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Five rights of delegation - Within delegatee’s scope of practice - Routine, frequently recurring task; minimal potential risk Right task - Established sequence of steps; requires little to no modification for individual clients - Predictable outcome - Relatively stable client; non complex task Right...

Five rights of delegation - Within delegatee’s scope of practice - Routine, frequently recurring task; minimal potential risk Right task - Established sequence of steps; requires little to no modification for individual clients - Predictable outcome - Relatively stable client; non complex task Right circumstances - Adequate staffing, resources, and supervision available - Delegator should assess competency prior to delegating Right person - Delegatee must have the appropriate knowledge, skills, & abilities - Delegator needs to provide clear instructions; must include specific client concerns and Right direction / communication observations to be reported back or recorded - Delegatee should verbalize understanding and have opportunity to ask questions - Monitor, evaluate, and intervene as needed Right supervision / evaluation - Delegator retains ultimate accountability for task Room assignments When assigning rooms, the nurse should consider infection control, physical location, acuity level, and individual client safety needs. Cognitive impairment and fluid and electrolyte disturbances pose the greatest risks to a client's safety. Disaster triage Research findings & Applying them to practice When seeking to apply research findings in practice, the nurse should consider the similarities between the research study population and the client population. LPN skills - LPNs are trained in many nursing skills; these include but are not limited to nasotracheal suctioning, Foley catheter and nasogastric tube insertion, dressing changes, and subcutaneous, intramuscular, and oral medication administration. - However, IV medication administration is typically reserved for the RN. - The charge nurse should assign the most stable clients to the LPN. Tasks exclusive to the RN includes assessment of an unstable client and intravenous medication administration. Advanced directive An advance directive is placed in the client's medical record and copies are given to health care proxies. Two witnesses are required for completion of the advance directive, but they should not be the health care proxies listed in the document. Legal terms with nursing - Assault is an act that threatens the client and causes the client to fear harm, but without the client being touched. - False imprisonment is the confinement of a client against the client's will or without legal justification (eg, client is not a threat to self or others). - Invasion of privacy includes disclosing medical information to others without client consent. Under the Health Insurance Portability and Accountability Act (HIPAA), a client's information regarding medical treatment is private and cannot be released without the client's permission. - Battery involves making physical contact with the client without permission. This includes harmful acts or acts that the client refuses (eg, performing a procedure). When interacting with the client, it is important to practice veracity, the ethical principle of being truthful. - An emancipated minor is an individual under the age of legal responsibility who has been legally freed from parental control through a court order (eg, due to enlistment in the military, marriage, pregnancy). The parent in this situation would not need to be called. Clients have the right to be informed of risks and benefits of procedures prior to care and to give informed consent. Blood transfusion It is the responsibility of the RN to stay with the client during the first 15 minutes of the transfusion, monitor client response, and measure vital signs. A transfusion reaction is most likely to occur during this time. However, the RN may delegate measurement of vital signs after the first 15 minutes. Deliberate inaccurate documentation When deliberate inaccurate documentation is suspected, gather evidence before confronting the staff member. One way of doing this is by checking the data personally (i.e. recheck blood glucose) and comparing it to what has been documented. Hypothermia The client with a low body temperature and drowsiness needs immediate intervention to prevent and/or reverse physiologic compromise. Signs of hypothermia include a core temperature (eg, rectal) less than 95 F (35 C), mental status changes, shivering, and impaired coordination. Alterations in acid-base balance, coagulation values, and cardiac function may also occur. Hypothermia can lead to cardiac and respiratory failure and coma Elderly & Anticoagulants Elderly clients and those taking anticoagulants are especially vulnerable to developing a chronic subdural hematoma. Manifestations of the condition (eg, headache, gait disturbance, memory loss, confusion) should be investigated immediately as this neurologic emergency can lead to increased intracranial pressure and death. Infant & Hypoglycemia - A normal blood glucose range for an infant is 40-60 mg/dL (2.2-3.3 mmol/L) within the first 24 hours after delivery. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline-low glucose level is symptomatic and should be assessed first. - Treatment is a glucose bolus or immediate feeding Infant Under 30 days old Infants <30 days old have immature immune systems and a blunted response to infection. The 7-dayold infant is at high risk for bacteremia. Infectious manifestations are often subtle at this age (eg, fever can be the only symptom), although some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0 C) is a "red flag" in a neonate. Delegated task completion When the completion of a delegated task is questioned, the nurse should first confirm its completion with the designated personnel. Prescription abbreviations Using approved abbreviations when transcribing health care provider prescriptions promotes client safety and prevents potential medication administration errors. Common abbreviations (per os, qhs, qd) can result in errors and should not be used. Pediatric RN floated to Adult med surg A pediatric nurse who is floated to an adult medical surgical unit should be assigned clients with diagnoses common to the pediatric client population. Some examples include sickle cell anemia, diabetic ketoacidosis, pneumonia, and acute appendicitis. Bronchiolitis A client with bronchiolitis will require frequent suctioning, especially before feeding. The nurse should use the ABC (airway, breathing, circulation) guidelines and see this client first. Alcoholic cirrhosis Clients with alcoholic cirrhosis are at increased risk for hemorrhage due to esophageal varices and coagulation disorders. Hypotension and tachycardia in the presence of blood loss can indicate hypovolemia and require immediate assessment. Abdominal aneurysm Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. UAP, RN, & Isolation procedures Experienced UAP can post signs on the client's door that display airborne isolation precautions, stock necessary equipment, and remind visitors to wear a respirator mask when entering the client's room. The RN is responsible for appropriate communication with other departments and providing instruction to clients and their families. Multiple myeloma Multiple myeloma is a cancer of the bone marrow that causes bone degeneration and skeletal pain. Clients commonly report spinal, pelvic, and rib pain with physical activity. Sepsis neonatorum Sepsis neonatorum is a medical emergency. Newborns may not exhibit obvious signs of infection but instead may have elevated temperature or be hypothermic. Subtle changes such as irritability, increased sleepiness, and poor feeding should be considered red flags. Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum antibiotics started. Nurse case manager - Case management involves assessing, planning, facilitating, and advocating for client health services to accomplish cost-effective quality client outcomes. This is done through communication and use of available resources. A professional nurse often serves in the case manager role. The case manager in the hospital setting assesses client needs, decreases fragmentation of care, helps to coordinate care and communication between HCPs, makes referrals, ensures quality standards are being met, and arranges for home health or placement after discharge. - Case managers typically do not provide direct client care. Medication reconciliation should be done between the primary nurse directly caring for the client and the HCP. - Case managers often make daily rounds to the nursing department to review documentation in the client's chart but do not necessarily visit the client personally. Mass casualty disaster & Release of hazardous substances Decontamination is a priority nursing action for clients who have been exposed to a chemical or radioactive agent. During a mass casualty disaster, the nurse should assist clients with complete decontamination before providing care. Decontamination limits further client injury and prevents exposure to other clients and staff. Discharge A client should not be allowed to leave until essential home supplies and equipment have been made available for a safe discharge. Chest pain Chest pain in an adult, regardless of age, is a priority. It is important to not make assumptions based on client age, race, or nationality. Pulmonary embolism Clients with pelvic or long-bone fractures are at risk for the development of life-threatening fat embolism syndrome. Respiratory distress, mental status changes, and petechiae (on chest, axillae, and soft palate) are the classic manifestations. Abdominal surgery & Vomiting / Dry heaving Vomiting and dry heaving place increased mechanical stress on surgical wound edges and increase the risk for wound dehiscence and evisceration. Obese clients who have undergone extensive abdominal surgery are especially vulnerable. Therefore, the nurse should first assess the client who is nauseated and dry heaving and administer an antiemetic medication Therapeutic INR = 2-3 - The higher the INR, the higher the bleeding risk - The nurse should NOT administer Warfarin if the INR is over 4 Interpreter An interpreter should only provide literal translation of the words spoken by the HCP, not adding any personal advice/information. The nurse should clarify if there is any question about the accuracy or content of the translation and ensure the client's concerns have been addressed prior to obtaining the signature on the consent. Visiting person has something happen - Providing care establishes a legal caregiver obligation/relationship between the nurse and the visitor. If a relationship is started, the nurse has a duty to continue care until the visitor is stable or other health care personnel can take over. If proper care is not continued, the nurse could be accused of negligence (ie, failure to act in a prudent manner as would a nurse with similar education/experience). - This visitor's symptoms are potentially serious as sudden onset of headache and numbness in half of the body may indicate stroke. In the event of a visitor emergency, the nurse should not establish a caregiver relationship but rather implement facility protocol to help the visitor get to the emergency department promptly to receive immediate assessment and further evaluation Advanced directives / Living will / Durable power of attorney Advance directives give people the chance to make decisions about their medical treatment ahead of time in case they are unable to personally make their wishes known. The 2 most common forms are living wills and durable power of attorney for health care (health care surrogate/proxy). Disaster scenario with Radiation - The key aspects related to radiation exposure are time and distance. The greater the distance, the less dosage received. Acute radiation syndrome has the following phases: prodromal, latent, manifest, and recovery or death. Initially, all victims will appear well; however, the damage is mainly internal, leads to cell destruction, and manifests later on. - Victims farthest away from the radiation source are the most salvageable. In this scenario, the principle of disaster nursing is to do the most good for the most people with the available resources. Amyotrophic lateral sclerosis (ALS) Amyotrophic lateral sclerosis (ALS) is characterized by the progressive loss of motor neurons in the brainstem and spinal cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involved in swallowing and respiratory function are eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALS focuses on maintaining respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis. The client with ALS and worsening ability to speak (dysarthria) may also have dysphagia and respiratory distress; this client should be seen first Quality improvement - A unit quality improvement committee assesses process standards (guidelines, systems, and operations) and clinical issues on a specific unit that affect delivery of client care and client outcomes. The committee implements a process to improve performance if the standards are not being met. - Examples requiring unit quality improvement include the following: • Medications prescribed STAT are not available in a timely manner • Catheter-associated bacterial infections are increasing within the unit - A unit quality improvement committee assesses clinical issues arising on a unit (eg, increased infection rate) and problems with the systems and standards (eg, late delivery of medications from pharmacy) created to ensure delivery of quality care. This committee is not concerned with administrative or management issues (eg, client satisfaction surveys, individual performance reviews). Management of DVT Bed rest is no longer required for a client with DVT unless the client is having severe edema or leg pain. Early ambulation does not increase the short-term risk of pulmonary embolism, and it can reduce edema and leg pain. The nurse should see this client second to assess the affected limb. Post tonsillectomy The risk of post-tonsillectomy hemorrhage persists for up to 14 days after surgery, and resuming strenuous activity too early increases this risk. The potential for bleeding is higher 7-10 days postoperatively while sloughing occurs. Legal protective custody by the hospital The hospital will seek court-appointed custody to treat this child who is seriously ill with dangerously high temperature and signs of severe neurologic deficit. Bacterial meningitis presents with high fever, change in level of consciousness, nuchal rigidity, and meningeal signs (positive Kernig's and Brudzinski's signs). Antibiotic treatment is essential. Room assignments - A client undergoing an extensive surgical debridement for an infected pressure injury should not be assigned to a room with a client who is vulnerable to infection (eg, immunocompromised) or who has an active infection. - A client with an infection should not be assigned to a semi-private room with a client who had surgery or is immunocompromised and receiving immunosuppressants as these clients are highly susceptible to infection. Post-splenectomy clients are also at lifelong risk for rapid sepsis. Hospice Hospice is a program for individuals with a terminal illness who have 6 months or less to live. The focus of hospice is to provide comfort measures and help the client die naturally and as free of pain as possible. While on hospice, the client cannot receive treatment designed to cure the illness. It is covered by Medicare. Assault & Battery - Assault is the threat of battery. - Battery is touching that is legally defined as unacceptable or occurs without consent. Examples include performing a procedure despite a competent client's refusal or without obtaining proper consent from a competent client (or parent/legal guardian when the client is a child). Below standards of care When a caregiver's performance is below the standard of care needed to provide safe and quality care to clients, the appropriate authority should be notified so that the situation can be handled. Guillain-Barre syndrome Guillain-Barré syndrome is ascending bilateral paralysis from segmental demyelination (remyelination eventually occurs). Normal deep tendon reflexes are 2+. Hypotonia (muscle weakness) and areflexia (loss of reflexes) are common manifestations. The current level of paralysis is at the knees and is therefore not the priority as it has not yet reached the diaphragm. S3 heart sound An S3 sound can be an expected finding in young adults. However, a new S3 sound in older adults requires prompt evaluation as it is often a sign of volume overload or heart failure. Occupational therapist The occupational therapist promotes development of the client's fine motor skills and ability to carry out activities of daily living. Physical therapist The role of the physical therapist is to assist the client with mobility issues. Violence in the workplace Violence in the workplace should not be tolerated or ignored by either staff or management. Actions that staff members can take if they become victims of lateral violence include: • Documenting and keeping a file of all incidents • Reporting the incidents to the immediate supervisor • Letting the bully know that the behavior will not be tolerated • Observing interactions between the bully and other colleagues (may validate the victim's experiences and serve as a source of support) • Seek support from within the facility or from an external source - Ignoring acts of lateral violence will perpetuate the bullying. - The chain of command should be followed when reporting incidents of lateral violence. If the immediate supervisor takes no action, the employee can move up the chain. Sleep apnea Clients with obstructive sleep apnea (OSA) who are receiving sedatives or narcotics require frequent monitoring as these can exacerbate OSA symptoms. These clients are at increased risk for respiratory complications such as over sedation, respiratory depression, hypoxia, and hypercapnia. Lung contusion A lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95%-100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary. Angina at rest = unstable angina Nursing principles - Autonomy is allowing the clients to choose the direction of their care. This is accomplished with advanced directives along with informed consent and choices regarding proposed treatments. - Paternalism is a type of beneficence whereby clients are treated as children. The nurse claims to know what is best for the client and coerces the client to act as the nurse wishes without considering the client's autonomy. - Veracity refers to the duty to tell the truth. This principle should always be applied to client care and documentation. - Fidelity is exhibiting loyalty and fulfilling commitments made to oneself and others. It includes meeting the expected responsibilities of professional nursing practice and provides the basis of accountability (taking responsibility for one's actions) - Justice refers to treating all clients fairly (ie, without bias) Diabetic Ketoacidosis A client with type 1 diabetes experiencing nausea, vomiting, and abdominal pain is a priority due to the possibility of diabetic ketoacidosis (DKA). Medication (insulin) noncompliance is common in teenagers. The body breaks down fat for fuel and the resulting byproducts, acidic ketones, can cause abdominal pain. Osmotic diuresis (polyuria) results from the elevated glucose levels. The client experiences rapid respirations (Kussmaul's sign) that help compensate for the metabolic acidosis by blowing off carbon dioxide. DKA is a serious condition that can lead to death. If it is ruled out, other pathologies (eg, appendicitis) should be explored. Mature minors Mature minors are adolescents between age 14-18 who can give independent consent for limited conditions such as STDs, family planning, drug and alcohol abuse, blood donation, and/or mental health care. Pregnant nurse Although rare, infection with parvovirus B-19 during pregnancy can cause fetal anomalies (eg, hydrops fetalis, stillbirth). It is recognized as a TORCH infection (Toxoplasmosis, Other [parvo-B19/varicella zoster], Rubella, Cytomegalovirus, Herpes simplex virus), a group of infections that cause fetal abnormalities. Delegation of this client to a pregnant nurse is inappropriate due to potential harm to the fetus. Toxic megacolon Toxic megacolon is a common, life-threatening complication of inflammatory bowel disease. Clients present with abdominal pain/distension, bloody diarrhea, fever, and signs of shock (eg, hypotension, tachycardia). Pyelonephritis Clients with acute pyelonephritis require aggressive IV fluids and IV antibiotics to stop progression of the infection and kidney scarring. A patent IV line is the priority. UAP, Buck’s traction, & Changing linens The UAP changes the linens from the top to the bottom of the bed with assistance; clients are instructed to lift themselves using the overhead trapeze. This approach maintains immobilization of the injured extremity. Logrolling the client will require multiple staff members, including one person to stabilize weights. Spleen-ectomy Overwhelming postsplenectomy bacterial infection is a major lifelong complication in clients without a functioning spleen. A minor infection can quickly become life-threatening and septic; therefore, any indicator of infection requires immediate attention and treatment intervention. Glaslow coma score - Normal GCS is 15. - Head injury classification – mild, GCS 13-15; moderate, GCS 9-12; severe, GSC ≤8. Oxygen saturation Children age <10 should automatically be upgraded to 1 level higher than the triaged urgency of their medical issues. The combination of status asthmaticus and an oxygen saturation ≤92% qualifies for the highest priority level of triage at any age. Thyroid storm Hyperthyroidism results from excessive secretion of thyroid hormones. Affected clients are at risk for developing thyroid storm, a life-threatening form of hyperthyroidism. Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation), nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise (eg, heart failure). Clear fluids from nose / ears after Head trauma - Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage (Option 3). When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. - This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics. Antihypertensives & Dialysis - Antihypertensives are held before dialysis to prevent hypotension Severe Anxiety - Clients with severe anxiety are unable to attend to their own safety or needs. The nurse should not leave the client alone at this time. - Clients should be allowed to engage in coping behaviors (eg, repetitive acts, pacing) during episodes of severe anxiety as long as they do not risk harm. These behaviors relieve tension and prevent escalation. Child <1 & Sepsis This child age <1 with fever, lethargy, and vomiting likely has sepsis or meningitis. Clients with suspected meningitis need to be seen immediately and require close monitoring (eg, level of consciousness, vital signs), isolation, spinal fluid cultures, and antibiotics. Blood products - Blood products are a protein- and sugar-rich medium for bacterial growth. Indications of contaminated blood include: • Green, black, white, or dusky discoloration • Accumulations of air • Evidence of clotting or presence of inclusions • Malodor - Units exhibiting any of these signs should be returned to the blood bank Frostbite Tissue damaged by frostbite may appear pale, waxy, blue, or mottled due to frozen intracellular fluid. Affected extremities are thawed in a warm water bath (98.6-102.2 F [37-39 C]), and analgesics are administered. Manual friction (eg, massage, ambulation) is contraindicated as it may further damage the tissue. Cyclosporine - Cyclosporine is an immunosuppressant prescribed to manage rheumatoid arthritis (RA) and psoriasis, and to prevent transplant rejection. This medication inhibits the normal immune response by interfering with T cell response, which slows the progression of certain autoimmune diseases. Clients taking cyclosporine have an increased risk for infection and are instructed to avoid large crowds (eg, concerts, movie theaters) and known sick contacts (Option 1). It can take 1-2 months for the full effect of therapy and relief of symptoms from autoimmune disease (eg, joint stiffness in RA, psoriasis symptoms) to occur. - This medication is for long-term use, and it is therefore important to monitor clients for adverse effects. The incidence of secondary malignancies (eg, skin cancer, lymphoma) is increased in these clients. Pressure injuries & infants Sedated infants are at increased risk of pressure injuries due to limited mobility, sensory deficits, and incontinence. The nurse should elevate the head of the bed ≤30 degrees to reduce pressure, apply a moisture barrier to any vulnerable tissue areas, reposition the pulse oximeter every 4 hours, and avoid the use of baby powder and donut pillows. Resources for Alcoholics & Families • Alcoholics Anonymous (AA) – provides help and support to individuals who want to stop drinking. AA uses a 12-step approach that provides guidelines on attaining and maintaining sobriety. • Adult Children of Alcoholics (ACOA) – provides assistance to adults who grew up in homes that were dysfunctional due to alcoholism. • Al-Anon – provides help for spouses, significant others, family, and friends of alcoholics to share their personal experiences and coping strategies. • Alateen – part of Al-Anon; provides support to adolescent children of alcoholics. • National Association for Children of Alcoholics (NACOA) – raises public awareness of alcoholism and its effects through leadership in public policy, advocacy for prevention services, and online resources. Tumor lysis syndrome - Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. - TLS may result in the following life-threatening conditions: • Hyperkalemia (eg, >5.0 mEq/L [5.0 mmol/L]) may progress to lethal dysrhythmias (eg, ventricular fibrillation) • Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) overwhelm the kidneys, leading to hyperuricemia and acute kidney injury from uric acid crystal formation • Hyperphosphatemia (eg, >4.4 mg/dL [>1.42 mmol/L]) can cause acute kidney injury and dysrhythmias - TLS is best prevented by aggressive hydration and prophylactic allopurinol for hyperuricemia. Organ donation Some regions have organ donor registries that allow individuals to express their wishes, but in most cases the client's family consents for donation. Iron oral supplements - Oral iron supplements are best absorbed on an empty stomach; however, iron may be given with meals to avoid gastric irritation. Consuming vitamin C with iron supplements increases iron absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration. - Liquid iron supplements can stain teeth and so are administered with a medicine dropper toward the back of the infant's cheek. The dose may be diluted with water or juice to prevent staining and improve flavor. Older children should use a straw to take the supplement and drink water or juice after each dose. 12 lead ekg Colostomy - After a colostomy, the stoma should be beefy red and edematous but will begin to shrink over the course of a few days as inflammation subsides. There should be no mucocutaneous separation (eg, separation of the stoma from the abdominal wall), unusual bleeding (eg, moderate to large amounts of blood in the ostomy pouch), or signs of inadequate circulation, including stoma ischemia (eg, pale, dusky) and necrosis (eg, dark red, purple, black). Appliances should be resized during the first several weeks to ensure proper fit, preventing skin breakdown (eg, excoriation) due to stool coming into contact with the skin. - Within 24 hours of surgery, the client should demonstrate signs of returning gastrointestinal motility, including resolution of nausea, active bowel sounds, and flatus (Option 3). Nausea and absent bowel sounds may indicate postoperative ileus and should be reported to the health care provider. - Clients should change the pouch according to the manufacturer's instructions (every 5-10 days) and when the skin surrounding the stoma is irritated (eg, burning). The nurse should also assess the client with a new ostomy for body image disturbance and ineffective coping (eg, client unwilling to care for the ostomy) Mechanical ventilator low pressure alarm When the mechanical ventilator low-pressure limit alarm sounds, the nurse should assess for conditions that decrease resistance in the airway or tubing (eg, loss of airway, tubing disconnection, cuff leak in artificial airway). Cushing triad Cushing triad is a neurologic emergency characterized by bradycardia, irregular respirations, and hypertension with a widening pulse pressure. The body attempts to increase perfusion to the brain by increasing blood pressure, which causes systolic hypertension with a widening pulse pressure. Fetal tachycardia Fetal tachycardia is defined as a baseline heart rate above 160 beats per minute. Tachycardia can be an early indicator of fetal hypoxia and acidosis. Other common causes include infection, maternal fever, maternal dehydration, maternal hypotension, and drug side effects. Maternal temperature should be taken to assess for fever, and blood pressure should be assessed to rule out hypotension. Certain medications can lead to fetal tachycardia (eg, terbutaline, bronchodilators, decongestants), and the nurse should review the medication administration record to determine whether potential causative medications were administered recently. Restraints - Clients in any form of restraints should not be in the supine position because it can cause aspiration, especially in those with altered mental status. Unless contraindicated, clients in restraints should be placed in the side-lying, semi-Fowler, or high-Fowler position to promote airway patency and expectoration of secretions or emesis. The supine position may also increase anxiety and agitation, especially in a restrained client. - Belt and vest restraints are secured around the client's waist. A client in a belt or vest restraint can be safely placed in the side-lying, semi-Fowler, or high-Fowler position. - Mitten restraints cover the client's hands and contain the fingers to help prevent removal of lines, tubes, and drains. These restraints are made of soft cushion and fabric that allow some movement of the hand and fingers within the mitten. The client in mitten restraints is able to reposition independently and can safely be placed in the side-lying, semi-Fowler, or high-Fowler position. Varicose veins Varicose veins are tortuous, distended veins that occur frequently in clients with a family history, certain chronic conditions, or jobs requiring prolonged sitting, standing, or heavy lifting. To improve venous return, the client should follow the 3 Es: elevation, exercise, and elastic compression hose, and should maintain an appropriate weight. Heart sounds If heart sounds are difficult to auscultate, the nurse can ask the client to either sit up and lean forward (best for aortic and pulmonic areas) or lie down on the left side (best for the mitral area). These positions move the heart closer to the chest wall. Erythropoiesis – stimulating agents - Erythropoiesis-stimulating agents (eg, epoetin alfa, darbepoetin alfa) treat chronic anemia by stimulating red blood cell production. Hemoglobin level should not exceed 11 g/dL (110 g/L) due to an increased risk of thrombotic events (eg, myocardial infarction, stroke). - normal hemoglobin = 13-18 Therapeutic elevation Therapeutic positioning must be evaluated carefully by the nurse. Elevating an extremity can reduce edema, promote comfort, and increase venous return. Elevation is inappropriate for clients with hip fractures, recent percutaneous coronary intervention, or above-the-knee amputation more than 24 hours ago. Hepatic encephalopathy Hepatic encephalopathy, a complication of liver disease, results from the accumulation of ammonia in the bloodstream. Clinical findings include changes in level of consciousness, asterixis, and fetor hepaticus. Therapeutic INR with mechanical heart valve A therapeutic INR is 2.5-3.5 for clients with mechanical heart valves. The nurse should hold the dose and contact the health care provider if the INR is >3.5. ACE inhibitors & Pregnancy Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril (Prinivil) should also not be used in pregnancy as they can affect kidney development in the fetus. Herbal remedies - Saw palmetto is one such herbal preparation, and clients most often use it to treat benign prostatic hyperplasia. - Hawthorn extract is used to treat heart failure and in some countries (eg, Germany) is an approved treatment for this purpose. - St John's wort has been used for centuries to treat depression. It may cause hypertension and serotonin syndrome when used with other antidepressants. - Black cohosh is an herbal supplement often used by perimenopausal clients experiencing hot flashes. Heparin reversal agent = Protamine Nasal polyps, Asthma, & NSAIDS Clients with nasal polyps often have sensitivity to nonsteroidal anti-inflammatory drugs (NSAIDS), including aspirin. In addition, NSAIDs can exacerbate asthma symptoms. Urinary retention Assessing the client's suprapubic area is the priority nursing action when urinary retention is suspected. Interventions are performed after a problem is identified and its cause is determined. Urinary retention is an expected side effect of opioid medications. Synthroid The client's therapeutic response to levothyroxine (Synthroid) is evaluated by resolution of hypothyroidism symptoms. The expected response includes improved well-being with elevated mood, higher energy levels, and a heart rate that is within normal limits. The nurse should consult the health care provider if the heart rate is >100/min, or if the client reports chest pain, nervousness, or tremors; this may indicate that the dose is higher than necessary. Pharmacological therapy manages the symptoms of hypothyroidism, but it takes up to 8 weeks after initiation to see the full therapeutic effect. Statin drugs Statin drugs (eg, simvastatin, atorvastatin, rosuvastatin) are prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. Most of the cholesterol in the body is synthesized by the liver during the fasting state, at night. Trials have found greater reductions in total and LDL cholesterol when statins (especially those that are short-acting; eg, simvastatin) are taken in the evening or at bedtime as opposed to during the day. Isotretinoin (for acne) Isotretinoin is a vitamin A derivative prescribed to treat severe and/or cystic acne. Side effects include birth defects, skin changes (eg, dry skin, skin fragility, cutaneous atrophy), and risk for increased intracranial pressure. Clients need to be instructed to avoid tetracycline, excess sun and tanning, and vitamin A supplements. Women of child-bearing age should use 2 forms of contraception to prevent pregnancy. IV furosemide High doses of IV furosemide should be administered slowly to prevent ototoxicity. Licorice root Licorice root is an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. When used in combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting" diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should discourage the client from using this herbal remedy and report the client's use to the PHCP. Potassium tablets The nurse should teach the client to take potassium tablets with plenty of water (≥4 oz [120 mL]) and to sit upright after ingestion to prevent pill-induced esophagitis. Potassium should be taken during or immediately following meals to prevent gastric upset. Sustained-release tablets should not be crushed. Nystatin for oral candidiasis The nurse should teach the client taking nystatin solution for oral candidiasis to swish it in the mouth for several minutes and then swallow the solution. Swallowing would help to clear any unseen esophageal candidiasis. Proton pump inhibitor (- prazole) - Long-term therapy with a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption of calcium and promote osteoporosis. A bone density test can assess if the client already has osteoporosis. Hospitalized clients also have an increased risk of diarrhea caused by Clostridium difficile. PPIs cause suppression of acid that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. - PPIs such as omeprazole are often prescribed to hospitalized clients without GERD or ulcers to prevent stress ulcers from developing during surgery or a major illness. Kawasaki disease IV immunoglobulin along with aspirin is the recommended initial treatment for Kawasaki disease, with the primary goal of coronary disease prevention. Metformin & IV contrast IV iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury (contrastinduced nephropathy). The side effect of metformin (Glucophage) is lactic acidosis. If the client takes metformin and develops kidney injury from contrast, then the lactic acidosis will worsen. As a result, most HCPs discontinue metformin on the day of IV iodine contrast exposure (regardless of baseline creatinine) and restart the drug at least 48 hours later, after stable renal function has been documented. Serotonin syndrome - Serotonin syndrome, a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. - The diagnosis is primarily clinical and based on medication history and clinical findings. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, musclerigidity, clonus, hyperreflexia). - There must be a minimum of 14 days between the administration of MAOIs and SSRIs to avoid serotonin syndrome; these medications cannot be administered concurrently. Evening primrose supplement = eczema or skin irritations Enoxaparin = Lovenox = Heparin Respiratory depression The following are at greatest risk for respiratory depression related to opioid use for analgesia: the elderly; those with underlying pulmonary disease, history of snoring (with or without apnea), obesity, or smoking (more than 20-pack-year history); the opiate naïve, especially if treated for acute pain; and post surgery (first 24 hours). Antiplatelet therapy Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) can pose a risk for serious bleeding. Clients should be monitored for bruising, signs of bleeding (eg, tarry stools, hematuria), and decreased platelet counts. Thrombolytic agents - Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) are often prescribed to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive pulmonary embolism). They are recombinant plasminogen activators that activate the blood fibrinolytic system and dissolve thrombi. - Thrombolytic agents are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood pressure >180/110 mm Hg). Therefore, the health care provider should be consulted for clarification. Administering alteplase in the presence of these conditions can cause hemorrhage, including lifethreatening intracerebral hemorrhage Clonidine Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death. Urine specific gravity Normal urine specific gravity is 1.003-1.030. Elevated specific gravity can indicate concentrated urine and be a sign of dehydration Sulfa Dehydration is a concern with sulfasalazine and most other "sulfa" medications due to the risk of crystal formation in the kidney. It is also a potential complication of inflammatory bowel disease. Heparin & Warfarin The therapeutic effect from heparin or warfarin (Coumadin) is 1.5-2.0 times the control value. Heparin is measured with aPTT and warfarin is measured with PT/INR. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin. ADHD - Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants. - The major problems with stimulant medications include: • Decreased appetite and weight loss – can lead to growth delays • Cardiovascular effects – hypertension and tachycardia (particularly in adults) • Appearance of new or exacerbation of vocal/motor tics • Excess brain stimulation – restlessness, insomnia • Abuse potential – misuse, diversion, addiction Sucralfate - Sucralfate is an oral medication that forms a protective layer in the gastrointestinal mucosa, which provides a physical barrier against stomach acids and enzymes. It doesn't neutralize or reduce acid production. It is prescribed to treat and prevent both stomach and duodenal ulcers. This medication is generally prescribed 1 hour before meals and at bedtime and, for effective results, is administered on an empty stomach with a glass of water. - Sucralfate also binds with many other medications (eg, digoxin, warfarin, phenytoin) and reduces their bioavailability. Therefore, all other medications are generally administered at least 1-2 hours before or after sucralfate administration. Constipation is a common side effect of this medication Erythropoieten Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin Clozapine Agranulocytosis is the most serious adverse effect of clozapine. Pretreatment assessment and ongoing monitoring of WBC and ANC are necessary. Clients are advised to contact their HCP if fever or a sore throat develops. Clozapine can also cause metabolic syndrome (weight gain, hyperlipidemia, insulin resistance/diabetes) and seizures. Isotretinoin - Isotretinoin (Accutane) decreases sebum secretion and is prescribed for severe, disfiguring nodular acne that has been unresponsive to other therapies, including antibiotics. It is a pregnancy category X drug and is known to cause serious birth defects if taken during pregnancy. - Females prescribed isotretinoin must have 2 negative pregnancy tests before taking the medication. Also, 2 forms of contraception must have been in place for at least 1 month prior to starting isotretinoin, and these must be continued both during treatment and for 1 month after the medication is discontinued. Before refills can be obtained, enrollment in a risk management program is required to verify that pregnancy tests are negative and 2 forms of contraception are being used. Blood donation is also discouraged while on therapy and for 1 month afterward to ensure that pregnant women do not receive any donated blood. Activated charcoal Activated charcoal is used as the initial treatment for aspirin overdose in clients with clinical signs of salicylate toxicity as well as in those who are asymptomatic. Activated charcoal binds with salicylate and therefore inhibits absorption by the small intestine. IV sodium bicarbonate is also used for treating aspirin overdose after treatment with activated charcoal has been initiated. DVT Venous thrombosis involves the formation of a thrombus (clot) and the inflammation of the vein. Anticoagulant therapy such as heparin does not dissolve the clot. The clot will be broken down by the body's intrinsic fibrinolytic system over time. The heparin slows the time it takes blood to clot, thereby keeping the current clot from growing bigger and preventing new clots from forming. ACE inhibitors & Cough The nurse should be aware that certain ethnic groups are at a higher risk for developing intractable dry cough with the use of ACE inhibitors. Asians and African Americans have the highest incidence of ACE inhibitor-related cough. Persons of African descent are also at high risk for angioedema. Digoxin Clients prescribed digoxin are taught to take their pulse and hold their medication if the heart rate is <60/ min. ACE inhibitor A common side effect of ACE inhibitor is mild hyperkalemia, which may require a lower intake of foods high in potassium. Clients taking loop diuretics (eg, furosemide) will need to increase their intake of foods high in potassium. ADHD meds (stimulants) Stimulants (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment of ADHD. Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6:00 PM. The sustained-release preparation should be given in the morning. The dosage in children is usually started low and titrated to the desired response. Children should be monitored closely during initial treatment for development of tics and continuously for adherence and response to therapy. Lithium Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Adenosine & SVT (supraventricular tachycardia) Adenosine is the drug of choice for the treatment of paroxysmal supraventricular tachycardia. It has a short half-life and should be administered rapidly over 1-2 seconds, followed with a 20-mL saline bolus. A brief period of asystole can be common. Flushing from vasodilation is seen frequently. Statin & Muscle ache The client taking a statin such as atorvastatin or rosuvastatin should be taught to call the HCP if generalized muscle aches develop as this may be a symptom of myopathy, a serious adverse effect of this type of medication. Vancomycin & Aminoglycosides The nurse should recognize that the risk of nephrotoxicity and ototoxicity is potentiated when vancomycin and aminoglycosides (eg, gentamicin) are administered together. Kidney and hearing functions should be closely monitored in these clients. Asthma & Ibuprofen Ibuprofen and aspirin are common over-the-counter anti-inflammatory drugs that can cause bronchospasm in some clients with asthma. Tardive Dyskinesia The client should call the health care provider immediately if TD symptoms develop, including uncontrollable movements such as: • Protruding and twisting of the tongue • Lip smacking • Puffing of cheeks • Chewing movements • Frowning or blinking of eyes • Twisting fingers • Twisted or rotated neck (torticollis) Fentanyl patch A transdermal fentanyl patch is indicated to treat moderate to severe chronic pain. It is not recommended for treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied. Rifampin Rifampin (Rifadin), used to treat tuberculosis, normally causes red-orange discoloration of all body fluids. The client should be alerted to expect this change but does not need to notify the HCP. Sucralfate Sucralfate (Carafate, Sulcrate), prescribed to treat gastric ulcers, should be administered before meals to coat the mucosa and prevent irritation of the ulcer during meals. It should also be given at least 2 hours before or after other medications to prevent interactions that reduce drug efficacy. Opiods The nurse should administer an opioid analgesic to a client who is experiencing moderate-level postoperative pain (5 is moderate pain). Oral medication is an appropriate choice when it has been effective previously. Cardiovascular disease & NSAIDS Clients with cardiovascular disease (eg, coronary artery disease) should be cautioned against taking nonsteroidal anti-inflammatory drugs (eg, naproxen) due to the increased risk of thrombotic events (eg, heart attack, stroke). Alpha blockers & BPH Alpha blockers are commonly used to treat symptoms of urinary retention in clients with BPH. Orthostatic hypotension is a common side effect that can be avoided by teaching the client to take the medication at bedtime, avoid abrupt position changes, and avoid medications for erectile dysfunction, which can worsen hypotension. Tiotropium - Tiotropium and umeclidinium are long-acting, 24-hour, anticholinergic medications. Ipratropium is a short-acting anticholinergic used as a rescue medication for COPD and asthma. Tiotropium is typically administered as a powder via a special inhaler. - The nurse must emphasize that the capsule should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. Opioid analgesics Opioid analgesics are effective for managing postoperative pain, which encourages participation in deep breathing exercises. Side effects of opioid analgesics include sedation, respiratory depression, hypotension, and constipation. The nurse should administer IV hydromorphone slowly over 2-3 minutes, monitor sedation level, instruct the client not to get out of bed unassisted, and administer PRN stool softeners. Sodium polystyrene sulfonate Sodium polystyrene sulfonate (Kayexalate) retention enema is a medicated enema administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level. Kayexalate can also be given orally and is much more effective. Kayexalate can rarely be associated with intestinal necrosis. Sodium polystyrene sulfonate = Kayoexalate - lowers potassium Bacterial meningitis - Due to the risk for severe complications (eg, hearing loss, permanent brain damage) associated with bacterial meningitis, the most critical intervention is initiation of antibiotic therapy. The causative organism is confirmed through LP and blood cultures. - Clinical manifestations of bacterial meningitis in infants age <2 include: • Fever or possible hypothermia • Irritability, frequent seizures • High-pitched cry • Poor feeding and vomiting • Nuchal rigidity • Bulging fontanelle possible but not always present Tetralogy of Fallot - Cyanotic cardiac defect. Infants with TOF will normally maintain oxygen saturation levels at 65% 85% until the defect is surgically corrected. - The normal range for hemoglobin in a 1-month-old is 12.5-20.5 g/dL (125-205 g/L). Hemoglobin of 24.9 g/dL (249 g/L) is diagnostic of polycythemia (elevated hemoglobin levels). Infants with cyanotic cardiac defects can develop polycythemia as a compensatory mechanism due to prolonged tissue hypoxia. Polycythemia will increase blood viscosity, placing an infant at risk for stroke or thromboembolism. This is a priority finding that should be notified to the HCP. - Poor oxygenation can cause elevated levels of hemoglobin (polycythemia), which increase blood viscosity. Thickened serum puts infants at risk for stroke or thromboembolism. An infant with polycythemia must stay hydrated. Toilet training Readiness for toilet training is dependent on the child's ability to voluntarily control the anal and urethral sphincters, which usually occurs at age 18-24 months. Other developmental and behavioral indicators of toilet training readiness include the child's ability to express the urge to defecate or urinate, understand simple commands, pull clothing up and down, and walk to and sit on the toilet. Infants & Iron supplements Premature infants require iron supplementation by age 2-3 months, which is when maternal iron stores are depleted. Appropriate sources include oral iron drops if breastfeeding or iron-fortified formula. Otitis media (OM) - Otitis media, inflammation of the middle ear, commonly occurs in children under age 2. Key interventions for prevention include avoiding exposure to tobacco smoke, obtaining routine immunizations, and discontinuing use of a pacifier after age 6 months. - Excess water in the ears from bathing or swimming can alter the protective environment of the external ear and contribute to otitis externa, known as swimmer's ear; however, this does not contribute to OM. - If AOM symptoms do not improve within 48-72 hours of starting antibiotics, a follow-up visit is required to determine if a different antibiotic is necessary. Acute glomerulonephritis Acute glomerulonephritis is most often caused by recent streptococcal infection. Nursing care is focused on monitoring vital signs (particularly blood pressure) and fluid status, avoiding salt in the diet, and conserving energy. Pediculosis capitis (head lice) - Preventing the spread of pediculosis capitis (head lice) may be accomplished by using hot water to launder clothing, sheets, and towels in the washing machine; these items should then be placed in a hot dryer for 20 minutes. Treatment of head lice consists of the use of pediculicides and the removal of nits (eggs). - Household pets do not transmit human lice; treating them is not necessary. - Pediculosis capitis (head lice) is a parasitic infestation that is seen often in school-age children. Measures to control the spread and reinfestation include using nit combs, soaking hair brushes and accessories in boiling water, and vacuuming rugs/carpets frequently. Nephrotic syndrome - Nephrotic syndrome is characterized by massive proteinuria, edema, and hypoalbuminemia. Home management includes a low-sodium diet with attractive foods; infection prevention (limiting social interactions); fluid restriction for severe edema; and monitoring of weight gain and proteinuria to detect relapse. - Nephrotic syndrome is a collection of symptoms resulting from glomerular injury. The 4 characteristic manifestations are proteinuria, edema, hypoalbuminemia, and hyperlipidemia. Developmental dysplasia of the hip (DDH) DDH is instability or dislocation of the hip joint that may be present at birth or develop during the first few years of life. Nonsurgical treatment methods such as the Pavlik harness are most successful when initiated during the first 6 months of life. After this time, surgery is generally required. Weight gain for toddler Weight gain slows during the toddler years with an average yearly weight gain of 4-6 lb (1.8-2.7 kg). By age 30 months, current weight should be approximately 4 times greater than birth weight. A toddler weighing 6 times the initial birth weight requires further evaluation. Family nutrition and meal habits should be discussed. Fifth disease - Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with nonsteroidal antiinflammatory drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days - Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition. Assessing infant - When assessing an infant, the nurse should observe, auscultate, palpate, and then perform traumatic procedures (eg, examine eyes, ears, mouth). Elicitation of the Moro reflex should be performed last. - Elicitation of the Moro reflex (ie, reflexive startle and cry to a sudden dropping or jarring motion) is performed last because the infant is usually awake and moving around by this point Autism - Because children with autism spectrum disorder often exhibit sensory processing problems, they need a calming environment with minimal stimulation away from the nurse?