stomach
cancer are associated with alcohol abuse), HIV, memory or concentration problems, problems with the law,
relapse of drug abuse, unsafe sexual practices


2. Etiology: not known; however, genetics, the action of the drug, peer pressure, emotional distress, anxiety,
depression or another mental health problem can contribute to use/abuse

3. Findings

a. stimulants: alertness with increased vigilance, a sense of well-being and euphoria; talkative, flight of ideas,
insomnia, anorexia, tachycardia, hypertension, pupillary dilation

b. opioids: symptoms of mild-to-moderate intoxication include drowsiness, pupillary constriction, slurred speech;
for overdose, respiratory depression, stupor and coma

c. depressants: drowsiness, relaxation, decreased inhibition, incoordination, slurred speech, staggered walk,
respiratory depression

d. specific to chronic alcohol use: anemia, cirrhosis, esophagitis, delirium tremens, hepatomegaly, malabsorption
syndrome, Wernicke-Korsakoff syndrome

e. non-specific: continuing to use drugs even when health, work, or family are being harmed; episodes of
violence/ hostility when confronted about drug use; lack of control over drug use; making excuses to use drugs;
missing work or school or decrease in performance; need for daily or regular drug use to function; neglecting to
eat; not caring for physical appearance; no longer taking part in activities because of drug use; secretive
behavior to hide drug use



4. Diagnostics

a. physical exam and mental health assessment

b. laboratory tests including toxicology screens on blood and urine samples, CBC, electrolytes; liver function tests,
hepatitis viral testing, HIV testing, blood cultures; also ECG, CT scan

c. other tests: naloxone challenge test (for opioid abuse)

d. questionnaires, including Michigan Alcoholism Screening Test (MAST), Cage Questionnaire


5. Treatment

a. begins with recognizing the problem

b. detoxification

i. alcohol

benzodiazepines and antipsychotic medications to treat acute phase

disulfiram (Antabuse) alcohol abuse deterrent

naltrexone (Revia) or nalmefine (Revek) - lower cravings for and less pleasure from drinking


ii. opioids: methadone, clonidine (Catapres) and buprenorphine (Buprenex)

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c. treat malnutrition; treat vitamin and mineral deficiencies (folate, B12, vitamin A, calcium) as needed

d. treat infectious diseases

e. support

counseling

support groups, such as Narcotics Anonymous, Alcoholics Anonymous, Smart Recovery, Lifering Recovery


f. after-care (abstinence)


6. Nursing care

a. during acute withdrawal

i. protect client from harm

ii. monitor vital signs

iii. seizure precautions

iv. consult dietitian

v. participate in total treatment program with other disciplines


b. during abstinence

i. provide emotional support

ii. support development of new coping skills

iii. set limits on manipulative behavior

iv. provide positive feedback for delayed gratification and using adaptive coping strategies


c. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

effects of substance on the body

ways in which use of substance affects life


ii. management of the illness

activities to substitute for substance in times of stress

relaxation techniques

problem-solving skills

essentials of good nutrition, including vitamins supplements


iii. support services, including financial and legal assistance; alcoholics anonymous (or other support group
specific to the abused substance); one-to-one support person



J. Trauma- and Stressor-related Disorders (PTSD)

1. Definition: a type of anxiety disorder in which there has been exposure to a traumatic or stressful event that
involved the threat of injury or death; types include reactive attachment, disinhibited social engagement,
posttraumatic stress (PTSD), acute stress, adjustment

2. Etiology: not known

a. traumatic events, such as an assault, car accidents, domestic abuse, natural disasters, prison stay, rape,
terrorism, war, cause someone to develop PTSD

b. the body keeps releasing the stress hormones and chemicals


3. Findings of PTSD

a. 3 main issues

i. reliving the event, which disturbs day-to-day activity

ii. avoidance

iii. hyperarousal

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b. may also have guilt about the event (survivor guilt)

c. symptoms of anxiety, stress and tension



4. Diagnostics

a. physical exam and mental health assessment

b. blood tests to rule out other illnesses

c. PTSD is diagnosed when someone has symptoms for at least 30 days

d. assessment tools, including the Clinician-Administered PTSD Scale (CAPS); Brief Interview for Posttraumatic
Disorder (BIPD), Acute Stress Disorder Interview (ASDI)


5. Treatment of PTSD

a. cognitive behavioral therapies

b. eye movement desensitization and reprocessing (EMDR)

c. hypnotherapy

d. medications

i. the only FDA-approved medication are SSRIs: sertraline (Zoloft) and paroxetine (Paxil)

ii. "off label" medications: other antidepressants (for example, fluoxetine [Prozac]), mood stabilizers and
anxiolytics (benzodiazepines)



6. Nursing care for PTSD

a. establish trust

b. encourage verbalization about the trauma when ready

c. stay with client during periods of flashbacks and nightmares

d. discuss coping strategies

e. assess for self-destructive ideas or behavior, including suicide warnings

f. assess for maladaptive coping (such as substance abuse)

g. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management, including side effects, length of time to take effect and what to expect from the
medication

stress management

teach ways to interrupt escalating anxiety


iii. support services, including crisis hotline, support groups, individual psychotherapy; legal and/or financial
assistance



K. Other Disorders

1. Disruptive, impulse-control, and conduct disorders
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a. these disorders include conditions involving problems in the self-control of emotions and behaviors

b. this group of disorders includes: oppositional defiant disorder, intermittent explosive disorder, conduct
disorder, antisocial personality disorder, pyromania, kleptomania


2. Dissociative disorders

a. these disorders are characterized by a disruption of and/or discontinuity in the normal integration
consciousness, memory, identify, emotion, perception, body representation, motor control, and behavior

b. this group of disorders includes: dissociative identify disorder, dissociative amnesia,
personalization/derealization disorder


3. Elimination disorders

a. these disorders involve the inappropriate elimination of urine or feces and are usually first diagnosed in
childhood or adolescence

b. this group of disorders includes: enuresis (repeated voiding of urine into inappropriate places) and encopresis
(repeated passage of feces into inappropriate places)


4. Neurocognitive disorders (NCD)

a. this category encompasses the group of disorders in which the primary clinical deficit is in cognitive function,
and that are acquired rather than developmental and represent a decline from a previously attained level of
functioning

b. this group of disorders includes: Alzheimers disease; vascular NCD; NCD with lewy bodies; NCD due to
Parkinsons disease, traumatic brain injury, HIV infection, Huntingtons disease, prion disease

c. formerly referred to as dementia, delirium, amnestic, and other cognitive disorders



5. Sleep-wake disorders

a. individuals with these disorders typically present with sleep-wake complaints of dissatisfaction regarding the
quality, timing, and amount of sleep; resulting daytime distress and impairment are core features

b. this group of disorders includes: insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related
sleep disorders, circadian rhythm sleep-wake disorders, non-rapid eye movement sleep arousal disorders,
nightmare disorder, rapid eye movement sleep behavior disorder, restless legs syndrome


6. Sexual dysfunctions

a. sexual dysfunctions are a heterogeneous group of disorders that are typically characterized by a clinically
significant disturbance in a persons ability to respond sexually or to experience sexual pleasure; an individual may
have several disturbances at the same time

b. this group of disorders includes: delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual
interest/arousal disorder, premature ejaculation


7. Somatic symptom and related disorders

a. somatic symptoms are associated with significant distress and impairment

b. this group of disorders includes: somatic symptom disorder, illness anxiety disorder, conversion disorder,
factitious disorder


8. Paraphilic disorders

a. a condition in which a person's sexual arousal and gratification depend on fantasizing about and engaging in
sexual behavior that is atypical and extreme

b. this group of disorders includes: voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual
masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, transvestic disorder


9. Gender dysphoria - a condition in which a person feels that there is a mismatch between his/her biological sex and
gender identify

L. Other significant conditions
Note: these conditions are not specified as mental disorders; however, they are clinically significant because they
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affect mental disorders:

1. Abuse and neglect : child physical abuse, child sexual abuse, child neglect, child psychological abuse

2. Relational problems: problems related to family upbringing and primary support group

3. Adult maltreatment and neglect : spouse or partner violence (physical or sexual), spouse or partner neglect,
spouse of partner abuse (psychological), adult abuse by nonspouse or nonpartner

4. Educational and occupational problems

5. Housing and economic problems

6. Other problems related to the social environment, such as living alone, acculturation, social exclusion, rejection,
discrimination

7. Problems related to crime interaction with the legal system: victims of crime, conviction in civil or criminal
proceedings without imprisonment, imprisonment, problems related to release from prison, problems with legal
circumstances


The only FDA-approved type of medications used to treat this disorder are SSRIs.
Post-traumatic stress disorder (PTSD)

Electroconvulsive therapy (ECT) is used to treat a severe form of this disorder.
Depressive disorder

Russells sign is observed with this disorder.
Bulimia nervosa

A person with this disorder may experience drastic changes in mood accompanied by extreme changes
in energy, activity, sleep and behavior.
Bipolar disorder

A drug holidays are sometimes used in the management of this disorder.
Attention deficit hyperactivity disorder (ADHD)

A person with this disorder recognizes their behavior is excessive and unreasonable but cannot stop the
behavior.
Obsessive-compulsive disorder

A person with this disorder experiences hallucinations and delusional thoughts.
Schizophrenia

Malabsorption syndrome and Wernicke-Korsakoff syndrome are associated with this disorder.
(Chronic) Alcoholism

This disorder includes Alzheimers disease, traumatic brain injury, and Huntingtons disease.
Neurocognitive disorders

The child with this disorder has difficulties with social interaction and verbal and nonverbal
communication and also exhibits repetitive behaviors.
Autism spectrum disorder (ASD)

Points to Remember
Coping and Defense Mechanisms

People use coping mechanisms and ego-defense mechanisms to relieve anxiety and stress.

They are usually unconscious; that is, the client is not aware of their use.

Depending on the situation and how often these mechanisms are used, they may be healthy or unhealthy.
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Therapeutic Communication

The three phases of a therapeutic relationship include the initial phase, the working phase, and the termination phase.

Make eye contact, without staring (but be aware of cultural differences regarding eye contact) and be aware of your own body
language - use an open body posture and appear relaxed.

Show empathy, genuine caring, and respect.

Use therapeutic techniques such as open-ended questions, unless the client is cognitively impaired; use "yes" or "no" questions
with the cognitively impaired, severely depressed clients or clients with respiratory distress.

Grief

Since the distinction between grieving and depression can be a matter of degree, look for signs of clinical depression.

Grieving takes time; the amount of time varies with individuals.

The stages of grief are not linear; they may come and go.

Grief follows death; but also follows any loss, e.g., divorce, loss of job, loss of financial status, retirement, loss of limb or other
physical disability.

Be aware of culturally diverse ways of responding to grief, which are important in collecting data about grief reaction and in
respecting the customs and rituals of a cultural group.

Beware of personal reaction to death and over identification with client; when necessary, seek assistance to cope with personal
issues.

Stress Management

Severity of reaction to a stressor depends on how it is interpreted or perceived by the individual and the meaning or significance
given to it.

Physical and emotional stressors trigger the same stress response; however the magnitude of the response may vary.

Duration and intensity of physiologic indicators are directly related to the duration and intensity of the stress.

Prolonged stress decreases the adaptive capacity of the body.

Points to Remember 2
Mental Disorders

Bipolar and related disorders are characterized by mood swings; depressive episodes are more common than mania.

Know the therapeutic lab values for the mood stabilizer, lithium carbonate (Lithane): 0.8 to 1.2 mEq/L; overdose symptoms may
include nausea, vomiting, diarrhea, drowsiness, muscle weakness, tremor, lack of coordination, blurred vision or tinnitus.

Suicide precautions are started when a client verbalizes and/or makes an overt suicidal attempt, including attempts at self-mutilation.

Electroconvulsive therapy (ECT) is a very effective and generally safe treatment for severe depression. The procedure uses a small
amount of electric current to trigger a seizure. Confusion and temporary memory loss is an expected side effect.

Feeding and eating disorders can affect every body system. Clients should be monitored for electrolyte imbalance, anemia,
malnutrition, dehydration, and bone density.

Autism (a neurodevelopmental disorder) affects the brain's normal development of social and communication skills; it affects boys
more often than girls and is typically diagnosed between the ages of 18 months to 2 years of age.

Attention deficit hyperactivity disorder (a neurodevelopmental disorder) symptoms fall into 3 categories: inattentiveness,
hyperactivity, and impulsivity.

Health care workers should take care to be sensitive to cultural differences, since personality disorders are typically based on Western
ideas.

Schizophrenia ranks among the top 10 causes of disability in developed countries; it is treatable but cannot be cured.

Programs that train clients with schizophrenia on the primary activities of daily living (ADLs) have been shown to enhance their social
skills, motivation, and desire to change while decreasing their lethargic and apathetic state.

Long-acting injectable antipsychotic medications (LAIs) or depot formulations are given once every 1 to 4 weeks, which improves
medication compliance.

Delirium tremens is a severe form of alcohol withdrawal, commonly occurring within 72 hours after the last drink; associated findings
may include seizures and severe mental status changes, e.g., agitation, confusion, delirium, hallucinations.

It's important to treat the symptoms of withdrawal as well as any underlying mental disorders and infectious processes.

Complementary and alternative therapies can be used to treat many of the mental disorders. Clients should understand that
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concurrent use of prescribed medications and some complementary and alternative medications may cause adverse or life-
threatening effects.

Treatment of post-traumatic stress disorder includes cognitive behavioral therapies, eye movement desensitization and reprocessing
(EMDR), hypnotherapy and medications.

A nurse is collecting data from a client on admission to a community mental health center. The client discloses that "I have been
thinking about ending my life." The nurse's initial response should be which approach?

A. "Do you want to discuss this with your pastor?"
B. "We will help you deal with those thoughts."
C. "Lets discuss issues of your life that would make you want to end it."
D. "Have you thought about how you would do it?"

An older adult Catholic Latino client with prostate cancer adamantly refuses pain medication because the client believes that
suffering is part of life and that my life is in God's hands. What action should a nurse take in response to this situation?

A. discuss the meaning of the hospitalization with the family
B. present the issue to the care management team
C. report the situation to the health care
D. ask if the client would like to speak with a priest

While a nurse administers medication to a client, the client states "I do not want to take that medicine today." Initially which
response by the nurse would be best? "Is there a reason why you don't want to take your medicine?"

A. "Is there a reason why you don't want to take your medicine?"
B. "Do you understand the consequences of not taking your prescribed medications?"
C. "That's OK. I will come back in a few minutes when you might change your mind."
D. "I will have to call your health care provider and report this."

To enhance a client's response to medication for chest pain from acute angina when the client is at home, a nurse should emphasize
what strategy during reinforcement of prior taught content?

A. limiting alcohol use
B. eating smaller meals
C. learning relaxation techniques
D. avoiding passive smoke

A Native American Chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. An
attending nurse comments to a colleague "I wonder if he has any idea how ridiculous he looks -- he's a grown man!" The nurse's
response is an example of?

A. ethnocentrism
B. discrimination
C. prejudice
D. stereotyping

Which behavior is consistent with the diagnosis of obsessive-compulsive disorder for a client in an inpatient setting?

A. verbalized suspicions about thefts in the agency
B. repetitive, involuntary movements of the hands
C. repeatedly checking that the door is locked
D. preference for daily consistent care givers

A client tells a nurse I am afraid of this planned surgery because I have evil thoughts about a family member. The initial response
by the nurse should be what approach?

A. reinforce recovery statistics
B. call a chaplain
C. listen to the client
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D. accept the feelings





A client with diagnosed Parkinson's disease spends over one hour dressing for scheduled therapies. The most appropriate action by
a nurse should be which of these?

A. demonstrate methods on how to dress more quickly
B. allow the client the time needed to dress
C. ask family members to dress the client
D. encourage the client to dress more quickly.

An older adult Latino client with prostate cancer rates pain as a 6, using a 0 to 10 scale. The client refuses all pain medication other
than ibuprofen (Motrin), which does not relieve the pain. What approach should the nurse take?

A. document the situation in the notes and medication record
B. report the situation to the health care provider
C. ask the client for more information about the refusal
D. talk with the client's family about the situation

A client who has a diagnosis of dementia tends to wander from the assigned room. A nurse can ensure the safety of this client by
which approach?

A. explain the risks of becoming lost to the client
B. repeatedly remind the client of the time and place
C. assign one staff member to check client every 30 minutes
D. attach a wander-guard sensor band to the client's wrist

A nurse states a dislike for African-American clients because "They are all so hostile." The nurse's statement is an example of what
behavior?

A. stereotyping
B. discrimination
C. prejudice
D. racism

A nurse admits a Mexican-American migrant worker after an accident in the fields. To facilitate communication, which of these
actions should a nurse take initially?

A. verify if English is the second language
B. speak through the family members
C. determine the client's ability to speak and understand English
D. request an interpreter

A Latino client, diagnosed with ovarian cancer, refuses both radiation and chemotherapy because they are "hot. The best action for
a nurse to take at this time is to?

A. set aside time to talk to the client about the meaning of hot
B. talk with the client's family about the client's refusal of treatment
C. report the situation to the charge nurse and the health care provider
D. document the situation in the nurses notes as objectively as possible

During postpartum a Hispanic client refuses the hospital food because it is "cold." A nurse should take which action initially?

A. consult with the dietitian as soon as possible
B. send the food to be reheated
C. ask the client what foods are acceptable
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D. encourage the client to eat for strength






A nurse is caring for a client diagnosed with end-stage heart failure. The family members are distressed about the client's impending
death. Which action should the nurse do first?

A. explain the stages of death and dying to the family
B. explore the family's past patterns for dealing with death
C. ask about their religious affiliations and participation
D. recommend an easy-to-read book on grief

A client calls a triage nurse to discuss a recent diagnosis of a panic disorder. Which characteristic identified during the discussion is
most significant for this client?

A. predictable episodes
B. sense of impending doom
C. fear of specific behaviors
D. compulsive behavior

An Hispanic couple confide in a nurse their concern that the staff may give their newborn the "evil eye." The nurse should
communicate to other personnel it is most important for them to have which action?

A. touch the newborn after looking at the child
B. bless the newborn while speaking to the child
C. avoid touching the newborn
D. look only at the parents and not the newborn

A postpartum mother is unwilling to allow a partner to participate in the newborn's care, although the partner is interested in doing
so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is only for mothers" A nurse's best initial
intervention is which action?

A. talk with the partner to provide help in the acceptance of the mothers decision
B. arrange for the parents to attend infant care classes within a few weeks
C. help the mother to express her feelings and concerns about the issue
D. discuss with the mother the sharing of parenting responsibilities

A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the mother sits in a chair.
The mother states, "This is not my baby, and I do not want it." How should the nurse respond?

A. "You seem upset. Tell me what the pregnancy and birth were like for you."
B. "Many women have postpartum blues and need some time to love the baby."
C. "What a beautiful baby! The baby's eyes are just like yours."
D. "This is a common occurrence after birth. Let's talk about how to accept the baby."

A two day-old child with spina bifida and meningomyocele is recovering after an initial surgery. As a nurse accompanies the
grandparents for a first visit since the childs birth, which of these grief responses might the nurse expect of the grandparents?

A. disbelief
B. anger
C. frustration
D. depression


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FOOD GUIDELINES


I. Nutrition and Hydration

A. Food guidelines

1.
Nutritional needs through the life cycle

a. newborns and infants

i. fluid needs - adequate to maintain hydration (approximately 6-8 wet diapers per day)


ii. infants - protein needs approximately 2.2 gm/kg/day

iii. breast milk or formula alone is adequate for the first six months of life; whole milk should be introduced
around age 1 year


b. childhood - gradual increase of all nutrients


c. adults - unchanged except for

i. pre-pregnancy - add 400 ug/day folic acid

ii. pregnancy - add per day: 300 calories, 15 mg iron, 30 g protein, 400 g calcium, and 400 ug folic acid in first
trimester

iii. lactation - add 500 calories, two quarts extra fluid each day

d. age 65 and older - adequate protein to maintain immune and circulatory system



2. Factors affecting dietary patterns

a. health status


b. ability to chew, swallow, and drink

c. culture and religion

d. socioeconomic status

e. personal preference


f. psychological factors, e.g., depression, mania, paranoia

g. non food substances, e.g., alcohol, drugs, pica


3. Energy needs

a. basal metabolism: amount of energy (measured in calories) required to sustain life in a resting individual


b. basal metabolic rate (BMR)

i. influenced by genetic and environmental factors, e.g., gender, age, activity level, body surface area, body fat
percentage, diet

ii. several different formulas can be used to determine BMR

iii. 3500 kcal = 1 pound





Essential nutrients

1. Carbohydrates (CHO)

a. includes sugars, starches and fibers (cellulose)

b. simple sugars (monosaccharides and disaccharides) are most easily metabolized

c. starches are more complex in structure and metabolism

d. most dietary sources are plant-based (except for lactose)


e. excessive carbohydrate calories are stored as fat

f. functions of carbohydrates

i. quickest source of energy (4 kcal/gram)
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ii. main source of fuel for brain, peripheral nerves, WBCs, RBCs, and healing wounds

iii. protein-sparer


g. recommended daily intake: approximately 50 to 60% of total calories (complex carbohydrates are
recommended)


2. Lipids (fats)

a. basic lipids are composed of triglycerides and fatty acids

b. includes saturated fatty acids (animal sources) and unsaturated fatty acids (from vegetables, nuts
and seeds)

c. essential unsaturated fatty acids - linoleic acid is the only essential fatty acid in humans; linolenic
acid and arachidonic acid can be manufactured by the body when linoleic acid is unavailable

d. deficiencies lead to skin, blood and artery problems


e. functions

i. most concentrated source of energy (9 kcal/gram)

ii. body's major form of stored energy

iii. insulation

iv. cell membrane component

v. carries fat-soluble vitamins A, D, E and K


vi. intake should not be more than 30% total caloric intake; should be low in saturated fats



f. recommended dietary intake: total fat intake should not exceed 30% of daily calories with saturated
fats not exceeding 10% of total daily caloric intake



3. Proteins

a. complex organic compounds comprised of amino acids

b. body breaks protein down into 22 amino acids


c. all but eight amino acids are produced by the body

d. "complete protein" food - contains the eight essential amino acids not produced by the body (most meat, fish, poultry
and dairy products)

e. "incomplete protein" food - lacks one or more of the eight amino acids (most vegetables and fruits)

f. incomplete proteins can be combined to yield a complete protein: for example, beans and rice


g. functions of protein

i. secondary energy source (4 kcal/gram) after carbohydrates


ii. essential for cell growth and wound healing

iii. efficiency can affect all of body - organs, tissues, skin, muscles

iv. the body's only source of nitrogen (negative nitrogen balance can occur with infection, burns, fever, starvation, and
injury)


h. recommended protein intake includes 0.8 grams per kilogram body weight each day




4. Vitamins

a. organic substances essential for body growth and metabolism

b. the body cannot synthesize vitamins, which is why regular dietary intake is required

c. types (according to their solvent)

i. water soluble : vitamin C and B-complex vitamins (thiamin, riboflavin, niacin, pantothenic acid, biotin, B6, folate, B12)

cannot be stored in body

daily intake required
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excess is eliminated daily

little risk of toxicity


ii. fat soluble : A, D, E, K
stored in body (primarily in liver and adipose tissues)
absorbed by the body from the intestinal tract
risk of toxicity



d. function: act as coenzymes for chemical reactions required for various body functions, e.g., nerve function, energy and
protein metabolism, normal vision and skin health



5. Minerals

a. inorganic substances essential as catalysts in biochemical reactions

b. form most inorganic material in the body

c. functions

i. catalyst for many body reactions such as regulation of acid-base balance


ii. help cells metabolize, tissues absorb nutrients, and heart muscle respond

iii. minerals work synergistically, i.e., a deficiency or excess of one mineral can disturb the action of other minerals


iv. types - grouped according to amount found in body

major minerals (macrominerals) - calcium, magnesium, sodium, potassium, phosphorus, sulfur, chlorine
(function is known function)

trace minerals (microminerals) - iron, zinc, copper, iodine, manganese, cobalt, and molybdenum; function
unclear

other group of trace minerals (found in even smaller amounts whose function is unclear) - nickel, silicon,
vanadium, cobalt




6. Water

a. accounts for 60 to 70% of total body weight in adults (70 to 75% of total body weight of children)

b. functions

i. temperature regulation

ii. transportation of oxygen and nutrients through the blood


iii. a necessary component of chemical reactions

iv. aids in elimination of waste

v. lubrication of joints


vi. major component of body fluids (mucus and tears)


c. recommended intake: approximately 2 to 3 liters a day



C. Fluid and electrolyte balance

1. Total volume of fluid and amount of electrolytes remain relatively constant in the body

2. Fluid balance and electrolyte balance are interdependent

a. body balances fluid and electrolytes primarily by adjusting output and secondarily by adjusting intake

b. fluid balance is also maintained by osmosis



3. Major electrolytes

a. anions
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i. chloride

most abundant anion in extracellular fluid

helps balance sodium

normal lab value for serum chloride is 95-105 mEq/L


ii. bicarbonate

part of bicarbonate buffer system

limits the drop in pH by combining with an acid to form carbonic acid and a salt

important in acid-base analyses (arterial blood gases [ABG])

normal arterial bicarbonate 22-26 mEq/L, normal venous bicarbonate 24-30 mEq/L


iii. phosphate

participates in cellular energy metabolism

combines with calcium in bone

assists in structure of genetic material

balanced by parathyroid gland, along with calcium

normal serum phosphate level 2.8-4.5 mg/dL






b. cations

i. sodium

most abundant cation in extracellular fluid

regulates cell size via osmosis

needed to maintain water balance, transmit nerve impulses, and contract muscles; used to control blood
pressure and blood volume

regulates acid-base balance by exchanging hydrogen ions for sodium ions in kidney

sodium is regulated by salt intake, aldosterone, and urinary output

normal lab value for serum sodium is 135-145 mEq/L

large changes may occur with minimal clinical findings

low levels of 125 mEq/L or less result in mental confusion, hostility, hallucinations

excess levels may result in hypertension or generalized edema, called anasarca



ii. potassium

most abundant cation of intracellular fluid

potassium pump draws potassium into cell

essential for polarization and repolarization of nerve and muscle fibers

regulates neuromuscular excitability and muscle contraction

regulated by kidneys

normal lab value for serum potassium is 3.5-5 mEq/L

small changes may result in significant clinical findings

high and/or low findings may result in a fast or slow heart rhythm and muscle function with results of
cramping in abdomen or legs



iii. calcium
needed for cardiac contraction, healthy bones and teeth, functioning of nerves and muscles, clotting of blood
vitamin D is needed for calcium absorption
normal values - total calcium 8.5-10.5 mg/dL

hypercalcemia
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causes: hyperparathyroidism, metastasis of cancer, Paget's disease of bone, prolonged immobilization

findings: weakness, paralysis, decreased deep tendon reflexes

hypocalcemia

causes: rickets, vitamin D deficiency, renal failure, pancreatitis, chelation therapy, hypoparathyroidism

findings: muscle tingling, twitching, tetany



iv. magnesium

about half of total body magnesium is found in bone

needed for more than 300 biochemical reactions - involved in normal muscle and nerve function, heart
rhythm, immune system, blood sugar regulation, blood pressure, energy metabolism, protein synthesis, and
bone strength
normal values - 1.5-2.5 mEq/L

hypermagnesemia

causes: chronic renal disease, overuse of magnesium-containing antacids as Maalox and Mylanta, Addison's
disease, uncontrolled diabetes mellitus

findings: lethargy, nausea, vomiting, slurred speech, muscle weakness, paralysis, decreased deep tendon
reflexes, slowing of cardiac conduction

hypomagnesemia

causes: malnutrition, toxemia in pregnancy, malabsorption, alcoholism, diabetic acidosis

findings: mood irritability, cardiac irritability, muscle tingling, twitching, tetany, delirium, convulsions






6. Maintenance of fluid volume

a. osmoreceptor system

i. balances fluid intake volume by the regulation of water output volume

ii. dehydration stimulates osmoreceptors which activate the thirst control center; person feels thirsty and seeks water

iii. also stimulates antidiuretic hormone (ADH) secretion which decreases urinary output by causing the reabsorption of
water in the tubules


b. circulatory system

i. increases in fluid intake increase circulatory volume

ii. this increased volume stimulates the kidney for an increased glomerular filtration rate


iii. end result is an increase in urine output to decrease the initial circulatory volume




c. thirst center

i. located in hypothalamus

ii. stimulated by

increased plasma osmolality

angiotensin II

dry pharyngeal mucous membranes

decreased plasma volume

depleted potassium

psychological factors





7. Maintenance of electrolyte balance

a. aldosterone - hormone (mineralocorticoid)

i. when extracellular fluid sodium decreases or potassium levels increase, then

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ii. adrenal cortex secretes aldosterone, which causes

iii. kidneys to increase active reabsorption of sodium and decreased reabsorption of potassium, which

iv. results in passive water reabsorption along with active sodium reabsorption and increased blood volume


b. parathyroid

i. parathyroid secretes parathyroid hormone (PTH), also called parathormone


ii. stimulates release of calcium from bone

iii. stimulates reabsorption in small intestine and kidney tubules

iv. when serum calcium level is low, PTH secretion increases


v. when serum calcium level rises, PTH secretion falls

vi. high levels of active vitamin D inhibit PTH

vii. low levels of active vitamin D or magnesium stimulate PTH secretion


viii. interaction exists between calcium and phosphorus

when calcium is low, phosphorus is likely to be high

when calcium is high, phosphorus is likely to be low






D. Normal and therapeutic diets

1. Guidelines

a. reference dietary intake (DRI) - average daily nutrient intake for healthy people (replaces the previous recommended
dietary allowance [RDA])

b. ethnic food patterns

c. religious considerations in meal planning

d. personal choice, e.g. vegetarian


e. refer to the 2010 Dietary Guidelines for Americans and MyPlate for information about

a. balancing calories


b. foods to increase, i.e., fruits and vegetables, whole grains, reduced fat milk

c. food to reduce, i.e., sodium and sugary drinks





2. Therapeutic nutrition

a. modification of the nutritional needs based on a disease condition

b. considerations for administering therapeutic diets

i. condition of client

physical

emotional
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mental ability of client to tolerate diet


ii. willingness of client to comply with diet



c. types of therapeutic diets

i. diabetic

goals of nutritional management

providing all essential nutrients

meeting energy needs

achieving and maintaining a reasonable weight

preventing wide daily fluctuations in blood glucose levels

decreasing serum lipid levels


diet individualized according to client's age, build, weight, and activity level

recommended caloric distribution: 50-60% carbohydrates, 20-30% fat, and 10-20% protein

carbohydrate, fat, and protein counting an essential component of diet





ii. Dietary Approaches to Stop Hypertension (DASH) diet

used to help lower blood pressure, but may offer protection against osteoporosis, cancer, stroke, diabetes and
heart disease

encourages sodium reduction and eating a variety of foods rich in nutrients, including potassium, calcium and
magnesium

levels of restriction

standard DASH diet - 2,300 mg sodium/day

lower sodium DASH diet - 1,500 mg sodium/day

DASH diet is low in saturated fat, cholesterol, and total fat


iii. low protein diet

for renal disease such as pyelonephritis, uremia, kidney failure

limit protein less than 40 g/day (0.5 g/kg/day) instead of normal protein intake of 40 to 60 g/day (1g/kg/day)

restricted foods: meats and other foods high in protein such as legumes, fish, dairy


iv. high protein diet

for conditions such as burns, anemia, malabsorption syndromes, ulcerative colitis

include high quality proteins or protein supplements such as Sustagen

promote high protein intake more than 60 g/day (1.5 g/kg/day) instead of normal protein intake of 40 to 60
g/day (1g/kg/day)






REMEMBER IT
Types of Vegetarian Diets

Vegan: refrains from eating animal products
Lacto-ovo vegetarian: consumes eggs and dairy products but
excludes meat, poultry, seafood
Lacto-vegetarian: consumes dairy products, but excludes eggs,
meat, poultry, seafood
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v. low purine diet

prevents uric acid stone; used for clients with gout

lowers levels of purine, the precursor of uric acid

restricts glandular meats, gravies, fowl, anchovies, beer and wine (see gout diet for more details)


vi. low calcium diet

limit to 400 mg per day instead of normal 800 mg

restricts dried fruits and vegetables, shell fish, cheese, nuts


vii. acid ash diet

prevents kidney stone formation

restricts carbonated beverages, dried fruits, banana, figs, chocolate, nuts, olives, pickles


viii. gluten-restricted or gluten-free

used for people with sensitivity to glutens (proteins) in wheat, oats, rye, and barley

may eat rice, corn and millet products


ix. low cholesterol

used for cardiovascular disease, high serum cholesterol levels

normal amount of cholesterol intake - 250 to 300 mg/day

restricts eggs, beef, liver, lobster, ice cream


x. high fiber

used to correct constipation, prevent diverticulitis, lower risk of colon cancer

30 to 40 gram fiber/day recommended

increased intake of fruits, vegetables, bran cereals, whole grains



xi. low residue

used for conditions such as diarrhea, acute diverticulitis

reduce fiber intake: canned fruit, refined carbohydrates, pasta, strained vegetables

foods high in refined carbohydrates are usually low fiber

increased use of ground meat, fish, broiled chicken without skin, white bread



xii. mechanical soft

used with difficulty in chewing, such as poorly fitted dentures or edentulous clients (no teeth)

includes any foods which can be easily broken down by chewing


xiii. puree diet

used with dysphagia or difficulty in chewing

used for tube feedings, small babies

food is blended to smooth consistency


xiv. liquid diets

clear liquid: coffee without cream, tea, popsicles, fruit juices, including apple, cranberry, grape, and carbonated
beverages

full liquid: includes all clear liquids plus milk, cream, ice cream, pudding, yogurt, vegetable juice, creamy peanut
butter



4. Nutritional data collection

a. weight change - over what time frame and amount of weight lost or gained

b. appetite - increased, decreased
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c. food intolerance - result of intolerance such as nausea, vomiting, diarrhea, hives, stomach pain

d. chewing and swallowing

e. indigestion - frequency

f. elimination habits - urinary and bowel

g. eating behaviors - usual meals and amounts

h. nutrient - drug interactions


i. anthropometric measures



5. Feeding tubes

a. indications - inability to ingest, chew, or swallow food (with intact gastrointestinal tract)

b. insertion

i. through nose into stomach or small bowel

nasogastric (NG), nasoduodenal and nasojejunal feeding tubes

used either for short periods or intermittently with relatively low risk

NG tube sizes

adult: 16-18 Fr

pediatric: add 16 to the client's age in years and then divide by 2 (for example: [8 y + 16]/2 = 12 Fr)



ii. endoscopically - better for long-term enteral feeding

gastrostomy tube or PEG tube

jejunostomy tube




c. tube feeding formulas: Vivonex, Isocal, Portagen

d. complications: aspiration, diarrhea, electrolyte or metabolic disturbances



e. nursing care - for gastric-placed tubes

i. keep head of bed raised at least 30 degrees or semi-Fowler's position, to prevent aspiration for 1.5 to 2 hours after
feeding is infused

ii. recheck placement of tube prior to each feeding

iii. placement checks

obtain radiologic (x-ray) confirmation before instilling any feedings or medications or if there are concerns
about other forms of assessment

recommended practice is to aspirate gastric contents and check if pH is acidic (pH should be acidic)

injecting ten mL air into nasogastric tube (NG tube) and listening with stethoscope for rush of air over
stomach is no longer an accepted method to verify placement
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iv. administration of enteral feedings

may be continuous or intermittent

prevent bacterial growth by limiting infusions to hang for less than 8 hours and changing tubing every 24
hours

prevent fluid and electrolyte imbalances by administering at a rate of no more than 300 mL/hour

check gastric residual

every 4 hours if continuous feeding or prior to intermittent feedings

if residual is greater than 50-100 mL (or using facility policy), hold feeding until residual diminishes

reinsert residual into tube to prevent metabolic alkalosis

flush tube with 30 to 60 mL water after feeding




6. Nutritional supplements/liquids

a. used for severe dehydration or diarrhea

b. types

i. infants: Infalyte, Pedialyte, Ricelyte

ii. infant formulas: standard and high-calorie


iii. older children and adults: electrolyte replacement drinks

iv. specialty formulas

used when intolerance to usual milk or milk products

predigested, e.g., Pregestimil, Nutramigen

high-calorie supplements, e.g., Scandishakes, Carnation Instant Breakfast




7. Parenteral nutrition: see Lesson 6: Pharmacological for more information


8. Measures to improve nutritional intake of client

a. frequent small feedings

b. feeding assistance

c. offering preferred foods

d. ethnic foods


II. Mobility/Immobility

A. Prevention of complications of immobility

1. Skin - decubitus ulcers

a. turn client in bed every 2 hours

b. use heel/elbow protectors

c. use alternate pressure mattress or other skin care devices


d. do not massage reddened areas (doing so increases damage to tissues)

e. limit sitting in a chair to 2 to 4 hours or as tolerated with a shift in weight at least every 30 to 60 minutes

f. assess risk with Braden or Norton scales

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2. Musculoskeletal changes, especially contractures

a. perform range of motion exercises to joints on a scheduled basis daily

b. provide foot board, foot cradle or high-topped tennis shoes to prevent foot drop

c. reposition every 2 hours

d. maintain correct body alignment


3. Respiratory - atelectasis, pneumonia

a. instruct client to cough and deep breathe every 2 hours, or more frequently

b. turn at least every 2 hours

c. suction if needed


d. chest physiotherapy

e. incentive spirometry


4. Urinary: renal, calculi, urinary tract infection, glomerulonephritis

a. increase fluid intake (2000 to 3000 mL/day)

b. restrict foods that contribute to renal stone formation



5. Psychosocial

a. provide stimuli to maintain orientation

b. develop and follow mutually agreeable activity schedule with client to maintain mental sharpness




6. Cardiovascular system - decreased cardiac output, clots, emboli

a. orthostatic hypotension

i. instruct client to change position slowly

ii. highest risk is from supine to standing position



b. increased cardiac workload

i. reinforce for client to avoid bearing down (Valsalva maneuver)

ii. minimize coughing


iii. limit sitting in high Fowler's position for more than 1 to 2 hours


c. thrombus/emboli formation

i. apply thigh or knee-high anti-embolic stockings as ordered


ii. monitor use of sequential compression device


iii. turn every 2 hours

iv. monitor anticoagulation therapy, as indicated

v. initiate ambulation or exercise of dorsi and plantar flexion of the foot


vi. limit sitting with feet in a dependent position to 1 to 2 hours



B. Types of exercise

1. Active - client performs exercise independently to retain joint mobility and maintain blood circulation

2. Passive - carried out by the health care provider without assistance from client; purpose is to retain joint mobility and
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blood circulation

3. Resistive - done by the client working against resistance; purpose is to increase muscular strength; enhances bone
integrity

4. Isometric - carried out by the client with no assistance by contracting muscle groups for 10 seconds and then relaxing
muscle group; purpose is to maintain muscular strength when the joint is immobilized

5. Range of motion (ROM) - joint is moved through entire range; purpose is to maintain joint mobility




C. Mechanical aids or assistive devices and interventions

1. Crutches - provides support and assist ambulation for people with weight-bearing restrictions

a. adjust handbars to allow 15 to 30 degrees of elbow flexion

b. keep tips of crutches 8 to 12 inches to side of feet


c. use well fitting shoes with nonslip soles

d. use rubber suction tips on crutches

i. inspect weekly

ii. replace when worn



e. may be used temporarily or permanently

f. prevent axillary damage by avoiding pressure with position of crutch at least one hand's width below axillary bend


g. teach client crutch walking



2. Cane - provides stability when walking and relieves pressure on weight-bearing joints

a. adjust cane with handle at level of greater trochanter, elbow flexed at 30 degree angle


b. have client hold cane close to body

c. have cane held on stronger side

d. client to move cane at same time as the weaker leg




3. Walker - assists in weight bearing and mobility

a. client must be strong enough to pick walker up and move it forward before taking the next step (walkers with wheels
are available for clients who are not strong enough to lift a walker but who can slide it forward)

b. teach client how to sit, stand and turn

c. do not allow client to place hands on walker to stand from sitting position (it is unstable)



4. Gait belt

a. usually a canvas belt, with or without handles, positioned over the client's clothing

b. the gait belt should fit tightly around the waist

c. safety devices for ambulatory clients who may have some balance problems



D. Prosthetic devices - used to replace a missing body part

E. Brace - support for weakened muscles




B. Urinary incontinence: involuntary release of urine

1. Types

a. stress incontinence: sudden increase in intra-abdominal pressure, such as sneezing or coughing, causes urine to leak
from bladder

b. overflow (reflex) incontinence: bladder empties incompletely, so urine dribbles constantly

c. urge incontinence: uncontrolled contraction of the bladder results in leakage of urine before one reaches the
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bathroom

d. functional incontinence: incontinence not due to organic reasons; for instance, altered access to toilet, impaired
mobility or dexterity may prevent the client from reaching the bathroom in time


2. Diagnosis of urinary incontinence

a. history and physical examination


b. urinalysis - determines the presence of blood or infection

c. cystoscopy - determines if abnormalities exist

d. post void residual - measures amount of urine that remains in the bladder after voiding

e. stress test - determines if urine leaks after bladder is stressed when coughing, lifting, bearing down


REMEMBER IT
Remember the reversible causes of urinary incontinence using the
mnemonic D.R.I.P.

Delirium
Restricted mobility (or Retention [urinary])
Infection (or Inflammation or Impaction [fecal])
Pharmaceuticals (or Polyuric states)

3. Treatment

a. pharmacologic

i. antispasmodics and anticholinergics relax and increase capacity of the bladder, e.g. oxybutynin (Ditropan)

ii. alpha-adrenergic agonists - increase urethral resistance


b. Kegel exercises - strengthen weak muscles of the pelvic floor

c. behavioral training - client learns different way to control urge to urinate


d. bladder retraining - scheduled periods to empty bladder throughout the day

e. pessary

f. surgery - repair of weakened or damaged pelvic muscles or urethra



4. Nursing interventions

a. provide appropriate skin care and protective undergarments


b. establish toileting schedule - provide easy access to bathroom and privacy

c. teach client Kegel exercises

i. stop and start urinary stream while voiding

ii. hold contraction of perineal muscles for 10 seconds and relax for 10 seconds

iii. work up to 25 repetitions three times a day


d. prevention of infection

i. cleanse urethral meatus after each void; females to wipe from front to back

ii. acidify urine with vitamin C or increased intake of citrus juices (cranberry, orange)

iii. increase daily intake of fluids to a minimum of 2000 to 3000 mL, unless contraindicated




C. Urinary catheterization

1. Purposes

a. relieve acute urinary retention


b. relieve chronic urinary retention

c. drain urine preoperatively, postoperatively, or post procedure
154


d. determine amount of post void residual

e. accurately measure urine output in the critically ill

f. obtain sterile urine specimen

g. continuous or intermittent bladder irrigation



2. Types of catheters and general guidelines

a. indwelling urethral catheter

i. use a closed drainage system

ii. use sterile technique to insert a urethral catheter


iii. advance catheter almost to bifurcation of catheter, especially in male clients

iv. inflate balloon within guidelines of manufacturer only after urine is draining properly, then slightly withdraw
catheter until slight resistance is met

v. ensure client is not lying on the tubing; secure catheter to client's thigh and allow for some slack to accommodate
movement and to lessen drag

vi. care of indwelling urinary catheter

cleanse the urinary meatus with soap and water during the daily bathing routine and after defecation

do not pull on catheter while cleansing

do not use powder or spray around perineal area

avoid disconnection of the drainage system

keep the drainage bag below the level of the bladder or the insertion site

avoid clamping the drainage tubing unless ordered to do so on a scheduled basis to maintain bladder
tone

catheter is irrigated only with an obstruction, usually following prostate or bladder surgery, if blood
clots anticipated; usually PRN or with standing order





2. suprapubic catheter: achieved via a percutaneous catheter or by way of an incision through the abdominal wall


3. Intermittent self-catheterization

a. used by clients with spina bifida or other neuromuscular deficits


b. can be taught to children as young as 6 years of age

c. teach the client to

i. gather equipment - urethral catheter, water-soluble lubricant, soap, water, urine collection container

ii. wash hands with antibacterial soap

iii. cleanse urethral meatus and surrounding area with soap and water

iv. lubricate tip of catheter with water-soluble lubricant

v. insert catheter until urine flows

vi. withdraw catheter when urine flow stops

vii. clean off residual lubricant from meatus

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viii. dispose of urine

ix. wash hands with antibacterial soap




D. Ostomies

1. Types of bowel ostomies

a. ileostomy - small bowel

i. liquid to semi-formed stool, dependent upon amount of bowel removed

ii. may skew fluid and electrolyte balance, especially potassium, sodium, and bicarbonate

iii. digestive enzymes and alkalinity in stool irritate skin easily


iv. do not give laxatives

v. ileostomy lavage may be done if needed to clear any blockage

vi. usually requires a pouch or appliance


ii. may not require appliance with continent ileal reservoir or Kock pouch procedure

viii. may require scheduled emptying throughout the day

ix. may be used for urinary diversion as in bladder tumor


b. colostomy

i. ascending colon must wear appliance semi-liquid stool

ii. transverse colon must wear appliance semi-formed stool

iii. loop stoma

proximal end functioning stoma; if irrigation needed, this end is used

distal end drains mucous

plastic rod used to keep loop out

usually temporary to rest the distal, large bowel

placement is commonly in transverse colon


iv. double barrel

two stomas

similar to loop but bowel is surgically severed

most likely temporary


v. sigmoid or descending

formed stool

bowel can be regulated so appliance usually not needed

may be irrigated to help regulate evacuation of bowel







2. Nursing assessment and data collection for stoma care

a. color - the stoma will always stay red (due to the rich supply of blood in the lining of the intestine)
156


b. edema - common after surgery for 48 to 72 hours

c. bleeding - some is expected after surgery for 48 to 72 hours

d. drainage consistency and frequency - depends upon stoma location

e. surrounding skin integrity


3. Psychological reaction to ostomy

a. disturbed body image, especially young adults


b. anxiety related to feared rejection

c. ineffective coping related to ostomy care



IV. Rest and Sleep

A. Factors affecting sleep

1. Physical illness

2. Drugs or alcohol

3. Lifestyle


4. Excessive daytime sleep

5. Emotional stress


6. Environment


7. Exercise just before bedtime/fatigue

8. Food intake



B. Sleep disorders

1. Bruxism: tooth grinding during sleep

2. Insomnia: chronic difficulty with sleep patterns

a. initial insomnia: difficulty falling asleep

b. intermittent insomnia: difficulty remaining asleep

c. terminal insomnia: difficulty going back to sleep


3. Narcolepsy: to fall asleep without warning during daytime hours

4. Sleep apnea

a. intermittent periods of not breathing while asleep

b. usually due to problems with upper airway; can be treated with continuous positive airway pressure
(CPAP) during sleep


5. Sleep deprivation: decrease in the amount and/or quality of sleep


6. Somnambulism: sleepwalking, night terrors, or nightmares

7. Depression

a. secondary to disease process

b. can occur with any sleep disorder

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8. Manic behavior - hyperactive behavior with minimal sleep


C. General nursing interventions for promotion of restorative sleep

1. Comfort measures

2. Give prescribed medications: sedatives, hypnotics

3. Assist client to set a sleep routine


4. Encourage daytime activity

5. Eliminate naps

6. Reinforce relaxation techniques


7. Discuss the benefits of environmental control

8. Reinforce limiting alcohol, caffeine, and nicotine in evening

9. Advise client to avoid drinking fluids after 8 to 9 pm to prevent the need to void at night







V. Pain

A. Theories

1. Specificity theory - proposes that pain can be initiated only by painful stimuli

2. Pattern theory - stimulus goes to receptors in the spinal cord, which signals the brain to perceive pain and
muscles to respond


3. Gate control theory - pain impulses can be altered or regulated by gating mechanisms along nerve
pathways; it explains how past and present experiences can influence the perception of pain


B. Variables influencing pain perception

1. Culture and social groups shape attitude towards pain


2. Religious beliefs regarding the reasons for pain

3. Previous experience with pain

4. Age


5. Sex

6. Coping style

7. Family support



C. Types - may be intermittent or constant

1. Acute - pain episode lasting up to six months

2. Chronic - pain lasting longer than six months



REMEMBER IT
Pain Management ABCs

A- Assess the client by asking about the pain
B- Believe the client's pain is real
C- Let the client make pain management choices


D. Therapeutic treatment of pain

1. Pharmacologic interventions - refer to Lesson 6: Pharmacological Therapies

2. Complementary and alternative therapies

a. acupuncture

b. accupressure - pressure put at selected points on the body

c. relaxation techniques - biofeedback, visualization, meditation and hypnosis, which help the client control anxiety,
other emotions, or mild pain

d. electronic stimulation such as transcutaneous electric nerve stimulation (TENS) - electrodes applied over the painful
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area or along nerve pathway

e. distraction - focusing client's attention on something other than mild pain

f. massage - generalized cutaneous stimulation of the body; makes the client more comfortable as a result of the
muscle relaxation

g. ice and heat therapies - effective in some circumstances; ice may decrease prostaglandins which intensify the
sensitivity of pain receptors

h. guided imagery - using one's imagination in a guided manner to achieve a specific positive effect



3. Nursing interventions

a. categorize pain using a pain assessment scale

i. scale of 1 to 10, or absence of pain to worst pain

ii. pain scale using faces, such as the Wong-Baker FACES scale (especially useful with children)

PQRST Format for Assessing Pain

P- What provokes the pain?
Q- What is the quality of the pain?
R- Does the pain radiate? What causes relief?
S- What is the severity?
T- What is the timing?

b. discuss client's coping strategies and factors that produce ineffective coping


c. reinforce client teaching regarding appropriate strategies to deal with different levels of pain




VI. Alternative and Complementary Therapies

A. Herbal therapy

1. Used as dried herbs in capsules or tablets, tinctures, teas, and ointments

2. Use only products standardized with a specific amount of active ingredients

3. Over 600 herbal products, many of which interact with prescribed drugs, particularly cardiac drugs and
antidepressants

4. St. John's wort is the number one herbal product

a. interacts with over 60 percent of all prescription drugs

b. the interaction is to make drugs less effective, including digoxin, cyclosporine, tamoxifen, highly active
antiretroviral therapies (HAART) and combined oral contraceptives




B. Aromatherapy

1. Uses oils produced by plants for inhalation or topical application

2. Different scents are thought to produce different responses in the body

3. Scents of vanilla and green apple are thought to enhance memory and recall




C. Therapeutic massage

1. Manipulates the soft tissue of the body and assists with healing

2. Physiologic effects: primarily improves circulation, oxygenation, perfusion


3. Research findings indicate: muscle relaxation, reduction of some types of pain, sedative effect on nervous system,
increased peristalsis, increased lymphatic circulation

4. Can be relaxing or energizing

5. Is contraindicated for a client with phlebitis, thrombosis, varicose veins, diabetes, pitting edema


159

D. Reflexology

1. Applies pressure to specific areas of the feet and body

2. Uses - relieves stress and muscle tension; promotes relaxation and sleep



E. Hypnosis

1. Used in the treatment of many disorders, including osteoarthritis, rheumatoid arthritis, sciatica, whiplash, chronic pain


2. May also be used to replace traditional surgical anesthesia


F. Chiropractic treatment

1. Effective by manipulating the musculoskeletal system


2. Manipulation to put the vertebrae in proper alignment

3. Used to treat pain at a variety of locations



I. Acupuncture

1. a traditional Chinese therapy using tiny needles placed in the skin to help regulate the flow of (qi) vital energy through
the body; electro stimulation, laser beams or ultrasound waves may be used in place of the needles


2. despite being one of the most widely researched of all CAM/complementary and alternative therapies it remains
unknown how acupuncture works physiologically


J. Acupressure

1. Uses gentle pressure at specific points

2. Used for prevention and relief of muscle tension or pain


Protein is the body's only source of nitrogen. True False
Women who are planning on becoming pregnant need about 200 ug/day of folic acid. True False
Less than 6 to 8 wet diapers a day may be a sign of dehydration in a baby. True False
Glucose is the only fuel used by brain cells. True False
People with insomnia either have difficulty falling asleep or staying asleep. True False
The client using a cane should hold it on his strong side and move the cane at the same time as the weaker leg. True False
Iron is one of the macrominerals found in a healthy human body. True False
Complementary and alternative therapies (CAT) replace the need for pharmacologic interventions. True False
The thirst center is located in the parathyroid gland. True False
A client with gout is prescribed a pureed diet. True False
The flow rate for a nasogastric tube feeding should be no faster than 300 mL/hour. True False
Urinary incontinence is a normal part of aging. True False
A 7 year-old child can be taught to self-catheterize him or herself. True False
The client with a sigmoid colectomy will have semi-liquid stool collect in a colostomy bag. True False
Neuropathic pain is also called musculoskeletal pain. True False

Points to Remember
Nutrition & Fluid Intake

All individuals require the same nutrients, but the amounts vary according to factors such as age, weight, activity level, and health
state.

The energy value of foods is defined in calories; only proteins, fats and carbohydrates provide calories.

Essential amino acids cannot be synthesized; they must be ingested daily.

Weight is maintained when daily food intake equals energy expenditure.
160


Weight loss is a long-term process and patients need long-term support.

Increased fiber in the diet may cause flatulence.

The normal thirst mechanism in the elderly may be diminished and they may need encouragement to drink sufficient water to
prevent dehydration.

The average adult drinks 2 to 3 liters of water per day.

Normal lab values to know:

Sodium: 135 - 145 mEq/L

Potassium: 3.5 - 5.1 mE1/L

Chloride: 98 - 107 mEq/L

Bicarbonate: 22 - 29 mEq/L

Elimination

In constipation, increase fluid to 3000 mL/day (unless contraindicated).

Small frequent loose stools or seepage of stool are often indicative of a fecal impaction.

Use transparent drainage bag initially for assessment of stoma and drainage.

Avoid foods that cause odor, gas, diarrhea, or may block ileostomy.

The majority of residents in nursing homes are incontinent but incontinence is not a normal sequela of aging.

Points to Remember 2
Pain

Allow the client to rate the degree of pain (typically using a 10 point scale) and later to assess (and chart) degree of relief from pain
relief measures.

Self-control methods to manage pain: distraction, massage, guided imagery, relaxation, biofeedback, and hypnosis.

Initiate pain relief before the pain becomes unbearable.

Patient controlled analgesia (PCA) is effective at controlling pain and avoiding the peaks and valleys of nurse-administered narcotics;
clients typically use less pain medication overall than clients receiving nurse-administered narcotics.

Be sure to assess and monitor respiratory rate for client on PCA; naloxone (Narcan) is used to reverse the effects of narcotics.

Mobility

There should be at least two inches between axilla and top of arm piece of crutch to prevent pressure on the brachial plexus.

Prevent deformities and complications such as contractures, thrombophlebitis, and pressure ulcers by regularly turning and
positioning the client in good alignment.

Discontinue range of motion exercises at point of pain.

Use non-skid, rubber tips on crutches and canes to prevent slipping.

A nurse is reinforcing methods to maintain regular bowel movements to an older adult client. The nurse would caution the client to avoid which over-the-
counter item?

A. laxatives
B. vitamin enhanced drinks
C. fiber supplements
D. stool softeners

A nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of decubitus ulcers?

A. an obese client who uses a wheelchair throughout the facility
B. an ambulatory older adult who has had type 2 diabetes mellitus for the past 40 years
C. an ambulatory client who had three incontinent diarrhea stools in the past 24
D. a malnourished older adult client who is bedfast

What topic should a nurse reinforce with a client who has been diagnosed with type 2 diabetes mellitus?

A. reduce carbohydrates intake to 25% of total calories
B. continue a regular schedule of meals and snacks
C. maintain previous calorie intake from your age 10 years prior
D. keep a candy bar available for hypoglycemic episodes


161

The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement
of the G-tube?

A. Measure the length of tubing from the insertion site each shift
B. Listen for active bowel sounds in all four quadrants
C. Measure the pH of stomach content aspirate
D. Auscultate the abdomen while instilling 10 mL of air into the G-tube

Which action would be appropriate for a nurse to reinforce about diaper dermatitis to the parents of a nine month-old infant?

A. do not use occlusive ointments on the rash
B. use only cloth diapers that are rinsed in a bleach solution
C. discontinue any new food that was added to the infant's diet just prior to the rash
D. use commercial baby wipes with each diaper change

A nurse is caring for a seven year-old diagnosed with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea
nitrogen and creatinine are both elevated. What dietary modifications are most appropriate at this time?

A. increased potassium and protein
B. decreased carbohydrates and fat
C. decreased sodium and potassium
D. increased sodium and fluids

A nurse is caring for a group of older adult clients who are on complete bed rest. What is the appropriate action by the nurse to prevent skin breakdown?

A. massage their legs twice a shift
B. massage any reddened areas
C. turn every one to two hours
D. apply a sheepskin pad under the torso

A 14 month-old had cleft palate surgical repair several days ago. Which lunch selected by the parents is the best example of an appropriate meal?

A. peanut butter and jelly sandwich, chips, pudding, milk
B. hot dog, carrot sticks, gelatin, milk
C. soup, blenderized soft foods, ice cream, milk
D. baked chicken, applesauce, cookie, milk

A two year-old child is brought to the pediatrician's office with a report of mild diarrhea for two days. Nutritional counseling by the nurse for
reinforcement of information should include which statement?

A. give bananas, apples, rice and toast as tolerated
B. place NPO for 24 hours, then rehydrate with milk and water
C. place the child on clear liquids and gelatin for 24 hours
D. continue with the regular diet and include oral electrolyte replacement drinks


The RN has provided care instructions to the parents of a toddler diagnosed with atopic dermatitis. Which of these actions will the LPN/VN now reinforce
to the parents?

A. Dress the child warmly to avoid chilling
B. Wrap the child's hand in mittens or socks to prevent scratching
C. Clean the affected areas with tepid water and antibacterial soap
D. Keep the child away from other children for the duration of the rash

A mother of a three month-old infant tells a nurse I want to change from formula to whole milk and add cereal and meats to my infants diet. What
should be emphasized as the nurse reinforces information about correct infant nutrition?

A. tap water with fluoride should be used to dilute the milk
B. whole milk is difficult for a younger infant to digest
C. solid foods should be introduced at three to four months
D. supplemental apple juice can be used between feedings

A nurse is making a home visit to a client diagnosed with chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I used to be able to
walk from the house to the mailbox without difficulty. Now, I have to pause to catch my breath halfway through the trip." Which nursing diagnosis would
the nurse expect on the plan of care for this client?

A. self care deficit related to dyspnea
B. impaired mobility related to chronic obstructive pulmonary disease
C. ineffective airway clearance related to increased bronchial secretions
D. activity intolerance related to chronic tissue hypoxia





162

A nurse is discussing dietary intake with an adolescent who has acne. Which of these statements should a nurse include during the discussion?

A. "Decrease fatty foods from your daily diet."
B. "Increase your intake of protein and vitamin A."
C. "Eat a balanced diet for your age group."
D. "Do not drink caffeinated beverages and avoid chocolate"

A client diagnosed with heart failure has been instructed about proper nutrition associated with the disease process. The selection of which lunch items by
the client indicates that the client has learned about sodium restriction?

A. cheese sandwich with a glass of 2% milk
B. sliced turkey sandwich and fresh pineapple
C. cheeseburger and baked potato
D. mushroom pizza and ice cream

Which choice indicates a client understands dietary needs that help prevent digitalis toxicity?

A. small banana
B. medium baked potato
C. average sized naval orange
D. three apricots

Which information should be reinforced and included in a handout on infant feeding that is to be distributed to families visiting the clinic?

A. solid foods are introduced one at a time beginning with cereal
B. cereal is highly recommended to be mixed with formula in a bottle
C. egg white is added early to increase protein intake
D. finely ground meat should be started early to provide iron

During a review of proper nutrition with a client who has a history of emphysema, a clinic nurse should emphasize which of these actions?

A. use oxygen during meals to minimize oxygen deficits
B. cleanse the mouth of dried secretions to reduce the risk of infection
C. perform exercises after respiratory treatments to enhance appetite
D. eat foods high in sodium to increase sputum liquefaction

A client is with hospice at home with the diagnosis of stage 4 heart failure. A home care nurse should encourage the client to rest in which position?

A. left lateral
B. high Fowler's
C. low Fowler's
D. supine

A nurse is reinforcing foot care instructions to a client with a history of arterial insufficiency to the legs. The nurse should identify which client's statement
as incorrect and the need for additional reinforcement?

A. "I cannot go barefoot around my house."
B. "I should ask a family member to inspect my feet daily."
C. "I can only wear cotton socks."
D. "I will trim corns and calluses regularly."

A nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse should emphasize that the diet would have
which characteristics?

A. high carbohydrate, low protein, moderate fat
B. high calorie, low fat, low sodium
C. high fat, high sodium, low carbohydrate
D. high protein, high calorie, unrestricted fat

163



I. Pharmacology Terms and Responsibilities

A. Medication nomenclature
Medication nomenclature: some examples
Chemical Name Generic Name Trade
(Brand)
Name
Tall Man
lettering
3,4dihydroxyphenethylamine
hydrochloride
dopamine Intropin DOPamine
4-[2-[4-(4-hydroxyphenyl) butan-2-
ylamino] ethyl]benzene-1,2-diol
dobutamine
hydrochloride
Dobutrex DOBUTamine
1. Chemical name: description of a medication's chemical molecular structure/composition

2. Generic name: description assigned by the U.S. Adopted Name Council; identified by
lowercase letters

3. Trade (brand) name: manufacturer's registered name for a medication that is capitalized
and treated as a proper noun; many different trade names may refer to the same generic
medication


4. TALL MAN lettering

a. one part of a drug's name is written in capital letters (tall man letters) to distinguish it
from the other look-alike and sound-alike drugs, e.g., predniSONE and prednisoLONE

b. used to help prevent medication errors


5. High-alert drugs: medications with a high potential to cause harm if administered
incorrectly to the client




6. Controlled substances

a. medications controlled by the federal Controlled Substances Act (CSA) because they have a
higher risk for abuse

b. controlled substances in the United States - 5 categories

i. Schedule I - category of drugs with high abuse potential and no medical use (generally
unsafe), e.g., heroin, lysergic acid diethylamide (LSD), and marijuana

ii. Schedule II: high risk for abuse or physical or psychological dependency but also have safe
and accepted uses, e.g., morphine, amphetamines, short-acting barbiturates

iii. Schedule III: less potential for abuse or addiction than Schedule II, e.g., paregoric, various
analgesic compounds containing codeine

iv. Schedule IV: medically useful category of drugs with less potential for abuse or addiction
than Schedule II drugs, e.g., chloral hydrate, diazepam, meprobamate, phenobarbital

v. Schedule V: lowest potential for abuse of all categories, medically acceptable uses e.g.,
antidiarrheals and antitussives with opioid derivatives


c. providers must register with the Drug Enforcement Agency (DEA) to prescribe these
medications and include their DEA number on the prescription





164

REMEMBER IT
As a general rule, classes of drugs have the same generic "last" name:
"PRILS" = ACE inhibitors (enalapril, lisinopril)
"SARTANS" = angiotensin receptor blockers (losartan, valsartan)
"TRIPTANS" = treatment of acute migraine headache
"STATINS" = lower LDL cholesterol (simvastatin, rosuvastatin)
"DIPINES" = calcium channel blockers (amlodipine, nifedipine)
"PRAZOLES" = proton pump inhibitors (omeprazole)
"AZOLES" = antifungals (miconazole)


B. Pharmacodynamics (how a medicine changes the body) - it's the mechanism of drug action and
its relationship between drug concentration and responses of the body

1. Used to help predict if the medication will assist the client or will produce a significant change
in the client

2. Replaces a missing substance

3. Destroys or inhibits a pathogen

4. Stimulates, suppresses, or disrupts a process


C. Pharmacokinetics (how the body affects the drug)

1. Consists of four processes: absorption, distribution, biotransformation (metabolism) and
excretion

a. absorption: movement of the drug through blood circulation from the site of administration
to target tissue

i. onset of action: the time between the administration of a medication and the beginning
of its effects


ii. duration: amount of time that a medication exerts its effects, therapeutic and adverse

iii. bioavailability: amount of drug that reaches the target tissue


b. distribution

i. process by which the drug diffuses or is transferred from the intravascular space (blood
stream) to extravascular space (body tissues)

ii. factors affecting distribution

blood flow to the tissue, e.g., vasoconstriction reduces drug distribution and
vasodilation enhances drug distribution

solubility of the drug

binding of the drug to macromolecules in the blood or tissue

ability to cross barriers, e.g., blood-brain barrier, placenta



c. metabolism (biotransformation): chemical conversion or transformation of drugs into
compounds that are easier to eliminate

i. phase I: oxidation, reduction, or hydrolysis by the cytochrome P-450 enzyme system

ii. phase II: conjugation of substance, improves renal excretion

iii. half-life: time it takes the amount of drug administered to decrease to 50% of the peak
drug level



d. excretion: elimination of unchanged drug or metabolite from the body, through renal,
biliary, or pulmonary processes

i. route of excretion depends on the drugs chemical properties

ii. kidneys are responsible for excreting most drugs






2. Factors affecting pharmacokinetics
165


a. client influences

i. body mass index

ii. cultural guidelines

iii. genetic and ethnic factors

iv. pathophysiological impact

v. environmental and immunological factors

vi. developmental (growth and development) factors

vii. nutritional and dietary restrictions


b. drug-related factors

i. dose


ii. timing


iii. route and administration

iv. drug-drug interactions

potentiate

inhibit: decrease or blunt the effectiveness of another medication

incompatible: agent that usually causes harm to the client or causes
complications with the administration of another medication


v. drug-diet interactions

vi. drug metabolism



REMEMBER IT
If you learn drug classifications, it may be easier to
remember specific medications and their indications for
use, adverse effects, and client/family teaching. Refer
to our Drug Classifications guide for more details.



3. Therapeutic range

a. range of concentrations at which a drug or other therapeutic agent is effective with minimal
toxicity to most people

b. common drug examples: acetaminophen, aminophylline, digoxin, lithium, phenytoin,
propranolol, theophylline



4. Peak and trough levels

a. peak: point in time after the administration when a medication exerts its strongest therapeutic
and adverse effects; a serum blood sample is drawn (about 1 hour) after the drug is
administered

b. trough: the lowest drug level that is needed to reach therapeutic range; a serum blood is
drawn (about 30 minutes) before medication administration



5. Drug effects

a. therapeutic: desired primary effect for which drug is given

b. side effect: undesirable or unpleasant client response to pharmacotherapy that tends to be a
nuisance

c. adverse: undesired responses to pharmacotherapy that are harmful to the client or make
administration of the drug very difficult or harmful

d. toxic: dangerous or harmful adverse effect including secondary effect; hypersensitivity, tissue
166

and organ damage

e. cumulative: occurs when drug is administered too frequently or when excretion of the drug is
impaired, may lead to adverse and toxic effects

f. hypersensitivity: immunological response of client; allergy and anaphylaxis

g. tolerance: over time the drug loses its therapeutic effect; requires increased dosing to produce
same effect, not predictive of addiction

h. dependence: disruption of a homeostatic function set-point when an agent is stopped leading
to clinical indicators of withdrawal

i. psychic: predictive of addiction

ii. physical: not predictive of addiction


i. subtherapeutic: not reaching therapeutic effect due to low dosing



D. Administration routes

1. Oral (PO)

a. types

i. capsules, elixir, powder, sprinkles, tablets

ii. timed release tablets or capsules (CR, XR, XL)


b. preferred route of administration

i. less expensive


ii. fewest complications


iii. amenable to home therapy


c. rate of absorption affected by

i. gastric HCl


ii. perfusion to GI tract


iii. rate of gastric emptying


iv. presence of interacting foods or drugs


d. effects on mechanism of action

i. exposes drug to endogenous HCl

ii. time spent in stomach (effects 'absorption;' may alter drug action or effectiveness)

food in stomach: drug spends more time in stomach, delayed absorption

empty stomach: drug is passed out of stomach quickly, faster absorption


iii. food or drug may bind to drug or block absorption

iv. may require injection if action is severely affected


e. first-pass metabolism

i. orally administered drugs primarily absorbed from small intestine

drug enters portal circulation and travels to liver

immediate transformation via liver enzymes


ii. destroys a larger percentage of the active ingredient than injected agents

usually requires larger oral dose versus injected forms








2. Inhaled

a. absorption rate affected by

i. integrity of lung tissue
167


ii. proper administration of drug

iii. perfusion to pulmonary vasculature


b. aerosols

i. information common to aerosol delivery of drugs

goal - to deliver high concentration of drug in the lungs with limited systemic effects

most commonly used in the treatment of asthma, COPD, wheezing

effectiveness of delivery depends on

slow, deep inhalation and

holding breath for 5 to 10 seconds after inhalation

size of particles (most desirable is 1 to 5 microns)

amount of drug reaching lungs and GI system


ii. metered-dose inhaler (MDI)

advantages
less expensive, more portable than nebulizer
delivers high concentration of medication with few side effects

disadvantages

higher risk of dispensing medication into mouth

very young, very old, and weak clients may have difficulty activating device

technique must be correct for medication delivery

canister must be shaken before each use

hand-breathing coordination required

medication remaining in canister can be difficult to determine


technique without spacer: administer one puff using MDI

shake canister for 2 to 5 seconds

hold MDI with thumb under the mouthpiece and the index and middle fingers on
top of the canister

positioning mouthpiece - client has two options

place mouthpiece of MDI in mouth with opening pointing toward the back of
the head; client tightens lips around mouthpiece

position MDI 1 to 2 inches in front of widely opened mouth pointing toward
back of the head; lips should not touch mouthpiece

inhale deeply and exhale completely

tilt head back slightly and simultaneously inhales slowly and deeply through
mouth while depressing canister

continue to inhale slowly for 2 to 5 seconds, then hold the breath for 10 seconds

technique with spacer

insert mouthpiece of MDI into spacer

shake canister for 2 to 5 seconds

insert mouthpiece of spacer device into mouth being careful not to cover
exhalation vents on spacer
168



breathe normally through spacer

depress canister, spraying one puff into spacer

inhale slowly and fully for 5 seconds

hold breath for 10 seconds


rinse mouth after using MDI with or without a spacer

wait 20 to 30 seconds between puffs before administering second puff or
additional medication with MDI

divide the number of doses in the container by the number of doses used per day
to determine how long the MDI will last




iii. nebulizer

advantage - delivery of finer aerosol, less risk of oral medication delivery

disadvantage - not portable; very young, very old, and debilitated clients may have
difficulty setting up equipment

procedure

add medication to nebulizer cup with diluent and attach nebulizer cup to nebulizer

insert mouthpiece of nebulizer into client's mouth; may use face mask if client unable
to follow instructions

instruct client to inhale slowly and deeply, hold breath for a second, then passively
exhale; dyspneic clients may limit breath-holding to every fourth or fifth breath

turn nebulizer on and verify release of mist

tap medication cap toward end of treatment session

reinforce use of breath-holding

check client's heart rate before and during treatment

after finishing treatment

turn nebulizer off

follow agency policy for storing and cleaning tubing and medication cup

provide oral rinse to client

check bilateral breath sounds, peak flow rates, SaO
2
, and heart rate





iv. nasal spray

gently blow nose before administration

shake container

tilt head slightly back

occlude one nostril, insert spray tip into the other nostril

activate spray and gently inhale


v. dry powder

rotacap inhalers

requires high airflow: avoid use with children and older clients and in high humidity

contraindicated for severe asthma exacerbations


3. Topical

a. transdermal medications

i. analgesics

169


ii. antidepressants


iii. hormones


iv. cardiac medications


b. absorption rate affected by

i. skin integrity


ii. tissue perfusion



c. applied locally, but has systemic effects

d. remove previous patch and wash the area to prevent further absorption prior to applying the
next dose

e. use cautiously with older clients due to increased rate of absorption through aging skin



4. Transmucosal: vaginal, buccal, rectal

a. types: vaginal, sublingual (under the tongue), buccal (in the pouch of the cheek), rectal

b. absorption rate affected by

i. length of exposure

ii. perfusion of tissue

iii. integrity of mucosa


c. suppositories - wear gloves for procedure; remove foil wrapper and lubricate the suppository if
necessary

i. rectal suppositories

if used for systemic indication, have client defecate if possible to allow facilitation
of medication

position client on left lateral position and insert just beyond internal sphincter

instruct client to retain the medication for 20 to 30 minutes for stimulation of
defecation and 60 minutes for systemic absorption


ii. vaginal suppositories

position client supine with knees bent, feet flat on bed and close to hips (a
modified lithotomy position)

use application device to insert suppository




5. Intradermal

a. slower absorption rate

b. common sites: inner aspect of forearm, upper chest and upper back

c. administration

i. use tuberculin syringe

calibrated in 0.1 mL and 0.01 mL

needle: 25 to 27 gauge

length: 1/4 to 1/2 inch


ii. dose: 0.1 to 0.01 mL

iii. angle 10 to 15 degrees from the skin to the deposit the medication below the epidermis; a
wheal will form under the skin



6. Subcutaneous (SubQ): implants, injection

a. parenteral administration of medication into the loose tissue between the skin and muscle
(medication must not enter muscle)
170


b. administration

i. needle type
use 5/8 inch needle, greater than 21 gauge

insulin syringes come in many smaller sizes: 5/16 inch or 8 mm and the pen
needles are 1/2 inch (12.7 mm), 5/16 inch (8 mm) and 3/16 inch (5 mm) lengths


ii. inject medication into subcutaneous tissue to avoid muscle

iii. use 45-degree or 90-degree angle

iv. aspiration not required

v. do not massage injection site

vi. rotate injection sites


c. suitable medications for subcutaneous administration

i. isotonic


ii. nonviscous


iii. non-irritating


iv. water-soluble


v. small volumes of medication (0.5 to 1 mL)


d. contraindications

i. shock, cardiac arrest

ii. decreased perfusion to tissue




7. Intramuscular (IM)

a. four common sites: ventrogluteal, dorsogluteal, vastus lateralis, and deltoid

b. absorption affected by the muscle's perfusion, fat content, and degree of vasoconstriction

c. administration


i. verify need to aspirate

ii. inject medication into large muscle; avoid soft tissue other than muscle, especially nerves
and vessels


iii. needle angle: perpendicular (90 degrees) to tissue being injected

iv. children
younger than 18 months: vastus lateralis muscle
older than 18 months: use vastus lateralis, ventrogluteal, deltoid
inject up to 2 mL for children (deltoid should be limited to 0.5-1 mL)
171




v. adults
injection sites: vastus lateralis, ventrogluteal, and deltoid muscles
inject up to 3-5 mL for adults (deltoid: should be limited to 0.5-1 mL)



d. needle length for injections

i. infants 0 to 12 months: 5/8 inch

ii. toddlers and preschoolers: 5/8 up to 1 inch

iii. school-age and adolescent: 5/8 up to 1 inch

iv. adults: 1 to 1 inch

v. older or debilitated adults: 5/8 to 1 inch


e. landmarks for IM injections

i. ventrogluteal muscle

index finger of non-dominant hand on anterosuperior iliac spine (iliac crest, upper,
outer buttocks)

form a V with index finger and middle finger; aim opening of V laterally the middle
finger pointed towards the iliac crest and index finger pointed toward the
anterosuperior iliac spine.
injection site: between index and middle fingers
low potential for injury


ii. vastus lateralis muscle

anterior, lateral aspect of thigh between greater trochanter and knee

use middle third of muscle to inject

low potential for injury


iii. deltoid muscle

locate lower edge of acromion process (protrusion at end of clavicle)

move straight across upper arm to midpoint of the lateral aspect of deltoid
muscle
this line is the base of a triangle pointing toward the elbows
injection site is 1 to 2 inches below acromion process

alternate method: place four fingers across the deltoid muscle placing the top
finger just below the acromion process with injection site just under the third
172

finger

higher potential for injury: radial, brachial, and ulnar nerves and brachial artery lie
under triceps along the humerus
use only for small volume (0.5-1 mL) injections


iv. dorsogluteal muscle: location of sciatic nerve varies between people; avoid using this site
because of high risk of sciatic nerve injury



f. special types of IM injections

i. Z-track method

indication: parenteral medications likely to harm or irritate tissue

technique

after drawing up the appropriate medication amount, add a 0.2 mL airlock, change
the needle to ensure the medication is not tracked into the SQ tissue during needle
insertion
select a large, deep muscle (such as ventrogluteal)

pull skin tightly down or laterally before injection

inject medication and continue to hold tissue in position

allow needle to remain in place for 10 seconds after injection

withdraw medication and quickly release skin so that layers of tissue move over
needle track to "seal" the medication in place



ii. depot injection

intramuscular injection of a drug in an oil suspension that results in a gradual release
of the medication over a period of time (from several days to weeks to months)

administer regular dose of agent first in controlled setting to prevent sustained allergic
reaction

examples: Somatuline Depot (used to treat acromegaly) and Clopixol Depot (used to
treat schizophrenia)
injection techniques, needle angle, landmarks, Z-track method



8. Intravenous (IV)

a. rate of absorption not affected

b. rate of distribution dependent on stable cardiovascular status

c. titration of dose (typically an RN-only action)

i. usually based on therapeutic effect and dosage/kilogram

ii. requires accurate calculations


d.
catheters

i. 26 gauge (smallest) to 14 gauge (largest); 3/4 inch to 1 1/4 inch in length

ii. blood must flow around inserted catheter (but ease of flow and risk of phlebitis increase as
size increases)



e. complications of IV therapy

i. insertion site: air embolism, bleeding, hematoma, site infection

ii. miscalculation of rate or programming error of infusion control device

iii. IV solution: extravasation, infiltration, hypervolemia

iv. catheter

dislodgement, malposition, migration, rupture

occlusion, thrombosis of catheter
173


insertion site infection, sepsis




f. locations for IV therapy

i. peripheral

insertion site: peripheral vein usually in the arm, may be scalp or foot in pediatrics

bedside procedure for insertion and withdrawal

uses

short-term IV therapy

medication: repletion of fluids and electrolytes; nutrition

isotonic infusions, blood products, solutions not to exceed 10%

duration: usually up to 72 hours per site


nursing care

monitor site for edema, redness, induration, drainage, paresthesia, pain,
temperature

assess vital signs, breath sounds, I&O, peripheral edema, nutritional status and
possibly daily weight and compare to baseline data

maintain dry, transparent occlusive dressing

follow agency guidelines for documentation, reusing IV tubing, dressing changes
and types of dressings, insertion site changes




ii. non-tunneled central venous

indications
emergent situations and trauma
lack of suitable peripheral veins
short-term therapy, critical care, surgery


procedure

sterile procedure performed at bedside

place client in Trendelenburg position, with rolled towel between shoulder blades
(potentially contraindicated for clients with respiratory conditions, spinal deformities,
increased intracranial pressure)

subclavian, internal jugular or femoral veins used, with catheter ending in superior
vena cava


size and appearance

can have up to 4 lumens or ports

usually 6 to 8 inches in length


dressing changes require using aseptic technique
174


unused ports must be routinely flushed with heparin solution and clamped

uses

hypertonic solutions

vasoconstricting agents

pressure monitoring

fluid resuscitation


complications : thrombophlebitis, bleeding, infection, extravasation, occlusion


iii. peripherally inserted central catheters (PICC)

smaller, longer (40 to 65 cm catheters) and more flexible than other central line

procedure

sterile procedure performed at bedside

inserted through a peripheral vein in the upper arm, usually either the basilica,
cephalic or brachial vein; catheter ends before superior vena cava

can stay in place for as long as a year if properly maintained

must measure and document external length of PICC with each dressing change

unused ports must be flushed with heparin solution and clamped


iv. tunneled central venous catheters: part of the catheter is encased in subcutaneous tunnel; tissue
granulates onto cuff surrounding catheter creating a barrier and anchor

inserted surgically through the subclavian vein

useful for frequent, long-term IV therapy

typically no dressing is required after cuff heals

types

Broviac

Hickman

Groshong


complications



v. implanted port (vascular access devices (VAD)

surgically implanted

dense septum with reservoir and attached catheter

painful needle insertion: Huber (non-coring) needle must be used to access port

must always confirm needle placement before medication administration

requires flushing after each use; unused port is flushed monthly with heparin solution



175

Comparison of Central Venous Catheters
Non-tunneled Peripherally
Inserted Central
Catheter (PICC)
Tunneled Implanted Port
Insertion
Procedure
sterile (with client in
Trendelenburg position)
bedside sterile surgical surgical
Dressing sterile sterile sterile none required
Insertion
Site
subclavian or internal
jugular ending in superior
vena cava
antecubital fossa or
upper extremity;
ends before
superior vena cava
subclavian upper chest,
upper extremity
Uses hypertonic solutions,
vasoconstricting agents,
pressure monitoring, fluid
resuscitation
suitable for all
infusions, long-term
therapy
frequent long-
term IV
therapy
intermittent, long-
term therapy
Unique
Features
triple lumen catheter used
for monitoring
teach client to
protect arm and
care for insertion
site
types:
Broviac,
Hickman,
Leonard
access: Huber
(non-coring)
needle through
silicone septum
Note: All central venous catheters require Luer-Lok connections and x-ray confirmation of tip placement before
therapy begins.

g. methods of IV administration

i. continuous infusion: risk of fluid volume overload

ii. infusion control device (ICD, pump)

mechanical control of rate and volume

types: syringe (small volume), peristaltic action, and
microchamber

verify volume infused (on time strip of IV bag) without using
pump indicators every hour


iii. IV push

administration by bolus; verify rate of IV push

verify if allowed by scope of practice in Nurse Practice Act and
agency policy


iv. secondary infusion (piggy-back, rider, intermittent)


v. patient-controlled analgesia (PCA) pump

client has limited control of opioid dosing

pump settings prescribed: dosing parameters including basal
rate, bolus dose amount and frequency of boluses

benefits

avoids delay of pain medication

avoids frequent IM injections

greater sense of client control
176

Non-tunneled Peripherally
Inserted Central
Catheter (PICC)
Tunneled Implanted Port

lower incidence of respiratory depression when used with
short-acting opioids






h. IV therapy solutions : used to replace fluids, electrolytes, and nutrients; also rapid administration
of drugs

i. isotonic crystalloid solutions - osmotic pressure similar to plasma; expands extracellular fluid
without changing osmolarity

ii. hypotonic crystalloid solution - exerts less osmotic pressure than plasma; fluids shift into
interstitial spaces and cells, causing cells to swell

iii. hypertonic crystalloid solution - exerts more osmotic pressure than plasma; osmosis pulls
fluids out of the cells, causing them to shrink

iv. hypertonic colloid solutions - also expand intravascular volume plasma but colloids contain
molecules too large to pass through semipermeable membranes


i. additional equipment for IV therapy

i. volumetric device (such as Buretrol)

ii. Luer-Lok: collared slip-lock that fits onto a female catheter hub

iii. filter

place as close to insertion site as possible

can rupture under excessive pressure

various sizes (in microns) depending on solution

removes particulate matter, microorganisms, and air within limits; use only if
indicated



j. role of PN with IV therapy

i. verify state-approved IV skills and IV responsibilities (scope of practice) in Nurse Practice Act

ii. most states allow well-defined IV related tasks only after additional education and training

iii. most states require LPN/VNs to observe IV sites and to report the findings to the RN or health
care provider; observe for

leakage

clean, dry dressing

site: less than 3 days old

infection

warmth

redness

swelling

drainage

tenderness or pain

infiltration

swollen

cool to touch
177


infusion rate slowing or stopping

phlebitis

regional pain and swelling

red streak along vein line

leakage, infiltration, or impaired infusion rate




10. Intrathecal

a. types

i. spinal


ii. epidural: standard drug instillation and liposomal instillation of morphine



b. direct administration of opioids and local anesthetic agents into epidural space or intrathecal
space


c. benefits

i. lower systemic side effects

ii. lower dosing of therapeutic agents


d. dose-dependent effects

i. itching, nausea, vomiting

ii. respiratory depression, urinary retention


e. adverse effects: delayed respiratory depression



11. Intraosseous infusion

a. percutaneous placement of intravenous catheter into a marrow cavity

b. used when peripheral blood vessels are collapsed or inaccessible



12. Ophthalmic

a. preparation

i. wash hands and apply gloves - rinse powdery residue from gloves

ii. instruct client to recline or tilt head back

iii. instruct client to look up






178


b. technique - eye drops
Instilling Eye Drops
1. Wash hands and apply gloves; rinse powdery residue from gloves
2. Instruct client to recline or tilt head back
3. Instruct client to look up
4. Pull lower lid down and to the side
5. Apply drop at lower, outer aspect of eye (lower conjunctival sac)
6. Apply mild pressure to inner canthus for 1 minute to decrease systemic
absorption
7. Instruct client to gently close eyes
8. Wait 2 to 5 minutes before instilling additional eye drop (in same eye)


c. technique - eye ointment

i. apply a thin line of ointment along the edge of the lower lid moving from inner canthus to
outer canthus


ii. instruct the client to gently close the eye and move the eye around



13. Otic

a. ear drops preparation

i. warm medication

ensure tightly sealed medication container

run container under warm water


ii. position client on unaffected side with affected ear facing up

iii. remove ear drainage or cerumen with cotton-tip applicator; avoid pushing cerumen into
ear canal


iv. open ear canal

In a child younger than age 3, pull the lobe down and back

In a child older than 3 years, pull the pinna up and back




b. instillation of drops

i. fill dropper with medication

ii. hold dropper about 1/2 inch above ear canal

iii. gently squeeze bulb on dropper to instill prescribed number of ear drops

iv. instruct client to remain in place for 5 to 10 minutes

v. repeat in other ear if necessary after waiting 5 to 10 minutes


c. if cotton balls are prescribed - place in outermost part of ear canal and remove in 15 minutes


E. Medication delivery

1. Single dosing
179


a. bolus: a single dose administered IV, from a syringe (usually), and at one time (usually an
RN-only task)


b. STAT dose: give prescribed amount of medication immediately

c. one-time dose: prescription is administered only one time

d. loading dose: prescribed amount of medication

i. administered (usually larger than normal) at the beginning of therapy to establish a
therapeutic blood level


ii. administered as single or divided doses

iii. followed by maintenance therapy



2. Intermittent dosing

a. as needed (PRN)

b. IV push: indicates a bolus of medicine in a syringe (usually an RN-only task)

i. therapeutic dose by IV administration given at one time

ii. can be single daily dose or multiple daily doses




c. IV piggy-back

i. small volume IV containing a medication infused over at least 30 minutes

ii. also called a "rider" or "secondary infusion"



3. Continuous dosing

a. subcutaneous implant or pump

b. transdermal infusion system

c. IV infusion

i. continuous IV fluid infusion

ii. titration: drip rate is adjusted to maintain predetermined parameters within an
acceptable range based on amount/client weight/time





F. Nursing responsibilities

1. All medications must have a signed, provider prescription

2. Administer drug as indicated: typically allowed 30 minutes before through 30 minutes after
prescribed time to administer medication

3. Prior to administering a medication

a. know and understand medication incompatibilities

b. verify drug safety in pregnancy and lactation

c. review hepatic and renal function before administration

d. obtain cultures before beginning anti-infective therapies

e. know lab values or other test results prior to administration


4. Individualize pharmacotherapy according to developmental stage or Erickson's Stages of
Development

5. Older adults

a. may retain lipid-soluble drugs longer

b. serum levels of water-soluble drugs may be higher than normal

c. many medications may cause confusion in the elderly


6. Establish baseline data for monitoring medication effectiveness
180


7. Remain up-to-date on information about medications, including evidence-based practice
guidelines

8. Understand concepts, i.e., indications, naming of drugs, related to medication classification

9. Avoid distractions while dispensing and administering medication



10. Five rights of medication administration

a. right dose: check medication label against the administration record
PATIENT SAFETY - Check medication label against the administration record three times
while preparing the medication!
1. When first taking the medication out of the container
2. Just before opening the medication package or pouring the dose
3. Just before replacing the container in the storage area or giving a unit dose to the client

b. right time: check facilities policies, usually 30 minutes before or 30 minutes after the ordered
time


c. right route: Check the medication order that the route is specified

d. right drug

i. proper mixing or dilution

ii. speed of infusion or push

iii. accurate dosage calculations


e. right client

i. check ID bracelet for client name and birth date (depending on facility, include bar code
check of ID bracelet)

ii. have client state full name and birth date

iii. verify information using medication administration report (MAR)



11. Other rights of medication administration include

a. right documentation

i. document immediately after medication is given on MAR or computerized medical record

ii. document if client refuses medication

iii. include drug, time, dose, route, signature


b. right assessment

i. vital signs, ability to swallow, pain

ii. check client data, lab tests, and diagnostic studies before administration


c. right education

i. about the medication - important to stay up-to-date on meds

ii. expectations



d. right evaluation, i.e., response to therapy

e. right to refuse medication

i. nurse should explain any problems associated with not taking a medication

ii. notify health care provider


f. client privacy and client rights



12. Medication errors

a. higher rate of medication errors associated with

i. high-alert drugs


ii. poor communication
181


iii. clients over the age of 60 years

iv. poorly written prescriptions, use of ambiguous abbreviations, and misunderstanding of
prescription's meaning

v. prescribing errors - mistakes made by provider in prescribing drugs involving unsuitable
drug choices, dosing errors, incompatibilities, and contraindications

vi. failure to reconcile client medication list at client hand-offs

vii. most common nursing medication errors
incorrect dose, time, route, and client
multiple routes of administration for single drug on MAR



b. preventing medication errors

i. perform medication reconciliation

reconcile medications at any client hand-off: admission, transfer, discharge,
postoperatively, and at shift change

involves comparing the client's list of medications with the prescriptions

may involve client and family in reconciliation



ii. avoid distractions while dispensing and administering medication

complete check of client's rights: dose, time, route, drug, and client

check client identifiers on each page of MAR

check client data, lab tests, and diagnostic studies before administration

read medication labels three separate times


iii. typical identifiers in acute care setting - follow agency guidelines
check client wristband with name and medical record number
ask client for first and last name; avoid revealing client's name to client


iv. clarify poorly written prescriptions; never attempt to interpret

v. complete client admission assessment
history
allergies
identify the accurate list of client's medications


vi. maintain up-to-date drug information

clarify questions with research or consulting with the pharmacy

refer to agency policy for administration guidelines


vii. report medication errors and problems according to agency policy



13. Client privacy and client rights

a. privacy

i. cover MAR (or reduce screen) except when needed to dispense medication

ii. close door to client's room or pull the privacy curtain to obscure viewing of procedures

iii. request visitors and family members leave the client's room during medication
administration except when allowed by client

iv. avoid discussing client medication except on a "need to know" basis


b. confidentiality

i. avoid sharing information about client's medications except on a "need to know" basis

ii. avoid associating medications or medication related information to client in public areas
182



c. informed consent

i. provide information on medications dispensed before initial dose and during therapy

indications

therapeutic or anticipated effects

adverse effects

risks of accepting or refusing therapy


ii. reinforce client teaching


d. self-determination: client may refuse a dose of a medication or the entire course of therapy
without coercion or threats of retribution



14. Client teaching plan - assist health care team or RN to formulate and implement client teaching
plan

a. do not crush or chew tablets unless directed to do so

b. avoid sharing medication with other people and family members

c. avoid driving and performing hazardous activities until drug effect is well established

d. travel with medication in original containers

e. cutting pills - discuss with health care provider first

i. cost-cutting measure

ii. use commercial pill-cutter

iii. disadvantages
may result in decreased therapeutic effect
serious adverse effects due to rapid release of medication


iv. do not cut capsules, enteric-coated, sustained-release, or extended-release tablets, or
pills intended for transmucosal administration


f. provide drug information

i. name, dose, and indication

ii. administration guidelines

iii. storage


iv. resources for client and family


g. reinforce information about expected effects, side effects and adverse effects

i. side effects may subside after 4 to 6 weeks of therapy

ii. notify provider before stopping therapy due to side or adverse effects

iii. comfort measures for relief of side and adverse effects


h. advise client to contact provider

i. adverse effects or disease process worsens

ii. indications of drug toxicity


i. provide individualized instruction about dosing and administration guidelines

i. avoiding certain foods

ii. preparing drug before administration

iii. dosing schedule and length of therapy

iv. avoiding hazardous activities or driving until the full effects of the medication are well-
183

established


v. taking as directed, even when feeling better

vi. store drugs properly, away from light, heat, and moisture

vii. avoiding over-the-counter (OTC) drugs and herbal remedies without provider discussion


j. discuss need for monitoring and follow-up care


k. notify other providers about drugs on medication profile (complete list of client's drugs)
including

i. herbal supplements - may have adverse effect on prescription drug action

ii. diet pills


iii. over-the-counter drugs

iv. minerals, vitamins, nutritional supplements

v. contraceptive drugs or devices, laxatives, and sleeping aids


l. avoid Internet and international purchase of drugs and dietary supplements

i. some medications may be counterfeit

ii. purity is unreliable

iii. therapeutic equivalents are difficult to determine because

identically-named medications sold in different countries are frequently different
medications (different chemical composition)

identical medications (same chemical composition) sold in different countries will
frequently have different generic and brand names




15. Client safety

a. identify and manage hazards related to pharmacotherapy

b. safety

i. chemical
avoid over-the-counter (OTC), herbal, and other nonprescription remedies
carefully review drug profile when adding or deleting a drug from the list


ii. physical: orthostatic hypotension, stairs, shaving, etc.


c. avoid administering drug with known client...

i. hypersensitivity


ii. pregnancy or lactation

balance of risk versus benefit

some drugs used to preserve life of mother

most drugs are contraindicated due to risk for fetus

pregnancy categories

A: no risk to fetus in the first trimester

B: may or may not show risk in animals, no risk shown in human studies

C: risk shown in animals, insufficient data in pregnant women

D: demonstration of human risk in selected clinical studies

X: clear demonstration of risk to human fetus



iii. hepatic or renal dysfunction


184


II. Total Parenteral Nutrition: Nursing Care of Clients

A. Nutritional support

1. Nutritional deficiency

a. clinical indications for hyperalimentation include clients who

i. cannot use GI tract for absorption of nutrients

ii. require nutritional therapy to maintain or improve nutritional status

iii. have risk factors for malnutrition

body mass index for height and age below average

admission to hospital, nursing home, rehabilitation facility

anorexia, nausea, vomiting from agent, event, or condition

inadequate nutritional intake, increased nutritional loss, or increased
metabolic rate

impaired ability to prepare, obtain, or eat food

substance abuse, older clients

low socioeconomic status, educational deficiencies

dysphagia, infection, multiple chronic illnesses, trauma




b. clinical indicators of malnutrition

i. gold standard: prealbumin below normal (protein deficiency)

ii. other labs: low hemoglobin, transferrin, cholesterol, total lymphocytes

iii. physical findings
gums and teeth in poor repair
reddened and open areas, susceptibility to infection
dull, dry eyes, nails, skin, hair, inadequate muscle bulk





Included on the Institute for Safe Medication Practices (ISMP) List of High-Alert Medications is
all total parenteral nutrition solutions.

2. Hyperalimentation

a. partial parenteral nutrition

i. indications: central line contraindicated, prolonged postoperative ileus

ii. infusion

via large peripheral IV

solutions

isotonic lipid emulsion: may be administered with IV solution

hypertonic amino acid and dextrose solution




b. total parenteral nutrition (TPN)

i. long-term intensive nutritional support for
trauma, major surgery, hypermetabolic state

GI impairment: inflammation, malabsorption, obstruction, side effects of
chemotherapy


ii. hyperalimentation solution used to meet goals of therapy

contains hypertonic dextrose and amino acid solutions
25%-35% dextrose
3%-5% amino acids
10%-20% lipids


infuses via central venous catheter in subclavian or internal jugular vein
185


includes electrolytes, minerals, trace elements, and insulin added by pharmacist

prepared and administered under strict aseptic technique


iii. benefits

individualizes formula according to client needs

protein-sparing action with calories

supplies amino acids for tissue repair and healing

delivers all nutrients with lower risk of fluid overload than nutritional equivalent of
standard IV therapy



c. complications from central venous catheter

d. selected complications from TPN solution

i. infection: solution provides breeding ground for microorganisms

ii. fluid imbalance
hypertonic solution infuses directly into venous circulation
fluid shifts occur due to hyperosmolar nature of solutions


iii. hyperglycemia: most solutions contain insulin or client on sliding scale insulin regardless of
history of diabetes mellitus



B. Nursing care

1. Assist health care team to establish baseline data and check prior to initiating therapy and
periodically thereafter

a. vital signs, SaO
2
, right atrial pressure

b. blood urea nitrogen (BUN), creatinine, liver function tests, pH

c. glucose monitoring (Accu-Chek) minimum once a shift (due to impairment of glucose
metabolism)

i. hyperglycemia: nausea, weakness, thirst, headache, tachypnea

ii. hypoglycemia: diaphoresis, tachycardia, hunger, trembling, confusion


d. fluid volume status: daily weight, I & O, edema, breath sounds

e. nutritional status: skin, serum electrolytes, glucose, cholesterol, triglycerides

f. infection: temperature, WBC, insertion site

g. other: neurologic status

h. refeeding syndrome (first 24 to 48 hours of therapy): bradypnea, lethargy, confusion,
weakness



2. Prevent complications

a. rebound hypoglycemia: withdraw TPN slowly

b. microemboli: use 0.2 m-filter (except with lipid emulsion)

c. injury: check expiration date of solution, verify TPN order and client identity

d. hyperglycemia: verify insulin coverage, check blood glucose frequently

e. acidosis: maintain tight glycemic control, encourage coughing and deep breathing

f. infection

i. avoid contamination from oily skin or tracheostomy

ii. insert catheter with surgical asepsis

iii. refrigerate until 30 minutes before using, discard after 24 hours

iv. sterile dressing change, use aseptic technique, change tubing daily


186


g. fluid shifts, hypervolemia, osmotic diuresis

i. do not increase infusion rate

ii. mantain tight glycemic control: verify provider or agency policy for tracking serum
glucose levels


iii. administer 10% dextrose if TPN infusion is interrupted

iv. carefully control infusion rate, carefully program infusion device

verify volume infused with time strip on TPN container

start infusion slowly; titrate to client response



h. air emboli

i. use Luer-Lok connections

ii. cover site with occlusive dressing

iii. clamp tubing when changing solution or tubing; may need to position client in supine
position or ask client to perform Valsalva maneuver




3. Assist health care team to implement client and family teaching plan for home therapy

a. review purpose and procedure

b. verify written instructions for all procedures, troubleshooting, and complications

i. review procedures and equipment

record keeping

infusing solution

ordering supplies

glucose monitoring


ii. request return demonstration for understanding and competency


c. verify aseptic technique (do not disconnect tubing)

d. verify temperature in refrigerator

e. promptly report

i. fever


ii. breathing difficulties

iii. weight gain, edema, orthopnea

iv. recurring hyperglycemia

v. swelling, redness, or drainage at central venous catheter site




III. Blood Product Administration

A. Administration of blood and blood products

1. Blood products: red blood cells (RBCs)

a. washed RBCs: RBCs washed with sterile saline before administration; removes some
immunoglobulins and proteins

b. packed RBCs: blood cells are separated from plasma and platelets, decreases risk of
fluid overload


c. autologous blood transfusion

d. leukocyte-poor RBCs: removal of most leukocytes, fewer RBCs than packed RBCs


2. Plasma

a. serum albumin


b. immune serum globulin


c. factor concentrates: factors VIII and IX
187


d. fresh frozen plasma: contains coagulation factors

e. cryoprecipitate: clotting factors VII and VIII


3. Other blood components

a. platelets


b. RhoGAM


c. granulocytes






B. Purpose of transfusions and method(s)

1. Restore blood volume

a. provide albumin

i. normal serum albumin


ii. plasma protein fraction



b. increase oncotic pressure

i. serum albumin


ii. packed red blood cells



c. increase fluid volume: whole blood


2. Increase oxygen-carrying capacity

a. increase hematocrit: red blood cells

b. increase hemoglobin: red blood cells


3. Enhance immunologic defense

a. provide immunological factors

i. immune serum globulin


ii. granulocytes



b. prevent Rh-sensitization



4. Enhance hemostasis

a. provide clotting factors

i. cryoprecipitate


ii. fresh frozen plasma



b. provide platelets

i. apheresis packs


ii. random donor packs






C. Risks

1. Allergic reaction

a. most common type of reaction

b. findings: hives and itching

c. may be treated with antihistamines, e.g., diphenhydramine (Benadryl)


2. Febrile reaction

a. a reaction to the white blood cells in the donated blood

b. more common in clients who have had previous transfusions and in multi-para women
188


c. findings: fever within 24 hours of the transfusion, including headache, nausea, chills, or a
general feeling of discomfort

d. may be treated with antipyretic, e.g., acetaminophen (Tylenol)


3. Transfusion-related acute lung injury (TRALI)

a. may occur with any type of transfusion but more common with fresh frozen plasma or
platelets


b. more common in clients who are gravely ill

c. findings: trouble breathing, often within 1 to 2 hours of starting the transfusion but may
begin up to 72 hours post transfusion

d. findings are often under-recognized (which leads to a delay in treatment and an increased
mortality rate)



4. Acute hemolytic reaction

a. rare, but most serious type of transfusion reaction

b. occurs when donor and client blood types do not match

c. usually the result of human error, e.g., mislabeled pre-transfusion specimen, transfusion of
properly labeled blood to the wrong person, clerical errors

d. findings: chills, fever, chest and lower back pain, nausea progressing to hypotension,
bronchospasm, vascular collapse and disseminated intravascular coagulation (DIC)


5. Delayed hemolytic reaction

a. this reaction involves the body slowly attacking the antigens on the transfused blood cells

b. findings

usually none, but may develop fever 4 to 8 days, up to 1 month, after blood
transfusion

lab findings include falling hematocrit and a positive direct antiglobulin (Coombs)
test


c. more common in clients who have had previous transfusions



6. Graft-versus-host disease (GVHD)

a. occurs in severely immunocompromised clients

b. white blood cells in a transfused blood product attack client's tissues

c. more common when a relative or someone with the same tissue type has donated blood

d. findings: within a month of the transfusion, the client may have fever, liver dysfunction, rash,
diarrhea, pancytopenia

e. high mortality rate


7. Non-immune hemolysis

a. lysis of RBCs due to improper storage, handling, or transfusion conditions

b. findings: may include hemoglobinemia and hemoglobinuria


8. Disease acquisition

a. bacterial

i. more common in platelets since they must be stored at room temperature, allowing bacteria
to grow quickly


ii. sepsis


189


b. viral (including Hepatitis B & C, HIV)

c. babesiosis, malaria, Lyme disease, syphilis, Chagas disease, Creutzfeldt-Jakob disease can
be spread by blood product transfusions



9. Hypotension

a. findings: a drop of at least 10 mm Hg in systolic or diastolic arterial blood pressure in the
absence of other findings of transfusion reactions

b. may be associated with use of angiotensin converting enzyme (ACE) inhibitor drugs


10. Post-transfusion purpura (PTP)

a. findings: thrombocytopenia, usually profound

b. typically occurs 7 to 48 days after transfusion


11. Circulatory overload

a. caused by the infusion of blood at a rate too rapid for the client to tolerate

b. findings: dyspnea, orthopnea, tachycardia, sudden anxiety, progresses to pulmonary edema
if transfusion is continued

c. diuretics given after or between transfusions to clients at risk of, or already in, circulatory
overload



D. Nursing care

1. Observe RN prepare and initiate transfusion

a. signed consent required

b. blood products are picked up from the blood bank and must remain refrigerated until ready
for infusion

a. do not store blood in the refrigerator used for food

b. initiate transfusion within 30 minutes of removal from blood bank

c. complete transfusion in 4 hours after removal from blood bank


c. baseline data is established and monitored (following agency policy for frequency and
duration)

i. vital signs, SaO
2
, skin every 15 minutes and 1 hour after completion

ii. breath sounds (crackles especially), dyspnea, jugular vein distention

iii. hemoglobin and hematocrit, urine output; serum potassium, calcium, and creatinine



d. transfusion is given slowly for first 15 to 20 minutes

i. remain at bedside


ii. question client about unusual feelings

iii. monitor vital signs every 5 minutes during first 15 minutes and then as required by
agency policy



e. most reactions...
are due to human error
require symptomatic treatment
mandate notifying the provider and blood bank; follow agency policy
occur within the first 15 minutes of a transfusion



2. Observe RN prevent complications

3. Assist health care team to implement client teaching plan
190


a. reinforce information about contracting infections from blood

b. reinforce information about administration method, monitoring, duration of transfusion,
symptom recognition and reporting




4. Nursing care for transfusion reaction

a. immediately stop transfusion and take vital signs

i. clamp IV tubing and disconnect at hub of catheter

ii. do not allow additional blood to enter client's system, do not flush tubing with saline to clear


b. collaborate with provider for pharmacologic treatment

i. supplemental oxygen

ii. diuretics


iii. antibiotics


iv. antihistamines


v. glucocorticoids



c. monitor hemoglobin and hematocrit

d. complete transfusion reaction form

e. save entire administration set and blood bag, return to blood bank

f. follow agency policy on criteria for transfusion reactions and follow-up nursing actions



IV. Dosage Calculations

A. Ration and proportion

1. Equation description

a. each side of the equation represents the same percentage, fraction or ratio

b. example: 75%

i. equal percentages: 75% = 0.75


ii. equal fractions:



iii. equal ratios: 3 : 4 = 7.5 : 10



c. both sides of the equation represent an equal relationship but are expressed with
different quantities; the two sides match
To figure the calculation, multiply the means (numbers that are closet to each other) by
the extremes (numbers that are the farthest from each other). You are solving X, so X
goes first.


d. use a proportion equation to solve

i. dosage calculations


ii. metric to metric conversion

involves multiples of 10, 100, or 1000

grams : mg : mcg (1 x 1000 x 1000)

1 gram = 1000 mg

1 mg = 1000 mcg

1 gram = 1,000,000 mcg

191



mcg : mg : grams (1 1000 1000)

1 mcg = 0.001 mg

1 mg = 0.001 gram

1 mcg = 0.000001 gram




liters : mL 1 liter = 1000 mL

mL : liters 1 mL = 0.001 liter



e. applicable to other conversions









2. Dosage calculation: solve for x using a proportion problem
Example: The client with heart failure receives furosemide (Lasix) 40 mg by mouth daily. The
pharmacy stocks furosemide 20 mg tablets. How many tablets does the nurse administer for a 40
mg dose?


a. step one: set up proportion problem

i. advantage: proportion problems are easy to set up

ii. both sides of equation must match: display an equal relationship of the factors (mg and
tabs)


iii. first method

one side of the equation is what you have

the pharmacy stocks 20 mg tabs (20 mg per tab)

1 tab = 20 mg


the other side of the equation is what you want

the nurse wants to administer 40 mg; how many tablets does that require?

X number of tabs = 40 mg




iv. second method

make the equation match by placing each factor on opposite sides
one side of the equation is a factor
the other side is the second factor

make the equations match

use what you have as the numerator on opposite sides

use what you want as the denominator on opposite sides
192



the left side of the equation displays the relationship of the factor mg according to


the right side of the equation displays the relationship of the factor tablets according to




v. the answers for the equations in method 1 and 2 are the same: 2 tabs



b. step two: cross multiply and divide


i. (40 mg) 1 tab = (20 mg) x tabs [cross multiply]



ii. 40 = 20x [simplify each side: (40) 1 = 40 and (20) x = 20x]


iii. 20x = 40


iv. solve for x and divide both sides by 20



v. [simplify]



vi. x= number of 20 mg tabs of furosemide (Lasix) equals a 40 mg dose (carefully apply the
desired unit of measure to the solution)




3. Dosage calculation: solve for x using dimensional analysis (DA)

a. Advantage: only one equation used
Example: The client receives 300 mg phenytoin (Dilantin) by mouth daily for seizures. The
pharmacy sends phenytoin 125 mg/5 mL suspension. How many mL of suspension will the
nurse administer?

b. set-up DA equation

i. left side of the equation: what you are solving for (what you want)

x mL of suspension


ii. right side of the equation

available information related to unit of measure on the left side of equation: what
you know aboutmL (what you know or what you have)

what you have written as a fraction
193



place this information on the right side of the equation so the unit of measure from the
left side appears as the denominator on the right side

allows the unit of measure (mL) to be cancelled-out

in the example, the unit of measure on the left side of the equation is mL

in this problem,mLmust then be the numerator on the right side



iii. find the remaining information matching the unit of measure used in the numerator

in the example, this information is the prescription - place this information in the equation
so the mg cancel-out


mg cancel-out



x = 12 mL/day of phenytoin elixir




4. Order: Acetaminophen (Tylenol) elixir 100 mg by mouth every 4 hours as needed for pain.
Available concentration of Tylenol is 80 mg/0.8 mL. How much Tylenol elixir will the nurse
administer?

a. amount desired = 100 mg

b. amount on hand = 80 mg in 0.8 mL

c. (desired) 100 mg/x mL = 80 mL/0.8 mL (have on hand)

d. cross multiply:


100 (0.8) = 80 x


e. solve for x:


x = 100 (0.8)/80

x = 1 mL


f. the nurse would administer 1 mL Tylenol elixir


B. Conversions

1. Metric conversion

a. metric to metric

i. 0.001 kg = 1 gram = 1000 mg = 1,000,000 mcg

ii. 1 mcg = 0.001 mg = 0.000001 gram
194


iii. 1000 mL = 1 liter, 1 mL = 0.001 liter

iv. 1000 mm = 100 cm = 1 meter, 1 mm = 0.1 cm = 0.001 meter


b. metric to other

i. 2.5 cm = 1 inch


ii. 1 kg = 2.2 lbs


iii. 1 gram = 15 grains
1 grain = 60 miligrams


iv. 30 mL = 1 ounce = 2 tablespoons
5 mL = 1 fluid dram (dr)= 1 tsp
2 Tablespoon = 30 mL= 1 oz = 8 drams




2. Temperature conversion

a. Centigrade =


b. Fahrenheit =




C. Weight based dosage calculation
Scenario: The child weighs 68.2 pounds. The nurse must administer amoxicillin (Amoxil) by
mouth at 30 mg/kg/day in divided doses every 6 hours. How much amoxicillin does the nurse
administer each day? How many milligrams of amoxicillin does the nurse administer for each
dose?


1. Step one: convert the weight in pounds to kilograms



2. Step two: how much amoxicillin does the nurse administer each day?

a. insert weight (kg) into dosage equation


b. the nurse administers 930 mg/day


3. Step three: how much amoxicillin does the nurse administer for each dose?

a. calculate doses/day


b. divide total daily dose by the number of doses


c. check your answer

i. total daily dose


ii. dose = prescription






D. Intravenous calculations
195


1. The nurse prepares vancomycin (Vancocin) 500 mg IV in 250 mL of normal saline to infuse
over 2 hours. What is the administration rate in mL/minute?

a. useful equations for calculating administration rate:

b. set up the equation for this problem:


c. administration rate expressed as:



d. determine hourly rate:


e. solve this problem (convert 1 hour to 60 minutes):



2. The prescription is linezolid (Zyvox) 600 mg IV in 300 mL of D5W to infuse over 2 hours. The
IV tubing drip rate = 10 gtts/mL. What drip rate should the nurse use?

a. set up the problem and determine the hourly rate:


b. convert 1 hour to 60 minutes and determine milliliters per minute


c. determine drops/minute:
drip rate of IV tubing = 10 gtts/mL
multiply (units/min) x gtts/mL





3. IV flow rate using DA. The client receives epinephrine (Adrenalin) 0.25 mcg/min IV via infusion
pump. The pharmacy sent epinephrine 0.1 mg in 250 mL of normal saline. What rate in mL/hr will
the nurse use to program the infusion pump?


a. left side of the equation: what is being solved for (what you want)
i. x = mL/hr



b. right side of the equation: what is available (what you have)

i.



ii. first section

since x = mL/hr, the numerator in this section must be mL

the information attached to mL in the example is the epinephrine solution: 1 mg in
250 mL


iii. second section: the example asks for mcg, so mg must be converted to mcg

iv. third section: the example asks for, we have a prescription for


196


need to cancel-out mcg and relate the answer to time

insert prescription into equation: what we have, what is available


v. fourth section: convert minutes to hours

vi. check the equation: all units of measure should cancel-out except for those that solve for x

in the example: x=mL/hr


vii.


mg: cancel-out

mcg: cancel-out

min: cancel-out

remaining units of measure: mL and hr


viii.



ix.



x.





c. standard equation for IV flow rate (using information found in number 3 on epinephrine)

i.



ii. place information about epinephrine above into equation

iii.


the solution was sent in mg, convert mg to mcg



iv.




The nurse will apply mild pressure to the inner canthus of the eye after instilling eye drop medication. True False
Taking a medication sublingually avoids the first-pass effect. True False
Examples of Schedule I medications include morphine and secobarbital (Seconal). True False
The nurse asks the client with emphysema to bear down during insertion of a non-tunneled central venous
catheter (CVC).
True False
An elderly client is more sensitive to the active substance in a transdermal patch than a younger adult. True False
Lactated ringer's (LR) solution is a hypotonic fluid. True False
Clients risk adverse effects if they use herbal supplements along with prescription medications. True False
The nurse infuses 1 liter of 5% dextrose solution over 8 hours at 17 gtts/min; the IV has a drip factor of 15 gtts/mL. True False
The nurse can crush the oral medication disopyramide CR (Norpace CR) and mix it with applesauce. True False
Hypovolemia is a risk for the client receiving whole blood products. True False


Points to Remember
The following are basic critical thinking guidelines for safe drug administration.
Before administration

Assist health care team to gather general baseline data

vital signs, including height and weight

allergies, co-morbidities

laboratory results

hepatic, pulmonary, renal, neurologic, nutritional, and cardiovascular status
197



Identify client factors, including the affect of developmental status, cultural factors, and history of drug
action, safe to use during pregnancy

Determine purpose of therapy

indication for drug

desired therapeutic outcome


Know expected side effects, adverse effects and/or toxic effects and how to prevent or treat adverse
effects

Reconcile medication profile with client, family, nursing staff, provider

Verify prescription and client, including dose, time, calculations, dosing range, dispensing method

After administration

Assist health care team to check client response to therapy and report findings

therapeutic effect

adverse effects or toxicity


Document findings including data requiring action or follow-up nursing care

Document nursing care including care given before and after drug administration

Evaluate care and processes, including any med errors or problems

Reinforce client teaching: assist health care team to implement client teaching plan

What to report

How to administer

Food, substances, activities to avoid

Need for follow-up care and testing

How and when to activate emergency services or contact provider

Points to Remember 2
The following is a list of basic nursing care to prevent or minimize common adverse effects of drug
therapy.

Nausea, vomiting, anorexia

Nursing care: collaborate for antiemetic, eliminate triggers, maintain NPO status

Monitoring: assist health care team to

check fluid and electrolyte balance; bowel sounds and elimination pattern; food intake

track blood pressure; skin and mucous membranes for moisture; urinary output; and serum sodium,
potassium and chloride


Assist health care team to implement client teaching plan:

progress from NPO to clear liquids to small, frequent meals

breathing techniques

avoid triggers


Constipation

Nursing care: provide fluid, fiber, stool softener, encourage ambulation

Monitoring: assist health care team to check bowel sounds, pattern; review diet for fluid, fiber

Assist health care team to implement client teaching plan: increase fluid, fiber; ambulate; establish
bowel habits


Diarrhea

Nursing care: provide hygiene, skin care, close supervision to prevent injury

Monitoring: assist health care team to check bowel pattern, fluid and electrolytes balance, weakness,
198

skin, cultures

Assist health care team to implement client teaching plan: increase fluid intake, wash hands, avoid
irritating foods


Rash, allergy

Nursing care: screen for allergies, previous reactions, provide skin care

Monitoring: assist health care team to check airway, breathing, blood pressure, skin, pruritus, cultures

Assist health care team to implement client teaching plan: report dyspnea, pruritus, hives, worsening
condition


Hypotension, dizziness

Nursing care: maintain supine position, encourage fluids, review med profile; protect client

Monitoring: assist health care team to check vital signs, SaO
2
, EKG, level of consciousness, urinary
output

Assist health care team to implement client teaching plan: remain in bed; ask for help to stand; avoid
alcohol, sedation


Points to Remember 3
The following is a list of adverse effects associated with drug classes or types and associated nursing
care and client teaching

Antihypertensives: orthostatic hypotension, fluid and electrolyte imbalance

Nursing care: assist with activity; eliminate drug interactions, vasodilators, central nervous system
depressants

monitoring: assist health care team to check blood pressure for hypotension if they are taking a diuretic
also, pulse, breath sounds, serum electrolyte levels, edema, dizziness

assist health care team to implement client teaching plan: get help to stand, report dizziness; avoid
alcohol, sedatives, over-the-counter agents, caffeine, change positions slowly. Reinforce client to take
blood pressure and pulse daily.


Anticholinergic agents: dry mouth, constipation, blurred vision

nursing care: provide sips of water and oral care; assist with activity; remove environmental hazards

monitoring: assist health care team to check bowel pattern, vision, oral mucous membranes

assist health care team to implement client teaching plan: frequent oral care, avoid dangerous activity,
ask for help to stand


Anticoagulants and anti-platelet agents: bleeding

nursing care: minimize invasive procedures, shaving; provide gentle oral care; assist with activity

monitoring: assist health care team to check bleeding, coagulation tests, complete blood count,
bruising; remove adverse drug and food affects

assist health care team to implement client teaching plan: avoid dangerous activity, wear MedicAlert
identification, avoid NSAIDs, alcohol, avoid eating food rich in vitamin K


Anticonvulsants: CNS depression, myelosuppression: infection and bleeding

nursing care: assist with activity; protect airway, breathing; minimize invasive procedures

monitoring: assist health care team to check seizure activity, complete blood count with differential,
temperature, regional redness, swelling, or drainage, monitor liver functions tests

assist health care team to implement client teaching plan: wear MedicAlert identification, avoid
dangerous activity, wash hands, avoid crowds, need for follow-up care and testing, avoid alcohol


Antidysrhythmics: new or more dangerous dysrhythmias, changes in blood pressure

nursing care: maintain fluid and electrolytes balance, SaO2 >95%, sinus rhythm; assist with position
changes

monitoring: assist health care team to check pulmonary function test, EKG, blood pressure, pulse,
199

SaO
2
, serum electrolytes, level of consciousness

assist health care team to implement client teaching plan: ask for help to stand; report irregular pulse
and technique for counting pulse, call doctor if the client develops palpitations, weakness, loss of
appetite


Antiinfective agents: renal and hepatic dysfunction

nursing care: obtain cultures before administration, verify administration guidelines, screen for renal
and hepatic dysfunction, allergy, nephrotoxic or hepatotoxic drugs

monitoring: assist health care team to check renal function tests, liver function tests, jaundice, dark
stool or urine, nausea and vomiting

assist health care team implement client teaching plan: report nausea, vomiting, dark stool or urine,
jaundice; need for follow-up care and testing, reinforce take all medications as prescribed, report any
allergic reaction, report sudden weight gain as this may indicate adverse effects on the kidney


Loop, thiazide diuretics: circulatory collapse, myelosuppression, fluid and electrolytes imbalance,
ototoxicity

nursing care: verify infusion guidelines, blood pressure, serum electrolytes, and urinary output before
giving

monitoring: assist health care team to check serum sodium and potassium, breath sounds, edema,
blood pressure, urinary output

assist health care team to implement client teaching plan: report palpitations, weakness, irregular
pulse, decreased urinary output, temperature


Female hormones: thromboembolic disorders, increased risk of breast and endometrial cancer,
hyperglycemia, hypercalcemia, depression, seizures

monitoring: assist health care team to check peripheral perfusion, edema; leg pain, tenderness; serum
calcium, glucose, cytology

assist health care team to implement client teaching plan: report lumps and abnormal bleeding, muscle
twitching


Medications causing confusion in the elderly

200




I. Managing Cardiac Disease

A. Therapeutic classification: antianginal agents

1. Type: nitrates

a. action: arterial, venous, and capillary vasodilation by relaxing vascular smooth muscle

i. decreases myocardial oxygen consumption

ii. decreases preload with venous pooling

iii. decreases afterload by decreasing peripheral vascular resistance


b.
example: nitroglycerin

i. (Nitro-bid) IV (titrate according to blood pressure)

ii. (Nitro-Dur) 1 transdermal patch daily

iii. (Nitrostat) one 0.4 mg sublingual tablet under the tongue; may repeat every 5 minutes up to 3 tablets


c. uses: prophylaxis, treatment, and management of angina, acute myocardial infarction (MI)

d. adverse effects

i. life-threatening: severe hypotension; nitrate tolerance, paradoxical bradycardia, anaphylactoid
reaction, methemoglobinemia

ii. most common: headache, nausea, vomiting, dizziness, reflex tachycardia, postural hypotension


e. contraindications

i. concurrent sildenafil, tadalafil or vardenafil use

ii. hypovolemia, hypotension, idiopathic hypertrophic subarortic stenosis (IHSS), methemoglobinemia, heart
failure, acute myocardial infarction, increased intracranial pressure


f. nursing care

i. assist health care team to establish baseline data and observe during acute angina or IV administration blood
pressure, heart rate, ECG, chest pain

ii. clarify data to report and frequency of report

iii. withdraw treatment gradually to avoid angina

iv. toxicity: central nervous system changes, hypotension, flushing, nausea

v. buccal area must be moist for sublingual absorption

vi. maintain a 6 to 8 hour nitrate-free period every 24 hours after acute episode to avoid tolerance

vii. assist health care team to implement client teaching plan

apply spray under tongue

do not chew tablets

sit down when taking, change positions slowly

report blurred vision or dry mouth, avoid alcohol

keep tablets away from light, moisture, and body heat; change tablets every 6 months

use spray or sublingual tablets for immediate relief; combine medication with rest for acute attack

for acute angina: take 1 tablet (or 1 spray under the tongue) sublingual every 5 minutes up to three
tablets, if not relieved seek emergency treatment

rotate site of ointment or patch; remove ointment or patch and clean skin for daily nitrate-free
period







2. Type: isosorbide dinitrate, mononitrate

a. action: vasodilation by relaxing arterial and venous smooth muscle; decreases preload with venous pooling, peripheral
vascular resistance, and myocardial oxygen consumption
201


b. examples

i.
isosorbide dinitrate (Isordil, Dilatrate-SR): used for both acute attacks and prevention of angina pectoris

sublingual (adults) - acute attack of angina pectoris: 2.5-10 mg every 2 to 3 hours

oral (adults) - prophylaxis of angina pectoris: 10-40 mg by mouth 2 to 3 times per day


ii.
isosorbide mononitrate (Imdur, Monoket): angina prophylaxis: 20 mg by mouth twice a day; maximum 40
mg/day


c. uses: maintenance therapy for angina, coronary artery disease (see also: nitrates: adverse effects, contraindications,
nursing care)


3. Other

a. type: beta-adrenergic blocking agents or "beta blockers" (examples: atenolol [Tenormin], metoprolol [Lopressor])

b. type: calcium channel blocking agents (examples: amlodipine [Norvasc], diltiazem [Cardizem], verapamil [Calan])



B. Therapeutic classification: anticoagulants

1. Type: oral

a. action: interferes with vitamin K dependent clotting factors in the liver resulting in prolonged bleeding time

b.
example: warfarin (Coumadin, Jantoven) 2-10 mg PO/IV for 2 to 4 days; then, adjust dose based on
international normalized ratio (INR)
Black Box Warning - bleeding risk

c. uses: maintenance therapy and prophylaxis to suppress formation of dangerous clots after myocardial infarction,
mechanical heart valve surgery, atrial fibrillation (A fib) and atrial flutter (A flutter), heart failure, deep vein
thrombosis, and pulmonary embolism (PE)

d. adverse effects

i. hemorrhage, peripheral skin necrosis

ii. bone marrow depression, liver dysfunction

iii. anorexia, many drug-drug interactions

iv. high-risk drug with older or incompetent clients


e. contraindications

i. clients at risk for falls, malabsorption syndromes

ii. severe hepatic or renal disease

iii. bleeding disorders and active bleeding

iv. recent invasive procedure to spinal cord


f. nursing care

i. assist health care team to establish baseline data and check

daily international normalized ratio (INR), prothrombin time (PT) and periodic liver function tests (LFTs)

evidence of bleeding, bruising, headache, level of consciousness, and risk of falls (particularly for older adults)


ii. apply prolonged pressure to any puncture wounds to stop bleeding

iii.
antidote : vitamin K

suppresses warfarin activity for 1 to 3 weeks

may need alternate form of anticoagulation


iv. assist health care team to implement client teaching plan

AVOID alcohol, NSAIDs

use electric razor for shaving

seek emergency treatment for falls
202


wear MedicAlert identification

take at same time daily, need for follow-up care and testing

AVOID herbal remedies including echinacea, licorice, green tea, and ginseng

AVOID foods containing vitamin K (decreases effect of warfarin) especially green leafy vegetables,
broccoli, and liver






2. Type: low-molecular weight (LMW) heparin (parenteral)

a. action: blocks action of Factors Xa and IIa without appreciably affecting thrombin or prothrombin

b. examples

i.
dalteparin (Fragmin) 2500- 5000 IU by subcutaneous injection daily
Black Box Warning - epidural/spinal hematoma risk


ii.
enoxaparin (Lovenox) 1 mg/kg or 40 mg by subcutaneous injection daily
Black Box Warning - epidural/spinal hematoma risk


c. uses: prophylaxis against thromboembolic disorders associated with surgery and bedrest

d. adverse effects

i. hemorrhage, thrombocytopenia, angioedema

ii. increased bleeding times and bruising

iii. inflammation at injection site, dyspnea, rash


e. contraindications

i. recent GI bleed or invasive spinal cord procedure

ii. active bleeding, thrombocytopenia , uncontrolled hypertension


f. nursing care

i.
establish baseline data and monitor complete blood count and platelets

ii. does not affect prothrombin time (PT), INR, or activated partial thromboplastin time (aPTT) with therapeutic doses

iii. lower risk of heparin-induced thrombocytopenia than unfractionated heparin

iv. give subcutaneously according to manufacturer's direction

v. client teaching: subcutaneous injection technique




3
.
Type: unfractionated heparin

a. action: inhibits conversion of prothrombin to thrombin thus preventing fibrin formation

b.
example: heparin sodium

c. uses: acute illness to suppress dangerous clot formation; unstable angina, myocardial infarction, cerebral vascular
accident, deep vein thrombosis, pulmonary embolism, atrial fibrillation and atrial flutter, disseminated intravascular
coagulation (DIC)

d. adverse effects

i. life threatening: hemorrhage, severe thrombocytopenia, heparin-induced thrombosis and thrombocytopenia
(HIT/HITT)

ii. other: prolonged clotting time, bleeding, cutaneous necrosis, fever, chills, rash, adrenal insufficiency


e. contraindications

i. IM administration, severe thrombocytopenia, hemorrhage

ii. active bleeding (except DIC), severe hypertension, recent major surgery, recent lumbar puncture or spinal
203

anesthesia

iii. DO NOT give benzyl alcohol-containing forms to neonates, infant, pregnant or breast-feeding clients


f
.
nursing care

i.
assist health care team to establish baseline data and check activated partial thromboplastin time (aPTT),
complete blood count (CBC), and platelets before administration and during therapy

ii. adjust dosage when given with nitroglycerin (NTG) - check aPTT frequently

iii. high-risk therapy for women, older clients, and with renal or hepatic insufficiency

iv.
antidote - protamine sulfate 1-1.5 mg IV/100 units of heparin given; maximum dose: 50mg/dose, rate 5mg/min
Black Box Warning - serious adverse events, appropriate use




C. Therapeutic classification: antiarrhythmic agents

1. Information common to antidysrhythmic agents

a. use

i. eradication of frequent premature ventricular contractions that cause hemodynamic instability or loss of
consciousness

ii. emergency eradication of ventricular dysrhythmias

iii. cardiopulmonary resuscitation

iv. chemical cardioversion of atrial and ventricular dysrhythmias
Antiarrhythmic Classifications
IA IB IC II III IV
Classified by their effects on cardiac conduction tissue



b. adverse effects

i. heart block

ii. most are have dysrhythmogenic potential (capable of causing dysrhythmias)

iii. prolongation of QT interval

iv. increased risk of torsades des pointes


c. assist health care provider to implement client teaching plan

i. count heart rate and pattern of rhythm, i.e., regularity

ii. provide acceptable range for heart rate

iii. report

new onset of irregular rhythm

findings outside of acceptable parameters

worsening heart rate, dizziness, lightheadedness, loss of consciousness, and edema






2. Type: sodium channel blocking agents (Class IA & IB)

a. action: suppresses various phases in myocardial cell action potential by blocking sodium channels; stabilizes
myocardial cell membrane

b. examples

i.
lidocaine (Xylocaine): titrate according to frequency of ventricular ectopy

ii.
quinidine gluconate (generic)
Black Box Warning - mortality
204


iii.
procainamide (generic)
Black Box Warning - positive ANA titer, proarrhythmic effects and blood dyscrasias


c. uses: ventricular dysrhythmias, chemical cardioversion with atrial fib and atrial flutter (except lidocaine)

d. adverse effects

i. life-threatening: ventricular fibrillation, asystole, seizures; thrombocytopenia, neutropenia and hemolytic anemia;
lupus erythematosus and agranulocytosis

ii. other: hypotension, bradycardia, flushing, urticaria, pruritus; central nervous system effects including sedation,
confusion, and seizures (especially lidocaine)


e. contraindications: 2nd or 3rd degree AV block, Torsades de pointes, myasthenia gravis and systemic lupus
erythematosus

f. nursing care

i. assist health care team to establish baseline data and monitor

drug levels

vital signs, ECG, QT interval, neurological status


ii. prevent client injury - associated with many adverse effects

iii. quinidine and procainamide reserved for use after many other therapies have failed

iv. assist health care team to implement client teaching

AVOID citrus juices, antacids, and milk products when taking oral forms

take heart rate daily: report change in rhythm





3. Type: beta-adrenergic blocking agents or beta blockers (Class II)

4. Type: potassium channel blocking agents (Class III)

a. action: slows the outward movement of potassium through myocardial cell membranes and prolongs the action
potential

b.
examples

i.
amiodarone (Cordarone, Nexterone, Pacerone) 200-600 mg by mouth daily; also available IV
Black Box warning - appropriate use, pulmonary toxicity, hepatotoxicity, proarrhythmic effects

ii. sotalol (Betapace) 80-160 mg by mouth every 12 hours


c. uses: ventricular and supraventricular dysrhythmias, chemical cardioversion

d. adverse effects

i. life-threatening: severe bradycardia, AV block, QT prolongation, ventricular arrhythmias, torsades de pointes

ii. most common: malaise/fatigue, ataxia, tremor, hyperkinesia, photosensitivity

iii. other: severe hypotension, cardiogenic shock, cardiac arrest, and ARDS with IV use


e. contraindications

i. cardiogenic shock, severe sinus node dysfunction, 2nd or 3rd degree AV block

ii. bradycardia associated syncope, pregnancy, or breast-feeding

iii. hypersensitivity to iodine


f. nursing care

i. assist health care team to establish baseline data and check vital signs, ECG; hepatic, pulmonary, endocrine,
neurological, and GI function

ii. follow oral and IV administration guidelines - timing and rates of infusion are very important

iii. assist health care team to implement client teaching plan
205


AVOID taking with echinacea

need for follow-up care and testing

protect skin and eyes from UV rays, e.g., wear sunscreen, protective clothing, and sunglasses

count pulse and report changes in rhythm





5. Type: anticholinergic agent

a. action: competes with acetylcholine for muscarinic receptor sites to produce mild vagal excitation

b.
example: atropine 0.5 mg IV every 3 to 5 minutes; maximum 3 mg

c. use: bradycardia associated with increased vagal tone

d. adverse effects

i. life threatening: paradoxical bradycardia with sub-therapeutic dosing; angina, tachycardia

ii. most common: anticholinergic effects, i.e., sedation, dry mouth, blurred vision, urinary retention, constipation,
orthostatic hypotension

iii. other: atropine flush 15 to 20 minutes after injection




6. Type: acetylcholine-sensitive potassium current activator

a. action: shortens duration of action potential, causes hyperpolarization, and slows normal automaticity

b.
example: adenosine (Adenocard, Adenoscan) 6 mg rapid IV bolus

c. use: chemical conversion of supraventricular tachycardia after failure of vagal maneuver

d. adverse effects

i. life threatening: severe bradycardia, ventricular fibrillation, ventricular tachycardia, atrial fibrillation, asystole,
complete heart block

ii. most common: bronchospasm, flushing, dyspnea, chest pressure, nausea. lightheadedness, headache


e. contraindications: 2nd

or 3rd

degree AV block, sick sinus syndrome, cardiac transplant

f. nursing care

i. assist health care team to establish baseline data and monitor continuously during therapy ECG, heart rate, blood
pressure, respiratory rate

ii.
monitor serum electrolytes



Updated clinical practice guidelines indicate that individuals with a systolic blood pressure of 120139 mm Hg or a
diastolic blood pressure of 8089 mm Hg should be considered as "prehypertensive" and will require health-
promoting lifestyle modifications to prevent cardiovascular disease (National Heart Lung and Blood Institute, 2003).


D. Therapeutic classification: antihypertensive agents

1. Information common to antihypertensive agents

a. uses: heart failure, primary and secondary hypertension

b. adverse effects

i. life threatening: orthostatic hypotension, reflex tachycardia, bradycardia

ii. other: dizziness, weakness, sexual dysfunction, nausea, vomiting, diarrhea, anorexia, and constipation


c. contraindications

i. severe deficiencies in serum electrolytes

ii. heart block, pediatrics, hypovolemia


d. nursing care

i. assist health care team to establish baseline data and check before initiating therapy and periodically thereafter:
blood pressure, potassium, fluid and electrolyte balance, renal function
206


ii. older clients more susceptible to toxicity, labile hypotension, and orthostatic hypotension

iii. assist health care team to implement client teaching plan

AVOID over-the-counter drugs

change positions slowly

take medication only as directed, even when feeling well and if blood pressure (BP) is controlled
(indicates that the therapy is effective)

combine with weight loss, smoking cessation, and an active lifestyle for the most effective therapy

reinforce instruction about blood pressure technique for self-monitoring






2. Type: angiotensin-converting enzyme (ACE) inhibitors

a. action: inhibits conversion of angiotensin I to angiotensin II in the lungs preventing vasoconstriction from angiotensin II
and the release of aldosterone

b. examples

i.
enalapril (Vasotec) 10-40 mg twice daily by mouth, initiate therapy at 5 mg
Black Box Warning - pregnancy

ii.
lisinopril (Prinivil, Zestril) 5-40 mg daily by mouth, initiate therapy at 2.5-10 mg
Black Box Warning - pregnancy


c. uses: hypertension and heart failure

d. adverse effects

i. angioedema of head, cough, neck and intestines, severe hypotension, hyperkalemia, renal impairment or failure

ii. hepatotoxicity, neutropenia, agranulocytosis, pancreatitis and Steven-Johnson syndrome


e. contraindications: ACE inhibitor angioedema history, hereditary or idiopathic angioedema, pregnancy

f. nursing care

i.
administer on empty stomach - take 1 hour before and 2 hours after eating

ii.
monitor serum potassium (ACE inhibitors can cause hypokalemia)

iii. assist health care team to implement client teaching plan

contact health care provider if persistent dry cough develops and becomes a problem (more common in
women)

seek emergency care for any indications of angioedema ("does my voice sound funny?")

ACE inhibitors are teratogenic - female client must use contraception when taking





3. Type: angiotensin II-receptor blockers (ARB)

a. action: binds to angiotensin II receptors to block vasoconstriction and release of aldosterone

b. examples

i.
Iosartan (Cozaar) 25-100 mg by mouth daily in 1 to 2 doses
Black Box Warning - pregnancy

ii.
valsartan (Diovan) 80-320 mg by mouth daily
Black Box Warning - pregnancy


c. uses: hypertension and heart failure

d. adverse effects: hyperkalemia

e. nursing care
207


i. relatively few drug-drug interactions

ii. assist health care team to implement client teaching plan

may take with food, avoid salt substitutes containing potassium without provider approval

take medication with a full glass of water





4. Type: calcium channel blocker (CCB)

a. action: block movement of calcium into muscle cell; negative inotropic action (decreases myocardial contractility)

b.
examples

i. amlodipine (Norvasc) 5-10 mg by mouth daily

ii. diltiazem (Cardizem, Cardizem CD, Cardizem LA, Cartia XT, Dilacor XR, Dilt-CD, Diltia XT, Taztia XT, Tiazac)
immediate release dose 30-90 mg by mouth 4 times daily; extended release dose 180-360 mg by mouth daily

iii. verapamil (Calan, Calan SR, Covera-HS, Isoptin SR, Verelan, Verelan PM) immediate release dose: 80-120 mg by
mouth 3 times a day; extended release form:120-480 mg/day 1 to 2 doses divided; IV 2.5-10 mg/kg, may repeat
with 5-10 mg in 15 to 30 minutes


c. uses: hypertension, angina, and dysrhythmias

d. adverse effects: severe hypotension, severe bradycardia, hepatotoxicity and paralytic ileus, heart failure and AV block

e. contraindications

i. severe LV dysfunction, 2nd or 3rd degree heart block, atrial fibrillation or flutter with bypass tract

ii. sick sinus syndrome, severe hypotension and cardiogenic shock


f. nursing care - assist health care team to establish baseline data and check before initiating therapy and periodically
thereafter

i.
BUN and creatinine, liver function tests

ii. monitor heart rate, ECG

iii. assist health care team to implement client teaching plan

AVOID grapefruit and grapefruit juice (may increase medication effects)

AVOID in older clients due to risk of severe constipation

remind clients to change position slowly and report dizziness to health care provider





5. Type: beta-adrenergic blocking agents (antagonists) (aka beta blockers)

a. action: selective (beta-adrenergic receptors) and non-selective (beta- and beta-adrenergic) blockers of the
sympathetic nervous system (SNS) resulting in

i. slower heart rate

ii. decreased vasoconstriction, decreased blood pressure

iii. decreased myocardial oxygen consumption


b. examples

i.
selective blockers

atenolol (Tenormin) 50-100 mg by mouth daily
Black Box Warning - avoid abrupt cessation

metoprolol succinate (Toprol) 25-400 mg by mouth daily; metoprolol tartate (Lopressor) 50-200 mg by mouth twice
a day
Black Box Warning - avoid abrupt cessation


ii.
non-selective blocker: propranolol (Inderal LA, InnoPran XL) 80-240 mg by mouth twice daily; IV 1-3 mg, may
repeat in 2 minutes
208

Black Box Warning - avoid abrupt cessation


c. uses: heart failure, hypertension, heart rate control, angina, and migraine headache prophylaxis

d. adverse effects

i. life-threatening: heart failure, heart block, severe bradycardia, bronchospasm

ii. most common: fatigue, dizziness, constipation, depression, insomnia, weakness, disorientation, nausea, diarrhea,
impotence

iii. other: suppresses clinical indicators of hypoglycemia


e. contraindications

i. cardiogenic shock, sinus bradycardia without pacemaker, sick sinus syndrome without pacemaker

ii. 2nd or 3rd degree AV block without pacemaker, uncompensated heart failure, bronchial asthma


f. nursing care

i. assist health care team to establish baseline data and monitor breath sounds and peripheral perfusion before
initiating therapy and periodically thereafter

ii.
avoid concomitant use of clonidine, thioridazine, and nonsteroidal anti-inflammatory drugs (NSAIDs)

iii. check with provider for administration limits for heart rate and blood pressure

iv. may hide symptoms of hypoglycemia

v. may cause bronchoconstriction and asthma symptoms

vi. taper dose before discontinuing

vii. assist health care team to implement client teaching plan

take pulse or blood pressure before administration

reinforce risk of orthostatic hypotension

take medication at bedtime

do not abruptly discontinue therapy





6. Type: combined alpha- and beta-adrenergic blocking agents

a. action: blocks all SNS receptors and inhibits release of epinephrine (Epi) and norepinephrine (NE) resulting in
decreased vasoconstriction, slower heart rate, and increased renal perfusion

b.
examples

i. carvedilol (Coreg) 6.25-25 mg twice daily by mouth, increase dose in 2 week intervals

ii. labetalol (Normodyne) 400-800 mg 2 to 3 times daily by mouth


c. uses: heart failure, hypertension secondary to renal failure, refractory hypertension

d. adverse effects

i. heart failure, heart block, severe bradycardia, angina exacerbation

ii. asthma, bronchospasm, interstitial pneumonitis

iii. leukopenia, thrombocytopenia, anemia


e. contraindications: severe bradycardia, 2nd or 3rd degree heart block, uncompensated heart failure, cardiogenic shock

f. nursing care

i. assist health care team to establish baseline data and check for bronchospasm, pulmonary edema, and liver failure

ii. taper dose before discontinuing

iii. assist health care team to implement client teaching plan




7. Type: alpha-adrenergic blocking agents

a. action: non-selective blocker of alpha-adrenergic receptors (of SNS)

209

b.
examples: phentolamine mesylate (Regitine)

c. uses: hypertension associated with pheochromocytoma, extravasation of epinephrine and DOPamine
(vasoconstricting agents)

d. adverse effects

i. life-threatening: myocardial infarction, stroke, severe hypotension, arrhythmias, peptic ulceration

ii. other: tachycardia, weakness, dizziness, flushing, orthostatic hypotension, nasal congestion


e. contraindications: coronary artery disease (CAD) and myocardial infarction



8. Type: alpha
1
-blocking agents

a. action: blocks alpha1-receptors of SNS

b.
examples

i. prazosin (Minipress) 3-7 mg by mouth twice daily

ii. terazosin (Hytrin) 1-5 mg by mouth every evening

iii. tamsulosin (Flomax) 0.4 mg by mouth daily


c. uses: hypertension, benign prostatic hypertrophy (BPH)

d. adverse effects: angina, priapism, headache, peripheral edema

e. contraindications: hepatic and renal failure; do not take with erectile dysfunction agents



9. Type: alpha
2
- agonists

a. action: displaces NE and stimulates alpha
2
-receptors of SNS resulting in decreased release of norepinephrine in the
periphery

b.
example: cloNIDine (Catapres, Duracion, Kapvay, Nexiclon XR) 0.1-0.3 mg by mouth twice daily

c. uses: hypertension, chronic pain related to cancer

d. adverse effects

i. life-threatening: severe rebound hypertension, severe hypotension, bradycardia, AV block, syncope, tachycardia

ii. other: dry mouth, drowsiness, dizziness, fatigue, weakness, constipation, sedation, orthostatic hypotension, sexual
dysfunction


e. contraindications

i. cardiovascular disease, severe coronary artery disease, recent myocardial infarction

ii. renal impairment

iii. history of depression or cerebrovascular disease


f. nursing care

i. taper dose before discontinuing

ii. do not discontinue before surgery

iii.
do not administer with monoamine oxidase inhibitors (MAOIs) or beta blockers




10. Type: centrally acting vasodilators

a. action: directly relaxes arteriolar vascular smooth muscle resulting in lowered peripheral vascular resistance and
reflex tachycardia

b.
example: hydrALAZINE (Apresoline) 10-50 mg by mouth daily divided in 4 doses

c. uses: hypertensive crisis, congestive heart failure

d. adverse effects

i. life-threatening: myocardial infarction, neutropenia, blood dyscrasias, lupus erythematosus, peripheral neuritis
210


ii. most common: headache, tachycardia, angina, palpitations

iii. other: nausea, vomiting, diarrhea, rash, flushing


e. contraindications: coronary artery disease, mitral valve rheumatic heart disease, cardiovascular or cerebrovascular
disease and severe renal impairment

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
during therapy complete blood count and antinuclear antibody test (ANA)

ii. reinforce client teaching

report chest pain, severe fatigue, muscle or joint pain

change positions slowly





11. Type: diuretics - especially thiazide and thiazide-like diuretics; to a lesser extent, loop diuretics; used alone or in
combination with other antihypertensive agents


E. Therapeutic classification: anti-lipid agents

1. Information common to anti-lipid agents

a. most affect liver function and require regular liver function tests

b. most effective when combined with low-fat diet, exercise and weight loss

c. instruct clients to avoid alcohol during therapy


2. Type: bile acid sequestrants

a. action: bind with bile acid in small intestine leading to decreased absorption and increased excretion of fat in stool

b.
example: cholestyramine (Prevalite, Questran, Questran Light) 4-8 grams by mouth twice daily

c. uses: in combination with low fat diet to lower serum lipids, primary hypercholesterolemia , and elevated low-
density lipoproteins (LDL)

d. adverse effects

i. fecal impaction, intestinal obstruction

ii. metabolic acidosis, fat-soluble vitamin deficiency

iii. decreased folate levels, osteoporosis


e. contraindications

i. biliary obstruction, constipation

ii. CAD, renal impairment, volume depletion


f. nursing care

i. assist health care team to establish baseline data and to check prior to initiating therapy and at regular intervals
thereafter

listen to bowel sounds before administering medication

monitor for vitamin deficiency


ii. assist health care team to implement client teaching plan

eat a low-cholesterol, low-fat diet

take before meals

take other medications at least 1 hour before or 4 hours after taking cholestyramine

prevent constipation with increased fluids, fiber, and physical activity









211


3. Type: HMG-CoA reductase inhibitors (statins)

a. action: controls final step in cholesterol formation by blocking formation of cellular cholesterol leading to decreased
serum cholesterol and slightly increased high density lipoproteins (HDL)

b. examples

i.
atorvastatin (Lipitor) 10-80 mg by mouth daily

ii.
simvastatin (Zocor) 5-40 mg by mouth daily at bedtime

iii.
rosuvastatin (Crestor) 5-40 mg by mouth daily


c. use in combination with low-fat diet and exercise

d. adverse effects

i. life-threatening: myopathy, rhabdomyolysis, acute renal failure, hepatotoxicity, pancreatitis, angioedema,
leukopenia, thrombocytopenia

ii. most common: pharyngitis, headache, diarrhea, dyspepsia, myalgia, back pain

iii. other: increased risk of rhabdomyolysis when given with niacin


e. contraindications

i. active hepatic disease, elevated liver function tests, pregnancy, breastfeeding

ii. myopathy, hypotension, sepsis or acute infection


f. nursing care

i. assist health care team to establish baseline data and check before beginning therapy and at regular intervals
thereafter:

liver function tests, creatinine, creatinine kinase (CK), lipid panel

muscle pain


ii. administer at bedtime, may take with food to diminish gastrointestinal upset

iii. assist health care team to implement client teaching plan

promptly report muscle pain

monitor for bleeding - check for dark urine and dark stool

maintain regular follow-up care and testing

most effective when combined with lifestyle changes including low-fat diet, weight loss, high-fiber diet, and
exercise





4. Type: fibrates

a. action: decreases synthesis of hepatic LDLs and cholesterol

b.
example: gemfibrozil (Lopid) 600 mg by mouth twice daily

c. uses: hypercholesterolemia and mixed dyslipidemia

d. adverse effects: myositis, myopathy, rhabdomyolysis

e. contraindications: gallbladder disease, hepatic involvement, severe renal impairment

f. nursing care

i.
assist health care team to establish baseline data and check before initiating therapy and at regular intervals
thereafter: serum lipids, liver function tests, complete blood count, creatinine

ii. assess muscle pain




5. Type: niacin

a. action: inhibits release of fatty acid from adipose tissue, improves removal of triglycerides from plasma

b.
example: niacin (Niacor, Niaspan, Slo-Niacin) 1500-3000 mg/day by mouth in 2 to 3 divided doses
212


c. uses: hypercholesterolemia, mixed dyslipidemia and hypertriglyceridemia

d. adverse effects

i. hepatotoxicity, fulminant hepatic necrosis, peptic ulcers, arrhythmias, anaphylaxis

ii. flushing, pruritus, hyperpigmentation, orthostatic hypotension, dyspepsia


e. nursing care

i.
assist health care team to establish baseline data and check prior to beginning therapy and at regular intervals
thereafter serum lipids, uric acid, fasting glucose

ii. assist health care team to implement client teaching plan

take at bedtime to minimize stomach upset

may cause facial flushing





6. Type: LDL absorption inhibitors

a. action: inhibits absorption of lipids from small intestines

b.
example: ezetimibe (Zetia) 10 mg by mouth daily

c. uses: hypercholesterolemia, mixed dyslipidemia, familial hypercholesterolemia

d. adverse effects

i. hypersensitivity reaction, anaphylaxis, angioedema, pancreatitis, hepatitis, cholecystitis, cholelithiasis

ii. avoid giving with cycloSPORINE and gemfibrozil


e. contraindications: liver disease or unexplained increase in liver function tests

f. nursing care

i.
assist health care team to establish baseline data before initiating therapy and check during treatment liver
function, lipid levels; muscle pain, bowel pattern

ii. assist health care team to implement client teaching plan

take with or without food

most effective when combined with low-fat diet and weight loss





7. Omega-3 fatty acids (from fish oil)

a. examples

i. over-the-counter preparations

ii.
Lovaza (465 mg EPA & 375 mg DHA) 4g/day by mouth or divided into 2 doses daily

iii.
Vascazen (680 mg EPA and 110 mb DHA) 1 capsule by mouth 4 times daily


b. use: as adjunct to diet in clients with triglycerides 500 mg/dL



F. Therapeutic classification: antiplatelet agents

1. Type: aspirin (ASA)

a. action: inhibits prostaglandin formation

b.
example: acetylsalicylic acid (Bayer Aspirin) 81-325 mg by mouth daily

c. uses: pain/fever, acute coronary syndrome, myocardial infarction prevention, TIA/thromboembolic stroke, arthritis,
rheumatic fever

d. adverse effects

i. anaphylactic reaction, angioedema, bronchospasm, bleeding, Reye syndrome

ii. GI ulceration/perforation, DIC, pancytopenia, thrombocytopenia, agranulocytosis, aplastic anemia


213

e. contraindications

i. ASA or NSAID-induced asthma or urticaria

ii. GI bleed, coagulation disorder, G6PD deficiency

iii. uncontrolled hypertension, recent surgery or trauma

iv. children younger than age 20 due to risk of Reye's syndrome


f. nursing care

i.
may take with food to decrease GI discomfort

ii. assist health care team to establish baseline data and monitor thereafter for toxicity, i.e., muffled hearing and
tinnitus; bleeding times

iii. assist health care team to implement client teaching plan

AVOID use with feverfew, garlic, ginger, echinacea, ginger, St. John's wort, and ginkgo biloba due to
increased bleeding times

report to provider and discontinue use with persistent ringing or buzzing in the ears, impaired hearing,
dizziness, or bleeding

take with a full glass of water

may chew tablet if taking aspirin 81 mg by mouth






2. Type: adenosine diphosphate inhibitor

a. action: inhibits platelet aggregation by preventing adenosine diphosphate binding to platelet receptor

b.
examples

i. clopidogrel (Plavix) 75 mg by mouth daily
Black Box Warning - diminished efficacy in poor metabolizers

ii. ticlopidine (Ticlid) 250 mg by mouth twice daily with food
Black Box Warning - neutropenia/agranulocytosis


c. uses: thrombotic stroke prevention, stent thrombosis prevention

d. adverse effects

i. intracranial hemorrhage, nephrotic syndrome, hyponatremia, pancytopenia

ii. agranulocytosis, thrombocytopenia, allergic pneumonitis, TTP, serum sickness

iii. diarrhea, nausea, dyspepsia, rash, neutropenia, bleeding


e. contraindications

i. active bleeding, recent trauma or surgery

ii. history of GI disorder or ocular disease


f. nursing care

i.
assist health care team to establish baseline data and check before initiating therapy and periodically during
therapy creatinine, absolute neutrophil count (ANC), complete blood count, platelets

ii. discontinue 7 to 10 days before surgery

iii. assist health care team to implement client teaching plan: avoid taking with acetaminophen, aspirin, and
carisoprodol


3. Type: non-nitrate vasodilator (example: dipyradidamole [Persantine])


G. Positive inotropes

1. Type: cardiac glycoside
214


a. action: slows A-V conduction, improves cardiac output, improves myocardial contractility (increases strength of
contractions) and slows heart rate

b.
example: digoxin (Lanoxin) 0.125-0.25 mg by mouth daily

c. uses: heart failure, ventricular rate control in atrial fibrillation (A fib) and atrial flutter (A flutter), PSVT conversion

d. adverse effects

i. AV block, severe bradycardia, ventricular arrhythmias

ii. thrombocytopenia, delirium, hallucinations

iii. dizziness, headache, diarrhea, nausea/vomiting, visual disturbances


e. contraindications

i. ventricular fibrillation/tachycardia

ii. idiopathic hypertrophic subaortic stenosis (IHSS), unblocked AV accessory pathway, sick sinus syndrome

iii. hypokalemia


f. nursing care

i. assist health care team to establish baseline data and monitor creatinine, electrolytes, heart rate at baseline,
then periodically and serum drug levels

ii. check apical heart rate before administration (hold if apical heart rate is less than 60 beats per minute)

iii. monitor for toxicity

therapeutic range 0.5-2 ng /mL (toxic: greater than 2 ng/mL)

signs and symptoms of toxicity include: altered heart rate or rhythm, visual disturbances or GI
disturbances

antidote for digoxin: digoxin antibodies including digoxin immune fab (DigiFab)


iv. assist health care team to implement client teaching plan

take medication as prescribed

measure heart rate daily before administration

weight daily and report weight gain of more than 2 pounds in 24 hours

report irregular pulse or change in rhythm, heart rate less than 60 beats per minute, signs of
potassium deficiency or digitalis toxicity

AVOID many herbal preparations and dehydration




Therapeutic drug levels are laboratory tests to look for the presence and the amount of specific drugs in the blood.
Some of the cardiac drugs that are commonly checked include digoxin, amitriptyline (Norpace), flecainide
(Tambocor), lidocaine, quinidine, and salicylate.


2. Type: phosphodiesterase inhibitors

a. action: blocks action of phosphodiesterase leading to increased myocardial contractility and vasodilation, increased
myocardial oxygen consumption, and dysrhythmias

b.
example: milrinone (Primacor) 0.375-0.75 mcg/kg/min IV

c. uses: heart failure and cardiac output maintenance post resuscitation stabilization per ACLS guidelines

d. adverse effects

i. ventricular arrhythmias, torsades de pointes, ventricular ectopy, ventricular tachycardia, supraventricular
arrhythmias, hypotension and headache

ii. anaphylactic shock, bronchospasm, severe infusion site reaction


e. contraindications

i. severe aortic and pulmonic valve disease

ii. acute myocardial infarction

215



f. nursing care

i.
assist health care team to establish baseline data and check before initiating therapy and at regular intervals
thereafter BUN/creatine, platelets, blood pressure, and ECG

ii. use infusion pump to administer these agents; change solution and tubing every 24 hours

iii. infuse with normal saline only




H. Therapeutic classification: thrombolytic agents

1. Action: binds with plasminogen to dissolve thrombi (clots) within 4 to 6 hours of occlusion (activates conversion of
plasminogen to plasmin; plasmin breaks down clots)

2. Examples

a.
alteplase (Activase) 15 mg IV for 1 dose then 0.75 mg/kg over 30 minutes, then 0.5 mg/kg over 60 minutes

b.
tenecteplase (TNKase) 30-35mg IV for 1 dose


3. Uses: acute myocardial infarction, acute thrombotic stroke, pulmonary embolism

4. Adverse effects

a. intracranial hemorrhage, stroke

b. severe bleeding, reperfusion arrhythmias

c. anaphylaxis, orolingual edema

d. recurrent pulmonary embolism, cholesterol embolism


5. Contraindications

a. active internal bleeding, intracranial aneurysm, arterial venous malformation, or neoplasm

b. coagulation disorder, severe uncontrolled hypertension, stroke history

c. intracranial hemorrhage, suspected subarachnoid hemorrhage


6. Nursing care

a.
assist health care team to establish baseline data and check during treatment prothrombin time, aPTT or INR

b.
have antidote available: aminocaproic acid (a fibrinolysis inhibitor) for life-threatening hemorrhage

c. AVOID IM or SubQ injections

d. minimize physical manipulation of the client and invasive procedures




I. Therapeutic classification: vasodilators

1. Type: non-nitrate

a. action: coronary artery vasodilation with action similar to papaverine; antiplatelet properties and mild positive
inotrope

b.
example: dipyridamole (Persantine) 50-100 mg orally 4 times daily

c. uses

i. exercise testing

ii. adjunct thromboembolism prevention

iii. angina prophylaxis


d. adverse effects

i. severe hypotension

ii. from IV use: bronchospasm, myocardial ischemia or infarction, arrhythmias and angina exacerbation


e. nursing care
216


i.
assist health care team to establish baseline therapy and check prior to beginning therapy and at regular,
predetermined intervals bleeding time

ii. reinforce client teaching

change positions slowly

AVOID alcohol and over-the-counter drugs, especially aspirin

notify health care provider if unusual bruising or bleeding occurs






2. Type: peptide hormone, synthetic

a. action: inhibits anti-diuretic hormone (ADH) to increase urine output and relax vascular smooth muscle

b.
example: nesiritide (Natrecor) - 0.01 mcg/kg/min IV

c. uses: acutely decompensated congestive heart failure

d. adverse effects

i. life-threatening: severe hypotension, bradycardia, azotemia, renal impairment/ failure, increased mortality

ii. other: elevated creatinine, hypotension, headache, insomnia, nausea, back pain, dizziness, anxiety, angina


e. contraindications

i. cardiogenic shock, systolic blood pressure <90, low cardiac filling pressure

ii. restrictive or obstructive cardiomyopathy, constrictive pericarditis, cardiac tamponade


f. nursing care: monitor blood pressure

3. Type: nitrates (example: nitroglycerin)
4. Type: calcium channel blockers (examples: amlodipine [Norvasc], diltiazem [Cardizem], verapamil [Calan])


J.
Therapeutic classification: vasopressors

1. Type: alpha- and beta-adrenergic agonists, sympathomimetic agents (mimics action of sympathetic nervous system)

a. action: increases heart rate, vasoconstricts peripheral vessels to increase blood pressure, and dilates renal and
splanchnic vessels to improve perfusion via stimulation of sympathetic nervous system; opposite action of alpha- or
beta-blockers

b. examples

i.
example: DOPamine (generic) 1-20 mcg/kg/min IV
Black Box Warning - extravasation

ii.
norepinephrine (Levophed) 2-12 mcg/min IV
Black Box Warning - extravasation

iii.
epINEPHrine (generic) 1 mg IV bolus every 3 to 5 minutes in cardiac arrest


c. uses

i. ACLS for asystole/pulseless electrical activity, V-fib/pulseless V-tach, bradycardia

ii. cardiac output maintenance

iii. adjunct treatment for cardiac arrest

iv. acute hypotension adjunct treatment for shock

v. adjunct treatment for shock

vi. refractory heart failure


d. adverse effects
217


i. life-threatening: pulmonary edema, arrhythmias, severe hypertension, cerebral hemorrhage, extravasation
necrosis, anaphylaxis

ii. most common: tachycardia, headache, nausea, hypertension, vasoconstriction, angina, dyspnea


e. contraindications: pheochromocytoma, peripheral vascular disease, closed angle glaucoma, severe volume
depletion, vascular thrombosis; use cautiously in clients receiving monoamine oxidase inhibitors or other
antidepressants

f. nursing care

i. observe RN establish baseline data and monitor blood pressure and ECG

ii.
antidote for extravasation: phentolamine (Regitine) - an adenergic blocking agent





2. Type: beta-agonist, sympathomimetic agent

a. action: selectively stimulates cardiac beta
1
-adrenergic receptors; primarily increases cardiac output; increases blood
pressure without concomitant increase in heart rate

b.
examples

i.
DOBUTamine (generic) 2-20 mcg/kg IV (do not confuse with DOPamine)

ii. isoproterenol (Isuprel) 2-6 mcg/kg IV


c. uses: cardiac decompensation, cardiac output maintenance, emergent arrhythmias, atropine-resistant bradycardia

d. adverse effects

i. life-threatening: Stokes-Adams seizures, arrhythmias, cardiac arrest, severe hypotension, bronchospasm

ii. most common: nervousness, insomnia, restlessness, headache, minor tremor


e. contraindications: digitalis intoxication tachycardia, angina

f. nursing care

i. observe RN establish baseline data and monitor potassium, blood pressure and ECG

ii. monitor and record blood pressure, heart rate, and rhythm every 15 minutes

iii. control with infusion pump

iv. infuse in central venous catheter




II. Managing Respiratory Conditions

A. Therapeutic classification: bronchodilators

1. Information common to bronchodilators

a. action: direct relaxation of bronchial smooth muscle resulting in increased diameter of airway, eases the work of
breathing

b. nursing care

i. encourage smoking cessation therapy

ii. assist health care team to establish baseline data and check before beginning and throughout therapy

breath sounds, oxygen saturation (SaO
2
), respiratory rate

vital signs and ECG


iii. assist health care team to implement client teaching plan

report worsening findings

AVOID caffeine and over-the-counter drugs

take medication only as directed; do not take extra doses

reinforce use of delivery method - oral, meter-dose inhaler, nebulizer, or aerosolized powder







218



2. Type: adrenergic agonist (sympathomimetic)

a. action

i. stimulates and enhances sympathetic nervous system (SNS) to relax bronchial smooth muscle

ii. may increase rate and depth of respirations

iii. inhibits release of inflammatory mediators (short-term effect)


b. examples

i. short-acting

type: alpha- and beta-adrenergic agonists, non-selective adrenomimetic

epinephrine (Adrenalin) 0.3-0.5 mg (1:1000) SubQ/IM every 20 minutes

terbutaline 2.5-5 mg by mouth three times a day
Black Box Warning - tocolysis use


type: beta-adrenergic agonists, selective adrenomimetic

albuterol (VoSpire ER) 2-4 mg by mouth three to four times a day; extended release 4-8 mg by mouth every
12 hours

metaproterenol (Alupent) 20 mg by mouth three to four times per day or 10-15 mg NEB three to four times
per day

levalbuterol (Xopenex, Xopenex HFA) 0.63-1.25 mg NEB every 6-8 hours or 2 puffs (45 mcg/spray) MDI
every 4 to 6 hours




ii. type: long acting, beta 2-adrenergic agonists

salmeterol (Serevent Diskus) 50 mcg inhaled every 12 hours
Black Box Warning - asthma-related death in pediatric and adolescent use

formoterol (Foradil Aerolizer, Performist) 20 mcg NEB twice daily
Black Box Warning - asthma related death



iii. long acting, beta 2-adrenergic agonist and corticosteroid combination medications formoterol & fluticasone
(Symbicort)

fluticasone/salmeterol inhaled (Advair, Advair HFA) 200/50 mcg (1 puff) inhaled twice daily
Black Box Warning - asthma related death

budesonide/formoterol inhaled (Symbicort) 80/4.5 or 160/4.5 spray MDI 2 puffs twice daily
Black Box Warning - asthma related death





c. uses

i. acute bronchospasm, anaphylaxis

ii. asthma, chronic bronchitis, COPD

iii. prophylaxis for exercise-induced asthma


d. adverse effects

i. desired effect lost when dose exceeds therapeutic level leading to life-threatening adverse effects, including:
paradoxical bronchospasm, asthma exacerbation, asthma related death, anaphylaxis, angioedema, hypokalemia,
arrhythmias, hypertensive crisis
219


ii. most common: adrenal suppression, hyperglycemia, nasopharyngitis, headache, URI symptoms, nasal congestion


e. contraindications: hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, seizure disorder, glaucoma,
increased intraocular pressure

f. nursing care

i. assist health care team to establish baseline data and check before and during therapy breath sounds, SaO
2
and vital
signs

ii. available in oral therapy

iii.
small frequent meals to ameliorate nausea, vomiting, anorexia

iv. assist health care team to implement client teaching plan

take before other inhaled medications and 30 to 60 minutes before exercise

report chest pain or palpitations

AVOID caffeinated beverages, dark chocolate, over-the-counter drugs




3. Type: xanthines

a. actions

i. stimulates the sympathetic nervous system: acts directly on bronchial smooth muscle to dilate airways and on
medulla in brainstem to increase rate and depth of respirations

ii. inhibits release of inflammatory mediators in anaphylaxis


b.
examples

i. aminophylline 380-760 mg/day PO/IV every 6 to 8 hours

ii. theophylline (Elixophyllin, Theo-24, Uniphyl) 300-600 mg/day by mouth once to twice daily


c. uses: bronchospasm, asthma, COPD

d. adverse effects

i. life-threatening: seizures, arrhythmias, hypotension, shock

ii. most common: exfoliative dermatitis, nausea, vomiting, headache, insomnia, irritability, restlessness


e. contraindications: seizure disorder, arrhythmias, heart failure, acute pulmonary edema, cor pulmonale, hepatic
impairment, hypothyroidism, febrile, sepsis with multi-organ failure, shock

f. nursing care

i. assist health care team to establish baseline data

ii.
monitor drug levels: theophylline has narrow therapeutic range at 5-15 mcg/mL; toxic levels > 20 mcg/mL

iii. assist health care team to implement client teaching plan: avoid caffeine




4. Type: anticholinergic

a. action

i. blocks muscarinic receptors, acetylcholine release, and stimulation of vagus nerve

ii. results in bronchodilation, diminished secretions, low central nervous system effect (less effect on heart rate)

iii. effects mucociliary clearance minimally

iv. parasympatholytic (reverses effects of), acts like atropine sulfate


b.
examples

i. ipratropium bromide inhaled (Atrovent HFA) 0.5 mg/2.5 mL NEB

ii. tiotropium inhaled (Spiriva HandiHaler) 18 mcg/cap DPI


c. uses

i. COPD

ii. bronchospasm maintenance treatment for asthma

220


d. adverse effects

i. anaphylaxis, angioedema, angel-closure glaucoma

ii. laryngospasm, paradoxical bronchospasm, cough, nervousness


e. contraindications: glaucoma (angle-closure), prostatic hypertrophy, bladder neck obstruction

f. nursing care: assist health care team to implement client teaching plan

i. not for use in acute bronchospasm or as rescue therapy

ii. rinse mouth after treatment

iii. wait several before administering other inhaled medications or as directed by provider




B. Mucolytics and expectorants

1. Mucolytics

a. action: thins respiratory secretions by splitting disulfite bonds in secretions; mobilizes secretions

b.
type: acetylcysteine (generic) 70 mg/kg by mouth every 4 hours for 17 doses; may be given by nebulizer,
intratracheal or nasogastric

c. uses

i. when mucolysis is needed for acute and chronic bronchopulmonary disease, tracheostomy care, pulmonary
complications of cystic fibrosis

ii. diagnostic bronchial studies

iii. acetaminophen overdose


d. adverse effects

i. bronchospasm, hypersensitivity reaction

ii. unpleasant odor during administration, stomatitis


e. contraindications

i. inadequate cough, asthma

ii. upper GI bleed risk


f. nursing care

i. give mucolytics by nebulizer

ii. as antidote for acetaminophen poisoning - direct instillation via nasogastric tube into stomach

iii. most effective when combined with other therapy - encourage ambulation plus coughing and deep breathing





2. Expectorants

a. action: liquefies respiratory secretions by decreasing the surface tension

b.
type: guaifenesin (Diabetic Tussin, Diabetic Tussin Mucus Relief, Kids-Eeze Chest Relief, Little Colds Mucus
Relief, Mucinex, Mucinex for Kids, Mucinex Maximum Strength, Robitussin Chest Congestion, Vicks DayQuil Mucus
Control) 200-400 mg by mouth every 4 hours

c. uses: chest congestions

d. adverse effects

i. nephrolithiasis

ii. rash, vomiting, nausea


e. nursing care

i. identify and resolve etiology of cough

ii. assist health care team to establish baseline data and then monitor appearance and amount of secretions

iii. most effective when combined with adjunct therapy - 8 ounces water with each dose, encourage ambulation,
coughing and deep breathing

iv. assist health care team to implement client teaching plan
221


avoid using combination products for expectorant (guaifenesin found in many over-the-counter combination
products)

avoid dairy products (thickens secretions) and caffeinated beverages (dehydrates to thicken secretions)





C. Antitussive

1. Type: narcotic (opioid)

a. action: cough suppression by depression of cough center in medulla of brainstem, similar to morphine; moderate
histamine releasing action

b.
example - codeine/guaifenesin (Cheratussin AC, Lophen C-NR, Robitussin AC) 10-20 mg by mouth every 4 to
6 hours

c. uses: cough

d. adverse effects

i. CNS and respiratory depression, orthostatic hypotension, bradycardia

ii. syncope, paralytic ileus, seizures

iii. increased ICP, dependency and abuse


e. contraindications: respiratory depression, acute or severe asthma, paralytic ileus

f. nursing care

i. assist health care team to establish baseline data and during therapy - level of consciousness, respiratory rate,
bowel movements, temperature, secretions

ii. provide adjunct therapy to relieve cough, including expectorants, fluid, humidification, lozenges

iii. assist health care team to implement client teaching plan

take only as directed

change positions slowly; ask for help before getting up and avoid dangerous activities until full effects
of treatment are well established

take with food to avoid nausea

drink fluids, increase fiber in diet, ambulate, and establish personal bowel habits to prevent
constipation






2. Type: non-narcotic

a. benzonatate

i. action: cough suppressant without suppression of respiratory center at therapeutic doses; acts like tetracaine
hydrochloride

ii.
example: benzonatate (Tessalon) 100-200 mg orally 3 times daily as needed; max dose is 600 mg/day

iii. uses: cough

iv. adverse effects

sedation, headache, dizziness

pruritus, rash, nausea, dyspepsia

constipation, confusion, hallucinations


v. nursing care

assist health care team to establish baseline data and check appearance and amount of secretions
before starting and periodically during therapy

assist health care team to implement client teaching plan

swallow soft capsules whole (if it dissolves in the mouth may suppress gag reflex)

store capsules in child-resistant container
222


may cause dizziness or drowsiness





b. dextromethorphan

i. action: cough suppression by depressing the medulla; in therapeutic doses comparable to codeine but without
central nervous system depression and analgesia; much less likely to cause constipation, drowsiness, or
gastrointestinal upset

ii.
example: dextromethorphan ( Children's Robitussin Cough Long Acting, Children's Triaminic Long Acting
Cough, Delysm, Robitussin Lingering Cold Long-Acting Cough, Sucrets DM Cough Formula, Vicks DayQuil Cough,
Vicks Formula 44 Costum Care Dry Cough Suppressant) up to 120 mg/day in divided doses

iii. uses: cough

iv. adverse effects

serotonin syndrome, abuse potential

nausea, dizziness, abdominal pain, drowsiness, fatigue

hyperexcitability, especially in children


v. contraindications: monoamine oxidase inhibitor use within 14 days; caution in children younger than 6 years-old

vi. nursing care: assist health care team to implement client teaching plan

humidify air

report cough lasting more than 7 to 10 days

do not crush or chew extended release forms

avoid irritants, should not completely suppress cough

do not overdose dextromethorphan by taking combination product





D. Type: antituberculars

1. Information common to antituberculars

a. actions: destroys or suppresses (bacteriostatic or bactericidal anti-infective agents for treatment of) Mycobacterium
tuberculosis

b.
examples

i. first-line therapy: isoniazid, rifampin (Rifadin), ethambutol (Myambutol), streptomycin (Streptomycin)

ii. second-line therapy: ethionamide (Trecator), pyrazinamide, cycloserine (Seromycin)


c. use: used in combination with other anti-tuberculosis agents; none are used alone to treat TB

d. adverse effects

i. hepatotoxicity, agranulocytosis, aplastic anemia, thrombocytopenia

ii. optic neuritis, peripheral neuropathy, toxic psychosis, paresthesia, nausea, vomiting


e. contraindications

i. acute hepatic disease

ii. severe renal disease and peripheral neuropathy


f. nursing care

i.
assist health care team to establish baseline data and check periodically thereafter creatinine and liver
function tests

ii. review drug-drug interactions for incompatibility

iii. M. tuberculosis eradicated after three negative sputum cultures in a row

iv. assist health care team to implement client teaching plan

report

worsening symptoms, return of fever
223


rash, decreased urine output, edema, weight gain

dyspnea, hallucinations, jaundice

AVOID alcohol, tyramine- and histamine-containing foods

take pyridoxine (vitamin B6) to help prevent or reverse peripheral neuropathy

duration of therapy usually several months; need for long-term care and follow-up testing

continue taking anti-tuberculosis therapy until instructed to stop; continue therapy even when feeling
good






2. First-line therapy

a.
isoniazid (generic) 5 mg/kg up to 900 mg PO/IM daily for 6 to 18 months
Black Box Warning - hepatotoxicity

i. action: bacteriostatic agent that interferes with DNA of M. tuberculosis

ii. use: active and latent tuberculosis infection; combination treatment

iii. adverse effects

agranulocytosis, aplastic anemia, thrombocytopenia

hepatotoxicity, pyridoxine deficiency

paresthesia, optic neuritis


iv. contraindication: acute liver disease

v. nursing care

assist health care team to establish baseline data and periodically check creatinine, liver function tests

administer on empty stomach

assist health care team to implement client teaching plan

report tingling, numbness, or burning of extremities - may indicate toxicity

take pyridoxine (vitamin B6) to help prevent or reverse peripheral neuropathy

AVOID foods with histamine (skipjack tuna, sauerkraut juice, yeast extract) and foods with tyramine (aged
cheese, cured meat, smoked fish)






b.
rifampin (Rifadin) 10 mg/kg PO/IV daily for 4 to 6 months

i. action: inhibits RNA synthesis inM. tuberculosis

ii. adverse effects

hepatitis, thrombocytopenia, leukopenia, hemolytic anemia, agranulocytosis, hemorrhage, DIC, interstitial
nephritis, renal failure

most common: reddish-orange body fluids, elevated ALT, AST


iii. contraindications

IM or SubQ administration

diabetes mellitus, hepatic impairment

porphyria


iv. nursing care

assist health care team to establish baseline data for creatinine, complete blood count, platelets, liver function
tests
224


assist health care team to implement client teaching plan
report bleeding or bruising
do not interrupt prescribed drug regimen

avoid wearing soft contacts - rifampin can cause reddish-orange discoloration of saliva, sweat, tears, feces
and urine





c.
ethambutol (Myambutol) 15-25 mg/kg by mouth daily

i. action: inhibits RNA synthesis

ii. adverse effects: anaphylaxis, hypersensitivity syndrome, erythema multiforme, thrombocytopenia, neutropenia,
leukopenia, irreversible blindness

iii. contraindication: optic neuritis

iv. nursing care

encourage regular eye exams

assist health care team to establish baseline data and check BUN/creatinine, complete blood count, liver
function tests




d.
streptomycin (Streptomycin) 15 mg/kg IM every 24 hours 5 to 7 times weekly
Black Box Warning - appropriate use, neurotoxicity/ototoxicity, neuromuscular blockade


3. Second-line therapy

a.
ethionamide (Trecator-SC) 500-700 mg by mouth daily

i. action: bacteriostatic and bactericidal

ii. use: active tuberculosis

iii. adverse effects

hepatitis, thrombocytopenia, psychosis

peripheral neuritis, optic neuritis, hypothyroidism

dyspepsia, excessive salivation, metallic taste


iv. contraindications: severe hepatic impairment, diabetes mellitus, thyroid disease

v. assist health care team to implement client teaching plan

take pyridoxine (vitamin B6) to help prevent or reverse peripheral neuropathy

take with food to decrease GI upset

not first line treatment



b.
pyrazinamide (generic) 1000-2000 mg by mouth daily for about 2 months; part of a multi-drug regimen - not first-
line treatment

c.
cycloserine (Seromycin) 500-750 mg by mouth daily in divided doses; part of a multi-drug regimen - not first-line
treatment



E. Therapeutic classification: anti-inflammatory agents

1. Glucocorticoids (inhaled)

a. actions

i. inhibits phagocytosis

ii. reduces capillary permeability
225


iii. stabilizes leukocyte membrane

iv. decreases release of inflammatory mediators


b.
examples

i. fluticasone furoate nasal (Veramyst) 27.5 mcg/spray, 1 to 2 inhalations in each nostril daily

ii. fluticasone inhaled (Flovent Diskus, Flovent HFA) 100-500 mcg/spray inhalations twice daily

iii. triamcinolone nasal (Nasacort AQ) 55 mcg/spray, 1 to 2 inhalations in each nostril daily

iv. beclomethasone nasal (Beconase AQ, Qnasl) 80 mcg/spray, 2 inhalations in each nostril daily

v. beclomethasone inhaled (Qvar) 40-320 mcg inhaled twice daily


c. uses

i. allergic rhinitis

ii. maintenance treatment for asthma


d. adverse effects

i. nasal septal perforation, nasal ulcer, nasal/oral candidiasis, increased intraocular pressure, glaucoma, cataracts,
hypercorticism, adrenal suppression

ii. most common: nasal irritation, headache, nausea, lightheadedness, epitaxis


e. contraindications

i. TB infection

ii. measles or varicella exposure

iii. immunosuppression, active respiratory infection


f. nursing care

i. assist health care team to establish baseline data and check periodically thereafter

weight, blood pressure

blood sugar, renal function, gastrointestinal bleeding

wound healing, mental and emotional status


ii. collaborate with dietitian and provider to manage fluid retention, hyperglycemia, and hypokalemia

iii. assist health care team to implement client teaching plan

not rescue therapy - not indicated for acute asthma or allergic attack

therapeutic effect takes 1 to 2 weeks

report infections and fever, worsening findings

blood glucose testing

avoid sick people, wash hands frequently

rinse mouth after treatment to avoid Candida albicans overgrowth (thrush)

if also prescribed a bronchodilator, use this first (to open up and relax airways) and then use steroid
inhaler

reinforce medication delivery method






2. Type: mast cell stabilizer

a. action: inhibits release of histamine and slow reacting substance of anaphylaxis (SRS-A) but without antihistaminic
properties

b.
example: cromolyn nasal (NasalCrom) 1 spray each nostril 3 to 4 times daily

c. uses: allergic rhinitis

d. adverse effects

i. bronchospasm

ii. most common: dry mouth, bitter aftertaste, sneezing, nasal burning

226


e. contraindications: hypersensitivity to drug

f. nursing care

i. therapeutic effects may take up to 1 week

ii. available over-the counter




3. Type: leukotriene-receptor antagonists

a. action: selectively interferes with leukotrienes to inhibit bronchospasm and airway edema

b.
examples

i. zafirlukast (Accolade) 20 mg by mouth twice a day

ii. montelukast (Singular) 10 mg by mouth every evening


c. uses: maintenance treatment for asthma and exercise induced bronchospasm

d. adverse effects

i. angioedema, anaphylaxis, erythema nodosum, aggressive behavior, hallucinations, depression

ii. Churg-Strauss syndrome, hepatic eosinophilic infiltration, hepatotoxicity, suicidality

iii. headache, influenza-like symptoms, abdominal pain, cough


e. contraindication: severe hepatic disease, severe asthma, PKU, tapering systemic steroids

f. nursing care

i. assist health care team to establish baseline data and check during therapy breath sounds, SaO
2
,
respiratory rate

ii. administer 1 hour before or 2 hours after meals

iii. assist health care team to implement client teaching plan

take medication on regular basis (missing a dose may result in a lapse in therapeutic effect)

report flu-like findings, worsening condition, jaundice, dark urine or stool





F. Therapeutic classification: antihistamines

1. Type: first generation antihistamines (for respiratory tract)

a. action: potent H-receptor antagonist (histamine blocking agent) to block the effects of histamine

b.
example: azelastine (Optivar) 137 mcg/spray 1 to 2 sprays each nostril twice daily

c. uses: allergic rhinitis, vasomotor rhinitis

d. adverse effects

i. bitter taste, headache, somnolence, dysesthesia

ii. nasal burning, URI, dry mouth, paroxysmal sneezing

iii. nausea, fatigue, dizziness, epitaxis, cough


e. contraindications: concurrent use of central nervous system depressants

f. nursing care

i. assist health care team to establish baseline data and check during therapy for upper respiratory system
congestion, drowsiness

ii. prime delivery unit before dispensing

iii. assist health care team to implement client teaching plan

AVOID alcohol

AVOID getting nasal spray in eyes

blow nose before instillation - tilt head forward slightly and sniff gently






227


2. Type: second generation antihistamines

a. action: blocks effects of histamine by blocking H
1
receptor and mast cell release of inflammatory mediators

b.
examples

i. loratadine (Alavert, Children's Claritin, Claritin, Claritin RediTabs 12 hour, Claritin RediTabs 24 hour) 10 mg by
mouth daily

ii. fexofenadine (Allegra Allergy 12 hour, Allergra Allergy 24 hour, Children's Allegra Allergy) 180 mg by mouth daily

iii. desloratadine (Clarinex, Clarinex Reditabs) 5 mg by mouth daily

iv. cetirizine (Children's Zyrtec Allergy, Children's Zrytec Hives, PediaCare Childrens 24 hour allergy, Zrytec Allergy)
5-10 mg by mouth daily


c. uses: allergic rhinitis, chronic idiopathic urticaria

d. adverse effects

i. bronchospasm, anaphylactic reaction, hepatotoxicity, cholestasis, seizures, hemolytic anemia, thrombocytopenia,
syncope, severe hypotension

ii. most common: drowsiness, fatigue, abdominal pain, headache, dry mucous membranes


e. contraindications: renal or hepatic impairment, CNA depressant use

f. nursing care

i.
assist health care team to establish baseline data and check during therapy clients creatinine

ii. assist health care team to implement client teaching plan

report unusual findings

may cause drowsiness

provide frequent oral care

AVOID alcohol and central nervous system depressants





G. Therapeutic classification: decongestants

1. Type: sympathomimetic

a. action: stimulate sympathetic nervous system causing vasoconstriction of nasal mucus membranes

b.
examples

i. tetrahydrozoline (Visine) 1 to 2 drops in each eye as needed

ii. oxymetazoline (Afrin, Afrin All Night, Afrin Extra Moisturizing, Afrin Severe Congestion, Afrin Sinus, Dristan
Nasal, Mucinex Nasal Spray, Neo-Synephrine Nighttime Spray, Sudafed OM, Vicks Sinex VapoSpray 12 Hour)
2-3 sprays in each nostril every 10 to 12 hours as needed


c. uses: decongestant for reducing eye redness, nasal congestion

d. adverse effects

i. life-threatening: arrhythmias, angina

ii. others: nasal irritation and dryness, sneezing, rebound congestion, dizziness, elevated blood pressure,
tachycardia, palpitations, restlessness, insomnia


e. contraindications

i. hypertension, cardiovascular disease,hypothyroidism

ii. use within 14 days of MAO inhibitor

iii. diabetes mellitus, prostatic hypertrophy, angle-closure glaucoma


f. nursing care

i. assist health care team to establish baseline data and check at regular intervals thereafter nasal congestion,
breath sounds, respiratory rate, heart rate, blood pressure

ii. administer with client in upright position

iii. assist health care team to implement client teaching plan - do not exceed recommended dose



228



2. Type: oral decongestants

a. action: stimulates alpha-adrenergic receptors in nasal passages resulting in vasoconstriction and shrinkage of swollen
mucus membranes

b.
example: pseudoephedrine hydrochloride (Children's Sudafed, Sudafed 12 Hour, Sudafed 24 Hour, Sudafed
Congestion) 60 mg by mouth every 4 to 6 hours as needed

c. use: nasal congestion

d. adverse effects

i. life-threatening: arrhythmias, hypertension

ii. most common: insomnia, nausea, headache, dizziness, CNS stimulation, anxiety

iii. other: palpitations, tachycardia, BP elevated, tremor, urinary retention


e. contraindications

i. urinary retention, coronary artery disease, prostatic hypertrophy

ii. hypertension, arrhythmias, cardiovascular disease, phenylketonuria (PKU)

iii. diabetes mellitus, angle-closure glaucoma, hyperthyroidism,

iv. within 14 days of MAO inhibitor

v. not recommended for children younger than age 6 years-old


f. nursing care

i. assist health care team to establish baseline data and check periodically during therapy nasal congestion, breath
sounds, respiratory rate, heart rate, blood pressure

ii. assist health care team to implement client teaching plan

avoid other over-the-counter drugs

discontinue if extreme restlessness occurs

do not crush or chew sustained release forms





H. Pharmacological interventions to help clients to stop smoking

1. Type: nicotine

a. action: stimulates nucleus accumbens reward system in the brain to increase extracellular dopamine, endogenous
opioids, and glucocorticoids in the region

b.
examples

i. nicotine gum (Nicorette Gum) 2-4 mg by mouth every 1-2 hours for 6 weeks

ii. nicotine inhaled (Nicotrol Inhaler) 4 mg delivered/cartridge 6-16 cartridges a day

iii. nicotine transdermal (Nicoderm CQ) 14-21 mg patch daily for 6 weeks

iv. nicotine nasal spray (Nicotrol NS) 0.5/spray; 1 spray each nostril 1-5 times a hour for 8 weeks


c. use: smoking cessation

d. adverse effects

i. bronchospasm, nicotine dependence transference, fetal harm risk

ii. most common: insomnia, headache, withdrawal symptoms


e. contraindications

i. severe arrhythmias, worsening or severe angina

ii. acute with in 2 weeks of myocardial infarction


f. nursing care

i. assist health care team to establish baseline data and check periodically breath sounds, frequency of nicotine
use, frequency of urge to smoke, complaints of nicotine withdrawal or nicotine toxicity

ii. nicotine withdrawal: headache, fatigue, drowsiness, irritability, severe cravings
229


iii. nicotine toxicity: gastrointestinal findings, hypotension, dyspnea, weakness, abdominal cramping, blurred vision,
tinnitus; withdraw nicotine therapy immediately

iv. assist health care team to implement client teaching plan

take only as directed

do not smoke when wearing patch

inhaler: puff on mouthpiece

gum: chew slowly for 30 minutes (reinforce it is as potent as cigarettes)

patch: apply daily, rotating sites (reinforce it is as potent as cigarettes)




2.
Type: antidepressants (example: buPROPion [Wellbutrin, Zyban])

3.
Type: antihypertensives (example: cloNIDine [Catapres])



I. Therapeutic classification: therapeutic gases

1.
Type: oxygen

a. action: essential gas for cellular energy production and metabolism

b. uses

i. supplemental oxygen to prevent or correct hypoxia

ii. hyperbaric oxygenation, extracorporeal circulation

iii. ventilatory support for respiratory failure, surgical anesthesia

iv. reduce partial pressure of inert gases, air embolism, decompression sickness


c. adverse effects

i. life-threatening: hypoxic drive in neonates

ii. other:

increased pulmonary capillary permeability

exacerbation of hypoxemia in hypoventilated lungs

atelectasis, irritation of tracheobronchial mucosa, decreased mucociliary transport

mask signs of desaturation from obstruction or hypoventilation



d. nursing care

i. assist health care team to establish baseline data and check at regular intervals respiratory rate, level of
consciousness, breath sounds, SaO
2


ii. humidify supplemental oxygen

iii. avoid 100% oxygen for more than 8 to 12 hours

iv. prevent client injury: avoid open flames and sparks, ground all equipment

v. FiO
2
affected by respiratory rate, tidal volume, inspiratory-expiratory ratio (I:E ratio), inspiratory flow, and
characteristics of delivery system

lowest control
room air

nasal cannula: nasopharynx is reservoir for oxygen; client may breathe from mouth or nose with
patent nares
tracheostomy collar
simple face mask

medium control: Venturi mask, oxygen nebulizer, and nonrebreather mask

high control: endotracheal tube, tracheostomy tube to ventilator

precise control of FiO
2
only achieved with
230

airtight, closed delivery system
separation of inspired gases from expired gases



vi. PaO
2
affected by FiO
2
serum hemoglobin, SaO
2
, efficiency of alveolar gas exchange

vii. assist health care team to implement client teaching plan: cough and deep breathe every hour while awake





2.
Type: carbon dioxide

a. action: by-product of cellular metabolism carried on the bicarbonate ion (HCO
3
-) and transported to the lung where it is
exhaled at the same rate it is produced

b. uses

i. insufflation of internal organs during endoscopic procedures

ii. vasoconstriction of cerebral vessels during cranial surgery

iii. displacement of air surrounding open heart in cardiac surgery




3.
Type: nitric oxide

a. action: cell-signaling molecule that decreases resting vascular tone, prevents platelet aggregation, effector of
macrophage-induced cytotoxicity (stimulates cell destruction by macrophages)

b. uses

i. pulmonary hypertension to vasodilate

ii. diagnostic testing in cardiac catheterization, pulmonary function, and for asthma


c. adverse effects

i. toxicity at levels greater than 50-100 PPM

ii. loss of ciliary action, hypertrophy of pulmonary tissue

iii. surfactant inactivation, methemoglobinemia formation

iv. increased bleeding time, impaired ventricular function due to increased blood flow to left ventricle


d. nursing care: observe RN establish baseline data and monitor

i.
arterial blood gases, methemoglobin levels, occult bleeding

ii. pulmonary artery pressure, cardiac output, breath sounds, pulmonary secretions




4.
Type: helium

a. action: low density, low solubility, and high thermal conductivity making other gases easier to breathe

b. uses

i. diagnostic testing for respiratory obstruction, laser surgery of airway, imaging label, pulmonary function

ii. oxygen dilution in hyperbaric applications




III. Managing neurological conditions

A. Therapeutic classification: anticonvulsants

1. Therapeutic classification: anticonvulsants - overview

a. action: stabilize neuronal membranes to prevent tissue excitability in the cerebral cortex

b. adverse effects

i. life-threatening: ventricular fibrillation, severe hypotension, cardiovascular collapse (IV use)

ii. CNS depression: insomnia, headache, drowsiness, lethargy, fatigue

iii. gastrointestinal upset, anorexia, constipation

231


c.
nursing care

i. assist health care team to establish baseline data and check at regular intervals seizure activity, level of
consciousness

ii. taper dose before discontinuing therapy

iii. assist with ambulation, institute seizure precautions

iv. assist health care team to implement client teaching plan

promptly report

seizure activity, easy bleeding or bruising

loss of balance, rash, jaundice, severe nausea, vomiting

avoid pregnancy

wear MedicAlert identification

need for follow-up care and testing

AVOID over-the-counter drugs

AVOID herbal supplements

change positions slowly, ask for help before getting up








2. Tonic-clonic (grand mal) seizures

a. type: hydantoin

i. action: stabilize neuronal membranes in CNS to limit spread of neuronal excitability

ii.
example: phenytoin
Black Box Warning - cardiovascular risk with rapid infusion

seizure disorder: 100 mg by mouth every 6-8 hours; extended release 300 to 400 mg by mouth daily

status epilepticus: 15-20 mg/kg IV x 1; may give additional 10mg/kg IV x 1 after 20 minutes


iii. uses

status epilepticus

seizure disorder

neurosurgery-associated seizure prophylaxis


iv. adverse effects

life-threatening: ventricular fibrillation, severe hypotension, cardiovascular collapse, AV conduction
abnormalities (IV use)

most common: nausea, vomiting, rash, nystagmus, ataxia, slurred speech

other: dizziness, confusion, paresthesia, blurred vision, somnolence, constipation, headache, insomnia,
gingival hyperplasia, tremor, taste changes, hyperglycemia


v. contraindications

SA block, 2nd or 3rd degree AV block, sinus bradycardia, Adam-Stokes syndrome, hypotension,
cardiovascular disease

renal or hepatic impairment, diabetes mellitus




vii. nursing care

assist health care team to establish baseline data and check periodically thereafter

seizure activity

monitor blood pressure, ECG, respiratory function continuously during and for 20 minutes after IV load

signs and symptoms of depression, behavior changes, suicidality
232


creatinine, complete blood count, folate, liver function tests

assist health care team to establish baseline data and check and report serum levels

therapeutic: 10-20 mcg/mL (total)

toxic: > 20 mcg/mL

timing: 2 to 4 hours after IV load, 24 hours after oral load or just prior to next dose

provide oral care, assist with ambulation

oral administration

avoid giving within 2 to 3 hours of antacids

prompt release forms not suitable for once daily dosing

IV administration - slowly warm IV solution to room temperature



viii. assist health care team to implement client teaching plan

report seizure activity, bleeding, jaundice, dark urine or stool

AVOID alcohol, sedatives, hypnotics, oral contraceptives

AVOID ginkgo biloba

use soft tooth brush; seek regular dental care

avoid hazardous activities without provider approval

do not crush or chew sustained release forms

may take calcium with vitamin D and folic acid



b. type: barbiturates

i. action: interferes with impulse transmission of cerebral cortex leading to central nervous system depression and
unconsciousness

ii.
examples

phenobarbital

seizure disorder: 60 mg by mouth 2 to 3 times per day

status epilepticus: 10-20 mg/kg IV x 1

sedation: 10-40 mg PO/IM/IV three times a day

primidone (Mysoline) 250 mg by mouth 3 times daily


iii. uses

seizure disorder, essential tremor

status epilepticus

sedation


iv. adverse effects

life-threatening: respiratory depression, erythema multiforme, Stevens-Johnson syndrome, angioedema,
megaloblastic anemia, TTP, blood dyscrasias, suicidality

most common: drowsiness, lethargy, hyperactivity (pediatric clients) nausea, vomiting, somnolence

other

porphyria exacerbation, rash, urticaria, pain, swelling, thrombophlebitis, necrosis, hepatitis

physical dependance

toxicity: ataxia, slurred speech, poor judgment, insomnia




233

v. contraindications

porphyria history, severe hepatic impairment

respiratory dysfunction

history of depression, uremia, elderly clients


vi. nursing care

assist health care team to establish baseline data and check periodically thereafter
signs and symptoms of depression, behavior changes, suicidality

liver function tests and drug levels (therapeutic drug level 10-40 mcg/mL; toxic level > 50 mcg/mL)

administration

intravenous

IM injection may not exceed 5 mg at one site

assist health care team to implement client teaching plan
drowsiness may improve over time
AVOID pregnancy, take only as directed
AVOID hazardous activity
AVOID alcohol
provide exposure to sun

take calcium with vitamin D and folic acid




c. type: benzodiazepines

i. very effective anticonvulsant, emergency drug of choice

ii.
example: diazepam (Valium) 5-10 mg IV every 5 to 10 minutes up to 30 mg

iii. adverse effects: respiratory depression


Therapeutic drug levels are laboratory tests to look for the presence and the amount of specific drugs in the blood.
Therapeutic drug levels should be monitored for the following medications used to control seizure activity, e.g.,
phenobarbital, phenytoin, valproic acid and carbamazepine.


3. Petit mal (absence) seizures

a. type: succinimides

i. action: modulates gamma-aminobutryic acid (GABA) to inhibit neuronal pathways

ii.
example: ethosuximide (Zarontin) 250 mg by mouth twice daily

iii. uses: absence seizures

iv. adverse effects

most common: anorexia, dyspepsia, nausea, vomiting, abdominal pain, weight loss

other: lupus erythematosus, paranoid psychosis


v. contraindications: renal or hepatic disease, intermittent porphyria

vi. nursing care: assist health care team to establish baseline data and check during therapy

complete blood count, liver function tests

therapeutic drug levels: 40-100 mcg/mL (toxic level > 150 mcg/mL)

signs and symptoms of depression, behavior changes, suicidality







234



4. Myoclonic

a. type: benzodiazepine

b. type: sulfonamides

i. action: facilitates dopamine and serotonin neuronal transmission

ii.
example: zonisamide (Zonegran) 100-600 mg by mouth divided 1 to 2 doses daily

iii. use: partial seizures

iv. adverse effects

life-threatening: hyperthermia and oligohidrosis in pediatric clients

other: Stevens-Johnson syndrome, toxic epidermal necrolysis, aplastic anemia


v. contraindication: renal failure

vi. nursing care

maintain cool environment

assist health care team to establish baseline data and check BUN/creatinine and complete blood count

assist health care team to implement client teaching plan: avoid dehydration

avoid strenuous activity and heat

drink fluids to avoid kidney stones

avoid alcohol and caffeinated beverages






c. type: valproic acid

i. action: stimulates GABA activity to decrease normal neuronal electrical discharge

ii.
examples

valproic acid (Depakene, Stavzor) 30-60 mg/kg divided 2 to 3 times per day
Black Box Warning - hepatotoxicity

topiramate (Topamax) 200-800 mg by mouth twice daily

tiagabine (Gabitril) 32-56 mg by mouth divided 2 to 4 times per day


iii. use: partial seizures, primary generalized seizures (tonic clonic), Lennox-Gastaut seizures, migraine prophylaxis

iv. adverse effects

life-threatening: hepatotoxicity, pancreatitis, SIADH, hyponatremia, pancytopenia, thrombocytopenia

most common: headache, nausea, vomiting, asthenia, somnolence, dizziness, ataxia, weight and appetite
changes

other: nervousness, emotional lability, insomnia, peripheral edema


v. contraindications
hepatic disease or impairment
urea cycle disorders
infants or young children, pediatric or elderly clients


vi. nursing care

assist health care team to establish baseline data and check at regular intervals liver function tests, platelets,
coagulation studies, ammonia levels

signs and symptoms of depression, behavior changes, suicidality

therapeutic level for valproic acid: 50-100 mcg/mL (epilepsy treatment)

reinforce client teaching

may open capsule and sprinkle granules on soft food
235


AVOID alcohol, over-the-counter drugs, central nervous system depressants





5. Partial (focal) seizures

a. type: benzodiazepines (example: clorazepate [Tranxene SD,Tranxene T-Tab] 7.5 mg by mouth 3 times a day)

b. type: iminostilbene

i.
examples

carbamazepine (Carbatrol, Equetro, Tegretol, Tegretol XR) 800-1200 mg by mouth divided doses 2 to 4
times daily; extended release 400-600 mg ER by mouth twice daily

oxcarbazepine (Trileptal) 600 mg by mouth twice daily; maximum: 2400 mg/day


ii. adverse effects: hyponatremia, leukopenia, thrombocytopenia, pancytopenia, agranulocytosis



c. type: phenytoin

i.
examples

gabapentin (Gralise, Neurontin) 300-1200 mg by mouth three times a day

lamotrigine (Lamictal, Lamictal XR) 250 mg by mouth 2 times daily Black
Box Warning - serious rash


ii. uses

partial seizures, Lennox-Gastaut seizures, primary generalized seizures (tonic clonic)

post-herpetic neuralgia, neuropathic pain, maintenance treatment for bipolar disorder


iii. adverse effects

life-threatening: Stevens-Johnson syndrome, angioedema, DIC

most common: nausea/vomiting, dizziness/vertigo, visual disturbances, somnolence, ataxia, headache





d. type: valproic acid - action: stimulates GABA activity to decrease normal neuronal electrical discharge

e. type: other

i.
example: levetiracetam (Keppra, Keppra XR) 500-1500 mg mg PO/IV every 12 hours; maximum 3000 mg/day

ii. use: adjunct therapy for partial seizures, adjunct treatment in juvenile myoclonic epilepsy

iii. adverse effects

most common: somnolence, asthenia, vomiting, headache, URI symptoms

other: depression, hostility, aggressive behavior


iv. contraindications: renal impairment, psychiatric disorder

v. nursing care

monitor for signs and symptoms of depression, behavior changes, suicidality

avoid abrupt withdrawal

assist health care team to establish baseline data and check during therapy creatinine

assist health care team to implement client teaching plan

avoid pregnancy

report loss of balance, problems with ambulation








236


B. Therapeutic classification: anti-Parkinson's agents

1. Type: dopaminergic

a. dopamine precursor

i. action: crosses blood-brain barrier to form dopamine

ii.
examples

carbidopa/levodopa (Parcopa, Sinemet, Sinemet CR) 10mg/100mg by mouth 3 to 4 times daily;
maximum 200mg/2000mg/day

carbidopa/levodopa/entacapone (Stalevo) 1 tablet by mouth every 3 to 8 hours


iii. use: parkinsonism, idiopathic Parkinson disease

iv. adverse effects

life-threatening: orthostatic hypotension, syncope, severe hypertension, myocardial infarction,
arrhythmias

most common: dyskinesia, nausea/vomiting, hypokinesia/hyperkinesia, diarrhea, dark
saliva/sweat/urine

rhabdomyolysis, depression, suicidal ideation, hallucinations, psychosis, malignant melanoma


v. contraindications: angle-closure glaucoma, melanoma history, undiagnosed skin lesions

vi. nursing care

assist health care team to establish baseline data and check periodically during therapy

increased intraocular pressure if chronic wide angle glaucoma

cardiovascular status if cardiovascular disease history

signs and symptoms of orthostatic hypotension

extrapyramidal side effects

complete blood count, creatinine, liver function tests with extended treatment

assist health care team to implement client teaching plan

report chest pain, palpitations, depression, urinary retention, severe nausea and vomiting, and
involuntary movements

frequent rinsing of mouth, good oral hygiene, and sugarless gum may decrease dry mouth

harmless darkening of saliva, urine, or sweat may occur

sometimes a "wearing-off" effect may occur at end of dosing interval

balance activity and rest, ask for help when getting up

may take with or without food but avoid high protein meals







b. type: dopamine agonists

i. action: acts like replacement therapy to increase dopamine levels but requires functioning neurons capable of
responding

ii.
examples

ropinirole (Requip, Requip XL) 3-6 mg by mouth three times daily; extended release form 6-24 mg by mouth
daily

bromocriptine (Cycloset, Parlodel) 10-30 mg by mouth three times daily

amantadine (Symmetrel) 100 mg by mouth twice daily


iii. use: Parkinson disease, extrapyramidal disorders, neuroleptic malignant disease, hyperprolactinemia, acromegaly

iv. adverse effects

life-threatening: heart failure, arrhythmias, cardiac arrest, psychosis, coma, respiratory failure, pulmonary
edema

most common: nausea, dizziness, insomnia, depression, anxiety, irritability, hallucinations, confusion
237


other: anorexia, dry mouth, constipation


v. contraindications

elderly, depression, psychiatric disorder

heart failure, cardiovascular disease, peripheral edema

angle-closure glaucoma, seizure disorder

renal and hepatic impairment


vi. nursing care

assist health care team to establish baseline data and check at regular intervals during therapy creatinine

AVOID abrupt withdrawal - taper dose to discontinue

assist health care team to implement client teaching plan

wear MedicAlert identification

dermatologic exams

ask for help when getting up, avoid dangerous activities





c. type: monamine oxidase B inhibitor

i. action: blocks breakdown of dopamine and may slow disease progression

ii.
example: selegiline (Eldepyrl) 2.5-10 mg by mouth in 2 doses

iii. use: parkinsonism

iv. adverse effects

life-threatening: hypertensive crisis. arrhythmias. orthostatic hypotension

most common: mental status alterations, hallucinations, extrapyramidal symptoms

other:

dyskinesia, melanoma risk, dizziness, nausea, pain, headache

insomnia, rhinitis, skin disorder, back pain, dyspepsia

hallucinations, confusion, dry mouth

vivid dreams, buccal mucosa irritation, compulsive behaviors



v. contraindications: pheochromocytoma, renal or hepatic impairment, cardiovascular or cerebrovascular disease

vi. nursing care

AVOID abrupt withdrawal

give with breakfast and lunch

AVOID giving with MAOIs, meperidine

reinforce client teaching

report severe headache, severe hypertension, palpitations

AVOID foods with tyramine (aged cheeses, sausage/salami, beer/wine, avocados/bananas/raisins, pickled
herring)

change positions slowly, ask for help getting up





d. type: catechol O-methyl transferase (COMT) inhibitor

i. action: increases availability of dopamine by inhibiting COMT, may allow increased dosing of levodopa

ii.
examples

tolcapone (Tasmar) 100 mg by mouth three times a day
Black Box Warning - hepatotoxicity
238


entacapone (Comtan) 200 mg by mouth with each dose of levo/carbidopa dose; maximum: 1600 mg/day


iii. use: Parkinson's disease adjunct treatment

iv. adverse effects

orthostatic hypotension, dyskinesia, syncope,hallucinations, rhabdomyolysis

most common: nausea/vomiting, hypokinesia/hyperkinesia, diarrhea, urine discoloration


v. contraindication: hepatic impairment, concurrent CNS depressant or alcohol use

vi. nursing care

assist health care team to establish baseline data and check signs and symptoms of orthostatic hypotension,
especially during dose titration

provide assistance for ambulation while initiating therapy

assist health care team to implement client teaching plan

sweat and urine may change color

change positions slowly, ask for help before getting up

AVOID abrupt withdrawal





2. Type: anticholinergic agents

a. action: decreases excess cholinergic effect of dopamine deficiency by competing with acetylcholine (ACh) for
muscarinic receptor sites

b.
examples

i. benztropine (Cogentin) 1-2 mg PO/IM/IV every evening

ii. trihexyphenidyl (Artane) 6-10 mg by mouth daily divided in three doses


c. uses: parkinsonism, extrapyramidal reactions, acute dystonic reactions, idiopathic Parkinson disease

d. adverse effects

i. hyperthermia, heat stroke, neuroleptic malignant syndrome, tardive dyskinesia

ii. most common: xerostomia, blurred vision, dizziness, nausea, anxiety, confusion

iii. other: anticholinergic psychosis, paradoxical bradycardia


e. contraindications: angle-closure glaucoma, elderly, glaucoma, cardiac disease, hypertension, renal or hepatic
impairment

f. nursing care

i. assist the health care team to establish baseline data and monitor gonioscope and intraocular pressure at regular
intervals

ii. assist health care team to implement client teaching plan

AVOID abrupt withdrawal

avoid becoming overheated or dehydrated during hot weather

give with food





C. General anesthetics

1. General

a. action

i. central nervous system depression for invasive procedures and surgery

ii. rapid distribution to brain and spinal cord resulting in rapid onset and short duration of action


b. uses: used in combination with local anesthetics, opioids, anticholinergics, and neuromuscular blockers to achieve
analgesia, unconsciousness, muscle relaxation, and amnesia during surgery

c. types

i. parenteral: short-acting barbiturates methohexital (Brevital)
239

Black Box Warning - appropriate uses, benzodiazepines Midazolam (Versed), opioids Fentanyl, sedative-
hypnotic propofol (Diprivan)

ii.
inhalation: stable gases (nitrous oxide), volatile gases (halothane)


d. adverse effects

i. life-threatening: respiratory depression, cardiorespiratory arrest, circulatory depression, cardiovascular collapse,
arrhythmias, seizures, bronchospasm

ii. most common: hypotension, excitatory phenomena, thrombophlebitis, tachycardia, bradycardia, dyspnea


e. contraindications

i. history of malignant hyperthermia

ii. hepatic or renal failure, severe cardiovascular disease, hypotension, shock

iii. status asthmaticus, increased intracranial pressure, myasthenia gravis


f. nursing care

i. observe RN establish baseline data and monitor - airway, vital signs, SaO
2
, level of consciousness

ii. verify preoperative evaluation of client by anesthesia provider and surgeon

iii. general anesthetics potentiate the effects of one another - used only by specially trained personnel

iv. have emergency equipment and drugs at the bedside

v. observe RN implement client teaching: preoperative instructions

do not eat or drink 6 to 8 hours before the procedure

take medication before procedure as directed by provider - oral drugs can be taken with small sip of
water

arrange chaperone for 24 hours after anesthesia

arrange for transportation home after procedure






2. Parenteral anesthetic agents

a. type: barbiturates

i.
examples

PENTobarbital (Pentothal) 100-500 mg IV

secobarbital (Seconal)


ii. use: in combination with inhalation anesthetics for induction and maintenance of surgical anesthesia (hypnotic and
sedative effects)


b. type: benzodiazepine

i.
example: midazolam (generic) 0.3-0.35 mg/kg IV
Black Box Warning - appropriate use, respiratory depression/arrest risk, individualize IV dose

ii. use: procedural sedation, preoperative sedation, anesthesia induction


c. type: opioids

d. type: propofol

i.
example: propofol (Diprivan) 2-2.5 mg/kg IV

ii. use: anesthesia induction, anesthesia maintenance, monitored anesthesia care induction and maintenance, ICU
sedation

iii. adverse effects

life-threatening: bradycardia, asystole, cardiac arrest, seizures, pulmonary edema

most common: injection site reaction, hypotension, involuntary muscle movements

240


iv. contraindications: hypersensitivity to eggs, soy or soybeans, glycerol; labor & delivery

v. nursing care: observe RN administer immediately after removing from sterile packaging, do not use past expiration
date




3. Inhalation anesthetics

a. type: stable anesthetic gases

i. action: severe central nervous system depression to induce and maintain unconsciousness

ii.
example: nitrous oxide - weak gas, low toxicity, and short acting (with strong analgesic properties)

iii. adverse effects: nausea and vomiting


b. type: volatile gases

i. action: stabilizing effect on postjunctional membrane and acts synergistically with competitive blocking agents

ii.
examples

halothane (Fluothane)

enflurane (Ethrane)

sevoflurane (Ultrane)


iii. uses: induction and maintenance of general anesthesia

iv. adverse effects

life-threatening: hypotension, respiratory depression, malignant hypothermia, hepatotoxicity

other: nausea, vomiting


v. nursing care

observe RN establish baseline data and monitor airway, vital signs

remain at bedside until client maintains airway and spontaneous respirations

collaborate about need for supplemental oxygen and ventilatory support

rapid onset and recovery





4. Perioperative emergency drugs

a. type: hydantoin

i. action: interferes with intracellular release of calcium, slows catabolism in malignant hyperthermia

ii.
example: dantrolene (Dantrium, Revonto) 100 mg by mouth 2 to 4 times daily
Black Box Warning - hepatotoxicity

iii. uses: chronic spasticity, malignant hyperthermia

iv. adverse effects

life-threatening: hepatotoxicity, pleural effusion, heart failure, aplastic anemia, seizures

most common: drowsiness, dizziness, weakness, malaise, fatigue, diarrhea

other:injection site reaction and thrombophlebitis from IV use


v. contraindications: spasticity-dependent posture, balance or function, CNS depressant or alcohol use

vi. nursing care

observe RN establish baseline data and monitor liver function tests

screen clients for client or family history of malignant hyperthermia

reinforce client teaching

report lack of improvement or worsening of findings, abdominal pain, jaundice, dark urine or stool, rash,
itching

take only as directed and do not double dose
241


AVOID alcohol, central nervous system depressants

wear sunscreen






b. type: anticholinergic agent (see Epocrates Online for greater detail)

i. action: blocks action of acetylcholine

ii.
example: atropine (Atropine)

iii. use: reduce respiratory secretions, reduce vagal tone


c. type: opioid antagonist

i. action: competes with opioids for opioid receptors

ii.
example: naloxone (Narcan)

iii. use: to reverse CNS and respiratory depression associated with opioid analgesics


d. type: cholinergic agent; anticholinesterase

i. action: inhibits destruction of acetylcholine

ii.
example: edrophonium chloride (Tensilon)

iii. use: antagonist of curare, diagnostic for myasthenia gravis


e. type: benzodiazepine receptor antagonist

i. action: antagonizes the action of benzodiazepines on the central nervous system

ii.
example: flumazenil (Romazicon) 0.2-0.5 mg IV every minute
Black Box Warning - seizure risk

iii. use: to reverse respiratory and CNS depression of benzodiazepines



D. Therapeutic classification: local anesthetic agents

1. Action: loss of sensation to a region of the body

2.
Examples

a. type: esters - procaine (Novocaine)

b. type: amines

i. bupivacaine (Marcaine)
Black Box Warning - appropriate and obstetrical use

ii. lidocaine (Lidocaine)



3. Uses

a. local, regional, spinal anesthesia

b. status epilepticus, ACLS VF/pulseless VT

c. ventricular arrhythmias, pain related to herpes zoster, post-herpetic neuralgia, cancers and intractable pain


4. Adverse effects

a. life-threatening: CNS toxicity, myocardial depression, convulsions, unconsciousness, anaphylactoid reactions,
respiratory distress, heart block, severe hypotension, bradycardia, ventricular arrhythmias, cardiac arrest

b. most common: nervousness, dizziness, blurred vision, tremor, drowsiness

c. other: nausea/vomiting, chills, pupil constriction


5. Contraindications: hypersensitivity to ester anesthetics

242

6. Nursing care

a. keep emergency equipment at bedside

b. protect client from injury until complete return of sensation and function

c. observe RN provide client teaching

i.
ask for help before trying to get up

ii. effects of local agent and anticipated return of sensation and function





E. Therapeutic classification: cholinergic agents

1. Type: direct-acting cholinergic agonists

a. action: mimics the action of acetylcholine (ACh) by stimulating postsynaptic muscarinic receptors

b.
example: bethanechol (Urecholine) 10-50 mg by mouth 3 to 4 times per day

c. uses: urinary retention, neurogenic bladder, chronic GERD, thymic carcinoma (TCA) adjuvant treatment,
phenothiazine adjuvant treatment

d. adverse effects

i. life-threatening: bronchospasm, hypotension, tachycardia, seizures

ii. most common: abdominal cramps/discomfort/pain, nausea, belching, borborygmi, urinary urgency

iii. other: diarrhea, salivation, headache, hypotension, vasomotor response, malaise, flushing, diaphoresis, miosis,
lacrimation


e. contraindications: bladder neck obstruction, recent bladder or GI surgery, GI obstruction, peptic ulcer disease

f. nursing care

i. catheterization may be ordered to assess postvoid residual

ii. assist health care team to implement client teaching plan

report cramping, bloody diarrhea, flushing

take on empty stomach - 1 hour before or 2 hours after meals

change positions slowly and ask for help when getting up






2. Type: indirect-acting cholinergic agents (anticholinesterase agent, cholinesterase inhibitors)

a. action: reversibly inhibits action of cholinesterase, the enzyme that degrades acetylcholine at the synaptic clef to
increase acetylcholine concentrations and improve neuromuscular impulse transmission

b.
examples

i. treatment

neostigmine bromide (Prostigmin) 45-375 mg/day in divided doses by mouth; IM or IV 0.5-2 mg every 1 to
3 hours

pyridostigmine (Mestinon) 60-180 mg 2 to 4 times daily by mouth; IV: use 1/3 of oral dose

ambenonium chloride (Mytelase) 1-2 grams IV, may repeat in hour; given with atropine IV


ii. diagnosis: edrophonium chloride (Tensilon) 2 mg rapid IV bolus


c. uses

i. diagnosis and treatment of myasthenia gravis, diagnosis of myasthenic crisis

ii. urinary retention prophylaxis and treatment

iii. nondepolarizing neuromuscular blocking agents reversal


d. adverse effects

i. life-threatening: severe cholinergic reaction, arrhythmias, bradycardia, hypotension, respiratory paralysis, seizures,
laryngospasm, bronchospasm

ii. other
243


lacrimation, pupillary constriction, accommodation spasm, diplopia, conjunctival hyperemia, dysarthria,
dysphonia, dysphagia, increased pulmonary secretions, increased GI secretions

reverses therapeutic effect of phenothiazines, antihistamines, and tricyclic antidepressants




e. contraindications

i. peritonitis

ii. bradycardia, hypotension

iii. obstruction of gastrointestinal or genitourinary tract


f. nursing care

i.
assist health care team to establish baseline data and monitor creatinine

monitor for weakness 1 hour after therapy: may indicate cholinergic crisis (overdose of cholinesterase inhibitor)

monitor for weakness 3 hours after therapy: may indicate myasthenia crisis (underdose)


ii. carefully review drug label for correct dosage and concentration

iii. keep atropine, airway, oxygen, and Ambu bag at bedside


Findings of insufficient medication (myasthenic crisis) and excessive medication (cholinergic crisis) can present in
similar ways, including bronchospasm with wheezing, respiratory failure, diaphoresis, and cyanosis. A tensilon test
is used to differentiate between the two; if no improvement is seen after administering edrophonium (Tensilon),
then cholinergic crisis is assumed.



3. Type: centrally-acting cholinesterase inhibitors

a. action: blocks cholinesterase activity at the synaptic cleft resulting in elevated acetylcholine levels

b.
examples

i. rivastigmine (Exelon): 1.5-6 mg by mouth twice daily

ii. galantamine (Razadyne, Razadyne ER): 8-12 mg by mouth twice daily; ER 16-24 mg by mouth

iii. donepezil (Aricept): 5-10 mg by mouth at bedtime
Complementary and Alternative Medicine
Coenzyme Q10, coral calcium, ginkgo biloba, huperzine A, omega-3 fatty acids are being used to help with
symptoms of dementia (Alzheimer's Association).



c. uses: mild-moderate Alzheimer dementia, mild-moderate Parkinson disease dementia, moderate-severe Alzheimer
dementia

d. contraindication: cardiac conduction defects, asthma or chronic obstructive pulmonary disease, GI ulcer risk

e. nursing care

i. assist health care team to establish baseline data and monitor signs and symptoms of GI bleed

ii. fall precautions

iii.
give rivastigmine (Exelon) and galantamine (Razadyne) with food

iv. assist health care team to implement client teaching plan

report excessive salivation, diarrhea, emesis, and frequent urination

apply artificial tears for dry eyes

ask for help before getting up, change positions slowly






244


4. Type: N-methyl-D-aspartate (NMDA) glutamate-receptor antagonist

a. action: blocks NMDA receptors to reduce rate of clinical deterioration

b.
example: memantine (Namenda) 10 mg by mouth twice daily

c. use: moderate-severe Alzheimer's dementia

d. adverse effects: Stevens-Johnson syndrome, headache, dizziness



5. Type: cholinesterase reactivator

a. action: restores response to neuromuscular stimulation by reactivating cholinesterase

b.
example: pralidoxime (2-PAM, Pralidoxime Auto-Injector, Protopam) 1-2 grams IV, then 250 mg IV every 5
minutes until symptoms reverse

c. use

i. treatment of organophosphate insecticide and nerve agent poisoning

ii. treatment of cholinesterase inhibitor overdose




IV. Managing musculoskeletal conditions

A. Therapeutic classification: neuromuscular blocking agents

1. Type: depolarizing

a. action: competes with acetylcholine for acetylcholine-receptor sites resulting in muscle cell depolarization,
initial contraction, and flaccid paralysis

b.
example: succinylcholine (Anectine) 0.3-1.1 mg/kg IV
Black Box Warning - cardiac arrest risk in pediatric clients

c. uses

i. neuromuscular blockade induction and maintenance

ii. rapid sequence intubation


d. adverse effects

i. life-threatening: prolonged paralysis, respiratory depression, apnea, malignant hyperthermia, arrhythmias

ii. most common: postoperative muscle pain, muscle fasciculation, jaw rigidity, elevated intraocular pressure

iii. other: hypersensitivity reaction, anaphylaxis, rhabdomyolysis with hyperkalemia, myoglobinemia


e. contraindications

i. malignant hyperthermia history, myopathy, acute major trauma or burns

ii. acute upper motor neuron injury, angle-closure glaucoma, penetrating eye injury


f. nursing care

i. observe RN establish baseline data and continually monitor vital signs, ECG, airway, ventilation, and SaO
2


ii. observe RN establish baseline data and monitor peripheral nerve stimulation, serum electrolytes

iii. remain at bedside during infusion

keep emergency equipment and drugs at the bedside

maintain oxygenation and ventilation while client is being treated


iv. administer sedation and analgesia to clients while being treated - client is conscious and alert without
sedation

v. fasciculations subside rapidly after initial administration

vi. observe RN implement client teaching plan: etiology of muscle pain, reassurance about drug-induced,
temporary paralysis






245

B. Therapeutic classification: skeletal muscle relaxing agents

1. Type: cyclobenzaprine

a. centrally acting

i. action: acts on central nervous system at the brain stem to relieve muscle spasm without loss of function; similar
in structure to tricyclic antidepressants

ii.
examples

cyclobenzaprine (Amrix, Fexmid, Flexeril) 5-10 mg by mouth 3 times daily

carisoprodol (Soma) 350 mg by mouth 3 times daily and at bedtime


iii. uses: muscle spasm, acute musculoskeletal pain

iv. adverse effects

life-threatening: seizures, cardiac conduction disturbances, arrhythmias, myocardial infarction, stroke,
heat stroke

most common: drowsiness, dry mouth, dizziness fatigue, headache, constipation

other: psychosis, hepatitis

most muscle relaxants are considered high risk drugs in the elderly (based on the Beers Criteria) due
to anticholinergic effects, sedation and weakness


v. contraindications: acute recovery myocardial infarction, cardiac conduction disturbances, arrhythmias, heart
block, heart failure, hyperthyroidism

vi. nursing care

contraindicated with all MAOIs and potassium salts

collaborate with physical therapy and provider for adjunct therapy to decrease need for muscle
relaxants

assist health care team to implement client teaching plan

change positions slowly, ask for help before getting up

AVOID dangerous activity, avoid alcohol and other central nervous system depressants

establish regular bowel habits including fluids, fiber, and physical activity







b. direct acting

i. action: interferes with calcium release in muscle fiber to prevent muscle contraction

ii.
examples

dantrolene (Dantrium) 100 mg by mouth 2 to 4 times daily
Black Box Warning - hepatotoxicity

onabotulinum toxin A (Botox, Botox Cosmetic) IM or injectable dose varies
Black Box Warning - distant spread of toxin effect


iii. uses

chronic spasticity, upper limb spasticity

blepharospasm, primary axillary hyperhidrosis

cervical dystonia, migraine headache prophylaxis


iv. adverse effects
hypersensitivity, anaphylaxis, spread of toxin effect, hepatotoxicity
other: drowsiness, dizziness, weakness, malaise, fatigue, diarrhea


v. contraindications: active hepatic disease

vi. nursing care

assist health care team to establish baseline data and check at regular intervals liver function tests
246


prevent extravasation when administered IV

assist health care team to implement client teaching plan

AVOID alcohol and other central nervous system depressants

report fever, rash, dark urine or stool, jaundice




2. Type: benzodiazepines

a.
example: diazepam (Valium)

b. very effective muscle relaxant, as well as an effective antianxiety agent and anticonvulsant


C. Type: nonsteroidal anti-inflammatory drugs (NSAIDs)

1. information common to NSAIDs

a. action

i. inhibits synthesis of prostaglandins

ii. analgesic, antipyretic, anti-inflammatory agent


b. uses

i. mild to moderate pain of musculoskeletal disorders including osteoarthritis (OA) and rheumatoid arthritis (RA)

ii. pleuritis, pericarditis

iii. primary dysmenorrhea, uterine relaxation


c. adverse effects

i. life-threatening: bleeding, bone marrow depression, fluid retention, hypertension, decreased renal blood flow
(especially in older clients)

ii. most common: irritation and erosion of GI tract resulting in bleeding, nausea

iii. other: headache, fatigue, rash, oral lesions, anaphylaxis


d. contraindications

i. hypertension, renal dysfunction

ii. bleeding disorders, recent trauma or surgery


e. nursing care

i.
assist health care team to establish baseline data and check periodically blood pressure, appearance of
stool, complete blood count, liver function

ii. assist health care team to implement client teaching plan
take only as directed
drink 6 to 8 glasses of water daily
report use of NSAIDs to all providers

AVOID over-the-counter drugs

monitor for bleeding

do not crush or chew sustained release forms

report headache, weight gain, fever, rash, or swelling






2. Sub-type: acetic acid

a.
examples

i. diclofenac sodium (Voltaren, Voltaren XR) 50 mg by mouth 2 to 3 times daily
Black Box Warning - cardiovascular and GI risk

ii. indomethacin 50-200 mg by mouth 2 to 3 times daily
247

Black Box Warning - cardiovascular and GI risk


b. adverse effects: GI bleed, GI ulceration/perforation, myocardial infarction, stroke, hypertension, heart failure

c. contraindications: ASA or NSAID-induced asthma or urticaria

d. nursing care

i.
assist health care team to establish baseline data and check at regular intervals BUN/creatinine, complete
blood count, chemistry profile

ii. monitor ophthalmic exams during long term treatment




3. Sub type: naphthaleneacetic acid derivative

a.
example: nabumetone 1000-2000 mg by mouth daily divided in 1 to 2 doses
Black Box Warning - cardiovascular and GI risk

b. adverse effects: GI bleed, GI ulceration/perforation, myocardial infarction, stroke, hypertension, heart failure



4. Sub type: pyrrolizine carboxylic acid

a.
example: ketorolac (Toradol) 60 mg IM 0r 30 mg IV x 1 dose
Black Box Warning - appropriate use, GI, cardiovascular, renal, bleeding and labor/delivery risk, concomitant
NSAID use, intrathecal/epidural use, hypersensitivity reaction and special populations

b. uses: moderate-severe pain



5. Sub type: oxicams

a.
meloxicam (Mobic) 7.5-15 mg by mouth daily
Black Box Warning - cardiovascular and GI risk


b.
piroxicam (Feldene) 20 mg by mouth daily
Black Box Warning - cardiovascular and GI risk

c. use: osteoarthritis, rheumatoid arthritis, ankylosing spondylitis

d. adverse effects: GI bleed, GI ulceration/perforation, myocardial infarction, stroke, hypertension, heart failure

e.
assist health care team to establish baseline data and check at regular intervals blood count, chemistry profile with
long term treatment, blood pressure



6. Sub type: propionic acids

a.
examples

i. ibuprofen (Advil, Advil Migraine, Caldolor, Children's Advil, Children's Motrin, Infants' Advil, Infants' Motrin, Junior
Strength Advil, Junior Strength Motrin, Midol Liquid Gels, Motrin IB, PediaCare Children's Pain Reliever/Fever
Reducer IB, PediaCare Infants' Pain Reliever/Fever Reducer IB) 300-800 mg by mouth 3 to 4 times daily, not to
exceed 3200 mg in 24 hours
Black Box Warning - cardiovascular and GI risk

ii. naproxen (EC-Naprosyn, Naprosyn) 250-500 mg by mouth every 12 hours, up to 1500 mg in 24 hours
Black Box Warning - cardiovascular and GI risk



b. nursing care
248


i. maximum dose: 3200 mg/day

ii.
give with food




7. Sub-type: COX-2 inhibitor

a. action: selectively inhibits COX-2; inhibits synthesis of prostaglandins; analgesic, antipyretic, anti-inflammatory

b.
example: celecoxib (Celebrex) 200 mg by mouth daily
Black Box Warning - cardiovascular and GI risk

c. uses: osteoarthritis, rheumatoid arthritis,familial adenomatous polyposis, ankylosing spondylitis, dysmenorrhea, acute
pain

d. adverse effects

i. GI bleed, GI ulceration/perforation, myocardial infarction, stroke, thromboembolism, hypertension, heart failure

ii. headache, dyspepsia, upper respiratory infection, diarrhea, abdominal pain, nausea/vomiting


e. contraindications

i. ASA or NSAID-induced asthma or urticaria

ii. aspirin triad, 3rd trimester pregnancy, perioperative use for CABG surgery


f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and periodically thereafter
pain, complete blood count, liver and renal function tests, gastrointestinal upset and bleeding

ii. assist health care team to implement client teaching plan

take with full (6-8 ounces) glass of water or milk and with food

AVOID aspirin and other NSAIDs





8. Sub-type: salicylates, acetylated

a.
aspirin (BAYER Advanced Aspirin Extra Strength, Bayer Advanced Aspirin Regular Strength, Bayer Aspirin, Bayer
Aspirin Extra Strength, Bayer Extra Strength Plus, Bayer Low Dose Aspirin, Ecotrin, Ecotrin Low Strength, St Joseph)
325-600 mg by mouth every 4 hours as needed

b. uses: analgesia, reduction of inflammation, reduction of fever, decreased incidence of transient ischemic attacks and
myocardial infarction

c. adverse effects: tinnitus, GI bleeding, anemia, hemolysis, hepatotoxicity rash

d. contraindications: hypersensitivity to ASA or other salicylates, bleeding disorders or thrombocytopenia; history of GI
bleeding or ulcer disease, chronic alcohol abuse; may increase risk of Reye's syndrome in children with viral infections

e. nursing care

i. may increase anticoagulant effect and bleeding risk with warfarin, heparin, feverfew, garlic, ginger, and ginkgo

ii. give after meals or with food or an antacid to minimize gastric irritation

iii.
monitor creatinine at baseline, serum drug levels




9. Sub-type: salicylates, non-acetylated

a.
example: choline magnesium trisalicylate 1500 mg by mouth twice daily

b. uses: analgesia, reduction of inflammation, reduction of fever

c. adverse effects: tinnitus, GI bleeding, hepatotoxicity, laryngeal edema

d. contraindications: hypersensitivity to ASA or other salicylates, cross-sensitivity with other NSAIDs

249

e. nursing care

i.
monitor creatinine at baseline, serum drug levels

ii. therapeutic drug levels 150-300 mcg/mL; toxic >300 mcg/mL




D. Related anti-inflammatory therapies

1. Type: heavy metal (gold)

a. action: modulates immune response and inhibits inflammation; may suppress phagocytosis and prostaglandin
synthesis

b.
example: gold sodium thiomalate (Myochrysine) 10 mg/week IM for week 1, then 25 mg IM for week 2, then
25-50 mg IM every week
Black Box Warning - appropriate use

c. uses: initial and maintenance treatment for rheumatoid arthritis

d. adverse effects

i. life-threatening: bone marrow depression, nephrotic syndrome; gold bronchitis and pneumonitis

ii. most common: hypersensitivity: flushing, fainting, dizziness

iii. other: Guillain-Barre syndrome, anaphylaxis, nitritoid reaction, aplastic anemia, angioedema, ocular gold
deposits


e. contraindications: severe prior gold toxicity, severe debilitation, systemic lupus erythematosus (SLE), severe
hypertension, blood dyscrasia, rash

f. nursing care

i.
assist health care team to establish baseline data and check periodically urinalysis, complete blood count
with differential, platelets

ii. administration

may give deep IM injection

do not use injectable if darker than pale yellow

client to remain seated or in bed for 30 minutes following injection


iii.
antidote : dimercaprol (British anti-Lewisite or BAL in oil) 2.5-3 mg/kg IM every 6 hours for 8 doses

iv. assist health care team to implement client teaching plan

protect skin from sun with sunscreen or clothing

report rapid improvement in joint edema, pruritus, easy bruising






2. Type: tumor necrosis factor (TNF) (genetically engineered) antagonist

a. action: acts as receptor for TNF to prevent related damage

b.
example: etanercept (Enbrel) 50 mg SubQ weekly
Black Box Warning - serious infection risk and malignancy

c. uses: ankylosing spondylitis, moderate -to-severe chronic psoriasis plaque, psoriatic arthritis, mod-severe rheumatoid
arthritis

d. adverse effects

i. serious infection, sepsis, opportunistic infection, tuberculosis, malignancy

ii. lymphoma, leukemia, HBV reactivation, heart failure

iii. injection site pain, localized erythema, infection, upper respiratory infection


e. contraindications: concurrent live vaccination, active infection, Wegener's granulomatosis on immunosuppressants

250

f. nursing care

i.
assist health care team to establish baseline data and check at regular intervals complete blood count with
differential, hepatitis B surface antigen (HBsAG)

ii. administer a tuberculin skin test prior to start of treatment

iii. administration: rotate sites, reconstitute slowly and gently rotate vial for clear solution

iv. assist health care team to implement client teaching plan

treatment must continue uninterrupted to achieve therapeutic effect

AVOID live vaccines, influenza nasal vaccine, BCG live intravesical

subcutaneous injection technique: rotate injection site by at least 1 inch for each injection in to abdomen,
thigh or upper arm





3. Type: chelating agent

a. action: combines with cystine hydrochloride to prevent stone formation and inhibit collagen formation; related to
penicillin without antimicrobial properties

b.
example: penicillamine (Cuprimine) 250-1000 mg by mouth 4 times daily
Black Box Warning - appropriate use

c. use: cystinuria, severe rheumatoid arthritis, Wilson disease, arsenic poisoning, lead toxicity, primary biliary cirrhosis

d. therapeutic effect may take 3 months to appear

e. adverse effects

i. thrombocytopenia, leukopenia, aplastic anemia

ii. anorexia, epigastric pain, nausea, vomiting, diarrhea

iii. proteinuria, thrombocytopenia, leukopenia


f. contraindications

i. pregnancy, breast feeding

ii. concurrent gold salt, cytotoxic and antimalarial drug use

iii. hypersensitivity to penicillin, renal impairment


g. nursing care

i. assist health care team to establish baseline data and check at regular intervals thereafter

skin/lymph nodes, temperature

liver function tests, creatinine, urinalysis (for protein), complete blood count with differential


ii.
administer on empty stomach 1 hour before or 2 hours after meals; give with pyridoxine 25 mg daily

iii. assist health care team to implement client teaching plan

skin care

take temperature at bedtime

report bleeding, rash, sore throat, fever

take as directed, do not interrupt therapy





E. Therapeutic classification: anti-gout agents

1. Type: uricosuric agent

a. action: inhibits tubular reabsorption of uric acid, increases its excretion, and lowers serum uric acid level

b.
example: probenecid (Benemid) 250-500 mg by mouth twice daily

c. use: prevent recurrence of gouty arthritis, penicillin adjunct

251

d. adverse effects

i. hemolytic anemia, aplastic anemia, hepatic necrosis, anaphylaxis

ii. headache, dizziness, anorexia, nausea

iii. vomiting sore gums, urinary frequency


e. contraindications

i. creatinine clearance <50, acute gout attack

ii. uric acid nephrolithiasis, blood dyscrasias


f. nursing care

i.
assist health care team to establish baseline data and check prior to beginning therapy and at regular
intervals thereafter creatinine, complete blood count

ii. administer lowest effective dose

iii.
collaborate with health care team for purine-restricted diet

iv. assist health care team to implement client teaching plan

do not interrupt therapy

AVOID NSAIDs

drink 3000 mL of fluids each day to keep urine dilute, especially during the night, avoiding caffeinated
beverages






2. Type: colchicine

a. action: inhibits formation of lactic acid in leukocytes resulting in decreased phagocytosis and joint inflammation

b.
example: colchicine (Colcrys) 1.2 mg by mouth x 1 dose, then 0.6 mg by mouth 1 hour later x 1 dose

c. uses: acute gout, gout prophylaxis, familial Mediterranean fever, Behcet's disease, recurrent pericarditis

d. adverse effects

i. life-threatening: myelosuppression, leukopenia, thrombocytopenia, granulocytopenia

ii. other: diarrhea, nausea/vomiting, cramping, abdominal pain, fatigue, headache


e. contraindications: hepatic or renal impairment

f. nursing care

i.
assist health care team to establish baseline date and check before beginning therapy and periodically
thereafter creatinine, complete blood count

ii.
collaborate with health care team for purine-restricted diet

iii. administration: may give with food

iv. assist health care team to implement client teaching plan

report pain, rash, erythema, sore throat, bleeding or bruising

AVOID alcohol and over-the-counter drugs





3. Type: antihyperuricemic agent - xanthine oxidase inhibitor

a. action: reduces endogenous uric acid inhibiting xanthine oxidase (converts hypoxanthine to uric acid in purine
metabolism)

b.
example: allopurinol (Aloprim, Zyloprim) 200-600 mg by mouth daily in 1 to 4 divided doses

c. uses

i. gout prophylaxis

ii. chem0related hyperuricemia
252


iii. recurrent calcium oxalate calculi


d. adverse effects

i. hypersensitivity syndrome, severe skin reactions, exfoliative dermatitis

ii. toxic epidermal necrolysis, Stevens-Johnson syndrome

iii. rash, diarrhea, nausea, gout flare


e. contraindications

i. renal impairment or risk, hepatic impairment

ii. concurrent myelosuppressive agents


f. nursing care

i.
assist health care team to establish baseline data and check before beginning therapy and at regular intervals
thereafter BUN/creatinine, liver function tests

ii. client teaching

promptly report rash, fever

protect eyes from ultraviolet rays

AVOID aspirin and acetaminophen

drink 3000 mL of fluid daily (avoid alcohol and caffeinated beverages)

life threatening reaction may occur 2 to 4 weeks after initiation of therapy - malaise, fever, aching, rash,
deteriorating renal function





4. Type: antihyperuricemic agent - enzyme

a. action: facilitates conversion of uric acid to allantoin

b.
example: rasburicase (Elitek) 0.2 mg/kg IV daily up to 5 days
Black Box Warning - anaphylaxis, hemolysis, methemoglobinemia, uric acid test interference

c. uses: chemo-related hyperuricemia

d. adverse effects

i. hypersensitivity reaction, anaphylaxis, hemolysis

ii. methemoglobinemia, neutropenia, sepsis, pulmonary hemorrhage

iii. fever, headache, anxiety, abdominal pain, constipation


e. contraindications: G6PD deficiency, hemolysis or methemoglobinemia history

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals during
therapy for pain, hemolysis, anoxia

ii. monitor for signs of allergic reactions

iii. administration: gently rotate vial, do not shake or swirl, should be colorless, dilute in 0.9% NaCl




F. Therapeutic classification: bone resorption inhibitors

1. Type: calcitonin

a. action: opposes action of parathyroid hormone to decrease serum calcium and increase bone density with calcium
deposition

b.
examples

i. calcitonin-salmon (Miacalcin) 100 units SubQ/IM 3 x per week

ii. calcitonin-salmon (Miacalcin Nasal) 200 units/spray 1 spray each nostril daily


c. uses: hypercalcemia, Paget's disease, post-menopausal osteoporosis, hypercalcemia

d. adverse effects
253


i. life-threatening: anaphylaxis, hypersensitivity reaction, bronchospasm, angioedema

ii. other:

nausea/vomiting, injection site reaction, flushing, rash, nocturia, earlobe pruritus, warmth sensation

hypocalcemic tetany (nervousness, irritability, paresthesia, muscle twitching, tetanic spasms)



e. contraindications: elderly patients, prior bisphosphonate use

f. nursing care

i. assist health care team to establish baseline data and check before beginning and at regular intervals during
therapy urine sediment

ii.
keep calcium gluconate immediately available if hypocalcemic tetany develops

iii. assist health care team to implement client teaching plan

subcutaneous injection technique

include weight bearing exercise in daily routine

include calcium and vitamin D rich foods in diet






2. Type: bisphosphonates

a. action: inhibit bone resorption and do not inhibit bone formation and mineralization

b.
examples

i. alendronate (Fosamax) 70 mg by mouth weekly

ii. risedronate (Actonel, Atelvia) 35 mg by mouth weekly

iii. zoledronic acid (Reclast, Zometa) 4 mg IV


c. uses

i. postmenopausal osteoporosis treatment, malignant hypercalcemia

ii. prevention postmenopausal osteoporosis, solid tumor bone metastases

iii. steroid-induced osteoporosis, male osteoporosis, multiple myeloma

iv. Paget bone disease


d. adverse effects

i. dysphagia, esophagitis, esophageal ulcer, erosion, perforation, or stricture

ii. other: gastric/duodenal ulcer, hypocalcemia, abdominal pain and acid regurgitation


e. contraindications

i. pregnancy, breastfeeding

ii. severe renal impairment, hypovolemia or dehydration


f. nursing care

i. assist health care team to establish baseline data and check before beginning and at regular intervals during therapy

bone density

creatinine prior to each does, calcium, electrolytes, magnesium, phosphate, hematocrit & hemoglobin

dental exam prior to treatment


ii. assist health care team to implement client teaching plan

calcium and vitamin D supplements recommended

therapy most effective when combined with weight bearing exercise

take first thing in the morning, 30 minutes before breakfast (or other medications) with 6-8 ounces
plain water; remain upright for at least 30 minutes after administration

if dose is missed, skip dose; do not double dose



254


V. Managing integumentary conditions

A. Therapeutic classification: scabicide, pediculicide

1. Type: chlorinated hydrocarbon

a. action: stimulates nervous system of arthropods to death

b.
example: permethrin topical (Nix, Elimite) 5% cream or 1% lotion

c. uses: scabies, pediculosis capitis or pubis

d. adverse effects: burning, pruritus, erythema, numbness and tingling

e. contraindications: infants, history of hypersensitivity

f. nursing care

i. perform full body scan for nits, lice, or scabies

ii. do not apply to broken skin, avoid application to eyes

iii. cleanse and dry skin before application

iv. assist health care team to implement client teaching plan

wear rubber gloves to administer

treat sexual contacts simultaneously

itching may continue for 4 to 6 weeks after treatment

wash clothing in hot water, dry thoroughly

pediatric use and frequency of treatment
refer to package insert
allow proper time span between applications

remove drug from skin after specified period to prevent toxicity

do not apply to face or mucus membranes; gently and thoroughly cleanse area for accidental
application, rinse very well







B. Therapeutic class: anti-infectives

1. Type: sulfa drugs

a. action: bacteriostatic, competitively inhibits bacterial or fungal dihydropteroate synthase

b.
example: silver sulfadiazine topical (Silvadene) 1 % cream

c. uses: 2nd-3rd degree burns

d. adverse effects: erythema multiforme, neutropenia, leukopenia

e. contraindications: pregnancy, clients younger than 2 months-old, G6PD deficiency

f. nursing care

i.
assist health care team to establish baseline data and periodically monitor thereafter BUN, creatinine,
urinalysis

ii. therapeutic drug levels 8-12 mg/dL; toxic levels > 12mg/dL

iii. application

cover entire surface

cleanse surface before application; remove old ointment before applying new

apply ointment to sterile gauze before applying to surface to prevent contamination of agent






2. Type: antifungal, topical

a. action: interferes with fungal cell permeability

b.
examples
255


i. metronidazole topical (MetroCream, MetroGel, MetroLotion, Noritate) 0.75% cream, gel, lotion

ii. ketoconazole topical (Extina, Nizoral A-D, Nizoral Topical, Xolegel) 2% cream, foam, shampoo

iii. selenium sulfide topical (Selsun, Selsun Blue) 1%, 2.25% shampoo, 2.5 % lotion


c. uses: acne rosacea, tinea corporis, pedis, versicolor, and cruris; seborrheic dermatitis, dandruff/seborrhea

d. adverse effects: skin irritation, hair loss, hair discoloration

e. nursing care

i. inspect surface before administration and at regular intervals during therapy for breaks in the skin or signs of
infection

ii. assist health care team to implement client teaching plan

use sunscreen

avoid alcohol

long-term therapy is usually required

wear gloves to prevent spread of fungus

avoid concurrent use of other over-the-counter agents

report worsening of findings or fever, sore throat, rash





3. Type: antiviral

a. action: interferes with viral DNA replication

b. examples

i.
acyclovir topical 400 mg by mouth three times a day for 7 to 10 days

ii.
penciclovir topical (Denavir) 10 mg/gm cream


c. uses: HSV encephalitis, genital/mucocutaneous HSV prophylaxis,

d. varicella and herpes zoster, herpes zoster ophthalmicus, herpes labialis

e. adverse effects: hallucinations, psychosis, encephalopathy, seizures, coma

f. nursing care

i.
assist health care team to establish baseline data and periodically monitor thereafter creatinine

ii. apply ointment to glove to prevention contamination of drug and spread of infection

iii. cover lesions completely with agent; do not get in eyes

iv. gently cleanse area to remove old agent prior to application of new agent




C. Therapeutic classification: anti-inflammatory agents, topical

1. Type: glucocorticoids

2.
Examples

a. hydrocortisone (Cortaib, Cortizone) 0.5% 1% 2.5% cream lotion ointment

b. triamcinolone (Kenalog, Trianex) 0.025%. 0.1%, 0.5% cream, ointment, 0.025%, 0.1% lotion


3. Nursing care

a. assist health care team to establish baseline data and check skin before beginning and during therapy

b. assist health care team to implement client teaching plan

i.
AVOID over-the-counter drugs

ii. cleanse and dry skin before application

iii. do not apply to wounds or breaks in the skin

iv. initiate therapy as soon as findings appear
256


v. do not apply to broken skin, avoid application to eyes

vi. continue to apply agent until directed to stop; interrupted therapy may result in ineffective therapy





D. Type: anesthetic agents, local anesthetics, topical

1.
Examples: lidocaine (Lidocaine viscous, Numby, Derma Flex)

2. Nursing care: protect client from injury due to impaired cutaneous sensation



VI. Managing gastrointestinal conditions

A. Therapeutic classification: antiemetics

1. Information common to antiemetics

a. action: depresses vomiting center

b. uses: motion sickness, nausea, nausea associated with chemotherapy, postoperative nausea

c. adverse effects

i. tachycardia, hypotension, sedation

ii. dry mouth, dry eyes, blurred vision, constipation, urinary retention


d. contraindications: narrow angle glaucoma, liver disease, intestinal obstruction, depression

e. nursing care

i. assist health care team to establish baseline data and check before initiating therapy and at regular intervals
thereafter fluid and electrolyte balance

ii. provide oral care for dry mouth

iii. verify gag reflex before administration of oral non-pharmacologic measures, e.g., tea, carbonated
beverages, crackers

iv. assist health care team to implement client teaching plan

AVOID alcohol and other central nervous system depressants

do not engage in dangerous activities; be prepared for sedation







2. Type: antihistamines

a. action: decreases vestibular stimulation by competing with histamine for H
1
-receptors

b.
example: dimenhyDRINATE (Dramamine) 50-100 mg by mouth every 4 hours

c. uses: antiemetic

d. adverse effects

i. dizziness, drowsiness, incoordination

ii. headache, epigastric discomfort

iii. dry mucus membranes, paradoxical CNS stimulation


e. nursing care

i. assist health care team to establish baseline data and check at regular intervals during therapy airway, respiratory
rate, level of consciousness

ii. administer IM or IV if vomiting

iii. do not confuse with diphenhydrAMINE (Benadryl)

iv. assist health care team to implement client teaching plan

ask for help before getting up

take 30 minutes before traveling




257

The FDA requires drug manufacturers to use Tall Man lettering for 35 look-alike generic drug names. The
distinguishing letters are capitalized to draw attention to the dissimilarities in their names and to prevent
medication errors. For example: predniSONE and prednisoLONE
Learn more about Tall Man lettering from The Food and Drug Administration (FDA) .


3. Type: anticholinergics

a. action: inhibits acetylcholine (ACh) at receptor sites to decrease secretions and stomach acids, blocks pupillary
accommodation

b.
example: scopolamine (Scopace) 0.3-0.6 mg IM/IV/SubQ as needed, 3 to 4 times daily

c. uses: nausea/vomiting prevention, anesthesia adjunct

d. adverse effects

i. life-threatening: toxic psychosis, tachycardia, seizures, heat stroke, severe hypersensitivity reaction

ii. most common: dry mouth, dry skin drowsiness, blurred vision, mydriasis

iii. other: photophobia, dizziness, flushing, tachycardia, urinary retention


e. contraindications: angle-closure glaucoma, benign prostatic hyperplasia, obstructive GI disease, obstructive uropathy,
acute myocardial infarction

f. nursing care

i.
assist health care team to establish baseline data and during therapy fluid and electrolyte balance

ii. assess for nausea, vomiting, extrapyramidal findings, urinary retention, bowel elimination pattern

iii. safely position client before subcutaneous or IV administration

iv. assist health care team to implement client teaching plan: discontinue drug and report blurred vision, severe
dizziness




4. Type: phenothiazines

a. action: depresses cerebral cortex, hypothalamus, and limbic system with strong alpha-adrenergic, cholinergic,
antipsychotic, and antiemetic properties

b.
examples

i. prochlorperazine maleate (Compazine) 5-10 mg by mouth every 4 to 6 hours
Black Box Warning - dementia-related psychosis

ii.
promethazine 12.5-25 mg PO/IM/IV every 4 to 6 hours
Black Box Warning - respiratory depression, severe tissue injury, gangrene




5. Type: serotonin (5-HT3) receptor antagonist

a. action: blocks peripheral and central serotonin action

b.
example: ondansetron (Zofran, Zofran ODT, Zuplenz) 32 mg IV x 1 dose start 30 minutes before starting
chemotherapy infusion or prior to induction of anesthesia

c. uses: severe nausea/vomiting, non-psychotic anxiety, schizophrenia, allergic conditions, motion sickness, sedation,
prevention of chemo-related nausea and vomiting, prevention of nausea and vomiting postoperatively and for
radiotherapy

d. adverse effects

i. life-threatening: severe hypersensitivity reaction, anaphylaxis, bronchospasm

ii. other: extrapyramidal symptoms, transient blindness, headache, constipation, fatigue, diarrhea


e. nursing care

i.
assist health care team to establish baseline data and check periodically thereafter fluid and electrolyte balance
258


ii. assess for nausea, vomiting, extrapyramidal symptoms

iii. first dose is administered prior to emetogenic chemotherapy

iv. client teaching: immediately report involuntary movement of eyes, face, or limbs





6. Type: combined cholinergic receptor agonist and dopamine receptor antagonist

a. action: enhances gastrointestinal response to acetylcholine resulting in increased peristalsis, relaxation of pyloric
sphincter, and blockage of chemoreceptor zone in brain

b.
example: metoclopramide (Metozolv, Reglan) 1-2 mg/kg IV every 2-3 hours
Black Box Warning - tardive dyskinesia

c. uses: GERD, diabetic gastroparesis, chemo-related nausea and vomiting prevention, postoperative nausea and
vomiting prevention, small bowel intubation, radiologic exam

d. adverse effects

i. extrapyramidal symptoms, acute dystonia, parkinsonism, tardive dyskinesia, neuroleptic malignant syndrome

ii. other: seizures, depression, suicidality, drowsiness, restlessness, fatigue, anxiety, insomnia


e. contraindications: pheochromocytoma, seizure disorder, GI bleed or perforation, GI obstruction

f. nursing care

i. assist health care team to establish baseline data and check at during therapy for nausea, vomiting, extrapyramidal
findings, tardive dyskinesia, mental status

ii. adverse effects more common in older clients

iii. do not confuse with methotrexate or metolazone (Zaroxolyn)





B. Therapeutic classification: antacids

1. Information common to antacids

a. action: neutralize gastric acid (hydrochloric acid)

b. uses: peptic ulcer disease, inflammatory conditions of gastrointestinal tract, concurrent steroid therapy

c. adverse effects

i. most common: inhibits absorption of other drugs

ii. other: constipation, diarrhea, acid rebound, metabolic acidosis, electrolyte excess, fluid retention, heart failure


d. contraindications: electrolyte imbalance, gastroparesis, renal dysfunction

e. nursing care

i.
assist health care team to establish baseline data and check before initiating therapy and periodically
thereafter serum electrolytes, acid-base balance

ii. monitor bowel elimination

iii. must be given 7 times daily to be effective, before and after meals and at bedtime

iv. administer 1 hour before or 2 hours after other drugs and do not give with enteric coated medications

v. assist health care team to implement client teaching plan

time antacids around other medication

chew tablets thoroughly, follow with 8 ounces of water






2. Type: sodium bicarbonate

a.
example: sodium bicarbonate 325 mg-2 g 1 to 4 times daily

b. uses: acute and chronic metabolic acidosis, urinary alkalinization, for antacid
259


c. adverse effects

i. life-threatening: metabolic alkalosis, exacerbation of heart failure, seizures, tetany

ii. most common: flatulence, gastric distention, edema

iii. other: twitching, hypernatremia, injection site pain, extravasation cellulitis


d. contraindications: hypochloremia, alkalosis, renal impairment, congestive heart failure, sodium

e. nursing care

i.
assist health care team to establish baseline data and check at regular intervals during therapy fluid and
electrolyte balance

ii. administration

follow oral administration with 8 ounces of water

if used to treat peptic ulcer, administer 1 to 3 hours after meals and at bedtime





3. Type: calcium carbonate

a.
example: calcium carbonate (Children's Mylanta, Children's Pepto, Maalox Children's Relief, Maalox Regular
Strength, Rolaids Extra Strength Softchews, Tums) 1-3 g by mouth 4 times daily as needed

b. uses: hyperphosphatemia, calcium supplement, osteoporosis, in combination with other antacids

c. adverse effects: constipation

d. contraindications: hypercalcemia, hyperparathyroidism, nephrolithiasis

e.
nursing care: assist health care team to establish baseline data and check serum calcium before and during
therapy



4. Type: magnesium salt

a.
examples

i. magnesium citrate 1.745 g/30 mL 150-300 mL/day divided doses 1-2 times daily

ii. magnesium hydroxide (Little Phillips', Pedia-Lax Chewable Tablets, Phillips' Chewables, Phillips' Concentrated Milk
of Magnesia, Phillips' Milk of Magnesia) 30-60 mL by mouth daily

iii.
magnesium sulfate (magnesium sulfate) 5 g IM, then 5 g IV every 4 hours, up to 40 g daily

iv. uses: acute constipation, bowel prep, ventricular arrhythmias, preeclampsia seizures, tocolysis, hypomagnesemia,
torsades de pointes


b. uses: acute constipation, bowel prep, ventricular arrhythmias, preeclampsia seizures, tocolysis, hypomagnesemia,
torsades de pointes

c. adverse effects

i. life-threatening: cardiovascular collapse, respiratory paralysis, hypothermia

ii. other: nausea, vomiting, anorexia, cramps, depressed reflexes, hypotension


d. contraindications: GI obstruction or bleed, heart block, renal failure, colostomy or ileostomy

e. nursing care

i. assist health care team to establish baseline data and check before initiating and at regular intervals during therapy

pattern of elimination

signs of magnesium toxicity, i.e., thirst, confusion, hyporeflexia

fluid and electrolyte balance

mental status

vital signs


ii.
antidote : keep calcium gluconate at the bedside during IV infusion to reverse respiratory depression or heart
260

block

iii. assist health care team to implement client teaching plan: take only as directed





5. Type: aluminum salt

a.
example: aluminum hydroxide gel (Alternagel, Amphojel) 320-1280 mg by mouth 4 times daily; give 1 to 3 hours
after meals and at bedtime

b. uses: hyperphosphatemia, GI bleeding prophylaxis

c. adverse effects

i. aluminum intoxication, osteomalacia, encephalopathy

ii. constipation, hypophosphatemia, abdominal pain


d. nursing care

i.
assist health care team to establish baseline data and check before starting and periodically during therapy
aluminum, calcium, phosphate if renal impairment

ii. assist health care team to implement client teaching plan

report black tarry stools, abdominal pain

diet: include cheese, corn, lentils, pasta, and prunes and avoid foods containing phosphorus, including dairy
products, eggs, and carbonated beverages






C. Therapeutic classification: antiulcer agents

1. Type: proton pump inhibitors

a. action: suppress the gastric acid pump by inhibiting hydrochloric acid (HCl) secretion by gastric parietal cells

b.
examples

i. omeprazole (Prilosec, Prilosec OTC) 20 mg by mouth daily for 4 to 8 weeks

ii. esomeprazole (Nexium) 20-40 mg by mouth daily for 4 to16 weeks

iii. lansoprazole (Prevacid) 15 mg by mouth daily for 8 weeks

iv. pantoprazole (Protonix) 20 mg by mouth daily for 4 to 8 weeks


c. uses

i. GERD, gastric ulcer, duodenal ulcer, hypersecretory conditions, H. pylori infection

ii. NSAID-associated gastric ulcer prophylaxis


d. adverse effects

i. life-threatening: blood dyscrasias, hepatic impairment, Stevens-Johnson syndrome

ii. other: headache, diarrhea, abdominal pain, nausea/vomiting, dizziness, flatulence, arthralgia


e. nursing care

i.
assist health care team to establish baseline data and check periodically thereafter complete blood count,
liver and renal function tests

ii. assess abdominal pain, regurgitation, heartburn

iii. administer 30 minutes before meals

iv. assess for anemia - client at risk of B12 deficiency

v. increased risk for Clostridium difficile-associated diarrhea

vi. assist health care team to implement client teaching plan

do not chew or crush capsules
261


avoid eating 2 hours before reclining

AVOID smoking, spicy food, caffeinated beverages and alcohol for effective therapy







2. Type: H
2
-receptor antagonists

a. action: reduction in HCl production (by blocking H
2
receptors) and pepsin secretion

b.
examples

i. famotidine (Pepcid) 20-40 mg every evening for 4 to 6 weeks

ii. ranitidine (Zantac) 150 mg by mouth twice daily

iii. cimetidine (Tagamet) 800 mg by mouth at bedtime for 4 to 8 weeks


c. uses

i. active and maintenance treatment for duodenal ulcer, gastric ulcer, GERD, Zollinger-Ellison syndrome, intractable
ulcers

ii. H. pylori infection, active benign and maintenance treatment of gastric ulcers, erosive esophagitis, hypersecretory
conditions

iii. dyspepsia, upper GI prophylaxis bleed


d. adverse effects

i. life-threatening: thrombocytopenia, hepatotoxicity, pneumonia

ii. other: headache, diarrhea, constipation, muscle aches, vertigo, malaise, dizziness, dry mouth, dry skin, rash

iii. cimetidine is a high risk drug in the elderly (based on the Beers Criteria) due to adverse CNS effects


e. nursing care

i.
assist health care team to establish baseline data and check before beginning and periodically during therapy
creatinine

ii. assess abdominal pain and findings indication gastrointestinal bleeding

iii. assist health care team to implement client teaching plan

pain relief may take several days

AVOID smoking, spicy food, caffeinated beverages and alcohol for effective therapy





3. Type: pepsin inhibitor

a. action: forms a viscous substance with HCl that adheres to the gastric mucosa

b.
example: sucralfate (Carafate) 1 gram by mouth before meals and at bedtime

c. uses: short-term therapy and maintenance treatment for duodenal ulcer, aspirin gastric erosion

d. adverse effects: bezoar formation, constipation

e. nursing care

i. assist health care team to establish baseline data and check prior to initiating and at regular intervals during therapy
bowel pattern, abdominal pain, GI bleeding

ii. contains aluminum

iii.
AVOID phosphate supplements

iv. assist health care team to implement client teaching plan

establish regular bowel habits including increased fluids, fiber, and exercise

AVOID smoking

AVOID spicy food, caffeinated beverages and alcohol



262




D. Therapeutic classification: antidiarrheal agents

1. Type: fluid absorbent

a.
example: bismuth subsalicylate (Kaopectate) 30 mL by mouth every 30 to 60 minutes as needed

b. adverse effect: encephalopathy, Reye syndrome, blackened stools and tongue, constipation, tinnitus

c. contraindications

i. pregnancy 3rd trimester, G6PD deficiency

ii. coagulation disorder, influenza, varicella, GI bleed

iii. renal failure


d. nursing care

i. assist health care team to establish baseline data and check bowel pattern

ii. administer 2 to 4 hours after other oral medication

iii. assist health care team to implement client teaching plan

do not exceed dosage recommendation

report diarrhea lasting for more than 48 hours






2. Type: motility suppressant

a. action: slows speed of peristalsis

b.
examples

i. loperamide hydrochloride (Imodium) 2-8 mg by mouth per dose after each loose stool

ii. diphenoxylate/atropine (Lomotil) 1-2 tabs by mouth 2 to 4 times daily as needed


c. adverse effects

i. life-threatening: respiratory depression, ileus, pancreatitis, toxic megacolon, angioedema

ii. other: nausea, vomiting, anorexia, abdominal pain, paresthesia, euphoria


d. contraindications

i. pseudomembranous colitis, toxin-related diarrhea

ii. severe volume depletion, electrolyte imbalance

iii. obstructive jaundice


e. nursing care

i. assist health care team to establish baseline data and check at regular intervals during therapy bowel pattern, fluid
and electrolyte balance

ii. monitor for dehydration in children and older clients

iii. assist health care team to implement client teaching plan

take only as directed

report bloody stool, fever, palpitations, abdominal pain

AVOID potassium salts






E. Therapeutic classification: laxatives

1. Information common to laxatives

a. uses: prevention and short-term treatment of constipation when straining is undesirable or contraindicated;
preoperative bowel evacuation

b. adverse effects

i. dependence
263


ii. diarrhea, cramping, nausea

iii. dehydration, electrolyte imbalance


c. nursing care

i. assist health care team to establish baseline data and check periodically thereafter bowel pattern, fluid and
electrolyte balance

ii. do not administer with intestinal obstruction, abdominal pain or bleeding of unknown origin

iii. most effective when taken with fluid

iv. assist health care team to implement client teaching plan

avoid combining different laxatives simultaneously

establish regular bowel habits including fiber, fluids, ambulation, regular pattern of defecation





2. Type: lubricant

a. action: coats stool and colon to facilitate bowel movement without stimulating the GI tract

b.
example: mineral oil 15-45 mL/day by mouth divided every 8 to 24 hours

c. uses: constipation



3. Type: stool softener

a. action: stool becomes softer by osmotic action without stimulation of GI tract

b.
examples

i. docusate sodium (Colace, Dulolax, Fleet Sof-Lax, Phillips Stool Softener) 100mg by mouth 1 to 2 times daily

ii. glycerin rectal (Colace Suppository for Adults & Children, Fleet Glycerin Suppository, Pedi-Lax Glycerin
Suppository) 1 suppository daily as needed

iii. polyethylene glycol 3350 (Dulolax Balance, GlycoLax, MiraLax) 17 grams by mouth daily


c. uses: constipation

d. adverse effects: electrolyte disorders and laxative dependence with prolonged use

e. contraindications: GI obstruction, known or suspected

f. nursing care

i. check bowel pattern

ii. assist health care team to implement client teaching plan: must be taken with adequate fluids




4. Type: bulk-forming

a. action: increase fluid content and bulk of stool stimulating stretch receptors in bowel and peristalsis resulting in bowel
movement

b.
examples

i. polycarbophil (FiberCon) 2 tabs by mouth 1 to 4 times daily as needed

ii. psyllium (Metamucil) 3.4 g by mouth 1 to 3 times daily as needed

iii. methylcellulose (Citrucel) 1 scoop oral powder 1 to 3 times daily as needed


c. uses: constipation

d. adverse effects: abdominal cramps, nausea, diarrhea

e. contraindications: acute abdomen, appendicitis, fecal impaction

f. nursing care

i. provide adequate fluid

ii. administer other medications one hour before or 2 hours after

iii. assist health care team to implement client teaching plan
264

take immediately after mixing in water
establish regular bowel pattern
do not use with abdominal pain, nausea, vomiting
establish regular bowel pattern and habits including fiber, fluid, and ambulation





5. Type: osmotic

a. action: exert osmotic pull of fluid through intestinal wall to increase fluid in intestinal contents, increase bulk, and
stimulate bowel evacuation

b.
examples

i. lactulose (Kristalose) 15-30 mL/day by mouth 1 to 2 times daily

ii. magnesium citrate 150-300 mL/day by mouth divided in 1 to 2 doses

iii. magnesium hydroxide (Phillips' Milk of Magnesia) 30-60 mL by mouth daily


c. uses: constipation, portal systemic encephalopathy

d. adverse effects

i. serious reaction: hypermagnesemia

ii. common reactions: diarrhea, abdominal pain, dehydration, nausea/vomiting


e. contraindications: renal failure, colostomy or ileostomy, appendicitis, acute abdomen

f. nursing care

i. provide comfort measures and perineal skin care after bowel evacuation

ii. assist health care team to implement client teaching plan

for short-term use only

take oral forms with a full glass of water

after bowel movement, ask for help before getting up





6. Type: chemical irritants

a. action: stimulate nerves of intestinal wall resulting in increased peristalsis and fluid content of stool

b.
examples

i. bisacodyl (Dulcolax, Ex-Lax Ultra-Strength, Fleet Stimulative Laxative) 5-15 mg by mouth daily

ii. sennosides (Senna Soft) 1 tablet by mouth 1 to 2 times daily


c. uses: constipation, bowel prep

d. adverse effects

i. cathartic colon, laxative abuse

ii. other: nausea, abdominal bloating and cramps, flatulence, diarrhea, urine discoloration


e. contraindications: GI obstruction, undiagnosed abdominal pain

f. nursing care

i. give alone and with a full glass of water

ii. administer 1 hour before or 2 hours after antacid

iii. assist health care team to implement client teaching plan

retain suppositories for 30 minutes

AVOID using to establish regular bowel habits







265


F. Therapeutic classification: digestive enzymes

1. Type: pancreatic

a. action: increases absorption of fat, carbohydrate, and protein

b.
example: pancrelipase (Creon, Ku-Zyme, Pancrease, Pangestyme Ultrase, Viokase, Zenpep) 500-2500 lipase
units/kg by mouth with meals and snacks

c. uses: exocrine pancreatic insufficiency

d. adverse effects: fibrosing colonopathy, intestinal obstruction, viral transmission risk

e. contraindications: hypersensitivity to pork protein

f. nursing care

i. report allergic responses, abdominal pain, cramping, hematuria

ii.
assist health care team to collaborate with dietitian and provider for low-fat diet





G. Therapeutic classification: inflammatory bowel disease agents

1. Type: aminosalicylates

a. action: anti-inflammatory action on the colon, splits into 5-acetylsalicylic acid and sulfapyridine

b.
examples

i. sulfasalazine (Azulfidine) 2 g/day by mouth divided in 4 doses

ii. mesalamine (Apriso, Asacol, Liada, Pentasa) 800 mg daily x 3 for 6 weeks


c. uses: rheumatoid arthritis, ulcerative colitis, Crohn's disease

d. adverse effects

i. acute intolerance syndrome, ulcerative colitis exacerbation, neuropathy, interstitial nephritis, renal failure,
hepatotoxicity

ii. other: headache, nausea, eructation, abdominal pain


e. contraindications: hypersensitivity to salicylates, influenza, varicella or febrile viral infections (in clients younger
than 20 years-old)

f. nursing care

i.
assist health care team to establish baseline data and check periodically during therapy BUN/creatinine,
complete blood count if older than 65 years-old

ii. assess elimination pattern, abdominal pain, temperature, urine output

iii.
may impair iron and folic acid absorption

iv. assist health care team to implement client teaching plan

avoid sunlight, protect skin

drink 2000 mL of water daily

report bleeding, rash, fever, sore throat

store in airtight, light-resistant container







2. Type: glucocorticoids

a. action: powerful and effective anti-inflammatory effect on bowel

b.
examples

i. budesonide (Entocort) 9 mg by mouth daily for up to 8 weeks

ii. predniSONE (Sterapred) 5-60 mg by mouth

iii. prednisoLONE (Flo-Pred, Millipred, Orapred, Pediapred, Prelone, Veripred 20) 5-60 mg by mouth daily in 1 to 4
266

doses

iv. hydrocortisone sodium succinate (Solu-Cortef) 100 mg IV every 6 to 8 hours for 24 to 48 hours, taper to oral dose


c. uses

i. mild to moderate Crohn's disease, corticoid-responsive conditions, acute asthma, severe persistent asthma

ii. PCP adjunct treatment, status asthmaticus, shock

iii. acute adrenal insufficiency, acute exacerbation of multiple sclerosis, acute alcoholic hepatitis


d. adverse effects: adrenal insufficiency, Cushing syndrome, anaphylaxis, infection, immunosuppression

e. nursing care

i.
assist health care team to establish baseline data and check periodically during therapy electrolytes, blood
pressure, weight, 2-hour postprandial glucose

ii. taper therapy over two week period before discontinuing


iii. assist health care team to implement client teaching plan

AVOID live vaccines

do not cut, crush, or chew medication

AVOID people who are sick or have
infections





VII. Managing endocrine conditions

A. Therapeutic classification: antidiabetic agents

1. Nursing care - information common to antidiabetic agents

a. oral agents contraindicated in pregnancy

b. assist health care team to establish baseline data and check before starting and at regular intervals during
therapy

i.
renal and hepatic function, blood sugar, serum pH, serum electrolytes

ii. visual acuity

iii. cardiovascular status, including peripheral perfusion


c. assist health care team to implement client teaching plan common to antidiabetic agents

i. need for follow-up care and testing

ii. use and frequency of blood glucose testing

iii. avoid over-the-counter drugs, herbal remedies, and alcohol

iv. beta-adrenergic blockers may mask signs of hypoglycemia

v. keep easily accessible - antidiabetic medication, equipment, high calorie snack

vi. recognition of hypoglycemia, hyperglycemia, and ketoacidosis by client and significant others

vii. monitor compliance with therapy or success of treatment plan with glycosylated hemoglobin (Hgb A1c)

viii. antidiabetic medication requirements may increase during illness or infection; clients with type 2 diabetes
mellitus (formerly called non-insulin dependent diabetes mellitus or NIDDM) may require insulin
periodically

ix. tight glycemic control, i.e., maintaining serum glucose within narrow range, is key to preventing
complications of diabetes mellitus

anti-diabetic medication only 1 part of effective glycemic control

must combine with consistent exercise with consistent diet (weight loss)


x. coordinate antidiabetic agent administration and dietary calories

calorie intake must be coordinated with drug onset, peak action, and duration

client must have calories in the body for onset, peak, and duration of insulin





267



2. Type: insulin

a. action: lowers blood sugar; drives metabolites and ions into cells, stimulates formation of glycogen, protein, and fat;
recombinant DNA replacement insulin made from human insulin

b.
examples, including onset, peak and duration of common insulins
Comparison Actions of Insulin
Type Agent Onset of Action Peak of Action Duration of Action
Rapid-acting Regular (IV)
lispro (Humalog R)
glulisine (Apidra)
aspart (NovoLog)
10-30 minutes
10-15 minutes
30-60 minutes
30-90 minutes
30-60 minutes
3-5 hours
Short-acting regular (Humulin R, Novolin R) 30-60 minutes 2-4 hours 5-7 hours
Intermediate-acting NPH (Humulin-N) 1-2 hours 4-8 hours 10-18 hours
Long-acting glargine (Lantus)
detemir (Levemir)
2-4 hours 8-14 hours 18-24 hours
Very long-acting glargine (Lantus) 1-2 hours No peak 24 hours



c. uses

i. diabetes mellitus type 1 and 2; hyperkalemia

ii. insulin lispro in combination with sulfonylureas in children

iii. ketoacidosis, diabetes mellitus associated with pregnancy


d. adverse effects

i. life-threatening: severe hypoglycemia, hypokalemia, generalized hypersensitivity reaction, anaphylaxis

ii. other; hypoglycemia, injection site reaction, lipodystrophy at injection site, pruritus, rash, weight gain


e. contraindications/cautions: infection, illness or stress, hypokalemia, renal or hepatic impairment

f. nursing care

i. assist health care team to establish baseline data and check blood sugar, anorexia prior to initiating and periodically
during therapy

ii. verify blood sugar before administration

iii. when mixing more than one insulin in a syringe, draw regular insulin first

iv. regular insulin and NPH insulin require 15 gram carbohydrate snack at peak action time

v. allow refrigerated insulin to warm to room temperature before injection by rolling (NOT shaking) between palms of
hands

vi. IV insulin: regular insulin only

small amounts suitable for IV push

use infusion control device to deliver units/hour

prime tubing with 50 mL of insulin solution before infusing (required to coat lumen of tubing)


vii. assist health care team to implement client teaching plan

wear MedicAlert identification

need for follow-up care and testing

blood glucose testing technique and frequency

subcutaneous injection technique; need to rotate injection sites
268


single-use vials of insulin may be stored at room temperature for 30 days - keep away from heat and light





3. Type: oral antidiabetic agents

a.
sub-type: sulfonylureas

i. action: increase insulin secretion by binding to potassium receptors on pancreatic beta cells (beta cells)

ii.
examples

chlorpropamide (generic) 100-500 mg by mouth daily

glyBURIDE (DiaBeta) 1.25-20 mg by mouth daily

glipiZIDE (Glucotrol) 2.5-20 mg by mouth 1 to 2 times daily

glimepiride (Amaryl) 1-4 mg by mouth daily


iii. uses: type 2 diabetes mellitus, as adjunct therapy with diet and exercise

iv. adverse effects
hypoglycemia, blood dyscrasias, hepatitis, hepatic failure
dizziness, asthenia, headache, nausea, photosensitivity

chlorpropamide is a high risk drug in the elderly (based on the Beers Criteria) due to due to a prolonged
half life


v. contraindications

diabetic ketoacidosis, hypersensitivity to sulfonamides

hepatic impairment, adrenal insufficiency, autonomic neuropathy, G6PD deficiency


vi.
nursing care: assist health care team to establish baseline data and check blood sugar, creatinine periodically
thereafter




b.
sub-type:non-sulfonylureas (alpha-glucosidase inhibitor)

i. action: delay glucose absorption by inhibiting an enzyme that breaks down glucose into smaller molecules for
absorption

ii.
examples

metformin (Fortamet, Glucophage, Glumetza, Riomet) 850-1500 mg by mouth twice daily
Black Box Warning - lactic acidosis
repaglinide (Prandin) 0.5-4 mg by mouth before meals

rosiglitazone (Avandia) 4-8 mg by mouth divided 1 to 2 times daily
Black Box Warning - appropriate use/restricted distribution program, congestive heart failure, myocardial
infarction


iii. uses: in combination with insulin and sulfonylureas to treat diabetes type 2

iv. adverse effects

hypoglycemia, blood dyscrasias, hepatitis, hepatic failure

dizziness, asthenia, headache, nausea, photosensitivity


v. contraindications

diabetic ketoacidosis, hypersensitivity to sulfonamides

hepatic impairment, adrenal insufficiency, autonomic neuropathy, G6PD deficiency


vi. nursing care
administer just before meals
much less likely to cause hypoglycemia than sulfonylureas


269




B. Glucose-elevating agents

1. Action: decrease release of insulin and facilitate glycogen breakdown and release from the liver

2.
Examples

a.
glucagon (GlucaGen) 20-25 mg SubQ/IM/IV x 1 dose

b.
diazoxide (Proglycem) 3-8 mg/kg/day by mouth divided every 8 to 12 hours


3. Uses: severe hypoglycemia, diagnostic procedures, beta blocker or calcium channel blocker overdose, anaphylaxis,
hyperinsulinemia-associated hypoglycemia

4. Adverse effects

a. diabetic ketoacidosis, hyperosmolar hyperglycemic state, severe hyperglycemia, heart failure, acute pancreatitis

b. other: sodium and fluid retention, hirsutism, hyperglycemia, glycosuria


5. Nursing care

a. establish baseline data and monitor blood sugar, blood pressure

b. keep insulin at bedside

c. maintain client safety until acute episode is resolved





C. Therapeutic classification: thyroid agents

1. Type: thyroid replacement, synthetic

a. action

i. regulation of protein synthesis

ii. increases rate of caloric turnover to increase cardiac output, renal blood flow, oxygen consumption, and
production of the by-products of metabolism, e.g., carbon dioxide, water and heat


b.
examples

i. levothyroxine (Levothroid, Levoxyl, Synthroid, Tirosint, Unithroid) 50-200 mcg by mouth daily
Black Box Warning - not for obesity/weight loss

ii. liothyronine (Cytomel, Triostat) 25-75 mg by mouth daily
Black Box Warning - not for obesity/weight loss


c. uses: hypothyroidism, myxedema, myxedema coma, nontoxic goiter, thyroid suppression test, adjuvant treatment
for depression

d. adverse effects

i. life-threatening: arrhythmias, cardiopulmonary arrest, myocardial infarction, angina, hypotension, hypertension,
heart failure

ii. most common: tachycardia, headache. irritability, nervousness, tremor, diaphoresis, diarrhea, vomiting,
menstrual irregularities


e. contraindications: myocardial infarction, untreated thyrotoxicosis, uncorrected adrenal insufficiency, cardiovascular
disease, coronary artery disease, diabetes mellitus or insipidus

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating and at regular intervals during
therapy BUN, creatinine

ii. assist health care team to implement client teaching plan

report excitability, insomnia, sweating, heat intolerance

wear MedicAlert identification
270


take in morning as a single dose with full glass (8 ounces) of water on an empty stomach

reinforce need for follow-up care and testing

different brands may not work the same - talk to pharmacists or notify provider if pills look different

AVOID stimulants, caffeinated beverages

AVOID iodine rich foods, e.g., seafood, fish liver oils, iodized salt

take only as directed, do not stop taking drug without notifying provider







2. Type: antithyroid agents

a. sub-type: thioamides

i. action: blocks production of thyroid hormone by inhibiting the conversion of T4 to T3

ii.
examples

propylthiouracil 100-150 mg by mouth divided every 8 hours
Black Box Warning - appropriate use, hepatotoxicity, antithyroid drug use in first trimester pregnancy

methimazole (Tapazole) 5-15 mg by mouth daily


iii. uses: hyperthyroidism

iv. adverse effects

agranulocytosis, leukopenia, thrombocytopenia

aplastic anemia, hepatotoxicity, periarteritis

rash, urticaria, nausea, vomiting, dyspepsia, arthralgia, paresthesia

loss of taste, hair loss, myalgias, headache, edema


v. nursing care

assist health care team to establish baseline data and check periodically during therapy complete
blood count with differential, PT

check for clinical indicators of overdose: muscle hyperexcitability, depression, non-pitting edema ,
intolerance to cold

assist health care team to implement client teaching plan
take at same time daily

AVOID iodine containing foods

do not discontinue taking drug

increase fluids to 3000-4000 mL daily

report bleeding and unusual bruising, fluid gain, edema, dyspnea on exertion, cold intolerance,
depression







b. sub-type: iodine solutions

i. action: blocks thyroid function in high doses by saturating thyroid cells with iodine

ii.
example: potassium iodide (losat, SSKI, ThyroSafe, ThyroShield) 50-250 mg by mouth three times daily

iii. uses: preop thyroidectomy, thyrotoxicosis, cutaneous sporotrichosis, expectorant

iv. adverse effects

life-threatening: arrhythmias, GI bleed, angioedema

other: parotitis, goiter, thyroid adenoma, metallic taste, dyspepsia, urticaria

271


v. contraindications: hyperkalemia, severe volume depletion, Addison's disease, hypothyroidism

vi. nursing care

assist health care team to establish baseline data and check prior to initiating and periodically during
therapy thyroid function

taper dose before discontinuing therapy

assist health care team to implement client teaching plan

may take with food

do not abruptly stop therapy

drink water to thin secretions

need for follow-up care and testing

report bleeding, abdominal pain, iodism

wear MedicAlert identification

AVOID iodine rich foods

AVOID over-the-counter medications including vitamins and herbal supplements without consulting
provider





D. Therapeutic classification: adrenocortical agents

1. Type: glucocorticoids - uses: adrenal insufficiency (Addison's disease), adrenal crisis

2. Type: mineralocorticoids

a. action: increase sodium reabsorption in renal tubules to increase hydrogen and potassium, water retention

b.
example: fludrocortisone acetate (Florinef) 0.1-0.2 mg by mouth daily

c. uses: adrenal insufficiency, orthostatic hypotension

d. adverse effects

i. life-threatening: adrenal insufficiency, steroid psychosis, immunosuppression, peptic ulcer, heart failure,
anaphylaxis

ii. most common: nausea, vomiting, dyspepsia, appetite change

iii. other: edema, headache, dizziness, mood swings, insomnia, anxiety


e. contraindications

i. systemic fungal infection, congestive heart failure, seizure disorder

ii. diabetes mellitus, hypertension, TB infection


f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and periodically
thereafter fluid and electrolytes, 2-hour postprandial glucose

ii. check blood pressure, weight

iii. chest x-ray and ophthalmic exams if prolonged treatment

iv.
collaborate with provider for potassium-rich diet , low-sodium diet

v. assist health care team to implement client teaching plan

report weight gain, peripheral edema, abdominal cramping, nausea, anorexia

do not stop taking this drug abruptly

wear MedicAlert identification








272

E. Therapeutic classification: hypothalamic hormones

1. Type: growth hormone

a.
example: nafarelin (Synarel) 1 to 2 sprays per nostril once or twice daily

b. uses: endometriosis, premature ovulation prevention

c. adverse effects

i. pituitary apoplexy, ovarian cysts, hypersensitivity reaction, bone mineral density decreases

ii. most common: hot flashes, libido changes, vaginal dryness, headache, emotional lability


d. nursing care

i.
assist health care team to establish baseline data pregnancy test, bone mineral density with periodic
pregnancy tests

ii. assist health care team to implement client teaching plan

report rhinitis; signs of puberty, i.e., vaginal bleeding, breast enlargement, after first month of therapy

nasal spray technique

pregnancy category X - client must use contraception throughout treatment







F. Therapeutic classification: anterior pituitary agents

1. Type: adrenocortical hormone

a.
example: menotropin (Pergonal combination therapy with luteinizing hormone, follicle stimulating hormone,
and human chorionic gonadotropin)

i. use: ovulation induction, assisted reproductive technology, spermatogenesis

ii. adverse effects

life-threatening: anaphylactoid reaction, spontaneous abortion, ectopic pregnancy

other: headache, abdominal cramps, ovarian hyperstimulation syndrome, nausea



b.
example: somatotropin (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Serostim) 0.04-
0.08 mg/kg/week SubQ

i. use: growth hormone deficiency, HIV-associated cachexia

ii. adverse effects: hypersensitivity, diabetes mellitus, hypothyroidism, intracranial hypertension, pancreatitis,
scoliosis progression





G. Therapeutic classification: posterior pituitary agents

1. Type: synthetic antidiuretic hormone

a. action: increases reabsorption of water in renal tubules to decrease urine formation and increase plasma levels of
factor VIII

b.
examples

i. vasopressin (Pitressin) 5-10 units SubQ/IM 2-4 times daily; 40 units IV/IO x 1 dose ACLS protocol

ii. desmopressin acetate (DDAVP) 0.1-1.2 mg/day by mouth in 2 to 3 doses


c. uses: diabetes insipidus, abdominal distention, abdominal radiographs, renal biopsy, GI hemorrhage, systole/PEA
and VF/pulseless VF ACLS, vasodilatory shock, nocturnal enuresis, hemophilia A, type I von Willebrand disease,
uremic bleeding

d. adverse effects

i. life-threatening: hyponatremia, water intoxication, seizures, anaphylaxis, thrombosis

ii. most common: flushing, headache, rhinitis, nausea, abdominal pain, dizziness, cough, epitaxis


e. contraindication: creatinine clearance < 50, hyponatremia, type IIB von Willebrand disease, coronary artery
disease, hypertension, congestive heart failure
273


f. nursing care

i.
assist health care team to establish baseline data and check periodically creatinine, blood pressure, heart
rate during infusion

ii.
serum blood levels may appear low due to hemodilution

iii. assist health care team to implement client teaching plan

wear MedicAlert identification

AVOID alcohol and over-the-counter drugs

missed doses: take up to 1 hour before next dose, otherwise skip dose, do not double dose






H. Therapeutic classification: parathyroid agents

1. Type: antihypercalcemic agents

a. action: inhibits bone resorption by binding to bone hydroxyapatite to inhibit osteoclast activity

b.
example: risedronate (Actonel, Atelvia) 35 mg by mouth weekly

c. uses: postmenopausal osteoporosis treatment

d. adverse effects

i. dysphagia, esophagitis, esophageal ulcer, erosion, stricture or perforation, gastric/duodenal ulcer, angioedema

ii. diarrhea, influenza-like symptoms, arthralgia, back and abdominal pain


e. contraindications: esophageal stricture, achalasia, inability to remain upright x 30 minutes, hypocalcemia,
creatinine clearance < 30

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and periodically thereafter
creatinine

ii.
collaborate with dietitian for calcium-rich foods

iii. AVOID antacids, calcium, magnesium or iron salts

iv. assist health care team to implement client teaching plan

take with water after breakfast; do not cut/crush/chew

remain upright for at least 30 minutes after taking

take calcium and vitamin D supplements if daily requirements cannot be attained with diet alone






VIII. Managing renal and urinary tract conditions

A. Therapeutic classification: diuretics

1. Information common to diuretics (except potassium-sparing diuretics)

a. action: increases the rate of urine flow by effecting the renal tubules to excrete sodium; alters renal handling
of other electrolytes, especially potassium

b. uses

i. increase volume of urine, sodium and chloride excretion

ii. heart failure, hypertension, hyperkalemia

iii. rapid fluid excretion, severe edema, pulmonary edema


c. adverse effects

i. life-threatening: severe hypokalemia, severe electrolyte imbalance, metabolic alkalosis,
hypovolemia/dehydration

ii. most common: urinary frequency, dizziness, nausea/vomiting, weakness, muscle cramps


d. contraindications
274


i. anuria, hepatic coma, electrolyte imbalances

ii. hypersensitivity to sulfonamide, diabetes mellitus, acute myocardial infarction


e. nursing care

i.
assist health care team to establish baseline data and check prior to initiating and at regular intervals
during therapy intake, urine output, serum electrolytes especially potassium, blood pressure, cardiac
rhythm, serum glucose and pH

ii. increased risk of digoxin toxicity

iii. assist health care team to implement client teaching plan

may take with food or milk; drink at least 6 to 8 glasses of water daily

AVOID alcohol and over-the-counter drugs

do not stop taking when feeling well

administer in early morning to avoid nocturia

potassium-rich diet (may need to avoid or increase intake)

report irregular heartbeat, low urine output, dizziness, rash, muscle cramps, twitching, weakness








2. Type: loop diuretics, sulfonamide derivative

a. action: blocks sodium-chloride pump in renal tubules preventing reabsorption of sodium and chloride in the ascending
loop of Henle and distal convoluted tubules, and to increase urine and solute excretion

b.
examples

i. furosemide (Lasix) 40-120 mg by mouth divided in 1 to 2 doses daily
Black Box Warning - fluid and electrolyte depletion

ii. bumetanide (Bumex) 0.5-10 mg by mouth divided in 1 to 2 doses daily
Black Box Warning - fluid and electrolyte depletion

iii. torsemide (Demadex) 10-200 mg PO/IV daily


c. adverse effects: azotemia, ECG abnormalities, arrhythmias, thrombosis, ototoxicity

d. contraindication: anuria, hepatic coma, electrolyte imbalances

e. nursing care

i. establish baseline data and monitor hearing, electrolyte depletion

ii. administration: verify serum potassium, blood pressure, and urine output before administration




3. Type: thiazide diuretics, sulfonamides

a. action: chloride pump in renal tubules prevents reabsorption of sodium and chloride in the ascending loop of Henle
and distal tubules resulting in increased excretion of water

b.
examples

i. thiazides

hydrochlorothiazide (Esidrix, Microzide) 12.5- 50 mg by mouth daily

chlorothiazide (Diuril) 500-1000 mg PO/IV 1 to 2 times daily


ii. thiazide-like: chlorthalidone (Hygroton) 50-100 mg by mouth daily


c. uses: hypertension, peripheral edema

d. adverse effects: severe hypokalemia, electrolyte imbalance, arrhythmias, pancreatitis

e. contraindication: anuria, hepatic coma, electrolyte imbalances, hypersensitivity to sulfonamides


275



4. Type: carbonic anhydrase inhibitors

a. action: mild diuretic action by inhibiting the movement of bicarbonate (HCO
3
) resulting in increased loss of sodium and
bicarbonate

b.
example: acetazolamide (Diamox) 250-375 mg Po/IV every other day to daily

c. uses: open-angle, acute angle-closure, and secondary glaucoma, altitude sickness, heart failure, drug-induced edema,
seizure disorder, pseudotumor cerebri, urinary alkalinization

d. adverse effects

i. metabolic acidosis, electrolyte imbalance, anaphylaxis

ii. fatigue, malaise, taste change, anorexia




5. Type: potassium-sparing diuretics

a. action: antagonizes aldosterone to maintain sodium excretion in the distal tubule and retain potassium

b.
examples

i. spironolactone (Aldactone) 25-200 mg by mouth daily
Black Box Warning - tumor risk

ii. triamterene (Dyrenium) 100 mg by mouth 2 times daily
Black Box Warning - hyperkalemia

iii. amiloride (Midamor) 5-10 mg by mouth daily
Black Box Warning - hyperkalemia


c. uses

i. edema, hypertension, primary hyperaldosteronism, diuretic induced hypokalemia, NYHA Class III/IV CHF

ii. lithium-induced polyuria


d. adverse effects: aplastic anemia, hyperkalemia, neutropenia

e. contraindications: hyperkalemia, anuria, renal impairment, creatinine > 1.5, diabetic neuropathy

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter BUN/creatinine, electrolytes, acid-based balance

ii. carefully review medication profile for other drugs associated with hyperkalemia: ACE inhibitors, angiotensin II
receptor blockers, salt substitutes

iii. assist health care team to implement client teaching plan

avoid potassium rich foods

take with food or milk in early morning

AVOID alcohol, over-the-counter drugs

AVOID herbal remedies






6. Type: osmotic diuretics

a. action: pulls large amount of fluid into renal tubules by osmotic pressure

b.
example: mannitol (Osmitrol) 50-100 g IV x 1 dose

c. uses

i. oliguria prevention and treatment, cerebral edema, elevated intraocular pressure and intracranial pressure
276


ii. adjunct treatment for forced diuresis


d. adverse effects

i. life-threatening: seizures, heart failure, cardiovascular collapse, pulmonary edema

ii. most common: headache, nausea, vomiting, polyuria, dizziness, rash, blurred vision

iii. other: osmotic nephrosis, acute renal failure, CNS depression, coma


e. contraindications: anuria, severe pulmonary edema, dehydration, intracranial hemorrhage

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter BUN/creatinine, electrolytes at baseline

ii. check neurologic status and intracranial pressure





B. Managing urinary tract disorders

1. Therapeutic classification: anti-infectives specific for urinary tract

a. information common to urinary tract anti-infectives: obtain urine cultures before initial administration

b. type: antibiotics

i. action: interferes with DNA metabolism of pathogen

ii.
examples
fosfomycin (Monurol) 3 g PO x 1 dose

norfloxacin (Noroxin) 400 mg by mouth twice a day
Black Box Warning - tendinitis/tendon rupture, avoid in myasthenia gravis

sulfonamide combination: trimethoprim/sulfamethoxazole (Bactrim, Septra, Sulfatrim) 160 mg TMP by
mouth every 12 hours

fluoroquinolones: ciprofloxacin (Cipro, Proquin) 250-750 mg by mouth every 12 hours
Black Box Warnings - tendonitis/tendon rupture, avoid in myasthenia gravis


iii. use: urinary tract infection

iv. adverse effects

Stevens-Johnson syndrome, toxic epidermal necrolysis

photosensitivity, fulminant hepatic necrosis

agranulocytosis, aplastic anemia, blood dyscrasias

nausea/vomiting, anorexia, allergic rash, urticaria


v. contraindications
G6PD deficiency, hypersensitivity to sulfonamides
megaloblastic anemia, folate deficiency
clients younger than 2 months-old, pregnancy near-term, breastfeeding


vi. nursing care

assist health care team to establish baseline data and check before starting and at regular intervals
during therapy BUN/creatinine, complete blood count, potassium with renal impairment, concomitant ACE
inhibitor, urinalysis

assist health care team to implement client teaching plan
AVOID caffeine and do not take at same time as dairy products
AVOID exposure to sunlight or tanning beds







277

c. type: urinary acidifiers

i. action: kills pathogens in bladder

ii.
examples

methenamine mandelate (Mandelamine) 1 g by mouth 4 times daily

methenamine hippurate (Hiprex, Urex) 1 g by mouth twice daily


iii. uses: urinary tract infection prophylaxis/suppression

iv. adverse effects: crystalluria, gross hematuria, nausea, dyspepsia, dysuria, rash

v. contraindication: renal dysfunction

vi. nursing care

assist health care team to establish baseline data and check at regular intervals thereafter creatinine, liver
function tests, urinary pH

assist health care team to implement client teaching plan

take with urinary acidifiers, such as cranberry juice

AVOID antacids, sulfonamides, urinary alkalinizers





2. Therapeutic classification: urinary tract antispasmodics

a. action: inhibits action of ACh; anticholinergics, muscarinic receptor antagonist increases bladder capacity and reduces
frequency of bladder contractions

b.
examples

i. tolterodine (Detrol) 4 mg by mouth daily

ii. solifenacin (VESIcare) 5-10 mg by mouth daily

iii. oxybutynin: (Ditropan) 5 mg by mouth 2 to 3 times daily; (Oxytrol) transdermal 3.9/day patch -1 patch twice a week

iv. trospium chloride (Sanctura) 20 mg by mouth twice daily


c. uses: overactive bladder

d. adverse effects

i. life-threatening: anaphylaxis, angioedema, Stevens-Johnson syndrome, rhabdomyolysis, heat stroke

ii. most common: xerostomia, constipation, headache, fatigue


e. contraindications: urinary and gastric retention, uncontrolled angle-closure glaucoma

f. nursing care

i.
assist health care team to establish baseline data and check at regular intervals during therapy creatinine,
urinary pattern, urinary retention

ii. interrupt therapy periodically to determine continued need

iii. assist health care team to implement client teaching plan: avoid hot environments




3. Therapeutic classification: cholinergic agents

a. action: increases bladder tone to increase stimulus for micturition

b.
example: bethanechol (Urecholine) 25-50 mg by mouth three times daily

c. use: urinary retention, neurogenic bladder, GERD, terminal cancer adjuvant treatment, phenothiazine treatment

d. adverse effects

i. life-threatening: bronchospasm, hypotension,tachycardia, seizures

ii. most common: abdominal cramps/discomfort/pain, nausea, belching


e. nursing care: give on empty stomach 1 hour before or 2 hours after meal

278



4. Therapeutic classification: urinary tract analgesic

a. action: direct topical analgesia on urinary tract mucosa

b.
example: phenazopyridine (Azo Standard, Pyridium) 100- 200 mg by mouth 3 times daily for 2 days

c. uses: dysuria

d. adverse effects

i. life-threatening: anaphylactoid reaction

ii. most common: rash, pruritus, nausea, headache, urine discoloration


e. contraindication: glomerulonephritis, severe hepatitis, uremia, renal impairment

f. nursing care

i.
assist health care team to establish baseline data and check prior to beginning and periodically during therapy
creatinine

ii. treat underlying urinary tract infection

iii. assist health care team to implement client teaching plan

urine will be orange-red in color; the dye may stain clothing

tears may be orange-red in color; do not wear contact lenses while using this medication

report jaundice

take with food





5. Treatment of benign prostatic hypertrophy (BPH)

a. therapeutic classification: alpha
1
-adrenergic receptor blockers

i. action: decreases blood pressure; reduces BPH findings; lowers LDL cholesterol, triglycerides and raises HDL
cholesterol

ii.
examples

tamsulosin (Flomax) 0.4 mg by mouth daily; 30 minutes after a meal

terazosin (Hytrin) 1-10 mg by mouth every evening


iii. use: increase force of urine stream


b. therapeutic class: 5-alpha
1
-reductase inhibitor

i. action: inhibits the enzyme responsible for conversion of testosterone to an androgen

ii.
examples

finasteride (Proscar) 5 mg by mouth daily; (Propecia) 1 mg by mouth daily

dutasteride (Duagen) 0.5 mg by mouth daily


iii. use: benign prostatic hypertrophy, hypertension

iv. adverse effects: angioedema, severe skin reactions, high-grade prostate cancer, impotence, decreased libido

v. nursing care

assist health care team to establish baseline data and check periodically thereafter PSA, digital rectal
exam results

administration: swallow capsule whole - do not open/chew/crush capsule

reinforce client teaching: AVOID pregnancy (teratogenic to male fetus); women and children should not
even handle capsules







279

IX. Managing Conditions of the Reproductive Tract

A. Female reproductive system

1. Therapeutic class: female hormones (see also Family Planning for overview of female hormones used in
contraception)

a. type: estrogen

i. action

necessary proper functioning of female reproductive system, development of secondary sexual
characteristics, and endometrial proliferation

stimulates release of pituitary gonadotrophins, inhibits ovulation, promotes calcification of bones


ii.
examples

estradiol (Estrace) 0.5-2 mg by mouth daily
Black Box Warning - endometrial cancer risk, cardiovascular and other risks

estradiol cypionate (Depo-Estradiol) 1-5 mg IM every 3 to 4 weeks
Black Box Warning - endometrial cancer risk, cardiovascular and other risks

conjugated estrogens (Premarin) 0.3-1.25 mg by mouth daily
Black Box Warning - endometrial cancer risk, cardiovascular and other risks

synthetic conjugated estrogens (Cenestin) 0.625-1.25 mg by mouth daily
Black Box Warning - endometrial cancer risk, cardiovascular and other risks

synthetic conjugated estrogens B (Enjuvia) 0.3-1.25 mg by mouth daily
Black Box Warning - endometrial cancer risk, cardiovascular and other risks


iii. uses

moderate-severe vasomotor menopausal symptoms, primary ovarian failure

menopausal vulvovaginal atrophy, hypoestrogenism, dysfunctional uterine bleeding, uremic
bleeding

postmenopausal osteoporosis prevention

palliative treatment for breast and prostrate cancer


iv. adverse effects

thromboembolism, retinal thrombosis, myocardial infarction, stroke, hypertension

other: breast, ovarian and endometrial cancer







vi. contraindications: undiagnosed vaginal bleeding, breast cancer, history of estrogen-dependent cancer or
thromboembolism

vii. nursing care

assist health care team to establish baseline data and check periodically thereafter free T4, T3 if
hypothyroidism

breast exam every 12 months, mammography, blood pressure

action inhibited by grapefruit juice

assist health care team to implement client teaching plan

report fluid retention, leg pain, jaundice, breast lumps, headache, blurred vision

may decrease libido, take only as directed

need for follow-up care and testing: pelvic exam and Pap smear

non-pharmacological comfort measures for the adverse effects of menopause

AVOID herbal supplements: ginseng, green tea, licorice, milk thistle



280



b. type: progesterone

i. action: inhibit secretion of pituitary gonadotrophins preventing the maturation of ovarian follicles, stimulating breast
tissue growth

ii.
example: progesterone micronized (Prometrium) 200-400 mg by mouth daily for 10 to 12 days
Black Box Warning - cardiovascular, breast cancer, and probable dementia

iii. uses: secondary amenorrhea, prevention of postmenopausal endometrial hyperplasia

iv. adverse effects: thromboembolism, hypertension, hepatic adenoma, depression

v. contraindications: hypersensitivity to peanuts, undiagnosed vaginal bleeding, breast and genital organ cancer

vi. nursing care - see previous page for estrogens




2. Therapeutic classification: hormone modulators

a. type: estrogen receptor modulators

i. action: stimulates some and blocks other estrogen receptor sites to elicit some of the positive effects of estrogen
therapy

ii.
examples

raloxifene (Evista) 60 mg by mouth daily
Black Box Warning - venous thromboembolism risk, fatal stroke risk

toremifene (Fareston) 60 mg by mouth daily
Black Box Warning - QT prolongation


iii. uses: postmenopausal osteoporosis prevention and treatment, breast cancer prevention, advanced breast cancer
treatment

iv. adverse effects

life-threatening: hepatotoxicity, ocular toxicity, hypercalcemia, pulmonary embolism

most common: hot flashes, cataracts, dry eyes, sweating, nausea, vaginal discharge

other: dizziness, abnormal visual fields, hypercalcemia


v. contraindications: pregnancy, thromboembolic history, endometrial hyperplasia, severe bradycardia

vi. nursing care

assist health care team to establish baseline data and check at regular intervals potassium,
magnesium, ECG, calcium, complete blood count, liver function tests

assist health care team to implement client teaching plan

report fluid retention, leg pain, jaundice, breast lumps, headache, blurred vision

need for follow-up care and testing







3.
Therapeutic classification: contraceptives

a. type: oral contraceptives

i. action: release of ovum and endometrial proliferation inhibited, increased viscosity of cervical mucus

ii.
examples

desogestrel/ethinyl estradiol (Apri, Azurette, Caziant, Cyclessa, Desogen, Emoquette, Karvia, Mircette, Ortho-
Cept, Reclipsen, Velivet, Viorele)
Black Box Warning - smoking and cardiovascular events

levonorgestrel/ethinyl estradiol (Altavera, Amethia, Amethia Lo, Amethyst, Avaine, Camrese, Camrese Lo,
281

Enpresse, Introvale, Jolessa, Lessina, Levoram LoSeasonique, Lutera, Lybrel, Marlissa, Nordette, Orythia, Partia,
Quasense, Seasonale, Seasonique, Sronyx, Triphasil, Trivora)
Black Box Warning - smoking and cardiovascular events

drospirenone/ethinyl estradiol (Gianvi. Loryna, Ocella, Syeda, Vestura, Yasmin, Yaz, Zarah)
Black Box Warning - smoking and cardiovascular events

norgestrel/ethinyl estradiol (Cryselle, Lo/Ovral-28, Low-Ogestrel, Ogetrel) NOTE: Black Box Warning-smoking
and cardiovascular events

norgestimate/ethinyl estradiol (MonoNEssa, Ortho Tri-Cyclen, Ortho Tri-Cyclen Lo, Ortho-Cyclen, Previfem,
Sprintec, Tri-Previfem, Tri-Sprintec, TriNessa)
Black Box Warning - smoking and cardiovascular events


iii. uses: contraception, moderate dysfunctional uterine bleeding, dysmenorrhea, emergency contraception,
endometriosis

iv. adverse effects: thrombosis/thromboembolism, myocardial infarction, stroke, cerebral hemorrhage, hypertension

v. client teaching

may be monophasic, biphasic or triphasic

monophasic is 28 day cycle

extended cycle or continuous regimes are bi- and triphasic

breakthrough bleeding may occur, especially during first few months after initiating therapy






b.
type: etonogestrel subdermal implant (Implanon, Nexplanon)

i. Restricted Distribution in U.S.

ii. 1 implant subdermally every 3 years

iii. requires surgery


c.
type: levonorgestrel intrauterine device (Minera)

i. inserted into uterus, used for contraception and menorrhagia

ii. effective for 5 years


d.
type: estrogestrel/ethinyl estradiol vaginal (NuvaRing)
Black Box Warning - smoking and cardiovascular events

i. inserted vaginally and left in place for 3 weeks, then remove

ii. insert new ring 1 week later


e.
type: medroxyprogesterone acetate (Depo-Provera)
Black Box Warning - BMD loss

i. effective for 3 months

ii. IM injection

iii. safety conditional for lactation


f.
type: norelgestromin/ethinyl estradiol transdermal (Ortho Erva)
Black Box Warning - smoking and cardiovascular events, venous thromboembolism risk, ethinyl estradiol
pharmacokinetic

i. apply patch firmly to lower abdomen, buttocks, upper outer arm or upper torso

ii. use one patch every week for 3 weeks, off for 1 week


282



4. Therapeutic classification: fertility drugs

a. action: enhance an aspect of follicular development or ovulation

b.
examples

i. type: gonadotrophins-releasing antagonist: cetrorelix (Cetrotide) 0.25 mg SubQ every day until hCG administration

ii. type: chorionic gonadotropin (Novarel, Pregnyl) 5000-10,000 units IM for 1 dose

iii. type: clomiphene (Clomid, Serophene) 50 mg by mouth daily for 5 days

iv. type: follicle stimulators

example: follitropin alfa (Gonal-F, Gonal-F RFF) individualize dose SubQ

example: follitropin beta (Follistim AQ) individualized dose SubQ/IM



c. uses: infertility in males and females, in combination with human chorionic gonadotropin (hCG)

d. adverse effects

i. anaphylactoid reaction, spontaneous abortion, multiple pregnancies

ii. ectopic pregnancy, ovarian hyperstimulation syndrome

iii. hemoperitoneum, adnexal torsion, thromboembolism, pulmonary complications


e. contraindications

i. hypersensitivity to streptomycin and neomycin, primary ovarian failure, pregnancy

ii. uncontrolled thyroid disease or adrenal dysfunction

iii. breast, ovarian or uterine cancer


f. nursing care

i.
assist health care team to establish baseline data and check at regular intervals thereafter estrogen and
estradiol levels, pregnancy

ii. administer with hCG

iii. assist health care team to implement client teaching plan

need for follow-up care and testing

subcutaneous or IM injection technique

record treatment days and days for sexual intercourse on client calendar






5. Therapeutic classification: abortifacients

a. action: cause intense uterine contractions leading to uterine evacuation

b.
examples

i. type: blocks progesterone receptors

dinoprostone vaginal gel or insert (Prepidil, Cervidil) 0.5 gel or 10 mg per vagina

carboprost tromethamine (Hemabate) 250 mcg IM for 1 dose
Black Box Warning - appropriate use


ii. type:mifepristone (Korlym, Mifeprex, RU486) 600mg by mouth for 1 dose (note: restricted distribution in U.S.)
Black Box Warning - serious infection risk, bleeding risk, and patient information

iii. type:levonorgestrel (Next Choice, Plan B One-Step) 1 tablet by mouth every 12 hours for 2 doses


c. uses: 13-20 week pregnancy termination, early pregnancy termination, abortion adjunct, emergency contraception

d. adverse effects

i. life-threatening: severe prolonged vaginal bleeding, severe or fatal infection, sepsis with atypical symptoms

ii. other: abdominal cramping and pain

283


e. contraindications

i. more than 7 weeks gestational age

ii. history of asthma, hypertension, adrenal disease

iii. pelvic inflammatory, cardiac, renal, or pulmonary disease


f. nursing care

i. observe RN establish baseline data and monitor blood pressure, uterine tone, uterine bleeding

ii. confirm gestational age before administration

iii. observe RN implement client teaching plan

do not use abortifacients for birth control

use of delivery method and timing of administration

need for follow-up care and testing

report heavy bleeding, temperature, foul-smelling lochia






B. Male reproductive system

1. Therapeutic classification: hormones

a. type: androgenic anabolic steroid

i. growth and development of male external genitalia and secondary sexual characteristics; increase protein
anabolism and muscle mass

ii.
examples

testosterone (Striant) 30 mg buccally every 12 hours

testosterone cypionate (Depo-Testosterone) 50-400 mg IM once every 2 to 4 weeks

methyltestosterone (Android, Methitest, Testred) 10-200 mg daily in 1 to 4 divided doses


iii. uses: male hypogonadism, advanced breast cancer, hypogonadotropic hypogonadism, male androgen
deficiency, palliative treatment for metastatic breast cancer

iv. adverse effects
virilization for females, BPH, priapism, testicular atrophy, hepatotoxicity
most common: gynecomastia, amenorrhea, menstrual irregularities, male pattern baldness
other: hirsutism, acne, deepened voice, hirsutism, acne, deepened voice


v. contraindications: male breast cancer, prostate cancer, pregnancy, breastfeeding

vi. nursing care

assist health care team to establish baseline data and check periodically thereafter weight, urine
output, blood pressure, hematocrit, hemoglobin, liver function tests, urine/serum calcium levels

hand and wrist X-ray exams every six months for prepubertal males

assist health care team to implement client teaching plan - do not abruptly discontinue therapy






b. type: anabolic steroids

i. action: develop muscle mass without androgenic effects

ii.
example: oxandrolone (Oxandrin) 2.5-20 mg by mouth per day in 2 to 4 divided doses
Black Box Warning - peliosis hepatis, hepatic tumors, lipid changes

iii. uses

adjunct treatment for weight gain, osteoporosis associated bone pain

Turner syndrome short stature, male delayed puberty


284

iv. adverse effects

peliosis hepatis, hepatic necrosis, failure and tumor

most common: acne, hirsutism, deepened voice, menstrual irregularities

other

priapism, gynecomastia, bladder irritability, male pattern baldness

clitoral enlargement, libido changes, impotence



v. contraindications: prostate cancer, male breast cancer, female breast cancer with hypercalcemia, hypercalcemia,
nephrosis

vi. nursing care

assist health care team to establish baseline data and check prior to initiating and at regular intervals
during therapy hematocrit and hemoglobin, liver function tests, lipid panel

establish baseline data and check weight, mental status, blood pressure





2. Therapeutic class: erectile dysfunction agents

a. action: activates or prevents the breakdown of cGMP PDE5 causing smooth muscle relaxation and blood to fill the
corpus cavernosum resulting in an erection

b.
examples

i. sildenafil (Viagra) 50 mg by mouth for 1 dose

ii. tadalafil (Cialis) 5-20 mg by mouth before desired sexual activity

iii. vardenafil (Levitra, Staxyn) 10 mg by mouth 1 hour before sexual activity


c. uses: erectile dysfunction

d. adverse effects

i. life-threatening: anaphylaxis, angina, myocardial ischemia and infarction

ii. most common: hyper or hypotension, syncope, tachycardia, QT prolongation

iii. other: headache, flushing, rhinitis, dyspepsia, sinusitis, flu syndrome, dizziness


e. contraindications

i. prolonged QT interval, moderate to severe hepatic impairment

ii. hereditary fructose intolerance

iii. concurrent nitrate therapy


f. nursing care: review medication profile for nitrates and antihypertensives




X. Managing Hematological Conditions

A. Therapeutic classification: antianemic agents

1. Type: erythropoietin

a. action: stimulates red blood cell (RBC) production in bone marrow

b.
examples

i. epoetin alfa (Epogen, Procrit) 50-100 units/kg SubQ/IV 3 times a week
Black Box Warning - increased mortality and serious cardiovascular events in chronic kidney disease,
increased mortality and/or tumor progression in cancer clients, increased thromboembolic events in post
surgery

ii. darbepoetin alfa (Aranesp) 0.45 mcg/kg SubQ/IV weekly
Black Box Warning - increased mortality and serious cardiovascular events in chronic kidney disease,
increased mortality and/or tumor progression in clients with cancer

285


c. uses: chronic kidney disease-associated anemia, chemo-related anemia

d. adverse effects

i. life-threatening: increased mortality, tumor progression, thromboembolism, myocardial infarction, stroke,
heart failure, hypertension

ii. most common: infection, hypotension, muscle spasm, myalgia

iii. other: diarrhea, nausea/vomiting, upper respiratory infection


e. contraindications: hypersensitivity to albumin, uncontrolled hypertension

f. nursing care

i.
assist health care team to establish ferritin, transferrin saturation at baseline, hemoglobin weekly; blood
pressure

ii. assist health care team to implement client teaching plan

store in refrigerator (but do not freeze), protect from light

do not shake medication

how to self-inject medication








2. Type: iron preparations

a. action: critical element in hemoglobin molecule and establishes its affinity for oxygen

b.
example: ferrous sulfate 750-1500 mg/day by mouth divided in 2 to 4 doses

c. uses: iron deficiency

d. adverse effects: dyspepsia, nausea, vomiting, constipation, diarrhea, dark stools

e. contraindications: primary hemochromatosis, hemolytic anemia, hemosiderosis, PUD, ulcerative colitis

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter - hemoglobin, hematocrit, bilirubin, bowel elimination pattern

ii.
encourage intake of iron-rich foods
Vitamin-rich foods
iron lean red meat, liver; also clams, oysters, sardines
folic acid green leafy vegetables, milk, eggs, liver
vitamin B12 meat, seafood, eggs, cheese
vitamin K dark green leafy vegetables



iii. therapeutic effect may take 2 to 3 weeks, therapy may last 6 to 12 months

iv. administration: best absorption with vitamin C

v. assist health care team to implement client teaching plan

do not crush or chew tablets

stools may be black and sticky

may take with food if gastrointestinal upset is severe

prevent constipation with fluids, ambulation, and fiber

take at least one hour before bedtime, avoid reclining for at least 30 minutes




286

3. Type: folic acid (vitamin B-complex group)

a. action: required for red bone marrow function of red blood cells, white blood cells, platelets

b.
example: folic acid (vitamin B9) 0.4 mg by mouth daily

c. uses: folate-deficient megaloblastic anemia, tropical sprue

d. adverse effects: anorexia, nausea, abdominal pain, flatulence, altered sleep patterns

e. contraindications: undiagnosed anemia

f. nursing care

i.
collaborate with dietitian for folate-rich diet

ii. review medication profile for medications that may interact with folic acid, including phenytoin (Dilantin),
methotrexate (Trexall), nitrofurantoin (Macrodantin)





4. Type: vitamin B 12

a. action: essential for cell growth and division, nerve function, protein and carbohydrate metabolism, red blood cell
development and reproduction

b.
example: cyanocobalamin (vitamin B12) 1000 mcg SubQ/IM every month

c. uses: Schilling test flushing dose, pernicious anemia, vitamin B 12 deficiency

d. adverse effects

i. life-threatening: anaphylaxis, peripheral vascular thrombosis, thrombocytosis, hypokalemia, pulmonary edema,
heart failure

ii. other: headache, nausea, anxiety, ataxia, nervousness


e. contraindications: hereditary optic atrophy

f. nursing care

i.
assist health care team to establish baseline data and check periodically thereafter potassium, platelets

ii. collaborate with dietitian for diet rich in vitamin B12

iii. may be mixed with TPN

iv. assist health care team to implement client teaching plan: may require life-long treatment





B. Therapeutic classification: hemostatic agents (promote blood clotting)

1. Type: heparin antagonist

a. action: binds to heparin and renders it ineffective

b.
example: protamine sulfate 1-1.5 mg IV per 100 units heparin
Black Box Warning - serious adverse events, appropriate use

c. use: heparin reversal

d. adverse effects

i. life-threatening: anaphylaxis, anaphylactoid reaction, bronchospasm, angioedema, circulatory collapse, severe
bradycardia and hypotension

ii. other: dyspnea, flushing, fatigue, nausea


e. contraindication: hypersensitivity to fish

f. nursing care: monitor ECG, blood pressure during infusion





287



2. Type: warfarin antagonist

a. action: promotes hepatic production of several clotting factors

b.
example: phytonadione (Mephyton, vitamin K) 100 mcg by mouth 1 to 2 times daily
Black Box Warning - severe reactions with IV use

c. uses: hypoprothrombinemia, warfarin stabilization

d. adverse effects

i. life-threatening: anticoagulant resistance, hypersensitivity reaction, anaphylaxis

ii. most common: taste changes, flushing, injection site hematoma


e. nursing care - assist health care team to implement client teaching plan

i.
AVOID alcohol and over-the-counter drugs

ii. report bleeding

iii. need for follow-up care and testing

iv. use soft toothbrush, avoid hazardous activity until INR is within normal limits





3. Type: systemic hemostatic agents

a. action: inhibits plasminogen activating substances to stop the endogenous system for dissolving clots

b.
example: aminocaproic acid (Amicar) 4-5 g IV for 1 dose, then 1g/h IV

c. uses: hyperfibrinolysis bleeding, hemophilia A dental bleeding, traumatic, hyphema, hereditary hemorrhagic
telangiectasia, chronic bleeding, missed abortion

d. adverse effects

i. life-threatening: anaphylaxis, coagulation disorder, agranulocytosis, leukopenia

ii. other: thrombocytopenia, thrombosis, rhabdomyolysis, intracranial hypertension

iii. seizures, acute renal failure, nausea, cramps, diarrhea, hypertension


e. contraindications: active intravascular clotting

f.
nursing care: observe RN establish baseline data and monitor creatinine kinase with long-term treatment




C. Therapeutic classification: clotting factors

1. Action: replacement therapy for clotting factor deficiency

2.
Examples

a.
factor VIIa: recombinant coagulation factor VIIa (NovoSeven RT) 90 mcg/kg IV bolus every 2 hours until
hemostasis
Black Box Warning - serious thrombotic events and off-label use

b. factor VII: desmopressin (DDAVP) 0.3 mcg/kg IV for 1 dose

c.
factor IX: coagulation factor IX (BeneFIX) individualized dose


3. Adverse effects

a. life-threatening: anaphylaxis/anaphylactoid reaction, thromboembolism

b. other: headache, dizziness, rash, injection site reaction and pain


4. Contraindications: hypersensitivity to hamsters or latex

5. Nursing care: observe RN assess and monitor blood pressure, heart rate before and during administration

288




D. Therapeutic classification: agents for sickle cell anemia

1. Type: anticancer

a. action: inhibits DNA synthesis

b.
example: hydroxyurea (Droxia, Hydrea) 1-35 5 mg/kg/day by mouth daily
Black Box Warning - appropriate use, serious adverse effects, cardiogenic risk

c. use: sickle cell disease

d. adverse effects

a. life-threatening: myelosuppression, anemia, leukopenia, thrombocytopenia

b. most common: stomatitis, anorexia, nausea/vomiting


e. contraindications: myelosuppression, pregnancy

f. nursing care

i.
observe RN establish baseline data and monitor BUN/creatinine, liver function tests

ii. provide oral care

iii. administration

avoid contact with skin

premedicate with antiemetic


iv. observe RN implement client teaching plan

report fainting, shortness of breath, bleeding, cough

AVOID aspirin, aspirin-like products or NSAIDs

avoid shaving, dangerous activities, and sick people







E. Therapeutic classification: granulocyte colony stimulator

1. Action: stimulates neutrophil production

2.
Example: filgrastim (G-CSF, Neupogen) 5-10 mcg/kg SubQ/IV daily

3. Uses: post-chemo neutropenia, post-bone marrow transplant neutropenia, peripheral blood progenitor cell (PBPC)
mobilization, AIDS neutropenia

4. Adverse effects

a. life-threatening: splenic rupture, ARDS, anaphylaxis, thrombocytopenia

b. bone and musculoskeletal pain, splenomegaly


5. Contraindications: hypersensitivity to Escherichia coli protein

6. Nursing care

a.
assist health care team to establish baseline data and check prior to beginning therapy and during therapy
complete blood count with differential, platelets

b. administration

i. administer no earlier than 24 hours after the administration of cytotoxic chemotherapy

ii. store in refrigerator, do not freeze; allow to warm to room temperature prior to administration


c. assist health care team to implement client teaching plan

i. injection technique

ii. avoid sick people, watch for signs of infection





289

XI. Managing immunological conditions

A. Therapeutic classification: anti-inflammatory agents

1. Type: non-steroidal anti-inflammatory agents

2. Type: steroidal anti-inflammatory agents

a. action: powerful suppression of inflammation by inhibiting the mobilization leukocytes, fibroblasts, and
inflammatory mediators; prevents increased capillary permeability

b. examples

i.
short-acting

hydrocortisone (Cortef) 20-240 mg by mouth daily in 2 to 4 divided doses

hydrocortisone sodium succinate (Solu-CORTEF) 20-240 mg IM/IV divided in 2 to 4 doses


ii.
intermediate-acting: predniSONE (Sterapred, Sterapred DS) 5-60 mg by mouth daily

iii.
long-acting: dexamethasone 0.75-9 mg/kg by mouth daily every 6 to 12 hours


c. uses

i. corticosteroid-responsive conditions, acute asthma, severe persistent asthma

ii. adrenal insufficiency, acute exacerbation multiple sclerosis, prevention for chemo-related nausea and
vomiting

iii. acute alcoholic hepatitis, adjunct treatment for pneumocystis carinii pneumonia (PCP)


d. adverse effects

i. life-threatening: adrenal insufficiency, steroid psychosis, immunosuppression

ii. other: peptic ulcer, heart failure, osteoporosis

iii. most common: nausea, vomiting, dyspepsia, appetite changes, edema





e. contraindications: systemic fungal infection

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals thereafter

blood pressure, weight

electrolytes, 2 hour postprandial glucose


ii. frequently monitor for signs of infection

iii. assist health care team to implement client teaching plan

take daily therapy in morning

report infection, fever, surgery, anorexia, fatigue, dizziness, joint pain, bleeding

need for follow-up care and testing

do not abruptly discontinue therapy

wear Medic Alert identification, take only as directed

protect skin, avoid sick people, wash hands frequently

injection technique for insulin to control hyperglycemia

AVOID herbal remedies

AVOID over-the-counter drugs





B. Therapeutic classification: antihistamines

1. Type: H-receptor blockers (first generation - associated with drowsiness)

a. action: compete with histamine for receptor sites to decrease allergic response
290


b.
examples

i. brompheniramine (Dimetapp) 12-24 mg by mouth every 12 hours

ii. clemastine (Tavist Allergy) 1-2 mg by mouth 2 to 3 times daily as needed

iii. diphenhydrAMINE (Benadryl) 25-50 mg PO/IM/IV every 4 to 6 hours as needed

iv. promethazine (Phenergan) 6.25-12.5 mg by mouth 3 times per day
Black Box Warning - respiratory depression, severe tissue injury, gangrene


c. uses

i. allergic rhinitis, urticaria, allergy symptoms

ii. moderate to severe allergic reactions, extrapyramidal symptoms, short term treatment for insomnia

iii. motion sickness prevention, sedation, nausea and vomiting


d. adverse effects

i. life-threatening: apnea, respiratory depression, seizures

ii. most common: drowsiness, sedation

iii. other: blurred vision, confusion, dizziness, disorientation, dry mouth, photosensitivity

iv. diphenhydramine is a high risk drug in the elderly (based on the Beers Criteria)


e. contraindications: clients who are comatose, respiratory depression

f. nursing care

i. assist health care team to establish baseline data and check prior to beginning therapy and periodically
thereafter breath sounds and respiratory secretions, temperature, level of consciousness

ii. assist with ambulation

iii. do not confuse diphenhydrAMINE (Benadryl) with dimenhyDRINATE (Dramamine)

iv. assist health care team to implement client teaching plan

may take with food

drink 2000 mL fluids daily

use sunscreen, ask for help when getting up

AVOID alcohol, over-the-counter drugs, central nervous system depressants

do not drive or engage in hazardous activities for 8 hours after taking




2. Type: second generation antihistamines - associated with less drowsiness and anticholinergic effects (examples:
fexofenadine [Allegra], cetirizine [Zyrtec], loratadine [Claritin] - all are sold over-the-counter)

3. Type: mast cell stabilizers (example: cromolyn [Intal inhaler])




C. Therapeutic classification: immune modulators - stimulants

1. Type: interferons

a. action: prevent viral replication in host cells, stimulate production of antiviral proteins, inhibits tumor growth, and
increases aggressiveness of phagocytes

b.
examples

i. interferon beta 1a (Avonex, Rebif)

ii. interferon beta 1b (betaseron, Extavia)

iii. interferon alfacon-1 (Infergen)
BLack Box Warning - fatal/life threatening events, concomitant ribavirin

iv. interferon alfa-2b (Intron A)
BLack Box Warning - fatal/life threatening events

291


c. uses: external condyloma acuminata, hairy cell leukemia, chronic hepatitis B infection, chronic hepatitis C, AIDS-
associated Kaposi sarcoma, follicular non-Hodgkin lymphoma, relapsing forms of multiple sclerosis

d. adverse effects

i. life-threatening: myelosuppression, aplastic anemia, pure red cell aplasia, idiopathic thrombocytopenic purpura,
thrombotic thrombocytopenic purpura

ii. most common: psychosis, aggressive behavior, depression, suicidality

iii. other: influenza-like symptoms, anorexia, pruritus/rash


e. nursing care

i. observe RN establish baseline data and monitor

ECG, ophthalmic exams

complete blood count


ii. avoid contact with skin

iii. clients may become hemodynamically unstable during therapy

iv. different interferons are not interchangeable: each has individual indications, dosing, and administration
guidelines

v. observe RN implement client teaching plan

avoid hazardous activity

report signs of infection

different interferons are not interchangeable - always check refills for correct brand and type of
medicine ordered







2. Type: interleukins (IL)

a. action: stimulates cellular immunity of helper T cells to inhibit tumor growth

b.
examples

i. aldesleukin (Proleukin)
Black Box Warning - appropriate use, capillary leak syndrome, serious infection risk, lethargy

ii. oprelvekin (Neumega)
Black Box Warning - anaphylaxis


c. uses: metastatic renal cell cancer, metastatic melanoma, chemo-related thrombocytopenia prevention

d. adverse effects

i. life-threatening: pulmonary edema, capillary leak syndrome, pleural effusion, atrial and ventricular arrhythmias

ii. most common: dilutional anemia, edema, dyspnea, tachycardia


e. contraindications: heart failure, risk or history

f. nursing care

i.
assist the health care team to establish baseline data for creatinine and monitor throughout therapy complete
blood count with differential, platelets

ii. observe RN implement client teaching plan

report changes in breathing, development of cough

watch for infection, avoid pregnancy

AVOID shaving, aspirin, ibuprofen, alcohol

AVOID pregnancy





292

D. Therapeutic classification: immune modulators, immunosuppressants

1. Information common to immunosuppressive agents

a. action: impair an aspect of the immune system most responsible for or likely to stimulate allograft rejection while
exposing the individual to risks of immunosuppression

b. adverse effects

i. life-threatening: susceptibility to opportunistic infections and malignancies, masks signs of infection, stimulates
latent infection, nephrotoxicity, hepatic dysfunction, hyperglycemia, hyperlipidemia, thrombocytopenia,
arrhythmias, embryotoxic and teratogenic

ii. most common: anorexia, nausea, diarrhea, potentiates the action and adverse effects of other
immunosuppressants


c. contraindications: when risk of immunosuppression outweighs benefit of drug; tolerance

d. nursing care

i. assist health care team to establish baseline data and check prior to beginning therapy and at regular intervals
thereafter

drug levels, renal and liver function tests, complete blood count, immune markers

chest x-ray, tissue biopsy

allograft function

cardiac: blood pressure, ECG

pulmonary: SaO
2
, PaCO
2
, pulmonary function tests

renal: creatinine, creatinine clearance

hepatic: liver function tests, prothrombin time (PT)

search for infection


ii. assist health care team to implement client teaching plan

need for follow-up care and testing, life-long duration of therapy

avoid pregnancy, promptly report signs of infection

follow manufacturer's instructions on mixing and administration, take only as directed, and take until
instructed to stop

hand washing and infection control

reinforce client teaching

avoid sick people, ceiling fans and room fans

wear tight fitting mask on windy days

cook meat, poultry, and fish until well-done

avoid digging in dirt and avoid cat litter boxes, birds and bird cages

restrict fresh fruits and vegetables to items that are easily peeled or washed in soap and water
such as bananas, oranges, apples, carrots, tomatoes, potatoes








2. Type: T- and B-cell suppressants

a. action: suppress antibody production, suppressor and helper T-cells, and release of interleukins

b.
examples

i. cyclosporine modified (Gengraf, Neoral)
Black Box Warning - appropriate use, immunosuppressant, bioequivalence, monitor drug levels, skin
malignancy risk in psoriasis, nephrotoxicity risk hypertension

ii. mycophenolate acid (Myfortic)
Black Box Warning - appropriate use, immunosuppressant, pregnancy
293


iii. sirolimus (Rapamune)
Black Box Warning - appropriate use, immunosuppressant, liver and lung transplantation

iv. tacrolimus (FK506, Hecoria, Prograf)
Black Box Warning - appropriate use, immunosuppressant


c. uses

i. kidney transplant rejection prophylaxis, organ transplant rejection prophylaxis, severe rheumatoid arthritis

ii. severe recalcitrant plaque psoriasis, heart transplant rejection prophylaxis, liver transplant rejection prophylaxis


d. adverse effects: see previous page immunosuppressants

e. nursing care: see previous page immunosuppressants




3. Type: monoclonal antibodies

a. action: impairs the effects of tumor necrosis factor alpha, competes with IL-2 for receptor sites, and impairs
immunological response to antigens

b.
examples

i. muromonab-CD3 (Orthoclone OKT3)
Black Box Warning - appropriate use, anaphylactic/anaphylactoid reaction

ii. basiliximab (Simulect)
Black Box Warning - appropriate use

iii. infliximab (Remicade)
Black Box Warning - serious infection risk, malignancy


c. uses

i. organ transplant rejection prophylaxis, ankylosing spondylitis, Crohn disease

ii. kidney transplant rejection prophylaxis, psoriatic arthritis, rheumatoid arthritis, active moderate to severe ulcerative
colitis


d. adverse effects: serious infection, sepsis, pneumonia, opportunistic infection, tuberculosis, malignancy,
lymphoma,leukemia, fever, chills, myalgia, back pain, headache, fatigue, arthralgia, dizziness, nausea, urticaria

e. nursing care

i.
establish baseline data and monitor HBsAG, signs and symptoms of active HBV, PPD, signs and symptoms of
active TB

ii. observe RN implement client teaching plan

AVOID pregnancy

promptly report signs of infection

need for follow-up care and testing

hand-washing and infection control

wear tight fitting mask on windy days

avoid sick people, ceiling fans and room fans

restrict fresh fruits and vegetables to items that are easily peeled or washed in soap and water such
as bananas, oranges, apples, carrots, tomatoes, potatoes; cook meat, poultry, and fish until well-done

AVOID digging in dirt, cat litter box, birds and bird cages



4. Type: glucocorticoids: used in combination with cyclosporine and other immunosuppressants


294

E. Therapeutic classification: anti-infectives

1. information common to anti-infectives

a. action: interferes with the cellular functioning of the pathogen resulting in impaired proliferation and death without
injuring host

b. uses

i. surgical prophylaxis

ii. treatment of infections from susceptible bacterial pathogens


c. adverse effects

i. life-threatening: hepatotoxic and nephrotoxic especially in older clients

ii. most common: diarrhea, secondary infections especially candidiasis, GI upset including anorexia, nausea,
diarrhea, especially common in children and older clients

iii. other: may render oral contraceptives ineffective


d. contraindications: viral infections

e. nursing care

i. assist health care team to establish baseline data and check prior to starting therapy and at regular intervals
thereafter hydration, temperature, white blood count, clinical indicators of the infection, bowel pattern and
indications of secondary infection

ii.
obtain cultures before initiating therapy

iii. assist health care team to implement client teaching plan

drink fluids, maintain nutrition

take entire course of the medication

continue to take medication when feeling better

barrier contraception may be required during therapy

resistant strains of bacteria and secondary infections may develop if not taken as directed and for
entire length of therapy

report secondary infection: vaginal itching, diarrhea, fever, rash, change in cough or sputum, white
plaques in mouth







2. Type: aminoglycosides

a. action: powerful bactericidal agents associated with many severe adverse effects

b.
examples (dosing adjusted according to blood level of drug and renal function)

i. gentamicin 1- 1.7 mg/kg IM/IV every 8 hours
Black Box Warning - neurotoxicity/ototoxicity, nephrotoxicity, neuromuscular blockade

ii. streptomycin 1-2 g/day IM divided every 6-12 hours
Black Box Warning - appropriate use, neurotoxicity/ototoxicity, neuromuscular blockade


c. uses: bacterial infections, severe PID, active tuberculosis, plague, tularemia

d. adverse effects

i. life-threatening: nephrotoxicity, myelosuppression, neurotoxicity/ototoxicity, neuromuscular blockade

ii. most common: nausea, vomiting, facial paresthesia

iii. other: rash, fever, urticaria


e. contraindications: hypersensitivity to sulfites, impaired vestibular and auditory function, concurrent ototoxic and
neurotoxic medications

f. nursing care

i. assist health care team to establish baseline data and check prior to starting and at regular intervals during therapy
295


signs of original infection

BUN/creatinine, urinalysis

therapeutic drug levels


ii. audiometry for high risk patients

iii. assist health care team to implement client teaching plan: report difficulty breathing, change in urine output or
changes in hearing



3. Type: antimyocbacterials (antituberculars)

4. Type: cephalosporins

a. action: bactericidal and bacteriostatic depending on the agent and dose

b.
examples

i. first generation: cephalexin (Keflex) 1000-4000 mg/ day by mouth divided in doses every 6-12 hours

ii. second generation: cefaclor (Ceclor) 250-500 mg by mouth every 8 hours

iii. third generation: ceftriaxone (Rocephin) 0.5-1 mg IM, IV every 12 hours

iv. fourth generation: cefepime (Maxipime) 0.5-1 gram every 12 hours


c. uses: bacterial infections, endocarditis prophylaxis, uncomplicated gonococcal infections, disseminated gonococcal
infections, gonococcal conjunctivitis, mild-moderate PID, surgical infection prophylaxis, epididymitis, endocarditis
prophylaxis, typhoid fever, febrile neutropenia, mild-moderate and severe UTI

d. adverse effects

i. life-threatening: anaphylaxis, encephalopathy, seizures, leukopenia

ii. other: rash, injection site reaction, diarrhea, hypophosphatemia, elevated ALT & AST, nausea


e. contraindications: hypersensitivity to penicillin, renal impairment

f. nursing care

i. check for signs of infection before initiating and at regular intervals during therapy

ii. assist health care team to implement client teaching plan

report severe diarrhea, headache, dyspnea, dizziness

AVOID alcohol during and 72 hours after therapy (may cause disulfiram-like reaction, including flushing,
headache, nausea, chest pain, dyspnea, blurred vision, seizures)






5. Type: dichloroacetic acid derivative

a.
example: chloramphenicol (Chloromycetin) 50-100 mg/kg/day IV divided every 6 hours
Black Box Warning - appropriate use, blood dyscrasias

b. use: bacterial infections, rickettsial infections, bacterial meningitis

c. adverse effects

i. life-threatening: aplastic anemia, hypoplastic anemia, agranulocytosis

ii. most common: headache, nausea, vomiting, diarrhea


d. contraindications: pregnancy, infancy, mild infection

e. nursing care

i. observe RN establish baseline data and monitor

clinical indicators of infection, secondary infection

therapeutic drug levels
296


creatinine, complete blood count


ii. screen clients for hypersensitivity to other antibiotics




6. Type: fluoroquinolones

a.
examples

i. ciprofloxacin (Cipro, Cipro XR, Proquin XR) 250-750 by mouth every 12 hours
Black Box Warning - tendinitis/tendon rupture, avoid in myasthenia gravis

ii. levofloxacin (Levaquin) 500 mg PO/IV every 24 hours for 7 days
Black Box Warning - tendinitis/tendon rupture, avoid in myasthenia gravis


b. uses: bacterial infections, complicated and uncomplicated UTI, anthrax. typhoid fever, chancroid, acute salmonellosis,
chronic carrier salmonella, acute bacterial exacerbation chronic bronchitis, community-acquired and nosocomial
pneumonia, acute pyelonephritis, acute bacterial sinusitis, non-gonococcal urethritis

c. adverse effects

i. anaphylaxis, hypersensitivity reaction, photosensitivity, C. difficile associated diarrhea

ii. superinfection, increased intracranial pressure, seizures

iii. toxic psychosis, depression, suicidal ideation, QT prolongation


d. contraindications: prolonged QT interval, hypokalemia, myasthenia gravis

e. nursing care

i.
assist health care team to establish baseline data and check at regular intervals during therapy creatinine and
glucose, if diabetic

ii.
administer 1 hour before or 2 hours after meals





7. Type: lincosamides

a.
example: clindamycin (Cleocin) 150-450 mg by mouth every 6 hours
Black Box Warning - C. difficile-associated diarrhea

b. uses: bacterial infections, bacterial vaginosis, mild-moderate PID, endocarditis prophylaxis, babesiosis

c. adverse effects: C. difficile associated diarrhea, thrombocytopenia, anaphylaxis, Stevens-Johnson syndrome

d. contraindications: ulcerative colitis

e. nursing care

i. assist health care team to establish baseline data and check prior to beginning therapy and periodically thereafter
rash, fever, chills, joint pain, bleeding

ii.
BUN, creatinine, liver function tests with prolonged use

iii. administration

do not crush or chew tablets

do not refrigerate oral preparations

give deep IM injection









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8. Type: macrolides

a.
examples

i. clarithromycin (Biaxin) 250-500 mg by mouth every 12 hours for 7 to 14 days

ii. erythromycin base (Ery-Tab, Eryc, PCE) 1000 mg by mouth daily divided every 6 to 12 hours

iii. azithromycin (Zithromax, Zmax) 500 mg by mouth on day one, then 250 mg by mouth every 24 hours for 4 days


b. uses: bacterial infections, acute maxillary sinusitis, acute bacterial exacerbation chronic bronchitis, community-
acquired pneumonia, HIV MAC prophylaxis, H.pylori infections, endocarditis prophylaxis, Legionnaires disease,
intestinal amebiasis, syphilis, gastroparesis

c. adverse effects

i. life-threatening: angioedema, anaphylaxis, cholestatic jaundice, hepatotoxicity, pancreatitis

ii. other: C. difficile associated diarrhea, QT prolongation, nausea, abdominal pain, vaginitis




9. Type: monobactam

a.
example: aztreonam (Azactam) 1-2 g IM/IV every 8 to 12 hours

b. use: serious infections (rarely used)



10. Type: oxazolidinone

a. action: prevents bacterial translation

b.
example: linezolid (Zyvox) 600 mg IV/PO every 12 hours for 14 to 28 days

c. uses: community-acquired or nosocomial pneumonia, VREF infections, complicated and uncomplicated skin/skin
structure infections, moderate severe bacterial infections, urinary tract infections

d. adverse effects: anaphylaxis, hypersensitivity reaction, toxic epidermal necrolysis, seizures, C. difficile associated
diarrhea

e. nursing care

i.
assist health care team to establish baseline data and check before beginning and periodically during therapy
liver function tests, creatinine

ii. assess and monitor for allergic reaction




11. Type: penicillins

a.
examples

i. penicillin G potassium aqueous (Pfizerpen) 1-24 milion units/day IM/IV divided every 4 to 6 hours

ii. penicillin V potassium (250 mg PCN VK=400,000 units PCN) 250-500 mg by mouth 2 to 3 times daily for 10 days

iii. sub-type: aminopenicillin

amoxicillin (Amoxil, Moxatag) 500-875 mg by mouth every 12 hours

ampicillin 250-500 mg by mouth every 6 hours


iv. sub-type: beta-lactamase inhibitors, e.g., amoxicillin with clavulanate (Augmentin, Augmentin ES-600, Augmentin
XR) 500 mg/125-875 mg by mouth every 12 hours



b. uses

i. bacterial infections, meningococcal meningitis, meningococcal septicemia, anthrax, bacterial meningitis

ii. intrapartum GBS prophylaxis, community-acquired pneumonia

iii. group A streptococcal tonsillopharyngitis, rheumatic fever prophylaxis, pneumococcal infection prophylaxis

iv. acute bacterial sinusitis, acute otitis media, H. pylori, endocarditis prophylaxis, anthrax, chlamydial
cervicitis/urethritis

v. dental abscess, early Lyme disease, acute salmonellosis, chronic carrier salmonella, typhoid fever

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c. adverse effects

i. life-threatening: anaphylaxis, immediate or delayed hypersensitivity reaction

ii. other: serum-sickness-like reaction, nausea, vomiting, diarrhea, urticaria


d. contraindications: hypersensitivity to penicillins, aminopenicillins, or cephalosporins, mononucleosis

e. nursing care

i.
assist health care team to establish baseline data and check periodically during therapy creatinine, complete
blood count, liver function tests

ii. female clients taking oral contraceptives should use alternate form of contraception during therapy





12. Type: streptogramins

a.
example: quinupristin/dalfopristin (Synercid) 7.5 mg/kg IV every 8 hours
Black Box Warning - VREF indication

b. use: serious/life-threatening VREF infections, complicated bacterial skin/skin structure infections



13. Type: sulfonamides

a. action: inhibit folic acid synthesis

b.
examples

i. erythromycin/sulfisoxazole (Pediazole) 40-50 mg/kg/day by mouth divided every 6 to 8 hours

ii. trimethoprim/sulfamethoxazole (Septra, Septra DS) 160 mg TMP by mouth every 12 hours


c. uses: bacterial infections, pneumocystis carinii pneumonia prophylaxis and treatment, acute salmonellosis, chronic
carrier salmonella, typhoid fever

d. adverse effects

i. superinfection, C. difficile associated diarrhea, hepatic impairment, hepatitis, fulminant hepatic necrosis

ii. other

QT prolongation, ventricular arrhythmias, torsades de pointes

nausea/vomiting, abdominal pain, anorexia, rash, urticaria, photosensitivity




e. contraindications

i. clients younger than 2 months-old, pregnancy near-term

ii. hypersensitivity to sulfonamides



f. nursing care

i.
assist health care team to establish baseline data and check BUN/creatinine, complete blood count, serum
drug levels

ii. assist health care team to implement client teaching plan

discontinue drug and report rash, hematuria, ringing in ears

drink 2000-3000 mL of fluids daily during therapy









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14. Type: tetracyclines

a.
examples

i. tetracycline (Sumycin) 1-2 g/day by mouth divided 2-4 times a day

ii. doxycycline (Adoxa, Doryx, Monodox, Oracea, Perostat, Vibramycin) 100 mg PO/IV daily

iii. minocycline (Dynacin, Minocin, Solodyn) 100 mg by mouth every 12 hours


b. uses

i. bacterial infections, acne vulgaris, chlamydia infections, primary or secondary syphilis, H. pylori infection

ii. mild-moderate to severe bacterial infections, periodontitis, mild-moderate to severe PID, uncomplicated
gonococcal infections

iii. lymphogranuloma venereum, non-gonococcal urethritis, epididymitis, proctitis, Lyme disease, anthrax, malaria
prophylaxis

iv. chlamydial infection prophylaxis, presumptive cervicitis, Mycobacterium marinum infection


c. adverse effects

i. life-threatening: hepatotoxicity, fetal harm

ii. other: tooth discoloration, oral or vulvovaginal candidiasis, tooth discoloration, oral or vulvovaginal candidiasis,
abdominal and epigastric discomfort, anorexia, flatulence


d. contraindications: pregnancy, avoid conception, clients younger than 8 years-old

e. nursing care

i.
assist health care team to establish baseline data and check before starting and at regular intervals during
therapy liver function tests, complete blood count, BUN/creatinine

ii. assist health care team to implement client teaching plan

use sunscreen

do not take with antacids,salts, milk or calcium products

use barrier protection to avoid pregnancy






15. Type: tricyclic glycopeptide

a.
example: vancomycin (Vancocin) 500-2000 mg/day by mouth every six hours for 10 to 14 days

b. uses: severe bacterial infections, C. difficile associated diarrhea, staphylococcal enterocolitis

c. adverse effects

i. life-threatening: anaphylactic/anaphylactoid reactions, severe hypotension, thrombophlebitis

ii. most common: red-man syndrome, fever, chills, eosinophilia


d. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter hearing, urine output, blood pressure, respiratory rate, ECG

ii.
assist health care team to establish baseline data and check at regular intervals during therapy
BUN/creatinine

iii.
assist health care team to establish baseline data and check at regular intervals during therapy drug peak
and trough

draw blood specimen 1 hour after a 1-hour infusion

draw blood specimen for trough before next dose


iv. assist health care team to implement client teaching plan: take at equal intervals around the clock to maintain
even drug levels



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F. Therapeutic classification: antifungal agents

1. Information common to antifungal agents

a. action: alter fungal cell permeability, prevents replication causing cell death

b. adverse effects

i. hepatotoxicity, renal dysfunction

ii. nausea, dyspepsia, anorexia

iii. rash, headache, dizziness, fever


c. contraindications: renal or hepatic dysfunction

d. nursing care

i.
obtain cultures before initiating therapy

ii.
assist health care team to establish baseline data and check at regular intervals thereafter creatinine, liver
function tests

iii. assist health care team to implement client teaching plan

therapy may last for 6 months

report unusual bruising or bleeding, jaundice

change position slowly, ask for help before getting up

take entire course of therapy, do not stop taking when feeling better






2.
Sub-type: azoles

a. action: fungistatic and fungicidal systemic agent

b.
example: fluconazole (Diflucan) 100 mg PO/IV daily

c. uses: candidiasis (bladder, systemic, vulvovaginal, esophageal, oropharyngeal), cryptococcal meningitis, bone marrow
transplant fungal prophylaxis

d. adverse effects: hepatotoxicity, seizures

e. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter liver function test

ii. IV administration - prevent extravasation

iii. assist health care team to implement client teaching plan

may take with food

shake oral suspension before using

use barrier contraception to avoid pregnancy

report jaundice, nausea, anorexia, fatigue or dark urine or stool





3. Sub-type: amphotericin B, systemic agent

a.
example: amphotericin B deoxycholate (Amphocin) 0.3-1 mg/kg IV daily
Black Box Warning - invasive fungal infection, overdose prevention

b. uses: systemic fungal infections, candida cystitis

c. adverse effects

i. life-threatening: hypokalemia, severe electrolyte imbalance, nephrotoxicity, renal failure

ii. most common: acute infusion reaction, fever, chills
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iii. other: headache, hypotension, injection site pain, epigastric pain, tachypnea


d. contraindications: renal impairment and electrolyte abnormalities

e. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter BUN, creatinine, complete blood count, electrolytes, liver function tests

ii. administer 2000-3000 mL fluid daily

iii. observe RN administer IV treatment

first dose: run a test dose of 1 mg over 30 minutes and monitor client's reaction

change needle after diluting, shake to mix well, then change needle after mixing in IV bag

administer over at least 2 hours

check closely for extravasation





4. Sub-type: nystatin

a.
example: nystatin (Mycostatin) 4-6 mL by mouth 4 times a day

b. uses: oral and intestinal candidiasis

c. adverse effects: nausea/vomiting, diarrhea, abdominal pain

d. nursing care

i. eliminate cause of fungal infection


e. assist health care team to implement client teaching plan

i. long-term therapy may be required

ii. avoid commercial mouthwash during oral therapy





G. Therapeutic classification: antiviral agents

1. Information common to antiviral agents

a. life-threatening adverse effects: heart failure, arrhythmias, cardiac arrest, psychosis, coma

b. contraindications: the elderly, clients diagnosed with depression



2. Sub-type: agents for influenza A and respiratory viruses

a. action: prevents viral replication

b.
examples

i. amantadine (Symmetrel) 100 mg by mouth daily for 3 to 5 days

ii. oseltamivir (Tamiflu) 75 mg by mouth twice daily for 5 days

iii. ribavirin (Copegus, Rebetol, Ribasphere) weight dosed
Black Box Warning - monotherapy not indicated, hemolytic anemia, teratogenic/embryocidal


c. uses

i. influenza A prophylaxis and treatment, extrapyramidal disorders, parkinsonism

ii. uncomplicated influenza B prophylaxis and treatment, chronic hepatitis C


d. adverse effects: hemolytic anemia, neutropenia, thrombocytopenia, aplastic anemia

e. contraindications: pregnancy, male partners of pregnant women, significant or unstable cardiac disease

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter complete blood count with differential, platelets, creatinine, liver function tests, ECG
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ii. initiate therapy as soon as possible after exposure

iii. assist health care team to implement client teaching plan: complete course of therapy to obtain full therapeutic
effect






3. Type: agents for herpes and cytomegalovirus (CMV)

a. action: inhibit viral replication

b.
examples

i. herpes: acyclovir (Zovirax) 400-800 mg by mouth 5 times a day for 5 to 7 days

ii. CMV: ganciclovir (Cytovene) 5 mg/kg IV every 12 hours for 7 to 14 days
Black Box Warning - hematologic toxicities, carcinogen/teratogen, aspermatogenesis, appropriate IV use,
appropriate oral use


c. uses

i. herpes: HSV encephalitis, genital/mucocutaneous HSV in immunocompetent and immunocompromised clients

ii. HSV prophylaxis in immunocompromised clients, HSV keratitis, varicella immunocompetent and
immunocompromised

iii. patients, herpes zoster in immunocompetent and immunocompromised clients, herpes zoster ophthalmicus

iv. CMV: HIV-associated CMV prophylaxis, CMV retinitis in immunocompromised clients


d. adverse effects

i. life-threatening: thrombocytopenia, neutropenia, pancytopenia, sepsis, nephrotoxicity, seizures

ii. other: retinal detachment, hypertension, pancreatitis, GI perforation, impaired fertility, depression, diarrhea, fever,
leukopenia


e. contraindications: ANC< 500/mm
3
or platelets < 25,000/mm
3
, renal disease or severe central nervous system disorders

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter creatinine, complete blood count, platelets

ii. monitor lesions

iii.
give with food

iv. assist health care team to implement client teaching plan

report swollen lymph nodes, fever, bleeding

therapy is not curative

avoid sexual intercourse to prevent spread of virus

need for follow-up care and testing: ophthalmologist, blood tests

complete course of therapy to increase effectiveness and to prevent emergence of resistant strains






4. Agents for HIV and AIDS

a. type: reverse transcriptase inhibitors

i. action: bind directly to HIV reverse transcriptase to prevent transfer of information vital to viral replication and
survival

ii.
examples

delavirdine (Rescriptor) 400 mg by mouth three times a day

nevirapine (Viramune, Viramune XR) 200 mg by mouth two times a day
Black Box warning - hepatotoxicity, skin reactions

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iii. use: HIV infection

iv. adverse effects

life-threatening: severe skin reactions, angioedema, dyspnea

most common: rash, nausea, headache, fatigue, depression, flu syndrome


v. nursing care

assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter liver function test

drug levels decrease with concurrent protease inhibitor therapy

assist health care team to implement client teaching plan

report signs of toxicity: severe nausea, vomiting, maculopapular rash

must be taken at equal intervals around the clock

missed dose: take up to 1 hour before next dose - do not double dose







b. type: protease inhibitors

i. action: block protease activity in the HIV critical for viral maturation

ii.
example: nelfinavir (Viracept) 1250 mg by mouth twice daily

iii. use: HIV infection

iv. adverse effects
life-threatening: seizures, leukopenia, thrombocytopenia, anemia, hepatotoxicity
other: diarrhea, nausea, anorexia, abdominal pain, hyperglycemia


v. contraindications: phenylketonuria (PKU)

vi. nursing care

assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter liver function tests, fasting blood glucose, fasting lipid panel

assist health care team to implement client teaching plan

report diarrhea, nausea, vomiting, rash

give with food






c. type: nucleoside analog antiretroviral agents

i. action: inhibit cell protein synthesis

ii.
examples

abacavir (Ziagen) 300 mg by mouth twice daily
Black Box Warning - hypersensitivity reaction, lactic acidosis/severe hepatomegaly

didanosine (Videx, Videx EC) 200-250 mg by mouth every 12 hours
Black Box Warning - pancreatitis, lactic acidosis/severe hepatomegaly

lamivudine (Epivir, Epivir HBV) 300 mg by mouth daily
Black Box Warning - lactic acidosis/severe hepatomegaly, non-interchangeable forms, hepatitis B exacerbation

zidovudine (Retrovir) 300 mg by mouth twice daily
Black Box Warning - hematologic toxicity, myopathy, lactic acidosis/severe hepatomegaly


iii. uses: HIV infection, prevention of maternal-fetal HIV infection
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iv. adverse effects

life-threatening: lactic acidosis, hepatomegaly with steatosis, hepatotoxicity, severe anemia

most common: headache, malaise, nausea, anorexia

other: asthenia, constipation, abdominal cramps, pain, arthralgia, chills, dyspepsia, insomnia



v. nursing care

assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter creatinine, complete blood count with differential, liver function tests

assist health care team to implement client teaching plan

report fever, flu-like findings, tiredness or weakness, dizziness

carry medication card warning guide at all times






1. Type: combination agents

a.
lamivudine/zidovudine (Combivir) 150/300 1 tablet by mouth twice daily
Black Box Warning - hematologic toxicity, myopathy, lactic acidosis/severe hepatomegaly

b.
abacavir/lamivudine/zidovudine (Trizivir)
Black Box Warning - appropriate use, hypersensitivity reaction, hematologic toxicity, myopathy, lactic
acidosis/severe hepatomegaly, hepatitis B exacerbation

c.
emtricitabine/tenofovir (Truvada) 200/300 1 tablet by mouth daily
Black Box Warning - lactic acidosis/severe hepatomegaly, not approved for HBV infection



2. Type: locally active antiviral agents

a. action: interfere with viral replication and metabolic processes

b.
example: penciclovir (Denavir) 10mg/gm cream apply every 2 hours for 4 days

c. uses: herpes labialis

d. adverse effects: headache, taste change, erythema, pruritus

e. nursing interventions: teach client that these agents are not curative



3. Highly active antiretroviral therapy (HAART)

a. aggressive, combination therapy of at least 3 antiretroviral drugs (a drug "cocktail")

b. suppresses viral replication, allowing body time to rebuild immune system and replenish destroyed CD4 or T cells,
which delays the progression to AIDS and prolongs life




H. Therapeutic classification: antiprotozoal agents

1. Type: antimalarial agents

a. action: inhibit DNA synthesis in susceptible protozoans

b.
examples

i. metronidazole (Flagyl, Flagyl ER) 500 mg by mouth every 6-8 hours for 7 to 14 days

ii. pentamidine (Pentam) 4 mg/kg IV/IM daily for 14 to 21 days
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iii. atovaquone (Mepron) 1500 mg by mouth daily for 21 days



c. uses

i. bacterial infections, trichomoniasis, amebic liver abscess, intestinal amebiasis, perioperative prophylaxis

ii. mild-moderate to severe PID, bacterial vaginosis, giardiasis, C. difficile associated diarrhea, recurrent or
persistent

iii. non-gonococcal urethritis, PCP prophylaxis and treatment, primary and secondary prophylaxis for
toxoplasmosis

iv. toxoplasmosis treatment, mild-moderate babesiosis


d. adverse effects

i. life-threatening-hypersensitivity reaction, angioedema, hepatitis, hepatic failure

ii. other: rash, diarrhea, fever, nausea/vomiting, headache, cough, URI, asthenia, abdominal pain, dyspnea,
insomnia, sweating, influenza-like symptoms


e. contraindications: visual field changes, porphyria

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter BUN/creatinine, glucose, calcium, complete blood count, platelets, liver function tests

ii. assist health care team to implement client teaching plan

medication may cause dizziness or lightheadedness

medication may cause unpleasant metal taste or dry mouth

AVOID alcohol







2. Type: antimalarial agents

a. action: attack various phases of the red blood cell phase of the Plasmodium malariae life cycle

b.
examples

i. chloroquine (Aralen) 500 mg by mouth weekly
Black Box Warning - appropriate use

ii. hydroxychloroquine (Plaquenil) 200-400 mg by mouth weekly
Black Box Warning - prescribing information


c. uses: malaria prophylaxis and treatment, extraintestinal amebiasis, systemic lupus erythematosus (SLE), rheumatoid
arthritis

d. adverse effects

i. life-threatening: seizures, angioedema, bronchospasm, exfoliative dermatitis

ii. most common: dizziness, ataxia, headache, abdominal pain, nausea, vomiting

iii. other: agranulocytosis, thrombocytopenia, aplastic anemia


e. contraindications: retinal or visual field changes, porphyria

f. nursing care

i.
assist health care team to establish baseline data and monitor complete blood count with prolonged treatment

ii. assist RN to check and monitor vision

iii. assist health care team to implement client teaching plan

avoid taking with digoxin

ask for help before getting up
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give with food or milk

AVOID driving and dangerous activities with impaired vision






I. Therapeutic classification: anthelmintics

1. Action: impair metabolic pathways present in invading worm that humans do not have

2.
Examples

a. pyrantel (Pin-X, Pronto Plus Pinworm Treatment, Reese's Pinworm) dose weight specific

b. albendazole (Albenza) 400 mg by mouth twice daily


3. Uses: pinworm, neurocysticerosis, hydatid disease

4. Adverse effects

a. life-threatening: Steven's-Johnson syndrome, renal failure, severe myelosuppression

b. most common: fever, malaise, dizziness, drowsiness

c. other:

i. rash, pruritus, alopecia, fever, headache

ii. abdominal pain, diarrhea, anorexia



5. Contraindications: pregnancy during treatment or 1 month after treatment

6. Nursing care

a.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter complete blood count, liver function tests

b. assist health care team to implement client teaching plan

i. report worsening of findings

ii. treat all family members

iii. complete full course of therapy for effectiveness

iv. avoid tub baths; shower at least once daily in the morning

v. sanitize toilet facility; wash bed linens and underwear in hot water

vi. wash hands and scrub under fingernails after voiding or bowel movement






J. Therapeutic classification: antineoplastic agents

1. Information common to anticancer drugs

a. action: disrupt processes related to synthesis of DNA or its precursors

b. adverse effects

i. life-threatening: secondary malignancy, sterility, hemorrhagic cystitis, urinary bladder fibrosis, heart failure,
infection

ii. most common: alopecia, sterility, amenorrhea, nausea, vomiting, diarrhea, stomatitis, anemia, leukopenia,
thrombocytopenia, rash, headache


c. nursing care

i.
observe RN establish baseline and monitor creatinine, complete blood count with differential, platelets,
urinalysis

ii. maintain nutrition, fluid and electrolyte balance

iii. protect client from infection

iv. provide frequent oral care

v. reinforce symptom management, such as nausea, vomiting, stomatitis, fatigue, constipation, diarrhea
307


vi. provide emotional support and therapeutic communication for client and family

vii. assist with hats, wigs, scarves

viii. provide rest, information, calm, soothing environment


ix. administration and handling

only trained RNs administer chemotherapy

dispose of waste safely, handle body fluids safely

empty body waste into toilet without splashing

urine for at least 48 hours and stool for 7 days after last dose

wear non-permeable gloves, gown, goggles for waste, fluids, and linens

prevent extravasation observe RN establish baseline data and monitor infusion site

stop infusion immediately if extravasation is suspected: do not remove IV catheter until antidote given
or confirm with pharmacy


x. reinforce client teaching

report: unusual bruising and bleeding, fever, chills, sore throat, dyspnea, flank pain, swelling

need for follow-up care and testing

avoid pregnancy: use barrier contraception

take as directed and take entire course of therapy

avoid sick people and perform thorough, frequent hand washing

wash fresh fruits and vegetables in soap and water

try to maintain balanced diet: eat highly nutritious food, drink 10-12 glasses of water daily







2. Type: alkylating agents

a. action: non-cell cycle-specific; affects neoplasm cell DNA, RNA, or protein in resting or active state to disrupt
intracellular mechanisms and cause cell death

b.
examples

i.
busulfan (Myleran) 2-8 mg by mouth daily
Black Box Warning - appropriate use, severe bone marrow hypoplasia

ii.
cyclophosphamide - dose may vary

iii.
CARBOplatin (Paraplatin) - dose may vary
Black Box Warning - appropriate use, serious adverse events, anaphylaxis

iv.
CISplatin (Platinol AQ) - dose may vary
Black Box Warning - appropriate use, overdose prevention, dose-related toxicity, ototoxicity, anaphylactoid
reaction


c. uses: mycosis fungoides, rheumatoid arthritis, breast cancer, leukemia, lymphoma, multiple myeloma, ovarian cancer,
retino/neuroblastoma, sarcoma, palliative treatment for chronic myelogenous leukemia (CML), myelofibrosis,
advanced ovarian cancer, metastatic ovarian and testicular cancer, advanced bladder cancer

d. adverse effects

i. life-threatening: nephrotoxicity, acute renal failure, anaphylactoid reaction, myelosuppression

ii. most common: nausea/vomiting, anorexia, elevated BUN & creatinine, hyperuricemia, tinnitus, hearing loss

iii. other: leukopenia, thrombocytopenia, anemia, electrolyte disorders


308


e. contraindications: hypersensitivity to platinum compounds, myelosuppression, renal or hearing impairment

f. nursing care

i. observe RN establish baseline data and monitor

BUN/creatinine, creatinine clearance, calcium, potassium, magnesium, and sodium prior to each dose

complete blood count weekly, liver function tests
neurological exam, audiometry at baseline and prior to each dose


ii. reinforce client teaching

report fever, bleeding, severe nausea, vomiting, diarrhea, edema, ringing in ears

use barrier contraception

ask for help before getting up

encourage clients to obtain head covering early in therapy

take drug as directed and do not stop until directed to do so

AVOID over-the-counter drugs and herbal remedies




3. Type: antimetabolites

a. action: replace normal metabolites to inhibit DNA production in malignant cells; S-phase specific and are most
effective on rapidly dividing cells

b.
example: mercaptopurine (Purinethol) 2.5 mg/kg by mouth daily

c. uses: ALL, Crohn's disease, ulcerative colitis

d. adverse effects

i. myelosuppression, immunosuppression

ii. hepatotoxicity, hepatosplenic T-cell lymphoma

iii. hepatic encephalopathy, ascites, GI ulceration




4. Type: antineoplastic antibiotics

a. action: cytotoxic to rapidly dividing cells and interfere with DNA synthesis

b.
examples

i.
bleomycin (Blenoxane) - dose may vary
Black Box Warning - appropriate use, pulmonary toxicity, idiosyncratic reaction

ii.
DOXOrubicin (Adriamycin) - dose may vary
Black Box Warning - appropriate use, cardiotoxicity, secondary AML or myelodysplastic, hepatic impairment,
myelosuppression

iii.
DAUNOrubicin (Cerubidine) - dose may vary
Black Box Warning - appropriate use, cardiotoxicity, myelosuppression, renal or hepatic impairment


c. uses: malignant pleural effusion, Hodgkin lymphoma, non-Hodgkin lymphoma, squamous cell cancer, testicular
cancer, AML

d. adverse effects

i. life-threatening; myelosuppression, hepatotoxicity, leukopenia, thrombocytopenia, cardiotoxicity, anaphylaxis

ii. other: stomatitis, alopecia, nausea, vomiting, mucositis, tissue necrosis


e. contraindications: impaired cardiac function, hepatic or renal impairment, myelosuppression

f. nursing care: observe RN to take steps to prevent extravasation

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5. Type: cell-protecting agents

a. action: binds to and detoxifies damaging metabolites of chemotherapy

b.
example

i. for cisplatin: amifostine (Ethyol) give 30 min before chemotherapy

ii. for ifosfamide: mesna (Mesnex); total daily dose = 60% total ifosfamide dose


c. adverse effects: anaphylaxis, allergic reaction, headache, injection site reaction, flushing, dizziness

d. contraindications: hypersensitivity to thiol compounds

e. nursing care

i.
observe RN establish baseline data and monitor calcium

ii. check oral mucosa, blood pressure

iii. cutaneous evaluation prior to each dose




6. Type: folic acid derivative

a. action: prevents toxicity by protecting normal cells

b.
example: leucovorin (generic) 200 mg/m
2
IV daily for 5 days

c. uses: rescue for high dose or overdose methotrexate

d. adverse effects: anaphylactoid reactions, seizures, syncope, urticaria, nausea and vomiting

e. contraindications: intrathecal administration, pernicious or megaloblastic anemia, or vitamin B12 deficiency

f. nursing care

i.
observe RN establish baseline data and monitor complete blood count, liver function tests, electrolytes

ii. increase fluid intake

iii. protect from heat and light

iv. reinforce that client should drink 3000 mL of fluid daily





7. Type: hormones and hormone modulators

a. action: block or interfere with hormone receptor sites with hormone-sensitive tumors

b.
examples

i. ACTH-releasing: goserelin (Zoladex) 3.6 mg SubQ every 28 days for 4 doses

ii. androgen: testosterone

iii. anti-estrogen: anastrozole (Arimidex) 1 mg by mouth daily

iv. corticosteroids: dexamethasone (Decadron)

v. estrogen antagonist: tamoxifen (Soltamox) 20-40 mg by mouth daily
Black Box Warning - serious/life-threatening events


c. uses: breast and prostate cancer, endometriosis, dysfunctional uterine bleeding, ovulation induction

d. adverse effects

i. general: thromboembolism, stroke, hypercalcemia

ii. gynecomastia, hot flashes, nausea/vomiting, vaginal discharge and bleeding

iii. peripheral edema, fatigue, headache


310





8. Type: mitotic inhibitors

a. action: cell-cycle specific agents that kill cells at the beginning of cell division and interfere with DNA synthesis; work in
the M phase of the cell cycle

b.
examples

i. paclitaxel (Onxol,Taxol) - dose may vary
Black Box Warning - appropriate use, anaphylaxis/severe hypersensitivity reaction, myelosuppression

ii. vinBLAStine (generic) - dose may vary
Black Box Warning - appropriate use, intrathecal use contraindicated

iii. vinCRIStine (generic) - dose may vary
Black Box Warning - appropriate use, intrathecal use contraindicated


c. uses: breast cancer, non-small cell lung cancer, AIDS-associated Kaposi sarcoma

d.
nursing care: observe RN establish baseline data and monitor bilirubin, complete blood count with differential



9. Type: monoclonal antibodies

a. action: inhibits proliferation of malignant cells by binding to extracellular aspect of human epidermal growth factor
receptor 2 (HER2)

b.
example: trastuzumab (Herceptin) - dose may vary
Black Box Warning - cardiomyopathy, infusion reaction and pulmonary toxicity, embryo-fetal toxicity

c. use: HER2-overexpressing metastatic and adjuvant therapy breast cancer, HER2-overexpressing metastatic gastric
cancer

d. adverse effects

i. life-threatening: severe or fatal ventricular dysfunction, cardiomyopathy, heart failure, thromboembolism, severe or
fatal infusion reaction

ii. other: dyspnea, anaphylaxis, angioedema, ARDS, pain, asthenia, fever/chills, nausea/vomiting, diarrhea,
headache, fatigue


e. contraindications: hypersensitivity to hamster proteins

f. nursing care

i. establish baseline data and monitor fatal infusion reaction: fever, chills, nausea, vomiting, pain, dizziness,
hypotension

ii. reinforce client teaching
may cause teratogenic effects - client must use contraception
AVOID vaccinations
report new onset or worsening of shortness of breath, cough, selling of ankles, face
AVOID crowds or persons with known infections






10. Adjunct therapy: agents used to manage nausea and vomiting

a. therapeutic classification: antiemetics

i. type: serotonin (5HT) receptor blockers

example: granisetron (Granisol, Kytril), ondansetron (Zofran, Zofran ODT, Zuplenz)

nursing care: very effective, often combined with corticosteroids


311

ii. type: benzodiazepine

examples: alprazolam (Xanax), lorazepam (Ativan)

nursing care: effective when combined with corticosteroids



iii. type: dopaminergic blocker

example: metoclopramide (Metozolov, Reglan)

nursing care: especially effective when combined with a corticosteroid, an antihistamine, and a centrally-acting
blocker (haloperidol)



iv. type: combined dopaminergic, a-adrenergic, anticholinergic blocker

example: haloperidol (Haldol)

nursing care: may cause extrapyramidal side effects, drowsiness, reduced blood pressure and increased heart
rate



v. type: phenothiazines

example: prochlorperazine (generic)

nursing care: these types of drugs are not very effective for chemotherapy-induced nausea and vomiting






b. therapeutic class: antihistamines

i. use: to control nausea and vomiting; decrease some of the side effects of other antiemetic drugs, e.g., benzamides,
butyrophenones, phenothiazines

ii.
example: diphenhydramine (Benadryl)



c. therapeutic class: anti-inflammatory agents

i. type: steroids

ii. use: can improve the antiemetic characteristics of other medications, especially serotonin antagonists or Reglan

iii.
examples: corticosteroids such as dexamethasone (Decadron) and methylprednisolone (Medrol)



d. neurokinin-1-receptor antagonists (NK
1
-receptor antagonists)

i. use: in combination with other antiemetic drugs, e.g., serotonin antagonist and a corticosteroid

ii.
example: aprepitant (Emend)



e. cannabinoids

i. uses: best used with chemotherapy drugs that cause minimal nausea and vomiting

ii.
example: dronabinol (Marinol)

iii. nursing care: mild drowsiness, dizziness and euphoria are common side effects



XII. Managing eye conditions

A. Medications used to manage glaucoma

1. Therapeutic classification: cholinergic agents

a. action: constrict the pupil and increase drainage of aqueous humor by stimulating the ciliary muscle to
contract
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b.
examples

i. pilocarpine ophthalmic (Isopto Carpine)

ii. carbachol ophthalmic (Isopto Carbachol)


c. uses: elevated intraocular pressure, open-angle and acute angle-closure glaucoma, mydriasis reversal

d. adverse effects

i. life-threatening: arrhythmias, asthma, hypotension, retinal detachment

ii. other: ocular burning/stinging, blurred vision, ocular discomfort


e. contraindications: acute iritis, pupillary block glaucoma

f. reinforce client teaching: may cause blurred vision, poor vision at night, periorbital discomfort






2. Therapeutic classification: beta-adrenergic agents - used in the management of chronic open-angle glaucoma and other
forms of ocular hypertension

a. action: decreases intraocular pressure by decreasing production of aqueous humor and increasing drainage

b.
example: timolol maleate (Betimol, Istalol, Timoptic, Timoptic-XE)

c. assist health care team to implement client teaching plan: may experience burred vision, burning; may cause
bronchospasm in clients with reactive airway disease



3. Therapeutic classification: carbonic anhydrase inhibitors

a. action: inhibits the enzyme needed to produce aqueous humor leading to decreased production

b.
example: acetaZOLAMIDE (Diamox) 125-250 mg by mouth 2 to 4 times daily

c. nursing care

i. assist health care team to establish baseline data and check at regular intervals BUN/creatinine, complete blood
count, platelets, electrolytes

ii. assist health care team to implement client teaching plan: report taste changes, anorexia, paresthesia, polyuria



Lipid soluble beta blocker eyedrops for glaucoma can be absorbed systemically. If your client states s/he is feeling
"blah" or has no energy, don't assume s/he is depressed. A CNS side effect of these drugs (timolol [Timoptic] and
betaxolol [Betoptic]) is fatigue.


4. Therapeutic class: osmotic agents

a. action: decreases IOP by moving water out of intraocular structures

b.
example: mannitol (Osmitrol)

c. nursing care: establish baseline data and monitor BUN/creatinine, serum electrolytes



5. Therapeutic class: prostaglandin agonists

a. action: increases outflow of aqueous

b.
example: latanoprost (Xalatan)

c. assist health care team to implement client teaching plan: may experience burning, blurred vision, dry eyes, foreign
body sensation



B. Therapeutic classification: anti-infective medications

1. Bacterial agents

a. types
313


i.
aminoglycosides - tobramycin ophthalmic (Tobrex)

ii.
erythromycin ointment

iii.
fluoroquinolones - ciprofloxacin ophthalmic (Ciloxan) & moxifloxacin ophthalmic

iv. quinolones - ofloxacin (Ocuflox)


b. uses: conjunctivitis, corneal ulcers


2.
Antifungal agents: natamycin 5% ophthalmic (Natacyn)

3. Antiviral agents

a.
types: trifluridine (Viroptic), famciclovir (Famvir), valacyclovir (Valtrex) or acyclovir (Zovirax)

b. uses: keratitis (H. simplex, varicella zoster)


4.
Glucocorticoid & bacterial agent: tobramycin and dexamethasone ophthalmic (Tobradex)



C. Therapeutic classification: anti-allergy

1.
decongestant: naphazoline (Naphcon, Vasocon)

2.
antihistamines: ketotifen fumarate ophthalmic solution 0.025% (Zaditen), olopatadine (Patanol), pemirolast
(Alamast)



XIII. Managing Ear Conditions

A. Managing infection: otitis externa

1.
ciprofloxacin 0.3% & dexamethasone 0.1% (Ciprodex)

2.
ciprofloxacin and hydrocortisone (Cipro HC Otic)

3.
hydrocortisone, polymyxin & neosporin (Cortisporin otic solution)

4.
equal parts white vinegar and isopropyl alcohol or other acidifying agents



B. Managing infection: otitis media

1. Therapeutic classification: antibiotics

a. types

i.
aminopenicillin: amoxicillin (Amoxil)

ii.
quinolone: ciprofloxacin otic (Cetraxal)

iii.
fluoroquinolone: ofloxacin (Floxcin Otic)


b. reinforce client teaching

i. take drug around the clock at regular intervals

ii. administration

warm medication (rub container between palms of hand or place in warm water)

gently rub the skin in front of the ear to facilitate drug flow in ear

place cotton ball in affected ear

rinse dropper after each use


iii. not to miss doses
314


iv. completely finish prescription






2. Therapeutic classification: decongestants

a. action: constricts smooth muscle to increase passageways

b. type: sympathomimetic

c.
example: pseudoephedrine (Sudafed)

d. nursing care

i. establish baseline data and monitor heart rate and blood pressure

ii. reinforce client teaching
AVOID taking right before bedtime
withhold medication if restlessness or palpitations or racing heart occur
AVOID other over-the-counter medications and stimulants








C. Adjuvant therapy

1. Managing cerumen (cerumenolytics)

a.
carbamide peroxide (Debrox)

b.
triethanolamine otic (Cerumenex drops)



2. Local anesthetic drops

a.
herbal ear drops containing mullein, garlic, and/or St. John's wort

b.
benzocaine & antipyrine (Auralgan) - pain relief and reduction of inflammation; also facilitates removal of
excessive or impacted cerumen

c.
hydrocortisone, chloroxylenol/pramoxine (Oticin HC Ear Drops)

d.
benzocaine (Pinnacaine Otic Drops)




315



I.Managing pain

A. Information common to analgesics

1. Therapeutic class: analgesics

2. Assist health care team to establish baseline data and check prior to initiating therapy
and at regular intervals thereafter

a. pain

i. objective: pain scale

ii. subjective: characteristics, location, type of pain


b. clinical indicators of pain

i. reluctance to move, ambulate, eat or breathe deeply

ii. restlessness, splinting, muscle tension

iii. higher than normal blood pressure

iv. faster than normal heart rate or respiratory rate
O-L-D-C-A-R-T: a comprehensive assessment of clinical indicators of pain
O = Onset When did it begin?
L = Locations Where is it?
D = Duration How long does it last?
C = Characteristics What are the qualities?
What is the
description?
A = Attributes How did it start? What
caused it?
R = Related findings What is the relationship
with other things such
as eating, position
changes, activity, rest?
T = Therapy & timing What effective and
remedies have been
tried? When does it
occur (time of day;
before or after
something else)? Any
patterns?



c. Documentation (follow agency policy)

time of administration

response to therapy at suitable interval after administration




316


3. Collaborate with provider and RN for comprehensive pain management

a. provide non-pharmacological methods of pain relief such as distraction, positioning, and guided
imagery with pharmacotherapy

b. eliminate factors that decrease pain tolerance: fatigue, boredom, anxiety, stress, anger, fear

c. individualize pain management according to

i. pain history

ii. context of therapy and available resources

iii. client's age, past experiences, values, expectations and physical and mental health


d. administer pharmacotherapy before severe pain develops

e. administer lowest dose of analgesic providing satisfactory pain relief according to client report

f. augment potential analgesic effect with adjunct therapy



4. Avoid alcohol and central nervous system depressants (potentiate analgesic effect)

a. high risk behavior

b. associated with increased risk of adverse effects including liver failure, respiratory depression,
overdose, and death



5. Opioids frequently combined with NSAIDs, acetaminophen or other medications

a. indications: moderate to severe pain, intractable pain syndromes

b. benefit: combination allows lower dose of opioid

c. consider: adverse effects of both agents; to prevent overdose or toxic effects, keep track of total
daily amount of each drug when using combination agents



6. Administration routes

a. oral

i. contraindicated with nausea and vomiting

ii. check response to therapy 30 minutes to 1 hour after administration

iii. slow-release preparations available but may require additional analgesic at initiation of therapy
and for breakthrough pain



b. intramuscular

i. assess response to therapy 30 minutes after administration

ii. avoid with hypothermia and vasoconstriction (placed client at risk for hypotension)



c. subcutaneous

i. check response to therapy 30 to 60 minutes after initiating therapy

ii. well-suited for clients with cancer

iii. requires ambulatory infusion pump (patient controlled analgesia [PCA])

iv. easier to establish steady-state blood level



d. epidural and intrathecal

i. check response to therapy 15 to 45 minutes after initiating therapy

ii. itching can be severe
317


iii. risk of hematoma, infection, meningitis

iv. effective management of severe pain without central nervous system depression

v. agents: preservative-free opioids and local anesthetics via PCA or implantable pump




e. transdermal

i. check response to therapy 1 to 2 hours after initiating therapy; regularly assess for respiratory
depression and skin irritation

ii. difficult to adjust dosage

iii. typical medications: fentanyl and morphine

iv. increased absorption with febrile clients

v. used in chronic and severe pain syndromes

vi. remove old patch and cleanse area before applying new patch; follow agency policy about patch
disposal



f. intravenous

i. check response to therapy 15 to 30 minutes after therapy


ii. delivery method: bolus

immediate, short-term pain management for moderate to severe pain

high risk of CNS depression, especially respiratory depression



iii. delivery method: patient controlled analgesia

can be programmed to deliver medication in small, on-demand doses, a bolus (initial) dose, and an
even flow (basal rate)

typical on-demand dose of morphine sulfate: 0.5-2 mg every 10 minutes

typical basal rate of morphine sulfate: 2-5 mg/hour

client may have concurrent oral pain medications ordered for breakthrough pain

observe RN provide client and family teaching - only client is to activate PCA for on-demand dose


g. other: sublingual, rectal


B. Therapeutic class: opioid analgesics

1. Type: opioid agonists

a. action: stimulate opioid receptors to cause analgesia; vary according to side effects, route of
administration, onset, peak, and duration

b. examples














318


Opioid analgesics
Generic Name &
Equianalgesic
Dose

Trade Name

Combination Products

Comments
fentanyl
100 mcg IM/IV
Duragesic,
Lazanda, Abstral,
Actiq, Fentora,
Onsolis, Subsys
NA Dosing may be nasal, transdermal or transmucosal
IV dosing used for induction and maintenance of
surgical anesthesia
HYDROmorphone
1.5 mg SC/IM/IV;
7.5 mg PO
Dilaudid, Dilaudid
HP, Exalgo
NA 2, 4, & 8 mg PO; 1-4 mg SubQ, IM, IV
morphine
10 mg SC/IM/IV; 30
mg PO
Avinza, Kadian,
MS Contin,
Oramorph SR,
Roxanol
Embeda (naltrexone) Avoid IM or SubQ route as can be painful and
unreliable
HYDROcodone
30 mg PO
NA Hycet, Lorcet, Lorcet Plus, Lortab,
Maxidone, Norco, Vicodin, Vicodin
ES, Vicodin HP, Zamicet, Zydone
(acetaminophen),
Zutripro (chlorpheniramine/
pseudoephedrine),
Hycodan, Tussigon
(homatropine),
Ibudone, Reprexain, Vicoprofen
(ibuprofen),
Rezira (pseudoephedrine),
TussiCaps, Tussionex
PennKinetic (chlorpheniramine)
Most widely prescribed drug in the United States
oxyCODONE
20 mg PO
Oxecta,
OxyContin,
OxyFast,
Roxicodone
Endocet, Magnacet, Percocet,
Primlev, Roxicet, Tylox, Xolox
(acetaminophen),
Percodan (aspirin),
Combunox (ibuprofen)
Tablets should never be dissolved and injected,
may cause local tissue necrosis, pulmonary
granulomas, endocarditis and valvular heart injury
meperidine
75 mg SC/IM/IV;
300 MG PO
Demerol NA May be used for drug-induced rigors or
postanesthesia shivering
considered a high risk drug in the elderly (based on
the Beers Criteria)
tramadol
100 mg by mouth
ConZip, Rybix
ODT, Ryzolt,
Ultram, Ultram ER
Ultracet (acetaminophen) Least likely to cause abuse by patient
codeine
120 mg SC/IM; 180
mg PO
NA Tylenol #3, Tylenol #4
(acetaminophen),
Fiorinal (butalbital, caffeine,
aspirin),
Soma Compound
(aspirin/carisoprodol),
Promethazine/Codeine
Fioricet (butalbital, caffeine,
acetaminophen)
May cause severe toxicity in breastfed infant when
mother takes codeine post birth
NA= not available




319


c. uses: moderate to severe acute and chronic pain, acute myocardial infarction, intraoperative analgesia,
antitussive

d. adverse effects

i. life-threatening: respiratory depression, CNS depression, hypotension, bradycardia, syncope, shock,
cardiac arrest

ii. most common: lightheadedness, dizziness, sedation, nausea/vomiting, sweating, dry mouth,
anorexia, urinary hesitancy/retention


e. contraindications

i. respiratory depression, paralytic ileus

ii. CNS depression, head injury, intracranial pressure increase

iii. asthma, COPD, acute abdomen


f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter respiratory rate, blood pressure, bowel pattern, platelets, level of consciousness,
allergic response

ii. accurately time doses to prevent overdose; reverse effects with antidote naloxone

iii. keep emergency equipment immediately available

iv. counteract adverse effects

nausea: administer antiemetic

pruritus: administer antipruritic or antihistamine

constipation

fluid, fiber, ambulation

stool softeners as monotherapy usually ineffective



v. transition client from IV, IM dosing to oral dosing with equianalgesic doses

vi. assist health care team to implement client teaching plan

ask for help when getting up

report rash, dyspnea, inadequate pain management

prevent constipation with fluid, fiber and ambulation

avoid nausea by taking with food

take only as directed, do not exceed recommended dose

AVOID

alcohol, CNS depressants, antihistamines

herbal remedies including chamomile and kava

driving, making important decisions, and dangerous activity





2. Type: opioid agonist-antagonists

a. action: stimulate some opioid receptors and block other opioid receptors; analgesic effect similar to
morphine

b. examples

i. pentazocine (Talwin) 30 mg IM/IV/SC every 3-4 hours

ii. buprenorphine (Buprenex) 300 mcg IM/IV every 6-8 hours

iii. nalbuphine (Nubain) 10 mg IV/IM/SC every 3 to 6 hours as needed


c. uses: mild to moderate pain, adjunct intraoperative analgesia, labor and delivery

d. adverse effects
320


i. reverses other opioids in system

ii. psychotic episodes with very high doses, severe bradycardia, angioneurotic edema and seizures


e. contraindications

i. physical dependence on opioids

ii. pulmonary impairment, cor pulmonale, biliary surgery or disease, hypothyroidism


f. nursing care: screen clients for previous use of opioids


REMEMBER IT
Switching a client from one opioid analgesic to another should be based on an equianalgesic
conversions to give the client similar pain relief.

For example: 10 mg of a parenteral dose of morphine sulfate is equivalent to 30 mg PO
Another example: conversion ratio of oral morphine to transdermal fentanyl is approximately 2:1 so
60 mg/day of oral morphine sulfate is equianalgesic to 25 micrograms/hour of transdermal fentanyl


3. Type: opioid antagonists

a. action: effectively block the action of opioid receptors

b. example: naloxone 0.4-2 mg IV every 2 to 3 minutes

c. uses: reverse adverse effects of opioids including respiratory depression and overdose, neonatal
respiratory depression

d. adverse effects

i. life-threatening

ventricular fibrillation, cardiac arrest and seizures

initiates acute withdrawal in clients physically dependent


ii. most common: elimination of analgesic effect

iii. other

duration of action is shorter than action of opioids

nausea, vomiting, tachycardia, hypertension, hypotension, tremors, withdrawal symptoms,
diaphoresis



e. contraindications: opioid addiction

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter airway, respiratory rate, SaO2,

blood pressure, heart rate and rhythm,
pain intensity

ii. provide information to client

iii. administer with emergency equipment nearby

iv. collaborate with provider and RN for pain management




4. Type: synthetic diphenylheptane derivative

a. action: depresses pain impulse transmission at level of spinal cord

b. example: methadone (Dolophine, Methadose) 15-30 mg by mouth for 1 dose then 5-10 mg
by mouth every 2 to 4 hours PRN
Black Box Warning - incomplete cross-tolerance, respiratory depression, cardiac conduction
effects, opioid addiction treatment

c. use: opioid dependence, severe pain
321


d. adverse effects

i. life-threatening: respiratory depression, hypotension, respiratory arrest, cardiac arrest, QT
prolongation and death

ii. most common: drowsiness, dizziness, headache, nausea, vomiting, anorexia, constipation


e. contraindications: respiratory depression, acute asthma, hypercarbia

f. nursing care: assist health care team to establish baseline data and check prior to initiating therapy
and at regular intervals thereafter

i. establish baseline data and monitor creatinine

ii. signs and symptoms of respiratory depression

iii. assess and monitor pain, vital signs, airway, level of consciousness, pupil reaction to light

iv. opioid intoxication: lack of analgesic effect, clinical indicators of withdrawal

v. assist health care team to implement client teaching plan

report neurologic changes, allergic reactions

avoid CNS depressants, alcohol for 24 hours after administration

change positions slowly, do not drive or engage in dangerous activity





C. Type: non-opioid analgesics

1. Sub-type: NSAIDs

a. action: anti-inflammatory, analgesic, antipyretic, antiplatelet

b. sub-type examples

i. cyclooxygenase-1 inhibitor (COX-1 inhibitor)

ii. cyclooxygenase-2 inhibitor (COX-2 inhibitor)

iii. aspirin



2. Sub-type: acetaminophen

a. action: blocks pain impulses that occur in response to prostaglandin synthesis; antipyretic,
without anti-inflammatory properties

b. example: acetaminophen (Tylenol) 325-1000 mg by mouth/rectally every 4 to 6 hours as
needed, not to exceed 4000 mg daily

c. uses: mild to moderate pain or fever, in combination with opioids

d. adverse effects

i. life-threatening: hepatotoxicity, renal failure, thrombocytopenia

ii. toxicity: nausea, vomiting, abdominal pain, cyanosis, thrombocytopenia, delirium, seizures,
coma


e. contraindications
severe hypovolemia
liver or renal failure, alcoholism


f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter

pain, nausea, vomiting

serum creatinine, liver function tests

temperature

urinary output
322


vital signs, neurologic status


ii. assist health care team to implement client teaching plan

AVOID alcohol

may crush or cut tablets

do not exceed recommended dose

AVOID over-the-counter medications containing acetaminophen

report nausea, vomiting, abdominal pain






D. Type: anti-migraine headache agents

1. Sub-type: triptan

a. action: cause cranial vasoconstriction and migraine headache relief by binding to serotonin (5-
HT1) receptor sites

b. examples

i. almotriptan (Axert) 6.25-12.5 mg by mouth, maximum of 2 doses in 24 hours

ii. naratriptan (Amerge) 1 mg or 2.5 mg by mouth, may repeat in 4 hours, do not exceed 5 mg
in 24 hours

iii. sumatriptan succinate (Imitrex) 25-100 mg by mouth, may repeat after 2 hours if needed, do
not exceed 200 mg in 24 hours


c. use: treatment but not prevention of acute migraine headache

d. adverse effects

i. life-threatening: hypertension, coronary artery vasospasm, ventricular tachycardia and
fibrillation

ii. most common: dizziness, myalgia, weakness

iii. other: paresthesia, feeling hot, cold, or strange


e. contraindications

coronary artery disease, clients with vascular disease, hypertension

older clients, hepatic or renal dysfunction

concurrent use of ergotamine agents, MAO inhibitor


f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter pain, blood pressure, ECG

ii. screen clients for cardiovascular or neurovascular history, drugs containing ergotamine

iii. assist health care team to implement client teaching plan

AVOID triggers: foods containing tyramine , sulfites, etc.

report chest pain, worsening of findings, paresthesia

AVOID pregnancy

do not crush tablets

remain in calm environment, away from noise, light






2. Sub-type: ergot derivatives

a. action: constricts vascular smooth muscle in periphery, cranial vasculature and uterus

b. examples

i. ergotamine with caffeine (Cafergot) 1/100 1-2 tabs by mouth every 30 minutes as needed until
323

attack subsides, up to 6 mg
Black Box Warning - peripheral ischemia

ii. dihydroergotamine (DHE 45) 1 mg IM/IV for 1 dose
Black Box Warning - peripheral ischemia

iii. preventative: beta blockers, tricyclic antidepressants, and antiepileptic drugs


c. uses: treatment of migraine headaches

d. adverse effects

i. life-threatening: coronary vasospasm, hypertension, peripheral vascular ischemia

ii. most common: peripheral numbness, myalgia, nausea

iii. other: numbness of fingers/toes, intermittent claudication, photosensitivity, rebound headache
on withdrawal


e. contraindications: vascular, hepatic, renal impairments and hypertension

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter

pain and clinical indicators associated with headache, including blurred vision, blood pressure, heart
rate

toxicity: nausea, weakness, intolerance to cold

level of consciousness, blurred vision

serum creatinine at baseline


ii. treat overdose with vasodilators, heparin, and dextran

iii. assist health care team to implement client teaching plan

iv. AVOID alcohol and over-the-counter drugs




3. Type: anticonvulsant

a. example: topiramate (Topamax)

b. uses: migraine prophylaxis



E. Other pain relief agents

1. Type: local anesthetics

a. examples

i. lidocaine topical (Lidoderm)

ii. lidocaine/prilocaine topical (EMLA)


b. nursing care: cream must be applied 1 hour before pain is anticipated as in a procedure



2. Type: herbal remedy

a.
example: capsaicin topical

i. apply 3 to 4 times daily; more effective with consistent use

ii. adverse effects: neurotoxicity, burning, erythema, thermal hyperalgesia

iii. nursing care

wear gloves to apply, rub into skin until cream is transparent

wash hands following application
324


assist health care team to implement client teaching plan






F. Adjunct therapy

1. Type: antihistamines

a. examples: promethazine (Phenergan), hydrOXYzine ( Atarax, Vistaril)

b. use: preoperative medication, sedation, enhance analgesic effect, nausea



2. Type: anticonvulsants

a. examples: gabapentin (Neurontin), carbamazepine (Tegretol)

b. use: neuropathic pain



3. Type: steroids

a. example: dexamethasone, predniSONE (Sterapred, Sterapred DS)

b. use: severe bone pain, nerve compression



4. Type: antihypertensive agent and centrally-acting analgesic: alpha-adrenergic agonist

a. example: cloNIDine (Catapres) - do not confuse with KlonoPIN

b. use: chronic pain syndromes




II. Managing Electrolyte Imbalances

A. Type: sodium

1. Action: the major extracellular cation; important in cell membrane function and action
potential, osmotic pressure, acid-base balance, and extracellular fluid volume; controls fluid
movement

2.
Examples

a. 0.9% NaCl (isotonic or normal saline)

b. 0.45% NaCl (hypotonic saline)

c. 3% NaCl (hypertonic)


3. Uses: hyponatremia, provide osmotic pressure, fluid volume expander, maintain
electroneutrality

4. Nursing care

a. assist health care team to establish baseline data and check prior to initiating therapy and
periodically thereafter

i. serum sodium, pH, and osmolality
Clinical Findings Consistent with
High Levels of Sodium
(Hypernatremia)
Clinical Findings Consistent with
Low Levels Sodium (Hyponatremia)
Serum Na+ level > 145 mEq/L

Thirst, elevated temperature, dry
mucous membranes, oliguria,
hyperreflexia; infants exhibit depressed
fontanelles and irritability
Serum Na+ level < 135 mEq/L

Nausea and vomiting; headache;
confusion; lethargy; fatigue; appetite
loss, restlessness and irritability; muscle
weakness, spasms or cramps; seizures;
decreased consciousness or coma

325


ii. fluid status: breath sounds, edema, weight gain, mucous membranes

iii. neurologic status: confusion, lethargy

iv. avoid fluid overload and administer with caution to older, debilitated, and very young
clients


b. assist health care team to implement client teaching plan

i. read food labels for sodium content

ii. daily weight






B. Type: potassium

1. Action: the major intracellular ion; maintains intracellular fluid volume and action potential of cell
membranes; maintenance of myocardial contractility

2. Example: potassium chloride (Klor-Con)

3. Uses: hypokalemia, concurrent diuretic therapy, ventricular dysrhythmias

4. Adverse effects

a. life-threatening: hyperkalemia, arrhythmias, GI obstruction, bleed, and ulcer/perforation

b. most common: nausea, vomiting, flatulence, abdominal pain/discomfort, diarrhea,
hyperkalemia


5. Contraindications: hyperkalemia, delayed GI transit, esophageal stricture, GI obstruction, renal
failure

6. Nursing care - assist health care team to establish baseline data and check before beginning and at
regular intervals during therapy

a. serum creatinine at baseline, acid base balance, potassium
Clinical Findings Consistent with
High Levels of Potassium (Hyperkalemia)
Clinical Findings Consistent with
Low Levels of Potassium (Hypokalemia)
Serum K+ level > 5 mEq/L

Client may experience irregular heartbeat; nausea;
bradycardia; EKG changes include peaked T wave and
depressed P wave, wide QRS complex
Serum K+ level < 3.5 mEq/L

Muscle weakness, aches and cramps; tetany;
hypotension; constipation; arrhythmias


b. ECG

c. administration

i. slow infusion through central line or large vein

ii. stop infusion with client complaints of pain in IV

iii. infuse slowly through large vein since rapid infusion may cause cardiac standstill


d. assist health care team to implement client teaching plan client teaching

i. take only as directed

ii. take with full glass of water

iii. do not crush or chew tablets

iv. need for follow-up care and testing

v. AVOID over-the-counter drugs and salt substitutes

vi. foods containing potassium include raw salmon, avocado, raisins, banana, spinach,
tomatoes



326



C. Type: calcium

1. Action: neuromuscular function, bone strength and density, enzyme activation, blood clotting

2. Examples

a. calcium chloride, calcium gluconate, calcium citrate

b. calcium carbonate (Maalox, Tums)


3. Uses: osteoporosis, hypocalcemia, hypersecretory (HCl) state, hyperphosphatemia,
hypoparathyroidism, life-threatening arrhythmias, adjunct treatment for hypermagnesemia, calcium
channel blocker overdose, prevention of postmenopausal osteoporosis

4. Adverse effects

a. life-threatening: hypercalcemia, nephrolithiasis, arrhythmias, syncope, extravasation necrosis

b. most common: hypercalciuria, hypomagnesemia, constipation, nausea


5. Contraindications

a. hypercalcemia, hypophosphatemia

b. ventricular fibrillation, digitalis toxicity


6. Nursing care - assist health care team to establish baseline data and check prior to initiating
therapy and at regular intervals thereafter

a. serum calcium, magnesium, phosphorous, and albumin
Clinical Findings Consistent with
High Levels of Calcium (Hypercalcemia)
Clinical Findings Consistent with
Low Levels of Calcium (Hypocalcemia)
Serum calcium level > 10.2 mg/dL

Constipation, anorexia, nausea,
abdominal pain, muscle twitches and
weakness, dementia, irritability
Serum calcium level < 8.2 mg/dL

Seizures; extrapyramidal symptoms;
papilledema; muscle stiffness, myalgias,
spasms; positive Chvostek's and Trousseau's
sign; prolongation of QT interval; diaphoresis


b. assess and monitor bone density, orientation, headache, blood pressure, ECG

c. provide adequate vitamin D

d. seizure precautions for hypocalcemia

e. administration

i. IV: infuse slowly in large vein, stop infusion with client complaints of burning, prevent
extravasation

ii. PO: give 1.5 to 2 hours after meals, avoid giving with enteric-coated tablets


f. prevent constipation with fluid, fiber, and exercise

g. assist health care team to implement client teaching plan client teaching

i. do not change antacids

ii. AVOID dehydration

iii. limit vitamin D intake to 400 units daily

iv. establish regular bowel habits with fluids, fiber, and exercise







327



D. Type: magnesium

1. Action: skeletal muscle contraction, energy production, carbohydrate metabolism activation of B-
complex vitamins, protein synthesis

2. Example: magnesium sulfate

3. Uses: ventricular arrhythmias, preeclampsia seizures, tocolysis, hypomagnesemia, torsades de
pointes

4. Adverse effects

a. life-threatening: cardiovascular collapse, respiratory paralysis, hypothermia, depressed cardiac
function, pulmonary edema

b. other:

i. depressed reflexes, hypotension, flushing, drowsiness

ii. depressed cardiac function, diaphoresis, hypocalcemia, hypophosphatemia, hyperkalemia



5. Contraindications: myocardial damage, heart block, diabetic coma

6. Nursing care - assist health care team to establish baseline data and check prior to initiating
therapy and at regular intervals thereafter

a. serum creatinine at baseline, magnesium, urine output
Clinical Findings Consistent with
High Levels of Magnesium
(Hypermagnesemia)
Clinical Findings Consistent with
Low Levels of Magnesium
(Hypomagnesemia)
Serum magnesium level > 2.1 mEq/L

Uncommon -Usually associated with
increased intake; prolonged PR interval and
widened QRS; hyporeflexia, hypotension,
respiratory depression and cardiac arrest
Serum magnesium level < 1.4 mEq/L

Anorexia, nausea, lethargy, weakness,
tetany, positive Trousseaus or Chvosteks
sign, fasciculations, tremor; usually
accompanies hypokalemia and
hypocalcemia


b. client teaching: foods rich in magnesium include tuna, avocado, spinach, rolled oats, yogurt

c. assess and monitor ECG, deep tendon reflexes, blood pressure; respiratory rate




E. Type: phosphorus

1. Action: vitamin B-complex activation, energy production, cell division; carbohydrate, protein, and
fat metabolism, acid-base balance

2. Uses: hyperparathyroidism, osteomalacia, cirrhosis, hypokalemia, excess IV glucose, respiratory
alkalosis

3. Contraindications: renal failure

4. Nursing care: assist health care team to establish baseline data and check prior to initiating therapy
and at regular intervals thereafter

a. serum phosphorus
Clinical Findings Consistent with
High Levels of Phosphorus
(Hyperphosphatemia)
Clinical Findings Consistent with
Low Levels of Phosphorus
(Hypophosphatemia)
Serum phosphorus level > 4.1 mg/dL

Serum phosphorus level < 2.4 mg/dL

328

Usually asymptomatic; similar to
hypocalcemia
Usually asymptomatic; anorexia, muscle
weakness, osteomalacia


b.
client teaching: foods rich in phosphorus include whole wheat and bran mixes, cottage
cheese or cheddar, corn, broccoli, sunflower seeds, garlic, legumes and nuts




III. Managing Pregnancy

A. Dietary supplements

1. Therapeutic class: vitamins

a. type: folic acid (vitamin B9)

i. action important for normal fetal growth and development, especially neurological
development, prevention of folate-deficient megaloblastic anemia

ii. recommended daily intake: 0.4 mg by mouth every day; may use SubQ or IM due to
oral malabsorption

iii. use: prevention of neural tube defects

iv. nursing care

encourage minimum daily intake in women of childbearing age

increase dietary intake of folic acid , including fresh dark, green leafy vegetables,
orange juice, liver, peanuts, whole grains



b. type: multivitamin, prenatal formula

c. type: vitamin K

i. action: essential ingredient in clotting cascade

ii. example: phytonadione (Mephyton)

iii. use: prevention hemorrhagic disease of newborn






2. Therapeutic class: minerals

a. type: ferrous sulfate

i. recommended daily intake

5 mg ferrous sulfate = 1 mg elemental iron

750-1500 mg divided 2 to 4 times a day by mouth for iron deficiency


ii. use: reduce risk of low-birth-weight infants, increase oxygen-carrying capacity of hemoglobin
and increase the number of erythrocytes

iii. nursing care - assist health care team to establish baseline data and check prior to initiating
therapy and at regular intervals thereafter

assist health care team to implement client teaching plan

stool will be very dark, sticky

take with food to avoid nausea

take with source of vitamin C

increase fiber, fluids, and ambulation to prevent constipation; avoid laxatives and stool softeners





b. type: calcium

i. recommended daily intake

adults 1000 mg by mouth daily (in divided doses for maximum absorption)
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tolerable upper level of 2500 mg daily


ii. use: fetal osteogenesis and tooth formation, blood clotting




B. Agents affecting uterine function

1. Therapeutic class: uterine stimulants

a. type: hormone

i. action: oxytocic; act directly on uterine myofibrils to cause contractions

ii. example: oxytocin (Pitocin)
Black Box Warning - not for elective labor induction

iii. use: increase strength and frequency of uterine contractions, induce labor, incomplete
abortion, postpartum hemorrhage

iv. adverse effects

uterine hypertonicity and tetany, abruptio placentae, seizures, postpartum hemorrhage

fetal distress, bradycardia, arrhythmias, seizures with subsequent brain damage and retinal
hemorrhage


v. contraindications: fetal distress, cephalopelvic disproportion (CPD), total placenta previa,
cord presentation or prolapse

vi. nursing care

requires continuous fetal monitoring

observe RN establish baseline data and monitor

assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter

uterine contractions: frequency, duration, and intensity; associate with fetal response

maternal: blood pressure, heart rate, and SaO
2
, fluid balance, urine output, neurologic status,
vaginal bleeding, and pain

fetal: fetal heart tones (FHT)
administer with infusion control device

immediately stop infusion for
fetal distress or abnormal deceleration patterns and maternal hypotension or hemorrhage
priority: stop oxytocin infusion

position mother on left side, lower head if possible; infuse isotonic fluids, administer
supplemental oxygen

observe RN implement client teaching plan: report sustained uterine contractions or vaginal bleeding,
foul-smelling lochia

assist health care team implement client teaching plan: report sustained uterine contractions or vaginal
bleeding, foul-smelling lochia






b. type: prostaglandins

i. action: stimulation uterine contractions and soften cervix allowing for cervical dilatation and
effacement

ii. example: dinoprostone (Cervidil, Prepidil)

iii. use: induce labor and stimulate initial contractions, oxytocin may be started 30 minutes after
insertion

iv. adverse effects

uterine rupture, bronchospasm
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severe bradycardia and hypertension

fetal acidosis and depression


v. contraindications
fetal distress, vaginal bleeding, placenta previa
cesarean section history, uterine hypertonicity and hyperactivity

suspicion of cephalopelvic disproportion (CPD), oxytocin infusion already infusing, 6 or more previous
term pregnancies


vi. nursing care

observe RN establish baseline data and monitor

assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter

maternal vital signs

associated fetal response and fetal heart tones

cervical dilatation and effacement

uterine contractions: frequency, duration, and intensity

provide information

administration

gel-filled syringe: insert applicator in cervical os

suppository: place in posterior fornix of vagina, leave in place for 30 minutes

place rolled-up towel under client hips to prevent escape of gel

provide continuous maternal and fetal monitoring

observe RN implement client teaching plan

assist health care team to implement client teaching plan

remain on bedrest

report vaginal bleeding, sustained contraction, dyspnea





2. Therapeutic class: tocolytics

a. type: electrolytes

i. action: depresses the CNS resulting in less acetylcholine (ACh), inhibited neuromuscular
function, smooth muscle relaxation

ii.
example: magnesium sulfate IV

iii. uses: pre-term labor, anticonvulsant, pregnancy induced hypertension (PIH)

iv. adverse effects

life-threatening: cardiovascular collapse, respiratory paralysis, hypothermia, depressed cardiac function

most common

fetus: transient decrease in variability

depressed reflexes, hypotension, flushing, visual changes, diaphoresis

other

lethargy (may persist for 1 to 2 days after discontinuing therapy)

fewer side effects than beta-adrenergic agonists



v. nursing care - assist health care team to establish baseline data and check prior to initiating
therapy and at regular intervals thereafter

observe RN establish baseline data and monitor

assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter
331

contractions: intensity, duration, frequency
blood pressure, respiratory rate, urine output
seizures, level of consciousness, deep tendon reflexes (DTRs)
serum magnesium - maintain maternal serum magnesium (5.5-7.5 mg/dL)

observe RN establish baseline data and monitor fetal heart tones

do not administer with concurrent calcium channel blocker therapy

antidote : keep calcium gluconate IV at the bedside





b. type: beta-adrenergic agonists

i. example: terbutaline (generic) 0.25 mg SC every 1 to 6 hours
Black Box Warning - tocolysis use

ii. use: inhibit uterine contractions

iii. adverse effects

life-threatening: hypersensitivity, paradoxical bronchospasm, hypertension, QT prolongation, seizures

serious reactions: neonatal hypoglycemia, reactive fetal tachycardia

most common: hyperglycemia

other: nervousness, tremor, headache, tachycardia, palpitations, drowsiness


iv. contraindications: hypertension, arrhythmias, cardiovascular disease, hyperthyroidism

v. nursing care - assist health care team to establish baseline data and check prior to initiating therapy
and at regular intervals thereafter

observe RN establish baseline data and monitor

fetal heart tones, uterine contractions: frequency, duration, and intensity

back pain, bleeding, urine output

provide information

observe RN and assist health care team to implement client teaching plan

report contractions occurring less than every 10 minutes, lower abdominal cramps, rupture of
membranes

report increased pelvic pressure, decreased fetal movement

report chest pain, insomnia





c. type: calcium channel blockers

i. example: NIFEdipine (Procardia)

ii. use: used alone or in combination with terbutaline to relax uterine smooth muscle

iii. life-threatening adverse effects: CHF, pulmonary edema, myocardial infarction, arrhythmias,
severe hypotension

iv. nursing care - assist health care team to establish baseline data and monitor

uterine contractions: frequency, duration, and intensity

maternal back pain, bleeding, urine output

fetal heart tones, fetal movements

provide information


v. assist health care team to implement client teaching plan: report contractions occurring less than
every 10 minutes, lower abdominal cramps, rupture of membranes, increased pelvic pressure,
decreased fetal movement


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C. Agents used with preterm labor

1. Therapeutic class: steroids

a. type: glucocorticoid

i. action: acceleration of maternal and fetal lung maturity

ii. examples

betamethasone (Celestone Soluspan)

dexamethasone


iii. use: preterm labor; to prepare fetus for eminent birth to increase lung maturation

iv. adverse effects

i. increased risk of infection

ii. neonate: lowered cortisol levels, hypoglycemia, sepsis


v. contraindications: systemic fungal disease, heart failure, seizure disorder

vi. nursing care - observe RN establish baseline data and monitor

uterine contractions, fetal movement

fetal movement

temperature and white blood cell



2. Therapeutic class: tocolytics



3. Therapeutic class: antihypertensives

a. type: alpha-adrenergic (centrally acting) vasodilator

i. action: causes selective dilation of arterioles

ii. example: methyldopa (Aldomet) 250-500 mg by mouth daily in divided doses

iii. use: safety and efficacy well-documented for fetus and mother

iv. adverse effects

life-threatening: myocarditis, hemolytic anemia, thrombocytopenia, hepatic necrosis

other

sedation, headache, asthenia, weakness, angina

CHF, orthostatic hypotension, bradycardia



v. nursing care - observe RN establish baseline data and monitor

blood pressure, heart rate, ECG

fetal heart tones and fetal movements

renal and liver function tests, complete blood count

observe RN implement client teaching plan

maintain hydration

do not abruptly discontinue therapy

AVOID over-the-counter medications and hazardous activities

change positions slowly, ask for help before getting up

protect clients (See also: Client protection)




b. type: non-selective beta blocker, such as labetalol (Trandate) 20 mg IV bolus followed by 40-80
mg every 20 minutes up to maximum dose of 300 mg

c. type: direct acting vasodilator, such as hydralazine (Apresoline) 5-10 mg via slow IV injection for
hypertensive crisis; alternatively, may be continuous IV dose


333



D. Diabetes mellitus, gestational and idiopathic

1. Therapeutic class: antidiabetic agent

a. type: insulin

i. lispro, regular, and intermediate acting insulin used in multiple injections

ii. regular insulin used with continuous infusion


b. type: oral hypoglycemic agents (contraindicated in pregnancy)


2. Nursing care

a. anticipate changing insulin needs in pregnancy

i. 1st trimester: insulin dosages may need to be decreased due to enhanced insulin response to
glucose

ii. 2nd and 3rd trimesters: insulin requirements increase


b. maintain blood glucose levels as close to normal as possible




E. Herbal agents

1. Lack of randomized-controlled trials to test safety and efficacy in pregnancy

2. General principles

a. AVOID essential oils

b. AVOID herbs and tonic herbs during first trimester

c. AVOID standardized and highly concentrated forms of herbs

d. AVOID herbal stimulants and laxatives; agents used as abortifacients and to induce
menstruation


3. AVOID: aloe, feverfew, kava, licorice, St. John's Wort and others

4. Use with caution: garlic, ginger, turmeric

5. Sources of vitamins and minerals

a. raspberry leaf: vitamin C and iron

b. oat straw: calcium, magnesium, iron

c. dandelion root: vitamins A and C, beta carotene, potassium



334


F. Pain management in labor and childbirth

1. Information about obstetrical analgesia

a. provide information to client: using anesthetics and analgesics
during labor and childbirth is a balance of risk versus benefit

i. may slow or enhance the progress of labor

ii. may lead to serious adverse effects

maternal: circulatory collapse

fetal distress or sedation



b. use alternative comfort measures alone or in combination
with anesthetic and analgesic agents

c. observe RN assess mother and fetus before initiating pain
management

d. emergency equipment for mother and neonate should
be immediately available

e. client teaching: remain in bed, ask for help before
getting up, empty bladder






Pre-Administration Criteria for Obstetrical Analgesia
Mother
Stable vital signs, SaO2 > 95%

Compliance with cultural considerations

Willingness to receive medication, comply with therapy

No known allergies, co-morbidities, drug dependence, respiratory dysfunction
Fetus
FHT 110-160

Short-term variability present

Deceleration patterns are benign

Acceleration patterns with fetal movement
Labor
Progressing labor with vertex presentation and no complications: station > 0,
cervix > 3-4 cm; established pattern of contractions












335


2. Analgesics used in labor and childbirth

a. type: opioid agonist-antagonist

i. example: nalbuphin (Nubain) 10 mg IV/IM/SubQ every 3 to 6 hours as needed, not to exceed
160 mg/day

ii. adverse effects

sedation, respiratory depression

reverses any opioid in the system


iii. nursing care - observe RN establish baseline data and monitor

pain for type, location, intensity, respiratory rate

frequency, duration, and intensity of uterine contractions

fetal heart tones




b. type: opioid agonists

i. examples

meperidine hydrochloride (Demerol) 50 mg IM every 4 hours

morphine sulfate (Morphine sulfate) 2-10 mg IM, IV every 2 to 4 hours


ii. adverse effects

life-threatening: maternal and fetal respiratory depression, sedation

other:

pruritus, dizziness, nausea, constipation

decreased intensity and frequency of uterine contractions



iii. nursing care

observe RN establish baseline data and monitor
pain for type, location, intensity, respiratory rate
uterine contractions for frequency, duration, and intensity
fetal heart tones

monitor neonate for 4 to 6 hours postpartum for residual respiratory depression

treatment of itching with antihistamine usually increases sedation




c. type: opioid antagonist

i. example: naloxone

ii. use: reverse maternal or neonatal respiratory depression, sedation, and hypotension caused by
opioid agonists and agonist-antagonists

iii. nursing care (neonate): establish baseline data and monitor vital signs frequently for 4
hours in special care area (respiratory depression may recur after naloxone wears off)




3. Anesthesia using local and regional methods

a. local anesthetics

i. action: regional impairment of nerve impulse transmission

ii. examples

procaine (Novocaine)

bupivacaine (Marcaine)
NOTE-Black Box Warning - appropriate use, obstetrical use


iii. uses: local and regional pain management during labor and delivery, alone or in combination
336

with opioid analgesics

iv. adverse effects

life-threatening: CNS toxicity, broad ligament hematoma, perforation of rectum

other: trauma to sciatic nerve


v. contraindications: severe hypovolemia, central nervous system disease, bleeding disorder

vi. nursing care

maternal: observe RN establish baseline data and monitor

blood pressure and heart rate

pain for type, location, intensity; return of sensation

contractions for frequency, duration, and intensity

neonatal: observe RN establish baseline data and monitor fetal heart tones, response to injections

provide information to client about importance of not moving during injection and related transient
discomfort

remain at bedside during injections





b.
nerve block analgesia and anesthesia : affects the uterus, cervix, vagina, and perineum

i. lumbar epidural block

used during first and second stages of labor; onset of action may take
30 minutes

catheter may be left in place for additional injections

major side effect is hypotension

client may exhibit "shiver response" after administration - offer warm
blankets



ii. spinal anesthesia block

first stage for both elective and emergent cesarean births

effects occur within 1 to 2 minutes; generally last 1 to 3 hours

single injection

low spinal anesthesia block may be used for vaginal birth but not suitable for labor

may cause postdural puncture headache

monitor maternal vital signs and fetal heart rate


iii. adverse effects

muscle twitching, dizziness, nausea, itching, shivering, urinary retention

laryngospasm, bronchospasm, respiratory depression, bradycardia, seizures


iv. nursing care

prior to therapy: infuse IV fluids, verify pre-administration criteria; ensure IV access, oxygen, maternal
cooperation, and continuous fetal monitoring

assist client with positioning: either on her side at edge of bed facing middle of bed, pulling knees into
chest, or dangling at bedside with back arched (like a cat)
slowly assist client to labor or childbirth position as directed after injection

establish baseline data and monitor maternal
vital signs every 1 to 2 minutes for 15 minutes, then every 15 minutes
337

pain: including type, location, intensity
contractions: frequency, duration, intensity

establish baseline data and monitor fetal heart tones every 5 minutes for rate, variability, acceleration-
deceleration pattern

client teaching: remain in bed and do not attempt to get up

emergency nursing interventions for maternal hypotension: position in left lateral, increase rate of IV fluids;
apply supplemental oxygen; turn off oxytocin if infusing




c. other anesthesia using local anesthetics

i. pudendal block

injection below pudendal plexus in second stage of labor

low risk of maternal hypotension or fetal depression


ii. local infiltration: injection into soft tissue of perineum, generally given for episiotomy


d. general anesthetics: usually reserved for obstetrical emergencies when fetal demise is expected due to
high risk of fetal depression

i. adverse effects

maternal: postoperative nausea, sedation, high risk of impaired airway

fetal and neonatal: impaired oxygenation, sedation and respiratory depression


ii. contraindications: high-risk fetus

iii. observe RN provide nursing care

maternal

priority to protect airway until gag reflex returns and client is able to maintain airway; and maintain
NPO

monitor vital signs frequently

prevent postpartum hemorrhage

neonatal

establish baseline data and monitor vital signs, especially airway and respirations

provide warmth, quickly dry infant

have emergency equipment immediately available

dedicate one neonatal nurse in delivery area

provide initial maternal-newborn bonding when mother awakens





4. Adjunct therapies for obstetrical pain management

a. therapeutic classes

i. antihistamines

ii. antiemetics

iii. barbiturates


b. uses in labor

i. anxiety, apprehension

ii. antiemetic (except barbiturates)

iii. pregnancy-induced hypertension


c. contraindications: active labor

d. nursing care
338


i. observe RN establish baseline data and monitor maternal

blood pressure, heart rate, respiratory rate and level of consciousness

pain for type, location, intensity

contractions for frequency, duration, and intensity


ii. observe RN establish baseline data and monitor fetal heart tones, response to injections

iii. observe RN provide client teaching - ask for help before getting up




G.
Agent for Rh incompatibility

1. Type: Rh IgG immune globulin

2. Action: suppresses immune response of nonsensitized Rh O (D) negative mothers exposed to Rh O
(D) positive blood from the fetus

3. Examples: human anti-D immune globulin (RhoGAM, HyperRho, WinRho SDF) 1500 IU/300
mcg IV/IM at 28-30 weeks gestation antepartum; 1500 IU IV/IM within 72 hours postpartum
Black Box Warning - intravascular hemolysis with WinRho SDF

4. Use

a. restricted to Rh negative mothers with positive fetus to reduce risk of antenatal sensitization in
mother

i. at 28 weeks gestation with negative antibody screen

ii. within 72 hours of birth if maternalindirectCoombs test and neonataldirectCoombs tests are
negative


b. following amniocentesis, spontaneous or elective abortion, ectopic pregnancy, chorionic villi,
percutaneous umbilical blood sampling, maternal trauma


5. Adverse effects: lethargy, irritation at injection site, fever, myalgia

6. Contraindications: Rh positive client, allergy to blood products

7. Nursing care

observe RN establish baseline data and monitor

verify consent for treatment

considered a blood product - follow agency policy for checking lot number of agent and cross-match

observe RN provide client teaching for Rh negative mothers: drug must be administered within 72
hours after exposure




H. Hemostatic agent - vitamin K1

1. Action: essential component of clotting cascade

2. Example: phytonadione (Mephyton) 1-5 mg IM/IV/SubQ within one hour of birth (IV rate not
to exceed 1 mg/min)
Black Box Warnings - severe reactions, including fatalities, have occurred during and
immediately after IV or IM use

3. Use: prevention of hemorrhagic disease of the newborn



IV. Managing Mental Disorders

A. Information common to psychotropic drugs

1. Consider psychosocial and cultural perspective of client

a. impact on behavior

b. impact on psychotropic drug compliance: unique social stigma about mental illness and
339

psychotropic drugs


2. Make sure client swallows medication to prevent hoarding

3. Assist health care team to establish baseline data and check prior to initiating therapy and
periodically thereafter using standardized rating scales when available

a. negative and positive behavior associated with condition

b. differentiation of psychiatric findings from adverse effects

c. compliance with and adverse effects of therapeutic regimen

d. expected therapeutic effects of psychotropic medication


4. Assist health care team to implement client and family teaching plan

a. take only as directed

b. store away from heat, light, and moisture

c. provide support, encouragement, and community resources

d. provide non-pharmacological strategies to avoid adverse effects; instruct client to take
medication consistently for 4 to 8 weeks before rejecting therapy due to adverse effects

e. identify barriers to compliance, develop collaborative plan to eliminate or minimize

f. psychotropic medication most effective when combined with psychotherapy (counseling)

g. expect drug titration

i. need for follow-up care and testing

ii. use of trial and error with choice of medication and dosing






B. Therapeutic class: antidepressants

1. Information common to antidepressants

a. actions relate primarily to the neurotransmitters norepinephrine (NE), serotonin (5-
hydroxytryptamine or 5-HT) and dopamine to:

i. inhibit the effects of monoamine oxidase

ii. block reuptake of neurotransmitters at the synaptic cleft

iii. regulate receptor sites and neurotransmitter breakdown


b. uses

i. depressive disorders

ii. anxiety disorders (social anxiety disorder, generalized anxiety disorder), obsessive
compulsive disorders, bipolar disorder, childhood enuresis, post-traumatic stress disorder,
diabetic peripheral neuropathic pain and neuropathic pain

iii. off label uses: fibromyalgia, hot flashes, premenstrual symptoms, eating disorders, Tourette
syndrome


c. adverse effects

i. life-threatening: increased suicidal ideation especially in children

ii. most common
anticholinergic effects: dry mouth and eyes, constipation, urinary retention, sedation, insomnia
headache, tremors, fatigue, GI upset
decreased libido and sexual performance, weight gain


iii. other: increased risk of adverse effects in older clients, especially sedation, dizziness,
hallucinations and constipation



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d. nursing care

i. assist health care team to establish baseline data and check prior to init