Transcript for:
Legal and Ethical Fundamentals in Healthcare

Title: fundamentals-butun URL Source: blob://pdf/021ac45c-028f-4756-8bec-61384a26e4a0 Markdown Content: # FUNDAMENTALS FUNDAMENTALS # LEGAL LAWS ETHNICAL PRINCIPALS - Advocacy: supports a persons health, wellness, safety, privacy, and personal rights. - Responsibility: respect obligations and follow through on promises. - Accountability: willingly taking responsibility for ones own actions. - Confidentiality: protection of a persons privacy. - Autonomy: a persons right to make own decision. - Beneficence: act of kindness and doing good for others. - Fidelity: keeps promises and fulfills them. - Justice: fair treatment of giving safe and quality care to each individual. - Non-maleficence: commitment to do no harm. - Veracity: commitment to telling the truth. # CLIENT RIGHTS - 1972 A Patients Bill of Rights adopted by AHA. - Clients rights must be respected and NURSES are responsible for protecting the rights of the client. - Client has the right to details of procedures, informed consent, advance directives, & confidentiality of information - Client has the right to REFUSE/DISCONT INUE treatment/medication/etc. (whether admission is voluntary or involuntary) - Client has the right to be active in decision-making of care plan, accept/refuse/modify care plan, receive competent care & respect. TORT: Person injured due to another persons unintentional or intentional failure to act. Injury can be physical, emotional, or financial. Unintentional tort: negligence - Negligence: person harmed due to neglected duties, procedures, or precautions. + FAILURE TO: follow standard protocols; report equipment malfunctions; give standards of safe care; prevent injuries; question physicians incorrect orders; AND performing procedures you were NOT taught. - Malpractice (Professional Negligence): improper or injurious treatment from a licensed persons actions or lack of actions. Intentional tort: assault, battery, false imprisonment, etc. - Assault: threat or attempt to do bodily harm > telling elder his/she will take a shower even if he/she refused. - Battery: physically touching someone or his/her possessions w/o consent > beating person, caring out procedures the person refused, forcing person out of bed, etc. Quasi-Intentional: - Libel: written statement or photo that is false of damaging. - Slander: malicious verbal statements that are false or injurious > gossip & exaggeration. - Defamation: act that harms a persons reputation. CRIME: Intentional wrong doing against another person, people, or environment. Considered both felony & misdemeanor. LIABILITY: Deliberate commission of a forbidden act or omission of an act required by law. - act of commission > participating in illegal abortion, giving person wrong med & is harmed, etc. - act of omission > person not given scheduled med & is harmed, failure to report elder or child abuse, etc. > Felony: serious crime > insurance fraud, practicing w/o license, theft of narcotics, etc. > Misdemeanor: not serious as felony, but still a crime > possession of controlled substances, etc. # 42 FUNDAMENTALS # INFORMED CONSENT - Legal documentation of pt.s approval to perform tests, treatments, surgeries, or give certain meds or blood products. - Pt. must be 18 or older, competent, & verbal. - Parent, guardian or advance directive signs consent if pt. is a minor, unconscious, unable to communicate, or mentally disabled. - Emancipation minors are LEGALLY capable of signing an informed consent. In a life or death situation, two physicians can sign emergency consent if pt.s family is NOT immediately located (some facilities allow this). - Non-consensual physical contact can be required if pt. is mentally ill, intoxicated, or endangering self or others safety. - Only the Physician MUST detail and explain the purpose of procedure, explain benefits & risks, & give options for alternative treatments. - Nurse MUST witness pt. sign consent and makes sure the patient understands what was said. - If does NOT understand, inform the physician & the physician is responsible to re-explain & answer questions about the procedure. - ALL T EACHING MUST BE DOCUMENT ED. Students DO NOT obtain or witness consent forms # HIPAA - 1996 Health Insurance Portability and Accountability Act. - Protects pt. info to remain private. Pt. has the RIGHT to privacy. - DO NOT give pt. info to family or friends w/o the pt.s consent. - Keep info within staff members who are directly involved in pt.s care (HCP, nurse, can, therapist, dietician, social worker, etc.) - DO NOT leave papers out in the open. Have them face-down. - Secure pt. info on computer screen from others. ALWAYS log off before leaving computer. - Wait for pt.s visitors to leave before discussing pt.s info (unless pt. gives consent to discuss with visitor(s) in the room). - ALWAYS close the door when discussing private matters. - DO NOT discuss pt. info w/ other health professionals during break, lunch, or outside of workplace. ## ABCs (AIRWAY, BREATHING, CIRCULATION) Oxygen is one of the most essential of all basic survival needs. Without oxygen circulating in the bloodstream, a person will die in a matter of minutes. Oxygen is provided to the cells by maintaining an open airway and adequate circulation. ABC is essential for survival Airway: determine whether airway is patent (open) or not. Remove anything that obstructs the airway whether it's food, blood, vomit, or the tongue falling back (common in unconscious person). Breathing: listen to breath sounds, watching for chest movements, & lay your cheek against persons chest. Circulation: The heart must pump effectively for oxygen to be carried to the cells. Also, there must be sufficient blood volume to carry needed oxygen. Find a pulse, observe the pulse, reassess breathing, & assess for signs of internal or external bleeding, control hemorrhage if bleeding does occur. MASLOWS HIERARCHY OF NEEDS reach for his/her highest potential SELF-ACTUALIZATION Self image, Self respect, Perception of self-adequacy SELF ESTEEM Social needs & Spiritual needs LOVE, AFFECTION, & BELONGING Freedom from harm (abuse), Healthcare, Shelter SECURITY & SAFETY Oxygen, Water, Food, Elimination, Sleep, Exercise, Sexual Gratification (for the survival of species), and Temperature Regulation BASIC PHYSIOLOGICAL # 43 FUNDAMENTALS 1. ASSESSMENT: - Subjective data (what the patient tells you; chief complaint) and Objective data (what you, as the nurse, observes); interview (medical history); Head-to-Toe Assessment Analyze Data: - Recognize significant data (which data is relevant or not to the patients care) - Validate observations (check them out) - Recognizing patterns (when does the symptom occur? Night, after eating, certain position, etc.) and clusters (relationship among symptoms). Ex: abdominal pain, bloating, and NO bowel movement in 3 days - Identifying strengths (ways patient can cope with problem) and problems (actual or potential problems) - Analyzing data to reach conclusions (no problem; may have problems; risk of problem; or clinical problem) - Continuously update information # SCOPE OF PRACTICE # RN - Hang & administer blood - Initial assessment on admitted patient - Patient care plan - Discharge teaching - Start IV & administer IV meds - Performs same duties as LPN/LVN & UAP # LPN/LVN - Reinforce client teaching taught by RN - Report ABNL findings to RN & HCP - Performs more skill procedures - Tracheostomy care & suctioning - Check NG tube latency - Enteral feedings - Insert urinary catheters - Administer meds # UAP - ADL (activity of daily living): hygiene, dressing, ambulating, feeding (NO aspiration risk pts.), bathroom breaks - Position & transfer (bed to chair, chair to bed) - Bed-making - Specimen collection - I&Os - Vital signs (stable patients) In some states, CANNOT give IV meds DO NOT delegate, teach, demonstrate, explain, & use clinical judgement - RN delegates the LPN/LVN and UAP - LPN/LVN delegates UAP - Right task - Right circumstance - Right person - Right direction & communication - Right supervision & evaluation FIVE RIGHTS OF DELEGAT IONS NURSING PROCESS # 44 FUNDAMENTALS 2. DIAGNOSING: - Statement about the actual or potential health problem of the patient that can be managed through independent nursing interventions - Medical Diagnosis vs Nursing Diagnosis - Three Components of a Nursing Diagnosis: P Problem E Etiology (cause) S Signs and Symptoms (objective and subjective data) - Writing a Diagnostic Statement: - Example: Fluid Volume Deficit (P) related to physiologic effects of dehydration (E) as evidence by dry mucous membrane, increased HR and RR, poor skin turgor, orthostatic hypotension, and fatigue (S). 3. PLANNING: - Development of goals to prevent, reduce, or eliminate problems and identify nursing interventions (actions taken) that will help client in meeting goals. - Set priorities (survival needs or imminent life-threatening problems is highest priority; Maslows Hierarchy of Needs and ABCs) - Establish expected outcomes (client-oriented, specific, reasonable, and measurable) + Short-term objective (goal met in hours or few days) vs Long-term objective (goal require longer time to accomplish) - Select nursing interventions (orders or actions taken to help client reach goal) - Write nurse care plan (formulated by entire nurse team) 5. EVALUATION: - Analyze clients response (measure clients progress; were the goals met?) - Identify factors contributing to success or failure of care plan - If care plan was not successful, modify goals and/or interventions and rewrite care plan - Discharge (problems are resolved; clients plan is individualized; healthcare team conference with client and family to discuss continued or new goals at home; next visit/ follow-up) - Plan for future nursing care 4. INTERVENTIONS: - Do it - putting nurse care plan in action - Continue collecting data (observe carefully, listen to what client says, watch what they do, check vital signs) - Share it - discuss clients progress or setbacks with nurse team - Write it down - document care given # NURSING PROCESS # 45 FUNDAMENTALS # CLIENT SAFETY FALL PRECAUTIONS Who are more at risk: - Greater than 65 yrs. - Impaired mobility - Cognitive and Sensory impairment - Bowel and Bladder dysfunction - Adverse effects of medications - Hx of falls - Determine individualized care plan based on Fall Risk Assessment - Orient the patient around assigned room and the use of grab bars and call light - Place fall risk patient close to the nurses station and check on frequently - Non-skid socks - Important note! Before transferring the pt., have pt. put on non-skid socks or hard sole footwear. - Lock wheels on bed, wheelchairs, lifts - Keep floor free of clutter (extension cords, carpet, coffee table, etc.). Clean up spills. - Provide good lighting to prevent falls at nighttime (lamp, plug-in, overhead light, bathroom light, etc.) - Instruct patient on the use call light for assistance before ambulating - Place call light within patients reach. Answer call lights promptly; especially with patients known for trying to walk independently. - Set bed at lowest height & Place floor mats on both sides of bed - Use bed sensors or chair/side table to stop patients from getting up without assistance or supervision. - Assistive devices if needed (wheelchair, cane, walker) HOW FALL RISK PTS. ARE IDENTIFIED: + yellow wristband + yellow non-skid socks + falling star sign outside room door SEIZURE PRECAUTION Considerations: - Assist with ambulation and transferring to prevent injury - Saline lock for immediate IV access for high risk patients - Remove items around patient that could cause injury during a seizure - DO NOT restrain patient during a seizure, can cause injury During A Seizure: - Stay with patient and Call for Help - If on floor, place pillow under head to prevent head trauma - Turn patient on side to prevent aspiration; loosen clothes - Maintain open airway and suction secretions to prevent aspiration - Administer medications - DO NOT put anything in clients mouth (finger, tongue blade, etc.) can bit down or choke. - Note duration of seizure, sequence, and type of movement - After seizure, determine mental status, measure O2 stat and vital signs. Explain what happened and provide comfort. - Document seizure and describe event (movements, injuries, duration, aura, postictal state), report to HCP RESCUE EQUIPMENT: + oxygen + suction + side rail padding + oral airway # 46 FUNDAMENTALS # CLIENT SAFETY RESTRAINTS & SECLUSION Types: human, mechanical, chemical, & physical device Considerations: - LAST measure used if less restrictive interventions does NOT work (diversion, frequent observations, calm/quiet environment, etc.) - Prescribed for the SHORT EST DURAT ION as possible - ALWAYS a Physicians order (written) - Prescription should be renewed every 24 hrs (if still needed) - Prescription must include reason, type, location, duration, and type of behavior that permits use of restraint. - ALWAYS check the facilitys policy on restraints - NOT given as PRN - Restraints SHOULD NOT + Intend to harm the patient + Be used for convenience, punishment, or for patients who are physically or emotionally unstable. - Assess neurovascular & circulation status and skin integrity (pulse, blood pressure, pulse ox, color, movement, pain) every 30 mins - Documentation every 15-30 mins + Reason, type of restraint, date & time, duration, neuro/circulation/skin assessment checks, evaluation of behavior for need to discontinue or prolong restraint use, clients behavior, medications given, vital signs, food & fluid intake, bathroom use Side Rails: - Top 2 are used and bed at lowest height. - NOT considered restraint when used to prevent sedated person from falling out of bed. Physical device: - 2 finger width of space between restraint and patient - Use quick-release knot to tie restraint to bed frame - Remove every 2 hrs. Have patient perform ROM. - Monitor neurovascular status and skin integrity every 30 mins. (pulse, skin color, movement) # 47 FUNDAMENTALS # THERAPEUTIC COMMUNICATION Dos Donts Nonverbal Cues (eye contact, nodding) Dont Worry Disregardes their concerns Why? Why did you do that? Closed-Ended Questions Yes or No (Except in Self-Harm) What? What makes you feel that way? Open-Ended Questions How are you feeling today? Clarifying Techniques Restating: use the client's precise words Paraphrasing: Restate the client's opinions to confirm what they said. Exploring: allows the nurse to collect additional information Therapeutic communication is a communication approach that uses verbal and nonverbal gestures to address a patient's physical and emotional needs. Assertive: expressing sentiments or wants clearly without infringing on the rights of others I respect your feelings and here are mine... Aggressive: expressing feelings and thoughts in a loud manner that violates the rights of others I am never wrong! Passive: evading or neglecting to express individual feeling or wants. I dont care about this. Passive Aggressive: On the appearance, passive, yet after discourse, covert hostility, either alone or with others. That is fine, but dont be surprised if others get mad. Types of Communication Incivility: harsh words or actions (sarcasm, eye roll) Bullying: repeated threats or intimidation Lateral Violence: peers' abusive comments or deeds (gossip, threats, defamation) Communication Between Interdisciplinary Team 1. Is there actions illegal? Yes Report to Supervisor No Go to #2 2. Is anyone in physical or psychological harm? Yes Confront and take over to keep others safe. No Go to #3 3. Is the behavior simply inappropriate? Yes Talk to them regarding your concerns at a convenient time. Inappropriate Behavior of Staff # 48 IV THERAPY COMPLICATIONS PHLEBITIS AIR EMBOLISM Inflammation of the vein Symptoms: Erythema (redness), Warm, Tender, Pain Tx: Stop infusion, Remove IV, Apply warm compression, Notify HCP & RN, Restart insertion & infusion elsewhere Air enter veins through an IV Symptoms: Tachycardia, Hypotension, Cyanosis, Dyspnea, Decreased LOC Tx: Notify RN, Clamp tubing, Turn pt. to side & place in Trendelenburg position, Notify HCP CATHETER EMBOLISM Catheter tip breaks off in vein during IV insertion or removal Symptoms: Missing catheter tip on removal, Hypotension, Pain along vein, Weak & rapid pulse Tx: Notify RN & HCP, Place tourniquet high above the IV site, X-ray, Surgery # FUNDAMENTALS # IV THERAPY COMPLICATIONS FLUID COMPARTMENTS Needle dislodged from vein & fluid leaks into surrounding tissue Symptoms : Edema, Pale skin color, Coolness, Damp, Pain, Slow IV infusion rate Tx: Stop infusion, Remove IV, Elevate extremity, Warm or cool compression (depends on what was infused), Do NOT rub area, Restart insertion & infusion elsewhere Intracellular Fluid (ICF ) > Fluid inside the cell. Extracellular Fluid (ECF) > Fluid outside the cell. Interstitial fluid (third spacing) is included in this compartment which is fluid surrounding cells, blood, lymph, bone, connective tissue, water & transcellular fluid. Third spacing refers to accumulation of trapped fluid (edema) in a body cavity (pericardial, pleural) due to disease or trauma. Intravascular > Fluid in the blood vessel. Leakage of vesicant or irritant solutions into surrounding tissue causing tissue damage. Similar to INFILT RAT ION. Symptoms: Edema, Pain, Erythema (redness), Sloughing of skin (necrosis), Blisters, Skin discoloration Tx: Stop infusion, Aspirate remaining solution through IV line, Antidote (per agency protocol), Remove IV, Elevate extremity, Warm or cool compression (depends on what was infused), Restart insertion & infusion elsewhere Or Fluid Overload. Excess volume of fluid infused into vein over short period Symptoms: Distended JVD, SOB, Crackle lung sounds, HT N, Tachycardia Tx: Raise HOB, Adjust & slow infusion rate, Monitor vital signs & O2, Give diuretics INFILTRATION EXTRAVASATION CIRCULATORY OVERLOAD Major ICF ions Major ECF ions Potassium Sodium Magnesium Calcium # 49 FUNDAMENTALS # OSMOSIS & SOLUTION TYPES Equal concentration on either side of the semipermeable membrane. + 0.9 % normal saline (NS) + 5% dextrose in water (D5 W) + 5% dextrose in 0.225% normal saline (D5 1/4 NS) + Lactated Ringers Solution has higher concentration of solute compared to a less concentrated solution. Fluid leaves the cell & causes the cell to shrink & shrivel from dehydration. + 5% dextrose in Lactated Ringers + 5% dextrose in 0.45% normal saline (D5 1/2 NS) + 5% dextrose in 0.9% normal saline (D5 NS) + 10% dextrose in water (D10 W) + 3% normal saline + 5% normal saline Solution has lower concentration of solute compared to a more concentrated solution. Fluid enters the cell & causes the cell to swell & sometimes burst b/c of excess fluid. + 0.45% normal saline (1/2 NS) + 0.225% normal saline (1/4 NS) + 0.33% normal saline (1/3 NS) HYPOTONIC (DILUTED) HYPERTONIC (CONCENTRATED) ISOTONIC (NORMAL) CENTRAL VENOUS ACCESS DEVICE A central venous access device is a type of IV therapy where a tube is inserted into a large VEIN that ends in the superior vena cava. Can last several weeks to years. Uses: Parenteral Nutrition Chemotherapy Administration Parenteral Nutrition Blood Administration Burn or Trauma Resuscitation Antibiotics Administration PICC Line: Central catheter placed from the outside. Access to the Basilic Vein Clots or infections are extremely likely The gadget is not sutured and can be removed by the nurse Port-A-Cath: a surgically implanted device with a catheter linked to a subcutaneous pocket Common with Chemo Patients Tunneled: put into vein through skin, generally in the chest Usual in a Domestic Setting Long-Term Application Reduced Infection Risk Catheter with cuff attached to anchor it to the skin Hemodialysis: central catheter (temporary) Larger Lumen = Faster Flow Short Term Application Types of Central Lines Maintain Line Patency Use Push/Pause method to risk of clots 10 mL of sterile 0.9 NS flush Dressing Care Check that the dressing is clean, dry, intact Dressing Changes Every 7 Days Infection Control Change Injection Cap on Lumens Q7 days Use an Antimicrobial Patch (CHG) Keep an eye out for Infection Signs Sterile Gloves During Dressing Care Central Line Care A lumen is an aperture at the distal end of a catheter that can be used to infuse or aspirate fluids. Number of Lumens = Diameter of Each Lumen Single Lumen: Sheath with a big bore for quick or massive infusions. Multiple Lumen: used to give many incompatible medications Lumen Types # 50 FUNDAMENTALS # PATIENT POSITIONING Supine: On my Spine: Flat on Back Uses: neck or spinal cord injuries, abdominal or facial surgery Prone: Away from that Tailbone: Flat on Stomach Uses: advanced acute respiratory distress syndrome, spinal cord operations SIMS: On your stomach, with your leg flexed and your arm flexed at the elbow. Uses: evaluating the rectal, vaginal areas Fowlers: Sitting Up Low Fowlers: 15-30 Semi Fowlers: 30-45 High Fowlers: 60-90 Uses: tube feeding or maintain ICP in neuro patients Lithotomy: Flat on your back, knees bent, and feet on stirrups Uses: examine the genitalia, reproductive tract, and rectum of the female. Trendelenburg: Lay flat on your back with head lowered below the level of your feet. Uses: air embolism, central line placement, hypotension Reverse Trendelenburg: Flat on back, with your head elevated above your feet. Uses: GERD, pulmonary aspiration prevention Lateral: Patient on Side Uses: one sided injuries # 51 FUNDAMENTALS # URINARY ELIMINATION URINARY TRACT INFECTION - Kidney failure - Too much/too litt le fluid intake - Weight of fetus on woman's bladder during pregnancy and relaxation of the woman's sphincter - Immobility (incontinent) - Hypo & Hypernatremia - Emotional stress and anxiety - Medications (diuretics, antihistamines, etc.) - Pain (withhold urge to pee to avoid pain, UTI) What affects urine elimination? - Urinalysis* - Renal function test (BUN, creatine) - Radiologic tests (kidney/uterus/bladder x-ray) - Renal angiography; Cystoscopy; Renal biopsy Diagnostic test - Urgency, Frequency - Dysuria - Chills - Abdominal and flank pain - Urine appears cloudy - Drink 2-3 L fluids/day; avoid caffeinated drinks - Administer prescribed antibiotics - Encourage frequent voiding - Female: wear cotton panties; wipe perineal front to back; use unscented soap; NO scented perfumes Manifestation/Care: Clean-catch urine sample (common method) Urinary catheter sample: - Straight: in and out catheter to collect sample for those unable to urinate. - Indwelling: insert needless syringe into sample port of the indwelling catheter. Specimen Collection: 30 mL/hr (appox. 500-2,400 mL/day) 0.5 mL/kg/hr Average excretion of urine by adult: To determine average urine excretion by all ages and sizes: - BUN: 10-20 - Creatine: 0.5-1.2 - Urine Specific Gravity: 1.005-1.030 - Urine's pH: 4.5-6.5 Lab tests: * Reagent strip test "dip-stick": test urine acidity, specific gravity, test for glucose, protein, nitrates, blood, WBCs, ketones. Assess urine's color, clarity, odor, volume. Both samples are done STERILE Altered mental status (confusion) can be primary sign of UTI in older adults, esp. older women * Less than 30 mL of urine over 2 hrs. is concerning & should be assessed # 52 FUNDAMENTALS # URINARY ELIMINATION PRESSURE ULCERS Urinary frequency: voiding more than usual Urgency: sensation to void immediately; common to experience involuntary leakage Dysuria: difficulty urinating due to pain and burning sensation (associated w. infection) Nocturia: frequent voiding at night Enuresis: "bedwetting" Polyuria: excessive excretion of urine; >2,500 mL/day is considered polyuria Oliguria: litt le excretion of urine; <500 mL/day is considered oliguria Incontinence: inability to control bladder Urinary suppression: stopping urination Anuria: absence of urine (<100 mL/day) Urinary retention: inability to empty bladder fully ABNORMAL URINARY PATTERNS Intact skin; redness typically over bony prominence; tissue swollen with possible discomfort; on darker skin, ulcer appears blue or purple. Stage 1: nonblanchable erythema: Dead tissue; damage of muscle, bone, and supporting structures; infection, tunneling, undermining, eschar (black scab-like), or slough (tan, yellow, green scab-like). Stage 4: full-thickness: Cannot determine stage because eschar or slough conceals the wound. Unstageable, full-thickness skin/tissue loss, depth unknown: Extends to epidermis and dermis; red-pink superficial area; NO slough or bruising; looks like an abrasion or blister; edema; ulcer can become infected; pain and litt le drainage. Stage 2: partial thickness: Damage, dead subcutaneous tissue; drainage and infection are common. Stage 3: full-thickness: # 53 FUNDAMENTALS # ENTERAL FEEDING - Poor gag reflux (stroke, decreased LOC) - Poor nutrient intake - Trauma (burns) > increased nutritional needs - Cancer affecting head, neck, and upper GI tract - GI disorders (IBD, enterocutaneous fistula) Reasons forventeral feeding? - Aspiration! - Gastric residual more than 250 mL (withhold feeding and notify HCP) - Diarrhea 3x or more in 24 hrs. - Infection or Bleeding at insertion site - Dislodge of tube Complications: Nasogastric; Nasoduodenal; Nasojejunal: - Inserted via nose - Short-term (less than 4 wks.) Gastrostomy; jejunostomy: - Long-term (more than 4 wks.) - Inserted surgically Percutaneous endoscopic gastrostomy (PEG); percutaneous endoscopic jejunostomy (PEJ): - Long-term (more than 4 wks.) - Inserted endoscopically Types: - ASEPTIC TECHNIQUE (avoid bacteria entering the GI tract) - Semi or High Fowlers position during & 30 mins after feeding - Flush feeding tube with 15-30 mL (0.9% NS) before and after administering medication - DO NOT crush a enteric coated or timerelease tablet and give by GI tube - Flush tube with 30-50 mL (0.9% NS) every 4-6 hrs. if on continuous feeding to prevent clogging. Nasogastric: give nose and mouth care (clean nose, brush teeth, moisturize) PEG: check skin integrity, for infection or drainage To check placement: > x-ray > aspirate gastric content and measure pH. Gastric pH is between 1.5-4 Open System: formula from cans either bottles are bloused into feeding tube, fed via pump either gravity drip. Discard formula Q4 hrs. Closed Ready to Hang: sterile, pre-filled formula containers that are spiked by the feeding tube and fed via pump. Open Vs. Closed System Standard Polymeric: 1-2 kcal/ml - Milk Based or Blenderized Foods - Complete Nutrient Formula - Requires patient to absorb entire nutrients Modular Formulas: 3.8-4 kcal/ml - Need to Supplement with other foods since not nutritionally complete - Preparation of a Single Macronutrient (protein, glucose, polymers, lipids) Elemental Formulas: 1-3 kcal/ml - Used for partially dysfunctional GI tracts - Contains predigested nutrients Specialty Formulas: 1-2 kcal/ml - Used in patients with hepatic failure, respiratory disease, or HIV - Meets specific needs related to individual illness Enteral Formulas # 54 FUNDAMENTALS # BOWEL ELIMINATION - Immobility - Too much/too litt le of fiber (require 25-30 g/day) - Decreased peristalsis, relaxed anal sphincter in older adults - Little fluid intake (require 2-3 L/day) - Physical activity - Opioid/narcotic common SE is constipation - Emotional distress or depression - Constipation and hemorrhoids during pregnancy - Medications (stool softeners, overuse of laxatives causing diarrhea) What affects bowel elimination? - Fecal occult blood test (guaiac test): test feces for blood - Specimen for stool culture: test to find possible bacteria, parasites, etc. Colonoscopy; Sigmoidoscopy Diagnostic Tests: - Give regular perineal care (to prevent skin breakdown and bad odor). Flatulence (trapped gas): Check for abdominal distention. - Ambulate to pass gas. Hemorrhoids: Use moist wipes to soothe and cleanse perineal and apply prescribed creams. - Sitz bath or ice pack to relieve pain. Ostomies (surgical bowel diversions through permanent or temporary stomas). Incontinence: Determine cause (medication, infection, impaction). - Abdominal distention, cramping - Straining to defecate, hard feces - Irregular bowel movement - Increase fiber and fluid intake - Increase physical activity (ambulate, etc.) - DO NOT strain/bare-down during bowel movement - Place feet on step stool or basket (squatting position to relieve pressure on colon) - Deep breathing exercises while defecating - Give enemas, stool softeners, laxatives as needed Manifestation/Care: - Fecal impaction - Hemorrhoids and rectal fissures - Bradycardia, hypotension, syncope (associated with straining or bearing down) Complications: CONSTIPATION - Frequent loose stool - Watery consistency - Abdominal cramping - Determine and treat underlying cause (IBD/IBS, antibiotic therapy) - Administer medications to slow GI activity - Give perineal care and apply prescribed cream after each bowel movement (prevent skin breakdown) - After diarrhea stops, eating yogurt re-establishes an intestinal balance of good bacteria Manifestation/Care: - Dehydration, F&E imbalance - Skin breakdown around anus Complications: DIARRHEA Types of Bowel Movements > The Bristol Stool Chart Type 1: Severe Constipation Maltesers Type 2: Mild Constipation Grapes Type 3: Normal Toffee Crisp Type 4: Normal Smooth Sausage Type 5: Lacking Fiber Chicken Nuggets Type 6: Mild Diarrhea Porridge Type 7: Severe Diarrhea Gravy # 55 FUNDAMENTALS Diverticulitis # OSTOMY CARE An ostomy is a surgical opening (stoma) in the abdominal wall that allows for the passage of stool and urine. It could be required because of: Irritable Bowel Disease Bladder Cancer Colon Cancer Ruptured Diverticulum Traumatic Injury to Bowel/Rectum To limit the possibility of leaks and odors, empty the Ostomy Appliance when it is 1/3 - 1/2 filled. For redness or irritation, apply powder For additional assistance, contact a WOC (wound, ostomy, continence) nurse. The stoma may be large at first, but it will settle in size 6-8 weeks after surgery. Keep Skin C/D/I: clean, dry, intact Monitor for Signs of Dermatitis or Yeast infection Offer emotional support and encouragement for a new body image Ostomy Care To eliminate waste, a stoma is an opening in the abdominal wall attached to the redirected area of the digestive system (colon=colostomy, ileum=ileostomy). Red-Pink: Normal Stoma Purple-Blue: Ischemia Pale Pink: Anemia A pouch is a device that connects to the stoma to collect bowel contents (gas, feces). Stoma & Pouch Colostomy: diversion of the Colon of the large intestine It could be caused by IBD, Colorectal Disease, or Diverticulitis. There are three varieties: Descending: stool semi-formed Transverse: stool unformed Ascending: liquid stool Ileostomy: "Ileum" diversion of the small intestine May be due to Colon Cancer, Polyps, Trauma. Amount of Output. Types of Ostomies Ileum Transverse Colostomy Descending Colostomy Sigmoid Colostomy Ascending Colostomy Colostomy Ileostomy # 56 FUNDAMENTALS # AUSCULTATING LUNG SOUNDS & LANDMARKS ## Vesicular Bronchial ## Bronchovesicular # VESICULAR NORMAL Soft, low pitched during inspiration and even softer during expiration # ABNORMAL WHEEZE High-pitched musical sound; heard more at expiration than inspiration Ex: Asthma # PLEURAL RUB FRICTION Low-pitch, rubbing or grating sound; heard at both inspiration and expiration. Loudest over the lower anterolateral surface. Not cleared by cough Ex: Pleurisy (inflammation of pleural surfaces) # RHONCHI Low-pitched, coarse, loud, snore-like; heard most ly at expiration. Clears with cough Ex: Chronic bronchitis # CRACKLES (RALES) FINE: high-pitch crackling, popping noise heard during end of inspiration. Not cleared by cough Ex: Heart Faikure, Pneumonia COARSE: low-pitched, bubbling or gargling sounds at early start of inspiration and expiration. Louder and lasts longer than fine crackle Ex: Pulmonary Embolism # BRONCHIAL Hollow; high-pitched compared to vesicular sounds; auscultated over the trachea # BRONCHOVESICULAR Equal, normal sounds; mixture of bronchial and vesicular; auscultated over bronchi (between trachea and alveoli of lungs) # 57 FUNDAMENTALS # NEUROCOGNITION 1. OLFACTORY: odor (smell) 2. OPTIC: vision (sight) 3. OCULOMOTOR: Muscle movement in the eyes 4. TROCHLEAR: superior oblique eye muscle movement 5. TRIGEMINAL: skin sensation and jaw movement 6. ABDUCENS: eye abduction 7. FACIAL: facial movement 8. VESTIBULOCOCHLEAR: hearing 9. GLOSSOPHARYNGEAL: taste and swallowing 10. VAGUS: parasympathetic stimulation 11. SPINAL ACCESSORY: shoulder abduction 12. HYPOGLOSSAL: tongue abduction Cranial Nerves Mental Status Full Consciousness or Alert A & O x 4 Inability to think quickly, poor memory, and short attention span Able to open eyes and respond, but tired and falls asleep rapidly Response to vocal cues is slow, and there is some shaking. Confusion Lethargic Obtunded Unresponsive save to painful stimuli Unresponsive as well as to stimuli Stupor Comatose Alert & Oriented A & O x 1 = Oriented to PERSON Sample Question: Can you state your name and date of birth? A & O x 2 = Oriented to PLACE Sample Question: What city are we in? A & O x 3 = Oriented to TIME Sample Question: What year is it? A & O x 4 = Oriented to EVENT Sample Question: What brought you into the hospital today? Deep Tendon Reflex Scale: 0 = Nonreactive 1+ = Hyperactive 2+ = Normal 3+ = Brisker than Average 4+ = Hyperactive with Clonus Spinal Nerves: Pink: Cervical Blue: Thoracic Purple: Lumbar Green: Sacral Nerves & Reflexes Glasgow Coma Scale: Eye, Verbal, Motor Severe: <8 Moderate: 9-12 Mild: 13-15 Normal: 15 # 58 FUNDAMENTALS # PAIN MANAGMENT A patient's response to and perception of pain can vary. Everyone interprets pain differently, and the patient's self-report of pain is the most reliable predictor. Acute Pain: <6 months and causes sympathetic fight or flight symptoms such as increased HR/BP, anxiety, diaphoresis. Chronic Pain: >6 months and has no effect on vital indicators. Chronic pain can also be idiopathic (no known cause). Acute vs. Chronic Nociceptive Pain: normal pain processing from a stimulus. There are 3 variations: Somatic: Subcutaneous tissue or skin Sx: Localized and Sharp. Ex: Cut Finger Visceral: the lining of organs and internal organs. Sx: Dull, Deep, Aching. Ex: MI Referred: detected in a location other than the origin Ex: Shoulder Pain from MI Neuropathic Pain: abnormal pain processing caused by dysfunctional or damaged pain nerves There are 3 variations: Diabetic Neuropathy: Diabetes causes severe, shooting, scorching, and "pins and needles" sensations in the limbs. Phantom Pain: limb amputation pain Nociceptive vs. Neuropathic Pain Threshold: min amount of pain before felt Pain Tolerance: max amount of pain a person can bear Modulation: nerves of the spinal cord cause muscles to contract away from area of painful stimuli. Transduction: conversion of pain to an electrical impulse through peripheral nerve fibers (nociceptors). Transmission: electrical impulse travels along nerve fibers Terms to Know FACES: most common for adults and children 3+ CRIES: 0-6 months COMFORT: Intubated pts (objective findings) NUMERICAL PAIN SCALE: 0-10 pain scale. PAINAID: ALZHEIMERS FLACC: 2 mo - 7 yrs for nonverbal face, legs, activity, cry, consolability. Pain Scales 0 1-3 4-6 7-9 10 No Pain Mild Moderate Severe Very Severe Worst Pain Possible Opioids for Severe Pain +/- Adjuvants or Non-Opioids Pain Increases Opioids for Mild to Moderate Pain +/- Adjuvants or Non-Opioids Pain Increases Non-Opioids: NSAIDs or Tylenol +/- Adjuvants: Gabapentin, Amitriptyline Pain Management Nonpharmacological Heat/Cold Massage Imagery Distraction Acupuncture # 59 NOTES ELECTROLYTE IMBALANCES Sodium ( Na+ ) 135 - 145 mmol/L Main role : Neuromuscular function 1. Mild hyponatremia (Na+ 115-135 mmol/L) Muscle cramp and feeling exhausted Dry mucous membrane 2. VERY severe hyponatremia (Na+ < 115 mmol/L) Show signs of neurological (Ex. confusion, seizures, hemiparesis) Serum sodium < 135 mmol/L Serum sodium > 145 mmol/L 1. Identify the cause of hyponatremia 2. Monitor V/S and record I/O, daily weight 3. Restrict fluid around 800 ml in 24 hrs 4. Administer IV and oral sodium intake (This depends on 'How much sodium loss') Mild : Add sodium in a food Moderate : Administer IV (Ex. 0.9% NaCl, Ringer's) Severe : Administer 3% or 5% NaCl, but need to closely monitor in ICU, it can caused cerebral edema, and neuro symptoms 1. Identify the cause of hypernatremia 2. Monitor V/S and record I/O, daily weight 3. Restrict fluid and sodium 4. Administer IV Isotonic with less percent of sodium Isotonic without sodium (Ex. D5W) > SIGNS & SYMPTOMS Low sodium intake High sodium secretion (Ex. vomiting, diarrhea, diuretics) Sodium dilution (Ex. SIADH, kidney disease) High sodium intake Low sodium secretion (Ex. corticosteroids) Too much water loss (Ex. fever, DI, watery diarrhea) > CAUSES Concepts : Sodium loss and water gain 1. Early signs : Extremely thirst Dehydration (Ex. dry and flushed skin, urine drop) Weakness 2. Late signs : Disorientation, delusions & hallucinations, it can caused 'Brain damage' Concepts : High sodium and water loss DIAGNOSIS TREATMENTS HYPERNATREMIA Hyper = HIGH HYPONATREMIA Hypo = LOW If the patient taking 'Lithium', should monitor lithium level. Hyponatremia can reduce 'Lithium excretion' caused 'Lithium toxicity' Serum sodium level < 135 mmol/L, mostly associated with fluid volume imbalances Serum sodium level > 145 mmol/L # FLUID & ELECTROLYTE IMBALANCES # 12 Magnesium ( Mg2+ ) 1.3 - 2.1 mEq/L Main role : Nerve impulses, muscle contraction & relaxation Muscle weakness Tremors Tetany Generalized tonic-clonic seizures 1. Serum magnesium level < 1.3 mEq/L 2. Physical examination : shows 'Chovstek's and Trousseu's signs positive' 3. EKG waveform changes : QRS prolonged, ST depressed 1. Serum magnesium level > 2.1 mEq/L 2. EKG waveform changes : PR prolonged, Tall T waves, QRS widened 1. Record V/S and monitor I/O 2. Increase magnesium intake By oral : rich food of Mg2+ (Ex. green leafy vegetables, legume, whole grain, nuts) By IV : administered IV 'Magnesium Sulfate' ONLY use with infusion pump and rate should not > 150 mg/min, giving too fast can caused 'Cardiac arrest' Nursing : Monitor V/S and I/O closely Observe side effects (Ex. respiratory distress, BP drop) Check deep tendon reflex Seizure precautions 1. Record V/S and I/O 2. Restrict magnesium intake and avoid using antacids & laxatives 3. Administer diuretic to increase magnesium excretion 4. Prepare 'Calcium gluconate' is the antidote for overdose of magnesium > SIGNS & SYMPTOMS Low magnesium intake (Ex. malabsorption, crohn's) High magnesium excretion (Ex. alcoholism) But mostly Mg2+ loss in GI tract (Ex. diarrhea, gastric suction) High magnesium intake Low magnesiun excretion (Ex. renal insufficiency) Excessive use of antacids & laxatives > CAUSES 1. Mild to moderate signs : Peripheral vasodilation (Ex. BP drop, HR drop) Facial flushing Nausea and vomiting 2. Severe signs : Drowsiness Lost of deep tendon reflex Lethargy Respiratory depressed > DIAGNOSIS TREATMENTS HYPERMAGNESEMIA HYPOMAGNESEMIA Serum magnesium level < 1.3 mEq/L Serum magnesium level > 2.1 mEq/L # FLUID & ELECTROLYTE IMBALANCES # 13 Potassium ( K+ ) 3.5 - 5.0 mmol/L Main role : Skeletal and cardiac muscle activity 1. Mild to moderate signs : Muscle weakness and leg cramps Dysrhythmias, irregular pulse Nausea and vomiting 2. Severe signs : cause of death Kidney failure (polyuria, nocturia) Increase sensitivity of digitalis 1. Serum potassium level < 3.5 mmol/L 2. EKG waveform changes : T wave : can be depressed / inverted / flatted U wave : elevated (ONLY found in Hypokalemia) 1. Serum potassium level > 5.0 mmol/L 2. EKG waveform changes : Tall peaked T wave ,flat P wave and wide QRS complex 3. Arterial blood gas : show 'Metabolic Acidosis' 1. Record V/S and monitor I/O 2. Monitor EKG closely and observe abnormal signs 3. Increase potassium intake as prescribed By oral : Eat rich foods in potassium (Ex. bananas, oranges, spinach, potatoes, whole grain) Administer oral K+ supplements By IV : ONLY use with diluted & infusion pump, NEVER administered by IV push, subQ or IM 4. Observe IV line to prevent phlebitis 5. Monitor urine output (If urine < 20 ml/hr for 2 consecutive hours, should notify HCP for stopping potassium infusion) 1. Record V/S and monitor I/O 2. Monitor EKG closely and observe abnormal signs 3. Restricted potassium intake and discontinue IV potassium 4. Make sure by repeating potassium lab again from a vein side that has NO IV with potassium 5. Prepare to administer medicines : Mild to moderate If renal function is OK : give diuretics If impaired renal function : give 'Kayexalate' Severe Administer 'Calcium gluconate' and observe BP Administer 'Sodium bicarbonate' to shif K+ Administer 'RI with dextrose solution' to shift K+ into the cells temporary > SIGNS & SYMPTOMS Low potassium intake High potassium excretion (Ex. diuretics, NG suction) Potassium dilution (Ex. IV therapy, water intoxication) High potassium intake Low potassium excretion (Ex. adrenal insufficiency) > CAUSES 1. Early signs : Muscle weakness and cramping Hyperactive bowel sounds & diarrhea 2. Late signs : Flaccid paralysis (block in muscle) Respiratory paralysis > DIAGNOSIS TREATMENTS HYPERKALEMIA HYPOKALEMIA Serum potassium level < 3.5 mmol/L, it can cause life threatening Serum potassium level > 5.0 mmol/L, it can cause 'Cardiac Arrest' # FLUID & ELECTROLYTE IMBALANCES # 14 Calcium ( Ca2+ ) 8.5 - 10.5 mg/dL Main role : Nerve impulses, muscle contraction & relaxation Tetany, seizures Tingling at the tips of fingers, around the mouth Muscles spasms V/S changed ( HR , BP ) Hyperactive deep tendon reflexes 1. Serum calcium level < 8.5 mg/dL 2. Physical examination : shows 'Chovstek's and Trousseu's signs positive' 3. EKG waveform changes : QT prolonged, ST segment 'Torsades de pointes' 1. Serum calcium level > 10.5 mg/dL 2. EKG waveform changes : shorten QT interval & ST segment 1. Record V/S and monitor I/O 2. Increase calcium intake as prescribed By oral : Take calcium with vitamin D will help to increase absorption DO NOT take with antacids because it can caused 'Hypophosphorus' By IV : Administered IV 'Calcium' with D5W DO NOT use with 0.9% NaCl or bicarbonates, it will increase renal calcium loss 3. Seizures precautions 1. Record V/S and monitor I/O 2. Restrict calcium intake 3. Discontinue IV calcium and vitamin D 4. Administered 0.9% NaCl to dilute and promote calcium excretion (sodium favours calcium excretion) 5. Administered IV phosphate that can help inhibit calcium resorption from bone > SIGNS & SYMPTOMS Low calcium intake & absorption from GI tract (Ex. ESRD, crohn's disease) Lack of vitamin D High calcium excretion (Ex. diarrhea, kidney disease) Medications (Ex. antacids, caffeine, steroids) Too much calcium and vitamin D intake Low calcium excretion (Ex. kidney disease, thiazide) Increase bone resorption of calcium (Ex. malignancies) > CAUSES Confusion Dehydration Muscle weakness V/S changed ( HR , BP ) Bone pain > DIAGNOSIS TREATMENTS HYPERCALCEMIA HYPOCALCEMIA Serum calcium level < 8.5 mg/dL Serum calcium level > 10.5 mg/dL # FLUID & ELECTROLYTE IMBALANCES # 15 FLUID & ELECTROLYTE IMBALANCES ## FLUID FLUID IMBALANCE FLUID VOLUME DISTURBANCES Help maintain body temperature and cell shape. Helps transport nutrients gases and wastes ## FLUID BALANCE Total body water (As percentage of body weight) in relation to age and sex. > AGE MALE FEMALE UNDER 18 18-40 40-60 OVER 60 65 % 60 % 50-60 % 60 % 55 % 50 % 40-50 % 50 % Changes in ECF volume = alterations in sodium balance Change in sodium/water ratio = either hypoosmolarity or hyperosmolarity Fluid excess or deficit = loss of fluid balance As with all clinical problems, the same pathophysiologic change is not of equal significance to all people For example, consider two persons who have the same viral syndrome with associated nausea and vomiting It is an abnormally decreased or increased fluid volume or rapid shift from one compartment of body fluid to another. 1-Hypovolemia 2-Hypervolemia > WEIGHT 70 KG 100% BODY WATER INTRACELLULER FLUID (ICF) EXTRACELLULER FLUID (ECF) PLASMA VOLUME (PV) 42 L 28 L 14 L 3.5 L 60 % 40 % 20 % 5 % ## FLUID DISTRIBUTION # 16 Fluid Volume FLUID & ELECTROLYTE IMBALANCES Main role : Nerve impulses, muscle contraction & relaxation Function loss Poor skin turgor Cool & clammy skin Weight loss Postural HT V/S changed HR high (rapid) Fever Neck veins flattened CVP drop Vasoconstrict Function loss Abnormal lung sounds Weight gain Edema V/S changed HR, RR, BP Wide pulse pressure CVP high Urine output high Power loss Muscle weakness Cramping 1. Physical examination : poor skin turgor, cool & clammy skin 2. Blood test : BUN & Cr , Hct 1. Physical examination : edema 2. Blood test : BUN & Cr , Hct , Na+ 1. The treatment depends on 'How much fluid loss?' Not severe : give the patient 'oral fluid intake' Severe : administered IV, normally use isotonic solutions Very severe : 'Fluid challenge test' help to improve tissue perfusion quickly 2. Frequently assess the patient V/S, I/O, conscious, CVP and skin color to estimate and avoid volume overload 3. Monitor weight daily to estimate fluid loss 4. Follow up lab results 1. Monitor V/S and record I/O 2. Daily weight to estimate fluid retention 3. Assess the degree of pitting edema at feet and ankles 4. Restrict fluid and sodium intake 5. Promoting rest to increase blood circulatory and renal perfusion 6. Administer diuretics to reduce edema by STOP kidney reabsorption of sodium and water 7. Observe side effects of diuretics, it can cause 'electrolyte imbalance' (Ex. Hypokalemia, Hyponatremia) > SIGNS & SYMPTOMS Inadequate fluid intake Abnormal fluid losses (Ex. diarrhea, suction, N/V) Other risk factors (Ex. blood loss, diabetes insipidus) Divided into 3 types 1. Isotonic : too much fluid ONLY in the ECF causes : uncontrolled IV therapy, steroid used 2. Hypertonic : fluid inside the cell drawn out causes : too much sodium intake 3. Hypotonic : fluid moves into the cells causes : heart failure, SIADH > CAUSES DIAGNOSIS TREATMENTS HYPERVOLEMIA HYPOVOLEMIA Loss of extracellular fluid volume (ECF) and electrolyte Abnormal of fluid and sodium retention 'Fluid overload' The severity depends on 'How much fluid loss?' # 17 NOTES HEAD TO TOE ASSESMENT Cardiovascular Respiratory Central Nervous System Fontanelles soft, not depressed or bulging Normal newborn reflexes, normal cry Infant is alert when awake Absence of seizure like activity No jitteriness, normal tone Behaviour is appropriate for age and development Awake, alert and oriented to person, place and time GCS normal Fontanelles normotensivebat rest and upright Awake, alert, oriented to person, place, and time Follows commands, clear speech, bilateral hand grasp equal Able to verbalize understanding of current health state Maintains eye contact Communicates thought processes Behaviour appropriate for age and development Regular heart rate 80-160 bpm BP mean > or = 36 mmHg Oxygen saturation > or = 92% Colour appropriate for gestational age Central capillary refill <3 secs No murmur Heart rate within normal range: 1mo-1yr 90-160 bpm 1-5yr 80-140 bpm 6-10yr 60-110 bpm 10+yr 60-100 bpm Regular pulse No murmur or abnormal heart sounds Capillary refill < 2 secs Skin warm and dry, colour within normal limits ( no pallor, mottling, dusky,cyanotic) Blood pressure within normal range: 0-1mo SBP>60 1mo-1yr SBP>70 1-10yr SBP>70+ 10+yr SBP>90 Regular apical rate between 60-100 bpm Skin warm and dry Colour normal (no pallor, mottling, dusky, cyanotic) Mucous membranes are pink and moist Capillary refill within 3 secs Radial, dorsalis pedis, and posterior tibial pulse is regular and palpable equally No calf tenderness, warmth, or redness No extremity edema No abnormal chest sounds Normal chest shape Symmetric chest rise andfall Airway patent Equal and bilateral air entry No evidence of increased work of breathing Breathing pattern regular, rate as expected for age: 1mo-1yr 25-45 bpm 1-5yr 20-30 bpm 6-10yr 16-24 bpm 10+yr 14-20 bpm Depth, rhythm, quality, and character as expected for age Respirations regular in rate (12-20/min), depth and rhythm Symmetrical movement of chest, absence of retraction in intercostal spaces No SOB at rest or on exertions Newborn Pediatric Adult HEAD-TO-TOE ASSESSMENT Newborn, Pediatric, and Adult Normals # 30 Gastrointestinal Genitourinary Respiratory continued No adventitious breath sounds Respiratory rate 30-60/min No apnea * Infants are obligate nose breathers and use abdominal muscles for breathing Symmetrical movement with each breath No intercostal retraction, no nasal flaring No shortness of breath at rest or on exertion Breath sounds normal, no adventitious sounds, no evidence of increased work of breathing Absence of cough and sputum production Able to clear airway secretions Able to eat/drink without SOB Breath sounds are normal, audibly clear with no adventitious sounds Absence of cough and sputum production Able to clear airway of secretions Oxygen saturation level normal (> 92% on room air) Ability to tolerate feedings No evidence of regurgitation or reflux symptoms Abdomen is soft, non tender, non distended Bowel sounds present Bowel movements and patterns are normal Ability to tolerate diet No evidence of nausea, vomiting, or other digestive symptoms Abdomen is soft, non tender, non distended Protuberant abdomen is absent by age 2-3 years Bowel sounds present in all quadrants Bowel movements normal for patients usual pattern No assist with delivery of nutrition or aids required (NG, G, GJ, J tubes, TPN) Ability to tolerate diet No evidence of nausea, vomiting or other digestive symptoms Abdomen is soft, non tender, non distended Bowel sounds present in all quadrants No assist with delivery of nutrition or aids required (NG, G, GJ, J tubes, TPN) Bowel movements normal for patients usual pattern Appropriate bladder and renal function Urine clear and yellow to amber 6 or more wet diapers per day Urine output 2-6 ml/kg/h No catheter present No inguinal hernia felt Testes in scrotum No genital swelling or bruising Urine output min 1 ml/kg/h Normal bladder and renal function Urine clear and yellow to amber No dysuria, discharge, or bleeding No catheterization required No incontinence or nocturia (if toilet trained) No genital swelling or bruising Genitalia structures appropriate for gestational age Appropriate renal and bladder function Urine is clear and pale yellow/straw coloured Voiding without pain, dysuria, frequency, enuresis, urgency, hematuria, incontinence, nocturia, polyuria, anuria, oliguria No indwelling catheters present, patient doesnt self catheterize Newborn Pediatric Adult HEAD-TO-TOE ASSESSMENT # 31 Integumentary Musculoskeletal No known structural abnormalities Ability to move all joints and extremities without limitation Symmetrical movements Limbs held in flexed position with some resistance to active extensions Ability to move all joints and extremities without limitation Meeting developmental milestones for tone and movement (age appropriate) When required, monitoring growth as per appropriate growth chart (e.g. maintaining 50th percentile on normal growth chart for age) Symmetry and no structural abnormalities (scoliosis) Ability to move all joints and extremities without limitation Ability to ambulate with steady balance and purposeful gait that is smooth, coordinated, easy and rhythmic with push off and swing through Skin colour within norm for gestational age Skin is warm, dry, and intact without surface irritation/rash /bruises and without visible or palpable abnormalities/marks Growth, pigmentation and location of hair appropriate to culture/race or infant Normal skin turgor Skin colour within patients norm Skin is warm, dry and intact without skin surface irritation and without visible or palpable deformities Growth, pigmentation and location of hair appropriate to person No open areas Normal skin turgor Skin colour within patients norm Skin is warm, dry, and intact without visible or palpable deformities Growth, pigmentation and location of hair appropriate to person No open areas Newborn Pediatric Adult HEAD-TO-TOE ASSESSMENT ## Physical Assessment Integument Skin: The clients skin is uniform in color, unblemished and no presence of any foul odor. He has a good skin turgor and skins temperature is within normal limit. Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. There are also no signs of infection and infestation observed. Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds. Head Head: The head of the client is rounded; normocephalic and symmetrical. Skull: There are no nodules or masses and depressions when palpated. Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses. 32 HEAD-TO-TOE ASSESSMENT ## PHYSICAL ASSESSMENT Eyes and Vision Eyebrows: Hair is evenly distributed. The clients eyebrows are symmetrically aligned and showed equal movement when asked to raise and lower eyebrows. Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward. Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks approximately 15-20 times per minute. The Bulbar conjunctiva appeared transparent with few capillaries evident. The sclera appeared white. The palpebral conjunctiva appeared shiny, smooth and pink. There is no edema or tearing of the lacrimal gland. Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was touched. The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA (pupils equally round respond to light accommodation), illuminated and nonilluminated pupils constricts. Pupils constrict when looking at near object and dilate at far object. Pupils converge when object is moved towards the nose. When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead. When testing for the Extraocular Muscle, both eyes of the client coordinately moved in unison with parallel alignment. The client was able to read the newsprint held at a distance of 14 inch Ears and Hearing Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile, firm and not tender. The pinna recoils when folded. During the assessment of Watch tick test, the client was able to hear ticking in both ears. Nose and Sinus Nose: The nose appeared symmetric, straight and uniform in color. There was no presence of discharge or flaring. When lightly palpated, there were no tenderness and lesions Neck The neck muscles are equal in size. The client showed coordinated, smooth head movement with no discomfort. The lymph nodes of the client are not palpable. The trachea is placed in the midline of the neck. The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible 33 HEAD-TO-TOE ASSESSMENT ## PHYSICAL ASSESSMENT Thorax, Lungs, and Abdomen Lungs / Chest: The chest wall is intact with no tenderness and masses. Theres a full and symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when assessing for the respiratory excursion. The client manifested quiet, rhythmic and effortless respirations. The spine is vertically aligned. The right and left shoulders and hips are of the same height. Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence of heaves or lifts. Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. The abdomen has a symmetric contour. There were symmetric movements caused associated with clients respiration. The jugular veins are not visible. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds. Extremities The extremities are symmetrical in size and length. Muscles: The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth, coordinated movements. Bones: There were no presence of bone deformities, tenderness and swelling. Joints: There were no swelling, tenderness and joints move smoothly Mouth The lips of the client are uniformly pink; moist, symmetric and have a smooth texture. The client was able to purse his lips when asked to whistle. Teeth and Gums: There are no discoloration of the enamels, no retraction of gums, pinkish in color of gums The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and with elastic texture. The tongue of the client is centrally positioned. It is pink in color, moist and slightly rough. There is a presence of thin whitish coating. The smooth palates are light pink and smooth while the hard palate has a more irregular texture. The uvula of the client is positioned in the midline of the soft palate # 34 HEAD-TO-TOE ASSESSMENT ## HEAD TO TOE PHYSICAL ASSESSMENT POLST/Code Status VS 7:30 Temperature: Pulse: Respirations: BP: / Pain: /10 VS 11:30 Temperature: Pulse: Respirations: BP: / Pain: /10 Age: Male /Female Body Build: Thin Cachectic Obese WNL Height: Weight: Facial Expression: Anxious Happy Sad Angry Well groomed Poorly Groomed GENERAL SURVEY How does the client look? Pink Pale Cyanotic Jaundiced Ruddy Flushed Diaphoretic CARDIOVASCULAR Skin / Mucous Membranes Radial: Palpable (L/R) Absent (L/R) Pedal: (DP PT) Palpable (L/R) Absent (L/R) Radial And Pedal Pulses (2 people simultaneously) Apical and Radial Pulse Deficit Apical Radial Pulses Oriented x 4: Person Place Time Event Response to touch/voice NEUROLOGICAL (LOC) Level of Consciousness Alert Awake Lethargic Obtunded Stuper Comatose Confused Decerebrate Decorticate Unaided hearing Hard to hearing Deaf Hearing aid Implant Cerumen Drainage Unaided sight Glasses Contact lens Implants Prosthesis Snellen 20/ Blind Equal Round Reactive to light Accommodates Sluggish Brisk Nonreactive to light Consensual Eyes Ears Character Onset Location Duration Severity Pattern Associated Factors COLDSPA Pain (DO NOT TAKE AT SAME TIME) Right Left Thrill Bruit Carotid Pulses Capillary Refill Pupils Hand grips +1 +2 +3 +4 +5 equal unequal Foot pushes +1 +2 +3 +4 +5 equal unequal Extremities I(smell) II (vision) III+IV+VI (eye movement) V (sensation of face/oral) VII (facial movement/taste) VIII (hear/balance) IX (taste/swallow) X(Chew/gag/speech) XI (shrug/turn head) XII (tongue movement) Cranial Nerves - intact Pupil size before light ________ mm Normal (<3 sec) __________ sec Pupil size after light _________ mm # 35 HEAD-TO-TOE ASSESSMENT Teeth Dentures Caries Dysphagia Mucous Membranes: intact moist dry pale leukoplakia GASTROINTESTINAL Oral CARDIOVASCULAR Telemetry: rythm____________ Pacemaker Defibrillator Location Heart Rhythm/ Sounds - S1S2 Not visible Visible Jugular Neck Veins Edema Absent Present: location Regular Irregular Murmur Extra sounds Strong Faint Muffled Solution______________ Rate ________ ml/hr Pump Site location (be specific) __________________________ IV Site appearance: Clear Edema Erythema Tender Pallor Dialysis access: type_________ Thrill Bruit Location:__________ Appearance:____________ Calf Tenderness Denies Positive Homan's sign R L calf size R_____ L_____ (team leader or charge nurse notified) Wheezes location: Rales/crackles location: Rhonchi location: Nasal flaring Sternal retraction Intercostal retraction Do lung sounds improve with cough and deep breath? If no, report to team leader Regular Irregular Even Uneven Unlabored Labored Symmetrical Asymmetrical None Nonproductive Dry Moist Productive Sputum: amount color frequency Room air Nasal Cannula Mask Tent CPAP BIPAP HHN medication Bipap Ventilator? TV rate 02% other Clear LUL RUL LLL RLL RML Anterior Posterior RESPIRATORY Respiration Lung Sounds Cough Oxygen Respiratory Treatments Pulse ox: Incentive Spirometer (IS): ml ________ frequency ________ hold for ____ seconds #of times_____ O2 at: ________ l/min ALLERGIES : BLOOD GLUCOSE: # 36 HEAD-TO-TOE ASSESSMENT ADLs independent or assisted with ____________________________________ MUSCULOSKETETAL Mobility Circulation: color pulses cap refill Motion Sensation Temperature RA LA RL LL Antiembolitic Hose: knee/thigh CMST None Cast Brace Splint Location Elevate Traction-Type Muscle treatment GASTROINTESTINAL Self feed Needs assistance Thickened liquids: honey nectar pudding Tube feed __________ Location: Nutrition Soft Round Flat Scaphoid Obese Firm Hard Nondistended Distended Tender Non Tender Abdomen: Inspect Auscultate Percuss Palpate Bowel Sounds RLQ RUQ LUQ LLQ Normoactive Hypoactive Hyperactive Absent Bowel Movement Continent Incontinent Last BM Color Size Consistency Ostomy Stool Diet _________ % eaten Breakfast _______ Lunch _______ NPO? Why _________ NG/ GT/ JT None Type of tube ________ patent nonpatent Suction: low high Color of drainage amount Fluid restriction Total I&O +/- _________________ Continent Incontinent Catheter type___________ Patent Nonpatent_____________ Color__________ Clear Cloudy Sediment Burning Frequency Male Female Vaginal Discharge LMP Post partum PO/ Oral/Tube Feed intake________ IV Intake________ Urine output________ Other output GENITOURINARY Urine Intake and Output Genitalia Not present Present- which extremity? What % decreased? Contractures Bed alarm Chair alarm 1 or 2 Person Transfer Floor pad Side rails Mechanical lift Slide board Risk for falls AROM AAROM PROM CPM Limited location ______________________ ROM Turns self Sits independently Dangles Stands independently Walks independently Ambulatory assistance: Gait belt Cane Walker Crutches Braces Wheelchair Gerichair Walks: Distance Frequency Tolerance PT OT RNA Mobility Intact Color___________ Pallor Rash Bruise Lesions Scar Location______________ Turgor________ seconds Site__________ INTEGUMENTARY Appearance 37 HEAD-TO-TOE ASSESSMENT INTEGUMENTARY None Surgical site - Location Well approximated Sutures Staples Steristrips Dressing: Dry/intact Non-intact Change: yes no Drainage: Color Amount ________________ Odor ___________ Wound Dressing Skin Warm Hot Cool Cold Dry Moist Pressure Ulcers Wound Appearance Drain type ________ Amount ___________ Stage Location Size Tunneling Eschar Slough Stage Location Size Tunneling Eschar Slough Stage Location Size Tunneling Eschar Slough Type Culture Site Type Culture Site ISOLATION Cooperative Uncooperative Pleasant Withdrawn Combative Other ________ RA LA RL LL PSYCHOSOCIAL Behaviour English = speaks and understands Other ________________ Interpreter Language Spoken None Chemical Physical: type location Restraints CMST of extremity Frequency Checked_____________ See Restraint Form STUDENT (printed)__________________________________ Date:_________________ Client Initials:_________________ Room Number:___________ NANDA DX___________________________________________________________________________________________________ # 38 NOTES ## Every accomplishment starts with the decision to try. LAB VALUES LAB VALUES # GLUCOSE 70 - 110 LOW Hypoglycemia is commonly caused by receiving too much insulin, adrenal issues or malnutrition < 40 = critical # HIGH Hyperglycemia can be caused by diabetes, cushings and pancreatitis > -350 = critical # pH 7.35 - 7.45 LOW Low pH is acidosis Can be caused by an excess of CO2 in the blood or by a loss of HCO3 in the kidneys # HIGH Increased pH is alkalosis It's caused by excess HCO3 or a decrease in CO2 CO2 can decrease d/t hyperventilation # BICARBONATE 22-26 LOW Can be caused by damage to the kidneys and their subsequent inability to reabsorb HCO3 # HIGH The kidneys reabsorb bicarbonate elevating the pH in the blood to compensate for acidosis HCO3 is a buffer and stabilizer of pH # BUN 8-25 LOW BUN is a byproduct of metabolism that indicates renal function + hydration Lower BUN can be caused by a low protein diet, liver failure and fluid overload # HIGH Increased BUN can be caused by CHF a 61 bleed, hypovolemia, kidney failure, pyelonephritis, heart attack, excess protein in the GI tract or shock # 21 LAB VALUES # LOW Lower creatinine levels can be caused by spinal cord injuries or abrupt declines in movement because creatinine is released by the kidney as a byproduct of metabolism # HIGH Can suggest renal failure, dehydration, rhabdomyolysis, hyperthyroidism, muscular dystrophy, or an obstructed urinary tract # LOW Higher hematocrit levels can be caused by dehydration, blood loss, chemotherapy, or lead poisoning # HIGH Hematocrit is usually directly proportional to hemoglobin and should be 3xHgb # LOW Blood loss, anemia, bone marrow suppression, leukemia, and renal issues are common causes of low Hgb # HIGH High altitude living, long-term smoking, tumors, polycythemia vera, and erythropoietin use can all cause it # CREATININE 0.6-1.5 LOW Neutropenia is typically caused by bone marrow failure, viral infection, chemotherapy, splenic insufficiency, and radiation # HIGH An elevated WBC count can be caused by infection, stress, inflammatory illnesses, or leukemia # WBC 4300-10800 HEMATOCRIT Male: 41-50% Female: 36-48% HEMOGLOBIN Male: 13.5-17.5 g/dl Female: 12-15.5 g/dl # 22 LAB VALUES # ALT 13-69 LOW Low ALT is normal and indicates normal liver function. # HIGH It is a more specific test than AST. High ALT levels might be an early sign of liver disease. # ALBUMIN 3.4-5.0 LOW Albumin levels in burns can also be reduced due to third spacing Because albumin is produced by the liver, a low albumin level usually indicates liver disease or cirrhosis # HIGH Dehydration can result in elevated albumin levels due to a lack of water in the blood # AST 5-40 LOW Low levels of AST in the blood are typical and anticipated # HIGH High AST values may indicate chronic-acute hepatitis, cirrhosis, or other liver problems # TOTAL PROTEIN 6.4 - 8.0 LOW Total protein levels might drop due to liver illness, hemorrhaging, diarrhea, or vomiting # HIGH Chronic inflammation, bone marrow diseases, hepatitis, and HIV can all cause elevated total protein levels # PLATELET 150k-350k LOW Low platelets increase the patient's risk of bleeding and can be caused by DIC or aplastic anemia # HIGH Platelet count increases can be induced by myelogenous leukemia, recent spleen resection, or inflammation # 23 LAB VALUES # Vitals REMEMBER: To avoid a misleading reading, make sure the BP cuff fits properly. Too LARGE = False Low Too SMALL = False High Hypertension Systolic Diastolic Pre-Hypertension Normal > 140 > 90 80-89 60-79 120-139 100-120 < 60 < 100 Hypotension Blood Pressure Vital Signs Blood Pressure Systolic: 120 Diastolic: 80 Oxygen Saturation: 97% Mean Arterial Pressure: 93 Heart Rate: 60 Normal 95-100% Mild Hypoxia 90-94% Moderate Hypoxia 86-89% Severe Hypoxia <86 Oxygen Saturation Bradycardia <60 BPM Normal 60-100 BPM Tachycardia 100 BPM Heart Rate Oral 97.6-99.6F / 35.5-37.5C Rectal 98.6-100.4F / 36.6 - 38.0C Axillary 96.6 - 98.6F / 34.7 - 37.3C Temperature Rate - 12 to 20 breaths per minute Assessment - Rhythm Regular / Irregular - Depth Normal, deep, shallow Tachypneic: >20 Bradypneic: <12 Respirations Pulse is absent 0Diminished 1+ 3+ 4+ 2+ Normal Full Bounding, Strong pulse Strength # 24 LAB VALUES Lipid Panel Total Cholesterol: <200 mg/dL Triglyceride: <150 mg/dL LDL: <100 mg/dL (Bad Cholesterol) HDL: >60 mg/dL (Good Cholesterol) Liver Function Test (LFT) ALP: 40- 120 U/L Bilirubin: 0.1 - 1.2 mg/dL ABG's PaCO3: 35 - 45 mmHg PaO2: 80 - 100 mmHg HCO3: 22 - 26 mEq/L Complete Blood Count (CBC) WBC: 4500 - 11000 / L RBC: 4.5 5.5 million/L PLT: 150000 - 450000/L Others... MAP: 70 - 100 mmHg ICP (Intracranial Pressure): 5 - 15 mmHg BMI: 18.5 - 24.9 Glascow coma scale: - Best: 15 - Mild: 13 - 15 - Moderate: 9 - 12 - Severe: 3 - 8 Basal Metabolic Panel (BMP) Sodium: 135 - 145 mEq/L Potassium: 3.5 - 5.0 mEq/L Chloride: 95 - 105 mEq/L Calcium: 9 - 11 mg/dL Albumin: 3.4 - 5.4 g/dL Total protein: 6.2 - 8.2 g/dL Renal Calcium: 9 - 11 mg/dL Magnesium: 1.5 - 2.5 mg/dL Specific gravity: 1.010 - 1.030 Phosphorus: 2.5 - 4.5 mg/dL GFR: 90 - 120 mL/min HbA1c Non-diabetic: 4 - 5.6% Pre-diabetic: 5.7 - 6.4% Diabetic: >6.5% COAGs PT: 10 - 13 sec PTT: 25 - 35 sec aPTT: 30 - 40 sec (heparin) INR - NOT ON Warfarin < 1 sec - ON Warfarin 2 to 3 sec Pancreas Amylase: 30 - 110 U/L Lipase: 0 - 150 U/LL Measured with Therapeutic Range Heparin aPTT 1.5 - 2.0 x normal "control" value Warfarin INR 1.5 - 2.0 x normal "control" value Protamine Sulfate Vitamin K # 25 ARTERIAL BLOOD GAS INTERPRETATION Uncompensated: If the pH is out of range and CO2 or HCO3 is in range Partially Compensated: If CO2 and HCO3 are both out of range and the pH is out of range Fully Compensated: If pH is in range (7.35 - 7.45) Know your Laboratory Values Determine whether the issue is respiratory or metabolic in nature. Respiratory - pH is high and CO2 is low Metabolic - pH is high and HCO3 is high Alkalosis Opposite - pH is low and CO2 is high Equal - pH is low and HCO3 is low Acidosis Determine if it is an uncompensated, partially compensated, or fully compensated pH Acidosis Therapeuti c Range Antidote CO2 HCO3 < 7.35 7.35 - 7.45 > 7.45 < 35 > 26 35-45 22-26 > 45 < 22 ## LABORATORY VALUES Potassium (3.5-5) Phosphorus (2.5-4.5) Calcium (9-11) Chloride (95-105) AST (9-40 U/L) Creatine (0.6-1.2mg/dL) Glucose (70-100 mg/dL) Magnesium (1.5-2.5) ALT (7-60 U/L) BUN (7-20mg/dL) Sodium (135-145) # 26 NOTES MENTAL HEALTH Behaviors you learn to manage - thoughts and feelings. Individual behaviors: Many mental health disorders are genetic. Genetics: Family and peer groups have a significant impact on development and mental health. Social Environment: Impacts access to mental health support. Economic Circumstances: Access to basic needs like healthcare, food, water, etc. Cultural beliefs also have a significant impact on what is considered mental illness and what is not. Environmental Factors: FACTORS AFFECTING MENTAL HEALTH Care for people in crisis, life problems, and long-term mental illness. - Ex: patients with diagnosed disorders, homeless patients, patients in jail, and patients who have experienced abuse. Psychiatric nurses work in a variety of settings. - Ex: hospitals, homes, halfway houses, shelters, clinics, etc. PSYCHIATRIC NURSING Published by the American Psychiatric Association. Identifies mental health disorders based on specific criteria. Describes the criteria for the diagnosis of 157 disorders. DSM-5 MENTAL HEALTH MENTAL HEALTH OVERVIEW Complete mental, physical and social well-being. Not just the absence of illness or disease. Able to cope with the normal stresses of life, be productive, and contribute to the community. Capable of rational thinking, communication, resilience, and self- esteem. All mental health disorders have defined diagnoses in the DSM-5. Alterations in thought process, emotions, or behavior. 1 in 5 adults in America have experienced a mental health issue. The definition of mental illness varies by culture. ## MENTAL HEALTH MENTAL ILLNESS MENTAL HEALTH CONTINUUM ## HEALTHY REACTING INJURED ILL Normal level of functioning. Resilient, normal sleep patterns, comfortable with others, etc. Common, reversible distress. Irritable, nervous, trouble sleeping, low energy, etc. Significant functional impairment. Hopelessness, worthlessness, withdrawal, etc. Clinical disorder, severe functional impairment. High anxiety, depression, thinking disturbances, etc. # 243 MENTAL HEALTH THERAPEUTIC RELATIONSHIPS Facilitates communication between nurse and patient. Promotes patient education, self-care, and independence. Allows patient to examine their behavior and find alternatives when necessary. Promotes patient recovery. Nurse-Patient Relationship: When a patient unconsciously transfers feelings they have for someone from their past onto a healthcare worker. - Ex: the nurse reminds the patient of their sister they dont like. Transference: Social Relationship: Superficial communication Friendship, enjoyment, advice Should not be used in nursing practice Therapeutic Relationship: Address concerns brought up by patient Establish clear boundaries Respect decisions made by the patient Encourage healthy coping skills and problem-solving Support behavior change when applicable Therapeutic Relationship: 1-Pre-Orientation Phase: Reviewing patient chart, receiving report on the patient. 2-Orientation Phase: Nurse and patient meet, rapport is established, goals are discussed, contract is formed. 3-Working Phase: Problems the patient is experiencing are explored and patient education occurs. 4-Termination Phase: Occurs when patient is discharged, new life-skills and coping strategies are reviewed. Stages of Nurse-Patient Relationship There are 3 important characteristics that a nurse should implement to promote patient growth: Empathy: Validates patient thoughts and feelings. Positive Regard: Respect every patient without judgement. Genuineness: Be open and honest when interacting with patients. Promoting Patient Growth: When a healthcare worker unconsciously transfers feelings they have for someone from their past onto a patient. Ex: A nurse has a patient who struggles with substance abuse that reminds them of their father. Countertransference: Establishing boundaries allow nurse and patient to effectively explore patient feelings and treatment. Blurring of boundaries occurs when: - A therapeutic relationship turns into a social relationship. - The nurse attempts to meet their needs through the patient. Establishing Boundaries: Under-Involvement Therapeutic Over-Involvement # 244 MENTAL HEALTH EATING DISORDERS Anorexia Nervosa: -Restriction of energy intake that leads to low body weight for height and age. * Most frequently occurs in females in adolescence and young adulthood. 4-Nursing Diagnoses: - Imbalanced nutrition: less than body requirements - Disturbed body image - Chrnoic low self-esteem - Ineffective coping - Risk for injury - Risk for imbalanced fluid volume Binge-Eating Disorder: Repeated episodes of binge eating followed by significant distress, but no purging. 2-Assessment: - History of weight cycling (gain and loss) - Nutritional pattern 1-Symptoms: - Obesity - Dysfunctional eating pattern - Loss of control when binging 3-Nursing Diagnoses: - Imbalanced nutrition: more than body requirements. - Ineffective coping - Social isolation - Powerlessness - Chronic low self-esteem - Repeated episodes where the patient consumes a large amount of food in a short period of time. - Binges are followed by actions such as self-induced vomiting, laxative consumption, fasting, or excessive exercise to rid the body of the calories consumed. 3-Nursing Diagnoses: - Disturbed body image - Decreased cardiac output - Ineffective coping Bulimia Nervosa: 1-Symptoms: - Recurrent binging and purging. - Most patients maintain a normal body weight and BMI. - Peripheral edema - Parotid swelling - Tooth erosion 2-Assessment: - Past and current nutritional patterns - Binging and purging patterns - How patient feels about their body - Deterioration of the mouth or throat Types: - Restricting type: Drastic reduction of food intake with no binging or purging. - Binge eating / purging type: Patient also binge eats and purges. Body Mass Index (BMI): - Mild: 17 or less - Moderate: 16-16.99 - Severe: 15-15.99 - Extreme: less than 15 1-Symptoms: - Weight that is lower than normal. - Extreme fear of gaining weight. - Disturbance in the way the patient views their weight or body shape. 2-Risk Factors: - Perfectionism - Environment - Ex: Patient participates in a sport that idolizes a thin body. - Significant life changes 3-Assessment: - Weight in relation to height - Lanugo (fine, downy hair on the face and back) - Eating habits - History of dieting - Value the patient attaches to weight and body size. # 245 MENTAL HEALTH ANXIETY DISORDERS AND OCD LEVELS OF ANXIETY A normal experience Allows individual to grasp more information and problem-solve. MILD ANXIETY May experience selective inattention Clear thinking is impaired but problem-solving can still occur. Somatic symptoms begin MODERATE ANXIETY Ability to grasp information is significantly impaired. Learning and problem-solving are not possible. Somatic symptoms increase. SEVERE ANXIETY Individual is unable to process what is going down around them. Patient could be a risk to themself or others. PANIC ANXIETY Anxiety that is out of proportion for the situation the individual is in. Symptoms include restlessness, fatigue, difficulty concentrating, irritability, sleep disturbances that cause significant distress. GENERALIZED ANXIETY DISORDER Severe anxiety caused by fear of doing something foolish in a social situation. Individuals will typically avoid social situations. SOCIAL ANXIETY DISORDER Severe anxiety that causes frequent panic attacks with feelings of impending doom. PANIC DISORDER Individual is obsessed with what they perceive to be a deformed body part. BODY DYSMORPHIC DISORDER Inappropriate level of anxiety about being away from a significant other for the individuals developmental level. May be caused by loss of a loved one, assault, immigration, etc. SEPARATION ANXIETY DISORDER Obsessions: persistent thoughts that can not be dismissed from the mind. Compulsions: behaviors the individual feels they must complete to reduce anxiety. Symptoms occur daily and cause distress. OBSESSIVE-COMPULSIVE DISORDER Irrational crippling anxiety/fear of an object, situation, or activity. SPECIFIC PHOBIA Irrational crippling anxiety/fear of an object, situation, or activity. AGORAPHOBIA # 246 MENTAL HEALTH Priority nursing intervention is to provide safety for the patient and others. Offer activities that provide distraction. Listen to the patients concerns. Reinforce reality when patient has a distorted perception. Provide a quiet, non-stimulating environment for patient if there is severe anxiety or panic. Ensure patient has adequate nutrition and fluid intake. NURSING INTERVENTIONS Antidepressants: (SSRIs, SNRIs, MAOIs) Anti-Anxiety Drugs: Benzodiazepines, Buspirone. Beta-blockers, antihistamines, anticonvulsants, and antipsychotics may be used if other medications do not work. MEDICATIONS Therapies Deep brain stimulation NON-PHARMACOLOGICAL TREATMENT ANXIETY DISORDERS AND OCD SOMATIC SYMPTOM DISORDERS SOMATIC SYMPTOM DISORDER SYMPTOMS: The expression of psychological stress through physical symptoms that cannot be explained by pathology. Patient has excessive thoughts, feelings, and distress related to the symptoms. Patients frequently seek out medical care and wont accept psychological diagnoses for their symptoms. ASSESS FOR: Extreme preoccupation with somatic symptoms. Somatic symptoms present for over 6 months. Possible overmedication. NURSING INTERVENTIONS: Encourage independent self-care. Encourage patient to verbalize feelings. Educate the patient on coping mechanisms. # 247 MENTAL HEALTH DEPRESSIVE DISORDERS Risk for self-directed violence Ineffective coping Chronic low self-esteem Social isolation Hopelessness Imbalanced Nutrition POTENTIAL NURSING DIAGNOSES Affect: may be flat. Thought Process: judgement, memory, and concentration may be poor. Mood: anhedonia (lack of pleasure). Feelings: hopelessness, guilt, anger, etc. Behavior: lack of energy. Cognitive Changes: difficulty carrying out daily activities. ASSESSMENT Electroconvulsive Therapy Transcranial Magnetic Stimulation Vagus Nerve Stimulation Deep Brain Stimulation NON-PHARMACOLOGICAL INTERVENTIONS - Increase availability of serotonin. - Monitor for serotonin syndrome (too much serotonin) - Increase availability of serotonin and norepinephrine. MEDICATIONS Depression is caused by imbalances of serotonin and norepinephrine. Selective Serotonin Reuptake Inhibitors (SSRIs) Selective Norepinephrine Reuptake Inhibitors (SNRIs) - Should not be used in patients with cardiovascular problems and older adults. Tricyclic Antidepressants - Prevents the breakdown of mood-boosting neurotransmitters in the brain. Monoamine Oxidase Inhibitors (MAOIs) Consistent/severe anger and irritability that begins before the age of 10 in children age 6-18. Introduced to decrease false diagnoses of bipolar disorder in children. DISRUPTIVE MOOD DYSREGULATION DISORDER Result of prolonged use or withdrawal from drugs or alcohol. SUBSTANCE-INDUCED DEPRESSIVE DISORDER Symptoms appear the week before a womans period begins. Symptoms include mood swings, irritability, anxiety, depression, and difficulty concentrating. Symptoms interfere with daily life. PREMENSTRUAL DYSPHORIC DISORDER 5 or more of the following in a 2-week period: Weight loss Change in appetite Feelings of worthlessness Fatigue or loss of energy Depressed mood or anhedonia Insomnia or hypersomnia Inability to concentrate Decreased interest in daily activities Recurring thoughts of death MAJOR DEPRESSIVE DISORDER Must have: Also known as dysthymia Feelings of depression most of the day for the majority of days. Must last at least 2 years in adults and 1 year in children/adolescents. Change in appetite Change in sleeping pattern Difficulty concentrating Low energy Hopelessness/low self-esteem PERSISTENT DEPRESSIVE DISORDER Must have at least 2 of the following: # 248 MENTAL HEALTH PERSONALITY DISORDERS 1- Patients with personality disorders can create strong emotional reactions within the nurse. Ex: Attempting to create tension between staff. 2- Maintaining safety in the milieu is the highest priority. * Patients with personality disorders are at risk for injury to self or others. 3- Maintain consistent care with the patient and maintain firm boundaries. 4- Self-assess for Countertransference reactions. Nursing Considerations: Treatments: - Medications are prescribed to treat symptom manifestations. - Antidepressants, antianxieties, antipsychotics, and mood stabilizers. - Behavioral and psychotherapy is also utilized. ## CLUSTER A - Belief that others want to harm, deceive, or exploit them. - Suspiciousness of others - RN should remain neutral and direct when interacting with patient. Paranoid: - Social withdrawal, emotional detachment. - Disinterest in close relationships. - Indifferent to praise or criticism. - Uncomfortable with social interaction. Schizoid: - Very strange behavior - Magical thinking, odd beliefs, strange speech patterns. - Severe social deficits. - Perceptual distortions (misinterpreting actions of others). Schizotypal: CLUSTER C - Avoidance of social contact. - Extreme fear of rejection. - Feelings of inadequacy. - Extreme anxiety in social situations. Avoidant: - Intense fears of separation. - High need to be taken care of. - Feelings of insecurity. - Lack of confidence in their own abilities and judgement. Dependent: - Perfectionism, orderliness, and control. - Stubbornness - Indecisiveness - Often can not accomplish tasks. ObsessiveCompulsive: Odd or eccentric behavior ## CLUSTER B - Disregard for others. - Exploitation of others. - Will not accept responsibility. - Manipulation - Impulsivity - Can be charming Antisocial: - Instability of identity. - Splitting behaviors - Fear of abandonment. - Ideas of reference. - Manipulation - Impulsivity Borderline: - Dramatic, attentionseeking behavior. - Extroversion - Selfcenteredness - Difficulty forming longlasting relationships Histrionic: - Lack of empathy - Arrogance. - Sensitivity to criticism. - Seeks admiration from others. - Fear of abandonment. - Usually will not accept treatment. Narcissistic: Dramatic, emotional, or erratic behavior Anxious or Insecure 249 MENTAL HEALTH # BIPOLAR DISORDERS Bipolar l: The most severe bipolar disorder. Mania is so severe that hospitalization is often required. Significant impairment in interpersonal relationships and occupational settings. At least 1 manic episode. Risk taking behaviors are common. Patients may begin to experience psychosis, including hallucinations and disturbed thoughts. After the mania subsides, the patient will fall into a depressive episode. Cyclothymic Disorder: Symptoms of hypomania that dont meet the full criteria, alternating with episodes of mild to moderate depression. Does not meet the criteria for Bipolar ll. Hypomanic episodes tend to be more irritable. Rapid cycling is more likely to occur and cause poor functioning. Nursing Diagnoses: Risk for injury Sleep depreciation Altered thought processes Risk for other-directed violence Impaired social interaction Self-care deficit Assessment: Assess: Mood Elevated expressions Energy levels Hyperactivity Sleep patterns Reduced need for sleep Behavior Risk-taking Thought-Processes Pressured, circumstantial, or tangential speech. Thought content Grandiose delusions, persecutory delusions. Bipolar ll: Less severe than Bipolar 1. At least one hypomanic episode alternating with major depressive episodes. Hypomania can increase functioning. EX: staying awake for excessively long periods to work on a project. Psychosis is not present with the hypomania. Does not usually cause impairment in interpersonal relationship or occupational settings. Nursing Interventions: Use firm and calm directions. Be consistent in expectations. Maintain safety in the milieu. Maintain an environment with low-stimulation. Redirect aggressive behavior. Maintain adequate nutrition. Provide frequent high-calorie finger foods. Encourage patient to take rest periods. Treatments: 1-Pharmacological: Mood stabilizers Treats mania Lithium (monitor for lithium toxicity) Anticonvulsants Anti-anxiety medications Second-generation antipsychotic medications. Antidepressants SSRIs 2-Non-Pharmacological: Electroconvulsive therapy Support groups Cognitive-behavioral therapy Mania: Abnormally elevated mood, expansiveness, irritability, and extreme activity lasting for at least 1 week. Hypomania: Less severe mania that lasts at least 4 days. Rapid Cycling: At least 4 episodes of mania/hypomania in the same year # 250 Schizophrenia: Psychotic thinking or behavior that lasts for at least 6 months. Typically presents between age 15 and 25. Hallucinations, delusions, disorganized speech or disorganized behavior. Symptoms significantly impair normal daily functioning Schizophreniform Disorder: Patient has all the same symptoms of schizophrenia, but only lasts 1-6 months. Usually does not impair social or occupational functioning. Schizoaffective Disorder: The patient meets the criteria for schizophrenia as well as bipolar or depressive disorder. Brief Psychotic Disorder: Sudden onset of hallucinations, delusions, disorganized speech, or disorganized behavior. Lasts between 1 day and 1 month. Nursing Diagnoses: Disturbed sensory perception Risk for violence Impaired communication Altered thought processes Assessment: Positive symptoms: characteristics that should not be present. Hallucinations, delusions, alterations in speech/behavior Negative symptoms: characteristics that should be present that are not. Blunted/flat affect, poverty of thought/speech, anergia (lack of energy), anhedonia (lack of pleasure). Delusions Alterations in speech Alterations in perception Difficulties with personal boundaries Alterations in behavior Schizotypal Personality Disorder: Patient has impairments surrounding their personality. Delusions, fears, and difficulties surrounding the formation and maintenance of relationships. Delusional Disorder Delusions that last at least 1 month. The delusions usually are not severe enough to impair functioning. Behavior is not usually strange or bizarre. Nursing Interventions: Provide a structured environment Ask the patient about their hallucinations/ delusions. Tell the patient you do not hear/see anything, but believe that they do. Focus conversations on reality. Identify what triggers symptoms. Assess for paranoid delusions, as they can lead to violence against self or others. Encourage the patient to participate in group activities and work on building social skills. Maintaining safety of the patient and other patients is the always the most important focus. Treatments: First-generation antipsychotics Second-generation antipsychotics Antidepressants Mood stabilizers # MENTAL HEALTH # SCHIZOPHRENIA SPECTRUM DISORDERS # 251 MENTAL HEALTH NEUROCOGNITIVE DISORDERS Rapid onset in a short period of time Considered a medical emergency Common in older patients Infection Malnutrition Electrolyte imbalances Substance use Medication interactions CAUSES Impairments of memory, thinking, judgement, and focus Disorientation and confusion Hallucinations and illusions Restlessness and anxiety Personality change SYMPTOMS Assess level of awareness Determine usual level of awareness Assess vital signs and potential for injury ASSESSMENT Risk for injury Acute confusion Impaired social interaction NURSING DIAGNOSES Identify cause of delirium Administer prn medications for anxiety Assist with nutrition and self-care needs Use simple and direct statements Maintain consistent environment/routines Maintain 1-on-1 supervision at all times INTERVENTIONS DELIRIUM Progressive deterioration of memory, cognitive functions, and the ability to complete activities of daily life. Organized into three stages: Memory lapses Misplacing items Difficulty planning and organizing Mild: Forgetting personal history Wandering and getting lost Personality and behavioral changes Moderate: Inability to perform self-care Changes in physical abilities Difficulty communicating Poor awareness of surroundings Severe: Risk for injury Impaired communication Impaired memory NURSING DIAGNOSES Community supports for family Cholinesterase inhibitors - Prevents breakdown of acetylcholine - Donepexil (Aricept) NMDA receptor agonist - Memantine (Namenda) Other medications may be used to control behavioral symptoms. TREATMENTS ALZHEIMERS Often referred to as dementia. Progressive deterioration of cognitive functioning. Occurs over a period of months or years. Advanced age Traumatic brain injury Genetics Diabetes Other neurological disorders CAUSES Memory impairments Inability to recognize familiar items Speech deficits Functional impairments Agitation Sundowning syndrome Personality change SYMPTOMS Monitor nutrition and weight. Give one direction at a time. Use distraction to manage behavior. Provide cues Utilize written signs Limit the amount of choices the patient has to make during the day. INTERVENTIONS # 252 MENTAL HEALTH SOMATIC SYMPTOM DISORDERS Ineffective coping Anxiety Powerlessness Social isolation Altered family processes POTENTIAL NURSING DIAGNOSES No medications have been approved for use specifically for somatic symptom disorders, but some antidepressants and anti-anxieties may be used off-label. MEDICATIONS ILLNESS ANXIETY DISORDER SYMPTOMS: Commonly referred to as hypochondriasis. Extreme anxiety and worry about the possibility of having a disease or disorder. Somatic symptoms are mild or non-existent. ASSESS FOR: Excessive fear surrounding health for over 6 months. Excessive healthcare-seeking behavior or healthcare avoidance. NURSING INTERVENTIONS: Build trust with the patient. Encourage patient to verbalize feelings. Educate patient on stress management techniques and alternate coping mechanisms. CONVERSION DISORDER SYMPTOMS: Neurological symptoms without a neurological diagnosis caused by psychological stress. Neurological symptoms may present as paralysis, blindness, numbness, loss of hearing or vision, etc. ASSESS FOR: Alterations in motor or sensory function. Assess recent stress levels. Some patients may experience extreme anxiety, while others seem indifferent (la belle indifference). NURSING INTERVENTIONS: Ensure safety of the patient Encourage the patient to identify what may have triggered the conversion. Educate the patient on stress management techniques. FACTITIOUS DISORDER FACTITIOUS DISORDER IMPOSED ON SELF: Previously known as Mnchausen syndrome Patient reports falsified physical or psychological symptoms. Patient may intentionally harm themself. Done with the intention of gaining attention or sympathy, not personal gain. FACTITIOUS DISORDER IMPOSED ON ANOTHER: Ensure safety of the patient Encourage the patient to identify what may have triggered the conversion. Educate the patient on stress management techniques. 253 Very common because many mental disorders have physical symptoms and there is less stigma. Primary Care: Psychiatrists, psychiatric nurse practitioners, psychologists, counselors, therapists, etc. Specialty Care: Provides health services, social services, acute care, and chronic disease management. Patient can utilize extended hours of service outside of the usual Monday-Friday 9-5 Patient-Centered Medical Homes: Provide care on a low-cost, sliding scale. Services include emergency services, home-based services, medication prescription, therapy groups, etc. Community Mental Health Centers: Provided for home-bound patients with a psychiatric diagnosis that requires the care of a nurse. Psychiatric Home Care: For patients in the community with serious, persistent mental disorders that are unable to participate in traditional treatments. These teams work with the patient wherever they are at that moment. Assertive Community Treatment: Programs that run Monday-Friday for about half a day. Structured activities, group therapy, and coping strategies are taught. Intensive Outpatient Programs: Programs that run Monday-Friday for about 6 hours (slightly longer than intensive outpatient programs). Structured activities, group therapy, and coping strategies are taught. Partial Hospitalization Programs: Primary goal is triage and stabilization. Patients may seek emergency care voluntarily, or may be brought in involuntarily for emergency evaluation. Emergency Care: Provide patients with rapid stabilization and a short length of stay, usually 72 hours or less Crisis Stabilization Units: Psychiatric units on a specific floor of a general hospital. General and Private Hospitals: Provide long-term care for patients with extremely serious, debilitating mental disorders and patients who cant be stabilized in a general hospital. State Hospital: # MENTAL HEALTH TREATMENT SETTINGS Most Acute Least Restrictive # 254 NOTES NUTRITION NUTRITION NURSING NUTRITION Nutrition refers to the science of how the body uses nourishing substances from food to support normal physiological functions and overall health. Nutrition is more important than ever. Nutrition is particularly critical during periods of rapid tissue growth and during illness. Nutrition is Essen to immune function for prevention of or recovery from disase. With nutritional intervention it is possible to restore normal nutritional status and improve outcomes such as, -Reduction in infection and complications, -Decrease in hospital lenght of stay, -Improve wound healing, -Reduction of mortality. Food component that are usable by the body are known as Nutrients. Functions of Nutrients: Supply energy for the body Ensure physical growth and cell maintenance Protect the body Nutrients can be classified into two major categories: 1. Macronutrients 2. Micronutrients If one or more nutrients are consistently missing from the diet, over time, serious illnesses may occur for example, without the proper nutrients in the right amount, one can become blind, sterile or mentally retarded. Bones can become brittle and break, teeth and hairs can fall out, and skin irritation may develop. Type: Classifications: Carbohydrate, fats, protein, water Carbohydrate and fat provide energy to the bodys cells, while protein help build cells and tissues. Appropriate proportions Carbohydrate 45-65% Fat 20-35% Protein 10-35% Water provides no energy but are essential as the medium in which all of the bodys chemical reactions takes place and it regulate body temperature Macronutrients: Vitamins, minerals and trace elements Requires in small quantities but it is also necessary, most of the micronutrients are considered Essen nutrients, indispensable to life processes, Additionally, most micronutrients are not produced within the body, but must be obtained from food. Micronutrient: # 63 NUTRITION NURSING NUTRITION Nutrients are categorized into three by their importance in the human diet. Essential nutrients: these are substances necessary to health that must be obtained from diet because the body with cannot produce them. Example; The body doesn tproduce vitamin C, but it requires for healthy teeth and gums, resistance to infection, improved iron absorption and may other functions. Non-Essential nutrients: these are necessary to health and are made within the body. These include choline, beta-carotene, some amino acids and other substances. Conditionally Essential Nutrients: these are made by the body and normally not required in the diet. Is the sum of all the chemical and physical processes required to produce, maintain and repair cells and to produce energy in the body. Catabolism: These terms specify, respectively the building up and breaking down of compounds and tissues within the body. Anabolism: These is a constructive process during which cells convert complex substances into simpler compounds, anabolism and catabolism are normal process the occur simultaneously, but anabolism predominantes during growth and healing, while catabolism predominantes during injury or illness. Many hospitalized patients are in catabolic state that compromises potential positive outcomes. For these patients, appropriate nutrition is especially important because good food can fuel the growth, repair and replacement of body tissues, along with providing a source of energy Metabolisms Catabolism and Anabolism Energy is the ability to do work, in human nutrition energy refers to the body use of fuel contained in nutrients by braking down or catabolizing them. A person engaged in vigorous activity requires more food nutrients to meet energy needs. The energy content in food is generally expressed in terms of Kilocalories or kilojoules(kJ) A kcal is the amount of energy necessary to raise the temperature of 1 kg of water (one liter) by 1 degree ( Celsius or centigrade) from 14.5 to 15.5C. One kcal is equal to 4.18 kJ. When nutrients metabolized, produce, Protein 4 kcal/g Carbohydrate 4 kcal/g Fat 9 kcal/g ENERGY: (Kcal/kJ) For adults, age 31-50 with average height, weight, body mass index and daily activity, the avg daily recommended energy intake is 3,021 kcal/day for men, and 2404 kcal/day for women. When people are sick or injured, their energy needs increase. # 64 NUTRITION Phases Include 1. Ingestion 2. Movement 3. Mechanical and Chemical Digestion 4. Absorption 5. Elimination > Digestion Mechanical (physical) Chew Tear Grind Mash Mix > Types Gastrointestinal (Gl) tract Tube within a tube Direct link/path between organs Structures Mouth Pharynx Esophagus Stomach Small intestine Large Intestine Rectum > Digestive System Teeth mechanically break down food into small pieces. Tongue mixes food with saliva (contains amylase, which helps break down starch). Epiglottis is a flap-like structure at the back of the throat that closes over the trachea preventing food from entering it. > Mouth Small intestines are roughly 7 meters long Lining of intestine walls has finger-like projections called villi, to increase surface area. The villi are covered in microvilli which further increases surface area for absorption. Nutrients from the food pass into the bloodstream through the small intestine walls. Absorbs: 80% ingested water Vitamins Minerals Carbohydrates Proteins Lipids Secretes digestive enzymes > Small Intestine About 5 feet long Accepts what small intestines don t absorb Rectum (short term storage which holds feces before it is expelled). Functions Bacterial digestion Ferment carbohydrates Protein breakdown Absorbs more water Concentrate wastes > Large Intestine J-shaped muscular bag that stores the food you eat, breaks it down into tiny pieces. Mixes food with digestive juices that contain enzymes to break down proteins and lipids. Acid in the stomach kills bacteria. Food found in the stomach is called chyme. > Stomach Approximately 10 long Functions include: 1. Secrete mucus 2. Moves food from the throat to the stomach using muscle movement called peristalsis If acid from the stomach gets in here that s heartburn. > Esophagus Chemical Enzymatic reactions to improve digestion of Carbohydrates Proteins Lipids 65 NUTRITION NUTRITION ASSESSMENT is the analysis of anthropometric, biochemical, clinical and dietary data to determine the nutritional status of a person or groups. Purpose of Nutrition Assessment: - To assess the nutritional status. - To determine the body needs from nutrition. Nutrition screening Identifies patients who are malnourished or at risk for malnutrition Screening tools include Subjective Global Assessment. Nursing diagnoses Clinical judgments about actual or potential health problems that provide the basis for selecting appropriate nursing interventions Malnutrition is fairly common in hospitals and can lead to delayed healing and increased length of stay and medical costs. Category Specific Examples Admission Data Anthropometric Data Functional Assessment Data Historical Information Laboratory Test Results Signs and Symptoms Age, medical diagnosis, severity of illness or injury Height and weight, body mass index (BMI), unintentional weight changes, loss of muscle or subcutaneous fat Low handgrip strength, general weakness, impaired mobility History of diabetes, renal disase or other chronic illness; use of medications that can impair nutrition status; extensive dietary restrictions; food allergies or intolerances; requirement for nutriyion support; depression, social isolation or dementia. Blood test results that suggest the presence of inflamation (such as low serum protein levels) or anemia Reduced appetite or food intake, problems that interfere with food intake (such as chewing or swallowing difficulties or nausea and vomiting), localized or general edema, presence of pressure sores Identifying risk for malnutrition # 66 NUTRITION ASSESSMENT NUTRITION Nursing Diagnosis with Nutritional Implications Chronic confusion Chronic pain Constipation Dierrhea Disturbed body image Feeding self-care deficit Imbalanced nutrition: less than body requirements Impaired dentition Impaired oral mucous membrane Impaired physical mobility Impaired swallowing Insufficient breast milk Nausea Obesity Readiness for enhanced nutrition Risk for aspiration Risk for deficient fluid volume Risk for for overweight Risk for unstable blood glucose level > The nutrition care process Systematic approach to medical nutrition therapy implemented by registered dietitians Nutrition assessment: collection and analysis of health-related data Nutrition diagnosis: what is included in a diagnosis? Nutrition intervention: appropriate plan Nutrition monitoring and evaluation: determine effectiveness. Nutrition screening or referrals Nutrition Assessment Nutrition Intervention Nutrition Monitoring and evaluation Nutrition Diagnosis 67 NUTRITION NUTRITION ASSESSMENT 1-HISTORICAL INFORMATION Sources Medical record Interviewing the patient or caregiver Medical history Medication and supplement history Personal and social history Food and nutrition history 2-DIETARY ASSESSMENT 24-hour dietary recall Guided interview Covers foods and beverages consumed during the previous day What is involved in the multiple-pass method? Medical History Age Current complaint(s) Past medical problems Ongoing medical treatments Surgical history Family medical history Chronic disease risk Menthal/emotional health status Medication and Supplement History Prescription drugs Over-the-counter drugs Dietary and herbal supplements Personal and Social History Cognitive abilities Cultural/ethnic identify Educational level Employment status Home/family situation Religious beliefs Socioeconomic status Use of tobacco, alcohol or illegal drugs Food and Nutrition History Food intake Food availability Recent weight changes Dietary restrictions Food allergies or intolerances Nutrition and health knowledge Physical activity level and exercise habits > Related to physical measurements of the human body Can reveal nutritional problems: overnutrition or protein-energy malnutrition (PEM) Height (or length) Box 13-3 describes standard techniques Estimation techniques: knee height, full arm span Anthropometric data Anthropometric assessment in adults > Used to evaluate the nutritional risks associated with illness Rate of involuntary weight loss Percentage of usual body weight (%UBW) (current weight usual weight) 100 Percentage of ideal body weight (current weight ideal weight) 100 # 68 NUTRITION NUTRITION ASSESSMENT Foods and beverages regularly consumed during a specific time period May collect qualitative only or semiquantitative information What are limitations of this tool? Weight changes may reflect changes in body water due to illness Involuntary weight loss can be a sign of PEM Box 13-4 provides tips for accuracy Used to evaluate growth Periodic measurements of height (length), weight, and head circumference taken Plotted on growth charts Growth patterns <5th percentile BMI-for-age <5th or >85th percentiles Waist: body fat evaluation Limbs: muscle mass determination Circumferences of waist and limbs Food frequency questionnaire Body weight Anthropometric assessment in infants and children Food record Head circumference Direct observation Written account of foods and beverages consumed during a specified time period, usually several consecutive days Food intakes directly observed and analyzed Nurses conduct patients kcalorie counts Assess brain growth and malnutrition in children up to 3 years old Used to track brain development in premature and small-for-gestational-age infants ## Rate of involuntary Weight Loss Associated With Nutritional Risk % Weight Loss >2% >5% >7.5% >10% Time Period 1 week 1 month 3 month 6 month a% weight loss = x100 amount of weight loss usual weight ## Body Weight And Nutritional Risk %UBW %IBW 85-95 75-84 <75 80-90 70-79 <70 Nutritional Risk Risk of mild malnutrition Risk of moderate malnutrition Risk of severe malnutrition 69 Dietary principal Energy : 20k.cal / kg bdwt Protein : 0.8 to 1g/kg bdwt Fat : 0.5g / kg bdwt Mineral: sodium is reduced Vitamins: A & D High fiber : 50g / day # NUTRITION NUTRITION ASSESSMENT Important Transthyretin (prealbumin) and retinol-binding protein Decrease rapidly during PEM Respond quickly to improved protein intakes C-reactive protein Rises rapidly in response to inflammation or infection Often elevated in critical illness Information about PEM, vitamin and mineral status, fluid and electrolyte balances, and organ function Typically blood and urine samples Repeated measures Indicate improving or worsening condition In addition to body weight, why are skinfold and limb circumference measurements important in a nutrition assessment? Anthropometric assessment in adults Biochemical analyses Biochemical analyses Biochemical analyses Serum proteins Used to assess protein-energy status Albumin Used to gauge severity of illness Transferrin What is the correlation between iron status and transferrin levels? ## Body Mass Index = weight (in kg) Height (in kg) 2 Weight Categories <18.5 18.5-24.9 25-29.9 30-34.9 35-39.9 BMI (kg/m ) Underweight Healthy Weight Overweight Obese Severely Obese Morbidly Obese >40 _ 2 # 70 THERAPEUTIC DIET TYPES OF THERAPEUTIC DIET IN VARIOUS DISORDERS Therapeutic diet are planned to maintain or restore good nutrition in patient In most cases the therapeutic diet are used to supplement the medical or surgical treatment of the patient, while in some instances like diabetes mellitus, a therapeutic diet is the most aspect of the patient s treatment rather the medical therapy Diet therapy is concerned with recovery from illness and prevention of disease. # NUTRITION NUTRITION ASSESSMENT Cholesterol rich food Whole cream, butter, cream, cheese Indian sweet meal like pudings, bakery products Organ meat Egg yolk, fish Nuts, oil seeds, pickles Fried food Alcohol Skim milk, paneer from skim milk Cereals and pulses Whole grain All vegetables and all fruits High fiber and soluble fiber like oat meal, pectin and gums lean meat, egg white and fish Vegetable oils, sugar and jaggery Objectives: -To relieve strain to the heart -To prevent further damage to the heart -To restore the damage heart Dietary management: Food to be avoided: Food recommended: Regular low cholesterol and low fat and high fiber diet: Energy- 1600 kcal Fat- 40 g Protein- 65 g Light diet: It must be given 2 hourly and contents must include milk, barley water, glucose at regular intervals To rebuild body tissues extra proteins must be given Examples milk, egg, curd etc Fried foods and diet containing fibers should be avoided The nutritional requirements will depend on the nature, severity and duration of the fever. During this phase, calories requirement is increase. Frequent feeding must be given to the client and fats must be restricted. Fluid intake must be from 3000-5000 ml in the form of glucose, fruits juices A readily digestible foods must be given. When fever goes down, bread with milk, milk puddings or rice dal must be given. DIET IN FEVER DIET MENU DURING HIGH GRADE FEVER NUTRITION FOR CARDIOVASCULAR DISEASES # 71 TYPES OF THERAPEUTIC DIET IN VARIOUS DISORDERS NUTRITION NUTRITION ASSESSMENT Low protein and low sodium diet for chronic renal failure Naturopathy is the art and science of disease diagnosis, treatment and prevention using natural therapies including botanic medicine, hydrotherapy, traditional chinese medicine and life style councelling Diarrhoea is increase frequently of loose or watery stools. It occurs in infectious condition of colon. Diet must include mainly fluids like oral boiled water containing electrolyte salts i.e glucose, sodium chloride etc Fluids should be given quarter one hourly frequently Oral rehydration solution must be given Constipation is decreased frequency of passing stools or complete retention of faces The diet should include food rich in fiber contains like whole cereals, whole legumes and mature vegetables Fruits rich in fibers like apple, banana, guava More fluids in the form of coffee, tea, fruit juices, warm water, butter milk etc DIET IN DIARRHOEA DIET IN CONSTIPATION FOOD TO BE AVOIDED Extra milk or ilk products Meat, poultry and fish Dry fruits Extra pulses, cereals, legumes, peas, beans Cakes, biscuits and bakery products, jams Campa cola, squash, Frits and fruit juices like lemon, mango, lime, plums Green leafy vegetables if potassium is restricted Naturopathy works on self healing. Here, every individual is the doctor as everyone can heal himself. Water is the main nutrient. It means not to avoid stress but how to deal with the stress. Sometimes naturopathy require to stay in Ashrams. Naturopathy best works in winter. Naturopathy practice require assistance. Do not harm Use the healing power of nature to rejuvenate the body and mind Identify and treat the cause Treat the whole person not the particular part with ailment Work on disease prevention and health promotion NATUROPATHY WORKS ON FIVE PRINCIPLES PRECAUTIONS Treatment based on nutrition and diet Detoxification: use of short period of fasting and controlled diets aid the natural processes by which body rids itself from toxic substances Manual healing method: massage, acupuncture, yoga, meditation, hypnotherapy, Herbal medicine, Homeopathy, Hydrotherapy: using water Exercise and relaxation technique METHODS USED IN NATUROPATHY NUTRITION FOR CHRONIC RENAL FAILURE NATUROPATHY Nutrient allowence Sedentary workers Prote ins Calor ies Sod ium Potass ium Phosphorus 20 g 2040 180 mg 1226 mg 441 mg 30 gm 2197 215 mg 1382 mg 586 mg 40 gm 2363 255 mg 1982 mg 717 mg Moderate workers Heavy workers # 72 NOTES OB MATERNITY PREGNANCY HISTORY & OUTCOMES gravida a pregnant woman gravidity number of pregnancies regardless of outcome nulligravida a woman who has never been pregnant primigravida a woman pregnant for the first time multigravida a woman pregnant for at least the second time Gravidity parity - number of births that have reached 20 weeks (not number of fetuses) regardless of the outcome (live birth, stillbirth, abortion) twins/triplets count as 1 nullipara a woman who has not had a birth 20 weeks gestation primipara a woman who has had 1 birth >20 weeks gestation multipara a woman who has had 2 or more births >20 weeks resulting in viable births Parity OB TERMINOLOGY > LMP: last menstrual period > LNMP: last normal menstrual period > Gestation: # of wks from woman's last menstrual cycle to the current date. Normal gestation is 37-42 wks. > Gravidity: # of pregnancies, previous & current, regardless of outcome (miscarriage, abortion, stillborn, alive) > Abortion: spontaneous (miscarriage) or induced (medical intervention) before 20 wk gestation > Parity: # of completed pregnancies/births that reached viability (> 20 wk gestation) regardless of outcome (stillborn or alive) > Living children: # of children alive today (does NOT include live births) > Live births: # of children who survived birth, but may have died anytime later > Term: babies born at normal 37-42 wk gestation regardless of outcome (stillborn or alive) > Preterm: birth of infant at 20-37 wks gestation regardless of outcome (stillborn or alive) > Post-term: birth of infant greater than 42 wks gestation regardless of outcome (stillborn or alive) > Puerperium: time between delivery and 42 days after delivery > Trimesters: First: week 1-12 Second: week 13-28 Third: week 29-delivery # OB MATERNITY # GTPAL 5-Digit System Multiples count as 1 for gravidity, term, preterm, & abortions Multiples actual number recorded for living children # 314 PREGNANCY HISTORY & OUTCOMES RAVIDITY G number of pregnancies, current pregnancy included Imagine a patient who has had 2 term deliveries, 1 preterm delivery, 7 miscarriages, and has 2 living children. G = 10 (the patient's combined 2 term birth + 1 preterm birth + 7 miscarriages ) T = 2 (the patient's 2 term births) P = 1 (the patient's 1 preterm births) A = 7 (the patient's 7 miscarriages) L = 2 (the patient's 2 living children) ERM BIRTHS T number born after 37 weeks (38 42) RE-TERM BIRTHS P number born before 37 weeks BORTIONS / MISCARRIAGES A number of pregnancies ending before 20 weeks IVING CHILDREN L number of current living children To further clarify what GTPAL means and doesn't mean, notice that the patient had a total of 3 births, but only has 2 living children. This patient lost their child at some point, and based on the available data, the child may have died in infancy or died at age 20 we don't know. # OB MATERNITY ## GTPAL Calculation Example # 315 NAEGELE'S RULE add 7 days to first day of last menstrual period (LMP) and count forward 9 months OR subtract 3 months and then add 7 days to first day of last menstrual period (LMP) and add 1 year if applicable First day of LMP July 15, 2022 subtract 3 months April 15, 2022 Add 7 days April 22, 2022 Add 1 year April 22, 2023 Example 1: Example 2: estimated delivery date +/- 2 weeks add 7 days to LMP July 22, 2022 count forward 9 months April 22, 2023 estimated delivery date +/- 2 weeks > Can be used if the woman has a regular 28-day cycle > Gestation is from fertilization to the delivery date approximately 280 days # OB MATERNITY # OB ACRONYMS GDM gestational diabetes mellitus GTPAL gravidity, term, preterm, abortion, living hCG human chorionic gonadotrophin IUFD intrauterine fetal demise IUP uterine pregnancy L&D labor & delivery LBW low birth weight LEP lumbar epidural LGA large for gestation age LMP last menstrual period LNMP last normal menstrual period NST non stress test PP postpartum PROM premature rupture of membranes PT L preterm labor ROM rupture of membranes PP postpartum PROM premature rupture of membranes PT L preterm labor ROM rupture of membranes SAB spontaneous abortion SB stillborn SGA small for gestational age SROM spontaneous rupture of membranes SVE sterile vagina exam TAB therapeutic abortion TOP termination of pregnancy U/V ultrasound VBAC vaginal birth after cesarean section AB abortion AFP alpha fetal protein AROM artificial rupture of membranes BCP birth control pills C/S cesarean section CE cervical exam CST contraction stress test CT X contractions D&C dilation & curettage D&E dilation & evacuation EAB elective abortion EDC estimate date of confinement EFM external fetal monitoring EGA estimate gestational age ERT estrogen replacement therapy FH fundal height FHT fetal heart tones FHR fetal heart rate # 316 PREGNANCY SIGNS & SYMPTOMS Signs of pregnancy ## The signs of early pregnancy can include: > Missed period > Breast tenderness and enlargement > Fatigue > Nausea and vomiting (often called morning sickness, but it can occur at any time) > Cravings for some foods, distaste for foods you usually like, and a sour or metallic taste that persists even when youre not eating (dysgeusia). > Passing urine more frequently than usual, particularly at night Many of the signs of pregnancy, such as a missed period (amenorrhoea), nausea (morning sickness) or tiredness can also be caused by stress or illness, so if you think you are pregnant take a home pregnancy test (urine test) or see your GP, who will administer a urine test, blood test or ultrasound scan. # OB MATERNITY ## Missed Period Missing a period is often the first sign of possible pregnancy. However, some women experience light bleeding around the time of their expected period. ## Breast hanges During pregnancy, the breasts become fuller, swollen and tender. These changes are similar to those you may have noticed in the few days before your period. During pregnancy, the skin around the nipple becomes darker and the veins in the breast become more obvious. ## Frequent Urination Pregnancy causes an increase in levels of body fluids and greater kidney efficiency. The swellingnuterus also presses against the bladder. As a result, most women start experiencing more frequent urination within the first few weeks of becoming pregnant. ## NauseaC and Vomiting Morning sickness is a condition that affects more than half of all pregnant women. The symptoms include nausea and vomiting, and loss of appetite. Many women with morning sickness dont just get symptoms in the morning but experience them throughout the whole day. Morning sickness usually begins around the fourth to sixth week of pregnancy and may settle by week 12, although it can continue for longer or return at around 32 weeks. # 317 Fatigue Overwhelming tiredness is common in early pregnancy. This is most likely caused by the massive increase in the sex hormone progesterone. Progesterone is needed to maintain the pregnancy and help the baby to grow, but it also slows your metabolism. Try to get some more sleep or rest when you can during this early stage. Your energy levels will probably rise again by around the fourth month of pregnancy when the placenta is well established. Tiredness during pregnancy can also be caused by anaemia, which is most commonly caused by iron deficiency. Eating iron-rich foods is important in the prevention of iron deficiency anaemia during pregnancy. Medical treatment of anaemia in pregnancy usually involves taking iron tablets. Sometimes an iron infusion (iron medicine given by a drip) is needed. This needs a hospital admission but only takes a few hours. Some iron infusions can be given by your GP. ## Food Cravings Cravings for certain foods are very common in pregnancy, especially for foods that provide energy and calcium, such as milk and other dairy products. You may also notice a sudden distaste for foods you previously liked. Some women even develop an unusual taste for non-food items such as soil or paper. This is called pica and may indicate a nutrient deficiency. Please speak to your GP or midwife if this develops. # PREGNANCY SIGNS & SYMPTOMS # OB MATERNITY ## Other symptoms of pregnancy ## Many of these symptoms may also be indicative of other conditions. If in doubt, see your GP . > Mood changes (such as unexplained crying) > Leg cramps > Backache > Headaches > Varicose veins and leg oedema (swelling) > Tingling and numbness in your hands > Heartburn and indigestion > Vaginitis > Vaginal discharge > Breathlessness > Constipation > Haemorrhoids (piles) > Itchy skin # 318 PREGNANCY SIGNS & SYMPTOMS # OB MATERNITY ## Back Ache Back pain during pregnancy can affect more than 1 in 3 women. This is usually due to loosening of ligaments and change in posture due to the growing pregnancy. ## Leg Cramps Leg cramps occur due to a build-up of acids that cause involuntary contractions of the affected muscles. They are experienced by up to half of pregnant women, usually at night. Leg cramps are more likely in the second and third trimesters. ## Head Aches Contact your GP or midwife if you have a headache during pregnancy that is not relieved by paracetamol (such as Panadol), especially in the second half of pregnancy. ## Mood Changes Some newly pregnant women experience mood changes such as irritability. Other pregnant women experience feelings of elation. It is thought that the pregnancy hormones influence chemicals in the brain, causing mood changes. During pregnancy, 1 in 10 women experience depression. Depression is treatable, so if you are feeling depressed or down during pregnancy it is extremely important to get help early. Please contact your GP (doctor), midwife or maternal and child health nurse as soon as possible. A persistent headache can be associated with pre-eclampsia a condition that can affect your kidneys and thus increase blood pressure and decrease blood flow to your baby. If you experience leg cramps, it is recommended that during an episode you: > Walk around. > Stretch and massage the affected muscle(s) to disperse the build-up of acids. > Apply a warm pack to the affected muscle(s). You can help reduce back pain during pregnancy by wearing flat heeled shoes, using chairs with good back support, avoiding lifting heavy objects, and doing gentle exercise. Exercising in water can reduce back pain in pregnancy, and physiotherapy and acupuncture may also help. 319 PREGNANCY SIGNS & SYMPTOMS # OB MATERNITY ## Heart Burn and Indigestion Heartburn, reflux or indigestion is the pain and discomfort associated with acid from the stomach entering and burning the oesophagus. Indigestion is more common during pregnancy due to the pressure of the enlarging uterus on the organs of the abdomen and the action of the hormone progesterone that relaxes the muscle between the oesophagus and stomach. ## Vaginitis Vaginitis is inflammation of the vagina, and is a distressing complaint for many women. It is more frequent during pregnancy. Some causes of vaginitis include vaginal thrush, bacterial vaginosis, trichomoniasis and chlamydia. See your GP for diagnosis and treatment. ## Carpal Tunnel Syndrome Carpal tunnel syndrome tingling and numbness in your hands affects up to 60 per cent of women during pregnancy. It is caused by compression of the median nerve due to an increase in the tissue fluids during pregnancy. Carpal tunnel syndrome may be mild, intermittently painful, or severe, which may cause partial paralysis of the thumb or loss of sensation. Symptoms usually resolve on their own soon after birth. If you are experiencing tingling and numbness in your hands, inform your doctor or midwife. In very severe cases, your doctor may recommend corticosteroid injections or surgical treatment. ## Varicose veins and leg oedema (swelling) Varicose veins of the legs are very common in pregnancy due to a combination of factors, including increased volume of circulating blood during pregnancy, and pressure of the pregnant uterus on the larger veins. This increased pressure on the veins can also result in swelling of the legs (oedema) that can cause pain, feelings of heaviness, cramps (especially at night) and other unusual sensations. If you have varicose veins, it is recommended that you: > Wear support stockings. > T ry massaging your legs. > Avoid standing for long periods. > Lie down to rest with feet elevated, when you can. > T ell your doctor or midwife at your next pregnancy visit. > Exercise gently and regularly (walking or swimming). If you experience leg cramps, it is recommended that during an episode you: > Walk around. > Stretch and massage the affected muscle(s) to disperse the build-up of acids. > Apply a warm pack to the affected muscle(s). 320 PREGNANCY SIGNS & SYMPTOMS OB MATERNITY ## Vaginal discharge An increase in vaginal discharge is a common change during pregnancy. If it is associated with itchiness, pain, a bad odour or pain on passing urine then it may be due to an infection. Seek treatment from your GP. ## Haemorrhoids (piles) You may develop haemorrhoids (also known as piles) as a result of straining from constipation or the pressure of your babys head. Be reassured, symptoms usually resolve on their own soon after birth. ## Constipation Constipation refers to infrequent, hard bowel movements that are difficult to pass. Constipation is a common problem in pregnancy that may be caused by pregnancy hormones slowing your gastrointestinal movement, or by the pressure of your growing uterus on your rectum. If you experience constipation during pregnancy, you are advised to: Don't take over-the-counter laxatives without first consulting your midwife or GP. If changes to your diet and lifestyle don't make a difference then your GP or midwife can prescribe a laxative that is safe to use in pregnancy. ## Breathlessness At the onset of pregnancy the hormone progesterone increases your lung capacity. This enables you to carry more oxygen to your baby and get rid of waste products such as the carbon dioxide that you both produce. At each breath you breathe more deeply and the amount of air you inhale (and exhale) increases significantly. This can make you feel short of breath. In addition, as pregnancy approaches term, the pressure of the enlarging uterus and baby on your diaphragm can make your breathing feel more laboured. Contact your doctor or midwife if you experience sudden onset of breathlessness associated with any of the following: - palpitations (heart pounding) - pain - exercise - extreme tiredness ## Itchy skin Widespread itching over the body is not common in pregnancy but it can be very distressing, interfering with sleep and enjoyment of pregnancy. Dry skin and eczema are the most common causes but sometimes there may be no apparent cause for the itching. In rare cases, where the palms of the hands and soles of the feet are itchy, it may be due to serious liver disease a blood test can be done to check for this. An itchy rash in the later part of pregnancy is thought to be caused by the bodys reaction to the stretching of the skin. This is called PUPPS. Itching can be controlled by using moisturisers and antihistamines. Ask your doctor or midwife what antihistamines are safe in pregnancy. drink plenty of water every day. increase your dietary fibre (such as bran, wheat and fresh fruit and vegetables). do gentle, low impact exercise such as swimming, walking or yoga. If you have bleeding from haemorrhoids, itching, discomfort or pain it is recommended that you: Alleviate or prevent constipation by increasing your daily water and fibre intake. Sit in warm salty water for about 15 minutes, especially after a bowel motion. Apply haemorrhoid cream. If the bleeding or pain continues, talk with your GP (doctor) or midwife. 321 THINGS TO STAY AWAY FROM DURING PREGNANCY ## TERATOGENIC DRUGS (Common Teratogenic Drugs) ## TORCH INFECTIONS TORCHToxoplasmosis Other viruses Rubella Cytomegalovirus Herpes simplex viruses # OB MATERNITY herpes can cause death of the newborn ## T - toxoplasmosis > Caused by infection with the parasite Toxoplasma gondii > Acquired by the mother when eating undercooked infected meat or exposure to cat litter of infected cats > Symptoms are a rash, and flu-like illness > The parasite crosses the placenta > Can cause spontaneous abortion in 1st trimester if the fetus is infected > Educate patient about washing hands after handling raw meat, or cat litter; cook meat fully ## C Cytomegalovirus (CMV) > Use contact precautions > Transmitted through body fluids; crosses the placenta > Fetus may be infected in the birth canal > Mother likely asymptomatic; most newborns asymptomatic at birth > Causes low birth weight, IGR, hearing loss, blindness, intellectual disability, seizures, enlarged liver and spleen > Antivirals are toxic to the fetus and PCHP must weigh benefit vs risk > retinoids > isotretinoin, (Accutane) > acitretin (for psoriasis) > pyrimethamine > sulfadiazine > protease inhibitors > warfarin > antibiotics (many) > fluoroquinolone > tetracycline > chloramphenicol > -mycin & micin, -cyclines > sulfonamides > antivirals > antifungals > hormones > carbamazepine (anticonvulsant) > phenytoin (anticonvulsant) > paroxetine (SSRI) > lithium (mood stabilizer) > valproate > lithium > MAOIs > phenobarbital > ace inhibitors, ARBs, statins > spironolactone (diuretic) > methotrexate (all chemo drugs) ## H Herpes simplex virus > Highly contagious, recurrent, incurable > Affects genital region, vagina, cervix > Painful, draining vesicles develop into ulcerative lesions > NO vaginal exams with active lesions > Virus is passed to newborn through birth canal or infection after rupture of membranes > Delivery is usually by c-section, but sometimes vaginally if lesions are not in the vagina > Acyclovir (Zovirax) may be prescribed to prevent outbreak during labor ## R - Rubella > Crosses the placenta > Teratogenic in 1st trimester > Causes congenital defects of the brain, heart, eyes, ears, liver > See Common Labs & DX testing above ## O - other viruses/infections > HIV, syphilis, parvovirus, hep B, varicella zoster, etc. # 322 OB MATERNITY PHYSICAL CHANGES DURING PREGNANCY 15-20% increased need for oxygen Diaphragm moves up putting pressure on lungs, can easily cause SOB Slight increase in RR & T otal lung cavity decreases Chest size enlarges to allow lung expansion RESPIRATORY CARDIOVASCULAR Decrease in total peripheral resistance Increase in plasma volume Increase in HR (by 25%; about 10-15 bpm) Increase in blood volume (by 50%) Increase in CO (by 30-50%) Blood pressure decreases slightly until mid-term RBCs - increase 20-30% > Blood clotting factors increase hypercoagulable state increased risk of venous thrombosis! RENAL/URINARY GFR increases 40-60% Kidneys enlarge Increased urine flow/volume Dilation of renal pelvis and uterus GASTROINTESTINAL Relaxation of LES GERD Heartburn (pyrosis) Increase in gingivitis/peridontitis Bloating/constipation Motility changes/transit slower Saliva more acidic Gums - swollen, bleed easily Nausea/vomiting Hemorrhoid formation Increased risk of gallstones HEMATOLOGIC SYSTEM Increased risk of DVT Increased WBCs Decreased Hbg causing increased demand for iron (Anemia) REPRODUCTIVE UTERUS Uterus enlarged due to estrogen Increase in size & number of blood vessels and lymphatics > CERVIX Becomes shorter, more elastic, & large in diameter Becomes soft & is a violet color (Chadwicks s sign) Secretes a thick, mucus gland when dilation begins > VAGINA Increased vaginal secretion (thick, white & acidic) Hypertrophy (enlarges) & thickening of the vaginal muscles ENDOCRINE > PITUITARY GLAND MSH increases Decrease in GH levels Enlarges by +135% TSH decreases during 1st trimester Oxytocin release increases > THYROID GLAND Increased thyroid hormone secretion BMR slowly increases to +25% Enlarges slightly and becomes more active > PANCREAS Decrease blood glucose in early pregnancy Decrease insulin in early pregnancy, then increases > ADRENAL GLANDS Increase cortisol and aldosterone secretion > PLACENTAL SECRETION Produces hC G, hPL, relaxin, progesterone, estrogen > INCREASE PROSTAGLAND IN PRODUCTION # 323 PHYSICAL CHANGES DURING PREGNANCY PRENATAL CARE # OB MATERNITY ABDOMEN Change in position of heart, lungs, & thoracic cage Uterus increase in size, shape, & position MUSCULOSKELETAL Relaxation & increased mobility of pelvic joint Low back pain Change of gravity "off-balance Inward curve of lower back (lordosis) Waddle gait SKIN Hyperpigmentation (linea nigra, chloasma) Stretch marks (striae) on abdomen, thighs, breast & upper arms BREASTS Superficial veins pronounced Increased size & tenderness May leak colostrum Nipples pronounced & areolae darker FIRST PRENATAL VISIT > Past or current illnesses, Current medications > Genetic background info to determine inherited illnesses > Multiples (twins, triplets, etc.) run on either side of parents > Any difficulties during previous pregnancies > Lifestyle (nutrition, activity, environment, support system, & physical/sexual/psychological/substance abuse) BASELINE DATA > Weight > Vital signs (BP, HR, RR, O2 stat, etc) > Ultrasound to confirm pregnancy (if no problems, secon ultrasound done later in second trimester) BLOOD TESTS > Determine woman's blood type and Rh factor (if negative, test is repeated at 24-28 weeks) > Complete blood count > HIV antibody screen & Syphilis test > Rubella titer, Hep B > Tuberculosis Test (after 20 wk gestation) PELVIC EXAMINATION > Check reproductive organs to confirm pregnancy, problems, and size & shape of pelvic > Pap smear (cervical cancer, herpes, or HPV) and STD test (gonorrhea, chlamydia) URINALYSIS > Urine pH & color, specific gravity, protein, glucose, and nitrates, WBC, RBC, albumin, acetone DETERMINE DUE DATE > Nageles Rule WOMANS HEALTH HISTORY RE-VISITS REGULAR CHECKS > Weight, Vitals signs > Ultrasound, FHR, Fetal movemen (begins at 16-20 week of gestation) > Measure fundal height > Urine "dipstick" analysis > Check for edema (face, hands, legs, feet) 15-22 WEEKS > Maternal serum alpha fetoprotein (MSAFP) blood screen for fetal neural defects > Additional screening, HCG and estriol, for fetal neural defects & down syndrome 24-28 WEEKS > Diabetes screening > 1-hour glucose tolerance test (greater than 140 mg/dL indicated gestational diabetes) > Rh antibody test repeated. If woman is Rh negative, RHoGAM given at 28 wks. 35-37 WEEKS > Repeated STD test > Vaginal culture (group B streptococcus, bacterial vaginosis) PRENATAL VISITS SCHEDULE > Conception - 28 weeks - every 4 weeks (once a month) > 28 weeks - 36 weeks - every 2 weeks > 36 weeks - birth - every week 324 FETAL MILESTONES OB MATERNITY ## WEEK 1 > the blastocyst floats freely ## WEEK 2-3 > brain, spinal cord, heart form > heart begins to beat > lung buds appear > leg and arm buds appear ## WEEK 5 > 2 heart chambers visible > heart beating at regular rhythm > muscles innervated > some cranial nerves are visible ## WEEK 32 > bones are fully developed > rapid increase in subcutaneous fat > fetus stores iron, calcium, and phosphorus ## WEEK 36 > lanugo begins to diminish > skin is pinkish and less wrinkled > body is rounded > testes are in the scrotum ## WEEK 40 > skin is pinkish and smooth > vernix caseosa fully formed & decreasing production > fingernails extend beyond the fingertips > soles of the feet have plantar creases covering most of the surface ## WEEK 8 > fetal circulation is established > arms and legs formed and moving > eyelids fuse > all organ systems are present (organogenesis) ## WEEK 12 > fetal movement occurring > urine forms and is excreted > buds for all temporary teeth form > genitals are recognizable > heartbeat detectable by Doppler between 10 12 weeks ## WEEK 16 > fetus makes active movements (aka quickening) > skin is transparent, fingernails and toenails are present > fetal weight quadruples > lanugo hair develops skeletal ossification (aka osteogenesis) occurs > sex of fetus can be seen on ultrasound ## WEEK 20 > fetal heart tones can be heard with a stethoscope > lanugo covers whole body > brown fat forms to help maintain temperature > head hair and eyebrows appear > vernix caseosa (a white creamy, greasy film) covers the skin ## WEEK 24 > lungs begin to produce surfactant > skin is reddish, wrinkled, translucent > startle reflex and hand grasp are present > can hear and responds to sounds > hair on head, eyebrows, eyelashes formed and distinguishable > vernix caseosa covers whole body ## WEEK 28 > rapid brain development > eye lids open and close lung surfactant present in the amniotic fluid > alveoli developed enough to produce gas exchange > neonate can breathe, if born, at this age > blood formation moves to bone marrow # 325 TRUE vs FALSE LABOR ## FALSE LABOR Braxton's hicks (painless, short, irregular) Low abdomen pain Pain relieved by change of position, walking, & other comfort measures NO effacement & dilation NO bloody show NO presenting part engaged ## TRUE LABOR Strong, lasts longer, & frequent First, irregular, then becomes consistent Lower back pain, reaching to abdomen Walking increases intensity Effacement & dilation Bloody show Presenting part engaged CONTRACTIONS CERVIX FETUS OB MATERNITY LABOR & BIRTH PROCESSES Braxton Hicks Irregular, painless contractions that occur throughout pregnancy and are more frequent in the third trimester. They thin the cervix towards the end of pregnancy but do not dilate it Descent Downward movement of the fetal head until it is in the pelvic inlet, occurs throughout labor until birth; assessed by station. Engagement Occurs when the presenting part is at the ischial spines, station 0 Extension after internal rotation is complete, the head crowns and extends and passes under the pubic arch. The head passes under the symphysis pubis and the occiput, the anterior fontanel, brow, face, and chin are born and extension is complete. External Rotation External rotation of the fetal head allows the shoulders to rotate internally to fit the anteroposterior diameter of the pelvis. Expulsion birth of the entire body Flexion The chin moves down toward the chest presenting the smallest fetal skull dimension Internal Rotation Usually occurs from the occipitotransverse position to the occipitoanterior position and lines up with the anteroposterior diameter of the pelvic outlet (the widest portion of the maternal pelvis) Lightening - When the fetal presenting parts descend into the true pelvis; aka dropping or engagement Restitution - The fetal head realigns with the body after the head emerges # 326 5 Ps OF LABOR # OB MATERNITY Passenger Fetus & Placenta The Birth Canal Mother Contractions Response Passageway Position Powers Psychology LABOR & BIRTH PROCESSES LEOPOLD MANEUVERS Palpation of mother's abdomen to determine babys presenting part, position, lie, attitude, & station. - Helps to easily locate fetal heart sounds 1. Fundal Grip: Start at the top & palate the fundus to assess whats there i.e. presenting part & lie - Head is hard, round, & moves independently - Buttocks is irregularly shaped, soft, & moves with manipulation - Baby is longitudinal if presenting part at top & if NOT, baby could be Transverse 2. Umbilical Grip: Feel alongside the stomach to identify the babys back & identify hands, feet, & elbows - Back is smooth & hard (determine if back is right or left of mothers abdomen) easily find & listen to fetal heart sounds! - Hands, feet, & elbows are irregular knobs & lumps 3. Pawlicks Grip : Feel the presenting part at the mothers pelvis with fingers - Determine engagement (if can lift presenting part = baby is NOT engaged OR if cannot lift presenting part = baby is engaged at ischial spine) 4. Pelvic Grip: Determine fetal attitude & degree of the baby - Need to turn & face mothers feet to perform - Locate fetals brow to determine if head is flexed or extended ## BEFORE starting maneuver: > If so, tell mother to empty bladder > Place pillow or rolled towel underneath one hip to avoid supine hypotension 327 OB MATERNITY ## Fetus & Placenta Passenger LABOR & BIRTH PROCESSES CEPHALIC BREECH SHOULDER PRESENTATION OCCIPUT back of head (O) or VERTEX MENTUM chin (M) or FACE BROW Body part (presenting part) closes to the pelvic inlet. FOOT SACRUM buttocks (Sc) SCAPULA shoulder (S) FLEXION EXTENSION ATTITUDE Chin tucked into chest & extremities flexed into torso How ALL the body parts are positioned. Chin extended away from chest & extremities stretched out POSITION The presenting part (occiput, mentum, sacrum) is the reference point used to determine its position Determine which side of moms pelvis does the presenting part face: - RIGHT (R) - LEFT (L) Next, determine which quadrant of the moms pelvis does the presenting part face: - ANTERIOR front (A) - POSTERIOR back (P) - TRANSVERSE side (T) Determines the fetus position using the four quadrants of mothers pelvis. LIE Longitudinal/Vertical up & down or Parallel to mothers spine Transverse/Horizontal across or Perpendicular to mothers spine Fetal spine in comparison to mothers spine. STATION Descent level of the fetuss presenting part (head, foot, buttocks, shoulder) into the mothers pelvis. Ischial spine is the point of reference used to determine how far the baby is to coming out. At ischial spines: 0 station Above ischial spines: - minus station Below ischial spines: + plus station # 5 Ps OF LABOR CONTINUED (-) Negative sign > Baby ABOVE the Ischial spine. Not close to coming out (+) Positive sign > Baby BELOW the Ischial spine. The baby is coming! > -3 -2 -1 0123 Ischial Spine # 328 OB MATERNITY TYPES OF PELVIS GYNECOID Round Shallow Most common pelvic shape ANTHROPOID Upright Oval Narrow & Deep PLATYPELLOID Side-lying Oval Wide & Flat Least common pelvic shape ANDROID Heart or Wedge Narrow Resembles a males pelvis # LABOR & BIRTH PROCESSES 5 Ps OF LABOR CONTINUED ## Mother Position Gravity helps to move fetal down into birth canal Positions: Standing, Squatting, Circling or Bouncing on exercise ball, Kneeling Mother's position relieves fatigue, increases comfort, & promotes circulation. ## Response PSYCHOLOGICAL Mental preparation for labor What affects mothers labor experience: Knowledge, Previous birthing experience, Pain level, Complication with mother or baby MOOD: Anxious, Tense, Excited, Irritable Mothers mental & emotional status. ## Contractions Power Urge to push, "bearing-down" Force of contraction causes fetus to gradually move downward. Contraction causes 10 cm dilation & 100% efface of cervix. ## The Birth Canal Passageway Shape & size of the pelvis, cervix, & vaginal opening Cervix: 100% effaced (soft tissue thins) & 10 cm dilated (wide vaginal opening) # 329 OB MATERNITY ACCELERATION FETAL HEART RATE # VEALCHOP # ariable Deceleration arly Deceleration cceleration ate Deceleration ord Compression M ove mom s position # I dentify labor progress, no intervention needed ead Compression Kay N o intervention needed lacental Insufficiency E xecute immediate intervention, non-reassuring Normal & healthy INCREASE in FHR atleast 15 beats/min, & lasting atleast 15 secs - Abrupt & temporary - Reassuring sign that the baby is responsive & receiving adequate O2 - Can be spontaneous & happen with or without contractions Causes: > Healthy placental-fetus exchange > Fetal movement > Uterine contractions > Vaginal examination > Fundal pressure > 60 90 120 150 180 210 30 FHR 240 bpm UA 0 mmHg 25 50 75 100 BABY MOTHER # 330 OB MATERNITY FETAL HEART RATE EARLY DECELERATIONS Normal DECREASE in FHR at beginning of contraction & returns to normal baseline at end of contraction - Lowest point at SAME TIME as peak of contraction - Head compression is a NORMAL occurrence since the babys head is descending through the birth canal & pressing against mothers pelvis/soft tissue - Mothers contraction MIRRORS/REFLECTS the dip in FHR (reassuring sign the baby is responding to stimuli) Causes: Compression of babys head due to uterine contractions 60 90 120 150 180 210 30 FHR 240 bpm UA 0 mmHg 25 50 75 100 BABY MOTHER LATE DECELERATION Abnormal, non-reassuring DECREASE in FHR after a contraction has started & returns to normal baseline way after contraction ends - Lowest point AFTER peak of contraction - Babys response DOESNT mirror/reflect mothers contractions (non-reassuring) - Notify HCP - If receiving, stop oxytocin infusion - Side-lying position - Give O2 at 8-20 L/min via face face mask > Give IV fluids - Continuously monitor FHR - Prep for delivery (C-section if no change) Causes: > Uteroplacental insufficiency (baby NOT receiving adequate oxygen) - Preeclampsia, maternal hypotension, placenta previa, abruptio placentae, maternal DM 60 90 120 150 180 210 30 FHR 240 bpm UA 0 mmHg 25 50 75 100 BABY MOTHER INTERVENTIONS # 331 OB MATERNITY FETAL HEART RATE VARIABLE DECELERATION Irregular & abrupt DECREASE in FHR - Varies in duration, intensity, & timing in relation to contractions - Blood flow in the umbilical cord is restricted - Notify HCP - If receiving, stop oxytocin infusion - Side-lying position or knee-chest position - Give O2 at 8-20 L/min via face face mask - Continuously monitor FHR - Vaginal examination to find prolapsed cord - Given amnioinfusion if needed (installation of saline fluid) - Prep for delivery Causes: > Cord compression - Short cord, prolapsed cord, nuchal cord (wrapped around fetal neck) > Oligohydramnios (little amniotic fluid surrounding baby) 60 90 120 150 180 210 30 FHR 240 bpm UA 0 mmHg 25 50 75 100 BABY MOTHER INTERVENTIONS Onset of contractions & cervical changes between 20-37 wks. of gestation. # PRETERM LABOR RISK FACTORS > Premature rupture of membrane (PROM) > Nipple stimulation in last trimester (releases oxytocin > uterine contracts) > Preeclampsia, Diabetes, Infection of vagina or amniotic sac > Poor prenatal care > Hx of preterm labors, miscarriages, or abortions > Younger than17 yrs or older than 35 yrs > Smoking, Substance use, Physical abuse > Sexual arousal or orgasm (for women high risk of preterm labor) ## Indomethecin (NSAID) Nifedipine (CA Channel Blocker) ## M agnesium Sulfate T erbutane (Adrenergic Agonist) SYMPTOMS > Uterine contractions > Cervical dilation (widening) and effacement (thinning, shortening) > Pelvic pressure > Persistent low backache > Abdominal cramping, Possible diarrhea > Vaginal discharge (change in consistency, color, odor) INTERVENTIONS > Bed rest, lie on side > Monitor fetal activity & HR > Tocolytics meds given IV to relax uterine (nifedipine, magnesium sulfate, indomethacin) If given magnesium sulfate, monitor for magnesium toxicity. Antidote is calcium gluconate. TOCOLYTIC MEDS (uterine relaxants) Its Not My T ime! # 332 OB MATERNITY STAGES OF LABOR ## THIRD STAGE -Assess maternal vital signs & uterine status -Fundus is firm, two finger widths below umbilicus -Check that placenta is intact and has cotyledons and membranes -Warm blanket for the mother -Encourage mother, baby attachment with skin-to-skin contact INTERVENTIONS Contractions continue until placenta separates and is expelled Monitor lochia discharge -Note how often peripads need changing -Every 15-30 minutes heavy/excessive! Monitor per facility policy Monitor -Every 15 minutes for 1 hour -Every 30 minutes for 1 hour -Every hour for 2 hours -Warm blankets -Ice packs to the perineum -Massage fundus if soft and teach mother -Provide breast feeding support as needed INTERVENTIONS FOURTH STAGE - 14 hours after birth - BP returns to pre-labor level - Cramping due to uterus contracting ## SECOND STAGE -Assessments every 15 minutes Monitor -Maternal vital signs -FHR - assess before, during, and after a contraction > normal FHR is 110 - 160 bpm contractions -Assist mother into a position for comfort and one that facilitates pushing efforts > lithotomy, side-lying, squatting, standing, kneeling INTERVENTIONS Baby is born! -From 10 cm dilation to birth of newborn -Intense contractions every 2 3 minutes -Contractions last 60 90 seconds -Fetal descent -Urge to push; assist mother in efforts to push -Progress of labor is measured by fetal station ## FIRST STAGE LATENT 1-4 cm, contractions 15-30 minutes, last 15-30 seconds ACTIVE 4-7 cm, contractions 3-5 minutes, last 35-60 seconds TRANSITION 8-10 cm, 2-3 minutes, last 45-90 seconds ## 3 PHASES Monitor -Maternal vital signs -FHR - assess before, during, and after a Ctx > Normal FHR is 110-160 bpm -Uterine contractions -Cervical dilation and effacement -Assess station, presentation, and position with Leopolds maneuvers -Assist with pelvic exam and prepare for a fern test INTERVENTIONS Longest stage 010 cm dilation of cervix If membranes have ruptured - Risk of prolapsed umbilical cord -Meconium-stained amniotic fluid can indicate fetal distress # 333 Hypertensive Disorders 4 categories of hypertensive disorders in pregnancy Chronic Hypertension - Exists before pregnancy or develops before 20 weeks Gestational Hypertension - New-onset elevated blood pressure after 20 weeks w/o proteinuria Preeclampsia/Eclampsia & HELLP Syndrome - most common HTN disorder in pregnancy; develops after 20 weeks, multisystem disease process; it becomes eclampsia when the mother has seizure activity Chronic Hypertension with Superimposed Preeclampsia - HTN that exists before pregnancy and then develops into preeclampsia # OB MATERNITY COMPLICATIONS 2 readings 4 - 6 hours apart with sustained BP of >140/90 mmHg after 20 weeks Proteinuria is not a reliable indicator of preeclampsia Persistent hypertension headache Edema of face and/or hands sudden weight gain Vision changes Upper abdominal or shoulder pain difficulty breathing Nausea vomiting RISK FACTORS BMI >30 Previous gestational HTN Carrying multiples Invitro fertilization African American descent Chronic HTN, renal disease, DM, other preexisting metabolic syndrome INTERVENTIONS Monitor BP, weight Strict I&Os, output of 30 mL/hr is normal RFT BUN, serum creatinine, 24-hour urine level Deep tendon reflexes (DTR), hyperreflexia (4+) indicates stress on CNS = seizure risk Fetal activity LABS dipstick: >1+ 24-hour urine: >300 mg creatinine/protein ratio: >0.3 mg/dL # S/S of Preeclampsia, Eclampsia -Flushing, RR <12, DTRs, UOP -Ant idote - calc ium gluconate MAGNESIUM SULFATE Monitor for s/s toxicity Given to prevent seizures during/after labor. ANTIHYPERTENSIVES Are used with caution BP must be reduced slowly Perfusion to the fetus must be maintained # 334 OB MATERNITY COMPLICATIONS Eclampsia = onset of seizures Pre = before Preeclampsia is a hypertensive disorder in pregnancy usually occurring after 20 weeks but CAN occur up to 48 hours after delivery of the baby. Hemolysis, elevated liver enzymes, low platelet count. # Preeclampsia, Eclampsia & HELLP Syndrome Severe preeclampsia can lead to: HELLP Syndrome eclampsia Fetal growth restriction placental abruption HELLP Syndrome Life-threatening condition Ruptured red blood cells Impaired coagulation Liver bleeding internally Abdominal or chest pain, N/V, thrombocytopenia # emolysis levated iver enzymes ow latelet count # HELLPBISHOP SCORE score Dilation Consistency of Cervix Position of Cervix Station Effacement of Cervix 0 1 2 closed Firm Posterior -3 -2 -1 Midposition Anterior Medium Soft 0-30% 40-50% 60-70% 3-4 cm 3 +1, +2 Anterior Soft 80% >5 cm 1-2 cm Indicated before inducing labor 8 indicates good chance of successful vaginal delivery shortened anterior (centered) softened partially dilated Cervical Ripening # 335 OB MATERNITY POSTPARTUM CARE UTERUS & FUNDAL MESSAGE 6 wk period after delivery, in which the mothers body return to its non-pregnant state (involution) UTERUS - Assess EVERY 8 hrs. - Should decrease 1 cm/day OR 1 finger width/day - Should be firm, centered, & at level of umbilicus - ABNL > Uterus shifted to side likely caused by distended bladder. EASY FIX! Have mother void - Soft & boggy uterus (decreased muscle tone > HEMORRHAGE!) - tender fundus (infection) FUNDAL MASSAGE - Firm, but still gentle massage - Uterus responds by contracting > constricting the uterine blood vessels > reduce risk of bleeding (hemorrhage) One hand is cupped to massage & gently compress the fundus toward the lower segment. The other hand remains cupped against the uterus at level of the symphysis pubis to support the uterus. # BREAST & CERVIX/VAGINA/PERINEUM - Days 2-3 (48-72 hrs), Colostrum (thin, yellow fluid) > Amazing benefits for baby! - Days 3-4 (72-96 hrs), milk produced after giving birth. Referred as milk coming in - Days 3-5, breasts are tender, swollen, hot, & heavy due to Engorgment (breast full of milk due to increased milk volume & hormonal changes) + possible Headache & Fever. > Tx for Nursing Mothers: Nurse frequently, Warm & moist compression on breast before nursing. > Tx for Non-Nursing Mothers: Cold packs on breast, Avoid pumping breast & nipple stimulation, Avoid excess fluid intake, Avoid hot showers/baths, Wear supportive bra, Pain meds. - Also watch for Cracked Nipples, Plugged Ducts, Mastitis. BREAST - Edematous & bruised. - Firms & shortens within 2-3 days. CERVIX - Gradually regains muscle strength & returns to pinkish color. VAGINA - Episiotomy (intentional surgical cut) or Laceration (unintentional tear) - Swelling is normal first few days. - Sitz bath & Ice packs for discomfort. - Stool softeners, High-fiber foods, & Increase fluids to avoid constipation (avoid painful straining) - Witch hazel wipes for hemorrhoids. - Area should be CLEAN & kept DRY. - ABNL: > Inflammation & Discharge (infection) > Edema, Hematoma, Bruising/Bleeding. PERINEUM Stimulation of the nipples, like breastfeeding, releases oxytocin which stimulate milk production & uterine contractions (helps to strengthen uterine muscles) # 336 OB MATERNITY POSTPARTUM CARE # LOCHIA SCANT < 2.5 cm (1 in) in 1 hour LIGHT 2.5-10 cm (4 in) in 1 hour MODERATE > 10 cm (4 in) in 1 hour HEAVY Entire pad saturated in 1-2 hours EXCESSIVE Entire pad saturated in 15 mins Discharge (blood, mucus, uterine tissue) > Day 1-3 > Fresh, dark red blood > Metallic smell (blood) Lochia Rubra > Day 4-10 > Slowly decreasing amount > Old, pink-brown "tinged" blood > Earthy smell Lochia Serosa > Day 10-28 > Great decrease > Yellow, white discharge > Still earthy smell Lochia Alba > Saturated pad within 15 mins (hemorrhage) > Excess bright, red blood (cervical or vagina tear) > Large clots > Foul odor (infection) > Lochia does not change in color or characteristics ABNL # POSTPARTUM HEMORRHAGE Blood loss of 500 mL (Vaginal delivery) OR Blood loss of 1,000 mL (Cesarean delivery) Blood loss within 24 hrs is PRIMARY (early) POSTPARTUM HEMORRHAGE Blood loss within 24 hrs is SECONDARY (late) POSTPARTUM HEMORRHAGE RISK FACTORS > Uterine atony (weak muscle tone) > Retained placental pieces > Tear at perineum (small area of skin between the vagina & anus) during delivery > Bleeding Complications (placenta previa, abruptio placentae) INTERVENTIONS > Closely monitor HR, BP, Pulse ox > Check fundus, bladder & vaginal discharge q. 15 mins > Fundal massage > Give O2 PRN > Keep hydrated, IV therapy > Possible blood transfusion > Meds: Oxytocin, methylergonovine, misoprostol, carboprost tromethamine SYMPTOMS > Perineal pad saturated in 15 mins or less > Continuous vaginal bleeding > Large blood clots > Uterus boggy, Fundal height above umbilicus (bellybutton) > Rapid pulse, Hypotension > Urinary retention usually from retained placenta fragments # 337 GLUCOSE: 40-60 mg/dL INFANT VITAL SIGNS & LAB VALUES BP (Blood Pressure): HR (Heart Rate): RR (Respiratory rate): T (Temperature): PULSE OX STAT: 60-80/40-50 110-160 beats/min > normal periods of apnea (15 sec); more than 15 sec should be reported immediately 30-60 breaths/min 97.7-99.5 F (36.5-37.5 C) > average 98.6 F (37 F) 95-100% PLAT ELETS: Hgb: WBC: RBC: Hct: 150,000-300,000 14-24 BILIRUBIN: BODY MEASUREMENTS (liver function; jaundice) 24 hrs: 2-6 mg/dL 48 hrs: 6-7 mg/dL 3-5 days: 4-6 mg/dL MOLDING TRAUMA FONTANELS soft spot HEAD > Bones not fused before birth, but will close months after birth > ANT ERIOR FONTANEL closes between 12-18 months > POST ERIOR FONTANEL closes at 3 months > Cone-shaped head due to pressure during a vaginal delivery. > A. Caput succedaneum: accumulation of fluid. Scalp is edematous & puffy. Crosses the midline of scalp. Normal & goes away within a few days. > B. Cephalohematoma: accumulation of blood. DOES NOT cross the midline because it s in a space between the periosteum & skull bone. Resolves after a few weeks. 9,000-30,000 4.8-7.1 million 44-64% Head: Weight: Chest: Length: 13-14 in (33-35.5 cm) 5.5-9.5 lbs (2,500-4,250 g) 10-12 in (25.5-30.5 cm) 18-22 in (46-56 cm) CIRCULAT ION (blood flow & breathing) Umbilical cord: TWO arteries & ONE vein > If only two vessels, possible congenital defect. Notify HCP! ONCE CORD IS CUT: > Baby breaths on his/her OWN > Lungs expand & pressure changes > THREE shunts close (ductus arteriosus, ductus venous, foramen ovals) # OB MATERNITY ALL ABOUT THE BABY When the shunts close, it reduces lung pressure. Increasing the pressure in left atrium of heart, relieving pressure in the right atrium. 338 THERMOREGULATION Ways for newborn to maintain heat; prevent cold stress (ineffective thermoregulation that leads to hypoxia, acidosis, & hypoglycemia) A. Conduction: heat loss from direct contact with cool surface - Preserve: rest baby on mother's chest to transfer heat B. Convection: heat loss from cool air - Preserve: swaddle baby in blanket, place cap on baby s head, or move baby away from air vent C. Evaporation: heat loss from cooling effect of water loss on skin - Preserve: thoroughly dry baby after bath, replace wet towels or blankets D. Radiation: heat loss via UV rays - Preserve: move baby away from window # OB MATERNITY ALL ABOUT THE BABY APGAR SCORE score Appearance GRIMACE Reflex irritability Activity muscle tone Respiratory effort PULSE 0 points 1 point 2 points Limp No response Blue / pale Absent Slow, Irregular, Weak cry > Good, Crying > Pink body, Blue > extremities > Pink all over, > Normal color > Weak cry, > Grimace > Strong cry, > Cough or sneeze Absent < 100 > 100 > Active, Moving Limbs flexed # REFLEXES > Babinski: Stroke outer edge of sole of foot, towards big toe. Baby's toes should fan out > Moro's: Sudden noise or movement cause baby to draw out arms & draw in legs > Palmar grasp: Give baby your finger, baby should tightly grasp finger > Tonic neck: Lie baby on back & turn his/her head, baby's extremities on same side should extend > Sucking: Baby latches onto mother's nipple or bottle nipple; goes hand in hand with rooting reflex > Stepping: Stand baby upright with feet touching surface, baby should step with one foot then the other > Rooting: Stroke cheek, baby should turn head towards direction of stroke 0-3 > Needs IMMEDIATE resuscitation. LIFE-THREATENING CONDITION 4-6 > IN DANGER! Give oxygen before it worsens 7-10 > Healthy baby! BEST CONDITION # 339 NOTES PEDIATRICS INFANT (Birth - 12 months) PEDIATRICS WEIGHT: 5.5 - 9.5 lbs (2,500 - 4,250 g) Gains approximately 1.5 lbs (680 g) per month for the FIRST 5 months Birth weight DOUBLES by 5 months & T RIPLES by 12 months HEIGHT: 18 - 22 in (46 - 56 cm) Grows approximately 1 in (2.5 cm) per month in FIRST 6 months. Increases by 50% after 6 months up until 12 months HEAD: 13 - 14 in (33 - 35.5 cm) Increases 0.75 in (2 cm) per month in FIRST 3 months, 0.4 in (1 cm) per month from 4-6 months, & 0.2 in (0.5 cm) per month by 12 months POST ERIOR FONTANEL closes by 2 - 3 months ANT ERIOR FONTANEL soft spot closes by 12 - 18 months Head circumference is 1-2 cm LARGER than chest circumference DENTAL: first tooth in 6 - 10 months (average 8 months) 6 to 8 teeth by 1 year of age Signs: irritable, biting, sucking, drooling, insomnia, mild fever, rub ears, decreased appetite for solid foods Treatment: - Analgesic (Tylenol, ibuprofen) - Frozen teething rings, cloth-wrapped ice cub, OTC teething gel AVOID falling asleep with bott le in mouth (cavities) PHYSICAL Breast milk or iron-fortified formula is the primary source of nutrition for the 1st year - Decreased when solid foods introduced At 4-6 months, solid foods introduced (graham crackers, mashed potatoes & bananas, oatmeal, butternut squash) Around 6 months, water & juice introduced After 6 months, 100% fruit juice limited to 4-6 oz/day Gradually wean from breast or bott le to a cup NUTRUTION Sensorimotor Phase (birth-2 yrs.) Object permanence is developed Can only see from ones own point of view (egocentric) Uses their senses & motor skills to explore the world COGNITIVE DEVELOPMENT: PIAGET Trust vs Mistrust (birth-18 months) develops trust when needs are met (affection, comfort, food) OR leads to future anxiety, loneliness, isolation, & fear PSYCHOLOGICAL DEVELOPMENT: ERKISON After walking independently for several months: Persistent tiptoe walking Does NOT develop mature walking pattern SIGNS OF DEVELOPMENT DELAYS Birth - 4 months 14-15 hours of sleep (of those, 9-11 hrs. at night) Between 4 months - 1 year, sleeps through the night w/ 1 or 2 naps during the day SLEEP Try new food one-at-a-time over 5-7 days to observe for allergies knows object still exist w/o being seen 343 PEDIATRICS INFANT: DEVELOPMENT MILESTONES (Birth - 12 months) Month Gross Motor Fine Motor Language Social Attempts to hold head up when prone (head lag) Strong grasp Maintains fisted hands Cries to communicate frustration/hunger Gazes on parents face Lifts entire head when prone Holds hand in open position Grasp reflex fades Cooing & gurgling sounds Turns head to sounds Smiles in response to people talking & smiling Bears full weight on feet Sits, leans on hands for support Moves object from hand to hand Sits w/o support Uses pincer grasp Rolls from back to tummy Holds bottle Imitates sounds Responds to name Constant sounds m,b Babble vowels together ah,eh,oh Differentiate between familiar & unfamiliar faces Stranger anxiety Responds to others emotions Rolls from side to back & tummy to back Holds head steady w/o support Grasps objects with both hands Uses palmar grasps Babbles & copy sounds heard Laughs & smiles spontaneously Ccries when playing stops Copies facial expressions Raises head & shoulders when prone (slight head lag) Keeps hand loosely open No longer has grasps reflex # 1234-5 678 344 INFANT: DEVELOPMENT MILESTONES (Birth - 12 months) INFANT: REFLEXES (Birth - 12 months) PEDIATRICS Month Gross Motor Fine Motor Language Social Begins to crawl Pulls up to stand Uses crude pincer grasp Moves object from hand to another Dominate hand evident hands Changes from tummy to sitting position Grasp rattle by hand Understands no Imitates sounds & gestures Makes different sounds Walk first steps alone! Sits from a standing position w/o help Crawls stairs Feeds self finger foods Tries to build a two-block tower Turn pages in a book Follows 1-step commands w/ gestures Says 3-5 words Says mama & dada Waves bye-bye & shakes head no Tries imitate sounds Plays peek-a-boo or pata-cake Cries when parent(s) leave Has favorite toys & people Take steps while holding onto something cruising Babinski: Stroke outer edge of sole of foot, towards big toe. Baby's toes should fan out (Birth to 1 year) Moro's: Sudden noise or movement cause baby to draw out arms & draw in legs (Birth to 4-6 months) Palmar grasp: Give baby your finger, baby should tight ly grasp finger (Birth to 4-6 months) (Birth to 3-4 months) Rooting: Stroke cheek, baby should turn head towards direction of stroke (Birth to 4 months) (Birth to 4 months) Sucking: Baby latches onto mother's nipple or bott le nipple; goes hand in hand with rooting reflex (Birth to 4 months) Stepping: Stand baby upright with feet touching surface, baby should step with one foot then the other Tonic neck: lie baby on back & turn his/her head, baby's extremities on same side should extend Uses neat pincer grasp Places object in container # 910 11 12 # 345 WEIGHT: gains 3 - 5 lbs (1.7 - 2.3 kg) per year At 30 months, should be 4x birth weight HEIGHT: grows 3 in (7.6 cm) per year HEAD: head-to-chest circumference is EQUAL around 1-2 years ANTERIOR FONTANEL soft spot closes by 12 - 18 months DENTAL: 20 deciduous teeth baby teeth by age 3 Established home dental routine by 1 years of age Cavities are common (AVOID prolonged exposure of sugary foods & drinks on teeth) Brush teeth & floss T WICE A DAY Low-fluoride toothpaste (important to use if living in areas with inadequate fluoride level in drinking water) Dental visit once FIRST tooth appears or around 1 year of age PHYSICAL Picky eaters, Ritualistic Psychological anorexia (decreased appetite) Drinks whole milk. After age 2, switches to low-fat milk Milk limited to 2-3 servings (24-30 oz) for adequate calcium & phosphorus (too much milk can lower iron) Juice limited to 4-6 oz/day Adequate iron, folate, vitamin A, C&D. REST RICT saturated fats Frequent finger-foods/healthy, nutritious snacks if not consuming full meals (toddlers are always on the go!) Adult supervision while eating & restrict play activities while eating Cut food into smaller, bit-size pieces (PREVENT CHOCKING) AVOID potential chocking hazards foods (popcorn, grapes, hotdogs, peanut butter, nuts, tough meat) NUTRUTION Transitions from Sensorimotor Phase to Preoperational Phase Preoperational Phase (2-7 yrs): Uses words & pictures to represent objects (symbolical thinking) Magical thinking, plays pretend Animism: gives life-less objects life-like qualities Aware, but struggles to see others point of view COGNITIVE DEVELOPMENT: PIAGET Autonomy vs Shame & Doubt (18 months-3 yrs.) develops independence & sense of control OR doubt abilities, frustrated with themselves PSYCHOLOGICAL DEVELOPMENT: ERKISON 11 - 12 hrs. of sleep w/ 1-2 naps during the day Establish bed routine & appropriate time Common for toddlers to resist sleeping to avoid missing out on family activity Can express fears (darkness, monsters, etc) Security objects to help with sleeping (blankets, stuffed animal, etc.) Difficult phase of getting child to sleep in own room SLEEP TEMPER TANTRUMS TERRIBLE TWOS also occurs between 2-3 years of age After walking independently for several months: Persistent tiptoe walking Does NOT develop mature walking patten By 18 months: Not walking Not speaking 15 words Does NOT understand the function of common household items By 2 years: Does NOT use 2-word sentences Does NOT imitate actions Does NOT follow basic instructions Cannot push a toy with wheels SIGNS OF DEVELOPMENT DELAYS # PEDIATRICS TODDLER (1 year - 3 years) # 346 TODDLER: DEVELOPMENT MILESTONES (1 year - 3 years) PEDIATRICS Plays pretend Ownership Explores alone with parents nearby Temper tantrum Begins parallel play Gets excited with other children Gains independence Walks up & down stairs while holding rail Kicks ball Runs w/o falling Builds 6-7 block tower Turns 1 page at a time Draws a line Separation anxiety! (can start before toddler stage or later into toddler stage) > Social Language Gross Motor Fine Motor Walks independently Jumps! Runs, but trips often Pushes & pulls toys Throws ball overhead Uses cup Feeds self finger foods Points w/ index finger Uses cup, spoon, fork Builds 3-4 block tower Turns 2-3 pages at a time Scribbles Says 30-50 words Forms 2-3 word sentences Follows simple instructions Knows name of familiar people Know names to familiar objects Looks at adult when communicating Follows 1-step commands w/o gestures Babbles & repeat words Understands 200 words Says 10-20 words Points to show what they want 15 months 18 months 2 years TODDLER (1 year - 3 years) Usually begins at 18-24 months or sometime later How To Determine Readiness Can communicate & follows simple commands Pulls clothes up & down, tug at clothes Shows interest in wearing underwear Keeps diaper/pull-up dry for > 2 hrs. OR after nap Walks to or sits on toilet Remains on toilet for 5-8 mins Makes connection between urge to pee/poop & going the potty POTTY TRAINING Bladder control is usually achieved before bowel control How To Help Toddler Succeed Plan a schedule/set aside time to potty train Use words associated with using the toilet (pee, poop, potty) Parent demonstrate & sit on toilet Regularly ask toddler if they need to potty Have toddler sit on toilet sometime after eating (bowel movement) & drinking liquids (bladder) Avoid clothing difficult to remove such as belts, overalls, shirts that snap (onesies) DO NOT punish toddler for wetting/pooping on themselves Be patient, encouraging, & reassuring Give rewards every time toddler potties # 347 WEIGHT: gains 4 - 5 lbs (2.3 - 3 kg) per year Average at 3 years: 32 lbs (14.5 kg) Average at 4 years: 36.5 lbs (16.5 kg) Average at 5 years: 41 lbs (18.5 kg) HEIGHT: grows 2.6 - 3.5 in (6.5 - 9 cm) per year Average at 3 years: 37.5 in (95 cm) Average at 4 years: 40.5 in (103 cm) Average at 5 years: 43.5 in (110 cm) BODY: Loses baby fat & protruding belly. Becomes slender, limbs elongate, & face is more defined DENTAL: loses first deciduous tooth baby teeth around 6 years of age (some kids lose first tooth before or after 6) Brush teeth & floss TWICE A DAY Adult supervision while brushing teeth & flossing Regular dental visits Cavities are common (AVOID prolonged exposure of sugary foods & drinks on teeth) Low-fluoride toothpaste (important to use if living in areas with inadequate fluoride level in drinking water) PHYSICAL Not as picky or ritualistic with food & willing to try new foods around age 5 3 - 5 servings of fruits & veggies INCREASED intake of iron, folate, calcium, protein, vitamin A, C&D. AVOID or decrease of saturated fats Limit screen time & Encourage physical activity NUTRUTION Preoperational Phase (2-7 yrs): Uses words & pictures to represent objects (symbolical thinking) Magical thinking, plays pretend Animism: gives life-less objects life-like qualities Egocentrism: lacks awareness & struggles to see others point of view Begins to understand time & sequence of events COGNITIVE DEVELOPMENT: PIAGET Nitiative vs Guilt (3 yrs.-6 yrs.) explores & learns new things to develop ambition & direction OR hesitant to try new things, feels shame/guilt for not completing a task or believing they misbehaved, heavily depends on others for help PSYCHOLOGICAL DEVELOPMENT: ERKISON 12 hours of sleep Consistent sleep routine Express fears (darkness, monsters, etc.) night light & reassure child of safety Security objects to help with sleeping (blankets, stuffed animal, etc.) SLEEP By 3 years Difficulty with stairs, Frequent falls Difficulty handling small objects Unable to build tower of 4 + blocks Extreme difficulty separating from parent/caregiver Cannot copy circle Does NOT understand simple instructions Does NOT play make-believe NO interest in interacting with other children Cannot communicate in short phrases Unclear speech, Drooling SIGNS OF DEVELOPMENT DELAYS PEDIATRICS PRESCHOOLER (3 years - 6 years) # 348 PEDIATRICS # PRESCHOOLER: DEVELOPMENT MILESTONES (3 yr. - 6 yrs.) More creative with makebelieve play Plays mom & dad Cooperates with other children Like to try new things Tells what theyre interested in Recognize differences & compares self to other children Aware of gender Shows more independence Can be demanding or cooperative Sings, dance, acts Throws & catches ball easily Jump ropes, swings Walk backwards Hops on 1 foot for 10 secs Somersault Uses toilet on own Dress & undress self Uses spoon, fork, & sometimes butter knife Tie shoe strings Begins associative play Take turns Imaginary friend Shows affection & concern Fear from major change in daily routine > Social Language Gross Motor Fine Motor Climb well Run & bend w/o falling Jumps forward Rides tricycle Stands on tiptoes Skips & hops on 1 foot Throw ball overhead or catch ball Walk upstairs (1 foot on each step) Draws circles Feeds self w/o assistance Grips crayon within fingers Builds 8 block tower Use scissors Draw & trace shapes Draws person w/ 2-4 body parts Pours juice into cup Mashes own food Lace shoes Says 2,000+ words Speaks clearly & in complete sentences Stuttering/stammering is normal Says name & address Uses future tense Asks why Says first name & age Says 1,000+ words Forms 3-4 word sentences Follows 3-part directions Says 1,500 words Forms 4-5 sentences Tell stories Sing songs from memory Says first & last name Correct ly uses simple grammar she, he 3 years 4 years 5 years PRESCHOOLER (3 years - 6 years) By 4 years: Cannot jump in place or throw ball overhead Cannot ride tricycle Cannot stack 4 blocks Cannot use words me & you appropriately Difficulty scribbling & copying a circle Doesnt grasp crayon with thumb or SIGNS OF DEVELOPMENT DELAYS By 5 years: Little interest in other kids Sad often, Unhappy Unable to separate from parents Extremely aggressive, fearful, passive, or timid Easily distracted Difficulty brushing teeth, undressing, washing & drying hands fingers Doesnt say sentences with 3+ words Doesnt engage in fantasy play Ignores children & not interested in interactive play Resist using toilet, dressing, or sleeping Still clings or cries if parents leave # 349 WEIGHT: gains 4.4 - 6.6 lbs (2 - 3 kg) per year Average @ 6 years: 46 lbs (21 kg) Average @ 12 years: 88 lbs (40 kg) HEIGHT: grows 2 in (5 cm) per year Average @ 6 years: 45 in (114.3 cm) Average @ 12 years: 59 in (149.9 cm) DENTAL: Permanent teeth erupt (grows) around 6 years of age By age 12, ALL 20 teeth should fallout & be replaced by 28-32 permanent teeth Regular dental visits Brush teeth & floss T WICE A DAY Fluoride toothpaste PREADOLESCENCE/PREPUBESCENCE: 10 - 12 years, physiological changes begins with rapid growth in height & weight Significant difference in rate of growth between girls & boys Girls grow FAST ER in height than boys (girls have a growth spurt approximately between 9-14 years) By age 12, girls surpass boys in height Girls can start FIRST menstrual cycle around age 12 Between 10 - 12, boys slow in height & increase in weight PHYSICAL Concrete Operational Phase (7 yrs.-11 yrs.) Concrete thoughts Understands concept of conservation (mass, weight, & volume) Egocentrism decreases, able to see others point of view Problem-solving Ability to read, expands knowledge & increase comprehension COGNITIVE DEVELOPMENT: PIAGET 9-12 hours of sleep By age 11, 9 hrs. of sleep SLEEP Ride bicycle Jump rope, hopscotch Swim Participate in team activities Write in cursive DEVELOPMENT GROSS & FINE MOTOR Value peers opinions, which will influence perception of self Compare self to others, aware of physical differences & abilities Primary association & relationships are made in school Develop interest in opposite gender at end of school-age stage Join clubs, organizations, & team sports BULLYING (heavily contributes to childs social & emotional growth) Self-evaluation to establish either confidence or self-doubt/low self-esteem SOCIAL/EMOTIONAL Eating majority of foods & adult/regular sized portions Risk of obesity is a concern Provide well-balance meals, AVOID fatty foods, AVOID frequent fast food, encourage physical activity NUTRUTION Industry vs Inferiority (6 yrs.-12 yrs.) learning & developing new skills, challenged, takes pride in abilities, recognizes everyone cannot master same or every skill OR feelings of failure & incompetence PSYCHOLOGICAL DEVELOPMENT: ERKISON EXAMPLE amount of liquid in a short, wide cup is equal to that in a tall, skinny glass Discussed in Adolescent Stage # PEDIATRICS SCHOOLAGE (6 years - 12 years) # 350 PUBERTY: Dramatic change in body size & proportion, Body mass increases to adult size Sexual characteristics & Reproductive maturity development Hormonal changes ( estrogen in girls. increase testosterone in boys) Acne, Increased production of sebaceous & sweat glands Girls usually stop growing about 2 - 2.5 years after onset of menarche (1st menstrual cycle) Boys have a growth spurt approximately between 11-17 years & stops growing around 18-20 years of age WEIGHT: Girls: gains 15.4 - 55 lbs (7 - 25 kg) overall Boys: gains 15.4 - 66.1 lbs (7 - 30 kg) overall HEIGHT: Girls: grows 2 - 8 in (5 - 20 cm) overall Boys: grows 4 - 12 in (10 - 30 cm) overall DENTAL: ALL permanent teeth Regular dental visits Brush teeth & floss T WICE A DAY Fluoride toothpaste Braces, Invisaligns, or other corrective devices are common during adolescent stage if needed PHYSICAL Rapid growth & high metabolism requires increase in nutrients Adequate intake of calcium, zinc, iron, folic acid, protein, vitamin A, C, & D Tend to snack more Eating disorders (anorexia nervosa, binge-eating, over-eating, etc.) can develop Encourage well-balance meals, AVOID fatty foods, AVOID frequent fast food, & encourage physical activity NUTRUTION Formal Operational Phase (11 yrs.+) Abstract thoughts, uses logical reasoning Thinks more about moral, ethical, social, & political issues Understand actions affect others Hypothetical questions/thinking Thinks about their future COGNITIVE DEVELOPMENT: PIAGET 8-9 hrs. of sleep Tend to stay up late & sleep-in late Sleeps more due to rapid changes of the body SLEEP Establishes independence, especially affects relationship with parents Develop & value relationships with others Spends more time with friends/peers Romantic relationships Value peers opinions, which will influence perception of self Peers play vital role in self-identity Peer pressure BULLYING (still has heavy affect) Compare self to others, Body image Can differentiate & accept own unique characteristics Risky behavior/Feels invincible DEVELOPMENT SOCIAL/EMOTIONAL Late SCHOOL-AGE & Early ADOLESCENCES can overlap each other first menstrual cycle around 12 years of age Identity vs Role Confusion (12 yrs. +) sense of self, has own beliefs & values OR weak sense of self, drifting because dont know where they fit in, lack of confidence PSYCHOLOGICAL DEVELOPMENT: ERKISON PEDIATRICS ADOLESCENTS (12 years - 20 years) # 351 MALE FEMALE PEDIATRICS Breasts bud & areola enlarge (no separation of breast) FIRST menstrual cycle around age 12 (appears about 2 years AFT ER breast bud) Pubic hair spreads & curls Genital pigmentation increases Body hair Hips & wastes start to build fat (after 12 years of age) Menstrual cycles become regular & usually consistent Pubic hair coarse in texture Pubic & Body hair increases Breast separates & can grow approximately to adult shape & size Hip, thighs, buttocks fill out in shape Continual growth of breast to adult shape & size until age 18 Mature hair distribution & coarseness Fully developed Pubic hair spreads & curls Genital pigmentation increases Growth & enlargement of decorum & testes Lengthening of penis Body hair Lengthy/leggy look (extremities growing faster than trunk) Adult(s) should be open & honest while giving information Provide a safe, non-judgmental space for teens to comfortably ask questions (discussing sex can be confusing & uncomfortable) Discuss the importance of protection & how to properly use them to avoid ST Is or pregnancies Emphasize that all forms of birth control (condom, pill, etc.) are NOT 100% effective. ONLY abstinence is 100% Teach safe sex for both heterosexual & homosexual relationships (whichever one obtains to teen) Nocturnal emission (wet dreams) starts between 13 - 17 years old BUT the average age is 14.5 Pubic hair coarse in texture Pubic & Body hair increases Facial hair appears Change in voice Continued growth of scrotum, testes, & penis Skin around scrotum darkens Increased breast tissue under nipples (goes away in couple of years) Builds muscle Adult size & shape scrotum, testes, & penis Mature hair distribution & coarseness Breast tissue disappears Fully developed 10-13 Years Early Adolescence SEX EDUCATION 14-16 Years Middle Adolescence 17-20 Years Late Adolescence PHYSIOLOGICAL CHANGES: ADOLESCENTS (12 yrs. - 20 yrs.) # 352 IMMUNIZATION & VITAL SIGNS PEDIATRICS Birth, 1-2 months, 6-18 months 2 months, 4 months, 6 months 2 months, 4 months, 6 months, 15-18 months, 4-6 years 2 months, 4 months, 6 months, 12-15 months 6 months, Yearly 12-15 months, 4-6 years 12-15 months, 4-6 years 12-24 months, 6 months after first dose 2 months, 4 months, 6 months, 12-15 months 2 months, 4 months, 6 months, 12-15 months Hepatitis B (HBV) Rotavirus (RV) DTap Haemophilus Influenza type B Polio (IPV) Influenza Measles, Mumps. Rubella (MMR) Varicella Hepatitis A (HAV) Pneumococcal Conjugate Vaccine (PCV) VACCINES AGE Age NEWBORN (birth-1 month) INFANT (1 month-1 yrs.) TODDLER (1-3 yrs.) PRE-SCHOOLER (3-6 yrs.) SCHOOL AGE (6-12 yrs.) ADOLESCENT (12 yrs.+) RR beats/min Pulse beats/min BP mm Hg TEMP 60-80/40-50 74-100/50-70 80-112/50-80 82-112/50-78 84-120/54-80 80-120/60-80 Oral 96-99.5 F (35.6-37.5 C) 100-160 80-180 80-140 70-115 65-110 60-100 30-60 20-40 20-30 20-25 17-22 12-20 Rectal 97-100.4 F (36-38 C) Tympanic 96-100.4 F (35.6-38 C) Axillary 94.5-99 F (34.7-37.2 C) # 353 PEDIATRICS PEDIATRIC DISEASE Pathogens stimulate the release of interferon, interleukins, and tumor necrosis factor. These pyrogens trigger prostaglandin production in the hypothalamus and increase the bodys temperature > activates the cold response > shivering > peripheral vasoconstriction, which decreases heat loss > the bodys temperature rises > fever Pathophysiology - Skin flushed, warm to touch - Chills, sweating (diaphoresis) - Lethargic or restless Symptoms NORMAL TEMP 97.5 F to 98.6 F(36.4 C to 37.0 C) FEVER > 100.4 F (38.0 C) - Remove excess clothing/blankets to decrease temp - Cool compression to forehead - Give antipyretics (ibuprofen) - DO NOT give aspirin (risk of Reyes Syndrome) - Sponge bath (tepid water for 20-30 mins) - Monitor for signs of dehydration & electrolyte imbalances - Keep hydrated Nursing Interventions/Treatment Febrile showing symptoms of a fever Exanthems rash or skin eruption Prodromal stage the period after incubation and before s/s of an infection develops Terms - Fever - an abnormal rise in body temperature above the normal range due to infection, inflammation, or other pathogens - Hyperthermia the bodys hypothalamic thermoregulation fails, which results in an uncontrolled rise in core temperature the bodys protective mechanism to fight infection - An infant younger than 1 month old with fever is a medical emergency FEVER MANAGEMENT # 354 PEDIATRICS Bacterial infection that happens to SOME kids who have strep throat - Group A-hemolytic streptococci - Transmission: direct contact & droplet - Symptoms develop during 1-7 day incubation period SCARLET FEVER - ONSET IS ABRUPT! - High Fever, Malaise, Flushed cheeks - Sore throat & Red, swollen tonsils - Enlarger neck lymph nodes - Red, sandpaper-like rashes - Red lines in folds of skin (groin, elbows, armpits, etc.) - Desquamation (sloughing skin of palms & soles at 1-3 weeks) - White, strawberry tongue that sloughs by the 3rd to 5th day - Red, strawberry tongue - ABD pain, Vomiting - Headache Signs & Symptoms Healthy T ongue White Coated T ongue Strawberry T ongue - Give plenty of fluids - Encourage bed rest - Treat Fever & pain (Tylenol, ibuprofen) - Antibiotics (penicillin) > initiate isolation, take antibiotics, & wait for 24 hours - Cold treats to soothe throat (popsicles) Nursing Interventions/Treatment - Ear infections, Nephritis, Arthritis, Cardiac problems, Pneumonia Complications Pathogen- Group A -hemolytic streptococci (GABHS) (strep throat) Incubation period - 1 7 days Contagious - for about 10 days during incubation period (highest during acute infection); not contagious 24 hours after starting antibiotics Source nasopharyngeal (nose & pharynx) secretions from an infected person or a carrier Transmission contact with an infected person or droplets, contact with contaminated objects, and foodborne transmission # PEDIATRIC DISEASE # 355 PEDIATRICS PEDIATRIC DISEASE - High-risk children must be isolated from a child with a communicable disease. - Infants and young children are vulnerable to infection due to an immature immune system - Always obtain culture specimen before administering antibiotics Infections & Communicable Diseases - High risk of mortality - Immune system not fully developed - Do not have immunoglobulin M (IgM) (needed to protect against bacterial infection) - Aggressive management admitted to hospital, IV antibiotics Neonates & infants More Susceptible to Sepsis: - Sepsis is commonly caused by bacteria and viruses - Bacteria or other pathogens enter the bloodstream Sepsis causes a systemic inflammatory response > leading to decreased blood flow and decreased tissue perfusion > septic shock SEPSIS Sepsis can lead to septic shock -a medical emergency septic shock can lead to systemic organ failure & death - E-coli - Group B streptococcus Common Causes - CBC - Blood & urine cultures - Liver function test - Cerebrospinal fluid (CSF) - C-reactive protein Diagnosis - Lethargic, pale - Dehydration - Fever or hypothermia - Rash - Diarrhea, vomiting - Tachypnea - Tachycardia - Jaundice Infants - Tachypnea - Tachycardia - Hypothermia - Weak cry - Abdominal distention - Elevated temp or hypothermia - Poor suck/feeding Signs & Symptoms Monitor - Vital signs - I & O, daily weight - For diarrhea - Admin antibiotics as prescribed - Monitor neonates & infants for toxicity Assess - Respirations - For jaundice - Feeding & sucking - In infants Nursing Interventions # 356 PEDIATRICS PEDIATRIC DISEASE Community-associated methicillin-resistant Staphylococcus aureus CAMRSA can enter the bloodstream through a cut or wound and cause sepsis, osteomyelitis, pneumonia, septic shock & death MSRA is resistant to methicillin and other antibiotics; occurs in people hospitalized, long-term care facilities, other health care facilities (hospital acquired) CAMRSA is an MRSA infection in a healthy person (community associated) Occurs in: - Day care facilities - Athletic teams - Crowded living conditions - IV drug abuse - Sharing personal items CAMRSA Staphylococcus aureus is present on the skin or in the nose of healthy people - Colonization S. aureus without symptoms - Infection - S. aureus with symptoms Skin Infection - Red, swollen, painful bump on skin - Purulent drainage (pus), pimples - Fever Serious Infection - Rash - Cough, SOB - Chest pain - Chills, fever - Headache Signs & Symptoms - Assess area of infection - Drain site, culture the wound and drainage as indicated - Obtain blood, sputum, and urine cultures as indicated - Administer antibiotics as ordered Nursing Interventions Healthcare settings - Frequent handwashing - Disposing of dressings properly - Strict aseptic technique - PPE Family education - Importance of taking antibiotics as directed & finish all - Handwashing, importance of personal hygiene - Avoid sharing personal items - Importance of cleaning & covering cuts/scrapes - Early recognition signs & symptoms, causes, and methods of transmission & early treatment Prevention & Patient Education - Person-to-person contact - Blood - Surfaces/items contaminated with MRSA Transmission # 357 PEDIATRICS PEDIATRIC DISEASE - Highly contagious - Children & adults who are not immunized (Tdap) are at risk - A grey, pseudomembrane forms over tonsils and throat and causes airway obstruction and suffocation DIPHTHERIA - Low-grade fever - Sore throat, malaise, headache - Difficulty swallowing (dysphagia) - A pseudomembrane forms over the tonsils and throat - Neck edema (lymphadenopathy) Signs & Symptoms - Strict isolation for patient - Diphtheria antitoxin - Antibiotics (usually erythromycin or penicillin G) - Airway management - Suction as needed - Humidified O2 Nursing Interventions Pathogen Corynebacterium diphtheriae (C. diphtheria) Incubation period 2 5 days Contagious up to 4 weeks, or a few days with treatment; 2 negative cultures 24 hours apart, 24 hours after medications are finished Source droplets or discharge from mucus membranes, skin lesions of infected person Transmission airborne droplets; direct contact with carrier or infected person, contaminated items By throat swab culture Diagnosis - An acute respiratory disorder with a sudden, violent cough - Highly contagious PERTUSSIS (WHOOPING COUGH) Pathogen Bordetella pertussis Incubation period can be 6 21 days; usually 7 10 days Contagious most contagious during the catarrhal phase Source discharge & droplets from respiratory tract of infected person Transmission airborne droplets or direct contact from infected person; contaminated items # 358 PEDIATRICS PEDIATRIC DISEASE - Presents as upper respiratory tract infection - Severe cough with whooping sound on inspiration - Progressive cyanosis , respiratory distress - Tongue protrusion - Lethargy Signs & Symptoms - Highly contagious isolate child during the catarrhal phase & at least 5 days after treatment has started - Droplet and contact precautions for the hospitalized child - Reduce respiratory irritants that cause coughing smoke, dust, sudden temperature change - Admin antimicrobials as ordered - Humidified O2 and suction as needed - Monitor heart, lungs, and pulse ox Nursing Interventions 3 Phases Catarrhal phase respiratory secretions, fever fatigue; lasts 1 to 2 weeks and most contagious phase Paroxysmal phase the sudden attack of coughing; the whoop sound may be heard on forceful inspiration Convalescent phase a residual cough can last for weeks to months - Infants do not have maternal immunity - Tdap vaccine diminishes after severalyears - Mother or anyone in close contact with the infant should receive the Tdap vaccine - Acute, often fatal neurological disease - Immunized women pass immunity to their infants TETANUS Pathogen Clostridium tetani Incubation period 3 21 days (average is 7 10 days) Contagious tetanus is not spread from person to person Source soil, dust, feces of humans or animals Transmission spores enter the body through a wound, splinter, or burn; drug use with contaminated needles PERTUSSIS (WHOOPING COUGH) # 359 PEDIATRICS PEDIATRIC DISEASE - Muscle spasms - Lock jaw - Difficulty swallowing - Stiff neck Signs & Symptoms - Debridement of the wound - Admin IV antibiotics as ordered - Tetanus immunoglobulin - Tetanus vaccine - Child may be admitted to ICU Nursing Interventions - Before rash - mild fever, malaise, diarrhea, vomiting, runny nose, or asymptomatic - Rash on face develops the red slapped cheek rash lasts 4-5 days - Rash spreads to trunk and extremities - Exposure to heat, cold, sun, may exacerbate the rash Signs & Symptoms - Usually treated at home - Antipyretics may be needed - Monitor immunocompromised patients closely - Pregnant women should avoid affected person Nursing Interventions 4 Phases - Neonatal tetanus - Generalized tetanus - Localized tetanus - Cerebral tetanus - The fifth most common viral rash in children - Transmitted from mother to fetus ERYTHEMA INFECTIOSUM (FIFTH DISEASE) Pathogen human parvovirus B19 Incubation period 4 21 days Contagious unclear; before rash appears; once rash develops no longer contagious Source infected person Transmission respiratory secretion droplets, and blood PERTUSSIS (WHOOPING COUGH) # 360 PEDIATRICS PEDIATRIC DISEASE - Fever - Inflammation & swelling of the parotid gland - Orchitis (testicle swelling) - Oophoritis (ovary swelling) - Complications (rare) meningitis, pancreatitis, hearing loss Signs & Symptoms - Isolate patient - Airborne, droplet and contact precautions Nursing Interventions - Pathogen - Paramyxovirus - Transmission airborne droplets or direct contact with infected person - Contagious several days before and after parotid gland swells MUMPS - The 3 Cs - conjunctivitis, cough, coryza (nasal discharge) - Koplik spots tiny red spots with a blue/white center in the buccal mucosa appearing a few days before the rash - Fever, rash starting on the face Signs & Symptoms - Airborne, droplet and contact precautions - Antipyretics, bed rest Nursing Interventions - Pathogen Paramyxovirus - Transmission airborne droplets or direct contact with infected person, blood, urine - Communicable several days before and after rash develops MEASLES (RUBEOLA) highly contagious, transmitted from mother to fetus # 361 PEDIATRICS PEDIATRIC DISEASE - Low-grade fever - Malaise - Raised and flat rash (maculopapular) starts on the face and quickly spreads to body Signs & Symptoms - Airborne, droplet and contact precautions - Isolate patient - Rubella can cause severe birth defects in pregnant women Nursing Interventions - Pathogen Rubella virus - Transmission airborne, contact w/droplets, nasal discharge, blood, urine, feces - Communicable several days before and after rash develops GERMAN MEASLES (RUBELLA) - Fever - Malaise - Anorexia - Headache - Rash starts on chest, back, scalp, face then spreads to rest of body Signs & Symptoms - Strict isolation in the hospitalized child - Home isolation until vesicles have dried - Immunocompromised children, pregnant women, newborns exposed to maternal varicella - Antiviral therapy - Varicella zoster immune globulin - Comfort measures (e.g., antipyretics) Nursing Interventions - A rash that forms small, itchy, blisters that form scabs - Highly contagious - Transmitted from mother to fetus VARICELLA (CHICKENPOX) Ransmitted from mother to fetus Pathogen Varicella-zoster virus Incubation period usually about 14 days Contagious 1 2 days before onset of rash until all blisters (vesicles) have crusted Source respiratory tract secretions, skin lesions Transmission direct contact, airborne, sneezing, coughing For Infections & Communicable Diseases Educate Families - The body uses fever to fight infection - On administration of antipyretics 362 PEDIATRICS PEDIATRIC DISORDERS - Genetics, Family Hx - Teratogenic effects (drugs, chemicals, or infections exposed & fatal to embryo during pregnancy) - Folate deficiency during pregnancy - Chromosome abnormalities Risk Factors CLEFT LIP cheiloplasty > 2-6 months of age - Done at early age to facilitate adequate sucking (breastfeeding, bottle nipple, pacifier) Surgical Repairs The congenital, abnormal opening of the lips or palate due to incomplete fusion of soft tissue or bony structures during embryonic development - Unilateral or bilateral - Types: + Notch in vermilion border + Unilateral cleft lip/palate (complete or incomplete) + Bilateral cleft lip/palate (complete or incomplete) + Cleft palate CLEFT LIP/PALATE Slight notch in the lip HELPFUL HINT think Maslow s Heirachy of Needs. The most basic, physiological needs (food, sleep, water) must be first met for survival CLEFT PALATE palatoplasty > 6-24 months of age - Done at later age to allow palate changes due to normal childs growth - Facilitates good speech development (done early as possible within this age frame) Surgical Repairs # 363 PEDIATRICS PEDIATRIC DISORDERS PRE-OP (BOTH) - Check childs ability to suck, swallow, handle normal secretions, & breath without distress - Support parents & provide needed services (financial, insurance) - Encourage bonding b/w parents & child - Educate parents on proper feeding - Feed small, gradual amounts & burp frequently - Hold child upright & support their head (prevent milk going into nose) - Flat, wide nipples with large holes - Encourage breastfeeding (depending on the type & size of cleft) - Prevent aspiration - After each feeding, give child sterile water + clean mouth & cleft - Good dental hygiene - Prevent EAR INFECT IONS (otitis media) > can lead to hearing loss POST-OP (BOTH) - Treat pain, Give analgesics, Provide comfort for child & parents - Assess surgical site for infection, crusting, or bleeding - Elbow restraints to prevent child from injuring the site - Avoid sucking on nipple or pacifier CLEFT LIP - Position child on back & upright OR on side to maintain integrity of repair - Clean site with normal saline or diluted hydrogen - Antibiotic ointment, if prescribed - Gent ly suction secretions (prevent aspiration & respiratory complications) CLEFT PALAT E - Turn child frequent ly (side to side) to facilitate drainage, breathing, & prevent aspiration - Give O2 via face mask - Clear, liquid diet first 24 hours - IV access, Give IV fluids & nutrition - Regular eating (bott le, sippy cup, etc.) is resumed per surgeon orders - AVOID placing objects in childs mouth (pacifier, sippy cup, utensils, oral suction, tongue depressor, thermometer) - Observe for signs of airway obstruction, hemorrhage, or laryngeal spasm - Dental & Speech therapy referrals Surgical Repairs CLEFT LIP/PALATE Dental surgery is often necessary to rebuild missing gums & replace missing teeth with the use of prosthetics 364 - Projectile vomiting - Non-bilious vomit (may contain blood or mucus) - Olive-shape mass palpable in RUQ of abdomen - Peristaltic waves visibly moving from left to right (pushing food through intestines) - Constant hunger, Irritable - Weight loss - Dehydration - Metabolic Alkalosis (the stomach is acidic & is losing acids from constant vomiting) Symptoms # PEDIATRICS GASTROINTESTINAL Thickening of the pyloric sphincter causing the pyloric canal between the stomach & duodenum to narrow. HYPERTROPHIC PYLORIC STENOSIS Proximal segment of the bowels telescopes (folds in on itself) into a more distal segment - Results in lymphatic & venous obstruction > compression on vessels > decreased blood flow > bowel ischemic > sloughing off intestinal mucosa, blood, or mucus (currant-jelly stool) INTUSSUSCEPTION - Maintain NPO - Give IV fluids - Monitor I&Os, dehydration, electrolyte imbalance - Monitor vomiting episodes & stools - Obtain daily weights - Educate/Prepare parents & child for surgery, if prescribed Nursing Interventions/Treatment PYLOROMYOTOMY Incision made through the plyorus muscle. This relieves gastric obstruction. Duodenum Pyloric Muscle Stomach Stomach PYLORIC STENOSIS NORMAL ANATOMY 365 PEDIATRICS GASTROINTESTINAL - Intermittent ABD pain/cramping - Child crys & draw knees to chest when in severe pain - Sausage-shaped mass in URQ of abdomen - Hypo or Hyperactive bowel sounds - Tender, Distended ABD - Currant-jelly stool (contains blood or mucus) - Vomit, Diarrhea, Fever Symptoms INTUSSUSCEPTION - Monitor for passage of normal, brown stool (sign of reduced intussusception) - Monitor for signs of perforation & shock - Give IV Fluids & Antibiotics - Decompression via NG tube - Air or Barium enema (educate parents & child about pre-op & post-op) - Surgery, if necessary for recurring intussusception Nursing Interventions/Treatment - Infants and young children have a greater amount of body fluid in proportion to adults - In infants 70% of their weight is water; in children, 65% of their weight is water as compared to adults at 60% - Need greater intake and excrete more fluid compared to adults - Infants and children have a higher metabolic rate DEHYDRATION Infant or Child at Risk of - Dehydration - Electrolyte loss - Metabolic alkalosis - Aspiration, collapsed lung, or Pneumonia VOMITING Children are at increased risk of dehydration and hypovolemic shock - Acute infections - Concussion, brain tumor ( ICP) - Food poisoning, ingesting toxins - Metabolic disorder (DKA, Addisons) - GERD, PUD, other GI disorder Causes # 366 PEDIATRICS GASTROINTESTINAL VOMITING - Patent airway - Place child on side (aspiration risk) + Coughing (s/s of aspiration) - Note characteristics, frequency of vomiting + Projectile vomiting (pyloric stenosis, ICP), effortless (GERD) Monitor - Strict intake & output - For s/s of dehydration - skin turgor, sunken fontanel in infant, low urine output - For electrolyte imbalance, metabolic alkalosis ( bicarb) - For abdominal pain - Administer oral rehydration solution (ORS) as ordered & tolerated (small & frequent) - IV fluids are given if oral rehydration therapy fails or not possible - Antiemetics (ondansetron) Nursing Interventions/Treatment Infants and children are susceptible to fluid overload - Give child oral rehydration solution, such as Pedialyte - small amounts, often for rehydration - Contact PCHP if s/s of dehydration, projectile vomiting, blood in vomit, abdominal pain Parent Education - Most common cause is an acute viral infection - Acute diarrhea causes dehydration in children - especially under 5 years old DIARRHEA Infant or Child at Risk of - Dehydration - Electrolyte loss - Metabolic acidosis # 367 PEDIATRICS GASTROINTESTINAL DIARRHEA Replenish fluid and electrolyte loss - Contact precautions & isolation for undiagnosed GI infection, C. diff, norovirus, etc Monitor - Amount, frequency, and characteristics of stool - Strict intake & output - For s/s of dehydration - skin turgor, sunken fontanel in infant, low urine output - For s/s of metabolic acidosis ( pH) - Electrolytes levels - Administer oral rehydration solution (ORS) as ordered & tolerated (small & frequent) - Admin IV fluids for severe diarrhea as ordered (NPO to rest GI tract) Nursing Interventions/Treatment Monitor rehydration: infants and children are susceptible to fluid overload - Teach parents and child proper handwashing - Soda, fruit juice, sugary drinks, spicy & high fat foods make diarrhea worse - Give child rehydration solution such as Pedialyte Parent Education - Viruses (e.g., norovirus) - Bacteria (e.g., E. coli, C. diff) - Parasites - Antibiotics - Gastroenteritis - Food sensitivity - IBD Causes # 368 PEDIATRICS RESPIRATORY Unexplained, sudden death of an infant younger than 1 year old. SUDDEN INFANT DEATH SYNDROME (SIDS) - Sudden death NO SIGNS & SYMPTOMS! - To prevent, educate parent(s) on risk factors - Emphasize importance of baby sleeping on BACK - If SIDS occur, provide family support as they grieve and mourn - Reassure family its no ones fault Nursing Interventions/Treatment - High fever - Sore, inflamed, cherry red throat - Difficult ly swallowing, Drooling - Inspiratory stridor - Dysphonia (muffled voice, frog-like, croaking sound) - Absent cough - Tachycardia - Tachypnea, Retractions - Nasal flaring - Tripod position - Sitting forward with neck extended to breath - mouth open to widen airway - Agitation, Rest lessness Symptoms Inflammation of the epiglottis - Caused by Haemophilus Influenzae type B or Streptococcus pneumonia EPIGLOTTIS EPIGLOTTIS flap of cartilage at the back of the throat that closes during swallowing to prevent aspiration of food/water - Maintain patent airway - Assess respiratory status (breath sounds, oxygen status, nasal flaring, etc.) - Give humidified oxygen - DO NOT leave child alone - AVOID using tongue blade, taking oral temperature, or throat culture - Remain NPO - IV access & give fluids - AVOID supine position (more respiratory distress) - Emergency intubation or tracheostomy if severe - Provide a calm & supportive environment for child & family - Meds: Corticosteroids, IV antibiotics, Antipyretics Nursing Interventions/Treatment Children with Hib vaccine has low chance of getting epiglottis # 369 PEDIATRICS RESPIRATORY - Age 1-6 months ( risk) - Boys > Girls - Premature - Low APGAR score - Co-sleeping - Soft bedding, Pillows, Stuffed animals - BABY SLEEPING ON STOMACH OR SIDE - Smoking during pregnancy/exposure after birth - Family Hx of SIDS - Socioeconomic status - Poor prenatal care Risk Factors - SLEEP SUPINE (back) - Sleep alone in crib - Firm mattress, NO toys, pillows, blankets, or stuffed animals - AVOID smoking - AVOID over bundling or overdressing infant - NO co-sleeping (rather, place crib/bassinet in parents room) - Normal room temperature - Offer pacifier while sleeping Education SUDDEN INFANT DEATH SYNDROME (SIDS) In these situations, an autopsy and a thorough child/family history is performed Inflammation of the bronchi & bronchioles. Thick mucus blocks the small airways of the lungs. - Viral illness caused by respiratory syncytial virus (RSV) - Transmission: direct contact with respiratory secretions BRONCHIOLITIS (RSV) Initial - Rhinorrhea (runny nose), Sneezing - Cough, Wheezing - Pharyngitis - Eye & Ear infection - Intermittent fever Continuous - Increased coughing & sneezing - Fever - Air hungry - Tachypnea, Retractions Severe - Tachypnea (> 70/min) - Poor breath sounds & gas exchange - List lessness - Cyanosis - Apneic episodes Symptoms - Hospitalization if symptoms are SEVERE - Initiate Contact & Standard precaution - Keep hydrated (oral, IV fluids) - Maintain patent airway > suction PRN & position child at 30-40 degree angle - Give cool, humidified oxygen - Monitor oxygen status - Meds: Antiviral med Nursing Interventions/Treatment Some children can be treated at home UNLESS symptoms are severe # 370 PEDIATRICS RESPIRATORY An inherited, multisystem disorder that affects the exocrine glands in vital organs (lungs, intestines, pancreas, reproductive) - Normally, exocrine glands produce & transfer T HIN & SLIPPERY secretions (mucus, sweat, enzymes, & tears) - In CF, exocrine glands produce overly T HICK & ST ICKY secretions > clogs small passageways - Caused by an autosomal recessive genetic disorder (inherited) - Progressive & NO CURE, but symptoms are treated to hopefully live past adolescence (up to 40 years old) CYSTIC FIBROSIS RESPIRATORY/NOSE - Non-productive cough (earliest sign) > progresses - Bronchitis - Atelectasis, Emphysema - Barrel-shaped chest, Clubbed finger & toes (emphysema) - Wheezing - Recurrent respiratory infections (bacteria loves the mucus) - Pneumothorax - Pulmonary hypertension (strain on lungs) > cor pulmonale (right-side heart failure) - Nasal polyps (sinuses, stuffiness, runny nose) INTESTINES - Meconium ileus (earliest sign in infants) > thick & sticky secretions causing bowel obstruction - Bowel obstruction (thick, intentional secretions) - Fecal impaction - Constipation, ABD distention, Pain & Cramping - Steatorrhea (frothy, foul-smelling stool) - Rectal prolapse PANCREAS - Pancreatic enzyme deficiencies (amylase, protease, lipase) > poor digestion & absorption + Weight loss + Malabsorption of vitamin A, D, E, K & protein - Failure to thrive - Insulin deficiency (risk of diabetes) REPRODUCTIVE - Infertility Issues! + Girls: thicken cervical secretion blocks sperm entry + Boys: thick secretion blocks vas deferens - Puberty delay INTEGUMENTARY - High levels of sodium & chloride in sweat - Salty sweat & salty tears > dehydration electrolyte imbalances Symptoms # 371 Inflammation of the larynx, trachea, & bronchi - Usually viral or bacterial & frequent ly seen in children 5 years or younger LARYNGOTRACHEOBROCHIT IS CROUP - Low-grade Fever - Barking cough, Hoarseness - Dyspnea, Labored breathing - Inspiratory stridor - Respiratory distress primarily at night - Intercostal retractions - Nasal flaring Signs & Symptoms - Give humidified OXYGEN via cool-mist tent - Closely monitor respiratory status & pulse oximetry (check for hypoxia) - Semi-Fowler position - Give plenty fluids (clear liquids, popsicles, gelatin) - If child cannot take take fluids oral, give IV - Encourage bed rest - At HOME, teach parents to use cool-air vaporizer or humidifier - Meds: Corticosteroids, Nebulized Racemic Epinephrine, Antibiotics Nursing Interventions/Treatment # PEDIATRICS RESPIRATORY CYSTIC FIBROSIS RESPIRATORY/NOSE - Chest physiotherapy (postural drainage) > loosens lung sections to be coughed up with vibrations (manual or vest) - Huff coughing - Nebulizers (bronchodilators, mucolytics, anti-inflammatories) - Encourage aerobic exercise GI - Drink plenty of fluids - Stool softens, Laxatives for constipation - Re-adjust rectal prolapse with lubricated, gloved finger NUTRITION - 3x meals/day with snacks - Diet high in protein, calories, & fats - Vitamin A, D, E, K - Give pancreatic enzymes with meals or within 30 mins of eating (increases absorption of food) + Pancreatin or Pancrelipase - If unable to control weight, feeding via NG tube or Gastrostomy tube - PREVENT INFECTION (hand washing, up-to-date on vaccines, avoid sick people, mask) Nursing Interventions/Treatment Diagnostic T est Quantitative Sweat Chloride T est - CF causes an increase in sodium & chloride because of pancreatic blockage - This test measures the amount of salt in sweat 372 PEDIATRICS NEUROLOGICAL Life-threatening, childhood disease in which the body cannot break down fatty tissue. This causes swelling in the brain (encephalopathy) & liver dysfunction. - Cause is UNKNOWN, but typically occurs after a viral illness (URI, influenza, varicella) thats treated with meds containing SALICYLAT ES (aspirin, etc.) REYE'S SYNDROME Associated with SALICYLATE use - Aspirin (most common) - Kaopectate - Alka-seltzer - Pepto Bismol - Diarrhea, N/V - Confusion, Lethargy - Irritable, Combative - Seizure - LOC, Coma - Liver enzymes Signs & Symptoms - Liver function test - Serum ammonia levels - Liver biopsy Diagnosis The exact cause and pathophysiology is unknown hepatic dysfunction causes serum ammonia levels > cerebral edema > increased ICP Pathophysiology - Educate harm of meds containing SALICYLAT E - Semi-Fowler position, Keep head midline, NO excessive movement (all to reduce ICP) - Monitor respiratory status - Closely monitor LOC - Seizure precaution - Maintain hydration, Give IV fluids (ST RICT LY monitor I&Os to prevent cerebral edema) - Monitor liver labs for prolonged bleeding (INR, PT T, PT) & liver dysfunction (AST, ALT) Nursing Interventions/Treatment - A spectrum of serious defects of the spine and brain (the CNS) from failure of the neural - Tube to close during development in utero folic acid supplementation reduces the risk of NTDs (rec. all for women childbearing age) cause is unknown - may be related to folic acid deficiency, genetics, medications, drug use NEURAL TUBE DEFECTS (NTDS) # 373 PEDIATRICS NEUROLOGICAL - A sac protrudes in the midline of the back in the lumbosacral area - The sac contains cerebral spinal fluid (CSF) - Spinal cord is normal and usually no neurological deficits - Surgery is needed to remove the sac - Diagnosis is by MRI Meningocele - The most severe form of NTD a type of spina bifida cystica - The meninges, CSF, nerve tissue, and part of the spinal cord protrude in a sac - The sac may leak, and the infant is at risk for meningitis - Absent motor and sensory function is evident - Developmental milestone delays - Prone to latex allergy the immune response can lead to anaphylaxis Myelomeningocele NTDS PRIMARILY AFFECTING SPINAL CORD DEVELOPMENT - An area in the posterior vertebral column in the lumbosacral area doesnt close in utero - The spinal cord and meninges do not protrude and are not visible externally (a dimple, or patch of hair sometimes visible) - Mildest form of NTDs and usually is a symptomatic and has no adverse effects Spina Bifida Occulta - Depends where the sac/lesion is located on the spinal cord - The higher on the spinal column, the more nerves affected - Neurogenic bladder - Bowel dysfunction - Paralysis of the legs - Hydrocephalus Symptoms - The sac is covered immediately after birth with a sterile dressing - Dressing is moist (saline), and non-adhesive - Monitoring for leakage of CSF and infection are a high priority - Place infant in the prone position - Neuro assessment - Change the dressing regularly and whenever it is soiled (infection) - Monitor for increased ICP, assess anterior fontanel for bulging - Administer antibiotics as ordered - Prepare infant and parents for surgery Nursing Interventions/Treatment # 374 PEDIATRICS NEUROLOGICAL - Rapid onset of HIGH fever - Family Hx of febrile seizures - Certain infections - Certain vaccines (DTP, MMR) Risk Factors - HIGH fever - Convulsion - Possible loss of conscience, Drowsy during postictal period Symptoms - Give antipyretics (acetaminophen, ibuprofen) - DO NOT give anticonvulsants (seizures are usually benign & fever related ONLY) - Tepid bath - Educate parents to seek help if seizures lasts longer than 5 minutes & are reoccurring Nursing Interventions/Treatment - Caused by a sudden rise in body temperature (>38 C, 100.4 F) - No other underlying cause (e.g., CNS infection, drug withdrawal) - Usually benign - Last less than 15 minutes (>15 minutes = febrile status epilepticus) - For children with recurring febrile seizures (with illnesses w/fever) benzodiazepines are often given for a short period - Classified as simple or complex - Simple generalized, less than 15 minutes, only one seizure in a 24 hours - Complex presence of one a focal seizure, lasts >15 minutes, or 2+ seizures within 24 hours FEBRILE SEIZURES Febrile seizures occur in children 6 months to 5 years old A seizure is a temporary, uncontrolled electrical discharge of activity in the brain that interrupts normal function. # 375 PEDIATRICS NEUROLOGICAL Depending on the type, a seizure may occur in 4 phases: > Prodromal phase feelings or behavior changes before a seizure by hours or days > Aural phase a sensory warning that occurs before a seizure and is considered part of the seizure > Ictal phase the seizure, from first symptoms to the end of the event > Postictal phase the recovery period after the seizure event Phases of a Seizure Seizure disorder is a group of neurologic diseases characterized by recurring seizures. - Seizures can be caused by various disorders or may occur without any apparent cause - Seizures without a known cause are called idiopathic generalized epilepsy (IGE) - Seizures caused by an underlying issue are not considered seizure disorder if they stop when the problem is corrected SEIZURE DISORDER (EPILEPSY) NEVER PUT ANYTHING IN THE CHILD'S MOUTH DURING A SEIZURE Firing of excitatory neurons > firing of progressively larger groups of excitatory neurons for an unknown reason > an imbalance of increased excitation and decreased inhibition initiates the discharge of uncontrolled electrical activity Glutamate the most common excitatory neurotransmitter GABA (gamma-aminobutyric acid) important inhibitory neurotransmitter Pathophysiology Generalized Seizures affecting both hemispheres of the brain Focal Seizures affecting one hemispheres of the brain ## Two Types of Seizures # 376 PEDIATRICS NEUROLOGICAL - Stiffening (tonic phase) of the muscles and extremities jerk (clonic phase) - Duration 1 3 minutes - Loses consciousness and falls - Postictal phase duration can take several hours to several days for patient to feel normal Tonic-Clonic (formerly called grand mal) - Appears to be staring into space, daydreaming. No stiffening of muscles - May occur several times a day - More common in children - Duration is a few seconds - Postictal phase immediate, no memory of seizure Absence - Brief jerking of muscles - May cause child to fall - Child aware and conscious - Duration a few seconds - Postictal phase immediate Myoclonic - Known as Drop Attacks - A sudden loss of muscle tone causing the child to fall or slump over - Usually stays conscious - Duration less than 15 seconds - Postictal phase immediate Atonic or Akinetic GENERALIZED SEIZURES - Child is aware of surroundings - Localized to a region of the brain therefore affecting a specific part of the body - May have sudden unexplainable feelings or see, hear, taste, feel things that are not real - Child remains conscious and may report an aura - Focal onset aware seizure can be the aura before a focal impaired awareness seizure Focal onset aware seizure (Aka simple partial) - Child Not aware of surroundings and have automatisms (repetitious behavior e.g., twitching, blinking seeming to be conscious) - Usually involving the temporal lobe - Aura (focal onset aware seizure) may happen before event Focal impaired awareness seizure (Aka complex partial seizure) FOCAL SEIZURES (AKA PARTIAL SEIZURE) # 377 PEDIATRICS NEUROLOGICAL Status epilepticus (SE) - A continuous or rapid succession of seizures without intervals of return to consciousness between seizures and can result in brain damage. - SE is defined as any seizure lasting longer than 5 minutes (exception is a febrile seizure, SE defined as >15 minutes) - A neurologic emergency that can occur with any type of seizure - Occurs most in children and older adults - As neurons become exhausted permanent brain damage can occur Complications - Infections (e.g., bacterial meningitis) - Acidosis - Electrolyte imbalance - Hypoglycemia, diabetes - Genetics - Congenital defects - Trauma Causes Acquire history from parents & child as age appropriate - Events/behavior before, during and after the seizure - Any prodromal signs mood changes, irritability, insomnia - Type of seizure - Aura before seizure? (child) - Loss of bladder or bowel control during seizure, LOC - Disoriented and sleepy after seizure Assessment & Interventions - Side rails raised on bed (pad side rails) - Waterproof pad on bed/crib - Medic alert bracelet/necklace - Precautions must be taken - Water activities bathing, swimming should be supervised - Wear a helmet and protective pads riding a bicycle, skateboarding, etc. Seizure Precautions in the hospital Parent/child education SEIZURES If the seizures stop when the underlying condition is corrected, it is not considered seizure DISORDER. # 378 PEDIATRICS NEUROLOGICAL SEIZURES During a Seizure: - If child is standing or sitting, gently place them on the floor on their side, protect their head put a pillow or blanket under their head - Airway, Breathing, Circulation - Maintain a patent airway - Do Not restrain the child - Do Not put anything in the childs mouth - Stay with child, loosen tight clothing, remove glasses - If child vomits, turn them to their side (head and body aligned) - Note time and duration of seizure 5 minutes or second seizure, initiate rapid response team Nursing Interventions/Treatment Did the child - Experience an aura - change facial expression - make a sound - have incontinent bladder or bowels Assess Behavior During Seizure - Note occurrences during postictal state headache, LOC, drowsiness, impaired speech or thinking - Assess for injuries - Neuro status - Repositioning, suction, O2, as needed - Monitor for cyanosis - Document and report to PHCP After The Seizure - To rule out underlying conditions + CBC, urinalysis + Electrolytes, creatinine, blood glucose - CT, MRI - EEG (electroencephalography) Diagnosis - Benzodiazepines + lorazepam + diazepam + midazolam - Barbiturates - phenobarbital - Hydantoins - phenytoin Common Medications - Avoid common seizure triggers - Stress - Fatigue - ensure child is getting enough sleep - Medication importance - do not stop taking meds! - Keep follow-up appointments - Medic alert bracelet/necklace Parent/Child Education # 379 PEDIATRICS CARDIOVASCULAR Cyanosis caused by CV disease Heart failure Pulmonary edema Cardiac surgery is scheduled Therapeutic interventions (e.g., balloon valvotomy) Indications for cardiac catheterization Health history & exam; iodine or shellfish allergy Assess for s/s infection Assess baseline vital signs & O2 saturation Is child taking anticoagulants Assess peripheral pulses & mark pedal pulses Educate parents & child (age appropriate) about procedure Signed consent form Interventions BEFORE procedure: An invasive diagnostic procedure to find cardiac defects or disease Catheter is inserted into vein until it reaches the heart, then contrast media is injected Procedure may be diagnostic, therapeutic intervention, or electrophysiologic Bleeding and clotting risk Inpatient or outpatient procedure CARDIAC CATHETERIZATION O2 saturation in heart chambers and major vessels Anatomy of the heart, valve & structural defects, and more can be examined Provides information on: Accurate height & weight are needed to choose the correct size catheter, amount of dye, & medications Immobilize affected limb (straight, flat) for 4-8 hours according to facility policy Monitor O2 saturation and cardiac monitor for 4 hours post procedure according to facility policy For complications (e.g., bleeding, clotting, arrhythmias) Vital signs every 15 minutes, then every 30 minutes according to policy Intake/output, encourage fluids, continue IV fluids as ordered Assess Pulses below the catheter site Pressure dressing should be intact, dry, no bleeding Report bleeding or signs of drainage on dressing The affected limbs color, temperature Cold or pallor may indicate an obstruction Interventions AFTER procedure: Family Teaching Remove the dressing the day after procedure & cover with a bandage for a few days Keep bandage clean and dry Sponge bath instead of a tub bath for 3 days Report fever, bleeding, drainage, change in color/temperature, swelling No strenuous activity for 3 days Return to regular diet as tolerated Acetaminophen or ibuprofen for pain if needed Important to keep follow-up appointment # 380 PEDIATRICS CARDIOVASCULAR CARDIAC CATHETERIZATION HEART FAILURE (HF) NURSING INTERVENTIONS Interventions are on one page to help you study efficiently and also to make room for important descriptions, pathophysiology, and illustrations to aid you in understanding each disorder/defect. FOR INFANTS & CHILDREN WITH CARDIOVASCULAR DEFECTS/DISORDERS Arrhythmia (dysrhythmia) - abnormal heart rhythm Cardiomegaly enlargement of the heart Clubbing abnormal enlargement of the fingertips & nails (s/s of chronic hypoxemia) Echocardiography a noninvasive ultrasound to record the activity of the structures heart Electrocardiogram (ECG/EKG) a noninvasive test that records the electrical impulses of the heart onto a rhythm strip Murmur abnormal (extra) heart sound Polycythemia (aka erythrocytosis), excess production red blood cells. Blood thickens and increases clotting risk. Terminology Monitor Vital signs often Heartrate - note rate, rhythm, abnormal sounds For nasal flaring, crackles, wheezes, rhonchi Admin O2 as ordered Respiration effort - reverse Trendelenburgs position if effort to breathe increases For hypercyanotic spells (Tet spells in tetralogy of Fallot) - knee-to-chest position (systemic vascular resistance) - O2 - IV fluids & medication as ordered Intake & output Daily weights Assess For s/s of HF - Edema around eyes (periorbital), hands, feet - Weight gain - Tachycardia urine output (notify PHCP) Peripheral pulses Parent Education Educate parents and child (as appropriate) on cardiac catheterization, Diagnostic & lab tests Allow child plenty of rest group interventions & interruptions as much as possible Provide appropriate activities and a quiet environment to reduce childs stress Inability of the heart to pump enough blood to supply sufficient oxygen to meet the O2 demands of tissues and organs of the body The most common cause in children is a congenital heart defect A congenital heart defect is present at birth Infants and children commonly have a combination of right and left-sided heart failure 381 PEDIATRICS CARDIOVASCULAR HEART FAILURE (HF) Monitor s/s respiratory distress s/s of infection Apical pulse; (murmur, irregular rhythm) - Count apical pulse for 1 minute Auscultate lungs; (wheezing, crackles) - Count respirations for 1 minute Medications Digoxin ACE inhibitors Diuretics Strict I & O, daily weight Weight gain of 0.5 kg (1 lb) in a day is Caused by fluid retention Potassium (3.5 5.0 mEq/L) Semi-Fowlers position O2 as ordered Promote nutrition and rest Interventions S/S Toxicity Anorexia, nausea, vomiting, diarrhea, poor feeding, arrhythmias, dizziness Parent Education Give medication exactly as prescribed, using cup/syringe/etc. provided by pharmacy Keep track with a calendar or notebook Teach s/s of toxicity & to report to pediatrician immediately Have parent demonstrate medication administration Action: calcium in the cells causing increased heart muscle contraction resulting in increased cardiac output Have another nurse verify dosage per facility policy Assess apical pulse rate for 1 minute before admin Hold if apical pulse is: - <90-110 bpm infants & young children - <70 bpm older children Concurrent use with a diuretic risk of toxicity DIGOXIN The heart initially adapts to the defect and causes changes that lead to hypertrophy (enlargement); eventually if not treated fibrosis and ventricular failure Simplified Pathophysiology *s/s in infants can be subtle Tachycardia Tachypnea Tiring, diaphoresis when feeding/sucking Signs & Symptoms Edema, weight gain urine output Failure to thrive Therapeutic Range 0.5 - 2.0 ng/mL GI s/s Early Sign of T oxicity # 382 PEDIATRICS CARDIOVASCULAR Monitor temperature frequently Strict I & O, daily weight Administer as Prescribed Aspirin Intravenous immunoglobulin (IVIG) Blood precautions Assess Heart sounds, rate, rhythm For s/s heart failure Tachycardia Respiratory distress urine output Edema, desquamation in hands, feet Conjunctivitis Parent Education Monitor fever until w/o fever for 3-4 days Report fever >100 F Irritability may last for 2 mos. after initial s/s Joint pain may last for a few weeks Morning bath may reduce joint stiffness Report s/s aspirin toxicity - Headache, tinnitus, dizziness, bruising - Stop aspirin if child is exposed to chickenpox or flu No MMR or chickenpox vaccine for 11 mos. after IV immunoglobulin Teach cardiac s/s Teach bleeding s/s Follow-up appointments are Critical to childs recovery Interventions Acute Subacute Convalescent 3 Phases Acute Phase Fever >5 days Strawberry tongue Red mouth and throat Conjunctivitis without exudate Rash, edema of hands and feet Signs & Symptoms CBC WBC acute phase platelets subacute phase Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) Cardiac enzymes Echocardiogram EKG Labs & Diagnostics Aneurysm Heart failure Myocardial infarction (MI) Others Cardiovascular Complications KAWASAKI DISEASE (KD) Irritability Heart complications Conjunctivitis Strawberry tongue Fever Rash An acute, systemic, inflammation of the blood vessels (vasculitis) A self-limiting disease (resolves without treatment) Can cause cardiovascular complications such as coronary artery aneurism Cause is unknown; may be an infectious organism to genetically susceptible people Subacute Phase Starts when fever subsides Cracked lips Desquamation of hands, feet Thrombocytosis ( platelets) Coronary artery aneurysms Convalescent Phase Clinical s/s not present May still have Inflammation & cardiac Abnormalities # 383 PEDIATRICS CARDIOVASCULAR INCREASED PULMONARY BLOOD FLOW Most congenital heart defects involve increased pulmonary blood flow Higher pressure in left side shunts blood to the lower pressure right side blood flow to the lungs can cause tachypnea, tachycardia, - a compensatory response An infant usually has signs and symptoms of heart failure (not present at birth) Pulmonary stenosis slows or obstructs the blood flow from the right ventricle -> blood flow to the lungs is decreased -> less oxygenated blood to the body The obstructed blood flow increases pressure in the left ventricle -> blood is shunted through the VSD (abnormal opening in ventricular wall) to the left atrium *can shunt either direction depending if systemic or pulmonary pressure is higher decreased O2 saturation -> cyanosis The right ventricle works harder to pump blood through the narrowed or obstructed pulmonary artery and valve -> hypertrophy -> heart failure Pathophysiology Occurring Together Pulmonary stenosis A narrowing of the pulmonary valve and artery, obstructing blood flow from the right ventricle to the pulmonary artery Ventricular septal defect (VSD) - A narrowing of the pulmonary valve and artery, obstructing blood flow from the right ventricle to the pulmonary artery Overriding aorta The aorta is over the VSD Right ventricular hypertrophy Abnormal enlargement of the muscle walls of the right ventricle 4 DEFECTS TETRALOGY OF FALLOT Decreased pulmonary blood flow causes cyanosis A congenital heart defect Tetralogy means: 4 related abnormalities occurring together Infants Loud murmur Hypercyanotic spells (aka tet spells) O2 demand is greater than heart can supply When feeding, crying, bowel movement Acute cyanosis hypoxemia, dyspnea Toddlers, Children Slow growth Squatting (helps the body compensate By vascular resistance) Clubbing of the fingers Interventions for a "Tet Spell" Knee-to-chest position ( systemic Vascular resistance) O2 IV fluids & medication as ordered Signs & Symptoms RBC, hematocrit, & Hemoglobin Echocardiogram EKG Cardiac catheterization Labs & Diagnostics Palliative temporary correction that may include a shunt to increase blood flow and O2 Corrective surgical repair usually done between 6 12 months of age Surgery is Required # 384 PEDIATRICS CARDIOVASCULAR ATRIAL SEPTAL DEFECT (ASD) Abnormal opening in the wall dividing the right and left atrium oxygenated blood flows to the right side of the heart The right atrium and ventricle become enlarged Most small ASDs will close spontaneously during the first year The right ventricle receives extra blood from the left ventricle (abnormal) -> this blood goes to the lungs and can eventually lead to -> pulmonary hypertension -> right side of heart pumps harder in response to pulmonary pressure -> right ventricular hypertrophy and eventually heart failure if not treated Pathophysiology INCREASED PULMONARY BLOOD FLOW Before birth pressure in the right & left sides of heart are equal At birth as the lungs inflate, pressure in the right atrium decreases Types ASD 1 opening is at the lower part of the septum (wall) ASD2 opening is near the center of the septum ASD3 opening where the superior vena cava and right atrium intersect Normal Physiologic Changes Cardiac catheterization (some ASDs can be closed during cardiac cath.) Echocardiogram MRI, CT scan Surgical repair Labs & Diagnostics Cardiac catheterization (some VSDs can be closed during cardiac cath.) Echocardiogram w/color Doppler CXR and EKG may be normal Surgical repair Labs & Diagnostics VENTRICULAR SEPTAL DEFECT (VSD) An opening in ventricular wall that normally separates right/left side of heart Deoxygenated blood mixes with oxygenated blood Causes an increase of blood flow to the lungs Most small VSDs close spontaneously during the first year Pressure in the left atrium increases with blood flow The foramen ovale, ductus arteriosus, and ductus venosus close Often asymptomatic Heart failure may develop May have decreased Cardiac output Signs & Symptoms s/s of heart failure Common Murmur Decreased cardiac output Signs & Symptoms # 385 PEDIATRICS CARDIOVASCULAR ATRIOVENTRICULAR CANAL DEFECT (AVSD) Endocardial cushions fail to fuse Most common defect in children w/Downs syndrome Can be a complete or partial defect Blood continues to flow from the aorta to the pulmonary artery as in utero -> blood passes through the PDA instead of entering the bodys circulation -> increased pressure and compensation Pathophysiology A complete AV canal defect allows oxygenated blood from the left side of the heart to return to the lungs (abnormal) -> increased workload on the left ventricle -> increased pulmonary pressure -> less oxygenated blood goes to the body -> increased blood in the lungs -> pulmonary edema Pathophysiology Cardiac catheterization Echocardiogram EKG CXR Surgical repair Labs & Diagnostics Echocardiogram CXR Labs & Diagnostics Indomethacin (prostaglandin inhibitor) Ibuprofen Surgical closure Premature Infants More Likely to Need: PATENT DUCTUS ARTERIOSUS (PDA) Failure of the shunt (fetal ductus arteriosus) connecting the aorta and pulmonary artery to Close within 2-3 weeks of birth COARCTATION OF THE AORTA (CoA) Narrowing of the aorta the major vessel carrying oxygenated blood to the body Usually before the ductus arteriosus Risk of aortic rupture, stroke (CVA) Murmur Decreased cardiac output S/s of heart failure Cyanosis (especially if crying) Signs & Symptoms Murmur May have s/s of heart failure Bounding pulses Widened pulse pressure Low diastolic BP Decreased cardiac output Signs & Symptoms The shunt allowed placental blood to bypass the fetal lungs in utero When the newborn first inhales, the shunt constricts and closes; closure is permanent in 2-3 weeks Normal Physiology OBSTRUCTIVE DISORDER 386 PEDIATRICS CARDIOVASCULAR PULMONARY STENOSIS An obstruction of blood flow at the entrance to the pulmonary artery The obstruction can be at the pulmonary valve (most common), above or below the valve A PDA or VSD allows for mixing of oxygenated and deoxygenated blood without a PDA or VSD life cannot be sustained pulmonary valve is stiffened -> narrowing -> obstruction of blood flow increases workload ofright ventricle -> hypertrophy of RV and decreased pulmonary blood flow Pathophysiology increases upper body blood pressure -> higher BP in the arms and lower in the legs in arms bounding pulses in legs weak or absent pulses, cool/cold compared to arms Pathophysiology Echocardiogram EKG Labs & Diagnostics TRANSPOSITION OF THE GREAT ARTERIES (TGA) The pulmonary artery and the aorta are reversed - aorta rises from the RV and pulmonary artery rises from the LV Pulmonary artery is carrying oxygenated blood which keeps recirculating from lungs to heart Aorta pumps deoxygenated blood back into the bodys circulation COARCTATION OF THE AORTA (CoA) Murmur Newborns are cyanotic if severe obstruction If severe HF will occur Decreased cardiac output Signs & Symptoms Mild - asymptomatic Moderate - s/s mild HF Severe - cyanotic Child/infant can exhibit: History & physical exam Assess BP in all extremities EKG Echocardiogram Labs & Diagnostics Signs of HF Headache Dizziness, fainting Nose bleeds ( BP) Signs & Symptoms Monitor BP & pulses in upper & lower extremities For s/s HF ( CO, fluid overload) Interventions Balloon angioplasty (children) Surgery (resection) Treatment /Management Cardiac cath dilation Surgical repair Treatment /Management Prostaglandin E1 (keeps ductus arteriosus open) Balloon atrial septostomy (during heart cath, temporary) Surgery in first few days of life once stable Treatment/Management Newborn w/o a septal defect severe cyanosis Newborn with septal defect s/s HF, less cyanosis Signs & Symptoms Pulmonary arteries carry deoxygenated blood tolungs Aorta carries oxygenated blood to the body Normal Physiology OBSTRUCTIVE DISORDER A MIXED DEFECT aka transposition of the great vessels (TGV) # 387 PEDIATRICS RENAL & UROLOGY ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS Most common in young children Caused by an antibody-antigen reaction to a strep throat or impetigo infection (streptococcal infection) Develops 1-2 weeks after strep throat or impetigo Most cases resolve completely A normal functioning glomerulus filters water, electrolytes, and waste from the blood, but does not allow blood cells and proteins to pass into the tubules because blood cells and proteins are too large the body makes antibodies to the streptococcal antigen -> these antibodies reach the glomerulus and cause inflammation and damage -> proteins and red blood cells permeate the glomerulus -> protein and RBCs pass into the urine Pathophysiology Glomerular filtration rate (GFR) is the rate at which the blood flows through the kidneys The GFR is slower in infants and toddlers than adults Infants and toddlers have an increased risk of dehydration because of the slower GFR Renal system reaches maturity about 2 years old Nephrons are the functional part of the kidneys where urine is produced Kidneys contain millions of nephrons Each nephron contains a glomerulus, Bowmans capsule, and tubules Each tubule in the nephron has a proximal convoluted tubule, loop of Henle, distal Convoluted tubule, and a collecting tubule Primary function of the kidneys is to filter the blood and maintain homeostasis GLOMERULONEPHRITIS (GN) Glomerulonephritis is inflammation of the glomeruli in the kidneys It refers to a group of kidney disorders that cause inflammatory injury in the kidneys Glomerulonephritis affects both kidneys equally GFR (glomerular filtration rate) = low urine output Temporary or permanent loss of kidney function can occur May be asymptomatic (hematuria or edema around the eyes are often the first signs in peds) Red blood cells and protein are present in the urine Acute glomerulonephritis comes on suddenly and is reversable. Occurs 1 2 weeks after a streptococcal infection Chronic glomerulonephritis can occur after the acute phase or slowly over time and can lead to permanent renal failure Two Types NEPHRONS Glomerulus Bowman's Capsule Efferent Arteriole Afferent Arteriole Distal Convoluted Tubule To Ureter Renal Cortex Proximal Convoluted Tubule Loop of Henle (Nephron Loop) Renal Medulla Collecting Tubule # 388 Corticosteroids (suppress immune response) Diuretics IV albumin Medications As ordered Fluid restriction Low sodium Low fat Diet s/s of relapse - foamy, frothy urine, weight gain, swelling in face, extremities, abdomen Testing urine for protein Preventing infection Parent Education PEDIATRICS RENAL & UROLOGY glomeruli are damaged and allow protein to pass through the glomerular membrane -> massive loss of protein (albumin) into the urine -> hypoproteinemia -> liver produces more proteins and lipids and oncotic pressure decreases -> hypovolemia and edema Pathophysiology NEPHROTIC SYNDROME A kidney disorder that allows massive amounts of protein loss through the urine -massive proteinuria, hypoalbuminemia (hypoproteinemia), edema Minimal change disease (MCD) - most common cause of nephrotic syndrome in young children Increased risk of clotting Massive proteinuria, >3 grams Hypoalbuminemia (hypoproteinemia) Hyperlipidemia Edema A syndrome defined by a set of clinical manifestations Edema around the eyes Hematuria (RBC present, dark, cloudy urine) Hypertension Proteinuria (protein present, foamy urine) BUN and creatinine levels Oliguria (decreased urine output) Signs & Symptoms Massive proteinuria foamy, frothy Edema face & eyes (esp. in morning), extremities, entire body Fatigue Anorexia Hyperlipidemia Signs & Symptoms Monitor Vital signs For fluid volume overload Lung sounds Fluid I&O, daily weight (same scale, same time of day) BP can lead to encephalopathy BUN & creatinine levels Weight gain is the first indication of fluid retention Watch for fluid volume overload Assess Urine color improving or worse? Edema in face Interventions Monitor for Fluid volume overload Intake & output Daily weights - same scale, same time, same clothing type Clotting, s/s DVT, pulmonary embolism Infection (corticosteroids suppress immune sys) Interventions ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS Kidney failure Hypertensive encephalopathy Seizures Heart failure Respiratory distress, edema Patient at Risk For Antihypertensives Diuretics Antibiotics if strep infection Medications Strep infection can reoccur Seek immediate treatment for skin infections, sore throat, chest congestion Report pink or dark urine, edema to PHCP Parent Education Urinalysis (proteinuria, hematuria present) Antistreptolysiin O (ASA) titer -A positive test reveals child has had a strep infection recently Diagnosis May be restricted depending on severity Fluid Sodium Potassium Low protein Diet # 389 PEDIATRICS HEMATOLOGICAL in SCA a decrease in oxygen causes RBCs to sickle (deoxygenated Hgb form a sickle shape, become rigid & clump together) -> obstruction of normal blood flow to small capillaries (vasoocclusion) -> tissue hypoxia, ischemia -> severe pain, especially in joints. Sickle cells clumped in the lungs (acute chest syndrome) -> oxygen -> more sickling which can lead to RBCs pooling in the spleen and multi-organ failure Simplified Pathophysiology Periods of acute exacerbations known as sickle cell crisis With repeated sickling of the RBCs, the patient becomes more anemic Sickle cell anemia is the most common and severe form of sickle cell disease (SCD) Risk factors African American descent; both parents have hemoglobin S - inherit a sickle cell gene (Hgb S) from one parent child will have sickle cell trait (Hgb AS) - inherit a sickle cell gene (Hgb S) from both parents child will have sickle cell disease (Hgb SS) Infants are asymptomatic until about 6 months old when fetal hemoglobin (Hgb F) decreases and Hgb SS starts to increase SICKLE CELL ANEMIA (SCA) An inherited autosomal recessive disorder in which hemoglobin A is replaced by abnormal, sickle-shaped, hemoglobin S SCA causes hemolysis and vaso-occlusive crisis (destruction of red blood cells and sickle cell crisis) Any increased demand for O2 Fever Dehydration Pain Stress physical or emotional Illness Sickle Cell Crisis Causes Sickledex a fingerstick blood test to determine if child has hemoglobin S (SC anemia or SC trait) Hgb electrophoresis differentiates between sickle cell trait & sickle cell anemia Diagnosis Fatgue and decreased hemoglobin Eye damage Bacterial infections Bouts of pain Leg ulcers Pulmonary and heart diseases Thrombosis in the spleen and liver Painful swelling of the hands & feet Symptoms of Sickle Cell Anemia # 390 SICKLE CELL ANEMIA (SCA) Complications (Sickle Cell Crisis) Vaso-occlusive crisis Painful swelling of the hands & feet Fever Abdominal pain Splenic sequestration RBCs pool & clump in the spleen -> splenomegaly, infection risk Anemia Hypovolemia Shock Hyperhemolytic crisis Accelerated rate of hemolysis Anemia Jaundice immature red blood cells Aplastic crisis Fast drop in Hgb - bone marrow ceases to produce RBCs Extreme anemia, paleness Shortness of breath # PEDIATRICS HEMATOLOGICAL Maintain adequate hydration oral and IV fluids Admin O2 & blood products as prescribed Admin pain medications around the clock, antibiotics Monitor respiratory status Monitor for complications (e.g., mental status and vital sign changes) Provide a high-calorie, high-protein diet Folic acid Teach parents & child prevention and early s/s of complications Interventions Hydroxyurea -Stimulates development of Hgb F (fetal hemoglobin) -Monitor for GI symptoms nausea, vomiting, diarrhea Iron supplements for anemia are NOT used Medications Preventing vaso-occlusive crisis -Maintain hydration, prevent infection Treatment of complications -Hydration, O2, pain management, rest Care Is Focused On Antibiotics (in the presence of infection) Folic acid preparations Hemotransfusions (used in some cases) Hydroxyurea Analgesics Immunization Erythropoietin Intravenous Rehydration Treatment Of Sickle Cell Anemia Hematopoietic stem cell transplant is the only cure 391 Otalgia Ear pain Otorrhea Discharge from the ear Pressure- Equalizing (PE) tubes tiny plastic tubes inserted surgically into the tympanic membrane (eardrum) Sensorineural hearing loss (SNHL) Hearing loss caused by damage/disease in the inner ear of the auditory nerve, cochlea, or CNS (neural = nerve) Conductive hearing loss Transmission of sound through the middle ear is disrupted Tympanostomy The surgical procedure to insert PE tubes in the tympanic membrane (eardrum) Tympanometry - A test to measure the movement of the eardrum using a probe in the ear canal; -it determines if there is fluid behind the eardrum Terminology An inflammatory process that usually starts with an upper respiratory infection -> fluid and pathogens travel from the nasopharynx area up the Eustachian tube (auditory tube). The Eustachian tube in children is short and in a horizontal position compared to adults -> ear infections -> as the child grows the Eustachian tube becomes more vertical and the child has fewer ear infections Pathophysiology ACUTE OTITIS MEDIA (AOM) An infection of the middle ear Otitis media can be classified as acute, chronic, or with effusion Infants and childrens eustachian tubes compared to adults are short, wide, and horizontal making them more prone to otitis media Otitis media commonly results from an acute respiratory infection (e.g., RSV, group A strep) Causes include bacterial & viral infections, allergies, environmental factors such as cigarette smoke, reflux # PEDIATRICS THE EARS # 392 ACUTE OTITIS MEDIA (AOM) PEDIATRICS THE EARS Teach proper admin of analgesic drops (lidocaine or benzocaine), antipyretics and antibiotics if prescribed IMPORTANT to finish and admin antibiotics exactly as prescribed (antibiotic resistance) Teach prevention of otitis media Parent Teaching Encourage fluids Warm heat or cold compress as prescribed Admin analgesic drops, antipyretics, antibiotics as prescribed Interventions Eustachian tube dysfunction Respiratory infections Family history of parent or sibling Cigarette smoke Lack of breastfeeding Risk Factors Feed infants in an upright position Encourage breastfeeding for 6 mos. minimum Avoid cigarette smoke and other allergens Prevention Pain management Parent education Prevention Management focus: Acetaminophen, ibuprofen Topical analgesic drops (lidocaine or benzocaine) Antibiotics (prescribed for a child >6 months old with severe s/s) Treatment Younger than 3 years gently pull the earlobe down and back Older than 3 years gently pull the ear (pinna) up and back To administer ear drops Acute ear pain (otalgia) Fever (usually low grade) Pulling or rubbing ear Rolling the head from side to side Fussiness, irritability, crying inconsolably, waking at night Lethargy, loss of appetite Fluid drainage from the ear (otorrhea) Bulging and/or red tympanic membrane (seen with otoscope) Hearing loss (with chronic otitis media) Signs & Symptoms # 393 Otitis Media with Effusion (OME) Fluid in the middle ear without s/s of infection Fluid builds up in the middle ear and eustachian tube The fluid puts pressure on the tympanic membrane (eardrum) preventing it from movingnormally # PEDIATRICS THE EARS An incision is made in the eardrum to drain the fluid from the middle ear Pressure-equalizing (PE) tubes are inserted to keep the incision open to equalize the Pressure, allow drainage & ventilation Myringotomy Otitis Externa (swimmers ear) Inflammation of the external ear canal that can occur with or without an infection S/s depend on the severity Ear pain (otalgia) Discharge (otorrhea) Itching/irritation Feeling of fullness in the ear Hearing loss The pinna and tragus are tender Typically treated with topical antibiotics, hydrocortisone drops Signs & Symptoms Usually an outpatient procedure Give ibuprofen or acetaminophen if needed Keep the ears dry use earplugs when bathing, swimming, etc. Tubes will fall out on their own notify the PCHP, but this is not an emergency Child should not blow nose for 3 days Teach how to administer ear drops if prescribed If child gets an ear infection contact the PHCP Parent Education # 394 Dysplasia Femoral head remains in acetabulum Mildest form acetabulum is shallow or sloping instead of cup-shaped Delay in development of acetabulum Subluxation Partial dislocation Stretched capsule and ligamentum teres causes partial displacement of the femoral head Femoral head remain in acetabulum Dislocation Femoral head is displaced and loses contact with acetabulum The displaced femoral head moves upward, shortening the leg Ligamentum teres is elongated and stretched tight Severity of DDH when partial dislocation (subluxation) or the femoral head loses contact (dislocation) with acetabulum, structural changes in the hips anatomy occur -> prolonged periods of abnormal position leads to the limited movement of the hip and muscles; the joint is shortened, and becomes stiff Pathophysiology DEVELOPMENTAL DYSPLASIA OF THE HIPS (DDH) Abnormal development of acetabulum (hip socket) in utero, infancy, or childhood with or Without dislocation of the hip The development of the hip joint is dependent on the relationship between the femur and Acetabulum (hip socket) in utero and infancy In normal development, the femoral head is deeply seated in the acetabulum If subluxation (partial dislocation) and dislocation occur in utero or infancy, structural changes In the hips anatomy occur and lead to DDH Can occur in one or both hips Early diagnosis prevents long-term complications # PEDIATRICS MUSCULOSKELETAL Family history Female Breech birth Native American Swaddling with hips and legs in adducted & extended positions Limited room for movement in utero (e.g., twins) Risk Factors Loose hip ligaments in the newborn (laxity) Asymmetry of the thigh and gluteal folds Leg is visibly shortened on affected side (knee is higher) in the prone position - Called a structural limb-length discrepancy Limited range of motion in the hip (abduction) in older nfant or child Positive Ortolani test Signs & Symptoms older than 12 months Affected leg is shorter than the other Positive Trendelenburgs gait - Hip drops/tilts when the affected leg is raised A waddle effect when walking # 395 DEVELOPMENTAL DYSPLASIA OF THE HIPS (DDH) # PEDIATRICS MUSCULOSKELETAL Persistent dislocation range of motion Early osteoarthritis of the hip Avascular necrosis of the femoral head Complications Pavlik harness Worn continuously until PHCP changes instructions - infant will be able to kick legs Do not adjust straps Socks and undershirt under the harness recommended Notify PCHP if rash develops, feet swell, or turn bluish Parent Education Supine position, knees to 90 Thumb placed on inner thigh (medial proximal) Fingers placed on outer thigh (greater trochanter) Performed on each hip, one at a time For Barlow & Ortolani Tests Confirms findings of the Barlow test Examiner abducts the thigh (away from midline) and gently pulls the femur forward (anteriorly) A clunk is felt as the femoral head moves back into acetabulum in a young infant (<4 weeks) Positive Ortolani's Test Examiner brings hips and thighs toward the midline (adducts) and applies gentle pressure, pushing downward (posteriorly) examiner will feel the femoral head dislocate (palpable) from the acetabulum Positive Barlow's Test Abduction the movement of a limb away from the midline of the body Adduction the movement of a limb toward the midline of the body Acetabulum hip socket in the pelvis dysplasia abnormal growth or development Terminology Review a kidnaper abducts = takes away add the limb back to midline socks and an undershirt are worn under the harness to prevent chaffing 1st 2nd after 2-3 months of age soft tissue shortens and becomes hardened (contracture) and these tests are not reliable younger than 6 months Splinting with a Pavlik harness worn for 3 6 months continuously until hip is stable Prevents extension & adduction Maintains flexion, abduction, & external rotation 6 to 18 months Closed reduction under general anesthesia -Hip spica cast for 2-4 months Followed by a flexion-abduction brace Older than 18 months Surgery open reduction and correction of abnormalities Interventions examiner holds both legs /knees to stabilize pelvis # 396 NOTES NOTES PHARMACOLOGY THROMBOLYTICS (FIBRINOLYTICS) # PHARMACOLOGY MED. ADMINISTRATION U --> unit IU --> intentional unit Q.D., QD, q.d., qd --> daily Q.O.D., QOD, q.o.d., qod --> every other day MS --> morphine sulfate MSO4, MgSO4 --> magnesium sulfate Trailing zero (Decimal point could be overlooked or not written) Ex: 5.0 mL --> write 5 mL NO leading zero (Decimal point could be overlooked or not written) Ex: .5 mL --> write 0.5 mL > sign --> greater than < sign --> less than cc --> mL Write FULL medication name ABBREVIATIONS TO AVOID -> WHAT TO USE INSTEAD RIGHT PATIENT RIGT MEDICATION RIGHT DOSE RIGHT ROUTE RIGHT TIME RIGHT DOCUMENTATION 6 RIGHTS OF DRUG ADMINISTRATION TYPES OF MED. ORDERS Standing: med. pre-established & approved to give in the absence of HCP or attending. Single: given one time only. PRN: given as needed. STAT: med. given soon as possible. COMPONENTS OF MED. PRESCRIPTION Pt. full name Date & time of Rx Name of med. (generic or brand) Strength & dosage Route Time & frequency Quantity & number of refills Signature of prescribing provider COMMON MED. ERRORS Wrong med or IV fluid Incorrect dose or IV rate Wrong client, route, & time Administration of an allergy-inducing med. Omission of dose Administration of extra dose Incorrect discontinuation of med or IV fluid Inaccurate prescribing Giving med that has similar name to other med(s) ALWAYS ask about allergies during medical Hx interview 258 PHARMACOLOGY # PHARMACOKINETICS A.D.M.E NON-PARENTAL How the medication is broken down. Enzymes cause meds to become less active or inactive. Primarily occurs in the liver, but also in the kidneys, lungs, intestines, & blood. What Affects This? Age (older adults are given smaller doses due to risk of accumulation). Increased Dose on med. First-pass effect (liver inactivates the first-time med before it reaches the systemic circulation. Should give med non-enteral i.e. IV). Similar Pathways (two meds taken, rate of metabolism decreases for one or both meds.) Poor nutrition M - METABOLISM Meds. administered from its starting location to the bloodstream. In order from fastest to slowest absorption rate: IV, IM, SC, ID, PO (oral) Route and amount of med. affects absorption. A - ABSORPTION D - DISTRIBUTION Transportation of medication by bodily fluids to where they need to go What Affects This? Circulation (conditions that hinder blood flow & perfusion). Permeability of the cell membrane (certain meds. must go through tissues & membranes to reach targeted areas). Plasma protein binding sites (two meds. fighting for same binding site to reach targeted area). SUBLINGUAL & BUCCAL Sublingual: under tongue Buccal: b/w cheeks & gum - Med must completely dissolve. - NO food or drink until med dissolves. E - EXCRETION Eliminating med primarily through the kidneys. Also excreted by the liver, lungs, intestines, & exocrine glands. Kidney dysfunction can cause accumulation of med. in body TOXIC LEVELS (monitor BUN & creatinine levels). ORAL (ENTERAL) Contraindications: Little GI mobility, No gag reflex, Vomiting, Dysphagia, Decreased LOC. Remain upright (High-Fowlers) DO NOT give with interacting foods & drinks (grapefruit). DO NOT crush time-released & enteric-coated meds. Mix crushed med with SMALL portion of food if needed. For liquid meds, base of meniscus (lowest fluid line) at level of ordered dose. # 259 PHARMACOLOGY NON-PARENTAL EYE, EAR, & NOSE Eye: Place dropper 1-2 cm above the conjunctival sac (inner corner of eye). Gent ly close eyes & if blinks during instillation, repeat the process. Gent ly press on nasolacrimal duct for 30-60 secs. Wait 5 mins if instilling more than one med. For ointment, apply thin layer from inner edge of lower lid to the outer. Ear: For adult, pull ear up & outwards. For children, pull ear down & back. Place dropper 1 cm above ear. Once instilled, gent ly press tragus of ear unless its too painful. Remain still for 2-3 mins. Nose: Use medical aseptic technique. Breath through mouth & not blow nose for 5 mins. TRANSDERMAL Clean & dry skin before and after use. Place patch on hairless area. Rotate sites to avoid skin irritation. TOPICAL INHALATION MDI: Hold 2-4 cm away from front of mouth or completely close mouth around mouthpiece. Take deep breath & exhale. Tilt head up, & at same time, press inhaler & deeply inhale. Deeply inhale for 3-5 secs and hold breath for 10 secs. Once finished, remove mouthpiece & exhale. DPI: Follow directions for prepping med. Exhale, close mouth around mouthpiece, & deeply inhale. Hold breath for 5-10 secs. Once finished, remove mouthpiece & exhale. Rinse mouth or brush teeth to lower risk of fungal infection. NS & GASTROSTOMY TUBES To prevent, clogging, flush with 15-30 mL of Liquid meds recommend & if dont have, crush tablets & capsules (but not extended/ time-released). NO sublingual meds. Completely dissolve crushed meds in 15-30 mL sterile water before administration. DO NOT mix meds. SUPPOSITORIES Rectal: Left lateral or Sims position. Insert beyond internal sphincter. Remain still for 5 mins. Vagina: Lithotomy or dorsal recumbent position. Place 7.5-10 cm on posterior wall of vagina. Remain still for 5 mins. DO NOT apply with bare hands. TO apply ointment & cream, use gloves, tongue blade, or cotton swab. # 260 ROUTE ID SC IM IV GAUGE 25-27 G 25-27 G 20-22 G 14-18 G(emergic, blood) 20-22 G(standard infusion) 22-24 G (children, older adults) LENGTH 1/2 or 5/8 3/8 or 5/8-1 in -1 1/2 in 0.5-1 1/2 in SYRINGE 1 mL 1-2 mL 2-3 mL No specific syringe ANGLE OF INSERTION 10 -15 45 -90 90 10 -30 # PHARMACOLOGY PARENTAL INJECTIONS Parental Route are injections absorbed through the blood stream, muscle, & tissue. Parental Routes: intradermal (ID), subcutaneous (SC), intramuscular (IM), and intravenous (IV). The gauge (G) is the needles inner diameter (bore), through which medication is administered. Example: A 23-G bore used for IM injection of more thicker liquids. An 18-G bore used for IV injections of large amounts of medication. Determine length based on the type of injection. Example: Med given ID, use short length needle b/c it's a superficial injection. Med given IM, use longer needle b/c it's beneath skin and underlying tissue. INTRAVENOUS INTRAMUSCULAR Epidermis Dermis Subcutaneous tissue Muscle INTRADERMAL SUBCUTANEOUS Larger the #, Smaller the gauge # 261 PHARMACOLOGY # PARENTAL INJECTIONS INTRAVENOUS ASPIRAT E. If you aspirate blood, GOOD JOB! You're in the vein! Monitor the IV site for infiltration, air embolism, phlebitis, infection, tissue damage. Potassium (K+) is a VERY uncomfortable and life-threatening electrolyte to give though IV. Potassium is rather given by mouth. If given IV, it must be diluted in solution (0.9% Normal Saline, 5% Dextrose, etc.) and regularly check on the patient. Potassium should NEVER be given IV push because it can stop the heart leading to death. Most common sites to start an IV are at peripheral veins: hand, forearm, and antecubital (inner elbow). INTRAMUSCULAR INTRADERMAL ASPIRAT E. If you aspirate blood, it is NOT in the muscle, but the vein. Z-track method Sites: Dorsogluteal (back of hip), Ventrogluteal (side of hip), Deltoid (upper arm), Vastus lateralis (side of thigh), Rectus femoris (anterior thigh) Ventrogluteal: common site for infants and children less than 3 yrs. Rectus femoris: rarely used site b/c its very close to the sciatic nerve and numerous blood vessels. If hit, permanent damage or paralysis. Only used when other sites are not available. A few meds/supplements/other(s) given for each parental route: ID: tuberculin (TB skin test) SC: heparin, insulin IM: iron, steroids, Influenza vaccine, IV: electrolytes, fluid (0.9% Normal Saline), morphine, blood products, TPN (Total Parental Nutrition) SUBCUTANEOUS Divided into two doses if injecting more than 1 mL. Once injected, remove needle at same angle. DO NOT MASSAGE DO NOT ASPIRAT E, cause nodules & tissue damage. Sites w/ adequate fat (abdomen, upper hips, lateral upper arms, thighs). For average-sized patients, give at 45-90. Obese patients, give at 90. TB skin test & medication or allergy sensitivities. DO NOT MASSAGE Bleeding or NO wheal formation indicates injection was given incorrect ly. Before inserting needle, be sure to rid of air bubbles inside syringe 262 PHARMACOLOGY ANALGESICS SIDE EFFECTS: - RESPIRATORY DEPRESSION - CNS DEPRESSION * RR < 12 breaths/min * Sedation, weakness, lightheadedness - Constipation, N/V - Orthostatic hypotension - Dry mouth - Urinary retention - Euphoria, Agitation, Tremors - Binds to opiate receptors in the CNS & act as agonists (stimulates a response, activates). Results in altering the perception of & response to pain. ACTION: - ICP, Head injury - Asthma, Emphysema - Kidney & Liver impairment, IBS - Pregnancy Category C (prescribed if benefits outweigh risk) CONTRAINDICATIONS: OPIOIDS ANALGESICS - morphine - codeine - fentanyl - oxycodone - meperidine - hydromorphone - methadone Relieves mild to severe pain USES: - IMMEDIATELY intervene if RR < 12 breaths/min - Antidote = Naloxone (Narcan) > watch for withdrawal symptoms - Risk of opioid dependence - If taking opioids long-term, DO NOT abruptly discontinue > WITHDRAW SLOWLY - Drink fluids, eat fiber, laxative or stool softeners (relieve constipation) - Monitor I&O, Encourage pt to empty bladder every 4 hours (urinary retention) - Asses pain & location - Closely monitor if receiving opioid through PCA pump machine - AVOID driving & other activities (sedation, weakness) NURSING CONSIDERATIONS: ! - Analgesic -- inhibits production of prostaglandins (trigger pain receptors) - Antipyretic -- dilates peripheral vessels which cools the body - Anti-inflammatory -- inhibit in prostaglandins also reduce inflammation ACTION: - Relieves mild to severe pain, reduces fever, & reduces inflammation - Reduces risk of transient ischemic attack (TIA) NON-OPIOD: SALICYLATES - aspirin (acetylsalicylic acid) - magnesium salicylate USES: DO NOT give to children Risk of Reyes Syndrome (give ibuprofen or Tylenol) # 263 PHARMACOLOGY ANALGESICS SIDE EFFECTS: - GI bleeding - GI upset, N/V, Anorexia (loss of appetite) - Hepatotoxicity - Heartburn - Allergic reaction * Hives, rash, angioedema, bronchospasms - Bleeding disorders - Pregnancy category C, D (aspirin) - Used cautiously during pregnancy & lactation CONTRAINDICATIONS: - Take med with full glass of water & sit upright for 15-30 mins - DISCONTINUE med 1 week before any surgery & DO NOT take med until completely healed (salicylates prolongs bleeding time by interfering with aggregation of platelets) - Closely monitor for bleeding (bruising; black, tarry stool; bleeding gums; bloody vomit) - Closely monitor for salicylism (toxicity) > common with aspirin because its an OTC drug & can accidentally self-treat with high doses * S&S: tinnitus, flushing, sweating, N/V, tachycardia, respiratory depression, confusion, drowsiness NURSING CONSIDERATIONS: - Analgesic & antipyretic affect same as salicylate - NOT an anti-inflammatory ACTION: - Relieves mild to severe pain & reduces fever - Alternative rather than aspirin (those with bleeding disorders or aspirin allergy) - Alcohol abusers (already have liver problems) - Taking concurrently with salicylate & NSAIDS - Pregnancy category B - Used cautiously during pregnancy & lactation CONTRAINDICATIONS: NON-OPIOD: NONSALICYLATES - acetaminophen USES: - Take with full glass of water & with or without meal - DO NOT exceed recommended dose - Antidote = acetylcysteine (Acetadote) - Monitor liver function (ALT, AST liver enzymes) - Watch for acute acetaminophen toxicity * S&S: N/V, jaundice, liver tenderness, hypotension, arrhythmias, hepatic & renal failure - AVOID alcohol - Monitor for rash (first sign of STEVENS-JOHNSON SYNDROME ) NURSING CONSIDERATIONS: SIDE EFFECTS: Too High Of A Dose: - HEPATOTOXICITY, HEPATIC FAILURE - STEVENS-JOHNSON SYNDROME ! # 264 PHARMACOLOGY ANALGESICS NON-OPIOD: NONSTEROIDAL ANIT-INFLAMMATORY DRUGS (NSAIDS) 1st Gen. (COX-1 & COX-2) - aspirin - naproxen - ibuprofen - keterolac 2nd Gen. (COX-2) - celecoxib only inhibit COX-2, NOT COX-1 but still have severe SE USES: - ALWAYS take with food, milk, or water to decrease GI upset - Watch for BLEEDING (ASPIRIN use) > easy bruising; dark, tarry stool; coffee-ground vomit - Closely monitor for salicylism (ASPIRIN use) - Watch for BLOOD CLOTS ( except for ASPIRIN) - Closely monitor renal function (BUN, creatinine) - Take lowest dose in the shortest time possible (decrease risk of severe SE) - OKAY TO TAKE if given in combination with a PPI (gastric med) > because of the inhibit of COX-1, this lowers chance of ulcers & GI bleeding - AVOID alcohol, omega 3 oils, vitamin E, & ginkgo/garlic (increases bleeding risk) NURSING CONSIDERATIONS: SIDE EFFECTS: - Drowsiness, Dizziness, H/A - N/V, Dyspepsia, ABD pain, Bloating - HTN, HF - Increased BUN & creatinine (kidney injury with long-term use) - Blurred or Diminished vision, Color changes Also refer to non-opioid: salicylates for ASPIRIN info - Analgesic, antipyretic, & anti-inflammatory affect same as salicylate - Inhibits production of prostaglandins by inhibiting the enzymes COX-1 (helps maintain stomach lining) & COX-2 (triggers pain & inflammation) - Decreases platelet aggregation -- ONLY with aspirin (RISK OF BLEEDING) ACTION: - Relieves mild to severe pain, reduces fever, & reduces inflammation + Osteoarthritis, rheumatoid arthritis + Ischemic stroke, MI (decreased platelet aggregation prevents this from happening) -- but use caution because RISK OF BLEEDING - Asthma p ts (cause bronchospams) - Peptic Ulcer pts (increases risk of GI bleeding EVEN MORE) - Hypertensive & HF pts (cause Na+ & fluid retention) - Pts with clots problems (MI, DVT, PE, Stroke) - Pregnancy category B CONTRAINDICATIONS: # 265 PHARMACOLOGY CARDIAC: ANTIHYPERTENSIVES ACE INHIBITORS (-PRIL) & ARBS (-SARTAN Nursing Considerations Closely monitor BP Watch for orthostatic hypotension (change positions SLOWLY) Watch for angioedema (AIRWAY RISK!) Watch ECGs levels --> peaked T waves, ST elevation AVOID K+ rich foods (green leafy vegetables, bananas, avocados, potatoes, beef, pork) AVOID pregnancy (take contraceptives) Pregnancy Risk Category D (cause fetal harm) Renal Stenosis, Angioedema Kidney impairment Diabetic pts. taking aliskiren (increased risk of hyperkalemia, kidney dysfunction, hypotension) Risk of lithium toxicity Hypertension MI, HF Uses blocks conversion of angiotensin I to angiotensin II & increases level of bradykinin. Results in vasodilation. blocks RAAS (increases BP by retaining Na+/H2O & excreting K+) Action Side Effects HYPERKALEMIA (since RAAS is blocked, body in retaining K+) Orthostatic hypotension Persistent Cough -- (ACE INHIBITORS) ANGIOEDEMA Diminished taste (ACE INHIBITORS) Dizziness, Lightheadedness ONLY LOWERS BP Contraindications / Precautions ACE INHIBITORS (-PRIL) - lisinopril - captopril - enalapril - ramipril ARBS (-SARTAN) - losartan - valsartan - candesartan - irbesartan ## BETA BLOCKERS (-LOL) Asthma, Bronchospasm, HF AV block, Sinus Bradycardia Kidney & Liver impairment Diabetes Hypertension MI, HF (do not give if congestive /worsening HF) Angina Pectoris Tachyarrhythmia Uses blocks beta 1 (affects heart) & beta 2 (affects heart & lungs) receptors Action Side Effects Bradycardia Bronchospasms Hypoglycemia Orthostatic hypotension SIGNS OF WORSENING HF: - SOB, new edema, rapid weight gain, crackle lung sounds, JVD LOWERS BOTH BP & HR Contraindications / Precautions HF pts are given Beta Blocker with EXCEPT IONS & are watched with caution. HCP starts by giving the med at a LOW DOSE & adjust as needed 266 Pregnancy Risk C, Lactation (nifedipine) Cariogenic shock & Other cardiac disorders (HF, MI, aortic stenosis, hypotension, 2nd or 3rd degree heart block, digoxin toxicity, etc.) Kidney & Liver impairment Older adults Contraindications / Precautions # PHARMACOLOGY CARDIAC: ANTIHYPERTENSIVES BETA BLOCKERS (-LOL) Nursing Considerations Check BP & HR BEFORE giving med If BP systolic LESS T HAN 100 OR HR LESS THAN 60/min -- HOLD MED! (an already low BP or HR will lower dangerously if BB given) DO NOT give to pts with worsening HF Monitor for hypoglycemia, especially in Diabetic pts (may mask symptoms of hypoglycemia) DO NOT give Beta 2 to asthma, COPD pts --> causes bronchospasms Watch for orthostatic hypotension (change positions SLOWLY) BETA 1 (cardioselective) - metoprolol - atenolol - esmolol BETA 2 (non-selective) - propranolol - nadolol - sotalo ## CALCIUM CHANNEL BLOCKERS (-DIPINE, -ZEM, -AMIL) Nursing Considerations Check BP & HR BEFORE giving med If BP systolic LESS T HAN 100 OR HR LESS THAN 60/min -- HOLD MED! (an already low BP or HR will lower dangerously if CCB given) DO NOT give to pts with worsening HF Watch for orthostatic hypotension & peripheral edema Hypertension Angina pectoris, dysrhythmias HF (do not give if congestive /worsening HF) Uses blocks movement of calcium which relaxes vascular smooth muscles Action Side Effects H/A (normal finding) Orthostatic hypotension Reflex tachycardia (Nifedipine -- can be easily corrected with beta blocker) Dizziness, Fatigue Bradycardia Peripheral edema Constipation (Verapamil) LOWERS BOTH BP & HR (only lowers BP) - nifedipine - amlodipine - felodipine (lowers BP & HR) - diltiazem - cardizem - verapamil 267 Pregnancy Risk Category C HF, MI, ventricle tachycardia & fibrillation, AV block, 2nd & 3rd degree heart block Hypokalemia (increased risk for digoxin toxicity), Diuretics Kidney impairment Contraindications / Precautions # PHARMACOLOGY CARDIAC: CARDIAC GLYCOSIDES MED NAME - DIGOXIN Nursing Considerations Watch for toxicity Monitor K+ level (NL: 3.5 - 5 mEq/L) Hypokalemia INCREASES risk of digoxin toxicity Maintain balanced consumption of K+ rich foods (green leafy vegetables, bananas, avocados, potatoes, beef, pork) Therapeutic Digoxin Range: 0.5 - 2.0 ng/mL Antidote = digoxin immune fab Take apical pulse for 1 FULL MINUT E (NL: 60-100) HR < 60/min -- HOLD MED Monitor kidney function (creatinine, BUN) --> decreased function = increased risk of toxicity (older pts more at risk) HF Atrial fibrillation Uses great ly increases contraction, increases cardiac output & decreases cardiac preload, & slows HR Action Side Effects N/V, Diarrhea Anorexia (loss of appetite) Blurry vision, Diplopia Dizziness, Lightheadedness Irregular pulse Confusion ONLY LOWERS HR Pregnancy Risk Category C & D Hypersensitivity to nitrates Antihypertensives & PDE-5 (causes severely low BP) Kidney & Liver impairment Head trauma, Glaucoma, Severe anemia (increases intracranial pressure) Contraindications / Precautions CARDIAC: VASODILATORS/ANTIANGINALS Nursing Considerations Check BP before giving med BP systolic < 100 -- HOLD MED AVOID taking viagra --> extremely lowers BP = DEATH Watch for orthostatic hypotension (turn positions SLOWLY) Angina pectoris attack HF Uses Relaxes smooth muscles, expanding lumen of vessels, lowers & BP, & increases blood & O2 flow throughout the body Action Side Effects H/A Orthostatic hypotension Dizziness Flushing Sublingual tingling, burning sensation WATCH FOR SERIOUS SIGNS + lack of coordination + pallor pale + lightheadedness + irritable 268 Spray direct ly on or under tongue Use 5-10 mins before activity Onset of angina, spray 1-2x. DO NOT exceed 3x within 15 mins Translingual (Aerosol) Spray # PHARMACOLOGY # CARDIAC: VASODILATORS/ANTIANGINALS NITROGLYCERIN EDUCATION Sublingual Pill Placed & dissolves under tongue Avoid eating, drinking, or smoking until it dissolves Can ONLY be taken 3x. So if pain continues after taking first pill, take two more in 5 minute intervals Sit or lie down when taking nitrate (relieves dizziness, lightheadedness) Keep nitrate in original container & avoid bott le exposure to heat, air, & moisture (loses potency) Immediately re-cover container with cap (loses potency when exposed toair) General Ointment/Transdermal Patch Worn for 12-14 hrs & Taken off for 10-12 hrs (Transdermal Patch) --> lowers risk of tolerance Apply at the same time each day Rotate choice of area (avoid skin irritation) Apply to dry, hairless area Remove old application & inspect skin to BE SURE its completely removed Clean old area thoroughly with soap & water BEFORE applying new application Wear Gloves! Avoid contact with hands! Upper chest Upper outer arm Lower abdomen Hip Normal blood vessel Vasodilation - nitroglycerin - isosorbide - nitroprusside - hydralazine - minoxidil 269 LOOP DIURETICS (-MIDE, -NIDE) # PHARMACOLOGY CARDIAC: DIURETICS DIURETIC OVERVIEW Nursing Considerations Replace K+ with rich foods & supplements if < 3.5 mEq/L If giving K+ via IV, NEVER GIVE K+ IV PUSH! = DEATH AVOID licorice (lowers K+ level) Given IV furosemide TOO RAPID = hearing problems Given IV furosemide TOO SLOW = kidney problems Closely monitor ECG (flat T waves, ST depression) Pregnancy Risk Category C, Breastfeeding (used if absolutely necessary when maternal benefits are justifiable) ,Cross-Sensitivity to sulfonamides, * Anuria, Kidney & Liver impairment, Electrolyte depletion, Dehydration, Gout, Diabetes, Cardiac disease, Digoxin, NSAIDS, Lithium, Antihypertensives Hypertension HF, edema Pulmonary edema Renal failure Uses I+ inhibits reabsorption of Na+ & Cl- in the distal & proximal tubule and the loop of Henle of the kidneys Action Side Effects HYPOKALEMIA (< 3.5 mEq/L) Hypo -natremia, -calcemia, -magnesmia Orthostatic hypotension Dehydration Hyperglycemia OTOXICIT Y (happens if diuretic given rapid IV push) - S&S: tinnitus, hearing loss - furosemide - torsemide - bumetanide K+ Foods - green leafy veggies - potatoes, avocados - tomatoes, bananas - cantaloupe - fish, pork, beef Potassium-Wasting * same for Thiazides Diuretics cause ORT HOSTAT IC HYPOT ENSION (the reduced volume of excess fluid in the blood causes the BP to drop) --> so SLOW position changes & SLOW to stand to avoid lightheadedness & dizziness - daily weights (report 2-3 weight gain in a day) - I&Os (report urine output < 30 mL/hr) - electrolyte levels & signs of imbalance (especially potassium in K+ wasting & K + sparing diuretics) - vital signs (ALWAYS obtain baseline vital signs to compare the current & previous) Low sodium diet (Na+ retains water making the body swell) Give in the morning, NOT at night (nocturia peeing the ENT IRE night) Always monitor DIURETICS = DIURESIS (increases the production of urine) = DRIES (DEHYDRATES) THE BODY Hold diuretic if BP is low Contraindications / Precautions # 270 Breastfeeding (endocrine dysfunction in babies) Hyperkalemia Concurrent use of potassium supplements or another potassium-sparing diuretic Kidney & Liver impairment, Diabetes Contraindications / Precautions THIAZIDE DIURETICS (-THIAZIDE) # PHARMACOLOGY CARDIAC: DIURETICS Nursing Considerations Replace K+ with rich foods & supplements if < 3.5 mEq/L Closely monitor ECG (flat T waves, ST depression) Closely monitor renal function (BUN, creatinine) --> can cause azotemia Monitor blood glucose (especially in diabetic pts) Give with meals to decrease GI upset AVOID giving to gout pts (can cause a gout attack) If allergic to sulfa, AVOID thiazide diuretics Pregnancy Risk Category B & C (only methyclothiazide & benzthiazide) Breastfeeding (breastfeeding can cause fetal harm) ,Cross-Sensitivity to sulfonamides & tartrazine Hypertension HF, edema Renal failure Cirrhosis Glucocorticoids therapy Estrogen therapy Uses Inhibits reabsorption of Na+ & Cl- in the ascending portion of the loop of Henle & the early distal tubule of the nephrons Action Side Effects HYPOKALEMIA (< 3.5 mEq/L) Hypo -natremia, -calcemia, -magnesmia Orthostatic hypotension Dehydration Hyperglycemia - hydrochlorothiazide - chlorothiazide - methyclothiazide K+ Foods - green leafy veggies - potatoes, avocados - tomatoes, bananas - cantaloupe - fish, pork, beef Potassium-Wasting * same for Thiazides Contraindications / Precautions POTASSIUM-SPARING DIURETICS Nursing Considerations AVOID K+ rich foods & supplements AVOID salt substitutes that contain potassium Closely monitor K+ levels (report < 5.0 mEq/L) Closely monitor ECG (tall, peaked T waves, flat P waves) Warn pts triamterene turns urine a bluish color Hypertension Edema (HF, cirrhosis, nephrotic syndrome) Hypokalemia Male-to-female hormonal therapy (spironolactone inhibits testosterone) Hyperaldosteronism Uses Blocks aldosterone (hormone that increases reabsorption of Na+ & water) at the distal tubule of the kidneys. This results in excretion of Na+ & water, but NOT K+ (spares K+) Action Side Effects HYPERKALEMIA (> 5.0 mEq/L) Dizziness, Weakness Gi upset, Diarrhea Sexual dysfunction, Deep Voice, Gynecomastia (males), Menstrual irregularities (females) Potassium-sparing diuretics are usually given with loop or thiazide b/c it s the weakest at blocking reabsorption of Na+ & water K+ Foods - green leafy veggies - potatoes, avocados - tomatoes, bananas - cantaloupe - fish, pork, beef - spironolactone - triamterene - amiloride 271 Pregnancy Risk Category X & Breastfeeding (fetal harm) Liver disorders, Metabolic disorders Caution in pts with kidney impairment (start on low dose) Grapefruit juice (increases statin level) Contraindications / Precautions OSMOTIC DIURETICS # PHARMACOLOGY CARDIAC: DIURETICS # CARDIAC: ANTIHYPERLIPIDEMIC Nursing Considerations Only given via IV (monitor for signs of phlebitis) Closely monitor respiratory & cardiac status (listen to lung & heart sounds, watch for signs of PE & HF) Closely monitor neurological status (if used to ICP cause by cerebral edema) Mannitol may crystallize (inspect solution before administering and if crystallized, take back to pharmacy to replace with new one) Kidney impairment, Anuria (no urine output) Active intracranial bleeding Severe pulmonary edema, Severe dehydration Concurrent use of digoxin (increased risk of hypokalemia) Cautiously used during pregnancy & breastfeeding Cerebral edema Decreased intracranial pressure (ICP) Intraocular pressure Renal failure (treatment during the oliguria stage) Uses Increases osmotic pressure of the glomerular filtration, inhibiting reabsorption of water, Na+, Cl Action Side Effects H/A, N/V Pulmonary edema, HF (rapid shift of fluids) Dehydration, Electrolyte imbalances Renal failure, Urinary retention Rebound ICP Blurred vision - mannito Contraindications / Precautions HMG-CoA REDUCTASE INHIBITS (-STATINS) Nursing Considerations Monitor cholesterol, LDL, triglycerides, HDL levels Continuously monitor liver function (must discontinue med if serious liver problems are present) --> N/V, anorexia (loss of appetite), jaundice, dark urine, RUQ abdominal pain IMMEDIAT ELY notify HCP of unexplained muscle pain, tenderness, or weakness (RHABDOMYOLYSIS) AVOID pregnancy (use contraceptives) Hyperlipidemia (lowers total cholesterol, LDL, & triglycerides. Increases HDL) Prevention of CAD (MI, T IA, stroke, angina, cardiac revasularization procedures) Uses An enzyme that act as a catalyst to inhibit the manufacture of cholesterol or promote the breakdown of cholestero Action Side Effects H/A, Amnesia Dizziness, Insomnia N/V, Constipation or Diarrhea Flatulence, ABD pain & cramping Rash HEPATOTOXICITY (elevated AST level) RHABDOMYOLYSIS (serious muscle toxicity) - atorvastatin - simvastatin - lovastatin - rosuvastatin 272 Pregnancy Risk Category C & Breastfeeding Kidney & Liver impairment Gallbladder disease Contraindications / Precautions BILE ACID RESINS # PHARMACOLOGY CARDIAC: ANTIHYPERLIPIDEMIC Nursing Considerations Eat high-fiber foods, drink plenty fluids (relieve constipation) Bile Resins interferes with absorption of MANY meds (notify HCP of pts current medication/supplement theyre taking) If taking other meds, take 1 hour BEFORE bile resins OR take 4 hours AFT ER bile resins Closely watch for BLEEDING (easy bruising; dark, tarry stool; coffee-ground vomit) Pregnancy Risk Category B & C Complete Biliary Obstruction Bowel obstruction, Constipation Hyperlipidemia (specifically lowers LDL) Uses Binds to bile acid in the intestines to prevent reabsorption of cholesterol Action Side Effects Constipation, Hemorrhoids Flatulence, ABD pain & cramping Deficiencies in A, D, K (low vitamin K increases risk of BLEEDING) Contraindications / Precautions FIBRATES Nursing Considerations Continuously monitor liver function (must discontinue med if serious liver problems are present) --> N/V, anorexia (loss of appetite), jaundice, dark urine, RUQ abdominal pain IMMEDIAT ELY notify HCP of muscle pain, aches, & tenderness (MYOPAT HY) Continuously monitor CK level (must discontinue med if CK level is high) --> another sign of MYOPATHY Closely monitor signs of gallbladder dysfunction (RUQ pain, fat intolerance, bloating) Take 30 mins BEFORE breakfast & dinner Hyperlipidemia (lowers cholesterol & triglycerides, increases HDL) Uses Decreases production of cholesterol & triglycerides either by destruction or excretion. Increases production of HDL Action Side Effects N/V, Diarrhea GI upset HEPATOTOXICITYXICITY (increased liver enzyme levels) MYOPAT HY (increased CK level) Cholesthiasis (gallstones) or Cholecystitis (gallbladder inflammation) - cholestyramine - colestipol - colesevelam - fenofibrate - gemfibrozil 273 CHOLESTEROL ABSORPTION INHIBITORS MEDICATION THERAPEUTIC LEVELS # PHARMACOLOGY CARDIAC: ANTIHYPERLIPIDEMIC Nursing Considerations Continuously monitor liver function (must discontinue med if serious liver problems are present) --> N/V, anorexia (loss of appetite), jaundice, dark urine, RUQ abdominal pain IMMEDIAT ELY notify HCP of muscle pain, aches, & tenderness (MYOPATHY) Continuously monitor CK level (must discontinue med if CK level is high) --> another sign of MYOPAT HY If taking ezetimibe/simvastatin in combination, AVOID pregnancy (take contraceptives) Pregnancy Risk Category B & C Complete Biliary Obstruction Bowel obstruction, Constipation Hyperlipidemia (specifically lowers LDL) Uses Inhibits absorption of cholesterol in bile & food Action Side Effects HEPATOTOXICITY (increased liver enzyme levels) MYOPATHY (increased CK level) Contraindications / Precautions - ezetimibe Acetaminophen: 10-20 mcg/mL Digoxin: 0.8-2.0 ng/mL Dilantin: 10-20 mcg/mL Gentamicin: 5-10 mcg/mL Lithium: 0.4-1.4 mEq/L Magnesium Sulfate: 4-8 mg/dL Phenobarbital: 10-40 mcg/mL Phenytoin: 10-20 mg/L Salicylate: 100-300 mcg/mL Theophylline: 10-20 mcg/mL Tobramycin: 10-20 mcg/mL Vancomycin: 10-20 mcg/mL # 274 MEDICATION ANTIDOTES # PHARMACOLOGY Acetaminophen Aspirin Opioids/Narcotics Warfarin Heparin Digitalis (digoxin) Beta blockers Calcium channel blockers Insulin reaction Lead Magnesium sulfate Benzodiazepine Anticholinergic Tricyclic antidepressant Iron Acetylcysteine Sodium bicarbonate Naloxone (Narcan) Vitamin K Protamine sulfate Digifab/Digibind Glucagon Glucagon/Calcium/Insulin Glucagon Chelation agents Dimercaprol (IM), Edetate Lead (cont.) calcium disodium (IV or IM), Succimer (oral) Calcium gluconate Flumazenil Physostigmine Sodium bicarbonate Deferoxamine Poisons except cyanide, iron, lithium, caustics, alcohol Alcohol withdrawal Cholinergic toxicity Cyanide Edrophonium Hypertensive Crisis Thrombolytics Methanol Ethylene glycol (Antifreeze) Activated Charcoal chlordiazepoxide Atropine Hydroxocobalamin Atropine Phentolamine injection Aminocaproic acid Fomepizole, Folic acid Fomepizole # 275 ANTICOAGULANTS # PHARMACOLOGY CARDIAC: ANTICOAGULANTS Nursing Considerations for Heparin Contraindicated in bleeding disorders, blood dyscrasias, ulcers, liver and kidney disease, hemorrhagic brain injury Therapeutic dose of heparin prevents new clots, does not dissolve Continuous IV infusions on pump only to insure precise delivery rate Monitor - aPTT, (if aPTT is too long dosage, if aPTT is too short dosage) - Monitor platelet count - Observe for side and adverse effects Instruct patient adverse reactions Measures to prevent bleeding Avoid foods high in vitamin K Heparin , warfarin, dabigatran, rivaroxaban, apixaban Parenteral argatroban, bivalirudin, dalteparin Common generics: Inhibit factors in the clotting cascade and thrombin formation, thereby decreasing coagulation Action Uses: MI, unstable angina, AFib, deep vein thrombosis, pulmonary embolism, mechanical heart valves Serious Adverse Reactions: Hemorrhage, blood in the urine, epistaxis (nosebleed), ecchymosis, bleeding gums, thrombocytopenia (low platelet count), hypotension; nausea, GI upset, diarrhea, and hepatic dysfunction indicates toxicity Patient Education Class P:Antithrombotic T: Anticoagulant SUFFIX: -xaban, -arol, -irudin Antidote: protamine sulfate Antidote: phytonadione (vitamin K) (works by vitamin K) Nursing Considerations for Warfarin warfarin prolongs the prothrombin time (PT); the therapeutic range is 1.5 to 2 times the control value If the PT value is longer than 30 seconds and the INR is greater than 3.0 in a patient receiving standard warfarin therapy, initiate bleeding precautions contraindicated in pregnancy, lactation nausea, GI upset, diarrhea, and hepatic dysfunction indicates toxicity Monitor for - PT & INR - Observe for side and adverse effects Bleeding is the primary concern with anticoagulant, thrombolytic, or antiplatelet medications 276 THROMBOLYTICS (FIBRINOLYTICS) # PHARMACOLOGY CARDIAC: THROMBOLYTICS Nursing Considerations Monitor - Vitals, pulses - For bleeding & check all excretions for occult blood - For slurred speech, lethargy, confusion, and hemiparesis - For hypotension and tachycardia - Withhold medication if bleeding develops and contact PHCP - Patient needs bed rest Alteplase, tenecteplase, retaplase Common generics: Thrombolytic medications activate plasminogen which generates plasmin. Plasmin is an enzyme that dissolves clots. Action Uses: Acute MI to restore blood flow, arterial thrombosis, deep vein thrombosis, pulmonary embolism, acute ischemic stroke, occluded catheters & shunts Serious Adverse Reactions: Bleeding, dysrhythmias, allergic reactions Contraindicated in: Active internal bleeding (excluding menses) History of hemorrhagic stroke Recent intracranial hemorrhage Recent head or facial trauma Recent intracranial or intraspinal surgery Thoracic, pelvic, or abdominal surgery in the previous 10 days History of hepatic or renal disease Uncontrolled hypertension Recent, prolonged cardiopulmonary resuscitation Known allergy Class P: Plasminogen activator T: Thrombolytic SUFFIX: -teplase -ase Bleeding is the primary concern with anticoagulant, thrombolytic, or antiplatelet medications Antidote: Aminocaproic acid 277 Pregnancy Risk Category B Kidney & Liver impairment Older adults (increased risk of CNS effects confusion) Contraindications / Precautions PROTON PUMP INHIBITOR (-PRAZOLE) # PHARMACOLOGY GASTROINTESTINAL: ACID-REDUCING AGENTS Nursing Considerations Closely monitor for signs of C-diff Closely monitor magnesium level & for signs of hypomagnesemia Increase calcium & vitamin D intake (bones fractures, osteoporosis) Take med whole & 1 hour before meal Pregnancy Risk Category B & C, Breastfeeding Liver impairment Prolonged use (inability for body to absorb vitamin B12, leading to anemia) Gastric & duodenal ulcers (associated with H. pylori infections) GERD Erosive esophagitis Hypersecretory conditions (Zollinger-Ellison syndrome) Uses Reduces gastric acid secretions by inhibiting the enzyme, ATPase (produces gastric acid) Action Side Effects N/V, Diarrhea, ABD pain H/A C-diff (severe colon infection) - Loose, foul-smelling, black, tarry stool (diarrhea) - ABD pain & cramping, Fever Long-term use Bone fractures, Osteoporosis Hypomagnesemia Contraindications / Precautions HISTAMINE2 RECEPTOR ANTAGONISTS (-TIDINE) Nursing Considerations DO NOT overeat AVOID smoking & alcohol AVOID taking aspirin or NSAIDS (increases risk of GI bleed) AVOID foods that increase gastric acid (fermented vegetables, caffeinated drinks, decaffeinated coffee) Take med 30 mins before eating (ranitidine either taken with/ without food) If taking both cimetidine & antacids, administer 1 hour apart SAFET Y! Prevent fall injury & AVOID driving or activities requiring alertness (due to drowsiness & dizziness) Gastric & duodenal ulcers GERD Hypersecretory conditions (Zollinger-Ellison syndrome) Heartburn, acid ingestion Uses Blocks histamine2 receptors, which reduces gastric acid & concentration of hydrogen ion in the stomach Action Side Effects N/A, Constipation or Diarrhea H/A Dizziness, Drowsiness, Confusion Decreased libido, ED, gynecomastia - esomeprazole - pantoprazole - lansoprazole - dexlansoprazole - cimetidine - ranitidine - famotidine - nizatidine 278 Pregnancy Risk Category B & Breastfeeding Congenital long QT syndrome, Heart block, & other Cardiac conduction problems Liver impairment, Electrolyte imbalances Concurrent use of antidepressants (increases risk of serotonin syndrome) Contraindications / Precautions ANTACIDS # PHARMACOLOGY GASTROINTESTINAL: ACID NEUTRALIZER Nursing Considerations Take 1 hour BEFORE or AFT ER meal Take with glass of water or milk NEVER mix with other meds (decreases absorption of those meds) --> allow 1 hour in-between antacid & other meds Closely monitor for signs of magnesium toxicity Pregnancy Risk Category C & Breastfeeding Abdominal pain Aluminum-containing (gastric out let obstruction, GI bleed, kidney impairment), Magnesium-containing (kidney impairment), Calciumcontaining (renal calculi), Sodium-containing (cardiac diseases, sodiumrestricted diet) GERD Peptic ulcer Heartburn, indigestion Uses Reduces or neutralizes gastric acid by producing neutral salts & inactivating pepsin Action Side Effects Aluminum-containing constipation, hypophosphatemia, hypomagnesemia Magnesium-containing Diarrhea, dehydration, sweating, hypermagnesemia Calcium-containing Constipation, hypercalcemia, H/A, confusion, neurological impairment Sodium-containing Fluid retention, systemic alkalosis Contraindications / Precautions SEROTONIN RECEPTORS ANTAGONIST (5-HT3 RECEPTOR ANTAGONISTS) GASTROINTESTINAL: ANTIEMETICS Nursing Considerations SAFET Y! Prevent fall injury & AVOID driving or activities requiring alertness (due to drowsiness & dizziness) Closely monitor ECG in pts. with cardiac conduction problems Monitor for signs of TORSADES DE POINT ES (ventricular tachycardia, dizziness, palpations, lightheadedness) Prevents induced nausea & vomiting (N/V) caused by chemotherapy/radiation Given BEFORE surgery to prevent vomiting during surgery Prevents vomiting postoperative Hyperemesis during pregnancy Uses Prevents emesis by blocking serotonin at the 5-HT3 receptor sites located at the chemoreceptor trigger zone (CT Z) & the vagaries nerve terminals in the CNS Action Side Effects H/A, Dizziness, Drowsiness Diarrhea, Constipation, Abdominal pain Prolonged QT interval (increases risk of TORSADES DE POINTES) - aluminum hydroxide - magnesium hydroxide - calcium carbonate - sodium bicarbonate - ondansetron - dolasetron - granisetron - palonosentron 279 BETA2 AGONISTS # PHARMACOLOGY RESPIRATORY MEDS Nursing Considerations Assess - lung sounds - for cough - wheezing (for paradoxical bronchospasm) Monitor - dysrhythmias - restlessness - intake & output Wait 5 min to take #2 inhaled med Wait 1-2 min to take 2nd dose of same med Report SOB not relieved by med to PHCP immediately Albuterol, short acting for acute attacks Salmeterol, long-acting for chronic conditions, taken with corticosteroids Common generics: Binds to beta-2 receptors in lungs; relax bronchi smooth muscle and dilates airways Action Indication: Asthma, COPD, bronchitis (low air flow through lungs) Serious Adverse Reactions: Palpitations, dysrhythmias, HTN, nervousness, restless, tremors Contraindicated in: Hypersensitivity, PUD, dysrhythmias; Use caution w/ HTN, DM, elderly, L&D Patient Education METHYLXANTHINES CLASS T: Bronchodilator P: Beta2-agonist SUFFIX: -terol Nursing Considerations Assess & Monitor - lung sounds - for cough - wheezing (for paradoxical bronchospasm) - dysrhythmias - restlessness Monitor for - theophylline therapeutic level 10 20 mcg/mL - IV theophylline admin slowly w/infusion pump - theophylline increases risk of digoxin toxicity - theophylline decreases effectiveness of lithium, phenytoin - if admin theophylline with beta2 agonist can dysrhythmias Wait 5 min to take #2 inhaled med Wait 1-2 min to take 2nd dose of same med Report SOB not relieved by med to PHCP immediately Avoid caffeine, alcohol Inhaler, spacer, nebulizer instruction Theophylline (oral), aminophylline Common generics: Stimulates CNS, relaxes smooth muscle, dilates vessels, diuresis Action Indication: long-term treatment of asthma, COPD (a last-line med) Serious Adverse Reactions: Restlessness, nervousness , palpitations, tachycardia, angina, seizures, dysrhythmias Patient Education SUFFIX: -phylline Adverse = early s/s of toxicity for theophylline CLASS T: Bronchodilator P: Xanthine # 280 INHALED ANTICHOLINERGICS # PHARMACOLOGY RESPIRATORY MEDS Nursing Considerations Admin order of multiple meds: 1)beta2-agonist 2)anticholinergics 3)steroids Asses lung sounds for cough, wheezing Monitor for dysrhythmias, restlessness wait 5 min to admin #2 inhaled med wait 1-2 min to take 2nd dose of same inhaled med Report SOB not relieved by med to PHCP immediately Inhaler, spacer, nebulizer instruction Order & timing of meds if multiple Suck on sugarless candy for dry mouth & throat irritation Tiotropium (long acting), ipratropium (short acting), & aclidinium Common generics: Blocks muscarinic receptors in the bronchi and inhibits parasympathetic response and bronchoconstriction Action Indication: Asthma, exercise-induced asthma, COPD Serious Adverse Reactions: Rare - blurred vision, palpitations, bronchospasm, urinary retention. Most common are dry mouth and irritation of the throat ipratropium Contraindicated in: Patients with peanut allergy, soy lecithin Patient Education GLUCOCORTICOIDS (CORTICOSTEROIDS) CLASS T: Bronchodilator P: Anticholinergic SUFFIX: -tropium, -clididiun Nursing Considerations Monitor - For infection - Glucose level, electrolytes - Can be used alone or with beta2 agonist - No NSAIDs - Dose during increased stress, e.g., surgery Do Not stop med abruptly taper dose No NSAIDs Not a rescue inhaler use spacer, rinse mouth after use Inhaled budesonide, beclomethasone, fluticasone; oral prednisone, prednisolone Common generics: Anti-inflammatory agents reduce edema in the airways and have an antistress, antiallergic affect. *affect glucose, protein, and bone; an immunosuppressant masks s/s of infection Action Indication: Asthma, other inflammatory respiratory conditions Serious Adverse Reactions: Hyperglycemia, hypokalemia ( K), osteoporosis, PUD, GI bleeding, pancreatitis, infections Contraindicated w/hypersensitivity, fungal infections. Caution in patients with diabetes, infections Patient Education SUFFIX: -asone, -onide, -olone CLASS T: Anti-inflammatory P: Corticosteroid # 281 LEUKOTRIENE MODIFIERS # PHARMACOLOGY RESPIRATORY MEDS Nursing Considerations Assess - Treatment effectiveness - Lung function - Liver function tests - Renal function tests Not for acute attack! Use prescribed rescue inhaler Do Not discontinue med w/o PCHP Take on empty stomach Montelukast, zafirlukast, zileuton (remember luk = affects leukotrienes) Common generics: Inhibits effects of leukotrienes, dilates smooth muscle, and reduces airway edema *leukotrienes play key role in inflammation Action Indication: Treatment & prevention of chronic asthma, seasonal allergies Not for acute attack! Serious Adverse Reactions: Headache, N/V, indigestion, diarrhea, back & generalized pain Contraindicated in : Hypersensitivity, caution with impaired liver function Patient Education NASAL DECONGESTANTS SUFFIX: -lukast Nursing Considerations Monitor - For dysrhythmias - Blood glucose - If taking OTC meds Avoid caffeine, palpitations, nervousness >48-hour use can cause rebound congestion Pseudoephedrine, oxymetazoline; includes adrenergic, anticholinergic, and corticosteroids Common generics: Shrinks respiratory mucosa and reduces fluid secretion ( inflammation), relieves sinus pain & congestion Action Indication: Rhinitis, sinusitis, common cold Serious Adverse Reactions: Rebound congestion, palpitations, nervousness, HTN, Contraindicated in HTN, heart disease, diabetes, hyperthyroidism Patient Education SUFFIX: -ephrine, -zoline Only beta2-agonists for bronchospasm! CLASS T: Nasal decongestant P: Nasal decongestant CLASS T: Anti-inflammatory P: Leukotriene receptor antagonist # 282 EXPECTORANTS # PHARMACOLOGY RESPIRATORY MEDS Nursing Considerations Assess - Lung sounds - Secretions characteristics - Admin with glass of water fluid intake cough & deep breathe Guaifenesin Common generics: Reduces viscosity and loosens bronchial secretions to make cough more productive Action Indication: Unproductive cough Serious Adverse Reactions: Headache, nausea, vomiting, rash; prolonged use can mask serious underlying cause of cough Contraindicated in: hypersensitivity, caution in pregnancy & lactation Patient Education MUCOLYTICS Nursing Considerations Monitor for side effects Do Not mix acetylcysteine admin via nebulizer with any other medication Iif admin w/bronchodilator, admin bronchodilator first, wait 5 minutes and then admin acetylcysteine 1) bronchodilator 2) wait 5 minutes 3) acetylcysteine fluid intake Cough & deep breathe Acetylcysteine Common generics: Breaks down mucus secretions making cough more productive Action: Indication: Cystic fibrosis (CF), COPD or other with thick mucus (inhaled); an antidote for acetaminophen overdose (IV); protects kidneys prior to dx testing with contrast dye (IV) Serious Adverse Reactions: possible anaphylaxis with IV admin; common - nausea, vomiting, stomatitis (inflammation, sores in mouth) acetylcysteine contraindicated in patients with asthma; airway resistance dextromethorphan, a cough suppressant, is contraindicated in patients with COPD Patient Education CLASS T: Expectorant P: Expectorant CLASS T: Mucolytic agent P: Acetaminophen antidote # 283 OPIOID ANTAGONISTS # PHARMACOLOGY RESPIRATORY MEDS Nursing Considerations Monitor every few min. until stable: BP; RR & rhythm, depth; pulse; EKG Do not leave unattended, monitor 3-5 hours Watch for opioid overdose s/s to return RR <12, unarousable give second dose if needed IV dose is titrated every 2 5 minutes as prescribed O2 & resuscitative equipment available Naloxone, naltrexone, methylnaltrexone, alvimopan (for opioid-induced constipation) Common generics: Blocks the effects of opioids Action: Indication: Reverses respiratory depression & CNS depression in opioid overdose Serious Adverse Reactions: Ventricular fibrillation, tachycardia, hypotension, hypertension, flushing; more common - opioid withdrawal s/s: anxiety, N/V, diarrhea, abdominal pain Contraindicated: Contraindicated: Not for use in nonopioid respiratory depression, pregnancy unknown, lactation Nursing Considerations Common generics: Action: Indication: Serious Adverse Reactions: Patient Education SUFFIX: -terol SUFFIX: CLASS T: Expectorant P: Expectorant CLASS T: P: Opioid antagonists reverses effects of analgesics! 284 - Inhibits synthesis of thyroid hormones (T4 & T3) - Destroys thyroid producing cells ACTION: ANTITHYROID DRUGS THIONAMIDES & IODINE - Hyperthyroidism - Given PRIOR to prevent surge of thyroid hormones during thyroidectomy or radioactive iodine therapy - Tx of thyroid cancer (RAIU) - Thyrotoxicosis USES: # PHARMACOLOGY ENDOCRINE SIDE EFFECTS: * Anxiety, Agitation * Tachycardia, Palpations * Heat intolerance, Sweating, Fever * Alerted appetite, ABD cramping - Thyroid storm (overuse of levothyroxine) - Synthetic thyroid hormone replacement (T4) that increases HR, RR, cardiac output, body temp, & metabolism of fats, protein, & carbs ACTION: - Pregnancy Risk Category A - Recent MI, Cardiac disorders (HTN, angina, ischemic heart disease) - Hyperthyroidism, Diabetes - Severe Renal Insufficiency, Uncorrected adrenocortical diseases - Older adults CONTRAINDICATIONS/PRECAUTIONS: THYROID HORMONE - Hypothyroidism - Hormone supplement after thyroidectomy - Emergency Tx for myxedema coma USES: - Educate pt that levothyroxine is a LIFE-LONG med (adjustments to dosage if needed is normal) - Begins at low dose & gradually increases over several weeks (6-8 weeks) - DO NOT discontinue med abruptly (everything starts to decrease = Myxedema coma = DEATH!) - Monitor TSH & T4 hormone levels - Take on EMPTY stomach 30-60 mins before breakfast (DO NOT take at night) - Watch for signs of thyroid storm NURSING CONSIDERATIONS: MED NAME > LEVOTHYROXINE - methimazole - propylthiouracil (PTU) THIONAMIDES - Radioactive Iodine Uptake (RAIU) IODINE 285 PHARMACOLOGY ENDOCRINE - Increases sensitivity to insulin - Decrease hepatic glucose production - Decreases intestinal glucose absorption ACTION: ORAL ANTIDIABETIC AGENTS BIGUANIDE - Type 2 diabetes - Polycystic ovary syndrome (PCOS) USES: SIDE EFFECTS: Thionamides - Hypothyroidism - Agranulocytosis (decreased WBC), Rash, Fever - H/A, Drowsiness - Diarrhea, N/V, Hepatitis Iodine - Hypothyroidism, Bone marrow depression - N/V, Neck swelling & tenderness - Metallic taste, Swollen saliva glands, Loss of taste, Dry mouth, Sore throat - NOT SAFE! Pregnancy Risk Category D, Breastfeeding (Thionamides) - NOT SAFE! Pregnancy Risk Category X, Breastfeeding (Iodine) CONTRAINDICATIONS/PRECAUTIONS: Both - Monitor for signs of hypothyroidism (cold intolerance, weight gain, edema, depression, bradycardia, dry skin, etc.) - AVOID foods & meds containing iodine (shellfish, iodized salt, aspirin) - AVOID pregnancy (use contraceptives) Thionamides - Therapeutic effects can take 3-4 weeks - Do NOT abruptly stop, Take SAME TIME each day (regular around-the-clock interval) - Monitor weight 2-3x a week & notify HCP if significant weight gain Iodine - Therapeutic effects can take 2-3 months - After treatment, for 7 days: * STAY 6 ft AWAY FROM OTHERS & PUBLIC PLACES (especially pregnant women & children) * Do NOT share utensils, food, toilet (flush 3x after use), etc. - Remove jewelry & other metallic objects during radiation treatment - DISCONTINUE antithyroid meds about 3 days before procedure - NO food or drinks after midnight NURSING CONSIDERATIONS: MOST IMPORTANT - TYPE 1 DIABETES: Insulin ONLY - TYPE 2 DIABETES: Insulin and/or Oral Antidiabetic Agents > Insulin and/or Oral Antidiabetic Meds should be used CONCURRENTLY with healthy diet & exercise to improve management of type 2 diabetes - metaformin # 286 PHARMACOLOGY ENDOCRINE SIDE EFFECTS: - LACTIC ACIDOSIS (greatest risk in severe kidney impairment pts.) * Diarrhea, abdominal pain, hypotension, bradycardia, hyperventilation, SOB, myalgia (muscle pain), malaise - N/V, Diarrhea - Bloating, Flatulence - Decreased vitamin B12 levels - Hypoglycemia (occurs if metaformin & insulin or other antidiabetic agent used concurrently) - Pregnancy Risk Category B, Lactation - Kidney & Liver Impairment - Alcohol Use - Lodinated Contrast used for radiologic imaging (discontinue metaformin 48 hours PRIOR & resume 48 hours AFTER if kidney function is at normal level) - Surgery requiring NPO (no food or fluids by mouth) - Infection, Hypoxic conditions (shock, sepsis, MI, acute HF) CONTRAINDICATIONS/PRECAUTIONS: - Pregnancy Risk Category C, Lactation - Sulfonamide allergy - Kidney & Liver impairment - Alcohol Use - Type 1 Diabetes - Cardiovascular Diseases (HF, MI) - Diabetic Coma, DKA MEDS - Beta Blockers (mask signs of hypoglycemia) - NSAIDS, Antibiotics, Ranitidine, Cimetidine (additive hypoglycemia effect) CONTRAINDICATIONS/PRECAUTIONS: - Take with meals - Closely monitor kidney function levels - Closely monitor for hypoglycemia (if taking concurrently with other antidiabetic drugs) - DISCONTINUE metaformin if symptoms of LACTIC ACIDOSIS occurs & notify HCP - DISCONTINUE if requiring NPO status or use of iodinated contrast - AVOID alcohol - Use contraceptives (if become pregnant, INSULIN is the recommended drug of controlling blood sugar during pregnancy) NURSING CONSIDERATIONS: Metaformin can be started ALONE or in combination with insulin or other oral antidiabetic agents (risk for hypoglycemia) SULFONYLUREAS ## - glipizide - glyburide - glimepiride - Reduces blood sugar by releasing insulin from pancreas - Increases sensitivity to insulin ACTION: - Type 2 diabetes USES: # 287 PHARMACOLOGY ENDOCRINE - Pregnancy Risk Category C, Lactation - Kidney & Liver Impairment - Alcohol Use - Type 1 Diabetes - Diabetic Coma, DKA - Older adults MEDS - Gemfibrozil CONTRAINDICATIONS/PRECAUTIONS: MEGLITINIDES (GLINIDES) ## - repaglinide - nateglinide - Reduces blood sugar by releasing insulin from pancreas - Short/rapid duration than sulfonylureas (taken 3x/day because of this) ACTION: - Type 2 diabetes USES: - Take 30 mins BEFORE meal (glipizide) - Take with breakfast or with FIRST main meal of the day (glimepiride, glyburide) - If experiencing signs of hypoglycemia, drink orange juice or take 2-3 tsp of sugar, honey, or corn syrup - Carry sugar (candy, sugar packages) AT ALL TIMES - AVOID alcohol - Wear sunscreen (due to photosensitivity) - Use contraceptives (if become pregnant, INSULIN is the recommended drug of controlling blood sugar during pregnancy) NURSING CONSIDERATIONS: SIDE EFFECTS: - Hypoglycemia (tachycardia, palpations, sweating, tremors, weakness, anxiety) - Photosensitivity - N/V, Diarrhea - Epigastric pain, Heartburn - Weight gain - Weakness - Taken 3x/day & 30 mins BEFORE meals - If experiencing signs of hypoglycemia, drink orange juice or take 2-3 tsp of sugar, honey, or corn syrup - Carry sugar (candy, sugar packages) AT ALL TIMES - AVOID alcohol - Use contraceptives (if become pregnant, INSULIN is the recommended drug of controlling blood sugar during pregnancy) NURSING CONSIDERATIONS: SIDE EFFECTS: - Hypoglycemia (tachycardia, palpations, sweating, tremors, weakness, anxiety) - Weight gain - Chest pain, Headache - Common cold symptoms (congestion, sneezing, sore throat) # 288 PHARMACOLOGY ENDOCRINE - Pregnancy Risk Category C, Lactation - Pregnancy risk in women (may restore ovulation) - HEART FAILURE pts. - Hx of BLADDER CANCER - Kidney & Liver impairment - Type 1 Diabetes, DKA CONTRAINDICATIONS/PRECAUTIONS: THIAZOLIDINEDIONES (GLITAZONES) - pioglitazone - rosiglitasone - Decreases insulin resistance by increasing glucose uptake in body cells - Increases sensitivity to insulin - Decreases glucose production ACTION: - Type 2 diabetes USES: - Take with or without meals - Watch for signs of HF, BLADDER CANCER, & LIVER DYSFUNCTION - Closely monitor liver function levels (due to LIVER DYSFUNCTION )- To AVOID pregnancy, advise women to use effective barrier contraceptive (thiazolidinediones reduces contraceptive effect) * if become pregnant, INSULIN is the recommended drug of controlling blood sugar during pregnancy NURSING CONSIDERATIONS: SIDE EFFECTS: - Fluid retention (can lead to HF & be fatal to preexisting HF pts.) - HEART FAILURE * Edema, SOB, crackle lung sounds, rapid weight gain, tiredness - Elevated LDL cholesterol level - LIVER DYSFUNCTION * Elevated liver enzymes, N/V, fatigue, abdominal pain, dark urine, jaundice, itching, anorexia (loss of appetite), clay-colored stool - Bone fractures in women - BLADDER CANCER * Hematuria, urinary urgency, dysuria # 289 - Give subcutaneous (SC); choose area with adequate fat (abdomen, underneath arm, upper thighs, buttocks) REMEMBER! pinch skin up. - Rotate injection sites - Watch for HYPOglycemia (sweaty, dizzy, weak, H/A, confused, high HR) - ONLY mix short (regular & intermediate (NPH) insulin - Draw out CLEAR (regular) before CLOUDY (NPH) to avoid contamination. - Gently roll vial between hands. DO NOT SHAKE. - Once an insulin vial has been punctured, before every use, clean the top with an alcohol wipe. # PHARMACOLOGY INSULIN TYPES RAPID Meds: Lispro, aspart, glulisine onset: 5-30 mins. peak: 30-90 mins. duration: 3-5 hrs. - Take before meals SHORT Meds: Regular (CLEAR) onset: 30-60 mins. peak: 2-4 hrs. duration: 5-7 hrs. - Take before meals - Given IV - Mixed with NPH INTERMEDIATE Meds: NPH (CLOUDY) onset: 1-2 hrs. peak: 4-10 hrs. duration: 14-24 hrs. - Take during meals & at night (2x/day) - NEVER given IV LONG Meds: Glargine, detemir onset: 1-2 hrs. peak: NONE duration: 24 hrs. + - Take ONCE daily at the same time each day - CANNOT be mixed KEY POINTS INSULIN INSULIN > INSULIN INSULIN Inject air NPH (cloudy) Inject air regular (clear) Draw out regular (clear) Draw out NPH (cloudy) # 290 PHARMACOLOGY MUSCULOSKELETAL DRUGS ANTIGOUT CLASS T: Antigout Agent P: Xanthine Oxidase Inhibitor Allopurinol (Zyloprim) Inhibits xanthine oxidase which decreases uric acid production ACTION: Treatment and prevention of gouty arthritis attacks, manage hyperuricemia INDICATION: ADVERSE REACTIONS: - Nausea - Vomiting - Diarrhea - Hypersensitivity - Bone marrow suppression - Caution in patients with hepatic - Renal - Cardiovascular - GI disease CONTRAINDICATED: Monitor - Assess uric acid level - I&O, CBC w/diff, LFT, RFT, glucose - Fluid intake of 2000-3000 mL/day (kidney stones) NURSING CONSIDERATIONS: - Report flu-like symptoms, rash, or fever - Report urinary changes, jaundice - No aspirin - can cause flare up - Avoid high purine foods red meat, organ meat, sardines, alcohol, caffeine PATIENT EDUCATION ## CLASS T: Antigout Agent P: Antigout Agent Colchicine (Colcrys) Disrupts leukocytes (WBC) reducing the inflammatory response uric acid ACTION: Treatment and prevention of acute gouty arthritis flare ups INDICATION: SERIOUS ADVERSE REACTIONS: - Nausea - Vomiting - Diarrhea - Headache - Alopecia - Bone marrow suppression - AST and ALT - Rhabdomyolysis Renal and hepatic impairment; - Caution in renal impairment - Alcoholism - GI disease - Older patients CONTRAINDICATED: Monitor - LFT, RFT, CBC w/differential - I&O, respiratory status - If GI s/s withhold med & notify PHCP NURSING CONSIDERATIONS: - Avoid high purine foods - Avoid grapefruit juice - No aspirin - can cause flare up - Report nausea, vomiting, diarrhea, bruising, bleeding, rash - Report dark or urine, muscle pain/weakness (rhabdo) PATIENT EDUCATION Increases effects of anticoagulants (warfarin), immunosuppressants (azathioprine), oral hypoglycemics (metformin) Given with an NSAID or colchicine can help prevent acute attacks during initiation of therap # !! > # 291 PHARMACOLOGY MUSCULOSKELETAL DRUGS ## CLASS T: Antigout P: Uricosuric Probenecid (Generic only) Probenecid inhibits the reabsorption of uric acid in the tubules more excretion and lower serum uric acid levels ACTION: Treats hyperuricemia associated with gout INDICATION: ADVERSE REACTIONS: - Nausea - Vomiting - GERD - Dizziness - Headache - Flushing - Hypersensitivity - Aspirin therapy (salicylates) - Uric acid kidney stones - Not for initiation during an acute gout attack CONTRAINDICATED: Monitor - Assess uric acid level - I&O, CBC w/differential - LFT, RFT, glucose - Fluid intake of 2000-3000 mL/day (kidney stones) NURSING CONSIDERATIONS: - Take with food to avoid mild GI s/s - No aspirin - can cause flare up PATIENT EDUCATION aspirin uric acid levels # > OSTEOPOROSIS MEDICATIONS ## CLASS T: Antigout Agent P: Antigout Agent Calcitonin-Salmon (Miacalcin) Inhibits osteoclastic bone resorption and promotes renal excretion decrease in serum calcium ACTION: Treat postmenopausal osteoporosis, hypercalcemia, Pagets disease of bone INDICATION: SERIOUS ADVERSE REACTIONS: - Hypersensitivity - Anaphylaxis - Nausea - Vomiting - Diarrhea - Flushing of face - Itching - Tingling palms - Hypersensitivity - Allergy to fish CONTRAINDICATED: Assess - For fish allergies - For tetany (Trousseaus & Chvosteks signs) Monitor - EKG, calcium levels (9-11 mg/dL) - Check nostrils for irritation w/intranasal rt NURSING CONSIDERATIONS: - Take medication exactly as directed - Diet - calcium & vitamin D - Report rash, hives, wheezing, swelling of - Face, lips, tongue PATIENT EDUCATION Medications that decrease bone resorption (breakdown) and promote bone formation # 292 PHARMACOLOGY MUSCULOSKELETAL DRUGS ## CLASS T: Antihypercalcemic P: Monoclonal Antibody, RANKL inhibitor Denosumab (Prolia and Xgeva) Binds to RANKL and inhibits osteoclast formation leading to bone resorption & bone density; RANKL (receptor activator of nuclear factor kappa-B ligand) ACTION: - Osteoporosis, - Cancer-related hypercalcemia - Bone cancer INDICATION: SERIOUS ADVERSE REACTIONS: - Fatigue - Rash - Hypocalcemia - Hypophosphatemia - Hypercholesterolemia - SOB - Peripheral edema - Weakness - Back pain - Musculoskeletal pain - Osteonecrosis of the jaw - Hypersensitivity - Hypocalcemia - Pregnancy CONTRAINDICATED: Monitor - For pregnancy, breastfeeding - Ca+, vit D, K+, phosphorous levels before administration - Monitor creatinine, Ca+ and vit D NURSING CONSIDERATIONS: - Have dental check-ups regularly - Notify HCP if pregnancy possible - Notify HCP of muscle cramps, numbness, tingling, fever, red or swollen skin, jaw pain, SOB, severe stomach or back pain PATIENT EDUCATION ## CLASS T: Antihypercalcemic P: Biphosphonate Alendronate (Fosamax), Ibandronate (Boniva), Pamidronate (Aredia), Risedronate (Actonel), Zoledronic acid (Zometa) Inhibits osteoclastic bone resorption decreased serum calcium and increased total bone mass ACTION: Postmenopausal osteoporosis, male osteoporosis, Pagets disease of bone, hypercalcemia associated with cancer INDICATION: ADVERSE REACTIONS: - Esophagitis - Acid reflux - Muscle pain - Eye inflammation; hypo- calcemia, -phosphatemia, -kalemia, -magnesia - Esophageal disorders - Unable sit upright for 30 minutes CONTRAINDICATED: Monitor - Electrolyte levels, vit D - baseline & therapy - CBC w/differential - Admin on empty stomach w/water - Teach patient adequate fluids, dental care NURSING CONSIDERATIONS: - Take in morning w/full glass of water, before any food, beverage - Sit upright for 30 minutes no food, beverage - Report side effects PATIENT EDUCATION # 293 PHARMACOLOGY ANTIBIOTICS ANTIBIOTICS OVERVIEW - Antibiotics fights off BACTERIAL INFECTIONS (NOT viral infections) - ALWAYS ask pt about allergies to antibiotic > manifestations: skin rash, urticaria, pruritus, wheezing, bronchospasms, angioedema, hypotension, chills. - Take FULL course. Educate pt to NOT discontinue med if feeling better (infection is NOT completely gone) - NO ALCOHOL (antibiotics are already hard on the liver) - SUPERINFECTION! Secondary infection because of antibiotic use (Candidiasis/Thrush, C-diff, Vaginal yeast infection) > prevent superinfection by taking yogurt, buttermilk, or Acidophilus capsules. - Culture & Sensitivity is ALWAYS performed (determines the type of bacteria & which med to use) before giving antibiotics. Binds to the bacterial wall to weaken & destroy ACTION: - Pneumonia, meningitis, endocarditis, pharyngitis - Septicemia - STI (syphilis) - Given as a prophylaxis (prevention) against potential bacterial infections USES: - Penicillin or Cephalosporin Allergy - Older adults, Kidney impairment - Pregnancy Risk Category C - PREGNANCY SAFE! Take EXTRA contraceptive if want to AVOID pregnancy (penicillin reduces contraceptive effect) CONTRAINDICATIONS/PRECAUTIONS: ANTIBIOTICS: DISRUPTS BACTERIAL CELL WALL PENICILLIN (-CILLIN) Broad-Spectrum - penicillin G - penicillin V - amoxicillin - oxacillin - nafcillin - ampicillin - piperacillin SIDE EFFECTS: - ANAPHYLACTIC REACTION - SUPERINFECTION - GI upset (N/V, Diarrhea, Abdominal pain) * Skin rash, urticaria, pruritus * Wheezing, bronchospasms, angioedema * Hypotension, chills Candidiasis/Thrush (swollen tongue, gums, & throat; ulcers or a black, furry tongue) > penicillin given oral * Dry mouth * Phlebitis at IV site * Hematologic changes (aplastic anemia, thrombocytopenia, leukopenia) # 294 PHARMACOLOGY ANTIBIOTICS - Ask PRIOR to administration about penicillin allergy > if allergic to penicillin, likely the pt is also allergic to cephalosporins (cross-sensitivity) - Stay with pt for 30 mins to watch for possible reaction - If reaction occurs > stop med, assess type of reaction, listen to lung sounds, & give epinephrine - Closely monitor for bleeding (monitor CBC) - Monitor for signs of infection (leukopenia) & easy bruising (thrombocytopenia) > handle pt with care - Closely watch for signs of a fungal superinfection (withhold med & notify the HCP) - Pregnancy & Lactation SAFE! But oral contraceptives are INFECTIVE if taking penicillin (use additional contraceptive if want to avoid pregnancy) - Take with glass of water on an empty stomach -- 1 hour before meal OR 2 hrs after meal (other penicillins) - Take with food if GI upset (penicillin V & amoxicillin) - Shake oral suspension well NURSING CONSIDERATIONS: Broad-Spectrum ## - cephalexin - cefazolin - cefaclor - ceftriaxone - cefepime - ceftaroline CEPHALOSPORIN (CEPH-, CEF-) SIDE EFFECTS: - ANAPHYLACTIC REACTION - SUPERINFECTION * Skin rash, urticaria, pruritus * Wheezing, bronchospasms, angioedema * Hypotension, chills C-diff > BAD diarrhea (loose, foul-smelling, black, tarry stool; ABD pain & cramping; fever) - Pain & tenderness at site given IM - Phlebitis or Thrombophlebitis at site given IV Binds to the bacterial wall to weaken & destroy ACTION: - Given as a prophylaxis (prevention) for pre-, intra-, & post- operative surgery - Primary drug to prevent STI following a sexual assault - UTI - Respiratory & bone infections - Otitis media (ear infection) USES: - Penicillin or Cephalosporin Allergy - Kidney impairment, Bleeding tendencies - Pregnancy Risk Category B - PREGNANCY SAFE! Take EXTRA contraceptive if want to AVOID pregnancy (cephalosporin reduces contraceptive effect) CONTRAINDICATIONS/PRECAUTIONS: # 295 PHARMACOLOGY SIDE EFFECTS: - RED MANS SYNDROME - OTOTOXICITY - NEPHROTOXICITY * Sudden hypotension, flushing, pruritus * Redness of face, neck, chest, back, & extremities * Throbbing neck or back pain - Phlebitis or Thrombophlebitis at site given IV - Binds to the bacterial wall to weaken & destroy - Fights VERY serious infections (MRSA, C-diff) that does not respond to other antibiotics ACTION: - MRSA - C-diff - Endocarditis, meningitis, osteomyelitis - Pneumonia, septicemia USES: - Corn Allergy, Vancomycin Allergy - Kidney impairment, Hearing loss - Pregnancy Risk Category C, Breastfeeding CONTRAINDICATIONS/PRECAUTIONS: - Ask PRIOR to administration about cephalosporin allergy > if allergic to penicillin, likely the pt is also allergic to cephalosporin, high chance pt is also allergic to penicillin (cross-sensitivity) - Stay with pt for 30 mins to watch for possible reaction - If reaction occurs > stop med, assess type of reaction, listen to lung sounds, & give epinephrine - Closely watch for signs of a C-diff superinfection (withhold med & notify the HCP) - Cephalosporins DO NOT treat C-diff, but can CAUSE C-diff - Regularly check IM or IV site - Pregnancy & Lactation SAFE! But oral contraceptives are INFECTIVE if taking cephalosporin (use additional contraceptive if want to avoid pregnancy) - Take with food to decrease GI upset NURSING CONSIDERATIONS: GLYCOPEPTIDE Highly T oxic & A Very Strong Med # - vancomycin - Closely monitor & report for signs of red mans syndrome (to prevent, give SLOW infusion over 1 hour) - Closely monitor & report for ear toxicity (vertigo, tinnitus) - Closely monitor & report for kidney toxicity (elevated BUN & creatinine, low urine output) - Regularly check IV site (vancomycin is VERY strong, so it irritates the skin & BURNS) - ALWAYS check peak/through level 15-30 mins BEFORE giving next dose * Therapeutic Vancomycin Range: 10-20 * Toxicity: > 20 NURSING CONSIDERATIONS: ANTIBIOTICS # 296 - Increase fluid intake (prevent crystal formation OR if already formed, to reduce pain during urination) - Take folic acid - Wear sunscreen & avoid direct sun exposure (photosensitivity) - Closely monitor for bleeding (monitor CBC) - Monitor for signs of infection (leukopenia & easy bruising (thrombocytopenia) > handle pt with care - Take with glass of water on an empty stomach -- 1 hour before meal OR 2 hrs after meal - Take with food if GI upset (sulfasalazine) - NOT PREGNANCY SAFE! Oral contraceptives are INFECTIVE (use additional contraceptive to avoid pregnancy) NURSING CONSIDERATIONS: ## - sulfadiazine - sulfasalazine - sulfamethoxazole SULFONAMIDES (SULFA-) Inhibits the activity of folic acid to stop bacterial growth ACTION: - UTI (associated with E.coli) - Otitis media - Ulcerative colitis - 2nd & 3rd degree burn SIDE EFFECTS: - N/V, Anorexia (loss of appetite) - Diarrhea, ABD pain, Stomatitis + Chills, Fever - Crystalluria (crystals in urine) - Photosensitivity - Hematologic changes (aplastic anemia, thrombocytopenia, leukopenia) - NOT PREGNANCY SAFE! Pregnancy Risk Category D, Breastfeeding (jaundice & hemolytic anemia to newborn if med given during last trimester of pregnancy) - Sensitivity to sulfonamides - Kidney & Liver impairment CONTRAINDICATIONS/PRECAUTIONS: # PHARMACOLOGY USES: ANTIBIOTICS # 297 PHARMACOLOGY ANTIBIOTICS ANTIBIOTICS: INTERFERES DNA/RNA SYNTHESIS ## - ciprofloxacin - gemifloxacin - levofloxacin FLUOROQUINOLONES (-FLOXACIN) Interferes with bacterial DNA synthesis causing bacterial cell death ACTION: -UTI - STI - Anthrax - Lower respiratory infections (pneumonia, etc.) - Bone & joint infections USES: SIDE EFFECTS: - Nausea, Diarrhea, ABD pain - Dizziness, H/A, Restlessness - Photosensitivity - ACHILLES TENDON RUPTURE - SUPERINFECTION Candidiasis/Thrush, C-diff, or Vaginal yeast infection (susceptible to any of these) - Pregnancy Risk Category C - Children younger than 18 years (increased risk of Achilles tendon rupture) - Concurrent use of corticosteroid (increased risk of tendonitis & tendon rupture) - Kidney impairment, Cardiac diseases - Older adults, CNS disorder CONTRAINDICATIONS/PRECAUTIONS: - Closely watch for signs of a superinfection (withhold med & notify the HCP) - Report new muscle pain, redness, & swelling at the achilles tendon (withhold med & notify the HCP) - Wear sunscreen & avoid direct sun exposure (photosensitivity) - Take with glass of water without regard to food (if GI upset, take ciprofloxacin with food) NURSING CONSIDERATIONS: # 298 PHARMACOLOGY ANTIBIOTICS Tetracyclines Aminoglycosides doxycycline (Vibramycin), minocycline (Minocin), tetracycline (Sumycin) Common generics: amikacin, gentamicin, neomycin, tobramycin (TOBI, Tobrex, Bethkis) streptomycin (highly toxic) Common generics: acne, skin infections, chlamydia, gonorrhea, syphilis, travelers diarrhea, periodontitis, inhalation & cutaneous anthrax, legionnaires disease, Mycoplasma, Rickettsia Indication: gram-negative aerobic bacterial infections, staphylococcus, and when penicillin is contraindicated; (e.g., infections of blood, bone, skin, UTI, meningitis, pneumonia) neomycin bowel surgery prophylaxis Indication: inhibits protein synthesis in the bacterial cell preventing it from multiplying Action: inhibits protein synthesis in the bacterial cell leading to death of the cell Action: Monitor Nursing Considerations hypersensitivity, pregnancy, lactation, children <12 years (teeth & bones) hepatic or renal disease, Myasthenia gravis; use with penicillins, isotretinoin (Accutane) RFT, LFT, CBC w/differential amylase and lipase Monitor Nursing Considerations RFT, LFT, CBC w/differential peak and trough levels prior to next dose IV site every 30 minutes for s/s toxicity I&O & nutrition Patient Education take medication as directed/finish all avoid milk, calcium, antacids take on empty stomach report rash, fever, bloody diarrhea oral contraceptives < effective Patient Education drink plenty of fluids finish all medication as directed report tinnitus, vertigo, dizziness, rash report palpitations, problems urinating Contraindicated: hypersensitivity, pregnancy & lactation, patients on neuromuscular blockers, IBD, Parkinsons, myasthenia gravis Contraindicated: nausea, vomiting, diarrhea, photosensitivity, rash, bone marrow suppression, superinfection, hepatotoxicity, anaphylaxis Serious Adverse Reactions: nephrotoxicity, ototoxicity, neuromuscular blockade, ALT, AST, confusion, dizziness, ataxia, palpitations, hypo/hypertension, allergic reaction Serious Adverse Reactions: CLASS T: Antibiotic P: Tetracycline CLASS T: Antibiotic P: Aminoglycoside SUFFIX: -cycline SUFFIX: -mycin, -micin # 299 PHARMACOLOGY ANATOMY OF THE BRAIN HYPOTHALAMUS FRONTAL LOBE THALAMUS THIRD VENTRICLE PARIETAL LOBE PINEAL GLAND OCCOPOTAL LOBE CEREBELLUM MEDULLA OBLONGATA PITUITARY GLAND TEMPORAL LOBE MIDBRAIN PONS - Maintains homeostasis - Maintains heart rate and blood pressure Auditory - Language comprehension - Memory of language and speech - Expression of emotions Reflex center - Balance - Heart rate - Respiration rate Vision - Interpret visual images - Visual memories - Visual association Sensory and motor actions - Receive sensory information - Body awareness - Left/right orientation - Reading, math - Formation of concepts Thought processes - Decision making - Judgement - Planning - Insight - Motivation - Voluntary motor actions - Controls endocrine gland / hormones - Pupil reflex - Eye movements - Processing for auditory pathways - Muscle contraction and coordination - Equilibrium - Regulates some hormones including melatonin - Protects brain from injury - Transports nutrients and waste - Relays sensory and motor functions - Regulates consciousness # 300 ACETYLCHOLINE FUNCTION: Regulates muscle contraction, dilation of blood vessels, bodily secretions, and slowing of heart rate. EXCESS: Muscle weakness, cramps, paralysis, blurry vision. DEFICIENCY: Cognitive decline, memory loss, Alzheimers Disease. NOO CH 3CH 3H C 3H C 3+PHARMACOLOGY NEUROTRANSMITTERS DOPAMINE FUNCTION: Regulation of movement, pleasure, attention, mood, motivation, reinforcement, reward. EXCESS: Mania, hallucinations, poor impulse control, anxiety, high energy, difficulty sleeping. DEFICIENCY: Depression, shaking or tremors, changes in coordination, lack of pleasure. HO HO NH 2GABA FUNCTION: Inhibits/reduces neuronal activity. Regulates behavior, cognition, and stress. EXCESS: Decreased brain activity, hypersomnia, daytime sleepiness. DEFICIENCY: Mood disorders, epilepsy, seizures. HO ONH 2SEROTONIN FUNCTION: Regulation of mood, happiness, and anxiety. EXCESS: Altered mental status, tremors, rigidity, muscle spasms, tachycardia, hypertension, sweating, fever. DEFICIENCY: Depressed mood, anxiety, aggression, impulsive behavior, irritability, insomnia. HO NH 2NH NOREPINEPHRINE FUNCTION: Regulation of the sympathetic nervous system. Increases heart rate and blood pressure. EXCESS: High blood pressure, excessive sweating, anxiety. DEFICIENCY: Depression, anxiety, changes in blood pressure and heart rate, low blood sugar, difficulty sleeping. HO HO OH NH 2 # 301 PHARMACOLOGY ANTI-ANXIETY AND HYPNOTIC DRUGS GABA: Major inhibitory/calming neurotransmitter in the central nervous system. - Promotes the activity of GABA, causing a calming effect. - Therapeutic uses: * Anxiety and panic disorders * Insomnia * Seizure disorders and muscle spasms * Alcohol withdrawl - Can cause: * Central nervous system depression * Decreased motor ability and concentration - Toxicity: * Respiratory depression, extreme hypotension, cardiac arrest. BENZODIAZEPINES GENERIC BRAND alprazolam lorazepam diazepam triazolam clonazepam temazepam midazolam Xanax Ativan Valium Halcion Klonopin Restoril Versed - Provides a sedative effect without anti-anxiety or muscle relaxant effects. - Very fast onset of action, but short duration of action. - Patient should take the medication when they are ready to go to bed. Z-HYPNOTICS GENERIC BRAND eszopiclone zaleplon zolpidem Lunesta Sonata Ambien - Reduces anxiety without sedative or hypnotic effects. - Not a central nervous system depressant. - Boosts serotonin levels. - May cause dizziness and insomnia. BUSPIRONE GENERIC BRAND buspirone BuSpar MEDICATION FOR SUBSTANCE ABUSE - Benzodiazepines: * Diazepam * Lorazepam - Decrease withdrawal symptoms ALCOHOL - Methadone substitution - Clonidine - Buprenorphine - Decrease withdrawal symptoms OPIOIDS - Bupropion - Nicotine gum, patch, etc. - Varenicline - Decrease cravings for nicotine NICOTINE # 302 PHARMACOLOGY ANTIDEPRESSANT DRUGS - Alleviates deficiency of: SEROTONIN, NOREPINEPHRINE + DOPAMINE - May take 4-6 weeks to notice therapeutic effects. - Advise patients to avoid alcohol consumption or stopping medication abruptly. SSRIs - Block the reuptake of serotonin, making more available. - Used to treat: * Depression * Panic disorders, PTSD, OCD - May cause: * Sexual dysfunction * Insomnia, agitation, anxiety * Weight changes - Serotonin syndrome: an excess of serotonin in the body: * Confusion, fever, hallucinations, agitation, abdominal pain, tremors. GENERIC BRAND fluoxetine sertraline paroxetine citalopram escitalopram fluvoxamine Prozac Zoloft Paxil Celexa Lexapro Luvox TRICYCLIC ANTIDEPRESSANTS - Block reuptake of serotonin and norepinephrine. - Less commonly used because there are more side effects. - Used to treat: * Depression, anxiety disorders, bipolar disorders. - May cause: * Hypotension, sedation, toxicity GENERIC BRAND nortriptyline amitriptyline Pamelor Tofranil SNRIs - Block the reuptake of both serotonin and norepinephrine. - Used to treat: * Depression * Panic disorder, generalized anxiety disorder. - May cause: * Headache, nausea, dry mouth * Hyponatremia * Hypertension * Sexual dysfunction GENERIC BRAND fluoxetine sertraline paroxetine citalopram escitalopram fluvoxamine Prozac Zoloft Paxil Celexa Lexapro Luvox MAOIs - Prevents the destruction of monoamines (norepinephrine, dopamine, and serotonin). - Patient should avoid consumption of tyramine in their diet to avoid a hypertensive crisis. - Should not be taken with other drugs that increase serotonin and norepinephrine levels. GENERIC BRAND isocarboxazid phenelzine selegiline tranylcypromine Marplan Nardil EMSAM Parnate # 303 PHARMACOLOGY LITHIUM - Creates neurochemical changes in the brain. - May decrease neuronal atrophy / increase neuronal growth. - Used to treat: * Bipolar disorders > Helps to control episodes of mania and depression. - May cause: * Tremors * Polyuria / thirst * Weight gain * Hypothyroidism * Hypotension, electrolyte imbalances - Nursing considerations: * Should not be used in patients with: > Hepatic, renal, or cardiac disease > Schizophrenia * Should not be taken with: > Diuretics > NSAIDs > Antihistamines, tricyclic antidepressants - Lithium toxicity: * Lithium levels I> 1.5 mEq/L * Confusion, sedation, slurred speech * Nausea, vomiting, diarrhea * Extreme polyuria * Tinnitus, blurred vision, ataxia * Hypotension (possibly leading to coma/death in extreme situations). # MOOD STABILIZERS ANTICONVULSANT DRUGS GENERIC BRAND carbamaxepine lamotrigine valproate Tegretol Lamictal Depakote, Depakene - Reduces mood swings by slowing the firing rate of certain neurons in the brain. - Suppresses central nervous system excitation by inhibiting glutamate. - Used to treat: > Bipolar disorder * Rapid-cycling bipolar disorders. CARBAMAXEPINE LAMOTRIGINE VALPROATE - May cause: * Vertigo, double vision, headache * Anemia, leukopenia * Rash - Nursing considerations: * Administer before bed * Monitor for bleeding/bruising * Monitor for edema - May cause: * Dizziness, double vision, nausea, headache. * Serious rash - Nursing considerations: * Withhold medication if a rash occurs. - May cause: * GI symptoms * Hepatoxicity * Pancreatitis - Nursing considerations: * Administer with food * Monitor for signs of hepatoxicity or pancreatitis 304 FIRST-GENERATION - Conventional/typical antipsychotics. - Have more adverse effects than second-generation antipsychotics. - Used to control: * Positive symptoms - Can cause: * Extrapyramidal symptoms * Anticholinergic adverse effects * Hypotension * Sedation GENERIC BRAND haloperidol fluphenazine loxapine thioridazine perphenazine Haldol Prolixin Loxitane Mellaril Trilafon - CNS stimulants - Blocks reuptake of norepinephrine and dopamine. - May cause: * Agitation, hypertension, growth suppression GENERIC BRAND methylphenidate dextroamphetamine Ritalin Adderall SECOND-GENERATION - Atypical antipsychotics - Less severe adverse effects than first-generation antipsychotics. - Used to control: * Both positive and negative symptoms - Can cause: * EMetabolic syndrome * Hypotension * Anticholinergic adverse effects * Mild extrapyramidal symptoms * Sedation GENERIC BRAND clozapine risperidone quetiapine olanzapine ziprasidone aripiprazole lurasidone Clozaril Risperdal Seroquel Zyprexa Geodon Abilify Latuda # ADHD DRUGS # PHARMACOLOGY ANTIPSYCHOTIC DRUGS - Used to treat: * Schizophrenia spectrum disorders > Positive and negative symptoms * Manic/psychotic symptoms of bipolar disorders * Other psychotic disorders - Goal is to help the patient to maintain the highest level of functioning possible. - Cholinesterase inhibitors * Slows rate of memory loss # ALZHEIMERS DRUGS GENERIC BRAND donepezil tacrine galantamine rivastigmine Aricept Cognex Razadyne Exelon 305 PHARMACOLOGY OB MEDICATIONS Relaxes uterine activity, stops uterine contractions, & gain time for fetal lung maturity. TOCOLYTICS Nifedipine (calcium channel blocker) - Prevent preterm labor - Used as a anticonvulsant to prevent seizure in preeclampsia (magnesium sulfate) USES: - Nifedipine (calcium channel blocker) - Magnesium sulfate (vitamin/supplement) - Terbutaline (beta2 agonist) - Indomethacin (NSAID) MEDS: - Mother: Severe preeclampsia, Eclampsia, Intrauterine infection, Active vaginal bleeding, Cardiac disease or Uncontrollable HTN - Fetus: < 20 wk gestation, > 37 wk gestation, Lethal fetal anomaly, Uterine fetal death, Acute fetal distress (no reassuring fetal status,), Chorioamnionitis (bacterial infection of the amniotic sac and outer membrane) CONTRAINDICATIONS: - Used to prevent preterm labor - Relaxes uterine smooth muscles by blocking calcium entry - Adverse Effects: * Mother: Headache, Hypotension, Dizziness, Facial flushing, Nervousness, Nausea * Fetus: Hypotension - Contraindications: * Mother: Hypotension - Interventions: * Closely monitor for SE (maternal hypotension) * If maternal hypotension, notify HCP & follow agency protocols * DO NOT give med to already hypotensive mother & DO NOT take med concurrently with magnesium sulfate (severe hypotension) Magnesium Sulfate (vitamin/supplement) - Used to prevent preterm labor & CNS depressant to prevent seizure in preeclampsia - Relaxes uterine smooth muscles by blocking calcium entry - Adverse Effects: * Mother: Headache, Facial flushing, Nausea TOXICITY: Respiratory depression, Hypotension, Extreme muscle weakness, Decreased DTRs, Pulmonary edema, Altered mental status, Decreased urine output, Increased serum magnesium level (> 9 mg/dL) * Fetus: Hyotonia, Sleepiness - Contraindications: * Mother: Myasthenia gravis, Kidney failure, Myocardial Infarction, Heart block * Fetus: 5-7 day use for preterm labor (increase risk of hypocalcemia & bone changes), Continuous use during active labor or within 2 hours of delivery (increase risk of magnesium toxicity) - Interventions: * Monitor contractions, fetal movement, FHR, & FHR variability * Closely monitor for signs of toxicity (CALCIUM GLUCONATE is antidote) * Administered via IV infusion pump, diluted with fluid (closely monitor dose being administered) * Monitor mothers vital sign every 30-60 mins, especially RR (Stop IV infusion pump & IMMEDIATELY notify HCP if RR is < 12 breaths/min) * Watch for signs of pulmonary edema (crackle lung sounds, dyspnea, increased RR, air hungry) * Use indwelling catheter to monitor urinary output (Stop IV infusion pump & IMMEDIATELY notify HCP if output is < 30 mL/hr) * Monitor DRTs & LOC * Magnesium Therapeutic Range (4-8 mg/dL), Toxicity Level (< 9 mg/dL) 306 PHARMACOLOGY OB MEDICATIONS Terbutaline (beta2 agonist) - Used to prevent preterm labor - Binds to B2 receptors & decreases intracellular calcium & their contractability - Adverse Effects: * Mother: Tachycardia, Arrhythmias, Palpations Hypotension, Tremors, Anxiety, Pulmonary edema, Hypoglycemia, Hypokalemia * Fetus: Tachycardia - Contraindications: * Mother: Cardiac disease, Uncontrolled Diabetes - Interventions: * Given subcutaneous 0.25 mg every 20 mins as needed * Before administering, check maternal HR & FHR * Monitor contractions & FHR (DO NOT give med & notify HCP if FHR is > 180 beats/min) * Monitor maternal HR & BP (DO NOT give med & notify HCP if HR is > 120 beats/min & BP is < 90/60 mm Hg) * Watch for signs of pulmonary edema (crackle lung sounds, dyspnea, increased RR, air hungry) * Used for ONLY 48-72 hours to suppress Preterm Labor (avoid maternal & fetal distress) Indomethacin (NSAID) - Used to prevent preterm labor - Inhibits enzyme Cyclooxygenase (helps produce prostaglandins) > Decreases production of prostaglandins, which results in relaxation of uterine smooth muscles. - Adverse Effects: * Mother: GERD, Gastritis (prostaglandins production ALSO protects the stomach lining from acid, but a DECREASE in prostaglandins causes risk of gastric injury) * Fetus: Oligohydramnios (little amniotic fluid surrounding baby), Premature closure of ductus arteriosus (can cause Pulmonary HTN & HF) - Contraindications: * Mother: Peptic ulcer disease, Bleeding disorders, Impaired kidney function, > 32 wk gestation (risk of premature closure of ductus arteriosus is HIGHEST) - Interventions: * Monitor maternal vital signs, contractions, & FHR * Take with food if GI upset * Indomethacin therapy should NOT exceed 48 hours * DO NOT give after 32 wk gestation (risk of premature closure of ductus arteriosus) * Continuously monitor maternal & fetal SE Stimulates smooth muscles of uterus to contraction. Increases force, frequency, & duration of uterine contractions. OXYTOCICS - Induce or augments labor (methylergonovine DOESNT induce labor) - Prevent & Treat postpartum hemorrhage USES: - Oxytocin (oxytocic) - Methylergonovine (ergot alkaloids) - Misoprostol (prostaglandins E1) & Dinoprostone (prostaglandins E2) - Carboprost tromethamine (prostaglandins F2) MEDS: # 307 Misoprostol (prostaglandins E1) & Dinoprostone (prostaglandins E2) - Used as a pre-induction agent to ripen the cervix - Used to induce abortion in combination with mifepristone (med to medically terminate pregnancy) - Stimulates uterine smooth muscles - Adverse Effects: * Mother: Diarrhea, N/V, Headache, Uterine cramps & pain, Hypertonic contractions/Tachysystole (frequent & long lasting contractions), Hypotension, Fetal passage of meconium, Miscarriage, Facial flushing, Chills, Fever - Contraindications: * Mother: Hx of C-section or other major uterine surgeries, Cardiac, pulmonary, kidney, or liver disease, PID, Maternal infection or fever, Vaginal bleeding, Regular uterine contractions * Fetus: Abnormal FHR & pattern - Interventions: * Check maternal vital signs, FHR & pattern, cervical ripening, Bishop score (discontinue med if Bishop score > 8) * Have mother void BEFORE administration * AFTER administration, move into a supine with lateral tilt or side-lying position (30-60 mins for GEL & up to 2 hours for INSERT) * Inform mother miscarriage (spontaneous abortion) can occur * Diarrhea can occur. Notify HCP if diarrhea lasts > 1 week with dark, tarry stool # PHARMACOLOGY OB MEDICATIONS Oxytocin (oxytocic) - Used to induce or augments labor & induces labor for incomplete abortions - Used to prevent & treat postpartum hemorrhage - Stimulates uterine smooth muscles. - Has a vasodilation & antidiuretic affect - Adverse Effects: * Mother: Hypotension, Painful contractions, Hypertonic contractions/Tachysystole (frequent & long lasting contractions), Uterine rupture, Water intoxication (can lead to seizure, coma & death) * Fetus: Late Deceleration (non-reassuring FHR pattern), Arrhythmias - Contraindications: * Mother: Mother who CANNOT delivery vaginally, Hypertonic uterine contractions, Active genital herpes - Interventions: * Administered via IV infusion pump & given with additional solution through piggyback (0.9% NS, Lactated Ringers) * DO NOT leave mother while oxytocin is infusing * Monitor maternal vital signs & FHR, especially HR & BP, every 15 mins * Monitor for hypertonic contractions (STOP infusion if contraction duration : > 60-90 secs & frequency : > 2-3 mins) * Monitor for late decelerations FHR pattenrn (STOP infusion) * Monitor fluid intake & for water intoxication (drowsiness, confusion, lightheadedness, headache, N/V, anuria, hyponatremia) if not treated, can lead to seizure, coma, & death Immediate Intervention For Hypertonic Contractions or Late Decelerations - Stop oxytocin infusion - Turn mother on her side, stay with mother, and ask another nurse to notify the HCP - Increase flow rate of IV solution that DOES NOT contain oxytocin - Give oxygen 8 L/min-10 L/min via face mask - Monitor maternal vital signs; FHR and patterns; and frequency, duration, and force of contractions. - Misoprostol: Vaginal tablet, - Dinoprostone: Vaginal insert, gel, suppository 308 PHARMACOLOGY OB MEDICATIONS Methylergonovine (ergot alkaloids) - Used to prevent & treat postpartum hemorrhage - Stimulates uterine smooth muscles (only used AFTER delivery of placenta) - Has a vasoconstriction & vasospasm affect - Adverse Effects: * Mother: Severe HTN, Headache, N/V, Uterine cramping, Chest pain - Contraindications: * Mother: Given during labor, Cardiovascular diseases, Peripheral vascular diseases, HTN - Interventions: * Administered IM or oral * Monitor uterine tone, vaginal bleeding, & contractions * Monitor maternal vital sign, especially BP (DO NOT give if BP is elevated) Betamethasone & Dexamethasone - Used to increase production of lung surfactant & speed up fetal lung maturity before premature delivery (given 24-32 wk gestation) - Used to reduce or prevent RDS in preterm babies - Suppresses inflammation & the normal immune response - Adverse Effects: * Mother: Hyperglycemia, Immunosuppression (increased risk for infection), Poor wound healing, Fluid & sodium retention, HTN, Depression, Nausea - Contraindications: * Mother: Hypersensitivity, Active untreated infection, Epidural use, Lactation - Interventions: * REPORT symptoms of Preterm Labor to HCP * Betamethasone: Administer deep IM 12 mg in 2 doses 24 hrs apart (24 mg in total) given 24-32 wk gestation * Dexamethasone: Administer deep IM 6 mg in 4 doses 12 hrs apart (24 mg in total) given 24-32 wk gestation * Monitor for pulmonary edema (secondary to fluid & sodium retention) & for infection * Monitor maternal lungs, HR, WBC, & blood glucose (monitor for hyperglycemia especially in mothers with DM) * After delivery, monitor babys lungs, HR, & blood glucose Carboprost tromethamine (prostaglandins F2) - Used to prevent & treat postpartum hemorrhage - Used for induction of mid-term abortion - Stimulates uterine smooth muscles - Adverse Effects: * Mother: Fever, Chills, Headache, N/V, Diarrhea, Uterine Rupture, HTN (given large dose), Anaphylaxis - Contraindications: * Mother: Hypersensitivity, Acute pelvic inflammatory disease, Pulmonary, kidney, or liver disease - Interventions: * Administered IM * Monitor maternal vital sings & contractions * Monitor for signs of anaphylactic reaction (wheezing, dyspnea, chest tightening, angioedema, rash, pruritus) - Used for pregnant woman who are Rho(D)-negative & carrying a Rho(D)-positive - Used to prevent erythroblastosis fetalis in Rh(o)-positive babies - Prevent production of anti-Rho(D) antibodies in Rho(D)-negative patients who are exposed to Rho(D)-positive blood - Adverse Effects: * Mother: Pain & tenderness at injection site, Fever, Dizziness, Headache, - Contraindications: * Mother: Rho(D)-positive patients, Hypersensitivity to immune globulin - Interventions: * Administered IM at 28 wks gestation & again 72 hours after delivery, miscarriage, abortion, or transfusion * NOT given to baby. ONLY the mother. And NEVER give IV * Mother should notify HCP if been previously exposed to Rh-positive blood through transfusion or during first pregnancy CORTICOSTEROIDS RHO(D) IMMUNE GLOBULIN # 309 PHARMACOLOGY OB MEDICATIONS Rubella (MMR) - Used to prevent infection of rubella (German measles) virus in a non-immune mother - Active immunizing agent that causes the body to produce antibodies against the virus - Adverse Effects: * Mother: Rash, Fever, Pain & stiffness at injection site, Swollen salivary glands - Contraindications: * Mother: Hypersensitivity to eggs, gelatin, or neomycin, Pregnancy - Interventions: * Administered subcutaneous * Given after delivery & before hospital discharge (vaccine can be harmful to the baby) * AVOID pregnancy 1-3 months after receiving Rubella vaccine (strict use of contraceptive) * Watch for anaphylactic (allergic) reaction Erythromycin Ophthalmic - Used to prevent ophthalmia neonatorum in babies of mothers who have neisseria gonorrhoeae or chlamydia trachomatis - Inhibits protein synthesis of the bacteria ribosome - Adverse Effects: * Baby: Eye irritation & redness, Temporary blurred vision - Contraindications: * Baby: Hypersensitivity - Interventions: * Eye prophylaxis for ophthalmia neonatorum is required by law in all U.S. states * Clean babys eyes before installation & DO NOT flush eyes after installation * Apply 1-2 cm ribbon of ointment to lower conjunctival sac to each eye (also comes in drops) * Stay for 1 min to assess eyes for irritation * Installation can be DELAYED for 1-2 hours to promote breastfeeding & bonding between baby & parent(s) Hepatitis B - Used to prevent hepatitis B (HBV) in babies who were birthed to Hep B-positive mothers - Hep B can be transmitted through mothers birth canal, blood, saliva, breast milk, placenta, or infected males semen - Provides high titers of antibodies to the hepatitis B surface antigen - Adverse Effects: * Baby: Rash, Fever, Erythema, Pain at injection site - Contraindications: * Baby: Hypersensitivity - Interventions: * Parental consent * Administered IM in the vastus lateralis muscle * Hepatitis B immune globulin & Hepatitis B vaccine are given within 12 hrs of birth (regular HBV vaccination schedule follows) * Watch for anaphylactic (allergic) reaction VACCINES EYE PROPHYLAXIS # 310 NOTES TEMPLATES & PLANNERS Nursing Diagnosis: Nursing Diagnosis: Supporting Data: Supporting Data: Goals: Patient Info Medical History Goals: Nursing Diagnosis: Nursing Diagnosis: Supporting Data: Supporting Data: Goals: Goals: COURSE: COURSE TRACKER SUBMITTED ASSIGNMENT / PROJECT DUE DATE SCORE COURSE: TEST / QUIZ TRACKER PASSED? CHAPTERS / TOPICS COVERED TEST DATE GRADE MONTH: HOURLY PLANNER > PRIORITIES PRIORITIES PRIORITIES PRIORITIES PRIORITIES PRIORITIES PRIORITIES MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY BAD GOOD GREAT BAD GOOD GREAT BAD GOOD GREAT BAD GOOD GREAT BAD GOOD GREAT BAD GOOD GREAT BAD GOOD GREAT > 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM # MONTHLY PLANNER > MONTH: YEAR: # WEEKLY PLANNER TO DO LIST NOTES TESTS / EXAMS PROJECTS / ASSIGNMENTS SELF-CARE MONDAY: TUESDAY: WEDNESDAY: THURSDAY: FRIDAY: SATURDAY: SUNDAY: PATHOLOGY RISK FACTORS COMPLICATIONS TREATMENT SIGNS & SYMPTOMS DIAGNOSIS DISEASE: PHARMACOLOGY TEMPLATE Drug Class: ACTION THERAPEUTIC USES CONTRAINDICATIONS PATIENT EDUCATION SIDE EFFECTS NURSING CONSIDERATIONS Generic Name Trade Name Suffixes or Prefixes: Antidote: MONTH: NCLEX DATE: NCLEX STUDY SCHEDULE > Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: > MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY > Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: Subject: # of Practice Questions: Body System: Self Care: # It s okay to learn from every experience, and it s okay to make mistakes. Louise Hay