Fundamentals session 10:

Here is session 10 already, and this is the second to last class before the final! In this session we focused on care plans, nursing diagnosis, as well as communication. There are common sense tactics for communication, and the care plans will be a skill that improves with time as more and more a written. Happy studying!

-Peter

Session 10:

Nursing process and Diagnosis

the nursing process has changed over the years

1950’s care cure and core: assessment decision and nursing action

1967 APIE – assessment, planning, implementation, evaluation

  • Discover, delve, decide, do, discriminate

1970 nursing diagnosis is a separate step

APIE additions – Nursing diagnosis, and outcome identification

  • assessment, Nursing diagnosis, and outcome identification, planning, implementation, evaluation
  • discrete 6 step process
  • You will need to be able to verbalize this to your preceptor

assessment

  • the initial assessment is very important and sets the baseline of that patient
  • it directs care, and will set the goal for discharge

outcome identification – the goal for discharge

  • realistic client focused goals that are measurable
    • activity or VS goals
  • can be the patient’s goal, said by the patient

Planning – five column plan of care (one problem per plan)

  • Assessment Data
  • Goals
  • Interventions
  • Rational
  • outcome/ replanning

Implementation

  • it’s what you do to the patient

Evaluation

  • how did the implementation go?
  • Should be measurable

Diagnosis

  • Identifies the plan of care
  • a nursing diagnosis provides the basis for selection of nursing interventions
    • pressure ulcer
    • fall risk
  • types
    • Actual – human response to a health problem that is happening right now
      • 1. Diagnostic label must be NANDA approved
      • 2. Related factors – what contributes to the problem
        • Related to…
      • 3. Defining characteristics – observable cues that are related to the problem Dx
        • as evidenced by….
      • EX: impaired physical mobility R/T hip replacement as evidenced by inability to ambulate w/ walker
    • Risk – problems that may develop
    • wellness – we didn’t really go over this
    • possible – or this but may be tested on the NCLEX

Communication in Healthcare Communication on teams

Reporting from nurse to nurse is an art and needs to be practiced

  • develop good habits around the end of shift reports
  • “I don’t know” is not acceptable

reporting to provider

  • make it specific to the person that you are talking to
  • always see and assess the patient before making the call to the physician
  • know the notes associated to the patient

Any information that the patient give to you needs to be shared with the patient

circle of confidentiality is inside the care team

SBAR – know the tool and be comfortable

document read back – RB*1

Team STEPPS

  • we will be trained in all of these
  • improves patient safety
  • optimises team
  • every voice is heard and empowers everyone on the team
  • focused on the care plan
  • checklists, huddle
  • support team members
  • the Brief is important and comes first
  • huddle can happen at any time, is a specific time sensitive issue
  • debrief after care, what we did well, and what can be improved on

two challenge rule

  • tell the person at least twice before moving up the chain of command

Closed loop communication is crucial

Handoffs

  • this is a area when error can occur at a higher rate
  • clarify and ask questions

Charting

  • make sure charting is top notch when the care is not going as planned or there are questions that you are unsure about.
  • watch out for copy forwarding there is a huge chance to make errors
  • use military time
  • avoid vague descriptions
  • be concise, and objective. not subjective

theory of interpersonal relationships

  • do things with the patient, not for the patient
  • positive regard for patient ie, warmth, trust, positive attitude

Nonverbal communication is a huge % of total communication, about 90% or as low as 75%

OARS style motivational interviewing

  • Open ended q’s
  • Affirm
    • make it genuine and your own style
  • Restate
  • Summarize

clarity, going over the big picture

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Fundamentals session 9:

Today we talked briefly about dosage calculations, then moved on to the main part which covered safety and pain management. In pain management there was a focus on the PCA and self titrating the medication. Happy studying!

-Peter

Dosing review topics

Pediatric dosing

calculate weight in lbs into kg

  • round to the first decimal place

Calculate the max daily dose by taking the dose amount times the amount of times that it is given

concentration of medication

  • 25,000u/500ml is twice as concentrated as: 25,000u/250ml
  • this means that the drip rate for #2 would be half as fast as #1

Safety

risk factors

  • bad systems
  • lack of communication systems
  • lack of standardization
  • fear of punishment for reporting

Culture of safety

  • cannot be a blame culture
  • focus on what went wrong, not the person
  • promote safety through education and training
  • cannot just “try harder” to stop errors
  • periodic assessment of the culture and relationship between the culture, and quality and safety

AHRQ

    • Measures culture of safety
  • reliable valid tools to measure culture of safety

Latent failure (blunt end of care)

  • affect the organizational policies

Active error (sharp end of care)

  • directly contacts the patient

NPSG – (national patient safety goals)

  • yearly update of the foci of the patient safety goals

Work safety

  • Make a “Brain” to make patient notes, to avoid relying on safety
  • work hours and, ratios, and under staffing
  • Using a checklist
  • team training
  • involve patients in care
  • Anticipate problems
  • Recovery – systems set up to improve errors once they occur
  • improving access to accurate information

Human factors

  • relationship between humans and technology
  • always a system contribution to the problem
  • Mindfulness – internal environment

Patients want an honest apology, know exactly what went wrong, and to have the system fixed.

the smetzer article

  • OB setting,
  • nurse thinking ahead but switching the antibiotic medication with the epidural
  • there are many system that added to this error
    • the mom died, but the baby made it.
  • Definitions to remember
    • hindsight bias – remembering differently than it actually happened
    • perceptual blindness – you see what you expect to see, no what is actually there.

Pain management

“Pain is whatever the experiencing person says it is, existing whenever they say it is” – M. McCaffery

Nociceptive pain – damage to somatic or visceral tissue

somatic pain – Localized – superficial or deep, stabbing, aching, throbbing

Visceral pain – damage to nerves PNS or CNS – in terms of internal organs

  • not always fully controlled with opiates

increase in vital signs does not always mean that the patient is in pain

the nurse cannot always tell whether or not the patient is in pain

pain can be associated with depression

there are many different scales but most measure from 0-10, 0 being no pain

  • there needs to be a system about assessment of pain

non medical interventions

  • relaxation
  • meditations
  • hypnosis
  • Acupuncture
  • Therapeutic massage

types of pain medications

opiate, non opiate, and Co-analgesic or adjuvant

fentanyl – is one of the quickest opiates, half life is .5 – 1 hr

respiratory depression is a fear when withholding pain medication

tolerance – need to increase the dose for same effect

physical dependence – suffering when the drug is stopped

IM injection is a bad way to administer pain medication

PCA – patient controlled analgesia

  • can track the number of attempts
  • usually morphine or dilaudid
  • loading dose is already given
    • the medication is locked in the pump
  • the basal rate is the minimum that will be given w/out the button being pushed
  • PCA dose by proxy is controlled by a family member or someone close to the patient
  • the delay/lockout is set so that the dose can only occur a specific amount of times per hour.
  • verify the programming of the pca pump

NARCAN is the antidote for opiates

Epidural analgesia – given into the space around the spine

  • block is a single dose
  • PCEA is a PCA but into the epidural space
  • risk for hypotension
    • fall risk
  • should not be on anticoagulants

maintenance of the epidural catheter

  • reinforce dressing as needed
  • monitor sight for issues

testing sensation for epidural

  • test sensation with ice at levels bilaterally
    • test to area away from numb site
    • OK: T7-L1 L=R
    • OR different: L T7-L1, R: T8- L2

Pharmacology Session 4:

This note group is focused on the GI system, and is basically a list of drugs without any concepts. We covered laxatives, antidiarrheals, mouthwashes, and stomach acid lowering agents. Good luck!

-Peter

GI drugs  

Session 4

This is the beginning of test 2 material

Drugs that affect the mouth

Basic types:

  • Mouthwashes
    • alcohol
      • This may be painful for patients with stomatitis
      • alcoholics
    • Hydrogen peroxide releases O2
    • fluoridated
    • antiseptic – Phenol
  • Dentifrice is abrasive

Pts with gum Dx or that are having major dental work done will put the patients at High risk for MI

Hyperacidity

  • Antacids that can be bought over the counter (the goal is to bring pH of the stomach to about 3.5): Tums, Caltrate, OsCal, Viactiv(not w/ coumadin), Citracal (not w/ KD)
    • Action: increase stomach pH
    • indications: Peptic ulcer, GERD, hernia
    • ADME:
      • onset: 20-40 min (give 1-3hr before meal + night)
      • not meant to absorb, just buffer the acid
      • excreted in the feces
    • reduces Absorption of other drugs (chelation) due to the raise in stomach pH
    • S/E: constipation, bone deg, increased acid secretion, Kidney failure, Diarrhea
      • increased Ca, K and NA, decreased Mg
      • Kidney failure in chronic use

Digestants and enzymes

  • pancrelipase (Pancreaze )
    • ind: Pancreas insufficiency (pancreatitis, cystic fibrosis, Pancreatectomy)
    • Act: increased digestion in GI (enzymatic)
    • Enteric coated
    • S/E all abdominal, Fibrosing
    • hold if NPO, give before meals (dose based on calories)

Antiemetics

  • Action: Block CTZ (chemoreceptor trigger zone)
    • relieve nausea and vomiting
  • Anticholinergic: Scopolamine (Transderm-Scop)
    • for motion sickness
    • Side effects: Blurred vision, dry mouth and CNS depression
  • Antihistamines
    • Diphenhydramine (Benadryl)
    • Dimenhydrinate (Dramamine)
      • H1 blocker (antihistamine), CNS depression
  • Phenothiazine:
    • Prochlorperazine (compazine)
      • similar to atropine
  • Dopamine receptor blocker
    • Metoclopramide (Reglan)
      • Drousie, extrapyramidal effects, Diarrhea
  • Cannabinoid
    • Dronabinol (Marinol)
      • Made from THC
  • Bismuth Salts
    • Bismuth subsalicylate (Pepto-Bismol)
      • OTC, constipation, grey stool, ASA

Ondansetron (Zofran)

  • Block serotonin 5 HT3 receptors

Peptic ulcer Drugs

  • Acid-Neutralizing Drugs
  • H2 receptor blocker
    • Cimetidine (tagamet)
    • ranitidine (Zantac) fewer side effects and strogerew
      • Better value to prevent ulcer than PPI
      • Action: Lowers H2 secretion by stopping histamine from stimulating H2 receptors
      • Prevents PUD, acid reflux, hypersecretion
  • Cytoprotective agents (IMP)
    • Sucralfate (Carafate, Sucralfate)
      • Protects ulcer by forming a barrier with the ulcer cells from acid in the stomach.
      • For PUD, and protect other ulcers from forming. (NSAID’s)
    • Misoprostol (cytotec)
      • PG E1 analog – ↓Acid secretion, ↑ Bicarb (HCO3) and mucus secretion
      • Category X
      • Prevents NSAID ulcers
  • Proton Pump inhibitors, PPI
    • omeprazole (Prilosec) -prazole
      • better at repairing ulcers than H2 blocker
      • Blocks acid secretion
        • Blocks ATPase at the parietal cells that would produce H2
        • treats: esophagitis from GERD, Duodenal ulcer, long term HTN
        • quick onset, 2h to peak, and ends effectiveness at 3-4 days
        • Side effects are: Heartburn, weakness, dizziness, C.diff risk increases, also cannot absorb Ca as efficiently
      • Ulcers can heal in a matter of weeks
  • Treatment plan for Peptic ulcer disease from H. pylori
    • Antibiotics, Bismuth, PPI
    • lasts for 2, and then the Antibiotics and bismuth drop off and the PPI is prescribed for 4 more weeks, about 90% of people are recovered after this treatment.

Laxatives

  • do other interventions before meds, such as diet and exercise
  • Bulk forming laxatives
    • psyllium (metamucil)
      • encreases stool size and softens by absorbing water, this increases the size of the bolus and pushes against the wall of the intestine to stimulate peristalsis
      • takes 12hr -3 days work
      • excreted in stool
      • NEED fluid for it to work!
  • Surfactant Laxatives (stool softeners)
    • Docusate sodium (Colace)
      • ↓ Surface tension softening the stool
      • 12hr- 3 days to work
      • does not interfere with absorption of nutrients
  • Stimulant Laxatives
    • bisacodyl (Dulcolax)
      • stimulate peristalsis by affecting the muscle and mucus secreting cells
      • works in 6-8hr
      • can cause fluid loss (watery discharge), cramping, and dependence
  • Osmotic Laxatives
    • lactulose and milk of magnesia
      • sugar, and salt that don’t absorb well and then attract water to induce peristalsis.
      • ↓serum Ammonia in people with chronic liver disease
      • works in 1-3 days and not much is absorbed into the body
    • polyethylene glycol (Golytely) (Glycerin sup in children)
      • draws water into intestine (sugar, salt, and PEG)
      • Cleansing before colonoscopy
      • (Other) metoclopramide (Reglan)
    • ↑ ACH, stim PSNS
    • ↑secretions, and motility
    • for GERD, risk of ileus, and to eliminate barium
    • Contra indicated in patient with intestinal blockage
  • Motion sickness
    • scopolamine
      • Muscarinic antagonist
      • blocks inner ear from vomiting center
        • H1, and cholinergic are blocked
      • PO, subQ, transdermal
      • similar action on motion sickness are antihistamines like meclizine (Antivert) and dimenhydrinate (Dramamine)

Antidiarrheals

  • concerned about fluid and electrolyte loss
    • Tachycardia, orthostatic hypotension, ↑ Hct, BUN
    • watch for dependance
  • Opioids
    • tincture of opium, paregoric
      • reabsorption of water out of the intestines and reduces pn, spasms
      • for persistent diarrhea, but not when caused by foreign organism
      • dose q 4-6hr
      • these are scheduled drugs, can be addictive
  • Synthetic Opioid
    • loperamide (imodium), diphenoxylate and atropine (Lomotil)
      • same action and effect as opioids
      • 5hr peak, 24 hr duration
      • side effects rash, agitation, and other low fluid S/E
      • Absorbents
        • cholestyramine (Questran)
          • attracted to acids, and bind to irritants
          • used in hypercholesterolemia
          • constipation is a side effects

antibiotic- induced Diarrhea for the elimination of C. diff with the antibiotic fidaxomicin (Dificid)

  • give probiotics to bring back normal flora

Obesity Drug

  • phentermine and toprate (QNexa)
    • taken off market Dt pulmonary HTN and heart valve problems
      • 10% weight loss
  • Orlistat (Xenical – Rx or Alli – OTC)
    • blocks fat absorption by blocking lipase
    • OTC
    • fatty stool, ↓ FS vitamins + beta-carotene

Fundamentals Session 8:

Hey all, here are the notes for fundamentals session 8! This is the last session for test 4, then after that it is the final! Good luck guys and happy studying!

-Peter

Session 8:

Nutrition and Altered Bowel Function, Interventional Hygiene, Fall Risk, and Safety

Nutrition and Altered Bowel Function

Important for all patients

Swallowing ability is crucial

meds that affect:

  • steroids increase appetite
  • insulin
  • Chemotherapy

subjective data:

  • 24 hour recall
  • Dx processes

objective data:

  • observations
  • height, weight
  • arm circumference
  • skin folds
  • Calorie count

serum albumin vs prealbumin

  • SA is > ½ of the body’s total protein, assess the long term protein stores.
  • Prealbumin has a shorter life and can test the short term protein stores.

types of diets

  • NPO – none through mouth
  • clear diet
  • full liquid
    • liquid at room temperature (ICE CREAM!! 🙂
  • Soft
  • diet as tolerated
  • Restrictive (Na, renal, ADA, reduced calorie diet)

why do we with hold food?

  • before surgery
    • prevent aspiration

We can have a pt NPO for up to 24-48 hours

Renal diet

  • low protein, K, Na, and fluid restriction

Liver Dx

  • early, only low Na
  • Late in Dx, low protein(lactulose can get the ammonia out of the blood), Na, and fluid

CHF – restrict Calories and fluid

CAD – lower Na, calories, Sat fat, and cholesterol

Burns- fluid replacement early, high protein, calories, Vit C and B

Respiratory – soft, high calorie and protein

HTN – restrict sodium

Normal bowel function

body pulls fluid from GI tract first if needed

narcotics and pain management can cause impaction and constipation

If you have a pt that chronically uses laxatives they need teaching to show them that taking them that frequently is not optimal.

Diarrhea can cause fluid and electrolyte imbalances

Ostomies

  • temporary or permanent
  • continent or incontinent
  • stoma or artificial opening
  • colostomy in the colon
  • ileostomy  
  • challenge body image

Enemas – cleanse bowel of stool

  • use warm water
  • cramping will occur if too fast infusion

Nutrition and tube feeding

different tube sizes

  • the large bore gastric tube is not used for too long due to the

Naso gastric – nose to stomach

  • large bore
    • salem sump tube
  • can suction and feed
  • placed by nurse
  • less than 4 weeks (short term)
  • hard to place, tuck the chin to avoid the trachea
    • can spray back of throat with medication to lessen the gag reflex
  • If connected to suction measure I/O’s

Dobb-hoff

  • nose to illium
  • white opaque, small
  • no suction only feedings
  • placed by radiology
  • weighted end that can be visualized in radiology

Jejunostomy tube

  • surgically
  • long term
  • small intestine out at stomach

Confirm placement before putting anything in the tube with x-ray

The rate of the feeding should not feed faster than the pt can digest

Checking gastric residuals volume Only for gastro, not small intestine, if the residual amount is over ½ of the previous bolus, then the rate of nutrition may be too fast.

There are pumps that can select the feeding rate

  • you ramp up to the rate you want and ween off when done.

Medications can go through these tubes

  • crush meds (some meds cannot be crushed, enteric coating and extended release drugs)

If the Patient is laying down flat there is a risk for aspiration

Parenteral Nutrition

not through the GI

TPN ALWAYS goes through a central line

    • large volumes
    • contains nutrients, insulin, and/or PPIs
  • BAG and LINE are changed every 24 hours
  • have to use a pump, and it is always continuous infusion
  • filter in the line

PPN Peripheral Parenteral Nutrition – same as TPN, but lower amounts, and in the peripheral vein

  • supplementally for short periods of time
  • may not have lipids

both of these are specific to patient

Complications:

  • Risk of infection
  • High Glucose levels

Interventional hygiene

Very important for the rapport with the patient and the patient’s family, shows that you care.

Patient safety:

positioning:

  • they all have risks and values

Left sided sims is a good position for an enema

reposition an immobile patient every 2 hours

Assess every single patient for fall risk

  • Age, hypotension, meds that depress CNS, or diuretics because of the need to get up a lot, post op, highly tethered patients, weakness, confusion

educate the patient and the family about their risk and how to deal with it.

Make sure the patients have their call light.

Restraints

    • they are dangerous and there needs to be an order
  • you must document the sefer ways that have been tried first before restraints are used
  • use measured interventions to lead up to restraints.
  • document the skin integrity, circulation, and status every 2 hours
  • Mitts to stop the patient from pulling things out.
  • Quick release knots are imperative and required to know how to tie.

Fundamentals session 7:

Hey guys, here is session 7 of the fundamentals lecture. It is the beginning of the test four material and covers, skin therapy with wound assessment, and urinary elimination techniques. Nice and quick with out to much to trip up on.

Thanks for reading!

-Peter

Skin integrity and wound healing

beginning of test 4 material

Session 7

Skin is the largest organ in the body

  • epidermis
  • Dermis
    • where the hair anchors to
    • the sweat gland starts in the mid bottom of the dermis
    • vascularity though the dermis
    • beefy red and wet wound is superficial dermal
    • pink red and less wet to dry wound is deep dermal
  • Subcutaneous

Assessment

  • color, vascularity, turgor, lesions

History

  • Age, diagnosis, DM, moisture(fecal or urinary incontinence), smoker(slow angiogenesis and vessel atrophy), nutrition(decent protein and water intake, zinc and vit C), perfusion assessment (ABI), mobility (bedridden), nasal cannula,

inspection of skin

  • jaundice will be seen in eyes first
  • erythema: palpate and inspect, temp, and blanch, erythema will blanch
  • assess on admission, when bathing, and moving

excoriation

  • abrasion or scration mark, uneven and red

Skin lesion

  • elevation- flat, raised, pedunculated
  • size in cm
  • exudate – drainage, from the white cells that were cleaning the wound
    • clean with NS or water, if infected the smell will not go away
  • chronology of appearance, and change in morphology
  • infected wounds hurt in a specific location
  • healing wounds hurt overall when exposed to air

Perfusion and O2 assessment

  • baseline VS
  • cap refill
  • color, temp

chronic wounds

  • not healed in 4 weeks
  • disorganized healing and chronic inflammation
    • inflammation over 96 hours, can be caused by DM or steroids
  • ex. DM ulcer, vessel ulcer

Acute wound

  • predictable healing less than 3 weeks
  • laceration, abrasion, incision
  • inflammation 96 hr

wound closure

  • First intention (primary union) – incision, sterile, early suture, small scar
  • second intention Granulation- gaping irregular wound, biggest scar
  • third intention (secondary suture)- wound, closure with wide scar
  • we want the least scarring for the pt’s well being and self image

phases

  • inflammation – reactive – macrophages
  • proliferation – reparative – Angiogenesis
  • maturation – collagen remodeling, in 6 months the wound skin is 90% as strong as uninjured skin.
  • extend the joint to avoid contracture
    • this can be painful

wound assessment

  • red yellow black
  • types of tissue
  • granulation tissue
    • red, moist, beefy, good sign of healing
  • slough
    • yellow, stringy substance on wound bed, use % for colors
  • eschar
    • described as “%covered in eschar
    • uncategorizable until eschar removed

tunneling – narrow channeling in wound

undermining – the skin is over the unhealed wound

Periwound – tissue around the wound

increase in drainage when the wound is getting infected.

Braden score assessing the skin 3-21, 18 is at risk for pressure ulcers higher is better

Deep tissue injury – acutely immobile, maroon/purple blood blister, if it breaks i can be a stage IV

  • off load the pressure!
  • stage if breaks

Stage 1-IV

  • I – skin unbroken
  • II – breaks epidermis into dermis
  • III – deep dermis
  • IV – into subcutaneous tissue  
  • unstageable – the wound is covered in eschar and level cannot be seen

MAAD – moisture associated dermatitis

IAD – incontinence associated dermatitis

psoriasis – skin growing too quickly and creates a silvery scaly patch

wound cleaning

  • Keep a moist wound covering over the wound
  • don’t scrub wounds anymore, just rub gently and tap water is ok for cleaning ie shower

Keloid scar – raised scar

Urinary Elimination: Altered Function Assessment

factors affecting the process – renal conditions

  • Prerenal
  • intrarenal
  • Postrenal

Healthy adequately hydrated patient will produce 30 ml of fluid an hour  

  • > 30ml for more than 2 hr is important and action needs to be taken

UTI – bacteria entered the urinary tract

  • cloudy(turbid) urine

Altered urinary elimination define:

  • Dysuria, polyuria, oliguria, urgency, frequency, nocturia(urination at night), hematuria(blood in urine) pyuria(pus in urine)
  • find the pt’s normal range

5 types of incontinence – Urge, stress, functional,

Urinary samples that are less self explanatory

  • Clean catch – sterile.
  • 24 hour specimen – collect urine over 24 hours.

catheter types

  • intermittent
    • spinal injury pt’s use this as opposed to a sterile foley.
  • Indwelling:
  • Foley
    • insert to the Y tubing before inflating the balloon to avoid inflating in the urethra.
    • keep bag lower than the bladder. (no back flow)
    • 50% infection rate after 7 days
    • Can be delegated
      • still responsible!
    • secured to leg
    • document time of removal

CAUTI – catheter Associated UTI

  • risk factor is duration of foley insertion

when is it ok for indwelling cath

  • accurately measure output (kidney injury)
  • bladder outlet obstruction
  • immobile
  • end of life care

Meatal care – skin around the foley needs to be clean

Non invasive therapies

  • Bladder Ultrasound measures volume
  • Bed pan

Stoma is an internal organ to the abdominal wall, in this case to transport urine from the ureters to the outside of the body. this would happen if a bladder was removed.

Neobladder – new bladder from intestinal tissue

Ureterostomy – brings ureters to the abdominal wall to drain,
supra pubic catheter is surgically placed and is long dwelling, the tube is directly inserted into the bladder.

Fundamentals study guide for test 3:

Hey guys, here is the fundamentals study guide! Its a little late, but I think this material is reasonable and somewhat easier to understand than the previous tests. I will post the not filled out study guide below and the finished one will be in a link at the end. Thanks for reading!

-Peter

test three study guide

  1. Crystalloid vs colloid fluids
  2. Bolus and push are pretty synonymous in this class, how long are they infused over?
  3. Intermittent infusion is what?
  4. what are primary and secondary bags used for?
  5. When do you change the IV line?
  6. how much does one liter of water weigh
  7. Normal values for Na, K, Ca, Glu, BUN, creatinine
  8. when giving a bolus of K what should always be used to set the rate?
  9. A high/low specific gravity indicates what?
  10. s/s with fluid volume excess
  11. s/s with fluid volume deficit
  12. 8oz of ice is 240ml but ___ml when melted?
  13. Donor vs autologous blood?
  14. types of blood products, 4 types?
  15. which has the biggest volume
  16. ABO blood typing system and rh factor
  17. three reactions to blood products?
  18. Pulmonary embolism s/s
  19. Sa02 Sp02 and Pa02 definitions
  20. flow rates range for nasal cannula, and nonrebreather
  21. what is a yankauer? what level of suction does it use?
  22. What does VAP stand for?
  23. Patient satisfaction organizations of management (3)?

Here is the filled out version!

Pharmacology test 1 study guide: Concepts

Concepts of the first test material of nursing pharmacology. The information here is as deep as I think that they will test on, but I am sure that this is not an inclusive list of information that will be asked about. Supplement this material with the pharm book and reading the slides. Happy studying!

-Peter

Pharm study guide 1:

Concepts:

Special population considerations

  • Elderly – they can have multiple chronic conditions, polypharmacy, adherence issues, functional limitations, use 31% of the drugs even though they represent 12% of population. Issues in All parts of ADME
    • A: ↓ GI motility and gastric emptying, ↑ gastric pH
    • D: ↑ body fat %, ↓ body H2O, Lean body mass, albumin
    • M: ↓ hepatic (Liver) mass, blood flow, and metabolism.
    • E: Renal issues will cause excretion issues and can lead to toxicity and negative drug effects
  • African population responds poorly to ACE inhibitors, but responds better to calcium channel blockers and Diuretics.
  • Kiddos, but I did not find information about this population in the slides except do not recommend over the counter cough meds to a child less than 6 yo. (per the American Academy of Pediatrics)

Scheduled vs. legend drugs

  • Legend drug is a drug that is illegal to have without a prescription
  • Schedule drugs are regulated more and are in 5 schedules
    • Schedule 1: High abuse potential and no medical use
    • Schedule 2: High abuse potential and accepted medical use
    • Schedule 3: Potential for abuse and accepted medical use
    • Schedule 4: Low potential for abuse and accepted medical use
    • Schedule 5: Lowest potential for abuse and accepted medical use

Half-life

  • (t ½ )The amount of time it takes for the body to eliminate half of the drug.

Pregnancy categories (old and new) Davis Drug Guide for Nurses Appendix I.

  • A: have not shown an increased risk of fetal abnormalities
  • B: Studies in animals show no negative effects, but there are no studies in pregnant women, or there are animal studies that show adverse effects and studies in pregnant women are not adequate
  • C: animals have shown adverse effect, and there are no adequate and well-controlled studies in pregnant women, OR no animal studies have been conducted and there are no adequate and well controlled studies in pregnant women
  • D: studies, adequate well-controlled or observational, in pregnant women have demonstrated a risk to the fetus. however, the benefits of therapy may outweigh the potential risk.
  • X: Studies, adequate well-controlled or observational, in animals or pregnant women have demonstrated positive evidence of fetal abnormalities. the use of the product is contradicated in women who are or may be pregnant.

Concepts of potentiation and interference in CYP 450 system

  • System overview: 12 channels, 50 isoenzymes, 90% of drugs go through 6 channels. If 2 or more drugs need one channel there can be interference.
  • Interference: one drug can increase or decrease the excretion or metabolism of another drug.
    • ex. Erythromycin taken w/ increases serum digoxin levels, and increases action of Coumadin  
  • potentiation: when two similar drugs have an effect that adds on one another.
    • ex. Coumadin + aspirin can = excessive bleeding
    • ex. sedatives + ETOH can = excessive sedation

How other organ system issues impact drug dosing  (i.e. renal)

  • The renal system if not working well or in a disease state, will cause drug accumulation. this is an extremely important and common cause of toxicity and adverse med effects.

Protein binding

  • a drug is competing to bind a protein in the blood and will end in a “drug reservoir” and allows accumulation to occur.
    • the drug must be unbound to be useful or work.
    • the most common protein that a drug binds to is albumin
    • two similar drug molecules will have compete for binding sites on serum proteins

Therapeutic index

  • is a ratio between the lethal dose and the effective dose. TI=LD/ED
  • Therapeutic range: the area between the ED and LD, so effective but not lethal or toxic.

First pass effect

  • for most oral or enteral drugs will be metabolized by the liver on the first pass through the liver.
  • Some drugs could be 90% metabolized on the first pass.

Nursing interventions to reduce adverse effects

  • Monitor for drug interactions
  • know pt allergies history
  • monitor patient for s/s

Drug interactions

  • interference – one drug stops or slows the action of a second drug.
    • cyp450 system
  • can be used on purpose
    • HIV meds: ritonavir inhibits metabolism of lopinavir so the second drug can be effective.
  • Potentiation: similar meds have effects that add to each other
  • displacement is when two drugs are fighting for the same binding sites and only one can win. this leads to a drug with a higher affinity for the site or higher serum levels to displace the lesser drug.

Different forms of meds and how fast into the system

  • Oral: swallowed, sublingual, buccal:  30 mins to and hour?
  • enternal: NG, gastric tubes, rectal:
  • Parental: SC, IM, IV, intrathecal, epidural:
    • from slow to fast: ID, SC, IM, IV (IV is almost instantaneous in some cases)  
  • Pulmonary: gas, mist:
    • fast due to the large amount of capillaries
  • topical: local effect usually, must be lipid soluble.

Loading doses

  • initial dose that is larger than maintenance dose that brings the levels of the drug up to the desired range.

Duration of action and minimal effective concentration

  • measurable action of the drug from the beginning to end
  • lowest serum levels that produce the desired effect.

BBB and drugs

  • the Blood-brain barrier is a barrier that is harder to pass through than normal endothelial cells. this is due to the fatty sheath that covers the endothelial columns
  • only lipid soluble meds can pass through (also drugs that are compatible with specific active transport site but this was not covered in class soooo)

What is ADME?

  • Absorption, Distribution, Metabolism, Excretion
    • This is all a part of pharmacokinetics

What is included in patient education?

  • How, when, why, how much, how long, for what reason, diet, when not to take it, side effects, adverse effects, s/s of toxicity, when to notify HCP

Emergency care  (Appendix T) of Davis Drug Guide for Nurses Appendix T.

  • Early management of anaphylactic reactions
  1. Stop the administration of the drug
  2. Maintain airway: bronchodilators and Aminophylline may be needed to keep the airways open in severe resp. distress.
  3. Administer epinephrine:
    1. IM, SubQ; adults 0.3-0.5 mg q5-15 mins, Kiddos 0.01mg/kg or 0.1 q5-15 mins
    2. IV: Adults 0.1mg over 5mins or 1-4 mcg/min infusion, Kiddos 0.01mg/kg or  0.1-0.2 mg over 5 mins q 30 mins, infusion 0.1-1.5 mcg max/ kg/min
  1.   Administer antihistamines: diphenhydramine (Benadryl) IM, IV: 50-100 mg initial,      kiddos 5mg/kg/day divided into doses q6-8hr do not exceed 300mg/day (so child >15kg should not get the maximum dose)
  2.   Support BP w/ fluids and vasopressors
  3.   Administer corticosteroids: hydrocortisone (Sulo-cortef) IV 100-1000mg mg followed by 7mg/kg/day IV for 1-2 days
  4.   Document the reaction in medical reaction and have the pt/family to carry ID

Side effects of anti-HTN meds and digoxin

  • Thiazides cause a shift of K out of the body causing Digoxin toxicity
  • Furosemide can cause ototoxicity
  • Spironolactone (K sparing diuretic) will increase the half life of digoxin

Inotrope, chronotrope, dromotrope

  • Cardiac drug effects
  • inotropic ↑ contractility
  • Chronotropic ↑ HR
  • dromotropic ↑ conduction velocity of the heart

Selecting a BP medication

  • Step I: A diuretic, calcium channel blocker, or ACE inhibitor
  • Step II: increase dose of the first med, or ad another
  • Step III: Pick another drug from a different class
  • Step IV: Add another one or two meds, three or four total.

Labs and HTN meds

  • Labs:
    • Urinalysis for kidney function, lipid panel, electrolytes, Basic metabolic panel
  • Meds: Beta blockers, ACE inhibitors, Diuretics

Disclaimer: This is for studying purposes only and is not for practice in a hospital setting or personal setting. Full disclaimer is under the main home page and can be found by searching “disclaimer” in the search bar.

Bibliography

Deglin, J., Vallerand, A., & Sanoski, C. (2015). Davis’s drug guide for nurses (14th ed.). Philadelphia, Pennsylvania: F.A. Davis.

Robinson PhD, FNP, M., & Gilbert DNP ARNP-BC, M. (2015, September 1). Pharmacokinetics & Pharmacodynamics. Lecture presented in Anschutz Medical campus, Aurora.

Robinson PhD, FNP, M., & Gilbert DNP ARNP-BC, M. (2015, September 8). Antihypertensives and Diuretics. Lecture presented in Anschutz Medical campus, Aurora.

Robinson PhD, FNP, M., & Gilbert DNP ARNP-BC, M. Nino, T. (2015, September 15). Respretory Pharmacology Fall 2015 Updates. Lecture presented in Anschutz Medical campus, Aurora.