Unit 4 Class Notes Nasal Fractures, Epistaxis, Facial Trauma - PDF

 =====================  ===================== Case Study \#1: Tissue Integrity ================================ 1. The school nurse is in the office when Samantha, a 7-year-old in second grade, comes in with her head tilted back and dabbing her n...

 =====================  ===================== Case Study \#1: Tissue Integrity ================================ 1. The school nurse is in the office when Samantha, a 7-year-old in second grade, comes in with her head tilted back and dabbing her nose with a tissue. Blood is running down her arm and her cheek. a. Which actions are indicated or contraindicated by the nurse? ***Action*** ***Indicated*** ***Contraindicated*** ---------------------------------------------- ------------------------------------------------------------------------ ------------------------------------------------------------------------------- ***Use standard precautions*** ***x- want to use standard precautions for all patients*** ***Keep her head tilted back*** ***x- lean head forward to reduce aspiration risk*** ***Reassure her*** ***x- will help keep her calm to not raise HR & to control bleeding*** ***Apply pressure at the base of the nose*** ***x- hold lateral pressure on tip of nose (anterior tip) for 5-15 minutes*** ***Apply ice*** ***x- vasoconstricts to help stop bleeding*** ***Hold for 10 minutes*** ***x- hold for 5-15 minutes*** ***Remain calm*** ***x*** b. Why? Lean forward to keep blood out of lungs and stomach, keep calm so they stay calm to decrease their anxiety and BP. Hold continuous pressure to tip of nose for at least 10 min (not base) 2. Sam is calm and her nose has stopped bleeding. The nurse has cleaned her up and is calling the parent. 2\. Tell her not to let Sam blow/pick/rub her nose for the next 24 hours Case Study \#2: Tissue Integrity ================================ 1. Thomas and another student were fist fighting in the cafeteria. Thomas is being brought to the school nurse after being punched in the face. What would the nurse do when Thomas arrives at the office? - 1^st^: Airway---assess for SOB(RR)/dyspnea (Respiratory effort)/hypoxia (O2 sat)/airway obstruction (from broken bone)/restlessness because no O2/LOC - Assess for bleeding and fractures-looking for edema, facial asymmetry, pain - Assess vision and eye movement; "follow my fingers," "can you tell me the time on the clock?" - Check behind ear for battle sign or racoon eyes= basilar skull fracture which may indicate brain injury - Call 911, take to hospital if needed - Plan for: head CT, facial series, cervical spine x-rays too 2. Assessment findings: RR 20, normal effort, O2 sats 96% - Emergency Care of Nosebleed. See previous case study on actions to perform. Provide pain management (if allowed differs per school system) - Cold compresses to minimize swelling - Call a parent because he will need to see MD. This is a severe fracture and will probably require rhinoplasty. 3. Thomas is a 16-year-old male who had a fractured nose and jaw. He is recovering from a rhinoplasty and fixed occlusion (jaw wired shut). He has a moustache dressing in place that is dry and intact. - Keep wire cutters at all times---6 -10 weeks that the jaw will be wired shut, if any emergency occurred (Vomiting, Chocking, etc.) wire cutters will be needed to cut the wire - Sleep flat with a small pillow---stay elevated - Apply warm compresses to help with pain---apply ice to help w/ swelling - Drink at least 2 and a half liters a day---hydration is important after a rhinoplasty - Do not sniff or blow your nose---to prevent bleeding as much as possible - Take the Miralax you were prescribed---prevention of straining while having a bowel movement - Ibuprofen 600 mg for pain---recommend Tylenol instead d/t risk of bleeding - You should see the final results in 4-6 weeks---takes up to a year after rhinoplasty to see full results - A sonicare (Waterpik) is a great idea for oral care - You will need to follow the liquid diet the dietitian talked to you about---patient needs to get proper nutrition for best healing **Unit 4 Medications** +-------------+-------------+-------------+-------------+-------------+ | **Medicatio | **Examples* | **Uses** | **Side | **Nursing | | n** | * | | Effects** | Considerati | | | | | | ons** | +-------------+-------------+-------------+-------------+-------------+ | **Antipyret | **NSAIDs: | -Decreases | **1^st^ gen | **Permissib | | ics** | Aspirin & | body | NSAIDS (ASA | le | | | Ibuprofen** | temperature | and | for kids to | | | | (Lower | Ibuprofen) | run low | | | **Acetamino | fever) of | block COX1 | grade | | | phen** | many | & COX 2. | fever; txt | | | | causes: | Cox 2 is | recommended | | | | (Infection | formed ONLY | for 101 and | | | | and drugs: | after | greater** | | | | SSRIs, | tissue | | | | | Antipsychot | injury and | **Ensure | | | | ics, | therefore | not taking | | | | Neutropenic | promotes | multi-sympt | | | | drugs, etc) | inflammatio | om | | | | | n | cold | | | | -Restores | so COX2 | medication | | | | thermoregul | blocking is | with | | | | atory | positive | additional | | | | set point | (decreasing | acetaminoph | | | | | inflammatio | en/ibuprofe | | | | | n, | n** | | | | | pain, | | | | | | fever). | **ASA: | | | | | However, | never given | | | | | COX 1 is | to children | | | | | protective: | under 19 | | | | | providing | d/t risk of | | | | | gastroprote | Reye's | | | | | ction | syndrome | | | | | (dec acid | (pot fatal) | | | | | production | unless they | | | | | & increased | have | | | | | mucus | Kawasaki | | | | | production) | dx. 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| without a | | | | | where | prescriptio | | | | | aqueous | n. | | | | | humor | However, | | | | | drains out | these drugs | | | | | of eye) | often cause | | | | | being | sedation | | | | | blocked, | and should | | | | | increasing | not be used | | | | | eye | before | | | | | pressure** | driving or | | | | | | operating | | | | | **-MAOIs | machinery | | | | | b/c can | or in | | | | | cause | children. | | | | | hypertensiv | Even if you | | | | | e | do not feel | | | | | crisis** | excessively | | | | | | drowsy | | | | | **1st | after | | | | | generation | taking an | | | | | do not | antihistami | | | | | drive or | ne, | | | | | operate | these drugs | | | | | heavy | can have a | | | | | machinery** | sedating | | | | | | effect, so | | | | | | it is | | | | | | important | | | | | | to be | | | | | | careful. | | | | | | Because of | | | | | | the side | | | | | | effects | | | | | | associated | | | | | | with the | | | | | | older | | | | | | antihistami | | | | | | nes, | | | | | | the newer, | | | | | | nonsedating | | | | | | versions | | | | | | are | | | | | | typically | | | | | | preferred | | | | | | if an | | | | | | antihistami | | | | | | ne | | | | | | is used.** | +-------------+-------------+-------------+-------------+-------------+ | **Intranasa | **Fluticaso | Decreases | **No | **First-lin | | l** | ne | inflammatio | serious | e | | | (Flonase)** | n | systemic | drugs in | | **Cortico-s | | | effects | the | | teroids** | **Budesonid | Prevent | (unlike PO | treatment | | | e | allergic | and IV | of allergic | | | (Rhinocort) | rhinitis | routes) b/c | rhinitis** | | | ** | (our gold | works only | | | | | standard | in nasal | **Take 1-3 | | | **Mometason | tx) | mucosa** | weeks to | | | e | | | see peak | | | (Nasonex)** | | **Transient | effect (do | | | | | nasal | NOT have | | | | | irritation* | immediate | | | | | * | benefits)** | | | | | | | | | | | **Dryness | - **Can | | | | | of nasal | be | | | | | mucosa with | taken | | | | | continued | daily** | | | | | use: may | | | | | | see | **Highly | | | | | epistaxis** | effective | | | | | | if taken | | | | | **Couse see | before | | | | | Increase in | start of | | | | | blood | s/s** | | | | | glucose: | | | | | | diabetics | **Bad taste | | | | | may need | after | | | | | higher dose | administrat | | | | | of | ion** | | | | | insulin** | | | | | | | **Generally | | | | | | , | | | | | | pregnancy | | | | | | safe** | +-------------+-------------+-------------+-------------+-------------+ | **Medicatio | **Examples* | **Uses** | **Side | **Nursing | | n** | * | | Effects** | Considerati | | | | | | ons** | +-------------+-------------+-------------+-------------+-------------+ | **De-conges | **Oral:** | Constricts | **PO; 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Wean | cold meds | | | | | off and | to contain | | | | | switch to | phenylephri | | | | | intranasal | ne | | | | | corticoster | rather that | | | | | oids** | pseudoephed | | | | | | rine | | | | | **Sedation, | but... | | | | | dizziness, | 9/25/23: | | | | | hyperexcita | FDA | | | | | bility** | announced | | | | | | that oral | | | | | | phenylephri | | | | | | ne | | | | | | is | | | | | | ineffective | | | | | | as a nasal | | | | | | decongestan | | | | | | t** | | | | | | | | | | | | **Intranasa | | | | | | l: | | | | | | Produces an | | | | | | effective | | | | | | response | | | | | | within | | | | | | minutes** | +-------------+-------------+-------------+-------------+-------------+ | **Antitussi | **[Opioids: | Used to | **Opioids: | **Not all | | ve** | ]{.underlin | dampen | NV, | coughs | | | e} | cough | constipatio | should be | | | codeine, | reflex | n; | dampened so | | | hydrocodone | | can cause | use | | | ** | Opioids and | respiratory | w/caution** | | | | dextrometho | depression, | | | | **[Nonopioi | rphan | bradycardia | **Watch for | | | d:]{.underl | act by | ; | abuse in | | | ine} | directly | can be | teens with | | | dextrometho | acting on | addictive** | non-opiods | | | rphan | cough | | b/c of | | | (Robitussin | center in | **Nonopioid | hallucinati | | | )** | brain | s: | on, | | | | | drowsiness, | euphoria | | | **Benzonata | Indicated | GI upset; | s/s** | | | te** | for dry, | can cause | | | | | hacking, | paradoxical | **Prolonged | | | **(Tessalon | NONproducti | excitation, | use (with | | | Perles)** | ve | hallucinati | opioid) can | | | | cough | on | cause | | | | | and | dependance* | | | | Benzonatate | euphoria; | * | | | | suppresses | dry mouth | | | | | cough | and | **Avoid use | | | | reflex by | constipatio | w/alcohol, | | | | anesthetizi | n** | opioids, | | | | ng | | CNS | | | | stretch | **Non-opioi | depressants | | | | receptors | ds | ** | | | | in the | Contraindic | | | | | lungs. | ated | **In 2018, | | | | | for | FDA issued | | | | | children | safety | | | | | under 2 yrs | alert that | | | | | old and | meds | | | | | those | containing | | | | | taking MAOI | codeine or | | | | | or SSRI b/c | hydrocodone | | | | | can cause | should be | | | | | serotonin | limited to | | | | | syndrome** | adults 18 | | | | | | and older** | | | | | **Opioid: | | | | | | contraindic | **American | | | | | ated | Academy of | | | | | in | Pediatrics | | | | | pregnancy | stated that | | | | | and | OTC cough | | | | | breastfeedi | and cold | | | | | ng | medications | | | | | b/c | do not work | | | | | neonatal | for | | | | | opioid w/d | children | | | | | syndrome** | under 6; | | | | | | Adams says | | | | | | do not give | | | | | | to children | | | | | | under 6, | | | | | | and FDA | | | | | | said don't | | | | | | give to | | | | | | children | | | | | | under 2.** | +-------------+-------------+-------------+-------------+-------------+ | **Medicatio | **Examples* | Uses | **Side | **Nursing | | n** | * | | Effects** | Considerati | | | | | | ons** | +-------------+-------------+-------------+-------------+-------------+ | **Expectora | **Guaifenes | Increases | **N/V, | **Safe for | | nts** | in | water | drowsiness, | all ages** | | | (Mucinex)** | content of | GI upset** | | | | | secretions | | **Avoid | | | | to reduce | **Contraind | taking with | | | | thickness/ | ication | other CNS | | | | viscosity | for chronic | depressants | | | | of | cough** | /alcohol | | | | bronchial | | bc of risk | | | | secretions | | of | | | | so can be | | drowsiness* | | | | removed | | * | | | | easily by | | | | | | coughing | | **Guaifenes | | | | | | in | | | | Relieve | | should not | | | | chest | | be given to | | | | congestion | | children | | | | | | and infants | | | | | | younger | | | | | | than 2 | | | | | | years of | | | | | | age unless | | | | | | you are | | | | | | directed to | | | | | | do so by | | | | | | your | | | | | | doctor.** | | | | | | | | | | | | **Do not | | | | | | give any | | | | | | over-the-co | | | | | | unter | | | | | | (OTC) cough | | | | | | and cold | | | | | | medicine to | | | | | | a baby or | | | | | | child under | | | | | | 4 years of | | | | | | age | | | | | | (Guaifenesi | | | | | | n | | | | | | is often an | | | | | | ingredient | | | | | | in | | | | | | cough/cold | | | | | | meds)** | +-------------+-------------+-------------+-------------+-------------+ | **Mucolytic | **Acetylcys | Directly | **Dry | **Can | | s** | teine | loosens | mouth, | trigger | | | (Mucomyst)* | thick, | N/V** | bronchospas | | | * | viscous | | m** | | | | bronchial | **Use with | | | | | secretions | caution in | **Offensive | | | | so mucus | asthma b/c | smell | | | | becomes | of inc. | resembling | | | | thinner and | airway | rotten | | | | removed | resistance | eggs** | | | | more easily | and | | | | | by coughing | exacerbatio | **Also used | | | | | n** | as an | | | | Relieve | | antidote | | | | chest | | for pts who | | | | congestion | | OD on | | | | | | acetaminoph | | | | | | en** | | | | | | | | | | | | **Eat small | | | | | | frequent | | | | | | meals if GI | | | | | | discomfort* | | | | | | * | +-------------+-------------+-------------+-------------+-------------+ **Unit 4 Antibiotics** For ALL abx; nurses play a leading role in abx stewardship; educating pts that even though they will feel better likely within 24 hours, they will need to complete full course (up to 10 days) A 2018 American Journal of Obstetrics & Gynecology review of 29 studies looked at the common myth that antibiotics render oral contraception ineffective and it found [no proof] that any antibiotics other than the rifamycins affect how well your birth control works. +-------------+-------------+-------------+-------------+-------------+ | **Medicatio | **Examples* | **Uses** | **Side | **Nursing | | n** | * | | Effects** | Considerati | | | | | | ons** | +-------------+-------------+-------------+-------------+-------------+ | **Penicilli | Broad | Drug of | Allergy | Safest | | n | Spectrum | choice for | (most | class of | | (PCN)** | PCN: | sinus, | common): | abx (even | | | | upper | rash, | when | | **(a | Amoxicillin | respiratory | pruritis | pregnant) | | bactericida | & | and | and fever | | | l | | genitourina | | BEST when | | Beta-Lactam | Ampicillin | ry | GI | taken on | | abx)** | | tract | discomfort | empty | | | \*all end | infections | including | stomach (1 | | | in | | N/V and | hr before | | | "-cillin" | | diarrhea | or 1 hr | | | | | | after meal) | | | | | C-Diff | with FULL | | | | | induced | glass of | | | | | diarrhea | water | | | | | | | | | | | Can cause | Safe in | | | | | dec RBCs | pregnancy | | | | | (hemolytic | and | | | | | anemia) b/c | breastfeedi | | | | | abx destroy | ng | | | | | own RBC | | | | | | | Amoxicillin | | | | | Oral PCN | has | | | | | may cause | generally | | | | | black hairy | replaced | | | | | tongue | ampicillin | | | | | which | for oral | | | | | occurs | use because | | | | | because of | amoxicillin | | | | | irritation | is absorbed | | | | | of the | better, has | | | | | glossal | fewer GI | | | | | surface and | effects, | | | | | keratinizat | and can be | | | | | ion | given less | | | | | of the | frequently. | | | | | superficial | | | | | | layers. | Many | | | | | This is a | patients | | | | | rare and | report | | | | | harmless | adverse | | | | | condition | reactions | | | | | that | to | | | | | resolves | penicillin | | | | | after the | that are | | | | | drug is | not truly | | | | | stopped. | allergic | | | | | | | | | | | | Most | | | | | | penicillin | | | | | | are | | | | | | excreted | | | | | | primarily | | | | | | in the | | | | | | urine, so | | | | | | doses must | | | | | | be adjusted | | | | | | in pts with | | | | | | renal | | | | | | insufficien | | | | | | cy. | | | | | | | | | | | | Some are | | | | | | combined | | | | | | with a | | | | | | beta-lactam | | | | | | ase | | | | | | inhibitor | | | | | | Ex | | | | | | Augmentin | | | | | | is combo of | | | | | | Amoxicillin | | | | | | + BL | | | | | | inhibitor | | | | | | (Clavulanat | | | | | | e | | | | | | potassium) | | | | | | and Unasyn | | | | | | is combo of | | | | | | ampicillin | | | | | | + | | | | | | sulbactam. | +-------------+-------------+-------------+-------------+-------------+ | **Medicatio | **Examples* | **Uses** | **Side | **Nursing | | n** | * | | Effects** | Considerati | | | | | | ons** | +-------------+-------------+-------------+-------------+-------------+ | **Cephalosp | There are | Essentially | Allergic | 1-7% with | | orins** | more than | same | rxns | PCN allergy | | | 20 | mechanism | (especially | will be | | **(a | available | of action | w/1^st^ | allergic to | | bactericida | all with | and uses as | gen) | cephalospor | | l | similar | PCN | | ins | | Beta-Lactam | sounding | | C-Diff | | | abx)** | names | Bactericida | induced | Take with | | | | l | diarrhea | food | | | Ex | against | | | | | Cephalexin | gram +/- | Diarrhea, | Store oral | | | (Keflex), | organisms | fatigue, GI | suspensions | | | Ceftriaxone | | complaints, | in the | | | , | \*You don't | kidney | fridge | | | Cefepime | need to | toxicity | | | | | know | | Most | | | \*all start | 1^st^-5^th^ | Bleeding | frequently | | | with "cef" | gen | tendencies | prescribed | | | or "ceph" | differences | from | parental | | | | | cefotetan | abx | | | | | and | | | | | | ceftriaxone | Safe in | | | | | : | pregnancy | | | | | avoid in | and | | | | | those who | breastfeedi | | | | | have | ng | | | | | bleeding | | | | | | d/o's and | Most | | | | | taking | cephalospor | | | | | anticoagula | ins | | | | | nts. | are | | | | | | excreted | | | | | | primarily | | | | | | in the | | | | | | urine, so | | | | | | doses must | | | | | | be adjusted | | | | | | in pts with | | | | | | renal | | | | | | insufficien | | | | | | cy. | +-------------+-------------+-------------+-------------+-------------+ | **Macrolide | Erythromyci | Safe | -Mild GI | Alternative | | s** | n | alternative | upset, | if allergic | | | | to PCN | diarrhea, | to | | **(bacterio | Azithromyci | | abd pain | penicillin. | | static)** | n | Effective | common | | | | (Zithromax) | against +/- | | Take with | | | | organisms | Increased | or after | | | \*all end | | chance of | food | | | in | Use for | resistance | (recommende | | | "thromycin" | streptococc | & | d | | | (NOT just | al | superinfect | to dec GI | | | mycin) | pharyngitis | ions | probs) | | | | /tonsilliti | d/t broad | | | | | s | spectrum | Not | | | | | | recommended | | | | | Can cause | during | | | | | C-Diff | pregnancy | | | | | induced | | | | | | diarrhea | -Azithromyc | | | | | | in | | | | | Can cause | given for 5 | | | | | ototoxicity | instead of | | | | | (esp | 10 days bc | | | | | azithromyci | of | | | | | n); | prolonged | | | | | however, | half-life | | | | | once the | and less GI | | | | | med is | effects | | | | | stopped, | | | | | | hearing | Erythromyci | | | | | usually | n | | | | | returns and | is | | | | | s/e stop | generally | | | | | | effective | | | | | | with strep | | | | | | throat, but | | | | | | its use, | | | | | | esp with | | | | | | kids, is | | | | | | complicated | | | | | | by need for | | | | | | mult daily | | | | | | doses and a | | | | | | lengthy txt | | | | | | period and | | | | | | inc rate of | | | | | | GI side | | | | | | effects. | | | | | | (30 to 50 | | | | | | mg/kg/day | | | | | | PO in 3 to | | | | | | 4 divided | | | | | | doses (Max: | | | | | | 1 g/day) | | | | | | for 10 | | | | | | days.) | | | | | | | | | | | | Can prolong | | | | | | QT interval | | | | | | monitor ECG | | | | | | | | | | | | TROmycin | | | | | | THROWS ecg | | | | | | waves -\> | | | | | | prolonged | | | | | | QT | | | | | | | | | | | | Hepatotoxic | | | | | | so check | | | | | | AST/ALT | | | | | | | | | | | | Therefore | | | | | | careful | | | | | | with ?? | | | | | | Acetaminoph | | | | | | en | +-------------+-------------+-------------+-------------+-------------+