Académique Documents
Professionnel Documents
Culture Documents
Pts having a MI ( heart attack ) remember MONA = morphine, oxygen, nitroglycerine, and aspirin.
The pathophysiology of HTN includes damage & inflammation of the vessel walls that stimulates the
vessels to thicken, harden, and become narrow. Narrowing causes vasoconstriction and increases
the permeability of the vessel walls leading to the influx of sodium, calcium, water, plasma proteins,
and other substances. Calcium further increases smooth muscle contraction.
Clinical manifestations of HTN result from damage of organs and tissues outside the vascular system.
These include heart disease, renal disease, central nervous system problems, and muscular
dysfunction.
Adenosine is for supraventricular tachycardia.
Epinephrine is given during code to vasoconstrict the periphery & shunt the blood to the central
circulating system. ( hope I explained it right )
Atropine is used in asystole & symptomatic bradycardia.
Lidocaine is the drug of choice for ventricular irritability. It suppresses ventricular ectopy.
Hypokalemia can cause increase in cardiac electrical instability, ventricular dysrhythmias, & increases
risk of digoxin toxicity.
CK-MB if up means myocardial damage, the elevation happens aprox. 4-6 hrs after an acute
ischemic attack. Normal for CK-MB is 0-7 U/L.
Lactic dehydrogenase ( LDH ) increases within 48 hrs of myocardial infarction. Normal is 70-200 U/L.
Mitral Valve Prolapse, valve leaflets protrude into left atrium during systole.
Cardiac:
ACE Inhibitors:
Benazipril ( Lotensin )
Captopril ( Capoten )
Lisinopril ( Zestril )
Enalapril ( Vasotec )
Ramipril ( Altrace )
Quinapril ( Accupril )
Calcium Channel Blockers:
Amlodipine ( Norvasc )
Diltiazem ( Cardizem )
Nicardipine ( Cardene )
Verapamil ( Calan , Isoptin )
Atrial Septal Defect : abnormal opening between atria which causes increased flow of oxygenated
blood to go into right side of heart. Right atrial & right ventrical enlarge. May be closed using cardiac
catheterization or surgically with cardiopulmonary bypass which is done before school age.
Ventricular Septal Defect: characteristic murmur, CHF is common, many times will close by itself if
small-moderate defect.
Patent Ductus Arteriosus ( PDA ): characteristic machine like murmur , can be asymptomatic or s/s of
CHF, wide pulse pressure & bounding pulses.
Coartication of the aorta: narrowing near insertion of ductus arteriosus. S/S of CHF in infants, HTN &
bounding pulses in arms but weak or absent femoral pulses, low extremities may be cool.
Tetrology of Fallot
Tetra means four so it consists of four defects:
pulmonary artery stenosis
hypertrophy of right ventricle
venticular septal defect
overriding of aorta
Dx of Tetrology of Fallot is done by chest x-ray that shows a typical boot shaped heart. An
echocardiogram, 3 dimentional echocardiography, & cardiac cath help to confirm diagnosis.
s/s of TOF include: " blue spells or tet spells " relieved by having child squat. Murmur may be present.
Poor growth, clubbing of fingers.
Beta Blockers:
Used for angina, dysrhythmia, HTN, migraine, prevent MI, & glaucoma. Contraindicated in asthma,
bradycardia, CHF, severe renal/hepatic disease, CVA, & hyperthyroid. May mask hypoglycemia so
monitor diabetics closely.
Side Effects : hypotension, bradycardia, bronchospasm, dizziness, hyperglycemia to name a few.
Atenolol ( Sectral )
Labetolol ( Normodyne, Vescal )
Metoprolol ( Lopressor, Toprol )
Propranolol ( Inderal )
Nadolol ( Corgard )
Hold if BP or pulse not within prescribed parameters. Call MD for orders. Follow hospital/facility policy.
In diastole, that is where the ventricles relax & fill with the blood.
There are 4 valves in the heart.
The apical pulse sometimes can be seen in children with thin chest walls.
Cardiac tamponade is caused by pericardial fluid that accumulates & compresses the heart.
Virchow's Triad is slowed circulation, altered blood coagulation and trauma to a vein that can lead to
thrombus formation.
The SA node is the natural pacemaker of the heart.
The pulmonary veins return the oxygenated blood from the lungs.
Starling's law = The greater stretch of the myocardium results in a stronger ventricular contraction.
Cardiac output is the amount of blood that is pumped out of the left ventricle every minute.
-caine ;
-cillin;
-dine ;
-done;
-ide;
-lam;
-mide ;
-mycin ;
-nium;
-olol;
-oxacin ;
-pam ;
-pril ;
-prazole;
-sone ;
-statin ;
-vir;
-zide;
local anesthetics
antibiotic
anti-ulcer ( H2 blocker )
opioid analgesic
oral hypoglycemics
antianxiety
diuretic
antibiotic
neuromuscular blocking
beta blocker
antibiotic
antianxiety
ACE inhibitor
proton-pump inhibitor
steroids
cholesterol
antiviral
diuretic
gr 1 = 60 mg
gr 5 = 300 mg
gr 15 = 1000 mg = 1 gram
1 oz = 30 ml = 30 cc
1 dr = 4 ml
1 Tbsp = 15 ml = 3 tsp
anticholinergic meds:
can't see
can't pee
can't spit
can't shit
Gout Meds: Probenecid (Benemid), Colchicine, Allopurinol (Zyloprim)
Theophylline: tx of asthma or COPD. Therapeutic drug level: 10-20
To Reverse Toxicity:
heparin=
protamine sulfate
coumadin=
vitamin k
ammonia=
lactulose
acetaminophen=
n-Acetylcysteine.
Iron=
deferoxamine
Digitoxin, digoxin= digibind.
Alcohol withdraw= Librium.
Know your onset, peak, and duration of action for your meds.
1) The onset is the time it takes to reach the minimum effective action after a drug is given.
2) The Peak happens when the drug reaches its highest blood or plasma concentration.
3) The duration of action is how long the drug maintains its effect.
The Main Route of Drug Excretion is through the kidneys. Other routes of excretion are: breast milk,
Ketorolac ( toradol ) for short term pain management. Do not give longer than 5 days.
60gtts = 1 tsp
3 tsp = 1 Tbsp
6 tsp = 1 ounce
2 Tbsp = 1 ounce
6 oz = 1 teacup
8 oz = 1 glass
8 oz = 1 cup
Diseases that can affect a drugs response are:
- cardiac disease
- gastrointestinal disease
- liver disease
- kidney disease
Anticholinergic agents cause Dry mouth, urinary retention and constipation.
Phenazopyridine (Pyridium)--Urine will appear orange.
Dexamethasone used to decrease cerebral edema and pressure.
Remember, when it comes to iron administration:
Iron supplements IM or IV----iron dextran
(IV route is preferred)
IM causes pain, skin staining, higher
incidence of anaphylaxis
Take oral supplements with meals if
experience GI upset
Then resume between meals for max
absorption
Use straw if liquids are used
Diltiazin (Cardizem) a calcium-channel blocker, inhibits Ca++ transport in heart and vasculary muscle
cells therefore inhibiting excitation and subsequent contraction.
Ace Inhibitors can cause hyperkalemia and chronic cough- pt's should
not use salt substitutes because they are mostly made from K+ which
will further increase the K+.
Tylenol = Liver toxic (no more than 4 g/day) Give Mucomyst for
overdose. Whereas, Ibuprofen = kidney toxic .
Alkylating Agent: [ Cisplatin ( Platinol ) ] - used for lymphoma; myeloma; melanoma; osteosarcoma;
cervical,ovarian,testicular,lung,esophageal,and prostate cancers.
Cisplatin caauses nephrotoxicity and ototoxicity, ensure adequate hydration and give diuretics prior to
therapy. Have client void every hour or insert foley before therapy. Assess for hearing loss/deficits.
Carbidopa/Levodopa ( Sinemet )- tx for Parkinson's, carbidopa prevents metabolism of levodopa and
allows more levodopa for transport to brain. Levodopa ( Larodopa ) should be d/c'd 8 hours before
statring Sinemet.
Bromocriptine ( Parlodel ) - tx of Parkinson's, amenorrhea, galactorrhea, female infertility, suppression
of postpartum lactation, acromegaly.
Ropinirole ( Requip ) - tx of idiopathic Parkinson's disease.
Quinidine - give with food, monitor electrolytes, monitor liver and kidney function, encourage patient
to report dizziness or faintness immediately.
Used in a-fib and a-flutter.
Alprazolam ( Xanax )- antianxiety agent, usual dose is 0.25-0.5 mg two to three times daily. Side
effects: drowsiness, dizziness, lethargy, confusion.
Amlodipine ( Norvasc )- CCB used for systemic vasodilation and decreased blood pressure.
Coronary vasodilation and decreased frequency and severity of angina. CONTRAINDICATION BP
<90mmHg.
Fosinopril ( Monopril )- tx of hypertension and CHF; dosage is 5-40 mg once daily max dose in a
day is 80mg
Rosiglitazone ( Avandia )-tx type 2 diabetes; dosage is 4-8 mg as a single daily dose or in 2 divided
doses ( use cautiously if edema or CHF )
When using a bronchodilator inhaler in conjunction with a glucocorticoid inhaler, administer
the bronchodilator first.
Theophylline increases the risk of digoxin toxicity and decreases the effects of lithium and Dilantin.
Long term use of amphogel (binds to phosphates, increases Ca, robs the bones...leads to increased
Ca resortion from bones and WEAK BONES).
Thiazide diuretics increase blood sugar.
Aldosterone conserves sodium and promotes potassium excretion which helps to control sodium and
water balance.
Prozac (a SSRI) side effects are diarrhea, dry mouth, weight loss, reduced libido.
Types of Bronchodilators:
Beta Adrenergic Agonists
Albuterol ( Proventil, Ventolin )
Metaproterinol ( Alupent )
Terbutaline
Bitolerol
Levalbuterol ( Xopenax )
Pirbuterol
Salbutamol ( Serevent )
Anticholinergic
Ipratropium bromide ( Atrovent )
Oxitropium bromide ( Oxivent )
Methylxanthines
Aminophylline
Theophylline ( Slo-Bid or Theo Dur )
Giving Eye Drops
1. ) Wash hands
2.) Have the person either lie down or sit down and look upwards.
3.) Using clean technique. Clean eyes with a separate cloth for each eye. Remove any exudate from
inner canthus outwards.
4.) Gently pull skin down below the affected eye(s) to expose the conjunctival sac.
5.) Give the drops per MD orders. Be careful not to let the dropper tip touch eyelashes or eyelids.
6.) Gently press on the lacrimal duct with sterile gauze or tissue for 1-2 minutes to prevent systemic
absorption via the lacrimal canal.
7.) Have the person keep eyes closed for 1-2 minutes afterwards to promote better absorption.
*Due to their mood lifting effects, depression medications often cause dependency.
*Withdrawal from depression medication can cause new symptoms and/or bring back old ones.
Chicken Pox:
Diptheria:
Lyme Disease:
Typhoid Fever:
tx with Acylovir
tx with diptheria antitoxin, penicillin; erythromycin
tx with tetracycline;penicillin
tx with chloramphenicol; ampicillin; sulphatrimethoprim
* Never, never leave any meds for any reason at a patient's bedside.
* Never leave a meds out of your site.
* Never give a med if the patient says it does not look like what they usually take. Go back and double
check again.
* Don't give any meds that another nurse dispensed.
* Never guess when giving medications. Double check dosages, double check calculations, ask when
in doubt. Take no chances. Triple check with the MAR. Call MD if there is any doubt about the
medication. Better safe than sorry.
* Always wash your hands before preparing someone's medications.
A major goal for the pt with COPD is that the pt. will use a breathing pattern that does not lead to
tiring and to plan activities so that he/she does not become overtired. Care should be spaced,
allowing frequent rest periods, and preventing fatigue.
Ethambutol, isonazid,
* The trachea lies just in front of ( anterior ) to the esophagus and is 10 to 11cm long in adults.
*Unequal chest expansion happens with flail chest, pneumonia, part of the lung is either obstructed or
collapsed or with guarding to avoid post-op insision pain or pleurisy.
*Persistant fine crackles scattered across the chest happen with pneumonia, bronchiolitis, or
atelectasis.
*In emphysema there is destruction of the alveolar walls and patient will often present with a barrel
chest.
Pertussis [ Whooping cough ]
What it is: Comes from Bordetella pertussis has an incubation period of 5-21 days with an average of
10 days. Source of infection is from the respiratory tract of infected person. It is transmitted by direct
contact or droplet spread from infected person; indirect contact from freshly contaminated articles.
What to do? Isolation during the catarrhal stage, start respiratory precautions.
Give antimicrobial therapy as ordered. Give pertussis-immune globulin as ordered. Reduce
environmental factors that promote coughing, such as dust, smoke, and sudden temperature
changes. Use a humidifier or tent to increase humidity.
Remember, the cough is severe. During the convalescent phase, respiratory precautions are no
longer needed.
When you go to change the trach ties,be sure to remove old ties with non-sterile gloves, then put on
sterile gloves to apply clean ties.
Mechanical Ventilators:
Can be short term, long term or in between!!!
As the nurse:1) assess pt. first then the vent 2) assess vitals, resp. rate and breathing pattern 3)
monitor color of lips & nail beds 4) monitor chest for symetry 5) assess need for suctioning & observe
type, color, and amount of secretions 6) check pulse ox 7) check alarms on vent 8) empty vent
tubings when moisture collects 9) turn pt. every 2 hours and prn 10) have resuscitation equipment by
bedside
Causes of Alarms:
High Pressure Alarm- a) increased secretions in the airway
b) wheezing or bronchospasm
c) displaced ET tube
d) obstructed ET tube( check 4 kinks )
e) pt coughing, gaging, bites tube
f) pt. fighting vent (bucking)
Low Pressure Alarm- a) disconnection or leak
b) pt.stops spontaneous breathing
Some Signs/Symptoms of Hypoxia
* fatigue
* dyspnea
* cyanosis
* anxiety/apprehension
* decreased concentration
* altered level of consciousness
* vertigo
* increased pulse rate
* faster and deeper respirations ( advanced hypoxia respirations get slower and more shallow
* increased blood pressure
* pallor
* dysrhythmias
* clubbing of nails if prolonged/chronic
Normal ABG's
pH = 7.35 to 7.45
Paco2 = 35 to 45 mm Hg
Pao2 = 80 to 100 mm Hg
HCO3 = 21 to 28 mEq/L
O2 saturation = over 95%
In older adults with pneumonia, hydration is very important as it helps to thin secretions and promotes
expectoration.
Dyspnea is labored breathing aka. shortness of breath.
Your lungs consist of 5 lobes. The right lung has 3 lobes and the left lung has 2 lobes.
Things that increase airway resistance ( make it difficult to get enough air ):
asthma-where the bronchial smooth muscle contracts
chronic bronchitis- where there is a thickening of the bronchial mucosa
obstruction of the airway- as in a tumor, an object swallowed that gets stuck, or mucus
loss of lung elasticity- as in emphysema
Eupnea is normal breathing - rate is usually 12 - 18 breaths per minute
Bradypnea is slower than normal breathing - rate is less than 10 bpm with normal depth and rhythm is
regular
Tachypnea is faster than normal breathing - rate is over 24 bpm and usually rapid & shallow
A cough that changes in character should cause suspicion of possible lung cancer.
Pulmonary ventilation
*movement of air into the lungs which is inspiration
*movement of air out of the lungs which is exhalation
External Respiration
*the movement of oxygen from the lungs to the blood
*the movement of carbon dioxide from the blood to the lungs
Three Regions of the Pharynx ( also known as your throat )
*nasopharynx
*oropharynx
*laryngopharynx
Your Trachea ( windpipe )
Functions as an air passageway and it cleans, warms, and moistens the incoming air.
Four Measurements ( respiratory volumes ) - values are set using a spirometer
* Tidal Volume - amount of air inhaled or exhaled with each breath when resting
* Inspiratory Reserve Volume - air that can be inhaled during forced breathing in addition to the
resting tidal volume
* Expiratory Reserve Volume - is the amount of air that can be exhaled during forced breathing in
addition to tidal volume
* Residual Volume - amount of air that remains in the lungs after a forced exhalation
Surfactant - decreases surface tension which 1) lowers the effort needed to expand the lungs 2)
lessens the risk for the alveoli to collapse.
40 mm Hg is the typical partial pressure of oxygen in the cells of the body.
Atelectasis (post-op):
Collapsed alveoli
*Usually caused by bronch secretions
*not coughing & deep breathing
*may be all or part of the lung
S&S
*restless
*tachycardia
*decrease PaO2
*decrease cap refill
*tachypnea
*fever/infection - tx with abx
*inadequate chest expansion
*dullness of percussion
Treat post-op atelectasis:
* Enc to cough & deep breath ( huff )
* respiratory activity as prescribed
* reposition
Post -Op Hemorrhage
hemothorax - hypovolemia - shock
S&S - decrease BP/ increase pulse rate
restless - pallor
decrease CVP - decrease urinary output
PVC or A-Fib on heart monitor
Give fluids and blood, may need to return to surgery
Pulmonary Edema
* lungs do not expand fast enough & circulatory overload
early S&Sx
*cough
*dyspnea
*restless
*anxiety
*low pitch wheezes
Late S&Sx
*acute dyspnea
Hypothyroidism is when your thyroid doesnt produce enough hormones. The thyroid hormones T3
and T4 help regulate your bodys metabolism and how you use energy.
Addisons disease, a rare disorder, develops when the adrenal glands do not produce enough of the
hormone cortisol. Sometimes, the adrenal glands also dont produce enough of the aldosterone
hormone.
Common Signs/symptoms
*weakness
*fatigue
*abdominal pain
*nausea
*weight loss
*low blood pressure
*darkened skin (in the case of Addisons disease)
*salt craving (in the case of Addisons disease)
*dizziness upon standing
*depression
Treatment of Addisons disease involves replacing the cortisol and/or aldosterone that your body is
not able to produceor that it secretes in an insufficient quantity.Cortisol is replaced with an oral
synthetic glucocorticoid. The drug is taken one or two times each day. Generic drug names for
glucocorticoids include hydrocortisone, prednisone, and dexamethasone.
Here is what a man who is an AMAZING teacher told me:
The Pituitary gland is like the president, the hypothalamus is the vice-president. All the other glands
are all the heads of states. Does the president just automatically know what is going wrong in the
states? No they talk to the vice president who tells it to the president who in turn reacts.
He also told me that all hormones with an S are from the pituitary and that the S stands for
stimulate.
Cushings Disease/Syndrome
Results from excessive glucocorticoids.
S&S:
Obesity - centripetal truncal and livid purple striae
Hypertension and headache
Moon face and Facial plethora and acne
Osteopenia and back pain and proximal myopathy
Thin fragile skin and bruising
Avascular necrosis of femoral head
Diabetes and IGT
Psychosis and neuropsychatric disorders
Menstrual disorders and impotence
Dorsocervical fat pad "Buffalo hump"
Impaired growth in children
Septicaemia, Immunosuprresion, TB reactivation
TX: When Cushing's syndrome is caused by glucocorticoids that are taken for another medical
condition, stopping the glucocorticoids often resolves symptoms. But, in most cases, the body has
adapted to the presence of the glucocorticoids, and they must be tapered off gradually to allow the
pituitary and adrenal glands to resume normal function.
When Cushing's syndrome results from an ACTH-producing tumor of the pituitary gland (Cushing's
disease), treatment may include surgery, radiation, or medication to lower cortisol levels.
The thyroid gland makes two hormones, thyroxine-T4 (with four iodines) and triiodothyronine T3 (with
three iodines). T4 blood levels are higher than those of T3, but T3 is four times more potent. Normally
the body converts T4 to T3 as needed.
The pathophysiology of all types of diabetes is related to the hormone insulin, which is secreted by
the beta cells of the pancreas.
Insulin should be stored in a refrigerator and must be taken out 15- 20 minutes before being given to
the patient. The nurse should take care that the injection locations don't repeat daily. As different sites
will have varied absorption ability, it is preferable to change the sites occasionally. A record of the
different sites where the injections are given to the patient should be maintained.
Most of the disorders of thyroid function are related to hypersecretion (hyperthyroidism) and
hyposecretion (hypothyroidism) of thyroid hormones. There are three common causes of
hyperthyroidism in adults: Grave's disease, toxic multi-nodular goiter, and toxic adenoma. Thyroid
storm is an exacerbation of all of the signs and symptoms of hyperthyroidism and is a true medical
emergency.
Hypothyroidism is a condition characterized by inadequate or low levels of thyroid hormones. There
are various causes, one of which is chronic thyroiditis (Hashimoto's Thyroiditis). Long-standing
hypothyroidism may result in myxedema
SIADH is characterized by high levels of ADH when the normal process for it's stimulation is not
working. It is associated with some forms/kinds of cancer and transient SIADH may follow pituitary
surgery as the stored ADH may then be released unregulated,
Main Features are water retention, sodium loss, urine sodium losses, improvement in hyponaturemia
with water restriction, thirst, impaired taste, anorexia, dyspnea on exertion,edema, fatigue,
nausea/emesis, basically the same symptoms you'd expect with hyponaturemia ( low sodium ) is
what you'll see.
In SIADH, high levels of ADH interfere with renal function which leads to hyponaturemia and hypoosmolarity. SIADH is associated with some kinds of cancers because of ectopic secretion oF ADH by
the tumor cells.
In an average cardiac arrest you have a mixed acidosis-low cardiac output and tissue hypoperfusion
causes lactic acidosis; but, ventilation is also depressed in cardiac arrest, which leads to respiratory
acidosis. If they are talking about a hospitalized pt who would be getting O2 and bagged, go with the
lactic acidosis answer.
Train cars carrying oxygen was just some little thing my prof used for my first nursing class to get us
to understand the relationship between H&H and oxygen/perfusion... just a stupid thing from class
http://nursetoday.net/nclex-question...ral-therapies/
http://nursetoday.net/nclex-question...ion-nutrition/
http://nursetoday.net/more-nclex-questions-rationales/
http://nursetoday.net/nclex-question...ial-reduction/
Study Summary
Change from "A-B-C" to "C-A-B." A major change in basic life support is a step away from the
traditional approach of airway-breathing-chest compressions (taught with the mnemonic "A-B-C") to
first establishing good chest compressions ("C-A-B"). There are several reasons for this change.
Most survivors of adult cardiac arrest have an initial rhythm of ventricular fibrillation (VF) or
pulseless ventricular tachycardia (VT), and these patients are best treated initially with chest
compressions and early defibrillation rather than airway management.
Airway management, whether mouth-to-mouth breathing, bagging, or endotracheal intubation,
often results in a delay of initiation of good chest compressions. Airway management is no
longer recommended until after the first cycle of chest compressions -- 30 compressions in 18
seconds. The 30 compressions are now recommended to precede the 2 ventilations, which
previous guidelines had recommended at the start of resuscitation.
Only a minority of cardiac arrest victims receive bystander CPR. It is believed that a significant
obstacle to bystanders performing CPR is their fear of doing mouth-to-mouth breathing. By
changing the initial focus of resuscitation to chest compressions rather than airway maneuvers,
it is thought that more patients will receive important bystander intervention, even if it is limited
to chest compressions.
Basic life support. The traditional recommendation of "look, listen, and feel" has been removed from
the basic life support algorithm because the steps tended to be time-consuming and were not
consistently useful. Other recommendations:
Hands-only CPR (compressions only -- no ventilations) is recommended for the untrained lay
rescuers to obviate their fears of mouth-to-mouth ventilations and to prevent
delays/interruptions in compressions.
Pulse checks by lay rescuers should not be attempted because of the frequency of falsepositive findings. Instead, it is recommended that lay rescuers should just assume that an adult
who suddenly collapses, is unresponsive and not breathing normally (eg, gasping) has had a
cardiac arrest, activate the emergency response system, and begin compressions.
Pulse checks by healthcare providers have been de-emphasized in importance. These pulse
checks are often inaccurate and produce prolonged interruptions in compressions. If pulse
checks are performed, healthcare providers should take no longer than 10 seconds to
determine if pulses are present. If no pulse is found within 10 seconds, compressions should
resume immediately.
The use of end-tidal CO2 (ETCO2) monitoring is a valuable adjunct for healthcare
professionals. When patients have no spontaneous circulation, the ETCO2 is generally 10
mm Hg. However, when spontaneous circulation returns, ETCO2 levels are expected to
abruptly increase to at least 35-40 mm Hg. By monitoring these levels, interruptions in
compressions for pulse checks become unnecessary.
CPR devices. Several devices have been studied in recent years, including the impedance threshold
device and load-distributing band CPR. No improvements in survival to hospital discharge or
neurologic outcomes have been proven with any of these devices when compared with standard,
conventional CPR.
Electrical therapies
Advanced cardiac life support. Good basic life support, including high-quality chest compressions
and rapid defibrillation of shockable rhythms, is again emphasized as the foundation of successful
advanced cardiac life support. The recommendations for airway management have undergone 2
major changes: (1) the use of quantitative waveform capnography for confirmation and monitoring of
endotracheal tube placement is now a class I recommendation in adults; and (2) the routine use of
cricoid pressure during airway management is no longer recommended.
As they did in 2005, the AHA acknowledges once again that as of 2010, data are "still insufficient ...to
demonstrate that any drugs improve long-term outcome after cardiac arrest."
Several important changes in recommendations for dysrhythmia management have occurred:
For symptomatic or unstable bradydysrhythmias, intravenous infusion of chronotropic agents
(eg, dopamine, epinephrine) is now recommended as an equally effective alternative therapy
to transcutaneous pacing when atropine fails;
As noted above, transcutaneous pacing for asystole is no longer recommended; and
Atropine is no longer recommended for routine use in patients with pulseless electrical activity
or asystole.
Post-cardiac arrest care. Post-cardiac arrest care has received a great deal of focus in the current
guidelines and is probably the most important new area of emphasis. There are several key highlights
of post-arrest care:
Induced hypothermia, although best studied in survivors of VF/pulseless VT arrest, is generally
recommended for adult survivors of cardiac arrest who remain unconscious, regardless of
presenting rhythm. Hypothermia should be initiated as soon as possible after return of
spontaneous circulation with a target temperature of 32C-34C.
Urgent cardiac catheterization and percutaneous coronary intervention are recommended for
cardiac arrest survivors who demonstrate ECG evidence of ST-segment elevation acute
myocardial infarction regardless of neurologic status. There is also increasing support for
patients without ST-segment elevation on ECG who are suspected of having acute coronary
syndrome to receive urgent cardiac catheterization.
Viewpoint
The AHA 2010 guidelines represent significant progress in the care of victims of cardiac arrest. Most
important is the stronger emphasis on post-cardiac arrest care. Induced hypothermia is underscored,
and perhaps the most important advance is the recommendation for urgent percutaneous coronary
intervention in survivors of cardiac arrest. The wealth of data thus far indicate that post-arrest
percutaneous coronary intervention may be the most significant advance toward improving survival
and neurologic function since defibrillation was first introduced decades ago.
In reviewing these guidelines, I must admit, however, that I was disappointed that AHA hesitated to
adopt the concepts of "cardiocerebral resuscitation" (CCR). CCR also promotes the "C-A-B"
approach to resuscitation, but it fosters even further delays in airway intervention -- withholding any
form of positive pressure ventilations, in favor of persistent chest compressions, for as long as 5-10
minutes after the cardiac arrest. The current guidelines recommend withholding positive pressure
ventilation for a mere 18 seconds. First described in 2002,[1] CCR has been studied more recently as
well and demonstrated marked improvements in rates of resuscitation and neurologic survival.[2-4] I
think that CCR should be incorporated into basic life support protocols for victims of primary cardiac
arrest as quickly as possible to further improve outcomes.
Optimal management of cardiac arrest in the current decade can be summarized simply by "the 4
Cs": Cardiovert/defibrillate, CCR, Cooling, and Catheterization.
Medscape: Medscape Access
TOP 100 MEDS : Brand Name & Generic (NEED TO KNOW ALL)
Lortab
Synthroid
Levothyroxine Sodium
Prinivil, Zestril
Lisinopril
Zocor
Simvastatin
Amoxil
Amoxicillin Trihydrate
Zithromax, Zmax
Azithromycin Dihydrate
Lipitor
Atorvastatin Calcium
Glucophage
Metformin Hydrochloride
Hydrochlorothiazide
Hydrochlorothiazide
Xanax
Alprazolam
Toprol-XL
Metoprolol Succinate
Tenormin
Atenolol
Lasix
Furosemide
Norvasc
Amlodipine Besylate
Ambien, Ambien CR
Zolpidem Tartrate
Potassium Chloride
Potassium Chloride
Lopressor
Metoprolol Tartrate
Percocet
Zoloft
Sertraline Hydrochloride
Prilosec
Omeprazole
Nexium
Esomeprazole Magnesium
Prednisone
Prednisone
Lexapro
Escitalopram Oxalate
Coumadin
Singulair
Montelukast Sodium
Cipro (XR)
Ciprofloxacin Hydrochloride
Motrin
Ibuprofen
Plavix
Clopidogrel Bisulfate
Prozac
Fluoxetine Hydrochloride
Ultram
Tramadol Hydrochloride
Keflex
Cephalexin
Ativan
Lorazepam
Klonopin
Clonazepam
Celexa
Citalopram Hydrobromide
Bupropion Hydrochloride
Neurontin
Gabapentin
Darvocet
Zestoretic, Prinzide
Dyazide
Augmentin (XR)
Flexeril
Cyclobenzaprine Hydrochloride
Bactrim
Effexor (XR)
Venlafaxine Hydrochloride
Prevacid
Lansoprazole
Advair
Desyrel
Trazodone Hydrochloride
Paxil (CR)
Paroxetine Hydrochloride
Allegra
Fexofenadine HCl
Flonase
7.The Law of Empathy: Leaders are sensitive to and aware of the needs, feelings and motivations of
their people.
8.The Law of Resilience: Leaders bounce back from the inevitable setbacks, disappointments and
temporary failures experienced in the attainment of any worthwhile goal.
9.The Law of Independence: Leaders know who they are, what they believe in and they think for
themselves.
10.The Law of Emotional Maturity: Leaders are calm, cool and controlled in the face of problems,
difficulties and adversity.
11.The Law of Excellence: Leaders are committed to excellent performance of the business task
and to continuous improvement.
12.The Law of Foresight: Leaders have the ability to predict and anticipate the future.
Speak clearly, directly, and honestly with short, unemotional answers. Sarcasm and wisecracks
should not be a part of the testimony.
Think about what to say before saying it. Do not blurt out an answer. For example:
1. If you are asked a question about a document, don't hesitate to ask to see the
document before responding to the question.
2. If you are asked a hypothetical question, note the differences from the actual case
before responding to the question.
Answer the question asked of you. Nurses, often use rephrasing techniques in practice to elicit
information from patients. This technique should not be used when giving testimony. Keep in
mind, the witness is to answer questions, not to ask them.
Stay alert. If you are tired and need a short break, ask for one. This is an accepted practice for
witnesses.
Do what your attorney advises. If you are concerned about a line of questioning, explain your
concerns to your attorney during a break.
The don'ts:
Don't guess. If you don't know the answer, say so. It is better to admit to a gap in knowledge
than to give the wrong answer.
Don't waste energy trying to anticipate what the plaintiff s attorney is leading up to. (If you are a
witness for the plaintiff, the attorney should have briefed you fully prior to the testimony.)
Don't apologize. If you don't remember what happened, say "I don't recall."
Don't be caught off guard. Attorneys use different approaches. For example, an attorney might
switch from a hostile manner to a soft spoken one or from a friendly attitude to an unfriendly
one in an effort to manipulate the witness.
Don't be evasive.
Don't take any documents to a deposition or other session that you were not asked by counsel
to bring.
Don't use medical jargon. Speak in laymen's terms. Don't try to convince the lawyers; try to
convince the jury or judge.
(1996) points out that some hospital policies have not kept up with the changing role of the nurse and
that an employer's policy may not cover nurses off-duty or volunteering in a community role.
O'Sullivan (1996) also advises that nurses can no longer assume the hospital will provide the best
defense in lawsuits as a hospital attorney's primary concern will be the hospital; concern for the nurse
will be secondary.
There are also a number of myths about liability insurance in the nursing profession. One myth is that
a nurse runs a greater risk of being sued if the nurse has liability insurance. "In reality, lawyers
normally do not know if the nurse named in lawsuits has extra insurance or not" (O'Sullivan, 1996).
Another myth is that a nurse who purchases liability insurance is no longer covered by an employer's
policy. It is illegal for an employer's policy to drop an employee because he/she has liability insurance.
ANA Continuing Education | ANA: ANA Nursing Risk Management Series: I: An Overview of Risk
Management
Vicodin (hydrocodone)
Oxycontin
Oxycodone
Codeine
Methadone
In addition to the prescribed opiates mentioned, the illegal drug, Heroin is also an opiate.
How Does Suboxone Help?
Suboxone (buprenorphine + naloxone) has been approved for the treatment of opiate dependence. It
is actually two drugs in one pill.
Buprenorphine - This is the active ingredient in Suboxone. Buprenophine is a partial opioid
agonist, meaning it can both activate and block opiate receptors, depending on the clinical
situation.
Naloxone - This drug is an opiate antagonist, meaning it blocks the effects of opiates. When
Suboxone is taken under the tongue as prescribed, naloxone is not absorbed in sufficient
amounts to have a clinical effect. Because Suboxone is an opiate agonist (a molecule that can
trigger a receptor), there is a risk of misuse by people addicted to opiates. To prevent this,
naloxone was combined with buprenorphine. If Suboxone is crushed and injected in hopes of
getting an opiate "high," naloxone blocks the effect of opiates, producing severe withdrawal
symptoms.
Important Warning!
If Suboxone is chewed or crush and injected, the naloxone contained in the drug will produce severe
opiate withdrawal symptoms.
How Does Suboxone Help Beat Opiate Addiction
When opiates are taken into the body, they attach to receptors in the brain, causing dopamine
release and euphoria.
Eventually, opiates leave the receptors causing the feelings of euphoria to fade and the
symptoms of withdrawal to begin.
As more of the receptors become empty, the withdrawal symptoms worsen. At this point,
Suboxone therapy can begin.
When Suboxone is taken, the buprenorphine attaches to the receptors in the brain once
occupied by opiates. Because the receptors are no longer empty, withdrawal symptoms
diminish.
Buprenorphine attaches firmly to the receptors, filling them and blocking other opioids from
occupying those receptors. Buprenorphine has a much longer duration of action than do other
opioids, so the effects do not wear off quickly as is the case with opiates.
Because there are no withdrawals, the person can stop taking opiates and start working on
kicking his opiate habit.
Patients have better long term success when the medication is combined with an outpatient therapy
program.
ANSWERS:
1. The answer is: Helping the patient to bathe
2. The answer is: Oral hygiene
3. The answer is: A patient scheduled to have a chest x-ray done
4. The answer is: The only patient you wouldn't give the new nurse is the patient in
sickle cell crisis with multiple IV medications.
5. The answer is: Ask her why she hasn't completed her med charting.
6. The answer is: Performing an EKG
7. The answer is: Advanced beginner
8. The answer is: Discuss with her why the task is not appropriate for the CNA.
Lisinopril (brand names include Prinivil and Zestril), a blood pressure drug -- 87.4 million
prescriptions
Generic Prilosec (omeprazole), an antacid drug -- 53.4 million prescriptions (does not include
over-the-counter sales)
Azithromycin (brand names include Z-Pak and Zithromax), an antibiotic -- 52.6 million
prescriptions
Hydrochlorothiazide (various brand names), a water pill used to lower blood pressure -- 47.8
million prescriptions.
- Note: increase in RDW occurs earlier than decrease in MCV therefore RDW is used for early
detection of iron deficiency anemia
Platelet Count:
- Normal: 140,000 - 440,000
* Low: worry patient will bleed
* High: not clinically significant
White Blood Cell (WBC):
- Normal: 3.4 10
* Increase: occur during infections and physiologic stress
* Decreases: marrow suppression and chemotherapy
Sodium (Na):
- Normal: 136- 145
- Major contributor to cell osmolality and in control of water balance
* Hypernatremia: greater than 145
Causes: sodium overload or volume depletion
Seen in: impaired thirst, inability to replace insensible losses, renal or GI loss
S/sx: thirst, restlessness, irritability, lethargy, muscle twitching, seizures, hyper flexia,
coma and death.
* Hyponatremia: 136 or less
Causes: true depletion or dilutional
Occur in: CHF, diarrhea, sweating, thiazides
Symptoms: agitation, anorexia, apathy, disorientation, lethargy, muscle cramps and
nausea
Potassium (K):
- Normal: 3.5- 5.0
- Regulated by renal function
* Hypokalemia: less than 3.5
* Hyperkalemia: greater than 5.0 (panic > 6)
NOTE: False K elevations are seen in hemolysis of samples!
Chloride (Cl):
- Normal: 96- 106
* Reduced: by metabolic alkalosis
* Increased: by metabolic or respiratory acidosis
Bicarbonate (HCO3):
- Normal: 24- 30
- The test represents bicarbonate (the base form of the carbonic acid-bicarbonate buffer system)
* Decreased: acidosis
* Increased: alkalosis
GLUCOSE:
Normal: 70- 110
* Hyperglycemia:
s/sx: increase thirst, increase urination and increased hunger (3Ps). May progress to coma
causes: include diabetes
* Hypoglycemia:
s/sx: sweating, hunger, anxiety, trembling, blurred vision, weakness, headache or altered
mental status
causes: fasting, insulin administration
BUN: Blood Urea Nitrogen
- Normal: 8- 20
- Panic = > 100 mg/dl
Serum Creatinine (SCr):
- Normal: 0.7- 1.5 for adults and 0.2- 0.7 for children
- SCr is constant in patients with normal kidney function.
* Increase:
Indicates worsening renal function
Total Protein and Albumin:
- Total protein: normal = 5.5- 9.0
- Albumin: normal = 3.- 5
* Related to liver status
* Low:
Cause: liver dysfunction
S/sx: peripheral edema, ascites, periorbital edema and pulmonary edema.
Serum Calcium (Ca):
- Normal = 8.5- 10.8
* Hypocalcemia: less than 8.5
Causes: low serum proteins (most common), decreased intake, calcitonin, steroids, loop
diuretics, high PO4, low Mg, hypoparathyroidism (common), renal failure, vitamin D
deficiency (common), pancreatitis
S/sx: fatigue, depression, memory loss, hallucinations and possible seizures or tetany
Lead to: MI, cardiac arrhytmias and hypotension
Early signs: finger numbness, tingling, burning of extremities and paresthias.
* Hypercalcemia: more than 10.8
Cause: malignancy or hyperparathyroidism (most common), excessive IV Ca salts,
supplements, chronic immobilization, Pagets disease, sarcoidosis, hyperthyroidism,
lithium, androgens, tamoxifen, estrogen, progesterone, excessive vit D or thyroid
hormone.
Acute (>14.5) s/sx: nausea, vomiting, dyspepsia and anorexia
Severe s/sx: lethargy, psychosis, cerebellar ataxia and possibly coma or death
Increased risk of digoxin toxicity
Phosphate (PO4):
- Normal: 2.6- 4.5
Magnesium (Mg):
- Normal: 1.5- 2.2
- Primarily eliminated by the kidney
* Hypomagnesemia: less than 1.5
Causes: excessive losses from GI tract (diarrhea or vomiting) or kidneys (diuretics).
Alcoholism may lead to low levels
S/sx: weakness, muscle fasciculation with tremor, tetany, increased reflexes, personality
changes, convulsions, psychosis, come and cardiac arrhythmia.
* Hypermagnesemia: more than 2.2
Caueses: incrased intake in the presence of renal dysfunction (common), hepatitis and
Addisons disease
S/sx: at 2-5 mEq/L = bradycardia, flushing, sweating, N/V, low Ca
at 10-15 mEq/L = flaccid paralysis, EKG changes
over 15 = respiratory distress and asystole.
Alkaline Phosphatase:
- Normal: ranges vary widely
- Group of enzymes found in the liver, bones, small intestine, kidneys, placenta and leukocytes (most
activity from bones and liver)
* Increased: occurs in liver dysfunction
Chloride. Used most often to hydrate patients and to treat hyperosmolar diabetes,
metabolic alkalosis where there has been sodium depletion and fluid loss. When used
continuously and exclusively, the patient needs to be monitored for hyponatremia and
calorie depletion (there are no calories in this solution).
Isotonic solutions
o
2.5% Dextrose and 0.45% Sodium Chloride (Osmolarity of 280, pH of about 4.0 to 4.5) provides calories and free water
5% Dextrose and 0.11% Sodium Chloride (Osmolarity of 290, pH of about 4.3) provides calories and free water, provides some sodium and chloride
0.9% Sodium Chloride (Osmolarity of 308, pH of 5.7) - primarily used to replace sodium
and chloride, treats hyperosmolar diabetes, metabolic alkalosis where there has been
sodium depletion and fluid loss. The reason for it's used with blood transfusion is
because it will not hemolyze erythrocytes. Often given as rapid bolus for fluid
replacement during resuscitation.
5% Dextrose and Water (Osmolarity of 253, pH of about 4.5 to 5.0) - provides calories
and free water.
Ringer's (Osmolarity of 310, pH of 5.5 to 5.8) - it's content is very similar to plasma, but
should not be used continuously since it contains no calories and could result in an
excessive amount of one or more of the electrolytes it contains. It's components include
sodium, chloride, potassium and calcium. It is used to replace electrolytes and to
hydrate, often where there has been extracellular fluid loss. Adding Dextrose increases
the osmolarity of the solution and lowers it's pH making it a hypertonic solution.
2.5% Dextrose in half strength Lactated Ringer's (Osmolarity of 263, pH of 5.0) provides calories and free water, provides electrolytes. Also contains sodium lactate
which is used in treating mild to moderate metabolic acidosis. Also see the information
above with Lactated Ringers.
depletion and fluid loss. It draws fluid into the vascular system. Dextran is a plasma
expander that is given for shock or anticipated shock related to trauma, surgery, burns
or hemorrhage, and for the prophylactic prevention of venous thrombosis and
pulmonary embolism during surgery. It should NOT be used as a blood substitute
except in emergencies when blood is not available. It's volume expansion effect lasts for
approximately 24 hours during which the dextran is slowly broken down to glucose and
metabolized into carbon dioxide and water. Complications with the use of this solution
include anaphylactic reaction, wheezing, tightness in the chest, GI problems of nausea
and vomiting, circulatory overload and tissue dehydration. If blood transfusion is
intended, the type and cross match needs to be done before this solution is started.
Because dextran pulls fluid into the vascular system it will result in altered blood tests.
o
10% Dextran and 0.9% Sodium Chloride (Osmolarity of 252, pH of 4.0 to 4.5) - 10%
Dextran is a low molecular weight dextran. It is used in treating shock related to
vascular system fluid losses such as in burns, trauma, hemorrhage and surgery. It is
also used for the prophylactic prevention of venous thrombosis and pulmonary
embolism during surgery. Complications include circulatory overload that results in
various kinds of congestion and increased bleeding time. As with the 6% Dextran
solutions, subsequent laboratory blood tests will be altered due to it entering the
vascular system. This Dextran is excreted through the renal system within 24 hours.
Hypertonic Solutions
o 5% Dextrose and 0.2% Sodium Chloride (Osmolarity of 320, pH of 4.0 to 4.4) - provides
calories and water, replaces sodium and chloride. This is given for fluid replacement.
o
5% Dextrose and 0.3% Sodium Chloride (Osmolarity of 365, pH of 4.0 to 4.4) - provides
calories and water, replaces sodium and chloride
5% Dextrose and 0.45% Sodium Chloride (Osmolarity of 405, pH of 4.0 to 4.4) provides calories and water, replaces sodium and chloride. This is given for fluid
replacement.
5% Dextrose and 0.9% Sodium Chloride (Osmolarity of 560, pH of 4.0 to 4.4) - provides
calories and water, replaces sodium and chloride. This is given for fluid replacement.
10% Dextrose and 0.2% Sodium Chloride (Osmolarity of 575, pH of 4.3) - provides
calories and water, replaces sodium and chloride
10% Dextrose and 0.45% Sodium Chloride (Osmolarity of 660, pH of 4.3) - provides
calories and water, replaces sodium and chloride
10% Dextrose and 0.9% Sodium Chloride (Osmolarity of 815, pH of 4.0 to 4.3) provides calories and water, replaces sodium and chloride
10% Dextrose and Water (Osmolarity of 505, pH of 4.3 to 4.5) - provides calories and
water
50% Dextrose and Water (Osmolarity of 2526, pH of 4.0 to 4.2) - provides calories and
water
1/6 M(olar) Sodium Lactate (Osmolarity of 335, pH of 6.5) - Contains sodium lactate
which is used in treating mild to moderate metabolic acidosis.
primarily used for intracranial pressure and cerebral edema where it acts within 15
minutes of being infused. It will also be used during the oliguric phase of acute renal
failure to promote the excretion of toxic substances from the body. In high intraocular
pressure, it pulls fluid from the anterior chamber of the eye within 30 to 60 minutes of
infusion. Complications include frequent and severe fluid and electrolyte imbalances,
cell dehydration, fluid overload, skin extravasation and necrosis with infiltration of the IV
site, precipitate formation in the IV line and altered laboratory blood tests. The patient's
blood tests should be monitored when the patient is receiving mannitol.
Basically
the Dextrose solutions also serve as diluents for the administration of many IV medications.
In general, the electrolyte solutions are isotonic. Adding Dextrose to them makes the resulting
solution hypertonic.
calorie depletion
peripheral edema
hyperchloremia
5% Dextrose in one liter of water contains 5 grams of dextrose per every 100mL which gives
170 calories per liter of fluid (this was a question on my state board exam in 1975).
Free water - The dextrose in IV solutions is metabolized very rapidly since it is a simple sugar
which leaves behind plain old water. This water is able to cross all cell and tissue membranes
to go into the various fluid compartments where is it needed.
The higher percentage Dextrose solutions are used to supply the patient with calories and
often need to be given via a central IV line.
Always review your patient's laboratory tests to determine if the IV solution is appropriate,
particularly
o the BUN (blood urea nitrogen) - Normal: 10-20 mg/dl
o
serum electrolytes
pH - Normal: 7.35-7.45
Dehydration may also be called fluid volume deficit or hypovolemia and is due to:
excessive fluid and electrolyte losses from the extracellular compartment
loss of GI fluids due to vomiting, diarrhea, suctioning and fistulas
fluid lost through the skin as the body attempts to regulate it's temperature or trauma of the
skin (burns, large open wounds, cuts).
loss of fluid through the renal system (these losses are usually excessive) by polyuria due to
hyperglycemia, renal disorders, administration of osmotic diuretics, administration of
concentrated IV solutions and tube feedings
third spacing - the shift of fluid from the circulation to a space where it is trapped and cannot be
exchanged with fluid in the extracellular space. There is no actual physical fluid loss but the
involved fluid is basically "out of commission". This occurs in intestinal ileus
decreased fluid intake due to confusion, coma, very young age or very old age and not
recognizing the sense of thirst
ecchymosis were improving, did the nurses stop looking at Berties arm daily? Were we so focused
on the current problem that we overlooked the new problem, a skin infection?
2. Set priorities
Did the nurses get so busy that checking Berties arm was no longer a high priority? There are so
many pressing tasks that must be done and so little time to do them. The interruptions seem endless
at times. But do nurses always focus on whats most important? Do we delegate some things to other
members of the nursing team so that we have time to perform important assessments of our
patients?
3. Fine tune your assessment skills
If you saw Berties forearm with a 10 cm by 6 cm area of erythema and edema, would you know to
check for increased warmth? Would you call the NP, PA or physician to describe your findings? When
you talked to the health care professional, would you mention Berties allergies and that she was on
Coumadin so if an antibiotic was prescribed, the PT/INR could be checked more frequently? (Many
antibiotics affect the blood levels of Coumadin.) Or would you just continue to monitor the site and
pass this information on to the next shift?
By following these three steps, you can lessen the chance that you will miss changes in your patients
conditions. Read and follow your nursing care plans. Dont let yourself get so busy that the highest
priorities get missed. Delegate tasks that other members of the nursing team can do. If you see an
abnormality, dont just pass on the information, take action.
their mission statement or theyre a magnet hospital). Engaging the interviewer in conversation about
the organization, also demonstrates your eagerness and ability to interact with people (which nursing
is all about). While you may not have years of experience to buttress your credibility, your excitement
and interest in the organization will do so.
4. Turn off your phone.
In a world in which we are constantly reminded to turn off our cell phones and pagers, you would
think it would be a no-brainer to do so before a job interview.
Interviewers are fully present for the interview, says Steffel. The candidate needs to abide by those
same principles.
5. Research the organization.
Be prepared to answer the questions: Why are you interested in our organization? What brings you
here? Why do you want to work at this hospital? And dont say, Because its the closest to where I
live. Take time to review the hospitals mission statement, read articles written about the hospital, or
review the job postingfind any information you can about the hospital and study it. It will be
invaluable information during your interview.
For instance, if you researched Edward Hospital, where Steffel is a recruiter, youd find its a magnet
hospital and about their brand promise to deliver care for people who dont like hospitals. During the
interview, use information like this to demonstrate your interest in the organization. But dont simply
say, I want to be hired because I want to be at a magnet hospital. Take it a step further, Steffel
recommends, and explain why you want to be at a magnet hospital: because of the nurse support,
the preceptor program, the internship, the transition training program, etc. This attention to detail
shows the interviewer how serious you are about the position you are vying for.
6. Ask the right questions.
Youre interviewing the organization just as much as were interviewing you, says Steffel, so you
need to have questions prepared. Maybe there was something that the interviewer said during the
interview that youd like to be clarified. Dont hesitate to ask. Now is the time to find out what wont
work for your personalityrather than later, once youve signed the dotted line.
Questions nurses should ask include the following:
What is your orientation program like? Do you have a preceptor program? What is its duration?
Do you allow time off for and/or pay for continuing ed?
Do you have nurse educators, and how often are they available?
How are performance evaluations done, and how frequently?
Will I have to work weekends and holidays? Will I be on call?
What is your retirement plan like? Will you contribute?
Preparation at every level will set you apart from your competitionand may help you even
enjoy the process.
Read more Managing Your Career articles
www.seasonedrn.com
Goals of New Recommendations
"The goal of an effective prevention program should be the elimination of CRBSI from all patient-care
areas," write Naomi P. O'Grady, MD, from the National Institutes of Health in Bethesda, Maryland, and
colleagues from HICPAC. "Although this is challenging, programs have demonstrated success, but
sustained elimination requires continued effort. The goal of the measures discussed in this document
is to reduce the rate to as low as feasible given the specific patient population being served, the
universal presence of microorganisms in the human environment, and the limitations of current
strategies and technologies."
The new recommendations are addressed to healthcare personnel responsible for intravascular
catheter insertion as well as those involved in surveillance and containment of infections in hospital,
outpatient, and home healthcare settings.
Multidisciplinary strategies and topics addressed in the updated guidelines include education,
training, and staffing; selection of catheters and sites; peripheral catheters and midline catheters;
central venous catheters (CVCs); hand hygiene and aseptic technique; maximal sterile barrier
precautions; skin preparation; catheter site dressing regimens; patient cleansing; catheter
securement devices; antimicrobial/antiseptic impregnated catheters and cuffs; systemic antibiotic
prophylaxis; antibiotic/antiseptic ointments; antibiotic lock prophylaxis, antimicrobial catheter flush and
catheter lock prophylaxis; anticoagulants; replacement of peripheral and midline catheters;
replacement of CVCs, including peripherally inserted central catheters (PICCs) and hemodialysis
catheters; umbilical catheters; peripheral arterial catheters and pressure-monitoring devices for adult
and pediatric patients; replacement of administration sets; needleless intravascular catheter systems;
and performance improvement.
Recommendations
Some of the specific recommendations include the following:
For peripheral and midline catheters, an upper-extremity site is preferred in adults. In pediatric
patients, the upper or lower extremities or the scalp (in neonates or young infants) can be
used.
Steel needles should be avoided when administering fluids and medications that might cause
tissue necrosis if extravasation occurs.
When the duration of intravascular therapy is likely to be more than 6 days, a midline catheter
or PICC is preferred to a short peripheral catheter.
The catheter insertion site should be evaluated daily, and peripheral venous catheters should
be removed if signs of phlebitis develop.
Risks and benefits of a central venous device to reduce infectious complications should be
weighed against the risk for mechanical complications.
In adult patients, use of the femoral vein for central venous access should be avoided. For
nontunneled CVC placement, a subclavian site is preferred to a jugular or a femoral site. To
avoid subclavian vein stenosis, the subclavian site should be avoided in hemodialysis patients
and patients with advanced kidney disease.
For patients with chronic renal failure, a fistula or graft instead of a CVC for permanent access
for dialysis should be used.
Ultrasound guidance by those fully trained in its technique should be used to place CVCs.
A CVC should have the minimal number of ports or lumens essential for patient treatment.
When adherence to aseptic technique cannot be ensured, such as for catheters inserted
during a medical emergency, the catheter should be replaced as soon as possible (within 48
hours).
Instead, say, I dont know how to do this yet. I need your help. This demonstrates a willingness to
learn. And it is completely appropriate; your preceptor needs to be in the room watching, helping, and
coaching. No one should be doing something they feel they cant do or have never done before. Its in
those instances that a good preceptor will be able to push youso, ultimately, you will be able to fly
on your own.
No longer A irway B reathing C irculation ...it's now C A B with emphasis on compressions FIRST, i. e.
no longer Look, Listen, Feel prior to compressions.
So, Push Hard [at least 2"] & Push Fast [at least 100 x's/min].
1: From behind the GRIPPER PLUS Safety Needle place fingers on each side of the base to stabilize
it. With the other hand, place a finger on the tip of the safety arm.
2: Begin to lift the safety arm straight back. Notice that the needle comes
out perfectly straight.
3: Continue lifting the safety arm until the needle "clicks" into the lock
position. It is now safely out of the way, ready to be disposed of in a sharps container.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
LifeGuard's needle trap fully encapsulates the needle upon de-access. Compared to traditional
needles and sharps, Lifeguard is designed for maximum control and safety with minor changes to
technique.
Safeguard against Needlestick injuries
Enhanced for Patient Comfort
Easy to Use
LifeGuard features:
Visual and audible confirmation of safety
Colored safety handle for needle gauge confirmation
Needleless compatibility
Easy to secure
LifeGuard Safety Needle will easily insert into all implanted ports and when de-accessing from the
port it encapsulates the sharp point fully, preventing unnecessary needlesticks to clinicians and
custodial staff.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Whether you're delivering chemotherapy, antibiotic therapy, or parenteral nutrition, the Surecan
Safety Huber Needle's patented safety clip will automatically engage as you withdraw the needle from
the base plate.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Simple to use
Robust safety mechanism
Easy visibility of access site
Small footprint
Non-absorbent patient comfort pad
Non-coring needle
Latex free
Best overall value
SafeStep Huber Needle Set combines excellent safety Huber needle technologan affordable, simple
to use product. SafeStep features ay in robust safety mechanism with a clear base for easy site
visibility. It boasts a small footprint, one of the smallest available today! Its patient comfort pad is soft
and supple for patient comfort during infusion. SafeStep is the best overall value for you, your nurses,
and your patients!
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MiniLoc Safety Infusion Set is Specialized Health Products premier safety Huber needle. MiniLoc is
designed with an ultra-low profile, small footprint and enhanced angled tubing to facilitate dressing
and help maintain dressing integrity.
MiniLocs specially lubricated needle reduces penetration and access forces during port access. Its
needle forward design facilitates dual lumen port access. MiniLoc is latex free and features DEHP
free tubing. MiniLocs ergonomic, integral wing design allows controlled, easy safety mechanism
engagement. An audible click as well as tactile feel and a visual indicator confirm safety mechanism
engagement
http://www.isips.org/Safety_Huber_Needle.php
Acid or Alka
______________________________________________________________
Basic Geriatric Respiratory Assessment
The objective of the pulmonary assessment of a geriatric patient is to check for the following:
Quality of respiratory efficiency;
Gas exchange; and
Presence of disease.
Respiratory Rate
Normal respiratory rates for older patients are 12 to 18 breaths per minute for those living
independently and 16 to 25 breaths per minute for those in long term-care.
Tachypnea.
A respiratory rate of 20 breaths per minute (or more than 25 breaths per minute for someone in a
nursing home) indicates tachypnea. In such cases, look for the following:
Infection (especially pneumonia);
COPD, the patient has air trapping and cannot empty the lungs.
Pulmonary embolus
Metabolic acidosis.
Bradypnea
Bradypnea is a form of hypoventilation, in which the patient has a respiratory rate of less than 10
breaths per minute.
Respiratory Effort
Normal breathing is quiet and unlabored. If it is labored, it is important to note respiratory effort. In
patients with pneumonia or acute abdomen, labored breathing prevents airway closure. Patients who
have air hunger will often breathe with an open mouth.
Audible Breath Sounds
Pay attention to the breath sounds. Wheezing is an important clue to reactive airways or local
obstruction. Coughing indicates lower airway irritation. Stridor implies partial airway obstruction.
Respiratory Patterns
Check for respiratory patterns and signs that indicate specific conditions. For example, inspiration
interrupted by cough suggests pleuritic pain or inflammation.
Chest Movement During Respiration
The next part of the chest inspection is to observe the patient's chest movement during respiration.
Use of Accessory Muscles
Using accessory muscles implies that the forced expiratory volume is decreased to 30% of normal. In
such cases, a sitting patient may lean forward with hands propped on the knees.
Percussion
Make sure your hands are warm before you begin percussion. Start at the back and check each side
to compare the quality of the sensation. It is key to keep the wrist loose and the hand floppy. As you
percuss, consider the characteristic of the structure you are percussing. One trick is to practice over a
table percussing from the center toward the legs. Notice how the percussion note feels firm when
over the leg of the table. Close your eyes and practice until you can reliably stop over the leg.
Sometimes an elderly patient is too ill to sit up and percussion must be accomplished with the patient
in the lateral decubitus position. This position can add some artifacts of lung compression, producing
dullness in the mid lung fields of both the dependent and upward lungs. Of note, the feel of the
resonance may be more sensitive than the sound of the percussion note, especially in a noisy setting
such as a crowded emergency room, where subtleties of sound are more difficult to appreciate.
Basic Percussion Techniques
1. Light pat. Gently pat the back on each side starting at the apices and moving down to the
diaphragm.
2. Direct percussion. Place your dominant hand on the skin and raise your forefinger and tap on
the skin directly.
3. Indirect percussion Place your non-dominant hand on the skin and with your dominant middle
finger tap the middle finger of your nondominant hand at the sistal interphalangeal joint.
Dullness and Its Indications
Dullness to percussion implies consolidation, pleural fluid, or pleural scarring.
Auscultation
Make sure that the listening area is quiet, and importantly, do not listen through the patient's clothing.
Warm your stethoscope either by carrying it in your pants pocket or by vigorously rubbing it. One
strategy is to place a rubber membrane on the bell and have the patient breath deeply with the mouth
open. Make sure that your stethoscope bell is securely placed flat on the chest and that you are not
breathing on your tubing. In fact, breathe on the tubing beforehand to appreciate the low-pitched
rustling sound your breath produces. Be sure that your earpieces are securely in your ears to exclude
environmental noise.
Listen to at least 2 respiratory cycles at each location. All breath sounds should increase in pitch with
inspiration and decrease with expiration.
Begin at the bases and work up the back. Starting at the bases allows you to appreciate any basilar
crackles secondary to atelectasis or early congestive heart failure. If you start at the apices and work
down, such crackles might disappear by the time you get to the bases. If you hear additional noises
make sure they are coming from the patient's chest and not from the skin, muscles, or other
extraneous source. For example, body hair can produce a crackling sound that resembles dry
cellophane crackles.
Wheezes
Wheezes are musical sounds that indicate airway obstruction, which when it occurs during expiration,
suggests a source within the chest. Wheezing that occurs on inspiration suggests obstruction in the
trachea (outside the chest). Hearing both inspiratory and expiratory wheezes is more concerning than
hearing either alone.
Crackles (Rales)
Inspiratory crackles are common in elderly people. Note the location of expiratory crackles. Fixed
crackles suggest fibrosis or pneumonia.
Rhonchi
Rhonchi are coarse flapping sounds that suggest fluid or mucus in an airway.
Pleural Friction Rubs
Pleural friction rubs are leathery, creaky sounds similar to the sound of slowly rubbing your palms
together. They do not have a musical quality, like a wheeze does, but suggest 2 inflamed pleural
surfaces rubbing together. They can occur on both inspiration and expiration, but they usually occur
with inspiration and tend to be localized. Hearing a pleural friction rub implies neoplasm, pulmonary
Alternatives (regardless of their cost or the extent to which the treatment options are covered
by health insurance);
In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the
treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a
particular course of medical intervention.
This communications process, or a variation thereof, is both an ethical obligation and a legal
requirement spelled out in statutes and case law in all 50 states. Providing the patient relevant
information has long been a physician's ethical obligation, but the legal concept of informed consent
itself is recent.
The first case defining informed consent appeared in the late 1950's. Earlier consent cases were
based in the tort of battery, under which liability is imposed for unpermitted touching. Though battery
claims occasionally occur when treatment is provided without consent, most consent cases generally
center around whether the consent was "informed", i.e., whether the patient was given sufficient
information to make a decision regarding his or her body and health care.
It is important that the communications process itself be documented. Good documentation can serve
as evidence in a court of the law that the process indeed took place. A timely and thorough
documentation in the patient's chart by the physician providing the treatment and/or performing the
procedure can be a strong piece of evidence that the physician engaged the patient in an appropriate
discussion. A well-designed, signed informed consent form may also be useful, but an overly broad or
highly detailed form actually can work against you. Forms that serve mainly to satisfy all legal
requirements (stating for example that "all material risks have been explained to me") may not
preclude a patient from asserting that the actual disclosure did not include risks that the patient
unfortunately discovered after treatment.
At the other extreme, listing all of the risks may not be wise either. A comprehensive listing will be
difficult for the patient to understand and any omission from the list will likely be presumed
undisclosed. Medicare participating physicians must also be cognizant of CMS's requirements for
informed consent.
________________________________________
When you find a pill lying about, or in an unmarked container, try this site for pill ID:
www.pharmer.org Righthand side, best resources in the NAVIGATION brown box. You land on other
sites, but the drug.com pill wizard is fantastic.
www.epocrates.com has my fav free drug guide and compatability stuff online or PDA/Blackberry, but
not all options are free.
And for my 'Como se dice esto en Espanol' issues, I like www.freetranslation.com
18.Assessment of a newborn five minutes after delivery reveals cyanosis of the hands, feet, trunk,
and face. Vital signs are pulse 160 beats/min and respirations 44 breaths/min. Treatment of this
newborn includes:
A.initiating bag-valve-mask ventilations.
B.performing intubation and positive pressure ventilation.
C.applying free flow oxygen by mask at 5 L/min.
D.reassessing the skin color in five minutes and then initiating oxygen therapy if needed.
19.An infant should be immediately evaluated by a physician if which of the following signs or
symptoms are present?
A.Use of abdominal muscles to breathe
B.Temperature of 37 degrees (98.6 F)
C.Acting fussier than normal
D.Refuses a pacifier
20.A 3-year-old boy who has a tracheostomy has had difficulty breathing and coughing for 2 days
because of increased secretions. He is on continuous oxygen. His mother states that his breathing is
getting much worse. Assessment reveals that he is lethargic, has cool, mottled skin, and has copious
secretions in the tracheostomy tube. Which of the following signs suggests significant obstruction of
the tracheostomy tube?
A.A slow heart rate and poor air exchange
B.Irregular respirations and wheezing
C.Crackles and decreased breath sounds
D.Unequal chest rise and wheezing
21.During transport, what is the correct way to manage the respiratory status of a boy who is on a
ventilator but also breathes on his own?
A.Allow the patient to remain on the ventilator if he is not in respiratory distress
B.Immediately deliver bag-valve-mask ventilations because you may not be familiar with the ventilator
C.Switch the patient to oxygen by blow-by method because the ventilator will not work in the
ambulance
D.Decrease the flow rate as the oxygen in the ambulance is more potent and requires a lower flow
rate
22.What is the danger of using a mask that is too large on a child who requires ventilatory
assistance?
A.Eye injuries may occur from the mask touching the globe
B.It will be more difficult to obtain a seal for ventilation
C.More pressure will need to be applied to obtain a mask seal, which may cause dislocation of the
mandible
D.If the mask extends across the eyes, it may exert pressure and stimulate the vagus nerve
23.What is the correct method to confirm proper placement of an endotracheal tube?
A.Palpate for chest rise and fall over the anterior chest and abdomen
B.Observe for gastric distention which indicates leakage of air around the tube in the trachea
C.Auscultate the anterior chest and mid-abdominal area for the presence of bubbling or gurgling
sounds
D.Auscultate for bubbling or gurgling sounds over the epigastrium and breath sounds at the
midaxillary regions
24.When should the child s head be secured to the spine board during the immobilization procedure?
A.After the body straps and lateral stabilization devices have been applied
B.After the body straps have been applied, but before the lateral stabilization devices to ensure that
the tape is applied tightly
C.Before any straps or lateral stabilization devices have been applied
D.If the child is quiet the head does not need to be secured once lateral stabilization devices are
applied
25.Which of the following substances can be infused via an intraosseous needle?
A.All medications and intravenous fluids
B.All medications except sodium bicarbonate and dextrose
C.Fluids or medications that are not acidic
D.Only medications and fluids that have a neutral pH
__________________________________
CDC - Infectious Disease Guidelines
Topic Sections
Antibiotic and antimicrobial resistance
Bacterial infections Diarrheal diseases
Infection control, healthcare quality, and healthcare-related infections (on Division of Healthcare
Quality Promotion site)
Occupational exposure and health (on Division of Healthcare Quality Promotion site)
Opportunistic infections
Parasitic infections
Sexually transmitted diseases
Surveillance
Travel and immigration
Note: for SARS-related guidelines, please see the Severe Acute Respiratory Syndrome site
Vaccination Viral infections
http://www.cdc.gov/ncidod/guidelines...ines_topic.htm
ECG ~ 6 Second Strips
Case 5 - A child with vomiting and diarrhea (Note this case is only available to users at the
University of Iowa)
http://www.virtualpediatrichospital....dsVPHome.shtml
The Virtual Autopsy
Ever had the urge to be a Medical Examiner? This site gives you 12 cases, their medical history &
exam results ~ You try to pinpoint the cause of death.
http://www.medi-smart.com/tut-40.htm
Traumatic Brain Injury Simulator
The Neurotrauma Moulage is a traumatic brain injury simulator. It is designed to simulate a range of
conditions affecting the management of the injured brain, and to encourage a greater understanding
of the main tenets of traumatic brain injury management - especially the prevention of secondary
injury.
The initial stages of the moulage take you through the acute, emergency department management of
the head injured patient. Once on the intensive care unit you are faced with various scenarios and
you have to act to minimise brain ischaemia. You will not be presented with the next scenario until
you've managed to get the brain back to it's calm, blue, oxygenated state as in the picture below!
http://www.medi-smart.com/tut-38.htm
ECG Workshop
ECG ROUNDS:Choose a case below
CaseDescription
http://wps.prenhall.com/chet_olsen_medicaldosage_9/
16. A 64 year-old male who has been diagnosed with COPD, and CHF exhibits an increase in total
body weight of 10 lbs. over the last few days. The nurse should:
A: Contact the patients physician immediately.
B: Check the intake and output on the patients flow sheet.
C: Encourage the patient to ambulate to reduce lower extremity edema.
D: Check the patients vitals every 2 hours.
17. A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The nurse
should do which of the following first?
A: Check the patients chest x-ray results.
B: Retake vitals including blood pressure.
C: Perform a neurological screen on the patient.
D: Request the physician on-call assess the patient.
18. A patient that has TB can be taken off restrictions after which of the following parameters have
been met?
A: Negative culture results.
B: After 30 days of isolation.
C: Normal body temperature for 48 hours.
D: Non-productive cough for 72 hours.
19. A nurse teaching a patient with COPD pulmonary exercises should do which of the following?
A: Teach purse-lip breathing techniques.
B: Encourage repetitive heavy lifting exercises that will increase strength.
C: Limit exercises based on respiratory acidosis.
Answer Key
1. (B) Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis make up the Rotator Cuff.
2. (B) The patient experiencing neurovascular changes should have the highest priority. Pain
following a TKR is normal, and breakdown over the heels is a gradual process. Moreover, a subacute
ankle sprain is almost never a medical emergency.
3. (A) All of these factors indicate a DVT.
4. (B) Pain may be indicating neurovascular complication.
5. (B) Stimulation in the form of pictures may decrease signs of confusion.
6. (D) Adolescents exhibiting signs of sexual development and interest are normal.
7. (C) Observation of the students hair is the next step.
8. (A) Nursing assistants should be competent on all transfers.
9. (D) All protective measures must be worn, it is not required to double glove.
10. (A) The cane should be placed in the patients strong upper extremity, and left arm/right foot go
together, for normal gait.
11. (B) The new onset of urinary incontinence may require additional medical assessment, and the
physician needs to be notified.
12. (C) Both the family and the patient should have the need for restraints explained to them.
13. (B) The suicide plan may have been decided.
14. (A) Thrush may be occurring and the patient may need Nystatin.
15. (D) Do not administer pain medication or start a central line without MD orders.
16. (B) Check the intake and output prior to making any decisions about patient care.
17. (B) Dizziness can be a sign of hypotension, that may a contraindication with Morphine.
18. (A) Negative culture results would indicate absence of infection.
19. (A) Purse lip breathing will help decrease the volume of air expelled by increased bronchial
airways.
20. (B) The Mantoux is the most accurate test to determine the presence of TB.
http://www.testtrade.com/nclex1.pdf
The Auscultation Assistant ~ Heart Sounds & Breath Sounds to improve your skills
Provides heart and lung sounds to help students improve their assessment skills.
http://solutions.3m.com/wps/portal/3...t-lung-sounds/