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PNEUMONIA med-surg respiratory PATHOLOGY Lower respiratory tract infection that causes inflammation of alveoli sacs! ∙ Community acquired pneumonia (CAP) ∙ Hospital acquired pneumonia (HAP) ∙ Healthcare associated pneumonia (HCAP) ∙ Ventilator-associated pneumonia (VAP) ∙ Aspiration pneumonia TYPES HEALTHY PNEUMONIA B reath out c0 REMPEaMrt BERgas exchange takes 2 place in the alveoli... O2 IN so pneumonia causes CO2 GasAHeRExEcAhLWaTnIHgDeYEisA&tLaVOkEiPnOEgLNpIl!ace & AFRLGUaVBLsECLeOSxO,cLhAFIaNInFSgDLeIUNBisIAFDiCLmSAT,pMEaWiRErBIeDAdCS, impaired OUT gas exchange. Breath in 0 2 SYMPTOMS p productive cough (purulent sputum) RISK FACTORS n Neuro changes (especially in the elderly) Can be community-acquired e elevated Lab (↑ PCO2 & ↑ WBCs) or hospital-acquired! u unusual breath sounds ✹ Prior infection ✹ Lung diseases (course crackles & rhonchi) ✹ Immunocompromised • COPD m Mild to high fever • HIV, young/old, ✹ Immobility auto immune infections ✹ Aspiration risk o oxygen saturation low ✹ Postoperative n Nausea & vomiting DIAGNOSTIC i increased HR & BP Chest X-ray ✹ ↑ White blood cells ✹ Sputum culture a achy (chills, fatigue) shows pulmonary can be infiltrates or BACTERIAL, VIRAL, INTERVENTIONS pleural effusions or FUNGAL ✹ Monitor... EDUCATE • Respiratory status • Vital signs: HR, temp, & pulse oximetry ✹ Use of Incentive Spirometer • Color, consistency & amount of sputum • Helps to pop open the alveoli ✹ Diet &Tdhfcreionohmsmysdpfereecavnrteeisortaintoenss sacs & get the air moving • ↑ Calories • ↑ Fluids (oral or IV) • ↑ Protein • Small frequent meals ✹ Up-to-date vaccines • Annual flu shot ✹ Medications cualdttumarkAeienslwibsBtalEeoyrFosiOndgRE • Bronchodilators • Pneumococcal vaccine • Antipyretics antibiotics • Cough suppressants • Antibiotics • Mucolytic agents ✹ Smoking cessation ✹ Hand washing & avoiding sick people (only for bacteria) • Antivirals ✹ Semi Fowler's position eHxeplpans sluionng © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 151

ASTHMA med-surg respiratory pathology &Wall is inflamed Tightened & thickened smooth muscle Chronic lung disease that causes an inflamed, narrow, & swollen airway (bronchi & bronchioles) causes cokmnpnoPlowaerttnte! ly ∙ Genetic ∙ Environmental • Smoke, pollen, perfumes, dust mites, pet dander, cold or dry air, etc. ∙ GERD Normal Asthmatic airway Asthmatic airway during attack ∙ Exercise-induced asthma ∙ Certain drugs • NSAIDS, aspirin Classifications: MILD MILD MODERATE SEVERE PERSISTENT PERSISTENT PERSISTENT Based on Symptoms INTERMITTENT < 2 a week > 2 a week Daily symptoms & Continually showing Not daily exacerbations that symptoms with happen 2x a week frequent exacerbations Signs & Symptoms Nursing Care Characterized by flare-ups status asthmaticus ∙ Assess client's airway (meaning: it comes & goes) ∙ High Fowler's position ∙ Provide frequent rest periods ∙ Dyspnea (shortness of breath) Medical emergency ∙ Adm. oxygen therapy ∙ Tachypnea (fast respiratory rate) Life-threatening asthma episode ∙ Chest tightness • Goal: keep the O2 at 95 - 100% ∙ Anxiety oxygen ∙ Maintain a calm environment to ↓ stress ∙ Wheezing ↓ ∙ Asses peak flow meter reading ∙ Coughing ∙ Asses for cyanosis & retractions hydration ↓ nebulization ↓ systemic corticosteroid ∙ Mucus production ∙ Use of accessory muscles Air trapping causes the client to retain CO2 Peak Flow Meter ∙ Air trapping which is ACIDIC = Respiratory Acidosis • Shows how controlled the asthma is & if it's getting worse medications • Establish a baseline by performing a \"personal best\" reading ∙ BronchoDILATORS • Client will exhale as hard as Short-acting (Albuterol) Rapid relief they can & get a reading Long-acting (Salmeterol) Prevents asthma attack Methylxanthines (Theophylline) Green = Good Yellow = Not too good ∙ Corticosteroids Anti-inflammatory Agents Red = BAD Suffix -Asone & -Ide Certain medications Ex: Beclomethasone are known to cause b Beta blockers ∙ Leukotriene Modifiers bronchospasms in patients a Aspirin with asthma. We want to n NSAIDs ∙ Anticholinergics “BAN” these medications from asthma patients. *For more information about respiratory medications, see the Pharmacology Bundle © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 152

CHEST TUBES med-surg respiratory A chest tube is a tube that is inserted why is it used? into the pleural space to remove excess air, blood, or fluid. This ∙ After thoracic surgery helps re-expand the lungs. ∙ During cardiac surgery 3 CHAMBERS: (drain fluid from around the heart) ∙ Spontaneous pneumothorax ∙ Pneumothorax ∙ Hemothorax ∙ Pleural effusion ∙ Empyema (infection) If the water stops DRAINAGE CHAMBER fluctuating, this could mean: If the tube becomes dislodged: 1. The lung has re-expand Cover the insertion site This is where the fluid is 2. The tubing is kinked with a sterile dressing collected from the patient Tidaling = GOOD If the chamber becomes damaged: WATER-m∙ SConoEliotAor L&r: qCuaHntAityMofBthEeR (rise & fall with each breath) Place the tubing in sterile water drainage in the drainage while waiting for a new system Excessive continuous bubbling = BAD Afrollomwtsh∙∙aeILcniuosrnplelgerttclisotoeoinoununsbidctrehsaeamlbreserpemvaeroychevouer d in the water seal chamber WITHOUT outside air nursing considerations entering the lungs ∙ Always keep the drainage system BELOW the patient's chest SUCTION-CONTROL CHAMBER (Two types) ∙ Never strip the tubing Debexeheaaprldeb,oreawnantdh, Wet suction & Dry suction ∙ Never clamp the tubing ∙ Educate the patient to do Valsalva maneuver when the HCP is removing the chest tube ∙ monitor: ∙ Color & quantity of the drainage in the drainage collection chamber every hour ∙ Lung sounds ∙ Insertion site ∙ report bright red blood (dark red is expected) WET SUCTION DRY SUCTION Uses water to control the level of suction There is no water column (it's DRY). The suction is controlled (actually filling the suction control chamber with water) by a suction monitor bellows that balances wall suction Both have a There will be no bubbling Will have gentle bubbling collection chamber and Water seal Wall suction an air leak Air & fluid monitor chamber Collection from patient chamber Amount Dry suction of suction regulator applied Suction Collecting fluid monitor or blood from bellows Air leak the patient monitor Suction Water seal Collection Patient pressure regulation chamber chamber float ball As the patient breaths in and out, the water will be \"tidaling\" © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 153

MECHANICAL VENTILATION med-surg respiratory A machine that helps a person breathe. why is it used? The machine pumps air into the lungs ∙ Control breathing during surgery unlike normal breathing. ∙ Rest the respiratory muscles ∙ When a patient is unable to breathe on their own (respiratory failure such as ARDS) VENTILATOR SETTINGS POSITIVE PRESSURE VENTILATION* Tidal Volume Volume of gas delivered The air is pushed into the lungs (VT) with each breath This forceful air entering into the 500 - 800 mL lungs can cause barotrauma Respiratory # of breaths delivered rate to the patient NEGATIVE PRESSURE VENTILATION* Normal breathing FiO2 12 - 20 breaths per min The diaphragm uses negative Positive End Fraction of inspired oxygen pressure to bring in oxygen expiratory (bOe2incgondceelnivteraretidontootfhtehepat.i)r pressure Negative think Normal breathing 21% - 100% (PEEP) The amount of pressure in the lungs after expiration (prevents collapse of the alveoli) UNDERSTANDING ALARMS High Pressure Alarms High think High low pressure Alarms low think leaks Causes: blockage of airflow Causes: Disconnection, cuff leak, Excessive mucous or secretions, kinks, coughing, tube displacement pulmonary edema, or pneumothorax, a patient \"fighting\" the ventilator nursing considerations monitor: oral care ∙ Level of consciousness ∙ Clean the mouth with ∙ Vital signs ∙ Lung sounds chlorhexidine every 2 hours ∙ Arterial blood gases ∙ Symptoms of ventilator mobilize secretions ∙ Turn/reposition the patient every 2 hours associated pneumonia ∙ Keep the head of the bed >30° ∙ The gastrointestinal system ∙ Nutritional status gastrointestinal system ∙ Administer PPIs & H2 blockers to suctioning Suction secretions only when needed: prevent stress ulcers and decrease acid ∙ Never suction when inserting a Omeprazole famotidine catheter into the airway ∙ Never suction for longer than Proton pump inhibitors Histamine H2 antagonists (PPIs) end in -prazole (H2-blockers) end in -dine 10 seconds ∙ Administered 100% oxygen 154 before suctioning © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

med-surg LAB VALUES RELATED TO THE HEMATOLOGICAL SYSTEM Hematology EXPECTED RANGE DESCRIPTION ↓↑ F Red blood cells ☞ Fluid volume overload Less volume 4.2 – 5.2 X 106 /uL transport oxygen to concentrates ☞ Hemorrhage the RBCs RED M the body's cells. ☞ Dehydration/ BLOOD CELLS 4.7 – 6.1 X 106 / uL ☞ Anemia More volume fluid volume deficit dilutes the RBCs (RBCs) ☞ Renal disease ☞ Hyperactivity of the bone marrow WHITE (lack of erythropoietin production) BLOOD CELLS COMPLETE BLOOD COUNT (CBC) 4,500 The white blood cells are a Leukopenia Leukocytosis (WBCs) - 11,000 / uL part of the immune system WBCs < 4,500 /uL WBCs > 11,000 /uL and help to fight infections and ☞ Immunosuppression ☞ Current or recent infection diseases. & inflammation PLATELETS 150,000 Platelets help clot the blood. Thrombocytopenia thrombocytosis (PLT) - 450,000 /uL Platelet aggregation is PLTs < 150,000 /uL PLTs > 450,000 /uL the clumping together of platelets that form a plug ↓ Platelets think BLEEDING ☞ Certain cancers ☞ Infection at the site of the injury. ☞ Dehydration (hemoconcentration) HEMOGLOBIN F Hemoglobin is an iron ☞ Fluid retention (hemodilution) (HGB) 12 - 16 g/dL containing protein found in ☞ Anemia ☞ Dehydration (hemoconcentration) red blood cells. It transports ☞ Hemorrhage ☞ Low oxygen availability HEMATOCRIT M (HCT) 13 - 18 g/dL oxygen from the lungs (smoking, pulmonary diseases to the tissues. (COPD), high altitudes) F 36% - 48% It also returns tCoOth2efrolumngtsh.e ☞ Heparin therapy tissues back M Numbers are too high 39% - 54% The percent of blood ☞ Fluid retention (hemodilution) = Patient will die that is made up of ☞ Anemia red blood cells ☞ Hemorrhage (from increased bleeding) (expressed as a %). ☞ Deficiency in vitamin K TYPES OF COAGULATION TESTS ACTIVATED NORMAL aPTT measures how Numbers are low ☞ Deficiency in clotting factor PARTIAL (not on anticoagulants) long it takes for a = ☞ Liver disease blood clot to form. THROMBOPLASTIN 30 - 40 seconds Clots will grow ☞ Warfarin therapy TIME (ªPTT) It's also used to monitor ON HEPARIN THERAPY the effectiveness of the Numbers are too high PROTHROMBIN anticoagulant: Heparin. = Patient will die TIME (PT) 1.5 - 2.0 x the normal value Prothrombin time (from increased bleeding) INTERNATIONAL measures the amount of Additional tests are needed NORMALIZED NORMAL time needed to form a clot. to confirm and determine a RATIO (INR) (not on anticoagulants) It's also used to monitor specific diagnosis the effectiveness of the D-DIMER 10 - 12 seconds anticoagulant: warfarin. ☞ Blood clot may be present in the body ON HEPARIN THERAPY INR is calculated from 155 the prothrombin time and 1.5 - 2.0 x the normal value is used to monitor oral anticoagulants such as NORMAL (not on anticoagulants) warfarin. <1 D-dimers are fragments ☞ Blood clot is ruled out of fibrin that are in the ON HEPARIN THERAPY blood when a clot dissolves INR 2.0 - 3.0 or is broken down. INR 2.5 - 3.5 D-dimer helps to determine if a (heart valve replacement ) clot is present somewhere in the body < 0.5 mcg/mL © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

IRON DEFICIENCY ANEMIA med-surg Hematology PATHOLOGY SIGNS & SYMPTOMSThere are many types of anemias an↓eimrtioayncpelaeuovsfeedlsby same symptoms as anemia COOMFMMAOONSNTETMYIAPE (iron deficiency, vitamin B12 deficiency, ∙ Pallor folate deficiency, etc). ∙ Weakness & fatigue Anemia: the body doesn't have enough RBCs ∙ Shortness of breath Anemia Normal to carry oxygen to the tissues and the body. (from lack of oxygen) ∙ Tachycardia red blood cells role ∙ Microcytic (small) red blood cells ∙ Transports O2 & removes CO2 from the irsopneadcniefefimcictiieaoncy severe symptoms body with the help of hemoglobin (Hgb) hemoglobin (hgb) ∙ Smooth, red tongue ∙ Brittle & ridged nails ∙ Found in the RBCs ∙ It's a protein that contains IRON TREATMENT/MEDICATIONS Normal Iron Treat the cause: D/C any drugs causing the anemia. red blood deficiency iron supplements (oral or liquid) MTORSETACTMOEMNMTON cells anemia Examples: ferrous sulfate, ferrous gluconate, Smaller in size & more pale ferrous fumarate (because hemoglobin makes the blood bright red) RISK FACTORS Iv administration of iron ∙ Lack of iron (vegetarian diet) If oral iron is poorly absorbed or poorly tolerated ∙ Blood loss PATIENT EDUCATION FioCruoBoSnlinldaassecufttkpieeppfsrafltteetaomicsootetsnlenotfs: (excessive menstruation, surgery or trauma) educate on administering iron supplements: ∙ Pregnancy ∙ Iron malabsorption ↑ absorption slttiqaeiuenitsdht!ihroen Vitamin C: (due to bariatric surgery or Celiac disease) Take iron with fruit juice & multivitamin. Take on an empty stomach DIAGNOSTIC ↓ absorption 1. Take with a straw ∙ Complete blood count (CBC) Calcium: 2. Brush teeth after ∙ ↓ hemoglobin & ↓ hematocrit Do not take iron with milk or antacids ∙ Bone marrow aspiration ∙ Stool sample, colonoscopy, educate on foods high in IRON: \"eat lots of iron\" iron-fortified cereals endoscopy (checking for blood) egg yolks legumes Potatoes red meats Apricots oysters fish Poultry normal values: tofu tuna nuts seeds Hemoglobin (Hgb) Female: 12 - 16 g/dL Male: 13 - 18 g/dL Hematocrit (HCT) Female: 36% - 48% Male: 39% - 54% © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 156

THROMBOCYTOPENIA med-surg Hematology PATHOLOGY plate↓lets SIGNS & SYMPTOMS ∙ Platelets help clot the blood ∙ Weakness, dizziness, tachycardia, hypotension ∙ Platelet aggregation: ∙ Prolonged bleeding time the clumping together of platelets that form a ∙ Petechiae (pinpoint bleeding) Purpura plug at the site of injury ∙ Purpura ∙ Bruising ∙ ↓ Platelets = think bleeding ∙ Bleeding from the gums & nose ∙ Heavy menstrual cycles normal platelet count thrombocytopenia ∙ Blood in stool or urine Bruising 150,000 - 450,000 /µL < 150,000 /µL RISK FACTORS Petechiae p Platelet disorders TREATMENT l Leukemia a Anemia ∙ Platelet transfusion t Trauma ∙ Bone marrow transplant e Enlarged spleen l Liver disease ∙ Platelets are made in the bone marrow e Ethanol (alcohol-induced) ∙ Splenectomy t Toxins (drug-induced) s Sepsis ∙ For those unresponsive to medical therapy DIAGNOSTIC PATIENT EDUCATION ∙ ↑ Bleeding time educate they will need to ∙ ↑ INR & ↑ PT/PTT follow bleeding precautions: ∙ ↓ Hgb & Hct ∙ Bone marrow aspiration & biopsy ∙ Use electric razors ∙ Use small needle gauges ∙ NO aspirin ∙ Decrease needle sticks ∙ Protect from injury IMMUNE THROMBOCYTOPENIC PURPURA (ITP) Type of thrombocytopenia, formerly called \"idiopathic thrombocytopenia purpura\" \"Purpura\" is in the name because the body bruises easily & petechiae may occur in the trunk & extremities pathology itp risk factors < 100,000 /µL Autoimmune disease where the body ∙ Children after viral illness produces antibodies against its own ∙ Females (ages 20-40) thrombocytes (platelets) ∙ Pregnancy © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 157

SICKLE CELL ANEMIA med-surg Hematology PATHOLOGY Normal Sickle cell An inherited disease that causes the hemoglobin molecule to be defective. RBCs are weak and die earlier than healthy RBCs. Hemoglobin S is sensitive to low Unrestricted Sticky sickle cells amounts of oxygen in the body! blood flow blocking blood flow Low oxygen 3 cell types of sickle cells crisis: ↓ Acute vaso-occlusive RBCs sticking in vessels = hypoxia COMMMOSOTN Causes RBCs to (this is very painful!) change their shape crisis ↓ Aplastic The body stops producing enough RBCs Sickled shaped, sticky, and stiff crisis (bone marrow can't keep up) ↓ Sequestration The spleen stops working & becomes Causes clumping which blocks crisis flooded with the sickle cells blood flow to the tissues ↓ Sickle Cell Crisis RISK FACTORS SIGNS & SYMPTOMS A patient is born with this genetic blood ∙ Anemia symptoms disorder. It's an autosomal recessive disorder (the sickle hemoglobin (HbS) gene is inherited). (fatigued, tachycardia, pallor) It's commonly recognized early in life after ∙ Pain maternal iron stores have been depleted. ∙ Dactylitis DIAGNOSTIC Autosomal Recessive (swelling of the hands & feet) hathbnatheuvheaetEemsvtiiy(ttechiHhhakhibt.eselaoeBSrdvs)OphpeiocgeaaekTsemsrlsiHeescnnonked'cpltgte.eoamcllowrclaeebetnnnrailanltnsit, ∙ Blood sample ∙ Stroke ∙ Test before birth ∙ Acute chest syndrome (testing the amniotic fluid) (tachypnea, wheezing, fever, cough) MEDICATIONS PATIENT EDUCATION ∙ Analgesics & opioids educate on how to prevent sickle cell crisis: To help with the pain ✔ Vaccines up to date TREATMENT/ ✔ Prevent infection NURSING CONSIDERATIONS (hand hygiene, avoiding big crowds) ∙ IV fluids (stops the clumping of RBCs) ∙ Oxygen therapy ✔ Limit stress ∙ RBC transfusions ∙ Stem cell transplant ✔ Avoid high altitudes ✔ Drink lots of water (stay hydrated) ✔ Smoking cessation ✔ Avoid over-exertion © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 158

med-surg DISSEMINATED INTRAVASCULAR COAGULATION (DIC) Hematology PATHOLOGY SIGNS & SYMPTOMS Causative factor (underlying disease) bleeding & blood clots ↓ Bleeding can be minimal Stroke, heart attack, Inflammatory response causes inflammation all the way up to & coagulation in the vasculature deep vein thrombosis, or ↓ hemorrhaging everywhere a pulmonary embolism The fibrinolytic system is halted ↓ Causes lots of small clots & platelets to clump Lots of small clots are Excessive ∙ Petechiae & purpura using all the blood's clotting causes ∙ Hematuria clotting factors. This ∙ Melena (black tarry stools) blockage of ∙ Nose bleeds leaves other parts blood vessel TREATMENT +of the body with no ∙ Treat the underlying cause! means of stopping ∙ Transfusion any bleeding. ∙ Packed RBCs too little HAPPENING Too much ∙ Fresh frozen plasma (FFP) clotting AT THE SAME clotting ∙ Platelets (bleeding) TIME Can lead to organ ischemia MEDICATIONS (because organs are ∙ Vasopressors not getting blood supply) Cause vasoconstriction which ↑ blood flow & increases perfusion to the organ RISK FACTORS ∙ Heparin infusion DIC is not a disease. Rather, DIC occurs Stops the clotting which increases due to an underlying condition or disease: blood flow to the organs ∙ Infection/sepsis ∙ Obstetric complications ∙ Cryoprecipitate ∙ Malignancy ∙ Trauma Replaces fibrinogen, factors V & VII ∙ Allergic reactions ∙ Shock ∙ Toxins DIAGNOSTIC NURSING CONSIDERATIONS ∙ Lab tests ∙ Administer oxygen monitor: ∙ ↓ platelet & ↓ fibrinogen levels ∙ IV fluids ∙ For signs of bleeding ∙ Prolonged clotting time (↑ PT, aPTT) ∙ Correct electrolyte ∙ Vital signs ∙ ↑ D-dimer (indicates there is a clot ∙ Lab values somewhere in the body) imbalances © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 159

GASTROINTESTINAL SYSTEM OVERVIEW med-surg gastro HANICAL DIGEST EMICAL DIGESTI ORAL CAVITY COMPONENTS ON ION MEC CHWhen food is broken amylase protease lipase Physical down by enzymes and movement of food pancreas (when food is broken down digestive juices amylase: into smaller pieces) TIP Enzymes end in \"-ase\" breaks down carbs into glucose Examples: Protease think Proteins protease: • Chewing Lipase think Lipids (fat) breaks down proteins • Churning of the stomach lipase: breaks down fats (think lipids = fats) ESOPHAGUS STOMACH Is a hollow muscular A hollow muscular organ tube that carries food Functions: & liquid from the mouth • Stores food during eating to the stomach. It does • Secretes digestive fluids this by peristalsis. • Moves partially digested LIVER food (chyme) into the small intestine Functions: • Filters the blood PANCREAS LARGE INTESTINE • Metabolism of sugar, protein, and fat • Synthesize lipoproteins (VLDL & HDL) Helps make By the time food reaches the large intestine, most of • Makes vitamin D pancreatic juice the absorption & digestion has been completed • Detoxifications (enzymes). This pancreatic juice break down sugar, fat, and starch. Functions: (excretion of bilirubin and other toxins) The pancreas has both exocrine • absorbs water and electrolytes from food that • Bile formation and endocrine functions. • Drug metabolism has not been digested yet • Helps in blood clotting • defecation rids the body of any waste leftover from • Synthesize proteins such as albumin and food and removes it through the rectum and anus coagulation factors Transverse SMALL INTESTINE colon The longest portion of the GI tract (longer than the large intestine) Functions: • Digestion of food from the stomach Ascending Descending colon colon • Absorption of nutrients, fats, carbohydrates, vitamins, minerals, etc.) and water Cecum from food into the bloodstream to be used by the body Proximal Duodenum Jejunum distal Ileum Proximal Cecum Rectum Sigmoid distal Ascending colon colon To remember the order Transverse colon (Proximal - Distal) Descending colon Anus DJ Ileum in the club! Sigmoid colon Rectum Anus © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 160

med-surg LAB VALUES RELATED TO THE GASTROINTESTINAL SYSTEM gastro Expected Range AMYLASE Lipase 30 - 110 U/L is a better indicator Pancreatic enzyme of pancreatitis than ↑ levels amylase because could indicate serum lipase remains elevated lipase think pancreatitis LIPASE < 200 U/L for a longer period longer of time. Pancreatic enzyme BILIRUBIN Total ↑ levels Jaundice: could indicate Yellow discoloration of Produced by the liver 0.2 – 1.2 mg/dL liver dysfunction the skin due to high ALBUMIN 3.5 - 5.5 g/dL ↑ levels levels of bilirubin. could indicate Visible when serum dehydration bilirubin is > 2 mg/dL Albumin helps keep fluid in your bloodstream PREALBUMIN 15 - 36 mg/dL ↓ levels Prealbumin is great for assessing could indicate nutritional status malnutrition Part of the liver function AST 0 - 35 U/L ↑ levels AST must be taken with ALT test (LFT) 0 - 48 U/L could indicate If ALT is normal, this means there is a Liver enzyme liver dysfunction problem other than liver disease, such as damage to another organ (heart, ALT brain, muscle, kidneys) Liver enzyme Ammonia (NH3) is produced AMMONIA 10 - 80 mcg/dL ↑ levels by cells throughout the body and is could indicate liver dysfunction used by the liver to make urea. If the liver stops working, © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. ammonia increases in the body. Too much ammonia is very toxic (especially to the brain) 161

ACUTE & CHRONIC PANCREATITIS med-surg gastro PATHO ACUTE CHRONIC The islets of Langerhans Sudden inflammation that is Chronic inflammation secrete Insulin & Glucagon reversible if prompt recognition that is irreversible into the blood stream and treatment is done ∙ Repeated episodes of acute pancreatitis Pancreatic tissue: ∙ Excessive & prolonged consumption of secrete digestive CAUSES ∙ Gallstones enzymes that break ∙ Blocks the bile duct alcohol (ETOH) down carbohydrates, ∙ Recurrent damage to the cells proteins & fats ∙ Alcohol (ETOH) of the pancreas ∙ Damages the cells of the pancreas Pancreatitis is an ∙ Cystic Fibrosis AUTO-DIGESTION of the ∙ Infection ∙ Medications pancreas by its own In chronic, you will see different S&S digestive enzymes ∙ Tumor ∙ Trauma due to the prolonged damage & loss of function released too early in the pancreas SIGNS & SYMPTOMS In Acute, there will still be working ∙ Chronic epigastric pain or no pain functions of the pancreas. ∙ Pain ↑ after drinking ETOH LABS ∙ Sudden sever PAIN! or after a fatty meal ↑ Amylase ∙ Mid-epigastric pain LUQ ∙ Steatorrhea \"fatty stools\" ↑ Lipase ↑ WBCs ∙ Nausea & vomiting ∙ Oily/greasy frothy stool ↑ Bilirubin ∙ Fever ∙ Weight loss ↑ Glucose ∙ ↑ HR & ↓ BP ↓ Platelets ∙ ↑ Glucose ∙ Can't digest food properly ↓ Ca & Mg ∙ Mental confusion & agitation ∙ Jaundice ∙ Abdominal guarding ∙ Rigid/board-like abdomen ∙ Yellowish color of the ∙ Grey-Turner's Sign skin from build up of bile ∙ Bluish discoloration at the flanks ∙ Diabetes Mellitus ∙ Cullen's Sign ∙ Damage to the islet of Langerhans ∙ Bluish discoloration of the umbilicus ∙ Dark urine ∙ From excess bile in the body Cullen's = Circle belly button Grey-Turner's Sign MEDICATIONS Cullen's Sign ∙ Opioid analgesics ∙ Insulin DIGESTIVE ENZYMES (EXOCRINE) ∙ Antibiotics ∙ Proton Pump Inhibitors (PPI's), ∙ Pancreatic enzymes H2 antagonists, antacids Amylase: Breaks down carbs to glucose INTERVENTIONS Protease: Breaks down proteins Lipase: Breaks down fats ∙ Rest the pancreas! MONITOR: ∙ NPO ∙ NO ETOH! DIET (we don't want stimulation of the enzymes) • Glucose ∙ ↑ protein • Blood pressure ∙ Limit sugars ∙ ↓ fat ∙ IV fluids • Intake & output (no greasy, fatty foods) ∙ Pain management • Laboratory values ∙ Positioning • Stools ∙ Complex carbohydrate (fruits, vegetables, grains) ∙ Side lying → fetal position, NOT supine! ∙ Insert NG tube ∙ Remove stomach contents © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 162

ULCERATIVE COLITIS VS. CROHN'S DISEASE med-surg gastro InflammatoTrYyPBoEwSelODFisease (IBD)tbhnoionwtgTethhalies(ssIyBiisrsnSardi)mtraoebmlee MOST ULCERATIVE CROHN'S COMMON COLITIS (UC) DISEASE DESCRIPTION Chronic ulceration Inflammation of the & inflammation gastrointestinal tract of the rectum & colon wall at ANY point through ALL layers LOCATION Affects the large intestine Can affect anywhere in the GI tract & rectum only (mouth to the anus) THICKNESS Inflammation affects the Inflammation is transmural APPEARANCE submucosa or mucosa (occurring across the entire wall) CURE Inflamed areas are continuous with no patches Patches of inflammation Crohn's think throughout the bowel Cobblestone Yes! Colectomy This makes a cobblestone appearance! no cure, but surgery can help with symptoms COMPLICATIONS Toxic mega colon, Increased Abscess, fistulas Increased rupture of bowel, risk for risk for infection dehydration hemorrhage/ (sepsis) shock SIMILARITIES • Both a form of inflammatory bowel disease (IBD) • Causes of both are not completely known • Both increase the risk for colon cancer • Both cause inflammation & ulcers • Both should consume the following diet: ↓ fiber, ↑ protein diet, & ↑ fluids © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 163

TYPES OF HEPATITIS med-surg gastro HEPATITIS CAUSED BY: • Viral (A, B, C, D, E) COMMOMSOTN LIVER INFLAMMATION • Excessive use of alcohol • Hepatotoxic medications \"INFLAMMATION OF THE LIVER\" TRANSMISSION SIGNS & SYMPTOMS DIAGNOSTIC TREATMENT VACCINE HAV Fecal & oral Anti-HAV Supportive Food & water IgM = therapy... ACUTE ONLY Active infection REST! Igg = GI symptoms Recovered (it’s gone) (N&V, stomach pain, anorexia) HBV B think Body Fluids HBsAG = ACUTE B IS BOTH Dark-colored urine Active infection Supportive ACUTE & CHRONIC (Semen, saliva) Clay-colored stool therapy & rest • Birth & blood Anti-HBs = • Childbirth, sex, Vomiting Immune / recovery CHRONIC Flu-like symptoms Antivirals & IV drugs Jaundice HCV Body fluids Anti-HCV Antivirals Most common: No post exposure Interferon ACUTE & CHRONIC IV drug users immunoglobulin HDV Depends on B HDAg Antivirals B & D = BuDs Anti-HDV Interferon ACUTE & CHRONIC Hep D occurs with Hep B YELLOW DISCOLORATION HEV Fecal & oral of the skin from the Food & water buildup of bilirubin ACUTE ONLY uncooked meats, Anti-HEV Supportive 3rd world countries therapy... REST! EDUCATION for ALL types of Hepatitis! LABS: eHlAeelpvlaawttieiltdlisbien • Rest • ↓ Protein & fat • Educate on toxic Liver enzymes: • Diet substances to avoid ALT: 0 - 48 U/L • Small frequent meals • Proper hand hygiene AST: 0 - 35 U/L • ↑ Carbohydrates • Alcohol, acetaminophen, • ↑ Calories • Do not share personal aspirin, sedatives Bilirubin: 0.2 - 1.2 mg/dL hygiene products Ammonia: 10 - 80 mcg/dL • Avoid sex until hepatitis antibodies are negative © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 164

CIRRHOSIS med-surg gastro FUNCTIONS STAGES OF LIVER DAMAGE of a healthy Liver healthy liver 1 DETOX the body aalldretiIohspfnrefrtuooshtphtepeteweeffuruodlilnvnyr,ckecttihrtniioeoigsnnns fatty liver cirrhosis 2 Helps to CLOT the blood liver 3 Helps to METABOLIZE liver enlargement due to fat liver cell deposits destruction (break down) drugs 4 SYNTHESIS (makes) ALBUMIN fibrosis liver healthy liver tissue is replaced with scar tissue PATHOLOGY CAUSES • Viral hepatitis B & C ☞ Liver cells are DESTROYED and MOST • Autoimmune • Hepatotoxic drugs replaced with fibrotic (scar) tissue. • Alcoholic cirrhosis COMMON • Toxins & parasites Caused by excessive alcohol intake • Fat collection in the liver ☞ Loss of normal function of the liver. (obesity, diabetes, ↑ cholesterol) • Nonalcoholic fatty liver disease (NAFLD) SIGNS & SYMPTOMS COMPLICATIONS • Asterixis • Jaundice • Portal HTN • Liver flap • Yellow discoloration • Portal veins become narrow due to scar tissue in the eyes & skin • Ascites • GI bleeding (esophageal varices) • Edema • ↑ Bilirubin & ammonia • Splenomegaly • Abdominal pain • ↓ Platelets • Anemia • Chronic dyspepsia • Hepatic encephalopathy/coma • Risk for bleeding (GI upset) • ↓ WBC's • Due to ↑ ammonia levels • Itchy skin (ammonia is a sedative) • Risk for infection • Gynecomastia TREATMENT • Breast development in men • Hepatorenal syndrome • Acute kidney injury in clients with liver failure • Stop alcohol consumption • Daily weights & I&O's norRcmbtelholmaoetloeltylmdhivhebeeerlrp:s MEDICATIONS Tdnmhriuetae'gsrtlAaiscsvvbiwecooorkhltciiezdainecn'st • Rest • Liver transplant • Antacids • Diuretics • Measure abdominal girth • Prevent bleeding • Vitamins • Paracentesis BLEEDING PRECAUTIONS • Lactulose • Removal of • ↓ serum ammonia through the stool fluid from the ∙ Use electric razor peritoneal cavity Lactulose think Lactuloose (ascites) ∙ Use soft-bristled because it loosens the bowels toothbrush Do not give acetaminophen to people with liver issues! ∙ Hold pressure on scrapes/cuts to minimize bleeding © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 165

NEUROLOGICAL ASSESSMENTS med-surg neuro LEVEL OF CONSCIOUSNESS (LOC) MENTAL STATUS Level of CONSCIOUSNESS (LOC) ☞ Are they aware of their surroundings? is always #1 with neurological assessment ☞ Are they oriented to person, place, time, & situation? ☞ Do they have their short term & long term memory? A change in LOC may be the only sign that there is a PROBLEM! typmeAesstnokotfaatqlshsuseetessasesttiuosn:s • What is your name? • Do you know where you are? PUPILLARY CHANGES • Do you know what month it is? PERRLA • Who is the current U.S. president? • What are you doing here? Pupils, equal, round, reactive to light & accommodation Normal Pupil size: 2 - 6 mm GLASGOW COMA SCALE DEEP TENDON REFLEX (DTR) RESPONSES Tool for assessing a client's response to stimuli 0 = No response ABSENT 1+ = Present, but sluggish or diminished Spontaneous 4 2+ = Active or expected response NORMAL 3+ = More brisk than excited; hyperactive EYE To speech 3 4+ = Brisk, hyperactive, with intermittent, OPENING RESPONSE To pain 2 or transient clonus VERBAL No response 1 RESPONSE Oriented 5 MOTOR Confused 4 RESPONSE Inappropriate words 3 Unclear sounds 2 No response 1 Obeys command 6 BABINSKI REFLEX (PLANTAR REFLEX) Moves to localized pain 5 Flex to withdraw from pain 4 Elicited by stroking the lateral side of the foot 3 Abnormal flexion 2 Intact CNS Abnormal extension 1 The lateral sole of the foot is stroked No response and the toes contract & draw together. TOTAL 3 - 15 INTERPRETATION brain dysfunction 3WORST Severe impairment of neurological Toes fan out when stroked. function, coma, or brain death <8 Unconscious patient Remember this is only normal in babinski think 15BEST Fully alert & oriented newborns & infants up to 2 years & normal in babies of age, but abnormal in adults! the big toe fans out © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 166

SEIZURES med-surg neuro What is a Abnormal & sudden causes • Hypoxia seizure? electrical activity of the brain • Brain tumor • ↑ fever • Hypoglycemia What is Chronic seizure activity (Febrile seizure in child) • Head injury EPILEPSY? due to a chronic condition • Hypertension • CNS infection • Drug or alcohol withdrawal • ABG imbalance stages of a seizure Prodromal Aura Ictus post -Ictus When symptoms start Warning sign right before SEIZURE! Recovery after the seizure before the actual seizure • Headache the seizure happens: Status Epilepticus: • Possible injury (can be days before a seizure that lasts • Confusion the seizure happens) • Weird smell or taste >5 minutes without • Very tired any consciousness • Altered vision exappnNaetaoriueiternanatlcsle during the seizure • Dizzy Generalized ATFBHFREEACEINNTETISDIRE Care during the seizure Seizures Seizure Precautions TONIC-CLONIC \"Used to be called grand-mal\" Note Remember: if the seizure lasts May begin with an aura. the time & > 5 minutes is status epilepticus. Stiffening (tonic) and/or maintain a duration of This needs IMMEDIATE attention rigidity (clonic) of the muscles. patent airway the seizure have oxygen & privacy provided MYOCLONIC Sudden jerking or stiffening suction available as soon as possible of the extremities (arms or legs). ABSENCE Usually looks like a blank loosened side rails up ATONIC stare that lasts seconds. clothing and padded Often goes unnoticed Sudden loss of muscle tone. May lead to sudden falls or dropping things. Partial (focal) TOAHNFEFEEBACRRTAEEIANDOISF pillow Seizures under head SIMPLE PARTIAL Sensory symptoms with motor bed in client in symptoms and stays aware. lowest position side-lying position They may report an aura. (immediately post-seizure) Don't COMPLEX PARTIAL Altered behavior/awareness • Place anything in their mouths and loses consciousness • Restrain the client • Leave the client for a few seconds. • Force the jaw open © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 167

med-surg CEREBROVASCULAR ACCIDENT (CVA) \"STROKE\" neuro PATHOLOGY BLOCKAGE Ischemic stroke Sudden interruption of \"Thrombotic or embolic\" blood supply to the brain. ∙ Thrombosis: The pathology of a stroke depends on the type of stroke. A blood clot that formed on the artery wall ∙ Embolism: RISK FACTORS A blood clot that has left part of the body Blood flow is cut off which leads to ischemia Modifiable transient ischemic attacks (TIAs) ∙ Hypertension ∙ Atherosclerosis \"Mini strokes\" • No cerebral infarction occurs ∙ Anticoagulation therapy ∙ Diabetes mellitus MEDICATIONS: 4.sg5yoimvhMneopsnueutsotrwtsmoibftfrsheoinm ∙ Obesity ∙ Stress ∙ Fibrinolytic therapy (\"clot buster\") ∙ Oral contraceptives Suffix: -ase Examples: alteplase, streptokinase non-Modifiable ∙ Family history of strokes Hemorrhagic stroke ∙ Older age ∙ Male gender ∙ Ruptured artery ∙ Black ∙ Aneurysm (weakening of the vessel) ∙ Hispanic ∙ Uncontrolled hypertension SIGNS & SYMPTOMS The collection of blood in the brain leads to f Face drooping BLEEDING ischemia & increased ICP ∙ Uneven smile TREATMENT: a Arm weakness ∙ Arm numbness; can't lift arm ∙ Stop the bleeding ∙ Prevent ↑ ICP s Speech difficulty ∙ Slurred speech t Time to call 911 NURSING CONSIDERATIONS Right brain positioning of the client assist with safe feeding ∙ Elevate head of bed to ↓ ICP ∙ Do not feed until gag reflex ∙ Behavioral changes ∙ Place a pillow under the affected has come back ∙ Lack of impulse control ∙ LEFT-sided hemiparesis arm in a neutral position ∙ ↓ chances of aspiration (1-sided weakness) preventative dvt measures ∙ Keep suction at the bedside tIhfinethtsbRehirdeeasmetilnreoeo,fkmtftehstbhiedoeerceri:cgouhfrts ∙ Crush medications Right think Reckless body will be ∙ Compression stockings affected ∙ Frequent position change diet modifications left brain ∙ Mobilization ∙ After a stroke, a patient ∙ Issues with language ∙ Encourage passive range will start on a liquid diet and progress slowly to a (aphasia) of motion every 2 hours regular diet. assist with communication skills ∙ RIGHT-sided hemiparesis liquid (1-sided weakness) ∙ Be patient ∙ Thin ∙ Make clear statements ∙ Honey-like left think languages ∙ Ask simple questions ∙ Don't rush! ∙ Nectar-like ∙ Spoon-thick food Types of aphasia: ∙ Pureed Receptive: Unable to comprehend speech (Wernicke's area) ∙ Mechanically altered ∙ Mechanically softened Expressive: Can comprehend speech, but can't respond back with speech (Broca's area) ∙ Regular © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 168

CRANIAL NERVES med-surg neuro What are Nerves that originate from the brain stem. se sensory M motor Cranial nerves? They send information to & from various parts of the body. Mnemonics START B both XII: Hypoglossal m Ooh, Olfactory Some Sensory I: Olfactory se Ooh, Optic Say Sensory Function: Glosso means tongue! Ooh Oculomotor Function: Marry Motor Tongue movement (swallowing & speech) To Trochlear Money Motor Sense of smell Touch Trigeminal Test: But Both Test: And Abducens My Motor Inspect tongue & ask to stick tongue out Feel Facial Brother Both Smell substance with eyes closed Very Vestibulocochlear / Acoustic Says Sensory (test each nostril separately) XI: Spinal Accessory m Good Glossopharyngeal Big Both Velvet. Vagus Brains Both II: Optic se Function: Such Spinal Accessory Matter Motor Heaven! Hypoglossal More Motor Controls strength of neck & shoulder muscles I Function: Test: II III Vision Ask the client to rotate their head & shrug their shoulders Test: X: Vagus b IV v • Snellen chart • Ophthalmoscopic exam Function: • Confrontation to check MOTOR - Swallowing, speaking, & cough peripheral vision SENSORY - Facial sensation VII Test: VI III: Oculomotor m Sensation coming from skin around the ear Function: IX: Glossopharyngeal b VIII X Ocular (eye) motor (movement) Function: Glosso means tongue! IX XII Controls most eye movements, pupil constriction, & upper-eyelid rise MOTOR - Tongue movement & swallowing Test: SENSORY - Taste (sour & bitter) XI • Look up, down, & inward Test: • Ask the client to follow your finger Test tongue by giving client sour, bitter, & salty substance. as you move it towards their face VIII: Vestibulocochlear / Acoustic se IV: Trochlear m Function: air WEBER TEST Function: Balance & hearing bone Controls downward & inward eye movement Test: RINNE TEST Test: • Stand with eyes closed • Look up, down, & inward • Otoscopic exam • Ask the client to follow your finger • Rinne & Weber Tests as you move it towards their face VII: Facial b VI: Abducens m V: Trigeminal b Function: Function: Function: MOTOR - Facial expression Controls parallel eye movement MOTOR - Mastication (biting & chewing) SENSORY - Taste (sweet & salty) Abduction - moving laterally AKA away from midline SENSORY - Facial sensation Test: Test: Test: • Ask client to do different facial expression • Pressure on the forehead cheek & jaw • Look up, down, & inward with a cotton swab to check sensation (Frown, smile, raise eyebrows, close eyes, blow etc) • Ask the client to follow your finger • Ask client to open mouth & then bite down • Test tongue by giving client sour, as you move it towards their face sweet, bitter, and salty substances. © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 169

CRANIAL NERVES med-surg neuro What are Nerves that originate from the brain stem. label the flags: Cranial nerves? They send information to & from various parts of the body. se sensory XII: Mnemonics START M motor Function: B both Test: Ooh, O________ Some S________ I: XI: Ooh, O________ Say S________ Function: Function: Ooh O________ Marry M________ Test: To T________ Money M________ Test: Touch T________ But B________ X: And A________ My M________ Function: Feel F________ Brother B________ Very V_____________ / A________ Says S________ Test: Good G______________ Big B________ Velvet. V________ Brains B________ IX: Such S________ Matter M________ Function: Heaven! H________ More M________ II: Test: I Function: II III VIII: Test: Function: IV v Test: • _______ chart VII: VII Function: III: VI Function: IX VIII Test: XI X XII air IV: Function: bone Test: _______ TEST _______ TEST ` V: VI: Function: Function: Test: Test: Test: Want more worksheets? 170 Check out The Complete Laminated Study Templates! © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

BURNS med-surg critical care WHAT IS A BURN? Damage to skin integrity 1st BURNS INJURY DEPTH Blanching: LAYERS OF THE SKIN present Degree • Epidermis Heals: EPIDERMIS • Pink & painful (still has nerves) a few days DERMIS Superficial • No scarring HYPODERMIS Blanching: 2nd Superficial • Epidermis & dermis present (SUBCUTANEOUS TISSUE) Partial • Blisters, shiny, & moist Heals: Degree • Painful 2 - 6 weeks Thickness 3rd • Epidermis, dermis, & hypodermis • May look black, yellow, red & wet Degree • No pain/ limited pain (nerve fibers are destroyed) • Skin will not heal (need skin grafting) Full • Eschar: dead tissue, leathery; must be removed! Thickness commomston TYPES OF BURNS INHALATION INJURY BURN LOCATION Damage to the respiratory system. Superficial heat Happens mostly in a closed area RESPIRATORY Thermal Examples: liquid, steam, fire SIGNS OF INHALATION INJURY: • Face ∙ Hair singed around the • Neck Chemical Burn caused by • Chest a toxic substance. face, neck, or torso • Torso Can be alkalotic or acidic ∙ Trouble talking Examples: bleach, ∙ Soot in the nose or mouth DISABILITY gasoline, paint thinner ∙ Confusion or anxiety • Hands Radiation Sunburns (UV radiation) CARBON MONOXIDE • Feet & cancer treatment (CO) POISONING • Joints (radiation therapy) • Eyes Carbon monoxide travels Inhalation Caused by inhaling faster than oxygen, allowing TROUBLE HEALING smoke which can cause it to bind to hgb first. • Poor blood supply Now oxygen cannot bind • Diabetes flame injury or carbon • Infection monoxide poisoning to hgb = HYPOXIA Classic symptom: cherry red skin INFECTION Friction Burn caused when an object rubs off the skin Treatment: 100% O2 Any open area where bacteria Examples: road rash, can easily enter scrapes, carpet burn POTENTIAL COMPLICATIONS • Perineum Skin has been Dysrhythmias, fracture • Ears of bones. Release of • Eyes Cold overexposed to cold myoglobin & hemoglobin into the blood which can COMPARTMENT SYNDROME Examples: frostbite clog the kidneys. • In the extremities Electric Electrical current that Tight skin such as eschar passes through the body, acting like a band around causing damage within the skin cutting off blood circulation © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 171

med-surg PHASES OF BURN MANAGEMENT critical care \"EAR\" = EMERGENT, ACUTE, REHABILITATIVE EMERGENT PHASE 24 - 48 HOURS after burn Onset of injury to the restoration of capillary permeability PATHO VITAL SIGNS NURSING CONSIDERATIONS ↑ Capillary permeability (leaky vessels) causing: ↑ Pulse hypsoThvhooicnlkke!mic • Establish IV access (preferably 2) Think ↓ Blood pressure ABCs ↓ Cardiac output • Plasma leaves the intravascular space leads • Fluids (Lactated Ringer's, crystalloids) • Albumin & sodium follows to ↓ Urine output • Parkland formula • Fluids shift to the interstitial tissue edema (from ↓ perfusion to the kidneys) • Foley catheter to monitor urinary output (UOP) Leads to fluids volume deficit (FVD) Goal: > 30 mL/hr of UOP in the intravascular space LABS ↑ Potassium (K+) • Decrease edema ↑ Hematocrit (HCT) • Elevate extremities above ↓ White blood cells (WBCs) ↑ BUN/ceatinine heart level ACUTE PHASE 48 - 72 HOURS after burn & until wounds have healed Capillary permeability stabilized - to wound closure PATHO NURSING CONSIDERATIONS Capillary permeability is restored which leads to the • Renal body diuresing (increased urine production). All the • Diuresis is happening excess fluid that shifted from the interstitial tissue • Foley catheter to monitor UOP shifts back into the intravascular space. • Respiratory GOALS • Possible intubation if respiratory complications occurred • Prevent infection • Gastrointestinal • Systemic antibiotic therapy • Since the client is in FVD, there is ↓ perfusion to the stomach • Paralytic ileus • Ensure proper nutrition • Curlings ulcer • Needs ↑ calories • Medication to decrease chance of ulcers • Protein & Vit C to promote healing • H2 histamine blocking agent (↓HCl) • Monitor bowel sounds • Alleviate pain • May need NG tube for suctioning • Wound care • Premedicate before wound care • Debridement or grafting REHABILITATIVE PHASE Could be weeks - years Burn healed and the patient is functioning mentally & physically GOALS • Psychosocial • Occupational theory (OT) • Activities of daily living (ADLs) • Cosmetic corrections • Physical therapy (PT) © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 172

med-surg FLUID RESUSCITATION FOR BURNS critical care THE PARKLAND FORMULA RULE OF NINES Used to calculate the total volume of Quick estimate of the % of the fluids (mL) that a patient needs 24 hours total body surface area (TBSA) has been effected by a partial & after experiencing a burn full-thickness burn in an adult client. Apply only in 2nd & 3rd degree burns. 4 mL X TBSA (%) X Body Weight (kg) = total mL of fluid needed ↓ Give the first 1⁄2 of the solution in the FIRST 8 HOURS ↓ Over the NEXT 16 HOURS, give the second 1⁄2 of the solution PRACTICE QUESTION PART 1: CALCULATING TBSA (%) A 25 year old male patient who weighs 79 kg has Back of right arm - 4.5% Answer: sustained burns to the back of the right arm, posterior Posterior trunk - 18% 36% trunk, front of the left leg, and their anterior head Front of left leg - 9% and neck. Using the Rule of Nines, calculate the total Anterior head & neck- 4.5% body surface area percentage that is burned. NOTE: The formula uses TBSA (%). However, you must calculate using 36. Not 0.36 (also written as 36%). PART 2: THE PARKLAND FORMULA Use the Parkland formula to calculate the 4 mL X 36% X 79 kg = 11,376 mL total amount of Lactated Ringer's solution that will be given over the next 24 hours. ↓ Answer: 11,376 ML 11,376 / 2 = 5,688 mL FIRST 8 HOURS ↓ 11,376 / 2 = 5,688 mL NEXT 16 HOURS Keep in mind: the question could ask you for mL given in the first 24 hours, the first 8 hours, etc., so read the question carefully. © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 173

SHOCK med-surg critical care WHAT IS SHOCK? A life-threatening condition resulting from inadequate tissue perfusion. This leads to possible cell dysfunction, cell death, and even organ failure. CTOMYSMOPHMSEOTOOCNKF Etiology Signs & Symptoms Treatment HYPOVOLEMIC ↓↓↓ Pulse CO HR BP → Large gauge IVs (at least 2) HYPOVOLEMIC SHOCK \"LOW\" \"VOLUME\" \"IN THE BLOOD\" Weak, → Fluids & blood replacement thready Decreased intravascular volume Not a lot of Tachycardia • Crystalloids pulse (example: normal saline causes blood being Compensating Hypotension or Lactated Ringers) pumped by to increase non-hemorrhagic blood flow • Colloids (albumin) the heart • Blood products (not from bleeding) (plasma, PRBCs, & PLTs) • Fluid Shift (edema or ascites) Skin CVP SVR 02 Sat Other Signs & Symptoms • Severe dehydration (vomiting, diarrhea, burns) Cyanosis labs can be: (Bluish tint of hemorrhagic the lips, tongue, ↑ HCT hemoconcentration and fingertips) (from bleeding) ↓ HCT actually hemorrhaging Cool, pale skin the RBCs • trauma ↓ capillary refill ↓ blood being • gi bleed (>3 seconds) • Oliguria (urine output of <30 mL/hr) • postpartum Vasoconstriction perfused to the body = low 02 • Confused, agitated due to decreased blood flow to the brain Etiology Signs & Symptoms Treatment The heart can't pump Pulse CO HR BP → For an MI: Angioplasty enough blood to meet the perfusion needs of the body Thrombolytics NOTE: → Oxygen Vasopressors There is enough blood, cause vasoconstriction the heart just can't → Vasopressors which ↑ blood flow pump it to the body and increases which causes fluid (example: epinephrine, accumulation in CARDIOGENIC SHOCK the lungs! dobutamine, dopamine) perfusion to causes Weak Not a lot of Tachycardia → Diuretics the organs peripheral blood being • Damage from an acute MI pumped by Compensating Hypotension • ↓ the workload of the heart • Severe hypoxemia pulses to increase • Acidosis the heart blood flow • ↓ extra blood volume • Hypoglycemia • Cardiomyopathy → Intra-aortic balloon pump • Cardiac tamponade (helps to improve coronary • Dysrhythmias artery blood flow & ↑ CO) Skin CVP SVR 02 Sat Diastole Systole Cool, Vasoconstriction ↓ blood being Other Signs & Symptoms clammy perfused to the body = low 02 • Jugular vein distention (JVD) skin • Chest pain ↓ capillary • Oliguria (urine output of <30 mL/hr) • Confused, agitation refill (>3 seconds) due to decreased blood flow to the brain From fluid • Dyspnea accumulation • Pulmonary edema in the lungs: BP = Blood pressure HR = Heart rate CO = Cardiac output SVR = Systemic vascular resistance CVP = Central venous pressure 174 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

DISTRIBUTIVE SHOCK med-surg (Septic, Neurogenic, Anaphylactic) critical care DISTRIBUTIVE: Leaky blood vessels Intravascular volume Since the blood is in the Excessive vasodilation pools in the peripheral peripherals, it is NOT perfusing (widening of vessels) blood vessels the vital organs which causes relative hypovolemia DCITSOMYTSMORPHMSIEOBTOOUCNTFKIVE Etiology Treatment Caused by widespread infection or sepsis Correct the underlying cause causes → Fluid replacement SEPTIC SHOCK (SEPSIS) • Pneumonia • Wound infection → Broad-spectrum antibiotics Broad spectrum → Vasopressors (norepinephrine & dopamine) antibiotics are used when • Urosepsis • Invasive procedures → Neuromuscular blockade agents & sedation the organism is not yet • Bacteria • Indwelling medical devices • ↓ metabolic demands & provides comfort known/determined. Once the organism is • Intra-abdominal infections (catheters) → Medications to prevent stress ulcers known, the client can • H2 blocking agents • Proton pump inhibitors (PPIs) be put on more specific antibiotics. Signs & Symptoms Pulse CO HR BP Other Signs & Symptoms Bounding CVP Tachycardia Hypotension → Hyperthermia & fever pulses → Increased respiratory rate SVR 02 Sat → GI upset: Nausea, vomiting, diarrhea, Skin Initially warm & flushed, Vasodilation decrease gastric motility but as the BP drops, → ↑ Inflammatory markers the skin becomes cool, ↑ WBCs pale & mottled ↑ C-reactive protein (CRP) Etiology Signs & Symptoms EVERYTHING IS Remember DECREASED parasympathetic Vasodilation due to a loss of balance between CO HR BP NEUROGENIC SHOCK (VASOGENIC) means relaxed everything In neurogenic shock, the Relative Hypovolemia: client mainly experiences parasympathetic Sympathetic stimulation which causes parasympathetic stimulation There is enough blood volume. However, the vascular VASODILATION for stimulation Hypotension space is dilated, so blood an extended period the sympathetic NS is not working volume is displaced causing to compensate & ↑ the HR hypovolemia. parasympathetic Causes dilation (relaxing) Skin CVP SVR 02 Sat stimulation of the smooth muscles Dry, warm extremities (Rest & digest) → (venous blood pooling) p think Sympathetic → Causes constriction (tightening) Hypothermia: Vasodilation peaceful stimulation of the smooth muscles warm/dry extremities, (Fight or flight) cold body causes Treatment Depends on the cause of the shock → Spinal cord injury • Spinal cord injury → Assess & manage airway Protect the spine: Keep spine immobilized (above T6, cervical) May need intubation or mechanical ventilation (cervical collar, backboards, log-rolling) • Spinal anesthesia → Elevate the head of the bed • Nervous system damage • Insulin reaction → IV fluids Watch for fluid volume overload S&S of blood clots: • Pain in the extremities Neurogenic = Issue with nervous system → Increased risk for clots due to pooling of blood • Redness • Tenderness • Watch for signs of a clot • Warmth • Compression devices • Antithrombotic agents (heparin) → Vasopressors (example: epinephrine, dobutamine, dopamine) BP = Blood pressure HR = Heart rate CO = Cardiac output SVR = Systemic vascular resistance CVP = Central venous pressure 175 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

DISTRIBUTIVE SHOCK med-surg (Septic, Neurogenic, Anaphylactic) critical care Leaky blood vessels Intravascular volume Since the blood is in the pools in the peripheral peripherals, it is NOT perfusing DISTRIBUTIVE: Excessive vasodilation (widening of vessels) blood vessels the vital organs which causes relative hypovolemia Etiology Signs & Symptoms BP Severe allergic reaction Pulse CO HR Foreign substance (antigen) Rapid, weak pulse Systemic antigen-antibody reaction (IgE) Tachycardia Hypotension Mast cells release potent vasoactive substance (histamine/bradykinin) Capillary permeability: 02 Sat Fluid is leaving the intravascular space Activates inflammatory cytokines Skin CVP SVR Causes vasodilation & capillary permeability Generalized flushing causes/triggers Vasodilation Often unknown (idiopathic) ANAPHYLACTIC SHOCK Other Signs & Symptoms • Foods (example: peanuts) • Medications  cardiac  Respiratory • Insects (example: bee sting) • Cardiac dysrhythmias • Bronchoconstriction • Latex or cardiac arrest • Exercise-induced anaphylaxis (EIA) • Difficulty breathing  GI • Wheezing Signs & symptoms usually occur • Nausea/vomiting • Coughing within 2 - 30 minutes of exposure to antigen • Acute abdominal pain • Unable to speak  Feeling of  skin impending doom • Itching, generalized flushing, redness, hives, or a rash may be present Treatment REMOVE How to use an epinephrine THE auto-injector (EAI) → High-flow oxygen → First-line drug: Epinephrine ALLERGEN! Education points: → Store in dark room • Causes vasoconstriction & bronchodilation → Administer EAI immediately → Other possible medications after the first sign of an TIT9NHH0JEIEGOC̊ HATUNATIGTNELRAE • Antihistamines allergic reaction • Diphenhydramine (Benadryl) Expected symptoms after administration: • Albuterol (Proventil) → Tachycardia • Corticosteroids → Palpitations → Dizziness → Fluids → Stay with the client & monitor Biphasic anaphylaxis: A recurrence of anaphylaxis after appropriate treatment BP = Blood pressure HR = Heart rate CO = Cardiac output SVR = Systemic vascular resistance CVP = Central venous pressure 176 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

ABGs med-surg ABGS A B G↓ 4 MUST-KNOW COMPONENTS ARTERIAL ↓ ↓ PH Measurement of how regulated by both 7.35 - 7.45 PACO2 acidic or alkalotic your blood is lungs & kidneys BLOOD GAS HCO3 PAO2 ABGS measure how Measurement of Regulated 35 - 45 carbon dioxide in the blood by the lungs 22 - 26 acidic or alkalotic CO2 think aCid Regulated the blood is in the by the kidneys arterial circulation. Measurement of bicarbonate in the blood *also a measure of gases Bicarbonate think Base such as O2 & Co2 Measurement of Regulated 80 - 100 oxygen in the blood by the lungs Value not needed to interpret alkalosis or acidosis. It just tells you if the patient is hypoxic or not. ABG INTERPRETATION 2 RESPIRATORY OR A METABOLIC PROBLEM? tionfatonh2raemlwryaeaztyeiasortnehe 1 KNOW YOUR LAB VALUES! ROME METHOD TIC-TAC-TOE METHOD acid normal base Acidosis Normal Alkalosis Respiratory PH ↑ C02 ↓ Alkalosis Opposite PH ↓ C02 ↑ Acidosis pH < 7.35 ↑ ↑ ↑ 7.35 - 7.45 > 7.45 ↑ CO2 > 45 ↑ 35 - 45 < 35 Metabolic PH ↑ HC03 ↑ Alkalosis HCO3 < 22 22 - 26 > 26 ↑ Equal PH ↓ HC03 ↓ Acidosis 3 UNCOMPENSATED, PARTIALLY COMPENSATED, OR FULLY COMPENSATED? If the pH is out of range & If CO2, hCO3 & PH If PH is in range 7.35 7.40 7.45 CO2 or hCO3 is in range are ALL out of range (7.35 - 7.45) Acidosis Absolute Alkalosis Normal = = = PARTIALLY FULLY UNCOMPENSATED COMPENSATED COMPENSATED ph in range? Just because the PH is \"normal\", it can still fall on a acidotic side or alkalotic side KIDNEYS Excreting excess LUNGS Hyperventilation acid & bicarb (HCO3) How do the ↓ CO2 = = organs OR Alkalosis Retaining Compensate? tBhBAinSkE Bicarb hydrogen & bicarb (HCO3) CO2 CO2 Hypoventilation Hydrogen tAhCinIkD ↑ CO2 ==Acidosis hours - days to compensate compensates FAST! © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 177

ABG PRACTICE QUESTION EXAMPLE med-surg ABGS QUESTION Ph 7.50 Value not PaCO2 50 mm Hg needed to A client with a bowel obstruction has been treated with gastric suctioning for 4 days. The nurse notices PaO2 90 mm Hg interpret alkalosis an increase in nasogastric drainage. Which Acid-base imbalance does that nurse correctly identify? HCO3 32 mEq/L or acidosis. It just The patient labs are the following → tells you if the patient is hypoxic or not. ROME METHOD TIC-TAC-TOE METHOD 1 What does the problem give you? 2 acid normal base pH 7.50 ACIDIC ALKALOTIC NORMAL co2 ph CO2 50 ACIDIC ALKALOTIC NORMAL HCO3 32 ACIDIC ALKALOTIC NORMAL hco3 3 UNCOMPENSATED, PARTIALLY COMPENSATED, If CO2, RESPIRATORY ACIDOSIS or FULLY COMPENSATED? hCO3 & PH RESPIRATORY ALKALOSIS METABOLIC ACIDOSIS UNCOMPENSATED are ALL METABOLIC ALKALOSIS out of range FINAL ANSWER: Is the pH in range? YES NO Metabolic Alkalosis, Is the CO2 in range? YES NO PARTIALLY COMPENSATED partially compensated Is the HCO3 in range? YES NO FULLY COMPENSATED 1 What does the problem give you? 2 Which of the four scenarios from the ROME method matches the pH 7.50 ACIDIC ALKALOTIC NORMAL information given in your problem? CO2 NORMAL HCO3 50 ACIDIC ALKALOTIC NORMAL Respiratory PH ↑ C02 ↓ Alkalosis Opposite PH ↓ C02 ↑ Acidosis 32 ACIDIC ALKALOTIC Metabolic PH ↑ HC03 ↑ Alkalosis PH ↓ HC03 ↓ Acidosis Equal 3 UNCOMPENSATED, PARTIALLY COMPENSATED, If CO2, RESPIRATORY ACIDOSIS or FULLY COMPENSATED? hCO3 & PH RESPIRATORY ALKALOSIS METABOLIC ACIDOSIS UNCOMPENSATED are ALL METABOLIC ALKALOSIS out of range FINAL ANSWER: Is the pH in range? YES NO Metabolic Alkalosis, Is the CO2 in range? YES NO PARTIALLY COMPENSATED partially compensated Is the HCO3 in range? YES NO FULLY COMPENSATED © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 178

med-surg RESPIRATORY ACIDOSIS VS. RESPIRATORY ALKALOSIS ABGS RESPIRATORY ACIDOSIS RESPIRATORY ALKALOSIS PATHOPHYSIOLOGY LUNG PROBLEM KIDNEYS COMPENSATE PATHOPHYSIOLOGY LUNG PROBLEM KIDNEYS COMPENSATE The lungs are The kidneys excrete excess The lungs are The kidneys excrete excess retaining hydrogen & retain losing bicarb (HCO3) & retain bicarb (HCO3) hydrogen too much CO2 too much CO2 CO2 CO2 PH PH > 45 < 35 < 7.35 > 7.45 CAUSES RETAINING CO2 : \"Depress\" breathing CAUSES LOSING CO2 : \"Tachypnea\" rugs (opioids & sedatives) ↑ Temperature dema (fluid in the lungs) Aspirin toxicity neumonia (excess mucus in the lungs) Hyperventilation espiratory center of the brain is damaged mboli (pulmonary emboli) SIGNS & SYMPTOMS  ↑ Heart rate nethfraayvpcTepiwpaoiiilntnccmghraueiltnsschcpgeleoemonfsfsaiweacthihtaeeoln pasms of the bronchial (asthma)  Confused & tired ac elasticity damage (COPD & emphysema)  Tetany  EKG changes All these things cause impaired gas exchange  (+) Chvostek's sign INTERVENTIONS SIGNS & SYMPTOMS  ↑ Blood pressure  Confusion  ↑ Respiration rate  Headache  ↑ Heart rate  Sleepy / coma  Restlessness INTERVENTIONS  Provide emotional support  Administer O2  Fix the breathing problem!  Semi-Fowler’s position  Encourage good breathing patterns  Turn, cough, & deep-breathe (TCDB)  Rebreathing into a paper bag  Pneumonia: ↑ fluids to thin secretions  Give anti-anxiety medications or sedatives & administer antibiotics to ↓ breathing rate  If CO2 >50, they may need an endotracheal tube  Monitor potassium levels Normal K+  Monitor K+ & Ca- levels Normal CA- 9 - 11 mg/dL 3.5 - 5.0 mmol/L © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 179

METABOLIC ACIDOSIS VS. METABOLIC ALKALOSIS med-surg ABGS METABOLIC ACIDOSIS METABOLIC ALKALOSIS PATHOPHYSIOLOGY KIDNEY PROBLEM LUNGS COMPENSATE PATHOPHYSIOLOGY KIDNEY PROBLEM LUNGS COMPENSATE Too much hydrogen The lungs will TooTomoulicthtlebiHcyadrrbo(HgeCnO3) The lungs will retain Too little bicarb (HCO3) blow off CO2 CO2 PH HCO3 PH HCO3 < 7.35 < 22 > 7.45 > 26 CAUSES  Diabetic ketoacidosis Not enough insulin CAUSES  Too many antacids Too much  Acute/chronic kidney injury = ↑ fat metabolism  Diuretics sodium bicarbonate (BASE)  Malnutrition = excess ketones (acid)  Excess vomiting Breaking down of fats  Hyperaldosteronism Excess loss of = excess ketones (acid) hydrochloric acid (HCL)  Severe diarrhea Remember Bicarb from the stomach comes out of your Base SIGNS & SYMPTOMS  ↑ Respiratory rate Kussmaul's breathing SIGNS & SYMPTOMS  ↓ Respiratory rate hypoventilation  Hyperkalemia Deep rapid breathing  ↓ Potassium (K+) <12 breaths per minute • Muscle twitching >20 breaths per minute • Weakness • Dysrhythmias • Tetany • Arrhythmias • Muscle cramps/weakness • Tremors • Vomiting • EKG changes  ↓ Blood pressure Metabolic Acidosis = ↑ serum potassium  Confusion Metabolic Alkalosis = ↓ serum potassium INTERVENTIONS  Monitor intake & output Normal K+ INTERVENTIONS  Monitor K+ and Ca- levels Normal CA- 3.5 - 5.0 mmol/L 9 - 11 mg/dL  Administer IV solution of sodium bicarb  Administer IV fluids to help to ↑ bases & ↓ acids the kidneys get rid of bicarbonate  Initiate seizure precaution  Monitor K+ levels  Replace K+ DIABETIC KETOACIDOSIS (DKA) KIDNEY DISEASE  Give antiemetics for vomiting • Give insulin (this stops the • Dialysis to (Zofran or Phenergan) breakdown of fats which stops remove toxins ketones from being produced)  Watch for signs of respiratory distress • Diet • Monitor for hypovolemia • ↑ Calories due to polyuria • ↓ Protein © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 180

FRACTURES med-surg musculoskeletal WHAT IS A FRACTURE? A fracture is a complete or incomplete disturbance in the progression of bone structure TYPES OF FRACTURES STAGES OF BONE HEALING comminuted transverse stage i He fell The bone is crushed The bone is fractured HEMATOMA FORMATION because causing lots of little straight across he was • First 1-2 days of fracture running fragments cchsoeimledmnreoinnnly • Bleeding into the injured site occurs stage iI oblique greenstick FIBROCARTILAGINOUS CALLUS FORMATION The fracture runs at an One side of the bone is • Formation of granulation tissue angle across the bone bent, the other is broken • Reconstruction of bone begins • Still not strong enough to bear weight impacted spiral stage iII The fractured bone is The break partially BONY CALLUS FORMATION (OSSIFICATION) driven into another bone encircles the bone • 3rd - 4th week of fracture healing • Mature bone is replacing the callus stage iV open/compound REMODELING A fracture where the bone • This may take months to years! breaks through the skin • Compact bone replaces spongy bone • X-rays are used to monitor the progress of bone healing increased NURSING ASSESSMENT risk for infection post-fracture Neurovascular assessments COMPARTMENT Pressure ↑ p Pain SYNDROME ↓ 5 P's p Pallor oserbntuisnrangtiilnoingng Increased pressure and build-up, causes Blood flow cut off p Pulselessness tissue impairment leading to cell death! p Paresthesia ↓ Tissue damage due to HYPOXIA p Paralysis SIGNS & SYMPTOMS (lack of oxygen) ∙ Deep, throbbing, unrelenting pain TREATMENT fasciotomy ∙ Pain unrelieved by medications Normal Compartment Syndrome ∙ Disproportional to the injury ∙ Place extremity at the heart level Fascia is cut Muscle swelling ∙ Intensifies with passive ROM immediate (not above heart level) to relieve tension causing compression ∙ Open the cast or splint & pressure of nerves and vessels © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 181

GOUT med-surg musculoskeletal PATHOLOGY WHAT IS Gout is a form of arthritis hyperuricemia URIC ACID? ☞ characterized by Uric acid is created from purine breakdown during digestion. It's ↓ ↓ ↓increased uric acid levels. \"high\" \"uric acid\" \"in the blood\" produced by the liver and is mostly excreted by the kidneys. This causes deposits of uric acid crystals in the joints. Expected range: F: 2.5 - 8 mg/dL TOPHI M: 1.9 - 7.5 mg/dL Accumulation of sodium urate crystals in joints such as the big toe and hands, or other areas such as the ears. Tophi think Toe CAUSES SIGNS & SYMPTOMS Can be acute or chronic ∙ Diet high in purines ∙ Certain medications ∙ Acute gouty arthritis ∙ Bone deformity ∙ Pain (severe) ∙ Joint damage ∙ Diuretics (causes dehydration) ∙ Swelling ∙ Tophi ∙ Aspirin ∙ Warmth at the site ∙ Renal calculi ∙ Cyclosporine ∙ Disorder of purine metabolism ∙ Kidney problems ∙ Inadequate excretion of uric acid by the kidneys EDUCATION foods high in purin es: ∙ Stay hydrated: ∙ Educate on avoiding: Organ 2- 3 liters per day ∙ Foods high in purines (livmere, aktidsney) ∙ Medications (aspirin) ∙ Uric acid deposits can cause kidney stones, ∙ Alcohol red ∙ Dehydration meats fluids help prevent this! MEDICATIONS seafood ∙ Weight loss program if overweight generic Al(bceoerh)ol allopurinol trade name generic trade name Aloprim, Zyloprim, colchicine Mitigare, Colcrys Lopurin Allopurinol → prevents gout Colchicine → for aCute gout attacks *For more information about gout medications, see the musculoskeletal section in the Pharmacology Bundle © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 182

OSTEOPOROSIS med-surg musculoskeletal PATHOLOGY Osteoporosis osteoporosis DIAGNOSTIC OsteoPorosis essentially means: ☞ Bone density test: ↓↓ having porous Dual-energy x-ray bones absorptiometry (DEXA) \"relating to bone\" \"porous\" This process takes X-ray images ☞ The rate of bone resorption (osteoCLASTS) is greater healthy measuring calcium than the rate of bone formation (osteoBLASTS) bone and other minerals in the bones = ↓ decreased total bone mass Normal bone marrow has small holes in it, but osteoporosis causes much larger holes RISK FACTORS SIGNS & SYMPTOMS FRACTURES Calcium & vitamin intake is LOW ☞ May be asymptomatic until a Clients often think they fracture occurs fell and broke something, Age: women after menopause ☞ Fractures (hips, spine, wrist) BUT bones may break (the decrease in estrogen at menopause ☞ Low back, neck, or hip pain first causing them to causes increase bone resorption) ☞ The back will be rounded fall. Lifestyle (smoking, excessive alcohol intake, (hunch back) causing height loss sedentary lifestyle, immobility) Caucasian or Asian women Inherited (family history) Underweight/malabsorption disorder →→ (Celiac disease, bariatric surgery, eating disorders) Medications: long-term use of corticosteroids, anticonvulsants, levothyroxine, long-term use of proton pump inhibitors, etc. prednisone NURSING INTERVENTIONS AT HOSPITAL Assessing for Educate on ways Teaching about • Use call light risk factors to prevent preventing injury • Non-slip socks Educate on stopping osteoporosis • Communicate falls risk smoking & limiting alcohol AT HOME • Clutter-free environment MEDICATIONS PREVENTION • No area rugs ☞ Calcium supplements (risk for falling) with Vitamin D • Weight-bearing exercises (weights, hiking, etc). • Watch out for pets ☞ Bisphosphonates (ends in \"dronate\") • Consume foods rich in • Keep glasses near by calcium & vitamin D Alendronate *For more information about bisphosphonates, see the Pharmacology Bundle © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 183

med-surg OSTEOARTHRITIS (OA) & RHEUMATOID ARTHRITIS (RA) musculoskeletal Osteoarthritis (OA) PATHOLOGY Eroded RISK FACTORS cartilage OA is a noninflammatory degenerative disorder of the joints. Bone ends ∙ Obesity It's caused by the breakdown of cartilage between the joints. rub together ∙ Older age ∙ Female gender The articular cartilage breaks down, which leads to damage to ∙ Certain occupations (heavy labor) the bone. ∙ Genetics TREATMENT SIGNS & SYMPTOMS ☞ Orthotic devices Distal ∙ Pain (splints, braces, knee braces) Distal ∙ Stiffness after activity Occurring ☞ Walking aids (canes) interphalangeal (subsiding within 30 min) mostly at the ☞ Exercise weight-bearing ☞ Weight loss (DIP) called ∙ Functional joints ☞ Occupational therapy (OT) Heberden’s nodes impairment (hips, knees) & physical therapy (PT) Proximal ∙ Bony enlargements ☞ Analgesics Proximal Movement / Exercise → Aggravated / symptoms worsen interphalangeal rest → Symptoms are relieved (PIP) called Bouchard's nodes acetaminophen NSAIDS PATHOLOGY Exact mechanism is unknown swollen, STAGES OF inflamed RHEUMATOID ARTHRITIS RA is a chronic, inflammatory type of arthritis. synovial It's classified as an autoimmune disease. membrane 1 Synovitis ∙ Inflammation of the synovium ∙ Synovial membrane thickens Rheumatoid arthritis (RA) SIGNS & SYMPTOMS 2 Pannus Formation ∙ Symmetric joint pain ∙ Deformity of the fingers ∙ Pannus is a layer of vascular This causes loss of... ∙ Symptoms are typically ∙ Can effect all joints fibrous tissue ∙ Articular surfaces bilateral & symmetric (fingers, wrists, neck, 3 Fibrous ankylosis ∙ Joint motion ∙ Stiffness in the morning shoulders, etc). ∙ Joint invaded by fibrous ∙ Ligament elasticity ∙ Systemic effects: heart, connective tissue (lasting >1 hour) lungs, skin, etc. ∙ Swelling, warmth, 4 Bony Ankylosis ∙ When the bones are fused together and redness DIAGNOSIS TREATMENT CNUORE ∙ Hard to diagnose because symptoms are very similar GOAL: Decrease joint pain & swelling. NSAIDS to other diseases Decrease changes of joint ☞ (+) Rheumatoid factor deformity & minimize disability. ☞ Increase erythrocyte sedimentation Corticosteroids ☞ C-reactive protein (indicates inflammation in the body) ☞ X-ray shows joint deterioration ∙ Medications DMARDS ∙ Surgery ∙ Synovectomy: removal of synovium ∙ Joint replacement ∙ Arthrodesis: \"joint fusion\" RISK FACTORS ∙ Joint support ∙ Splints & assistive devices ∙ Range of motion (ROM) exercise May cause an ∙ Environmental factors (smoking, pollution) ∙ Low impact exercise (walking, water aerobics, etc). inflammatory ∙ Bacterial or viral illness ∙ Cigarette smoking ∙ Occupational therapy (OT) & physical therapy (PT) response & ∙ Family history destructive ∙ Heat or cold? heat → For stiffness synovial fluid cold → For pain/inflammation © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 184

PHARMACOLOGY BROUGHT TO YOU BY © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 185

ANTIBIOTICS / ANTIBACTERIALS suffixes & Tetracyclines prefixes / suffixes Prefixes -cycline examples Sulfonamides sulf- doxycycline, tetracycline Cephalosporins -cef, ceph- sulfasalazine Penicillins -cillin cefazolin, cephalexin Aminoglycosides & macrolides -micin, -mycin ampicillin, oxacillin Fluoroquinolones -floxacin gentamicin, erythromycin ciprofloxacin, levofloxacin ANTIVIRALS prefixes / suffixes examples Antiviral (undefined group) vir-, -vir-, -vir oseltamivir, zanamivir Antiviral (anti-herpes virus agents) Antiretrovirals (protease inhibitors) -clovir acyclovir, famciclovir HIV / AIDS -navir atazanavir, nelfinavir -vudine zidovudine, stavudine ANTIFUNGAL prefixes / suffixes examples Antifungal -azole fluconazole, voriconazole ANESTHETICS / ANTIANXIETY Local anesthetics prefixes / suffixes examples -caine lidocaine, bupivacaine amobarbital, secobarbital Barbiturates (CNS depressant) -barbital alprazolam, lorazepam Benzodiazepines (for anxiety/sedation) -zolam, -zepam ANTSIDCEAVPNIDRFEEOSOSRANTS ANTIDEPRESSANTS examples Selective serotonin prefixes / suffixes fluoxetine, escitalopram, vilazodone reuptake inhibitors (SSRIs) -oxetine, -talopram -zodone Serotonin-norepinephrine reuptake -faxine, -zodone venlafaxine, nefazodone, milnacipran inhibitors (SNRI/DNRI) - nacipram Tricyclic antidepressants (TCAs) -triptyline, -pramine amitriptyline, clomipramine © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 186

ANALGESICS / OPIOIDS suffixes & Opioids prefixes / suffixes Prefixes -done, - one examples oxycodone, hydromorphone NSAIDs (anti-inflammatory) -profen ibuprofen, fenoprofen Salicylates aspirin (ASA) Nonsalicylates acetaminophen upper respiratory H1 Antagonists prefixes / suffixes examples (second-generation antihistamines) -tadine, -tirizine loratadine, desloratadine, cetirizine, levocetirizine Nasal decongestants -ephrine, -zoline phenylephrine, naphazoline, lower respiratory oxymetazoline prefixes / suffixes examples Beta2-agonists (Bronchodilator) -terol albuterol, levalbuterol Xanthine derivatives (Bronchodilator) -phylline aminophylline, dyphylline Cholinergic blockers -tropium tiotropium reslizumab, montelukast Immunomodulators & -zumab, -lukast leukotriene modifiers examples GASTROINTESTINAL cimetidine, famotidine prefixes / suffixes omeprazole, pantoprazole Histamine H2 antagonists -tidine (H2-blockers) Proton pump inhibitor (PPIs) -prazole Antidiabetic prefixes / suffixes examples Thiazolidinedione -glitazone rosiglitazone, pioglitazone Inhibitor of the DPP-4 enzyme sitagliptin, linagliptin -gliptin 187 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

CARDIAC: ANTIHYPERTENSIVES suffixes prefixes / suffixes & ACE inhibitors -pril Prefixes examples Beta-blockers -olol enalapril, captopril Angiotensin II receptor antagonists -sartan metoprolol, nadolol Calcium channel blockers -pine, -amil losartan, olmesartan Vasopressin receptor antagonists -vaptan amlodipine, verapamil Alpha-1 blockers -osin conivaptan, tolvaptan Loop diuretics -ide, -semide prazosin, doxazosin Thiazide diuretics -thiazide furosemide, bumetanide Potassium-sparing diuretics -actone hydrochlorothiazide, chlorothiazide spironolactone CARDIAC: ANTIHYPERLIPIDEMICS HMG-CoA reductase inhibitor prefixes / suffixes examples -statin simvastatin, rosuvastatin CARDIAC: other prefixes / suffixes examples Anticoagulant (Factor Xa inhibitor) -xaban apixaban Low-molecular-weight heparin (LMWH) -parin enoxaparin, dalteparin Thrombolytics (clot-buster) Antiarrhythmics -teplase alteplase -arone amiodarone MISCELLANEOUS prefixes / suffixes examples Corticosteroids -asone, -olone, -nide betamethasone, fluocinolone, amcinonide Triptans (anti-migraine) -Triptan almotriptan, sumatriptan Ergotamines (anti-migraine) -ERGOT- dihydroergotamine, ergotamine Antiseptics -chlor Chlor think Clean chlorhexidine, chloroxylenol Bisphosphonates -dronate risedronate, alendronate Neuromuscular blockers -nium vecuronium, rocuronium Retinoids (anti-acne) tretin- tretinoin Phosphodiesterase 5 inhibitors -afil sildenafil, tadalafil Carbonic anhydrase inhibitors -LAMIDE, - AMIDE acetazolamide, diclofenamide © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 188

common therapeutic levels antidotes & Therapeutic Digoxin ......................................................... 0.5 - 2.0 ng/mL (> 2 = Toxic) Lithium......................................................... 0.6 - 1.2 mEq/L levels Theophylline .................................................. 10 - 20 mcg/mL Dilantin (Phenytoin)........................................ 10 - 20 mcg/mL Magnesium sulfate.......................................... 4 - 7 mg/dL Acetaminophen (Tylenol).................................. 10 - 20 mcg/mL Gentamicin..................................................... 5 - 10 mg/L Salicylate (aspirin).......................................... 100 - 300 mcg/mL Vancomycin ................................................... Peak: 20 - 40 mcg/mL Trough: 5 - 15 mcg/mL Valproic acid .................................................. 50-100 mcg/mL antidotes ✘ Anti-dote ✘ Think Anti - Drug! Antidotes work to reverse the toxicity of a certain medication Opioids / Narcotics........... Naloxone (Narcan) NO more Opioids NARCAN→OPIOIDS Warfarin (Coumadin)........ Vitamin K During war, Vitamin k kills warfarin Heparin........................ Protamine sulfate You will need heLp from a pro to stop bleeding out Digoxin......................... Digibind or digifab digiBIND digiFAB Anticholinergics............... Physostigmine Benzodiazepines............... Flumazenil (Romazicon) I flu fast in my mercedes benz Cholinergic crisis.............. Atropine (Atropen) We don't have time to chat, we have a toxic situation chOLINERGIC→ ATROPINE Acetaminophen (Tylenol) .... Acetylcysteine (Mucomyst) acetAMINOPHEN → acetYLCYSTEINE Magnesium sulfate........... Calcium gluconate maggie calLs for help! magNESIUM→CALCIUM Iron............................. Deferoxamine DEferOXAMINE → ferrous means \"containing iron\" Lead............................ Succimer or Calcium disodium edetate chelaTthieosneaagreents Alcohol withdrawal........... Chlordiazepoxide (Librium) Beta blockers ................. Glucagon Beta blockers be gone with Glucagon Calcium channel blockers .... Glucagon, insulin, or calcium You take aspirin when you have a headache. You may Aspirin ......................... Sodium bicarbonate also want a salty snack when you have a headache. Insulin Reaction............... Glucagon If you want your insulin gone, you give Glucagon Pyridoxine ..................... Deferoxamine Tricyclic antidepressants .... Sodium bicarbonate ASNCTAVINIDDOFEOTORES Cyanide......................... Hydroxocobalamin © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 189

Pain Management SALICYLATES & NONSALICYLATES Meds Salicylates generic trade name NonSalicylates generic trade name aspirin - acetaminophen Tylenol Action Action ☞ Analgesic & antipyretic ☞ Analgesic & antipyretic Action is not completely known. ☞ Anti-inflammatory Does NOT have any anti-inflammatory ☞ Anticoagulant or antiplatelet effects.  Analgesic uses • Inhibits prostaglandins. Prostaglandins make pain  Mild to moderate pain receptors more sensitive to feel pain.  Aspirin substitute for those with:  Antipyretic • Allergy to aspirin • ↓ body temp by dilating the blood vessel • bleeding tendencies  Children with fever / flu-like symptoms & spreading the blood throughout the body.  Aspirin side effects • Prolongs bleeding times. • Inhibits the clumping of platelets.  Hives  Hemolytic anemia uses  Pancytopenia These side effects  Hypoglycemia rarely occur when the  Mild to moderate pain  Liver damage medication is taken as directed.  ↓ body temp  Inflammatory conditions • Hepatotoxicity They occur due to • Hepatic failure chronic use (RA, OA, & rheumatic fever) • Jaundice or  Aspirin is used to ↓ the risk of an MI & CVA higher dosage than recommended side effects  GI upset • Heartburn • Anorexia • Nausea / vomiting • GI bleeding contraindications EGNAN  Known sensitivity to acetaminophen b  Those with liver dysfunction • Chronic alcohol use CY C Y CA contraindications PR Y PR  Known sensitivity to Salicylates or NSAIDS EGNANC ATEGOR  Any bleeding tendencies D • GI bleeding (peptic ulcers) TEGORY • Blood dyscrasia • Bleeding disorders Nursing Considerations • On anticoagulants • Vit K deficiency  Before adm. of acetaminophen, assess overall  Children with recent viral infection health & alcohol use • Risk for Reye's Syndrome! • Malnourished clients & those with chronic Nursing Considerations alcohol use (>3 drinks /day) are at increased risk for liver damage  Stop taking salicylates 1-week prior to major surgery (remember ↑ risk for bleeding) • Limit dosage to 1000-2000 mg/day!  Monitor for GI bleeding Antidote: Acetylcysteine (mucomyst) Antidote: activated charcoal This protects the liver cells & destroys acetaminophen metabolism 1) Gastric lavage TOXICITY? 1) Gastric lavage (within 4 hours of ingestion) 2) Activated charcoal (within 2 hours of ingestion) 2) Give antidote via nebulizer TOXICITY? within 24 hours of ingestion © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 190

NSAIDS Pain Management Meds NSAIDS Non-steroidal Anti-Inflammatory Drugs Gets their name because they produce an generic trade name anti-inflammatory effect but they are not steroids! Ibuprofen Advil fenoprofen Action flurbiprofen Nalfon diclofenac ☞ Anti-inflammatory Inhibit prostaglandin – inIhnihbiiwbtiiitnthsgoCCuOtOXX21 ☞ Analgesic synthesis by blocking celecoxib – ☞ Antipyretic cyclooxygenase (COX) Celebrex sEtonmmzCyaoamincxteha1tilnihnsaintg tEringzgCyemorsxept2ahiant ketorolac Sprix (nasal spray) naproxen Aleve This means they inhibit indomethacin Indocin pain, but also inhibit the enzyme that maintains the suffixes: -profen, -olac lining of the stomach! uses side effects  Mild to moderate pain COMMOSMTON GI upset / diarrhea / vomiting  Menstrual cramps Nausea  ↓ fever •  Musculoskeletal disorders • Anorexia • OA & RA • Abdominal pain / discomfort  Heart contraindications dREGNAN • HTN & heart failure NSAIDs think Nephrotoxic!  Known hypersensitivity  Kidney clogging P CY CAT to NSAIDs or aspirin • NSAIDs are nephrotoxic!  Clients with clot history  Blood clots • MI, CVA, PE, DVT EGORY • Stroke  Clients with liver, kidney, Certain medications are known to cause bronchospasms in clients with asthma. or bleeding disorders We want to “BAN” these medications from asthma patients. Nursing Considerations b Beta blockers a aspirin  NSAIDs cause GI upset such as acid reflex n nSAIDS • Administer proton pump inhibitors (PPIs) • Omprazole • Pantoprazole  Educate: take with food to decrease stomach upset • Don't take on an empty stomach © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 191

OPIOID ANALGESICS Pain Management Meds generic Action Uses hydromorphone CNS Depressant  ↓ anxiety & sedate post-op codeine  ↓ anxiety in those with dyspnea Binds to opioid receptors in the brain which  Relieve pain (myocardial infarction) oxycodone causes an analgesic sedative, & euphoric effect.  Manage opioid dependence fentanyl  Treat diarrhea & intestinal cramping THE ∙ Most commonly used opioid for chronic pain. morphine sulfate STGAONDLDARD ∙ Can be given in many forms: Opioids do NOT produce an (PO, nasally, subcut, IM, IV, & suppository) anti-inflammatory effect or an Suffixes: antipyretic effect. So they are not -done, -one used to reduce fevers or for Side effects gout / rheumatoid arthritis. ∙ ↓ GI Function Long term Tolerance Vs. Dependence • Constipation side effects Client will NOT The body adapts to the The body goes through build tolerance drug (gets used to it) \"withdrawals\" & experiences ∙ ↓ Vital signs Higher doses of negative effects when • ↓ HR medication are needed the medication is STOPPED! • ↓ BP (hypotension) to achieve the same effect! • ↓ RR short term ANtidote: Naloxone (Narcan) ∙ ↓ CNS function side effects • Sedation, insomnia, → Reversal agent for opioid overdose weakness, dizziness Client WILL → Opioids last longer than the effect of naloxone (Narcan) build tolerance → Repeat doses may be needed ∙ Pruritus (itching) ∙ Nausea This reverses the opioid's effects ∙ IV admin and the client's pain will come back! ∙ Burning sensation REMEMBER nursing considerations Transdermal Patch  Preventative measures for constipation • Adm. stool softeners or laxatives  Remove old patch before placing • Daily exercise Fluids, Fiber, & Fruits a new one • Fluids, Fiber, & Fruits Fill up the toilet  Dispose old patch in the sharps container  Date & initial the patch • Encourage client to defecate when they feel the urge (do not wait)  Do not apply over hair  Rotate sites  Client respirations begin to drop  Avoid the sun or heat • Coaching the client to breath may increase the respiratory rate (it increases absorption) • Administer naloxone (Narcan)  Preventative measures for falls • Opioids causes orthostatic hypotension • Educate to rise slowly, assist the client with ambulatory activities When to STOP • Keep the room well lit the medication:  Take PO opioids with food to decrease GI upset Respiratory depression • RR < 12 ☞ Do not drink ETOH! ☞ If the client is unarousable 192 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

SULFONAMIDES & FLUOROQUINOLONES antibiotics Overview  Antibiotics and antibacterials are used interchangeably SUPER INFECTION of tAwhnhetici\"bhniooctarimncsacdlafuislosreurapa\"t  Antibiotics are only used for bacterial infection (not viral) super infection antibiotics (secondary  Finish the entire prescription of antibiotics (even if you are feeling better) infection)  NO alcohol (antibiotics are hard on the liver)  A culture & sensitivity test ∙ Culture is a test to determine the type of bacteria ∙ Sensitivity test is to determine what kind of medication will work best ∙ Always obtain cultures before administering an antibiotic generic trade name Sulfonamides \"Sulfa Drugs\" sulfadiazine – sulfasalazine Azulfidine action Nursing considerations Bacteriostatic (slow-growing) sulfamethoxazole Bactrim ∙ Increase fluids intake because Inhibit folic acid metabolism. sulfas dry out the body Prefix: Sulfa- It slows the growth of the bacteria enough for the body to take over with ∙ Since sulfas cause photosensitivity, Side effects its own defense mechanic (WBCs) we want to use sunblock and avoid the sun! ∙ GI UPSET! uses ∙ Nausea, vomiting, anorexia, ∙ Take folic acid daily diarrhea, abdominal pain, stomatitis ∙ UTIs (commonly caused by E.coli) ∙ Patient may bruise easily ∙ Acute otitis media ∙ Chills / fever ∙ Ulcerative colitis ∙ Monitor skin & handle with care ∙ Crystalluria ∙ Topical: used for burn wounds suflas think sunburn ∙ Crystals in the urine ∙ Photosensitivity Contraindications REGNAN CY CAT CY CAT ∙ Increased risk for sunburn! ∙ Hypersensitive to sulfa drugs Pd ∙ Hematologic changes PEGORY ∙ Leukopenia (↓ WBCs) ∙ Allergy to sulfonylureas ∙ Thrombocytopenia (↓ platelets) like Glyburide (antidiabetic medications) ∙ Aplastic anemia (↓ RBCs) generic trade name Fluoroquinolones ciprofloxacin Cipro action gemifloxacin Factive Interferes with the synthesis Contraindications REGNAN of bacterial DNA ofloxacin Floxin ∙ Clients with a history of C (Causes death of hypersensitivity to the EGORY the bacterial cell) fluoroquinolones moxifloxacin Avalox uses levofloxacin Levaquin ∙ Children <18 years old ∙ Lower respiratory infections suffix: -floxacin ∙ Bone & joint infections ∙ Give with caution to: ∙ UTIs ∙ Diabetics, those with renal Side effects ∙ STIs impairment, history of seizures, ∙ Infections of the skin & the elderly. ∙ GI UPSET! ∙ Ophthalmic solutions for eye infections ∙ Nausea, diarrhea, abdominal pain Nursing considerations ∙ Dizziness ∙ Fluoroquinolones cause ∙ Photosensitivity photosensitivity. We want to use sunblock and avoid the sun! ↑ risk for Tendonitis Your tendon is & tendon rupture near the Floor ∙ Take on an EMPTY stomach (Especially the elderly w/ full glass of water taking corticosteroids) & can rupture due to Flooroquinolones © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 193

PENICILLIN & CEPHALOSPORINS antibiotics generic penicillin action Contraindications P REGNANCY CAT penicillin G PRE penicillin V 4 TYPES: Broad Spectrum Antibiotic C amoxicillin ∙ History of allergies to EGORY ampicillin ☞ Natural Inhibits the integrity of cephalosporins or Penicillin EGORY piperacillin ☞ Penicillinase-resistant the bacterial cell wall ☞ Aminopenicillins ∙ Renal disease, asthma, oxacillin ☞ Extended-spectrum bleeding disorders, GI disease suffix: -cillin Side effects uses agcaao(PisipnmnerPsfenmetrviocscoepteiilnnolchiltnoynyioslnsaundaxs)raieserdy Nursing considerations ∙ GI UPSET! ∙ UTIs ∙ Pregnancy & breast-feeding safe ∙ Stomatitis & dry mouth ∙ Septicemia ∙ Penicillin makes oral contraceptive ∙ Gastritis, nausea, vomiting, diarrhea, ∙ Meningitis & abdominal pain ineffective (use additional contraceptive) ∙ Intra-abdominal infections ∙ Orally - Inflammation of the tongue (Glossitis) penicillin Bumps the pill ∙ IM injection - Pain at the site ∙ STIs (syphilis) ∙ IV injection - Irritation & inflammation (Phlebitis) ∙ Educate: take with food to ↓ GI upset ∙ Respiratory infections (pneumonia) ∙ Penicillin allergy is very common! Cross Sensitivity Ask about allergy to Penicillin or Cephalosporins before administering the first dose! A client who is allergic to penicillin also may be allergic to cephalosporins. 1 st Generation Medications cephalosporins bContraindications GNANC generic trade name action ∙ History of allergies to Y CAT cephalosporins or Penicillin cefadroxil Duricef Bactericidal - kills bacteria ∙ Administer with caution: clients with renal disease, cefazolin Ancef (Causes death of hepatic impairment, the bacterial cell) bleeding disorder cephalexin Keflex uses Nursing considerations 2 nd Generation Medications ∙ Otitis media ∙ Cephalosporins make oral generic trade name ∙ Respiratory infections contraceptive ineffective ∙ Bone infections (use additional contraceptive) cefaclor Ceclor ∙ UTIs ∙ Use prophylactically pre-opt, intra-opt, ∙ Do NOT drink alcohol cefoxitin Mefoxin while on this medication and post-opt to prevent infection cefotetan – during surgery. 3 rd Generation Medications generic trade name Side effects ∙ Aplastic anemia (↓ RBCs) cefdinir Omnicef ∙ Stevens-Johnson syndrome (SJS) ceftriaxone ∙ GI UPSET! ∙ Toxic epidermal necrolysis Rocephin ∙ Nausea, vomiting, diarrhea ∙ IV injection - Irritation & inflation (Phlebitis) ∙ IM injection - Pain at the site cefotaxime Claforan ∙ Dizziness ∙ Malaise Prefixes & suffixes: ∙ Heartburn -cef- & -Ceph- ∙ Fever ∙ Nephrotoxicity © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 194

TETRACYCLINES & AMINOGLYCOSIDES antibiotics generic trade name Tetracyclines tetracycline – uses Nursing considerations doxycycline Atridox ∙ SKIN ∙ Fluoroquinolones cause ∙ Skin & soft tissue infection photosensitivity. We want to use minocycline Arestin ∙ Severe acne sunblock and avoid the sun! demeclocycline Declomycin ∙ Rocky mountain spotted fever ∙ Tetracyclines make oral contraceptives ∙ Helicobacter Pylori (H. pylori) ineffective suffix: -cycline ∙ Use additional contraception Tetra think Teeth action P CY CAT ∙ Take on an EMPTY stomach Bacteriostatic (slow-growing) REGNAN PRE EGORY with a full glass of water EGORY Inhibits bacterial protein synthesis Contraindications d ∙ Causes tooth discoloration ∙ Do not give to children younger Side effects ∙ Known allergy to tetracyclines than 9 ∙ Contraindicated in lactation ∙ GI distress! ∙ Sit up for 30 min after taking medication ∙ Nausea / vomiting / diarrhea Tetracyclines think Toxic ∙ Do not lay down ∙ Stomatitis to the developing fetus ∙ Pill induced esophagus ∙ Skin rashes (HEARTBURN & scaring of the esophagus!) ∙ Photosensitivity reaction ∙ Avoid calcium/dairy products ∙ These prevent the absorption of the drug generic trade name Aminoglycosides gentamicin – action Bactericidal - kills bacteria kanamycin – Nursing considerations Blocks the ribosome from neomycin – reading the mRNA. Then the ∙ Monitor: bacterial can't multiply. ∙ Renal status streptomycin – ∙ Neuro status ∙ Respiratory status suffixes: -mycin, -micin ∙ Evaluate clients comments Side effects Contraindications GNANCY CAT related to any hearing issues ∙ GI distress! d uses ∙ Nausea / vomiting / anorexia ∙ Known allergy to aminoglycosides ∙ Bowel preparation: Decrease ∙ Rash & hives ∙ Hearing loss normal flora in the GI for those ∙ Musculoskeletal disorders having abdominal surgery AMinoglycosides are A mean antibiotic because they have very harmful side effects (Myasthenia gravis & Parkinson's disease) ∙ Management of hepatic coma ∙ Decreasing the ammonia in ∙ Contradicted for location the intestines Nephrotoxicity Hurts the kidneys: Proteinuria hematuria, & increase BUN & Creatinine. Ototoxicity Hurts the ears: Tinnitus, vertigo, hearing loss, which may be permanent. Neurotoxicity Hurts the brain: Numbness, tumors, convulsions, muscular paralysis. © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 195

DIURETICS OVERVIEW cardiac meds generic trade name furosemide Lasix LOOP DIURETIC bumetanide Bumex Potent (strong) torsemide Demadex diuretic suffix: -nide, - mide ACTION PURPOSE SIDE EFFECTS NURSING CONSIDERATIONS • Inhibit reabsorption • Hypertension • ↓ Hypokalemia of NA+ & Cl- • Heart failure • ↓ Hypotension • Obtain baseline vital signs • Renal disease • ↑ Hyperglycemia • Replace K+ if < 3.5 mEq/L Acts on 3 sites • Edema • Photosensitivity • Adm. furosemide SLOWLY = • Pulmonary edema • ↓ Hyponatremia • Dehydration (rapid adm. can cause ototoxicity) ↑ reabsorption REMEMBER Normal Potassium potassium wasting! 3.5 - 5.0 generic trade name hydrochlorothiazide Microzide THIAZIDE DIURETIC chlorothiazide Diuril methyclothiazide – suffix: -thiazide ACTION PURPOSE SIDE EFFECTS NURSING CONSIDERATIONS • Inhibit reabsorption • Hypertension • ↓ Hypokalemia of NA+ & Cl- • Heart failure • ↓ Hypotension • Obtain baseline vital signs • Renal disease • ↓ Hyponatremia • Monitor intake & output • Excretion of • Cirrhosis • ↓ Libido • Give w/ meals to ↓ GI upset Na+, Cl-, & H2O • Edema • ↑ Hyperglycemia • Replace K+ if < 3.5 mEq/L • Corticosteroids • Photosensitivity ↑ UOP • Estrogen therapy • Dehydration • NEVER give K+ IV push = • Azotemia • Avoid giving to pt.’s ↓ blood volume potassium wasting! with gout • Monitor renal function • Daily weights • Same time, same scale! • Clients with a sulfa allergy should avoid thiazide diuretics © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 196

DIURETICS OVERVIEW cardiac meds • Where sodium goes...water flows! • Instruct the client to make slow position MEMORY • Sodium makes us retain water changes (diuretics cause orthostatic hypotension) TRICK • Low sodium diet (sodium swells!) • Monitor: Diuresis the body • Give diuretics in the morning, not at night • Daily weights (report 2-3 lbs weight gain) Diuretics = Diuresis = Dry inside • You don't want your client peeing • Intake & output all night long (Nocturia) • Vital signs • Potassium levels OSMOTIC DIURETIC generic trade name mannitol Osmitrol ACTION PURPOSE SIDE EFFECTS NURSING CONSIDERATIONS • ↑ the thickness of • Treatment of • Edema the filtrate so cerebral edema • Blurred vision • Only administered IV water can't be • Nausea, vomiting, • May crystallize reabsorbed • ↓ intraocular pressure (IOP) & diarrhea (check solution before adm.) • Excretion of • Urinary retention • Perform neuro assessment Na+ & Cl- & LOC (if using for cerebral edema) K+ SPARING DIURETIC generic trade name spironolactone Aldactone S think Sparing ACTION PURPOSE SIDE EFFECTS NURSING CONSIDERATIONS • Blocks aldosterone • Hypertension • Hyperkalemia (> 5.0 ) • Avoid eating foods high (\"salt water\" hormone) • Edema • Diarrhea in potassium (green leafy • Lets fluid out of veggies, melons, bananas, the body, into • Hypokalemia • Gastritis avocado, etc.) the potty! • Hyperaldosteronism • Drowsiness • Avoid salt substitutes • Excretion of • Cross-sex hormonal & potassium supplements Na+ & H2O therapy • Erectile dysfunction • Monitor K+ levels NOT K+ Spironolactone • Gynecomastia (spares potassium) inhibits Watch out for hyperkalemia (enlargment of the ( K+ > 5.0 mEq/L ) testosterone breasts in men) Educate: gynecomastia is usually reversible after therapy has stopped © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 197

ANTIHYPERLIPIDEMIC DRUGS cardiac meds OVERVIEW Cholesterol LDL Want LOW Levels (<100 mg/dL) x Atherosclerosis is when lipids stick to the blood vessel Low Density walls which can obstruct blood flow Lipoprotein BAD CHOLESTEROL x The goal of all antihyperlipidemic drugs is to lower HDL Want HIGH Levels lipid levels in the blood (>60 mg/dL) High Density Lipoprotein HAPPY CHOLESTEROL HMG-COA REDUCTASE INHIBITORS \"STATINS\" generic trade name atorvastatin Lipitor USES x Hyperlipidemia CHOLLOEWSTEERRSOL SIDE EFFECTS ACTIONSx Inhibits the enzyme fluvastatin Lescol x PRIMARY PREVENTION: gi Neuro HMG-CoA Reductase lovastatin Altoprev Preventable treatment for patients at risk for x Statins are not a cure! pitavastatin Livalo coronary artery disease (CAD) • Headache simvastatin Zocor • Nausea x SECONDARY PREVENTION: • Dizziness rosuvastatin Crestor Stabilizes fatty plaques in clients with current coronary artery disease (CAD) suffix: -statin NURSING CONSIDERATIONS x Monitor liver enzymes • Constipation • Abdominal pain ➥ ALT/AST • Cramping • Hyperglycemia x Monitor therapeutic response RHABDOMYOLYSIS ➥ Statins should lower LDL, & increase HDL x Rare condition where the muscles are damaged x Avoid grapefruit consumption x Myoglobin leaks into the blood which can cause kidney damage ➥ Increases risk for toxicity of statins Signs & Symptoms: x Statins are pregnancy category X & should • Muscle pain, tenderness, or weakness not be taken while breastfeeding • Accompanied by malaise or fever • ↑ creatine kinase levels x Monitor for signs of rhabdomyolysis because • Dark urine color (tea or cocoa like urine) statins have been associated with this BILE ACID RESINS generic trade name cholestyramine Prevalie USES ACTIONS NURSING CONSIDERATIONS colestipol Colestid colesevelam Welchol x Hyperlipidemia Bile is made & secreted by the liver x Gallstone dissolution x Pruritus associated with Then, it's stored the gallbladder x Bile acid resins may interfere with the digestion of fats, partial biliary obstruction Once emulsified, the fats & lipids preventing the absorption of are absorbed in the intestines fat-soluble vitamins gi All Kids Eat Donuts SIDE EFFECTS Bile Acid Resins binds to the bile Bile • Vitamin A & D may x Constipation acid to form an insoluble substance Acid be given in a water-soluble x Increase risk for bleeding (can not be absorbed by the intestine) Resins for long term therapy R/T Vit K malabsorption So it's excreted with the feces x Bile acid resins may cause constipation, so educate to... x Vitamin A & D ↓ bile acids = liver uses cholesterol • Increase fluids, fibers to make more bile = ↓ cholesterol • Exercise regularly deficiencies • Use stool softener © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 198

ANTIHYPERTENSIVES cardiac meds ACE INHIBITORS BETA BLOCKERS angiotensin-converting enzyme inhibitors generic trade name generic trade name captopril – acebutolol Sectral enalapril Vasotec metoprolol Lopressor fosinopril – propranolol Inderal lisinopril Prinivil nadolol Corgard suffix: -PRIL suffix: -olol ACTION USES x Hypertension USES x Hypertension x Heart Failure x Stable angina x Chronic / compensated heart failure Dilates blood vessels, which lowers blood pressure. They do not directly affect the heart rate. (not acute heart failure) x Dysrhythmias x Inhibits RAAS Renin-Angiotensin-Aldosteron-System x RAAS is the main hormonal mechanism involved in ACTION x Blocks norepinephrine & epinephrine ↓ Resistance (fight or flight hormones) ↓ Workload regulating the blood pressure ↓ Cardiac Output x ACE converts angiotensin I → angiotensin II x Blocks the negative effects of the sympathetic nervous system (a powerful vasoconstrictor) x Inhibiting ACE will inhibit this vasoconstricting effect, ➥ Beta blockers can be (oBnEeThAea1rt) (twBoETloAb2es) selective or non-selective decreasing blood pressure! • Meaning they can NURSING CONSIDERATIONS SIDE EFFECTS block different beta sites (beta 1 and/or beta 2) A = Angioedema HOyprtohtoesntsaitoicn SIDE EFFECTS x Bradycardia & heart Blocks BLOTOFHCBEKEEBTR'ASS C = Cough (dry) Dizziness x Breathing problems E = Elevated K+ ➥ Bronchi spasms x Bad for heart failure patients (in an acute setting) x Assess BP & pulse routinely x Blood sugar masking x Monitor for hypotension ➥ Masks S&S of hypoglycemia (low blood sugar) • Educate on changing positions slowly x Blood pressure lowered - Hypotension x Monitor K+ levels NURSING CONSIDERATIONS x Monitor for hypotension • Normal 3.5 - 5.0 x Educate on changing positions slowly • Educate to avoid foods high in potassium x Do not give non-selective beta blockers to asthma & avoid salt substitutes patients or COPD patients (remember: non-selective x Assess for angioedema works on Beta1 & Beta2 = Lung constriction) x Educate to not suddenly stop the medication. It can • Swelling of the area beneath the skin or mucosa cause rebound hypertension (needs to be tapered off) (deep edema) x Monitor for S&S of heart failure • Dangerous: swelling of the face & mouth • These medications produce inotropic effects x Educate to not suddenly stop the medication it can (↑ contraction strength of the q ) cause rebound hypertension (needs to be tapered off) • S&S of q failure: x Ace inhibitors are contraindicated in pregnancy Wet lung sounds, weight gain, edema, etc due to the teratogenic effects on the fetus 199 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

ANTIHYPERTENSIVES cardiac meds CALCIUM CHANNEL BLOCKERS generic trade name VERY verapamil Calan NICE Nifedipine Procardia DRUGS Diltiazem Cardizem USES amlodipine Norvasc ☞ Lower HR & BP ∙ Hypertension nicardipine Cardine ∙ Angina ∙ Dysrhythmias suffixes: -dipine, -amil SIDE EFFECTS ∙ Orthostatic hypotension ∙ Dizziness ∙ Flushing SAIDLLECEOFFMEMCOTSN ∙ Headache ∙ Peripheral edema ∙ Constipation ACTION ∙ Relaxes blood vessels ∙ ↓ blood pressure Blocks movement of calcium ∙ ↑ supply of oxygen to the heart (↓ calcium = ↓ available for q∙ ↓ 's workload transmission of nerve impulses) ∙ Do not drink grapefruit juice HYPCSOAETNREVCNEASRUIEOSEN! NURSING CONSIDERATIONS ∙ Leg elevation & compression ∙ Antihypertensives cause to reduce edema orthostatic hypotension ∙ To help with constipation: ∙ Change positions slowly ∙ Sit on the side of the bed for Fluids, Fiber, & Fruits Fill up the toilet! a few minutes before standing ∙ Educate to not suddenly stop the medication. It can cause rebound hypertension (needs to be tapered off). © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 200