Rn101.net | Basic Concepts

BRADEN SCALE

ELEMENTS

Mo-bility.

Nu-trition.

F-riction and shear.

A-ctivity.

M-oisture.

S-ensory perception.

INTERVENTIONS

Make frequent position changes – at least q 2 hours. Use pressure ulcer mattress.

Eat a well-balance diet (rich in fruits and vegetables-high in vit. A, B6, C, K, protein) and hydrate well.

Use trapeze bar and transfer boards to prevent friction and shear (or two persons) during transfer.

Ambulate the patient. Instruct to do bed exercises.

Keep patient clean and dry. Use incontinence pad. Change patient immediately when wet.

Observe skin daily: especially bony prominences. (Apply SKIN BARRIER on sore and do not massage or rub).

A score of <18 patients are considered at risk: 15 or 16: Low risk, 13 or 14: Moderate risk, 12 or less: High risk

Common sites for pressure ulcers to develop: Head, shoulder, sacrum, buttock, heel, elbow, knee, ear, hip, ankle, sacrum and ischium.

WOUND ASSESSMENTS

A-natomic location: Exact location of the wound.

S-ize and shape: Width, length, diameter and oval, round, irregular.

S-inus tract, tunneling, undermining, fistula: None, present, located at ____ o’clock, depth.

E-xudate: Amount – none, scant, moderate, large. Color – serous, serosanguineous, sanguineous. Consistency - Thick, purulent, milky.

S-epsis: Systemic, local, both, none or odor present.

S-tage: Stage I, II, III, IV, and unstageable.

M-aceration: Present, cm and location.

E-dges, epithelialisation: Edge attached or not, edges rolled, surgical incision approximated, surgical incision open, sutures or staples intact. Epithelialisation present____cm or not.

N-ecrotic tissue: Present or not. Type – yellow, black, soft, hard, stringy. Percentage in wound.

T-issue bed: Granulation tissue present or not _____ amount, moist or dry. Tenderness or pain. Pain scale.

S-tatus: Improved, unchanged, healing, and deteriorating.

SERA: PATIENT DISCHARGE

S-upport: Person who can help the patient and availability of this person. (Family member, friend, caregiver).

E-nvironment: Verify the patient’s environment if adaptive to his need. (General household, bathroom, stairs).

R-esources: Verify the resources available. (CLSC, family doctor).

A-autonomy: Capability of the patient to care for himself/herself related to his/her disease and ADL’s or IADL’s of the patient.

ADL’s:

BATTED:

B-athing

A-mbulation

T-oileting

T-ransfer

E-ating

D-ressing

IADL’s

SCUM:

S-hopping

C-ooking

U-se of telephone/transport

M-oney/M-edication

FUNDAMENTAL NEEDS

Hy-giene: Any difficulties in bathing/shower, brushing hair or teeth, cutting nails etc.

M-obility: Any walking/balance problem. Need special equipment. If the patient need physiotherapy.

E-limination: Bowel movement (constipation/diarrhea). Can the patient clean herself or himself after toileting?

N-utrition: How much the patient eats? Any difficulties feeding himself/herself. Can the patient cook? Does the patient needs special equipment.

S-leep and rest: Any difficulties sleeping at night? How many hours do the patient sleep at night and during the day?

S-afety: How safe is the patient home? Does the patient needs special or safety equipment?

S-ocial: Any hobbies or does the patient do any activities? Does the patient go out with friends?

S-upport: Does the patient live with someone? Is the patient known by the CLSC? Availability of associations.

FALL

INTERVENTIONS

Fall risk factors:

I-nflammation of joints

H-ypotension orthostatic

A-uditory and visual problems

T-reatments or medications

E-quilibrium problems

F-all history

A-ctivity decrease

L-ighting inadequate

L-ots of clutters

I-ncontinence, Illness

N-utrition poor

G-ait unstable

S-afe environment:

-Pathways clear of clutter and tripping hazards.

-Bottom bed rails down.

-Lights are working and “on” as required or adequate lighting.

-Bed and chair brakes are “on”

A-ssist with mobility:

-Provide assistant during transfer as necessary.

-Mobilize at least twice per day.

-Safe and regular toileting

F-all risk reduction:

-Call bell and personal belongings at patient’s reach.

-Bed at lowest position.

-Proper footwear available and in use.

E-ngage patient and family:

-Discuss risk factors with patient and family.

-Develop a fall prevention plan.

POST-FALL INTERVENTIONS: 1. Don’t move the patient and reassure. 2. Call for help. 3. Immobilize patient (if head and neck pain is reported/suspected spinal injury). 4. Check for potential injuries (head to toe i.e. tenderness, swelling, deformity and ROM – shortened and externally rotated leg indicate hip fracture). 5. V/S (TPRBP, O2 sat, BG, pain). 6. Neurological assessment (GCS, PERRLA, FAST). 7. Observe for delirium, confusion, H/A, amnesia, vomiting or change in LOC. 8. Clean and dress wound if any. 9. Pain relief. 10. Test as ordered (CT scan, xrays, ECG, blood works etc.). 11. Continue to monitor the patient.

ADMINISTRATIVE INTERVENTIONS:

Notify MD and head nurse. 3. Write up an incident report.
Notify family. 4. Write up a progress note indicating the details of the fall. (Cause, patient condition, interventions etc…).

PAIN

“Whatever the experiencing person says it is and existing whenever the person says it does”

Acute pain

Short duration (< 6 months), sudden onset.

Reversible or controllable.

Identifiable and immediately onset.

Chronic pain

Long-term (> 6 months).

More difficult to treat.

Continual, persistent, and recurrent.

Neuropathic pain: Long lasting, unpleasant episodes of sharp, shooting pain resulting from damage to peripheral nerves or CNS.

Phantom pain: Pain perceived in a body part that is missing (amputated) or paralyzed.

Visceral pain: Results from stimulation of pain receptors in the abdominal cavity, cranium and thorax.

PQRSTU PAIN ASSESSMENT

P-rovoked and P-alliate: What causes the pain? What makes it better? What make it worse?

Q-uality: What does it feel like? Can you describe your pain?

R-adiates: Where does the pain radiate?-Is it in one place? Does it go anywhere else? Did it start elsewhere and now localised to one spot?

S-everity: How severe is the pain on a scale of 0-10? (0 as the lowest and 10 as the highest).

T-ime: What time the pain started? How long did it last?

U-nderstanding: Do you have any idea what it is?

Other possible questions to ask and look for:

Any medication or allergies? – i.e. nitroglycerine

Does it hurt on deep inspiration?

Any history of chest pain? Is it the same or different?

Any family history of heart disease lung problems, stroke or hypertension?

Any recent trauma?

NOTE:

Use short-acting preparation for breakthrough pain.

Consider lower dose in opioid naïve and elderly.

Consider stronger opioid if not controlled by this combination.

Drugs with depressant effects:

-Barbiturates -Antidepressant

-Opioids -Anti-emetics

-Neuroleptics -Anti-histamine

-Anxiolytics - + Alcohol

Non pharmacologic pain interventions:

-Relaxation techniques -Guided imagery

-Cutaneous stimulation -Hypnosis

-Heat and cold compress -Biofeedback therapy -Walking, swimming, stretching -Acupuncture and rest

-Massage (acupressure)

PAIN LADDER

SEVERE PAIN:

7-10 on pain scale

Morphine 15-30mg

Dilaudid 2-4mg

MS-contin 30-60mg

MODERATE PAIN:

4-6 on pain scale

Tylenol #3 (Acetaminophen 325 mg+codeine 30mg)

Tylenol #4 (Acetaminophen 325 mg + codeine 60 mg)

Acetaminophen 325/500 mg + oxycodone 5 mg (Percocet/Roxicet)

MILD PAIN:

1-3 on pain scale

Acetaminophen 650mg

ASA 650mg

Ibuprofen 400mg and other NSAIDS

OPIOID-INDUCED SEDATION SCALE

S-Sleep, easy to arouse.

Acceptable: No action necessary, may increase opioid dose if needed.

1-Awake and alert.

Acceptable: No action necessary, may increase opioid dose if needed.

2-Slight drowsy, easily aroused.

Acceptable: No action necessary, may increase opioid dose if needed.

3-Frequently drowsy, arousable, drifts off to sleep during conversation.

Unacceptable: Monitor respiratory status and sedation scale, notify prescriber or anesthesiologist for orders (may decrease opioid dose 25% or 50%). May consider administering acetaminophen or NSAID, if not contraindicated.

4-Somnolent, minimal or no response to verbal stimulation and physical stimulation

Unacceptable: Stop opioid. Consider administering naloxone, notify prescriber or anesthesiologist, monitor respiratory status and sedation level closely until sedation level is stable at <3 and respiratory status is satisfactory

Risk factors for respiratory depression

Opioid naïve, 1st 24-hour post-op, Receiving CNS depressants, advanced age > 70 y/o, Hx. Of sleep apnea/snoring, Altered LOC, hepatic insufficiency, renal insufficiency, pulmonary disease, recent alcohol consumption, infants under 6 months of age.

PRE-OPERATIVE CARE

C-onsent
A-llergy
M-edication
P-ast medical history
L-ast meal
E-vent or reason of surgery
S-ign and symptoms

Pre-operative checklist:

NPO, Consent form signed, In gown, Allergy and ID bands on, Skin prep, No jewelry, contact lens, dentures, and nail polish. Assess vital signs, lab values, and medication history. Voiding prior to transfer.

POST-OPERATIVE CARE

V/S q15 1st hour, q30 for 2hours, q1h next 4hours, q4h.
Head to toe assessment.
Assess equipments, drains, IV, foley, surgical site/dressing etc…
Comfort care.
Nutrition and elimination.
“I COUGH”: Incentive spirometry, Coughing and deep breathing, Oral hygiene, Understanding:patient and family education, Getting out of bed, and Head-of-bed elevation.
Fluids and electrolytes.

COMMON POST-OPERATIVE COMPLICATIONS

Hypovolemic shock
Pulmonary embolism
Pneumonia
Atelectasis
Paralytic ileus
Bladder distension
Infection
Dehiscence
Evisceration

↓ urine output, ↓BP, rapid weak pulse, tachypnea, restlessness, pale, cold and clammy skin.

Chest pain, dyspnea, cough, diaphoresis, tachycardia, weak pulse, clammy skin, wheezing.

Tachypnea, shallow respiration, fever, productive cough, tachycardia, hypoxia

Dyspnea, rapid-shallow breathing, coughing, low-grade fever, restlessness

↓bowel sounds, no stools or flatus, N/V, abdominal distension or pain, belching.

Unable to void 8-10hrs post-op, palpable bladder, frequent small voiding, suprapubic pain.

Redness, purulent drainage, fever, tachycardia, ↑ WBC.

Separation or splitting open of layers of a surgical wound.

Extrusion of viscera or intestine through a surgical wound.

COMMON CAUSE OF ACID-BASE IMBALANCE

RESPIRATORY ACIDOSIS: COPD, asthma, head injury, pulmonary edema, aspiration, pneumonia, ARDS, pneumothorax, cardiac arrest, respiratory depression, CNS depression, or head injury.

RESPIRATORY ALKALOSIS: Hyperventilation, anxiety, fear, pain, fever, sepsis, brain tumor, mechanical overventilation.

METABOLIC ACIDOSIS: Diabetes mellitus, acute and chronic renal failure, severe diarrhea, alcoholism, starvation, salicylate overdose, pancreatic fistulas.

METABOLIC ALKALOSIS: Loss of gastric acid (vomiting, gastric suction), long-term diuretic therapy (Thiazides, furosemide), excessive NaHCO3 administration, hypercalcemia.

BLOOD GAS INTERPRETATION

ACID-BASE DISORDER pH pCO2 HCO3

RESPIRATORY ACIDOSIS: LOW HIGH ↑ if compensating

RESPIRATORY ALKALOSIS: HIGH LOW ↓ if compensating

METABOLIC ACIDOSIS: LOW ↓ if compensating LOW

METABOLIC ALKALOSIS: HIGH ↑ if compensating HIGH

Normal values

pH: 7.35 -7.45

PCO2: 35-45 mm Hg

HCO3: 22-26 mEq/L

Full or total compensation: pH will be within normal limits

Compensation:

Respiratory problem – the kidneys compensate by conserving or excreting HCO3.

Metabolic problem – the lungs compensate by retaining or blowing CO2.

ROME:

R-espiratory M-etabolic

O-pposite E-qual

PHARMACOLOGY BASICS

Pharmacokinetics – what a body does to a drug. Pharmacodynamics – what the drug does to the body.

ADME: 1. Therapeutic effect-desired and intentional.

A-bsorption 2. Interaction – effects altered by other medication or food.

D-istribution 3. Adverse effects – effect other than therapeutic effect.

M-etabolism i.e. S/E, tolerance, allergic reaction.

E-xcretion

MEDICATION ADMINISTRATION

3 CHECKS:

1. When the medications are pulled or retrieved from the automated dispensing machine or the medication drawer.

2. When preparation of the medications for administration takes place.

3. At the patient’s bedside just before the medications are given.

5 RIGHTS: Right patient, Right medication, Right dose, Right route, Right time

ADDITIONAL RIGHTS: Right assessment, documentation, to refuse, education and evaluation.

MEDICATION ORDERS

1. Stat orders – order for a single dose to be given immediately.

2. Single dose orders – one time medication (often for diagnostic procedure).

3. Standing orders – scheduled orders (in effect until prescriber discontinues).

4. PRN orders – “as needed” basis as circumstances indicate.

COLLECTIVE ORDER

-Replaces standing order.

-Patient does not need to be seen by MD prior to initiating treatment.

-Can be for emergency, frequent and routine clinical situation.

-Must outline, which professional, which patient group, unit/service and under what circumstances.

TELEPHONE OR VERBAL ORDER GUIDELINES: “REWRITE”

R-epeat order to physician.

E-mergency only or without opportunity.

W-rite details of orders in Physician order.

R-equire MD to co-sign in 24 hours.

I-dentify the patient to whom the order is made

T-wo nurses to verify or listen to the order.

E-vening shift usually happens.

INDIVIDUAL ORDER

-Patient must be seen or consulted by MD prior to initiating treatment.

-Can be attached to a protocol.

-Can be for medication, medical treatment, examination or care.

CHECK PRINCIPLE

C-lassification.

H-our.

E-ffectiveness or expected outcome.

C-lient teaching.

K-eys to give it safely.

Remember to take your iron with full glass of orange juice!

FEROUS SULFATE

C-Iron preparation; hematinic.

H-Best taken on an empty stomach, if GI upset – p.c.

E-Prevention and correction of iron deficiency. (↓ fatigue & weakness, ↑ hgb. & hct.).

C-Swallow all tabs whole; do not break, crush or chew. Take b/n meals with juice. No antacids or milk-delay at least 1 hour. Eggs, milk, chocolate,

and coffee, it ↓ absorption.

Take liquid preparation with straw to avoid discoloration of tooth enamel; dilute thoroughly.

Take at least 1 hour before bedtime, corrosion may occur in stomach.

Store in airtight, light resistant container. Advise that iron make stool black or dark green.

K-Monitor blood studies: hgb., hct.; iron studies (Fe, ferritin) at least monthly.

Assess for toxicity: N/V, diarrhea, hematemesis, pallor, cyanosis, shock, and coma.

Assess bowel elimination: if constipation occurs - ↑ h2O & fiber in diet, and activity before laxative.

Assess nutrition: Amount of iron in diet (meat, dark green leafy vegetables, dried beans & fruits, eggs); provide referral to dietitian as needed.

Deferoxamine mesylate as antidote.

LASIX (FUROSEMIDE)

C- Diuretic (loop).

H- Best given in the morning.

E- Decrease edema; decrease BP.

C- Rise slowly from sitting or from bed (OH).

Eat foods high in potassium i.e. bananas and citrus fruits.

Educate patient to report any S/E: i.e. tinnitus, nausea, s/s of

hypokalemia (Tingling, numbness, fatigue, cramps, muscle

weakness palpitations, and dysrythmias).

K- Monitor electrolytes especially potassium.

Monitor patient I&O or count diapers and weight.

Assess patient for tinnitus or hearing loss.

Assess BP standing and sitting as needed.

MORPHINE SULFATE

C-Opioid analgesic.

H- PRN pain, RTC, breakthrough.

E- Decrease moderate to severe pain.

C- Avoid driving. Report severe N/V.

S/E teachings: i.e. drowsiness, constipation, palpitation, H/A

Educate the patient that drowsiness effect will stabilize in a few days. Respiratory depression and dependency are rare. Also take breakthrough doses because intense pain is harder to relieve, thereby taking it reduces the quantity of medication required in the long run.

K- Monitor patient V/S (especially RR and O2 sat.) + Sedation scale.

Have Narcan (naloxone) as antidote.

Avoid drugs with depressant effects.

Monitor patient carefully who are at risk for RD.

K-DUR

C- Potassium; Electrolyte, mineral replacement

H-Give with meal or after meal.

E-Prevention and treatment of hypokalemia.

C-Do not break, crush or chew extended release tabs/enteric coated.

Take with full glass of water. Store at room temp.

K-Assess cardiac status. Monitor K level 3.5-5.0 mmol/L.

Assess ECG for hyperkalemia: Peaking T-waves, widened QRS.

Monitor I&O – notify MD for ↓ output, check urine pH.

IV route: Administer in large-bore needle & large vein-↓ vein

inflammation.

After diluting in large vol of IV soln.-infuse slowly to prevent toxicity.

Never give IV bolus or IM.

Kayexalate for increase K level/hyperkalemia.

Levonorgestrel “Morning after pill/plan B” 1.5 mg

C-Emergency contraceptive.

H-Within 72h after unprotected sex, contraceptive failure, or sexual assault.

E-Prevent ovulation, fertilization and altering lining of uterus.

C-One dose, not use for abortion, does not protect STD, not a regular contraceptive, no long term protection. Abstain from sex while waiting for the next period. If vomit – come to hospital. S/E teachings.

K- Do pregnancy test. Assess any allergy. Have pt. remain 1h in clinic

If the patient vomit – repeat treatment.

Let pt. sign the “Morning after pill” form. MD referral for:

(>72h, sexual assault, allergic, + preg. test <16 y/o, poor candidate

according to PMH, if taking other meds.)

DRUGS TAKEN FOR LIFE

DRUG

Anticholinesterase (Mestinon):

Antithyroid drugs (PTU):

AZT:

Dopaminergic agents (L-dopa):

Glucocorticoids (Deltasone):

Glucocorticoids synthesis inhibitors (Mitotane):

Insulin (NPH, regular):

Miotics (Pilocarpine):

Thyroid supplement (Synthroid):

Vitamin B12:

DISEASE

Myasthenia Gravis

Hyperthyroidism

AIDS

Parkinson’s disease

Addison’s disease

Cushing’s disease

Diabetes Mellitus

Glaucoma

Hypothyroidism

Pernicious Anemia

DISEASE CONDITION

AIDS

Anemia, iron deficiency

Arthritis, gout

Arthritis, rheumatoid

Cystic fibrosis

Endocarditis

Hepatic encephalopathy

Hyperthyroidism

LABORATORY VALUES

(+) ELISA

↓ hgb. and ↓ hct.

↑ uric acid

↑ ESR

↑ Na and ↑ Cl

↑ ESR and ↑ WBC

↑ serum ammonia

↑ T4, ↑ T3 , ↓ TSH

DISEASE CONDITION

Hypothyroidism

Hyperparathyroidism

Hypoparathyroidism

Myocardial infarction

Pancreatitis

Renal failure

DRUGS ANTIDOTE

DRUG ANTIDOTE

Acetaminophen Acetylcysteine

Coumadin Vitamin K

Digitalis Digibind

Heparin/lovenox Protamine sulfate

Magnesium sulfate Calcium gluconate

Morphine sulfate Naloxone hydrochloride

Penicillin Epinephrine

LABORATORY VALUES

↓ T4, ↓ T3, ↑ TSH

↑ calcium, ↓ phosphate

↓ calcium, ↑ phosphate

↑ Troponin, ↑ CK-MB, and ↑ LDH

↑ amylase & lipase, ↑ BG, ↑ triglycerides

↑ BUN & creatinine, ↓ hgb., hct. & Na.

CONDITION

Asthma

Bronchoscopy, post

Cardiac catheterization

Cast

Cataract surgery

Cleft lip, post-op

Cleft palate

CHF

CVA

Dumping syndrome

Epistaxis

Hip surgery

Increased ICP

Liver biopsy

Lumbar puncture, post

Pulmonary edema

Seizure, post

Shock

Thrombophlebitis

POSITION

Sitting position, leaning forward

Semi-fowler’s

Bedrest, keep site extended and straight 4-6 hours

Elevate extremity

Semi fowler’s, unaffected side

Supine

Prone

High fowlers

Elevate head

Supine

Leaning forward

Keep legs abducted

Elevate head

Right side lying

Flat in bed/supine

Fowlers

Side-lying

Modified trendelenberg

Bedrest with legs elevated

RATIONALE

Facilitate breathing

Prevent aspiration

Prevent bleeding/hematoma, promote blood flow and thrombus formation.

Prevent edema

Prevent pressure on the suture line

Prevent aspiration

Improve oxygenation

↓ ICP

Prevent rapid emptying of stomach

Prevent aspiration

Prevent dislodge of head of femur from the acetabulum

Prevent further ↑

Prevent bleeding

Prevent spinal headache

Facilitate breathing

Prevent aspiration/tongue obstruction

Promote venous return to the heart

Promote circulation

RN101
Home of the Registered Nurses (RN) and
Licensed Practical Nurses (LPN)

BASIC CONCEPTS

PATIENTS RIGHTS

URINE ASSESSMENTS

PRESSURE ULCER STAGING

BRADEN SCALE

WOUND ASSESSMENTS

SERA: PATIENT DISCHARGE

FUNDAMENTAL NEEDS

FALL

INTERVENTIONS

PAIN

PQRSTU PAIN ASSESSMENT

PAIN LADDER

PRE-OPERATIVE CARE

POST-OPERATIVE CARE

COMMON POST-OPERATIVE COMPLICATIONS

COMMON CAUSE OF ACID-BASE IMBALANCE

BLOOD GAS INTERPRETATION

PHARMACOLOGY BASICS

CHECK PRINCIPLE