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Heart Rates: Babies - Infants = 120-160 bpm Toddlers = 90-140 bpm Preschoolers & School Aged = 75-110 bpm

Adults & Teens = 60-100 bpm On the ECG or EKG: P wave = atrial depolarization P-R interval = represents atrial,AV node, & Purkinje depolarization Q wave = septal depolarization R wave = apical depolarization S wave = depolarization of lateral walls QRS complex = spread of excitation through the muscle of the venticles T wave = ventricular repolarization Starling's Law = the greater the strength of the myocardium as the ventricles fill with blood, the stronger the contraction. Cardiac output = the amount of blood that is pumped out of the LV each minute. The mitral valve is the most common site for vegetations. ACE-I exert their effect by reducing preload. Digitalis and related cardiac glycosides act by directly inhibiting the Na/K pump in the cell membranes. After cardiac cath, monitor the person for bleeding &/or hematoma formation. Pulses are palpated distal to the site every 15 minutes for at least 1 hour, patient is on bedrest with lower extremities extended for at least 8 hours. Acute blood loss (hemorrhage) is likely to cause sinus tachycardia. When the heart rate increases with inspiration and decreases with expiration it is called sinus arrhythmia. When someones heart "skips a beat" this is most times called premature atrial complex. PVCs can lead into V-Fib Verapamil reduces afterload and with concurrent use of nitroglycerine can cause ( increase ) hypotension. Amlodipine ( Norvasc )- CCB used for systemic vasodilation and decreased blood pressure. Coronary vasodilation and decreased frequency and severity of angina. CONTRAINDICATION BP <90mmHg. Fosinopril ( Monopril )- tx of hypertension and CHF; dosage is 5-40 mg once daily max dose in a day is 80mg

Pts having a MI ( heart attack ) remember MONA = morphine, oxygen, nitroglycerine, and aspirin. The pathophysiology of HTN includes damage & inflammation of the vessel walls that stimulates the vessels to thicken, harden, and become narrow. Narrowing causes vasoconstriction and increases the permeability of the vessel walls leading to the influx of sodium, calcium, water, plasma proteins, and other substances. Calcium further increases smooth muscle contraction. Clinical manifestations of HTN result from damage of organs and tissues outside the vascular system. These include heart disease, renal disease, central nervous system problems, and muscular dysfunction. Adenosine is for supraventricular tachycardia. Epinephrine is given during code to vasoconstrict the periphery & shunt the blood to the central circulating system. ( hope I explained it right ) Atropine is used in asystole & symptomatic bradycardia. Lidocaine is the drug of choice for ventricular irritability. It suppresses ventricular ectopy. Hypokalemia can cause increase in cardiac electrical instability, ventricular dysrhythmias, & increases risk of digoxin toxicity. CK-MB if up means myocardial damage, the elevation happens aprox. 4-6 hrs after an acute ischemic attack. Normal for CK-MB is 0-7 U/L. Lactic dehydrogenase ( LDH ) increases within 48 hrs of myocardial infarction. Normal is 70-200 U/L. Mitral Valve Prolapse, valve leaflets protrude into left atrium during systole. Cardiac: ACE Inhibitors: Benazipril ( Lotensin ) Captopril ( Capoten ) Lisinopril ( Zestril ) Enalapril ( Vasotec ) Ramipril ( Altrace ) Quinapril ( Accupril ) Calcium Channel Blockers: Amlodipine ( Norvasc ) Diltiazem ( Cardizem ) Nicardipine ( Cardene ) Verapamil ( Calan , Isoptin ) Atrial Septal Defect : abnormal opening between atria which causes increased flow of oxygenated blood to go into right side of heart. Right atrial & right ventrical enlarge. May be closed using cardiac catheterization or surgically with cardiopulmonary bypass which is done before school age. Ventricular Septal Defect: characteristic murmur, CHF is common, many times will close by itself if small-moderate defect. Patent Ductus Arteriosus ( PDA ): characteristic machine like murmur , can be asymptomatic or s/s of CHF, wide pulse pressure & bounding pulses.

Coartication of the aorta: narrowing near insertion of ductus arteriosus. S/S of CHF in infants, HTN & bounding pulses in arms but weak or absent femoral pulses, low extremities may be cool. Tetrology of Fallot Tetra means four so it consists of four defects: pulmonary artery stenosis hypertrophy of right ventricle venticular septal defect overriding of aorta Dx of Tetrology of Fallot is done by chest x-ray that shows a typical boot shaped heart. An echocardiogram, 3 dimentional echocardiography, & cardiac cath help to confirm diagnosis. s/s of TOF include: " blue spells or tet spells " relieved by having child squat. Murmur may be present. Poor growth, clubbing of fingers. Beta Blockers: Used for angina, dysrhythmia, HTN, migraine, prevent MI, & glaucoma. Contraindicated in asthma, bradycardia, CHF, severe renal/hepatic disease, CVA, & hyperthyroid. May mask hypoglycemia so monitor diabetics closely. Side Effects : hypotension, bradycardia, bronchospasm, dizziness, hyperglycemia to name a few. Atenolol ( Sectral ) Labetolol ( Normodyne, Vescal ) Metoprolol ( Lopressor, Toprol ) Propranolol ( Inderal ) Nadolol ( Corgard ) Hold if BP or pulse not within prescribed parameters. Call MD for orders. Follow hospital/facility policy. In diastole, that is where the ventricles relax & fill with the blood. There are 4 valves in the heart. The apical pulse sometimes can be seen in children with thin chest walls. Cardiac tamponade is caused by pericardial fluid that accumulates & compresses the heart. Virchow's Triad is slowed circulation, altered blood coagulation and trauma to a vein that can lead to thrombus formation. The SA node is the natural pacemaker of the heart. The pulmonary veins return the oxygenated blood from the lungs. Starling's law = The greater stretch of the myocardium results in a stronger ventricular contraction. Cardiac output is the amount of blood that is pumped out of the left ventricle every minute.

Drugs with these endings........ usually are in this class -caine ; local anesthetics -cillin; antibiotic -dine ; anti-ulcer ( H2 blocker ) -done; opioid analgesic -ide; oral hypoglycemics -lam; antianxiety -mide ; diuretic -mycin ; antibiotic -nium; neuromuscular blocking -olol; beta blocker -oxacin ; antibiotic -pam ; antianxiety -pril ; ACE inhibitor -prazole; proton-pump inhibitor -sone ; steroids -statin ; cholesterol -vir; antiviral -zide; diuretic gr 1 = 60 mg gr 5 = 300 mg gr 15 = 1000 mg = 1 gram 1 oz = 30 ml = 30 cc 1 dr = 4 ml 1 Tbsp = 15 ml = 3 tsp anticholinergic meds: can't see can't pee can't spit can't shit Gout Meds: Probenecid (Benemid), Colchicine, Allopurinol (Zyloprim) Theophylline: tx of asthma or COPD. Therapeutic drug level: 10-20 To Reverse Toxicity: heparin= protamine sulfate coumadin= vitamin k ammonia= lactulose acetaminophen= n-Acetylcysteine. Iron= deferoxamine Digitoxin, digoxin= digibind. Alcohol withdraw= Librium. Know your onset, peak, and duration of action for your meds. 1) The onset is the time it takes to reach the minimum effective action after a drug is given. 2) The Peak happens when the drug reaches its highest blood or plasma concentration. 3) The duration of action is how long the drug maintains its effect.

The Main Route of Drug Excretion is through the kidneys. Other routes of excretion are: breast milk, feces, bile, liver, lungs, saliva, sweat. Steps for administering ear drops: 1) Wash your hands 2) Have medication at room temperature 3) Have the person sit up with head tilted slightly to the unaffected side. Straighten the ear canal by pulling up and back on the auricle (adult ) or (child) pull down and back on the auricle. (children over 3 yrs are same as adult ) 4) Give drops as ordered by MD 5) Be sure to not contaminate the dropper. 6) Have the person maintain the position for a good 2-3 minutes. 7) Wash Hands INSULINS: Rapid: ( Lispro ) Onset-15 minutes Peak-1 hour Duration- 3 hours Short: ( Regular ) Onset- 1/2 hour Peak - 2-3 hours Duration - 4-6 hours Intermediate: ( NPH or Lente ) Onset - 2 hours Peak - 6-12 hours Duration - 16-24 hours Long Acting: ( Ultralente ) Onset - 4-6 hours Peak - 12-16 hours Duration - > 24 hours Very Long: ( Lantus ) Onset - 4-6 hours Peak - None Duration - 24 hours continuous 7 Rights of Medication Administration Right Drug Right Amount Right Route Right time Right patient Right approach Right documentation Medication Administration 2 ml= maximum volume of injection per site for IM meds

Ketorolac ( toradol ) for short term pain management. Do not give longer than 5 days. 60gtts = 1 tsp 3 tsp = 1 Tbsp 6 tsp = 1 ounce 2 Tbsp = 1 ounce 6 oz = 1 teacup 8 oz = 1 glass 8 oz = 1 cup Diseases that can affect a drugs response are: - cardiac disease - gastrointestinal disease - liver disease - kidney disease Anticholinergic agents cause Dry mouth, urinary retention and constipation. Phenazopyridine (Pyridium)--Urine will appear orange. Dexamethasone used to decrease cerebral edema and pressure. Remember, when it comes to iron administration: Iron supplements IM or IV----iron dextran (IV route is preferred) IM causes pain, skin staining, higher incidence of anaphylaxis Take oral supplements with meals if experience GI upset Then resume between meals for max absorption Use straw if liquids are used Diltiazin (Cardizem) a calcium-channel blocker, inhibits Ca++ transport in heart and vasculary muscle cells therefore inhibiting excitation and subsequent contraction. Ace Inhibitors can cause hyperkalemia and chronic cough- pt's should not use salt substitutes because they are mostly made from K+ which will further increase the K+. Tylenol = Liver toxic (no more than 4 g/day) Give Mucomyst for overdose. Whereas, Ibuprofen = kidney toxic . Alkylating Agent: [ Cisplatin ( Platinol ) ] - used for lymphoma; myeloma; melanoma; osteosarcoma; cervical,ovarian,testicular,lung,esophageal,and prostate cancers. Cisplatin caauses nephrotoxicity and ototoxicity, ensure adequate hydration and give diuretics prior to therapy. Have client void every hour or insert foley before therapy. Assess for hearing loss/deficits. Carbidopa/Levodopa ( Sinemet )- tx for Parkinson's, carbidopa prevents metabolism of levodopa and allows more levodopa for transport to brain. Levodopa ( Larodopa ) should be d/c'd 8 hours before statring Sinemet. Bromocriptine ( Parlodel ) - tx of Parkinson's, amenorrhea, galactorrhea, female infertility, suppression of postpartum lactation, acromegaly.

Ropinirole ( Requip ) - tx of idiopathic Parkinson's disease. Quinidine - give with food, monitor electrolytes, monitor liver and kidney function, encourage patient to report dizziness or faintness immediately. Used in a-fib and a-flutter. Alprazolam ( Xanax )- antianxiety agent, usual dose is 0.25-0.5 mg two to three times daily. Side effects: drowsiness, dizziness, lethargy, confusion. Amlodipine ( Norvasc )- CCB used for systemic vasodilation and decreased blood pressure. Coronary vasodilation and decreased frequency and severity of angina. CONTRAINDICATION BP <90mmHg. Fosinopril ( Monopril )- tx of hypertension and CHF; dosage is 5-40 mg once daily max dose in a day is 80mg Rosiglitazone ( Avandia )-tx type 2 diabetes; dosage is 4-8 mg as a single daily dose or in 2 divided doses ( use cautiously if edema or CHF ) When using a bronchodilator inhaler in conjunction with a glucocorticoid inhaler, administer the bronchodilator first. Theophylline increases the risk of digoxin toxicity and decreases the effects of lithium and Dilantin. Long term use of amphogel (binds to phosphates, increases Ca, robs the bones...leads to increased Ca resortion from bones and WEAK BONES). Thiazide diuretics increase blood sugar. Aldosterone conserves sodium and promotes potassium excretion which helps to control sodium and water balance. Prozac (a SSRI) side effects are diarrhea, dry mouth, weight loss, reduced libido. Types of Bronchodilators: Beta Adrenergic Agonists Albuterol ( Proventil, Ventolin ) Metaproterinol ( Alupent ) Terbutaline Bitolerol Levalbuterol ( Xopenax ) Pirbuterol Salbutamol ( Serevent ) Anticholinergic Ipratropium bromide ( Atrovent ) Oxitropium bromide ( Oxivent ) Methylxanthines Aminophylline Theophylline ( Slo-Bid or Theo Dur )

Giving Eye Drops 1. ) Wash hands 2.) Have the person either lie down or sit down and look upwards. 3.) Using clean technique. Clean eyes with a separate cloth for each eye. Remove any exudate from inner canthus outwards. 4.) Gently pull skin down below the affected eye(s) to expose the conjunctival sac. 5.) Give the drops per MD orders. Be careful not to let the dropper tip touch eyelashes or eyelids. 6.) Gently press on the lacrimal duct with sterile gauze or tissue for 1-2 minutes to prevent systemic absorption via the lacrimal canal. 7.) Have the person keep eyes closed for 1-2 minutes afterwards to promote better absorption. *Due to their mood lifting effects, depression medications often cause dependency. *Withdrawal from depression medication can cause new symptoms and/or bring back old ones. Chicken Pox: Diptheria: Lyme Disease: Typhoid Fever: tx with Acylovir tx with diptheria antitoxin, penicillin; erythromycin tx with tetracycline;penicillin tx with chloramphenicol; ampicillin; sulphatrimethoprim

*Antihistamines can aggravate urinary incontinence. Teach pt accordingly. *Atropine is contraindicated for a client with angle-closure glaucoma b/c it can cause pupillary dilation with an increase in aqueous humor, leading to a resultant increase in optic pressure. *Demerol is contraindicated in clients with sickle cell disease. It may cause seizures. Dantrolene [ Dantrium ] Skeletal Muscle Relaxant Used for: Emergency treatment of malignant hyperthermia Contraindicated : pregnancy Cardizem [ Diltiazem ] Calcium Channel Blocker Used for: A-fib, A-flutter, PSVT refractory to adenosine Contraindicated: drug or poison induced tachycardia, wide complex tachycardia of unknown type, Wolf-Parkinson -White syndrome, cardiogenic shock, pulmonary edema About 1- 2 weeks after starting pt on antidepressants, assess for increased energy, could be sign of suicidal ideation. Sucralfate ( Carafate )used for peptic ulcers side effects: constipation, icrease fluids and fiber, no systemic effects antacids interfere with carafates absorbtion Letrozole is used to treat advanced breast cancer, skeltal and bone pain is a common side effect. Dilantin. Because the therapeutic levels are so small, maintaining good blood levels can be a problem when given through a tube. Discontinue feedings 1-2 hours before and after giving dilantin to enhance absorption. Theophylline. This drug may be poorly absorbed with continuous tube feedings. Monitor levels closely.

Warfarin. Tube-feeding solutions contain vitamin K & coumadin & vitamin K anatagonize each other. Monitor prothrombin times closely and adjust as indicated. * Never, never leave any meds for any reason at a patient's bedside. * Never leave a meds out of your site. * Never give a med if the patient says it does not look like what they usually take. Go back and double check again. * Don't give any meds that another nurse dispensed. * Never guess when giving medications. Double check dosages, double check calculations, ask when in doubt. Take no chances. Triple check with the MAR. Call MD if there is any doubt about the medication. Better safe than sorry. * Always wash your hands before preparing someone's medications.

Fact Files Volume 2 ( Respiratory ) Tidal volume is the volume of air breathed in and out ( inhaled/exhaled ) within a normal breath. Vital capacity is the maximum amount of air exhaled after a maximum inhalation. Thoracentesis is where a needle goes into the pleural space and removes fluids. ( needle aspiration of fluid from the pleural space ) Perfusion lung scan - is a lung scan that shows patterns of blood flow. Symptoms of an infectious or inflammatory issue going on within the upper airway may include: headache, fever, pain, and mild or moderate difficulty with breathing. Risk factors for laryngeal cancer may include: indoor/outdoor air pollution, indutrial pollution, tobacco use, chronic laryngitis, habitual overuse of the voice, and heredity. A tracheostomy cuff may be deflated and inflated periodically to prevent tissue necrosis. Initial treatment of a nose bleed includes having applying pressure by holding the soft parts of the nose firmly between thumb and finger to pinch nostils together. Here's a mneumonic my instructor used for an acute asthma attack & tx: NOAH nebulizers, oxygen, antibiotics/aminophyline, hydrocortisone Pleurisy is a inflammation of the viseral and parietal pleura. A collection of fluid between the viseral and parietal pleura is a pleural effusion. Tuberculosis- assessment findings: cough ( yellow mucoid sputum ) , dyspnea, hemoptysis, rales or crackles, anorexia, malaise, wt.loss, afternoon low grade temp., pallor, fatigue, pain, night sweats. Diagnostic Tests used in TB - Chest x-ray indicates presence and extent od disease but cannot show if active or inactive. Skin test (PPD) positive;area of induration 10mm or more in diameter after 48 hrs. Sputum positive for bacillus ( 3 samples is diagnostic for TB ). Culture will be positive. WBC & ESR will be elevated.

Trach care should be provided once every 8 hours and prn. A major goal for the pt with COPD is that the pt. will use a breathing pattern that does not lead to tiring and to plan activities so that he/she does not become overtired. Care should be spaced, allowing frequent rest periods, and preventing fatigue. Ethambutol, isonazid, * The trachea lies just in front of ( anterior ) to the esophagus and is 10 to 11cm long in adults. *Unequal chest expansion happens with flail chest, pneumonia, part of the lung is either obstructed or collapsed or with guarding to avoid post-op insision pain or pleurisy. *Persistant fine crackles scattered across the chest happen with pneumonia, bronchiolitis, or atelectasis. *In emphysema there is destruction of the alveolar walls and patient will often present with a barrel chest. Pertussis [ Whooping cough ] What it is: Comes from Bordetella pertussis has an incubation period of 5-21 days with an average of 10 days. Source of infection is from the respiratory tract of infected person. It is transmitted by direct contact or droplet spread from infected person; indirect contact from freshly contaminated articles. What to do? Isolation during the catarrhal stage, start respiratory precautions. Give antimicrobial therapy as ordered. Give pertussis-immune globulin as ordered. Reduce environmental factors that promote coughing, such as dust, smoke, and sudden temperature changes. Use a humidifier or tent to increase humidity. Remember, the cough is severe. During the convalescent phase, respiratory precautions are no longer needed. When you go to change the trach ties,be sure to remove old ties with non-sterile gloves, then put on sterile gloves to apply clean ties. Mechanical Ventilators: Can be short term, long term or in between!!! As the nurse:1) assess pt. first then the vent 2) assess vitals, resp. rate and breathing pattern 3) monitor color of lips & nail beds 4) monitor chest for symetry 5) assess need for suctioning & observe type, color, and amount of secretions 6) check pulse ox 7) check alarms on vent 8) empty vent tubings when moisture collects 9) turn pt. every 2 hours and prn 10) have resuscitation equipment by bedside Causes of Alarms: High Pressure Alarm- a) increased secretions in the airway b) wheezing or bronchospasm c) displaced ET tube d) obstructed ET tube( check 4 kinks ) e) pt coughing, gaging, bites tube f) pt. fighting vent (bucking) Low Pressure Alarm- a) disconnection or leak b) pt.stops spontaneous breathing Some Signs/Symptoms of Hypoxia * fatigue

* dyspnea * cyanosis * anxiety/apprehension * decreased concentration * altered level of consciousness * vertigo * increased pulse rate * faster and deeper respirations ( advanced hypoxia respirations get slower and more shallow * increased blood pressure * pallor * dysrhythmias * clubbing of nails if prolonged/chronic Normal ABG's pH = 7.35 to 7.45 Paco2 = 35 to 45 mm Hg Pao2 = 80 to 100 mm Hg HCO3 = 21 to 28 mEq/L O2 saturation = over 95% In older adults with pneumonia, hydration is very important as it helps to thin secretions and promotes expectoration. Dyspnea is labored breathing aka. shortness of breath. Your lungs consist of 5 lobes. The right lung has 3 lobes and the left lung has 2 lobes. Things that increase airway resistance ( make it difficult to get enough air ): asthma-where the bronchial smooth muscle contracts chronic bronchitis- where there is a thickening of the bronchial mucosa obstruction of the airway- as in a tumor, an object swallowed that gets stuck, or mucus loss of lung elasticity- as in emphysema Eupnea is normal breathing - rate is usually 12 - 18 breaths per minute Bradypnea is slower than normal breathing - rate is less than 10 bpm with normal depth and rhythm is regular Tachypnea is faster than normal breathing - rate is over 24 bpm and usually rapid & shallow A cough that changes in character should cause suspicion of possible lung cancer. Pulmonary ventilation *movement of air into the lungs which is inspiration *movement of air out of the lungs which is exhalation External Respiration *the movement of oxygen from the lungs to the blood *the movement of carbon dioxide from the blood to the lungs Three Regions of the Pharynx ( also known as your throat ) *nasopharynx *oropharynx *laryngopharynx Your Trachea ( windpipe ) Functions as an air passageway and it cleans, warms, and moistens the incoming air.

Four Measurements ( respiratory volumes ) - values are set using a spirometer * Tidal Volume - amount of air inhaled or exhaled with each breath when resting * Inspiratory Reserve Volume - air that can be inhaled during forced breathing in addition to the resting tidal volume * Expiratory Reserve Volume - is the amount of air that can be exhaled during forced breathing in addition to tidal volume * Residual Volume - amount of air that remains in the lungs after a forced exhalation Surfactant - decreases surface tension which 1) lowers the effort needed to expand the lungs 2) lessens the risk for the alveoli to collapse. 40 mm Hg is the typical partial pressure of oxygen in the cells of the body. Atelectasis (post-op): Collapsed alveoli *Usually caused by bronch secretions *not coughing & deep breathing *may be all or part of the lung S&S *restless *tachycardia *decrease PaO2 *decrease cap refill *tachypnea *fever/infection - tx with abx *inadequate chest expansion *dullness of percussion Treat post-op atelectasis: * Enc to cough & deep breath ( huff ) * respiratory activity as prescribed * reposition Post -Op Hemorrhage hemothorax - hypovolemia - shock S&S - decrease BP/ increase pulse rate restless - pallor decrease CVP - decrease urinary output PVC or A-Fib on heart monitor Give fluids and blood, may need to return to surgery Pulmonary Edema * lungs do not expand fast enough & circulatory overload early S&Sx *cough *dyspnea *restless *anxiety *low pitch wheezes

Late S&Sx *acute dyspnea *blood tinge sputum *increase pulse *decrease BP *anxiety *skin cool & clammy Tx for pulmonary edema MAD DOG M - morphine A - aminophylline D - digoxin D - diuretic O - oxygen G - gases Influenza has an incubation period of 1-3 days with a sudden onset, fever/chills, headache, & muscle aches. Usually last about 7-10 days. Incentive Spirometer * have patient sit upright unless contraidicated * mark the goal for inhalation * have pt exhale * have pt place the mouthpiece in their mouth * inhale slowly till the predetermined mark is reached * hold at the mark for 3-6 seconds * repeat this 10 times or as ordered every hour while awake or as ordered * do not rush during procedure and slow down if dizziness occurs Fact Files 4 ( endocrine ) The endocrine system affects 5 things: assists the nervous system, sex, growth, development, and health of the body. Exocrine glands = duct glands Endocrine glands = rely on blood/lymph to carry stuff to tissues Non-steroidal hormones are amino-based molecules. Your endocrine glands are: pituitary gland, thyroid gland, parathyroid gland, adrenal gland, pineal gland, thymus gland, gonads, pancreas, hypothalamus gland. Master gland is the pituitary gland. Anterior pituitary gland secretes ACTH, TSH, FSH, GH, LH, Lactogenic Hormone Posterior Pituitary gland secretes ADH and Oxytocin Disorders of the pituitary gland include: Hyperpituitarism = BIG, giantism, acromegaly Hypopituitarism = SMALL, hinders growth & development, inhibits secretion to target glands Insulin - regulates the movement of glucose across the cell membrane decreasing blood glucose levels.

Glucagon - stimulates your liver to release glucose to increase the blood glucose levels. Hypothyroidism is when your thyroid doesnt produce enough hormones. The thyroid hormones T3 and T4 help regulate your bodys metabolism and how you use energy. Addisons disease, a rare disorder, develops when the adrenal glands do not produce enough of the hormone cortisol. Sometimes, the adrenal glands also dont produce enough of the aldosterone hormone. Common Signs/symptoms *weakness *fatigue *abdominal pain *nausea *weight loss *low blood pressure *darkened skin (in the case of Addisons disease) *salt craving (in the case of Addisons disease) *dizziness upon standing *depression Treatment of Addisons disease involves replacing the cortisol and/or aldosterone that your body is not able to produceor that it secretes in an insufficient quantity.Cortisol is replaced with an oral synthetic glucocorticoid. The drug is taken one or two times each day. Generic drug names for glucocorticoids include hydrocortisone, prednisone, and dexamethasone. Here is what a man who is an AMAZING teacher told me: The Pituitary gland is like the president, the hypothalamus is the vice-president. All the other glands are all the heads of states. Does the president just automatically know what is going wrong in the states? No they talk to the vice president who tells it to the president who in turn reacts. He also told me that all hormones with an S are from the pituitary and that the S stands for stimulate. Cushings Disease/Syndrome Results from excessive glucocorticoids. S&S: Obesity - centripetal truncal and livid purple striae Hypertension and headache Moon face and Facial plethora and acne Osteopenia and back pain and proximal myopathy Thin fragile skin and bruising Avascular necrosis of femoral head Diabetes and IGT Psychosis and neuropsychatric disorders Menstrual disorders and impotence Dorsocervical fat pad "Buffalo hump" Impaired growth in children Septicaemia, Immunosuprresion, TB reactivation

TX: When Cushing's syndrome is caused by glucocorticoids that are taken for another medical condition, stopping the glucocorticoids often resolves symptoms. But, in most cases, the body has

adapted to the presence of the glucocorticoids, and they must be tapered off gradually to allow the pituitary and adrenal glands to resume normal function. When Cushing's syndrome results from an ACTH-producing tumor of the pituitary gland (Cushing's disease), treatment may include surgery, radiation, or medication to lower cortisol levels. The thyroid gland makes two hormones, thyroxine-T4 (with four iodines) and triiodothyronine T3 (with three iodines). T4 blood levels are higher than those of T3, but T3 is four times more potent. Normally the body converts T4 to T3 as needed. The pathophysiology of all types of diabetes is related to the hormone insulin, which is secreted by the beta cells of the pancreas. Insulin should be stored in a refrigerator and must be taken out 15- 20 minutes before being given to the patient. The nurse should take care that the injection locations don't repeat daily. As different sites will have varied absorption ability, it is preferable to change the sites occasionally. A record of the different sites where the injections are given to the patient should be maintained. Most of the disorders of thyroid function are related to hypersecretion (hyperthyroidism) and hyposecretion (hypothyroidism) of thyroid hormones. There are three common causes of hyperthyroidism in adults: Grave's disease, toxic multi-nodular goiter, and toxic adenoma. Thyroid storm is an exacerbation of all of the signs and symptoms of hyperthyroidism and is a true medical emergency. Hypothyroidism is a condition characterized by inadequate or low levels of thyroid hormones. There are various causes, one of which is chronic thyroiditis (Hashimoto's Thyroiditis). Long-standing hypothyroidism may result in myxedema SIADH is characterized by high levels of ADH when the normal process for it's stimulation is not working. It is associated with some forms/kinds of cancer and transient SIADH may follow pituitary surgery as the stored ADH may then be released unregulated, Main Features are water retention, sodium loss, urine sodium losses, improvement in hyponaturemia with water restriction, thirst, impaired taste, anorexia, dyspnea on exertion,edema, fatigue, nausea/emesis, basically the same symptoms you'd expect with hyponaturemia ( low sodium ) is what you'll see. In SIADH, high levels of ADH interfere with renal function which leads to hyponaturemia and hypoosmolarity. SIADH is associated with some kinds of cancers because of ectopic secretion oF ADH by the tumor cells.

In an average cardiac arrest you have a mixed acidosis-low cardiac output and tissue hypoperfusion causes lactic acidosis; but, ventilation is also depressed in cardiac arrest, which leads to respiratory acidosis. If they are talking about a hospitalized pt who would be getting O2 and bagged, go with the lactic acidosis answer. Train cars carrying oxygen was just some little thing my prof used for my first nursing class to get us to understand the relationship between H&H and oxygen/perfusion... just a stupid thing from class

More NCLEX Questions Hi guys, I wanna share more NCLEX Questions for practice. Dont worry it's all free. From Study Summary Change from "A-B-C" to "C-A-B." A major change in basic life support is a step away from the traditional approach of airway-breathing-chest compressions (taught with the mnemonic "A-B-C") to first establishing good chest compressions ("C-A-B"). There are several reasons for this change.

Most survivors of adult cardiac arrest have an initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), and these patients are best treated initially with chest compressions and early defibrillation rather than airway management. Airway management, whether mouth-to-mouth breathing, bagging, or endotracheal intubation, often results in a delay of initiation of good chest compressions. Airway management is no longer recommended until after the first cycle of chest compressions -- 30 compressions in 18 seconds. The 30 compressions are now recommended to precede the 2 ventilations, which previous guidelines had recommended at the start of resuscitation. Only a minority of cardiac arrest victims receive bystander CPR. It is believed that a significant obstacle to bystanders performing CPR is their fear of doing mouth-to-mouth breathing. By changing the initial focus of resuscitation to chest compressions rather than airway maneuvers, it is thought that more patients will receive important bystander intervention, even if it is limited to chest compressions.

Basic life support. The traditional recommendation of "look, listen, and feel" has been removed from the basic life support algorithm because the steps tended to be time-consuming and were not consistently useful. Other recommendations:

Hands-only CPR (compressions only -- no ventilations) is recommended for the untrained lay rescuers to obviate their fears of mouth-to-mouth ventilations and to prevent delays/interruptions in compressions. Pulse checks by lay rescuers should not be attempted because of the frequency of falsepositive findings. Instead, it is recommended that lay rescuers should just assume that an adult who suddenly collapses, is unresponsive and not breathing normally (eg, gasping) has had a cardiac arrest, activate the emergency response system, and begin compressions. Pulse checks by healthcare providers have been de-emphasized in importance. These pulse checks are often inaccurate and produce prolonged interruptions in compressions. If pulse checks are performed, healthcare providers should take no longer than 10 seconds to determine if pulses are present. If no pulse is found within 10 seconds, compressions should resume immediately. The use of end-tidal CO2 (ETCO2) monitoring is a valuable adjunct for healthcare professionals. When patients have no spontaneous circulation, the ETCO2 is generally 10 mm Hg. However, when spontaneous circulation returns, ETCO2 levels are expected to abruptly increase to at least 35-40 mm Hg. By monitoring these levels, interruptions in compressions for pulse checks become unnecessary.

CPR devices. Several devices have been studied in recent years, including the impedance threshold device and load-distributing band CPR. No improvements in survival to hospital discharge or neurologic outcomes have been proven with any of these devices when compared with standard,

conventional CPR. Electrical therapies

Patients with VF or pulseless VT should receive chest compressions until a defibrillator is ready. Defibrillation should then be performed immediately. Chest compressions for 1.5-3 minutes before defibrillation in patients with cardiac arrest longer than 4-5 minutes have been recommended in the past, but recent data have not demonstrated improvements in outcome. Transcutaneous pacing of patients who are in asystole has not been found to be effective and is no longer recommended.

Advanced cardiac life support. Good basic life support, including high-quality chest compressions and rapid defibrillation of shockable rhythms, is again emphasized as the foundation of successful advanced cardiac life support. The recommendations for airway management have undergone 2 major changes: (1) the use of quantitative waveform capnography for confirmation and monitoring of endotracheal tube placement is now a class I recommendation in adults; and (2) the routine use of cricoid pressure during airway management is no longer recommended. As they did in 2005, the AHA acknowledges once again that as of 2010, data are "still insufficient demonstrate that any drugs improve long-term outcome after cardiac arrest." Several important changes in recommendations for dysrhythmia management have occurred:

For symptomatic or unstable bradydysrhythmias, intravenous infusion of chronotropic agents (eg, dopamine, epinephrine) is now recommended as an equally effective alternative therapy to transcutaneous pacing when atropine fails; As noted above, transcutaneous pacing for asystole is no longer recommended; and Atropine is no longer recommended for routine use in patients with pulseless electrical activity or asystole.

Post-cardiac arrest care. Post-cardiac arrest care has received a great deal of focus in the current guidelines and is probably the most important new area of emphasis. There are several key highlights of post-arrest care:

Induced hypothermia, although best studied in survivors of VF/pulseless VT arrest, is generally recommended for adult survivors of cardiac arrest who remain unconscious, regardless of presenting rhythm. Hypothermia should be initiated as soon as possible after return of spontaneous circulation with a target temperature of 32C-34C. Urgent cardiac catheterization and percutaneous coronary intervention are recommended for cardiac arrest survivors who demonstrate ECG evidence of ST-segment elevation acute myocardial infarction regardless of neurologic status. There is also increasing support for patients without ST-segment elevation on ECG who are suspected of having acute coronary syndrome to receive urgent cardiac catheterization. Hemodynamic optimization to maintain vital organ perfusion, avoidance of hyperventilation, and maintenance of euglycemia are also critical elements in post-arrest care.

Viewpoint The AHA 2010 guidelines represent significant progress in the care of victims of cardiac arrest. Most important is the stronger emphasis on post-cardiac arrest care. Induced hypothermia is underscored, and perhaps the most important advance is the recommendation for urgent percutaneous coronary intervention in survivors of cardiac arrest. The wealth of data thus far indicate that post-arrest percutaneous coronary intervention may be the most significant advance toward improving survival and neurologic function since defibrillation was first introduced decades ago. In reviewing these guidelines, I must admit, however, that I was disappointed that AHA hesitated to adopt the concepts of "cardiocerebral resuscitation" (CCR). CCR also promotes the "C-A-B" approach to resuscitation, but it fosters even further delays in airway intervention -- withholding any

form of positive pressure ventilations, in favor of persistent chest compressions, for as long as 5-10 minutes after the cardiac arrest. The current guidelines recommend withholding positive pressure ventilation for a mere 18 seconds. First described in 2002,[1] CCR has been studied more recently as well and demonstrated marked improvements in rates of resuscitation and neurologic survival.[2-4] I think that CCR should be incorporated into basic life support protocols for victims of primary cardiac arrest as quickly as possible to further improve outcomes. Optimal management of cardiac arrest in the current decade can be summarized simply by "the 4 Cs": Cardiovert/defibrillate, CCR, Cooling, and Catheterization. Medscape: Medscape Access TOP 100 MEDS : Brand Name & Generic (NEED TO KNOW ALL) Lortab Synthroid Prinivil, Zestril Zocor Amoxil Zithromax, Zmax Lipitor Glucophage Hydrochlorothiazide Xanax Proventil HFA, Proair HFA, Ventolin HFA Toprol-XL Tenormin Lasix Norvasc Ambien, Ambien CR Hydrocodone Bitartrate with Acetaminophen Levothyroxine Sodium Lisinopril Simvastatin Amoxicillin Trihydrate Azithromycin Dihydrate Atorvastatin Calcium Metformin Hydrochloride Hydrochlorothiazide Alprazolam Albuterol Sulfate (salbutamol) Metoprolol Succinate Atenolol Furosemide Amlodipine Besylate Zolpidem Tartrate

Potassium Chloride Lopressor Percocet Zoloft Prilosec Nexium Prednisone Lexapro Coumadin Singulair Cipro (XR) Motrin Plavix Prozac Ultram Keflex Ativan Klonopin Celexa Wellbutrin (SR, XL) Neurontin Darvocet

Potassium Chloride Metoprolol Tartrate Oxycodone Hydrochloride with Acetaminophen Sertraline Hydrochloride Omeprazole Esomeprazole Magnesium Prednisone Escitalopram Oxalate Warfarin Sodium (Crystalline) Montelukast Sodium Ciprofloxacin Hydrochloride Ibuprofen Clopidogrel Bisulfate Fluoxetine Hydrochloride Tramadol Hydrochloride Cephalexin Lorazepam Clonazepam Citalopram Hydrobromide Bupropion Hydrochloride Gabapentin Propoxyphene Napsylate with Acetaminophen

Zestoretic, Prinzide Dyazide Augmentin (XR) Flexeril Bactrim Effexor (XR) Prevacid Advair Desyrel Paxil (CR) Allegra Flonase

Lisinopril with Hydrochlorothiazide Triamterene with Hydrochlorothiazide Amoxicillin Trihydrate with Clavulanate Potassium Cyclobenzaprine Hydrochloride Sulfamethoxazole with Trimethoprim Venlafaxine Hydrochloride Lansoprazole Fluticasone Propionate with Salmeterol Xinafoate Trazodone Hydrochloride Paroxetine Hydrochloride Fexofenadine HCl Fluticasone Propionate (nasal)


The 12 Absolutely Unbreakable Laws of Leadership 1.The Law of Integrity: Great business leadership is characterized by honesty, truthfulness and straight dealing with every person, under all circumstances. 2.The Law of Courage: The ability to make decisions and act boldly in the face of setbacks and adversity is the key to greatness in leadership. 3.The Law of Realism: Leaders deal with the world as it is, not as they wish it would be. 4.The Law of Power: Power gravitates to the person who can use it most effectively to get the desired results. 5.The Law of Ambition: Leaders have an intense desire to lead; they have a clear vision of a better future, which they are determined to realize. 6.The Law of Optimism: The true leader radiates the confidence that all difficulties can be overcome and all goals can be attained.

7.The Law of Empathy: Leaders are sensitive to and aware of the needs, feelings and motivations of their people. 8.The Law of Resilience: Leaders bounce back from the inevitable setbacks, disappointments and temporary failures experienced in the attainment of any worthwhile goal. 9.The Law of Independence: Leaders know who they are, what they believe in and they think for themselves. 10.The Law of Emotional Maturity: Leaders are calm, cool and controlled in the face of problems, difficulties and adversity. 11.The Law of Excellence: Leaders are committed to excellent performance of the business task and to continuous improvement. 12.The Law of Foresight: Leaders have the ability to predict and anticipate the future.

What to do if I get sued or have to testify? Testifying During the course of a career, a nurse might be called upon to testify in a trial on his/her own behalf as a defendant or as an expert witness on behalf of a plaintiff or other defendant. Giving testimony can be a terrifying experience. However, in-depth preparation can help alleviate those fears. Do's and don'ts of testimony, adapted from Myers and Fergusson, are as follows: The dos:

Get a good sleep the night before the testimony. Dress appropriately. If you want to be recognized as a professional, look like one. Have a clear understanding of the facts of the case. Speak clearly, directly, and honestly with short, unemotional answers. Sarcasm and wisecracks should not be a part of the testimony. Think about what to say before saying it. Do not blurt out an answer. For example: 1. If you are asked a question about a document, don't hesitate to ask to see the document before responding to the question. 2. If you are asked a hypothetical question, note the differences from the actual case before responding to the question. Answer the question asked of you. Nurses, often use rephrasing techniques in practice to elicit information from patients. This technique should not be used when giving testimony. Keep in mind, the witness is to answer questions, not to ask them. Stay alert. If you are tired and need a short break, ask for one. This is an accepted practice for witnesses.

Do what your attorney advises. If you are concerned about a line of questioning, explain your concerns to your attorney during a break.

The don'ts:

Don't guess. If you don't know the answer, say so. It is better to admit to a gap in knowledge than to give the wrong answer.

Don't waste energy trying to anticipate what the plaintiff s attorney is leading up to. (If you are a witness for the plaintiff, the attorney should have briefed you fully prior to the testimony.) Don't apologize. If you don't remember what happened, say "I don't recall." Don't be caught off guard. Attorneys use different approaches. For example, an attorney might switch from a hostile manner to a soft spoken one or from a friendly attitude to an unfriendly one in an effort to manipulate the witness. Don't be defensive. Tell the truth in an open, straightforward way. Don't be evasive. Don't answer off-the-record questions. Don't take any documents to a deposition or other session that you were not asked by counsel to bring. Don't use medical jargon. Speak in laymen's terms. Don't try to convince the lawyers; try to convince the jury or judge. Don't volunteer new information. Stick to what has been agreed to with counsel.

Student Nurses Can Be Sued Student nurses can be held liable for their actions and can be sued. A student nurse is held to the same standard of care as a registered nurse when performing RN duties. If a student nurse cannot safely function in the performance of these duties while unsupervised, the student should not be carrying out the duties. Kelly and Joel (1995) report the case of a first year student who administered an intramuscular injection into a patient's sciatic nerve causing severe damage. The student was found to be negligent because she should have known the proper procedure and taken special precautions with the patient who was very thin. In another set of circumstances, the instructor might have been found liable on the basis of inadequate supervision had the instructor given the task to the student knowing the student was not capable or competent to perform the task. Protection Against Suits Nurses must continuously monitor their practice to manage away from risk. Keeping up to date on new technologies, treatment modalities, medications, and employer policies and procedures is a must. Current knowledge about professional standards, codes of conduct, and accreditation criteria are also important. Familiarity with the reasons nurses are sued is also relevant to managing risk. A professional liability insurance policy is another risk management tool. Liability insurance protects against the financial consequences of suits. Insurance is basically a contract between an insured and an insurance company that upon the payment of a premium the company will provide the insured certain financial payments when the insured is accused of causing injury to another. Often, nurses believe that an employer's liability insurance is all the coverage needed. O'Sullivan (1996) points out that some hospital policies have not kept up with the changing role of the nurse and that an employer's policy may not cover nurses off-duty or volunteering in a community role. O'Sullivan (1996) also advises that nurses can no longer assume the hospital will provide the best defense in lawsuits as a hospital attorney's primary concern will be the hospital; concern for the nurse will be secondary. There are also a number of myths about liability insurance in the nursing profession. One myth is that a nurse runs a greater risk of being sued if the nurse has liability insurance. "In reality, lawyers normally do not know if the nurse named in lawsuits has extra insurance or not" (O'Sullivan, 1996). Another myth is that a nurse who purchases liability insurance is no longer covered by an employer's policy. It is illegal for an employer's policy to drop an employee because he/she has liability insurance.

ANA Continuing Education | ANA: ANA Nursing Risk Management Series: I: An Overview of Risk Management

Suboxone for Opiate Addiction Opiate addiction is a very common problem in our culture today. But the use of Suboxone for opiate addiction is making a difference in people living with opiate addiction. Using Suboxone for opiate addiction does work. In fact some consider Suboxone a miracle drug. Opiates are the most abused of all drugs. While many wish to quit, the physical and emotional attraction to opiates makes it almost impossible for most. But now there is hope for those people with opiate addiction who want to quit. The drug Suboxone is offering people with opiate addiction new hope in their attempts at kicking the habit. Opiates are a family of drugs derived either naturally or synthetically from the seed of a plant known as the poppy. Opiate drugs are narcotic sedatives that depress the activity of the central nervous system, reducing pain and inducing sleep. While opiates are an effective treatment for many types of moderate to severe pain, they have a high incidence of physical and emotional dependence. Longterm use of opiates can result in tolerance of the drug, meaning the amount taken must increase to acheive the same effect. As the amount of opiates increase to compensate for tolerance, dependence can occur. Often, dependence can lead to opiate overdose and even death. Some of the most commonly prescribed opiates include:

Fentanyl Morphine Vicodin (hydrocodone) Oxycontin Oxycodone Codeine Methadone

In addition to the prescribed opiates mentioned, the illegal drug, Heroin is also an opiate. How Does Suboxone Help? Suboxone (buprenorphine + naloxone) has been approved for the treatment of opiate dependence. It is actually two drugs in one pill.

Buprenorphine - This is the active ingredient in Suboxone. Buprenophine is a partial opioid agonist, meaning it can both activate and block opiate receptors, depending on the clinical situation. Naloxone - This drug is an opiate antagonist, meaning it blocks the effects of opiates. When Suboxone is taken under the tongue as prescribed, naloxone is not absorbed in sufficient amounts to have a clinical effect. Because Suboxone is an opiate agonist (a molecule that can trigger a receptor), there is a risk of misuse by people addicted to opiates. To prevent this, naloxone was combined with buprenorphine. If Suboxone is crushed and injected in hopes of getting an opiate "high," naloxone blocks the effect of opiates, producing severe withdrawal symptoms.

Important Warning! If Suboxone is chewed or crush and injected, the naloxone contained in the drug will produce severe opiate withdrawal symptoms. How Does Suboxone Help Beat Opiate Addiction

When opiates are taken into the body, they attach to receptors in the brain, causing dopamine release and euphoria.

Eventually, opiates leave the receptors causing the feelings of euphoria to fade and the symptoms of withdrawal to begin. As more of the receptors become empty, the withdrawal symptoms worsen. At this point, Suboxone therapy can begin. When Suboxone is taken, the buprenorphine attaches to the receptors in the brain once occupied by opiates. Because the receptors are no longer empty, withdrawal symptoms diminish. Buprenorphine attaches firmly to the receptors, filling them and blocking other opioids from occupying those receptors. Buprenorphine has a much longer duration of action than do other opioids, so the effects do not wear off quickly as is the case with opiates. Because there are no withdrawals, the person can stop taking opiates and start working on kicking his opiate habit.

Patients have better long term success when the medication is combined with an outpatient therapy program.

NCLEX Questions ~ Nursing Delegation 1. You are caring for a patient with an acute MI. You want to assign a certified nursing assistant to the patient. Which of the following would be an appropriate job to give the CNA? a. teaching the patient about a low salt diet b. helping the patient to bathe c. assessing their pain d. nothing 2. You are caring for a patient with extreme malnutrition and suspect anorexia nervosa. Which of the following would be an appropriate job to give an LPN/LVN? a. Daily weight b. Oral hygiene c. IV medications d. Teaching proper nutrition 3. From the following list of patients which one can be assigned to a nursing assistant/CNA? a. A patient with sudden unexplained bleeding b. A patient with unresolved pain over the past 8 hour shift c. A patient scheduled to have a chest x-ray done d. A patient who has multiple allergies to medications? 4. You are the charge nurse and have a new nurse on the floor. Which of the following patients would you assign to the new nurse? There is more than one answer. a. A woman with unstable diabetes who is scheduled for a pancreatic cat scan. b. A man with a history of chest pain who was admitted with shortness of breath. c. A young black woman with sickle cell anemia who has multiple IV medications ordered. d. An 83 year old woman with a history of leukemia, with temp and shortness of breath. e. A woman who is one day post-op for a lap choly. 5. At the end of the shift, the new nurse lets you now that she has not completed charting her medications for the shift. What do you tell her? a. ask her why she has not completed her med charting. b. help her document so you can both go home c. grant her overtime so she can get it done d. notify her nurse manager and make sure to include it on her evaluation.

6. Which of the following is a direct patient care task? a. restocking supplies b. transporting patients c. clerical activities d. performing an EKG 7. Which nurse still needs help in setting priorities and relies on rules and protocols? a. novice nurse b. advanced beginner c. competent nurse d. proficient nurse 8. You are listening as one of your co-workers, an RN, giving out assignments to her team with includes 2 LPN/LVN's and 2 nursing assistants. You know that one of the tasks she is assigning to the CNA should only be done by a licensed nurse. What should you do? a. Tell the charge nurse who is in a meeting. b. Discuss it at the next staff meeting c. Openly ask her about it and tell her that she is wrong and report her. d. Discuss with her why the task is not appropriate for the CNA.

ANSWERS: 1. The answer is: Helping the patient to bathe 2. The answer is: Oral hygiene 3. The answer is: A patient scheduled to have a chest x-ray done 4. The answer is: The only patient you wouldn't give the new nurse is the patient in

sickle cell crisis with multiple IV medications. 5. The answer is: Ask her why she hasn't completed her med charting. 6. The answer is: Performing an EKG 7. The answer is: Advanced beginner 8. The answer is: Discuss with her why the task is not appropriate for the CNA.

The 10 Most Prescribed Drugs April 20, 2011 The 10 most prescribed drugs in the U.S. aren't the drugs on which we spend the most, according to a report from the IMS Institute for Healthcare Informatics. The institute is the public face of IMS, a pharmaceutical market intelligence firm. Its latest report provides a wealth of data on U.S. prescription drug use. Continuing a major trend, IMS finds that 78% of the nearly 4 billion U.S. prescriptions written in 2010 were for generic drugs (both unbranded and those still sold under a brand name). In order of number of prescriptions written in 2010, the 10 most-prescribed drugs in the U.S. are:

Hydrocodone (combined with acetaminophen) -- 131.2 million prescriptions Generic Zocor (simvastatin), a cholesterol-lowering statin drug -- 94.1 million prescriptions Lisinopril (brand names include Prinivil and Zestril), a blood pressure drug -- 87.4 million prescriptions Generic Synthroid (levothyroxine sodium), synthetic thyroid hormone -- 70.5 million prescriptions Generic Norvasc (amlodipine besylate), an angina/blood pressure drug -- 57.2 million prescriptions Generic Prilosec (omeprazole), an antacid drug -- 53.4 million prescriptions (does not include over-the-counter sales) Azithromycin (brand names include Z-Pak and Zithromax), an antibiotic -- 52.6 million prescriptions Amoxicillin (various brand names), an antibiotic -- 52.3 million prescriptions Generic Glucophage (metformin), a diabetes drug -- 48.3 million prescriptions Hydrochlorothiazide (various brand names), a water pill used to lower blood pressure -- 47.8 million prescriptions.

Nursing Lab Values Cheat Sheet Lab Values: Cheat Sheet Red Blood Cells (RBC): - Normal: male = 4.6- 6.2 female = 4.2- 5.2 - Actual count of red corpuscles

Hemoglobin: - Normal: male = 14-18 g/dl female = 12-16 g/dl - A direct measure of oxygen carrying capacity of the blood Hematocrit : - Normal: males = 39- 49% female = 35- 45% - = the percentage of blood that is composed of erythrocytes Mean Cell Volume (MCV): - Normal: male = 80- 96 female = 82- 98 Mean Cell Hemoglobin (MCH): - Normal: 27- 33 - = % volume of hemoglobin per RBC * Increase: indicates folate deficiency * Decrease: indicates iron deficiency Mean Cell Hemoglobin Concentration): - Normal: 31- 35 Reticulocyte Count: - Normal: 0.5-2.5% of RBC - An indirect measure of RBC production Red Blood Cell Distribution Width (RDW): - Normal: 11-16% - Indicates variation in red cell volume * Increase: indicates iron deficiency anemia or mixed anemia - Note: increase in RDW occurs earlier than decrease in MCV therefore RDW is used for early detection of iron deficiency anemia Platelet Count: - Normal: 140,000 - 440,000 * Low: worry patient will bleed * High: not clinically significant White Blood Cell (WBC): - Normal: 3.4 10 * Increase: occur during infections and physiologic stress * Decreases: marrow suppression and chemotherapy Sodium (Na): - Normal: 136- 145 - Major contributor to cell osmolality and in control of water balance * Hypernatremia: greater than 145 Causes: sodium overload or volume depletion Seen in: impaired thirst, inability to replace insensible losses, renal or GI loss S/sx: thirst, restlessness, irritability, lethargy, muscle twitching, seizures, hyper flexia, coma and death. * Hyponatremia: 136 or less Causes: true depletion or dilutional

Occur in: CHF, diarrhea, sweating, thiazides Symptoms: agitation, anorexia, apathy, disorientation, lethargy, muscle cramps and nausea Potassium (K): - Normal: 3.5- 5.0 - Regulated by renal function * Hypokalemia: less than 3.5 * Hyperkalemia: greater than 5.0 (panic > 6) NOTE: False K elevations are seen in hemolysis of samples! Chloride (Cl): - Normal: 96- 106 * Reduced: by metabolic alkalosis * Increased: by metabolic or respiratory acidosis Bicarbonate (HCO3): - Normal: 24- 30 - The test represents bicarbonate (the base form of the carbonic acid-bicarbonate buffer system) * Decreased: acidosis * Increased: alkalosis GLUCOSE: Normal: 70- 110 * Hyperglycemia: s/sx: increase thirst, increase urination and increased hunger (3Ps). May progress to coma causes: include diabetes * Hypoglycemia: s/sx: sweating, hunger, anxiety, trembling, blurred vision, weakness, headache or altered mental status causes: fasting, insulin administration BUN: Blood Urea Nitrogen - Normal: 8- 20 - Panic = > 100 mg/dl Serum Creatinine (SCr): - Normal: 0.7- 1.5 for adults and 0.2- 0.7 for children - SCr is constant in patients with normal kidney function. * Increase: Indicates worsening renal function Total Protein and Albumin: - Total protein: normal = 5.5- 9.0 - Albumin: normal = 3.- 5 * Related to liver status * Low: Cause: liver dysfunction S/sx: peripheral edema, ascites, periorbital edema and pulmonary edema. Serum Calcium (Ca): - Normal = 8.5- 10.8

* Hypocalcemia: less than 8.5 Causes: low serum proteins (most common), decreased intake, calcitonin, steroids, loop diuretics, high PO4, low Mg, hypoparathyroidism (common), renal failure, vitamin D deficiency (common), pancreatitis S/sx: fatigue, depression, memory loss, hallucinations and possible seizures or tetany Lead to: MI, cardiac arrhytmias and hypotension Early signs: finger numbness, tingling, burning of extremities and paresthias. * Hypercalcemia: more than 10.8 Cause: malignancy or hyperparathyroidism (most common), excessive IV Ca salts, supplements, chronic immobilization, Pagets disease, sarcoidosis, hyperthyroidism, lithium, androgens, tamoxifen, estrogen, progesterone, excessive vit D or thyroid hormone. Acute (>14.5) s/sx: nausea, vomiting, dyspepsia and anorexia Severe s/sx: lethargy, psychosis, cerebellar ataxia and possibly coma or death Increased risk of digoxin toxicity Phosphate (PO4): - Normal: 2.6- 4.5 Magnesium (Mg): - Normal: 1.5- 2.2 - Primarily eliminated by the kidney * Hypomagnesemia: less than 1.5 Causes: excessive losses from GI tract (diarrhea or vomiting) or kidneys (diuretics). Alcoholism may lead to low levels S/sx: weakness, muscle fasciculation with tremor, tetany, increased reflexes, personality changes, convulsions, psychosis, come and cardiac arrhythmia. * Hypermagnesemia: more than 2.2 Caueses: incrased intake in the presence of renal dysfunction (common), hepatitis and Addisons disease S/sx: at 2-5 mEq/L = bradycardia, flushing, sweating, N/V, low Ca at 10-15 mEq/L = flaccid paralysis, EKG changes over 15 = respiratory distress and asystole. Alkaline Phosphatase: - Normal: ranges vary widely - Group of enzymes found in the liver, bones, small intestine, kidneys, placenta and leukocytes (most activity from bones and liver) * Increased: occurs in liver dysfunction

Aminotransferases (ALT and AST): - ALT and AST are measure indicators of liver disease. Sensitive to hepatic inflammation and necrosis. - Increase: occurs after MI, muscle diseases and hemolysis. - Normal ALT: 3- 30 Direct Bilirubin (Conjugated): - Normal: 0.1-0.3 mg/d; * Increase: associated with increases in other liver enzymes and reflect liver disease

Urine: - Normal: should be clear yellow * Cloudy: results from urates (acid), phosphates (alkaline) or presence of RBC or WBC * Foam: from protein or bile acids in urine - Side note: some medications will change color of urine * Red-Orange: Pyridium, rifampin, senna, phenothiazines. * Blue-Green: Azo dyes, Elavil, methylene blue, Clorets abuse * Brown-Black: Cascara, chloroquine, senna, iron salts, Flagyl, sulfonoamides and nitrofurantoin pH: - Normal: 4.5- 8 Protein content [in urine]: - Normal: 0 - +1 or less than 150 mg/day * Protein in urine: indication of hemolysis, high BP, UTI, fever, renal tubular damage, exercise, CHF, diabetic nephropathy, preeclampsia of pregnancy, multiple myeloma, nephrosis, lupus nephritis and others. Microscopic analysis of Urine: - Urine should be sterile (no normal flora) - Few, if any, cells should be found - Significant bacteriuria is defined by an initial positive dipstick for leukocyte esterase or nitrites. If more than 1 or 2 species seen, contaminated specimen is likely. Learn the Difference in IV Fluids

Hypotonic solutions o 0.45% Sodium Chloride (Osmolarity of 155, pH of 5.0 to 5.6) - replaces sodium, replaces chloride, and provides free water. Contains 77mEq of sodium and 77mEq of Chloride. Used most often to hydrate patients and to treat hyperosmolar diabetes, metabolic alkalosis where there has been sodium depletion and fluid loss. When used continuously and exclusively, the patient needs to be monitored for hyponatremia and calorie depletion (there are no calories in this solution). Isotonic solutions o 2.5% Dextrose and 0.45% Sodium Chloride (Osmolarity of 280, pH of about 4.0 to 4.5) provides calories and free water o 5% Dextrose and 0.11% Sodium Chloride (Osmolarity of 290, pH of about 4.3) provides calories and free water, provides some sodium and chloride o 0.9% Sodium Chloride (Osmolarity of 308, pH of 5.7) - primarily used to replace sodium and chloride, treats hyperosmolar diabetes, metabolic alkalosis where there has been sodium depletion and fluid loss. The reason for it's used with blood transfusion is because it will not hemolyze erythrocytes. Often given as rapid bolus for fluid replacement during resuscitation. o 5% Dextrose and Water (Osmolarity of 253, pH of about 4.5 to 5.0) - provides calories and free water. o Normosol R [Abbott] (Osmolarity of 295, pH of 6.6) - provides electrolytes o Plasmalyte A [Baxter] (Osmolarity of 294, pH of 7.4) - provides electrolytes o Plasmalyte R [Baxter] (Osmolarity of 312, pH of 4.0 to 6.5) - provides electrolytes. Also contains sodium lactate which is used in treating mild to moderate metabolic acidosis. o Isolyte E [McGaw] (Osmolarity of 315, pH of 6.0) - provides electrolytes o Ringer's (Osmolarity of 310, pH of 5.5 to 5.8) - it's content is very similar to plasma, but should not be used continuously since it contains no calories and could result in an excessive amount of one or more of the electrolytes it contains. It's components include

sodium, chloride, potassium and calcium. It is used to replace electrolytes and to hydrate, often where there has been extracellular fluid loss. Adding Dextrose increases the osmolarity of the solution and lowers it's pH making it a hypertonic solution. Lactated Ringer's [also known as Hartmann's solution] (Osmolarity of 275, pH of 6.5 to 6.6) - as with Ringer's, it's content is very similar to plasma, but should not be used continuously since it could result in an excessive amount of one or more of the electrolytes it contains. It's components include sodium, chloride, potassium, calcium and sodium lactate which is used to replace electrolytes and to hydrate, often used where there has been extracellular fluid loss. It is used in treating mild to moderate metabolic acidosis and hypovolemia. Often given as rapid bolus for fluid replacement during resuscitation. Since lactate is metabolized in the liver it shouldn't be used in patients with hepatic diseases. Using it in a patient with lactic acidosis will overload the person's buffering system. Adding Dextrose also increases the osmolarity of the solution and lowers it's pH making it a hypertonic solution. 2.5% Dextrose in half strength Lactated Ringer's (Osmolarity of 263, pH of 5.0) provides calories and free water, provides electrolytes. Also contains sodium lactate which is used in treating mild to moderate metabolic acidosis. Also see the information above with Lactated Ringers. 6% Dextran and 0.9% Sodium Chloride (Osmolarity of 308, pH of 4.0 to 4.5) - 6% Dextran is a high molecular weight solution. The NaCl replaces sodium and chloride. Treats hyperosmolar diabetes, metabolic alkalosis where there has been sodium depletion and fluid loss. It draws fluid into the vascular system. Dextran is a plasma expander that is given for shock or anticipated shock related to trauma, surgery, burns or hemorrhage, and for the prophylactic prevention of venous thrombosis and pulmonary embolism during surgery. It should NOT be used as a blood substitute except in emergencies when blood is not available. It's volume expansion effect lasts for approximately 24 hours during which the dextran is slowly broken down to glucose and metabolized into carbon dioxide and water. Complications with the use of this solution include anaphylactic reaction, wheezing, tightness in the chest, GI problems of nausea and vomiting, circulatory overload and tissue dehydration. If blood transfusion is intended, the type and cross match needs to be done before this solution is started. Because dextran pulls fluid into the vascular system it will result in altered blood tests. 10% Dextran and 0.9% Sodium Chloride (Osmolarity of 252, pH of 4.0 to 4.5) - 10% Dextran is a low molecular weight dextran. It is used in treating shock related to vascular system fluid losses such as in burns, trauma, hemorrhage and surgery. It is also used for the prophylactic prevention of venous thrombosis and pulmonary embolism during surgery. Complications include circulatory overload that results in various kinds of congestion and increased bleeding time. As with the 6% Dextran solutions, subsequent laboratory blood tests will be altered due to it entering the vascular system. This Dextran is excreted through the renal system within 24 hours.

Hypertonic Solutions o 5% Dextrose and 0.2% Sodium Chloride (Osmolarity of 320, pH of 4.0 to 4.4) - provides calories and water, replaces sodium and chloride. This is given for fluid replacement. o 5% Dextrose and 0.3% Sodium Chloride (Osmolarity of 365, pH of 4.0 to 4.4) - provides calories and water, replaces sodium and chloride o 5% Dextrose and 0.45% Sodium Chloride (Osmolarity of 405, pH of 4.0 to 4.4) provides calories and water, replaces sodium and chloride. This is given for fluid replacement. o 5% Dextrose and 0.9% Sodium Chloride (Osmolarity of 560, pH of 4.0 to 4.4) - provides calories and water, replaces sodium and chloride. This is given for fluid replacement.

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10% Dextrose and 0.2% Sodium Chloride (Osmolarity of 575, pH of 4.3) - provides calories and water, replaces sodium and chloride 10% Dextrose and 0.45% Sodium Chloride (Osmolarity of 660, pH of 4.3) - provides calories and water, replaces sodium and chloride 10% Dextrose and 0.9% Sodium Chloride (Osmolarity of 815, pH of 4.0 to 4.3) provides calories and water, replaces sodium and chloride 3% Sodium Chloride (Osmolarity of 1030, pH of 5.0) - used to replace severe sodium and chloride losses. Other conditions it might be used for are excessive sweating, vomiting, renal impairment and excessive water intake where hyponatremia has occurred. 5% Sodium Chloride (Osmolarity of 1710, pH of 5.0 to 5.8) - used to replace severe sodium and chloride losses. Other conditions it might be used for are excessive sweating, vomiting, renal impairment and excessive water intake where hyponatremia has occurred. 10% Dextrose and Water (Osmolarity of 505, pH of 4.3 to 4.5) - provides calories and water 50% Dextrose and Water (Osmolarity of 2526, pH of 4.0 to 4.2) - provides calories and water 5% Dextrose in Ringer's (Osmolarity of 562, pH of 4.3) - provides calories and free water, provides electrolytes. Also see the information above with Ringer's 5% Dextrose in Lactated Ringer's (Osmolarity of 527, pH of 4.9) - provides calories and free water, provides electrolytes. Also contains sodium lactate which is used in treating mild to moderate metabolic acidosis. Also see the information above with Lactated Ringers. 5% Dextrose and 5% Alcohol (Osmolarity of 1114, pH of 4.5) - Provides calories and free water 5% Sodium Bicarbonate Injection (Osmolarity of 1190, pH of 8.0) - Is an alkalizing solution that is used to treat metabolic acidosis associated with renal disease and cardiac arrest. The sodium in the solution is an antagonist to the cardiac effects of potassium. It is also used in severe hyperkalemia. It maintains osmotic pressure and acid-base balance. The major complications associated with it's use are related to electrolytes and include metabolic alkalosis, hypocalcemia, hypokalemia, water and sodium retention that cause hypernatremia, other electrolyte imbalances and IV site extravasation that causes chemical cellulitis, necrosis, ulceration and sloughing of the skin. 1/6 M(olar) Sodium Lactate (Osmolarity of 335, pH of 6.5) - Contains sodium lactate which is used in treating mild to moderate metabolic acidosis. 10% Mannitol Injection (Osmolarity of 549, pH of 5.7) - Mannitol is a sugar alcohol colloid and a plasma expander. It promotes diuresis by drawing fluid from the cells into the plasma. It acts rapidly and is excreted within 3 hours through the kidneys. It is primarily used for intracranial pressure and cerebral edema where it acts within 15 minutes of being infused. It will also be used during the oliguric phase of acute renal failure to promote the excretion of toxic substances from the body. In high intraocular pressure, it pulls fluid from the anterior chamber of the eye within 30 to 60 minutes of infusion. Complications include frequent and severe fluid and electrolyte imbalances, cell dehydration, fluid overload, skin extravasation and necrosis with infiltration of the IV site, precipitate formation in the IV line and altered laboratory blood tests. The patient's blood tests should be monitored when the patient is receiving mannitol. 15% Mannitol Injection (Osmolarity of 823, pH of 5.7) - Mannitol is a sugar alcohol colloid and a plasma expander. It promotes diuresis by drawing fluid from the cells into the plasma. It acts rapidly and is excreted within 3 hours through the kidneys. It is primarily used for intracranial pressure and cerebral edema where it acts within 15 minutes of being infused. It will also be used during the oliguric phase of acute renal failure to promote the excretion of toxic substances from the body. In high intraocular

pressure, it pulls fluid from the anterior chamber of the eye within 30 to 60 minutes of infusion. Complications include frequent and severe fluid and electrolyte imbalances, cell dehydration, fluid overload, skin extravasation and necrosis with infiltration of the IV site, precipitate formation in the IV line and altered laboratory blood tests. The patient's blood tests should be monitored when the patient is receiving mannitol. 20% Mannitol Injection (Osmolarity of 1098, pH of 5.7) - Mannitol is a sugar alcohol colloid and a plasma expander. It promotes diuresis by drawing fluid from the cells into the plasma. It acts rapidly and is excreted within 3 hours through the kidneys. It is primarily used for intracranial pressure and cerebral edema where it acts within 15 minutes of being infused. It will also be used during the oliguric phase of acute renal failure to promote the excretion of toxic substances from the body. In high intraocular pressure, it pulls fluid from the anterior chamber of the eye within 30 to 60 minutes of infusion. Complications include frequent and severe fluid and electrolyte imbalances, cell dehydration, fluid overload, skin extravasation and necrosis with infiltration of the IV site, precipitate formation in the IV line and altered laboratory blood tests. The patient's blood tests should be monitored when the patient is receiving mannitol.


the Dextrose solutions also serve as diluents for the administration of many IV medications. In general, the electrolyte solutions are isotonic. Adding Dextrose to them makes the resulting solution hypertonic. Sodium deficits occur in head injuries, SIADH (Syndrome of Inappropriate Antidiuretic Hormone) and cirrhosis I boldfaced the solutions with the lowest and highest osmolarity Problems with using IV solutions of strictly Sodium Chloride include o hyponatremia (with continuous infusions of 0.45%) o calorie depletion o hypernatremia (with continuous infusion of the higher percentage NaCl solutions) o peripheral edema o an exhaustion of other body electrolytes o hyperchloremia 5% Dextrose in one liter of water contains 5 grams of dextrose per every 100mL which gives 170 calories per liter of fluid (this was a question on my state board exam in 1975). Free water - The dextrose in IV solutions is metabolized very rapidly since it is a simple sugar which leaves behind plain old water. This water is able to cross all cell and tissue membranes to go into the various fluid compartments where is it needed. The higher percentage Dextrose solutions are used to supply the patient with calories and often need to be given via a central IV line. Hypovolemia occurs in acute pancreatitis.

Always review your patient's laboratory tests to determine if the IV solution is appropriate, particularly o the BUN (blood urea nitrogen) - Normal: 10-20 mg/dl o serum creatinine - Normal: 0.7-1.5 mg/dl o hematocrit - Normal: 44-52% (male); 39-47% (female) o hemoglobin - Normal: 13.5-18.0 g/dL (male); 12.0-16.0 g/dL o serum osmolality - Normal: 280-295 mOsm/kg o serum electrolytes sodium - Normal: 135-145 mEq/liter potassium - Normal: 3.5-5.0 mEq/liter chloride - Normal: 97-110 mEq/liter

calcium - Normal: 8.9-10.3 mg/dL, or 4.6-5.1 mEq/liter magnesium - Normal: 1.3-2.1 mEq/liter, or 1.8-3.0 mg/dL phosphate - Normal: 2.5-4.5 mg/dL, or 1.8-2.6 mEq/liter (adults); 4.0-7.0 mg/dL, or 2.3-4.1 mEq/liter (children) arterial blood gasses for the pH - Normal: 7.35-7.45 PaO2 - Normal: 80-100 mm Hg PaCO2 - Normal: 38-42 mm Hg bicarbonate - Normal: 22-26 mEq/liter base excess - Normal: -2 to +2

Dehydration may also be called fluid volume deficit or hypovolemia and is due to:

excessive fluid and electrolyte losses from the extracellular compartment loss of GI fluids due to vomiting, diarrhea, suctioning and fistulas fluid lost through the skin as the body attempts to regulate it's temperature or trauma of the skin (burns, large open wounds, cuts). loss of fluid through the renal system (these losses are usually excessive) by polyuria due to hyperglycemia, renal disorders, administration of osmotic diuretics, administration of concentrated IV solutions and tube feedings hemorrhage which causes loss from the intracellular compartment third spacing - the shift of fluid from the circulation to a space where it is trapped and cannot be exchanged with fluid in the extracellular space. There is no actual physical fluid loss but the involved fluid is basically "out of commission". This occurs in intestinal ileus decreased fluid intake due to confusion, coma, very young age or very old age and not recognizing the sense of thirst

3 Ways to Prevent Missing Critical Changes in Your Patients Condition Nurses-3 Ways to Prevent Missing Critical Changes in Your Patients Condition Heres 3 ways you can prevent missing critical changes in your patients. 1. Follow the care plan until the problem is resolved A few weeks ago, Bertie, on Coumadin for chronic atrial fibrillation, hit her forearm on a chair. Within hours her entire arm was edematous and ecchymotic. We suspected the bleeding was from her Coumadin dose being high. The PT/INR results proved we were right. Berties Coumadin dose was reduced. So far, so good. We wrote a nursing care plan stating the nurses needed to watch Berties forearm for edema, ecchymosis, pain, numbness or tingling or infection. Because the edema and ecchymosis were improving, did the nurses stop looking at Berties arm daily? Were we so focused on the current problem that we overlooked the new problem, a skin infection? 2. Set priorities Did the nurses get so busy that checking Berties arm was no longer a high priority? There are so many pressing tasks that must be done and so little time to do them. The interruptions seem endless at times. But do nurses always focus on whats most important? Do we delegate some things to other members of the nursing team so that we have time to perform important assessments of our patients? 3. Fine tune your assessment skills If you saw Berties forearm with a 10 cm by 6 cm area of erythema and edema, would you know to check for increased warmth? Would you call the NP, PA or physician to describe your findings? When you talked to the health care professional, would you mention Berties allergies and that she was on Coumadin so if an antibiotic was prescribed, the PT/INR could be checked more frequently? (Many antibiotics affect the blood levels of Coumadin.) Or would you just continue to monitor the site and

pass this information on to the next shift? By following these three steps, you can lessen the chance that you will miss changes in your patients conditions. Read and follow your nursing care plans. Dont let yourself get so busy that the highest priorities get missed. Delegate tasks that other members of the nursing team can do. If you see an abnormality, dont just pass on the information, take action.

Nursing Interview Tips from a Recruiter Nursing Interview Tips from a Recruiter Making a lasting impression. Diligently prepare and take your interview seriously. Heres her best advice from years of interviewing nurses: 1. Dress professionally. You may have a stellar resumeaced nursing school, received high marks on your NCLEX, hold great recommendationsbut if you come in as Sally or Sal Slop, your credibility will plunge. Steffel has had nurses arrive at interviews wearing shorts and flip-flops. Guess whether they got the job. Steffel recommends staying away from anything that will distract the interviewer from what youll bring to the organizationhiked-up hemlines, street attire, wrinkled slacks, flashy jewelry, disheveled hair, overpowering fragrances, or gum smacking. Since youre applying for a professional position, look the part: Keep it conservative, neat, and clean. First impressions are lasting. 2. Watch your non-verbal cues. According to Steffel, interviewers are looking for a nurse to be well composed and professional. They discern this through the nurses non-verbal cues. Dont forget interviewing fundamentals, like a firm handshake, a pleasant smile, direct eye contact, uncrossed arms, and an energetic tone of voice. Aside from displaying enthusiasm and sharpness, these gestures also reveal how you will interact with future customers (patients). And your poise points to how you will handle the countless unfamiliar and frightening scenarios a nurse faces during his/her career. In short,interviewers appraise your non-verbal communication as much as your verbal communication. 3. Exude enthusiasm. When Steffel interviews nurses, she also looks for a passion for the profession and the organization for which the nurse is applying. Steffel knows people are nervous and might occasionally flounder for wordsthats expected. Still, nurses should demonstrate excitement about their careers, that they have something unique to offer, and that they are fond of the organization for a specific reason (i.e., their mission statement or theyre a magnet hospital). Engaging the interviewer in conversation about the organization, also demonstrates your eagerness and ability to interact with people (which nursing is all about). While you may not have years of experience to buttress your credibility, your excitement and interest in the organization will do so. 4. Turn off your phone. In a world in which we are constantly reminded to turn off our cell phones and pagers, you would think it would be a no-brainer to do so before a job interview. Interviewers are fully present for the interview, says Steffel. The candidate needs to abide by those same principles. 5. Research the organization. Be prepared to answer the questions: Why are you interested in our organization? What brings you here? Why do you want to work at this hospital? And dont say, Because its the closest to where I live. Take time to review the hospitals mission statement, read articles written about the hospital, or review the job postingfind any information you can about the hospital and study it. It will be invaluable information during your interview.

For instance, if you researched Edward Hospital, where Steffel is a recruiter, youd find its a magnet hospital and about their brand promise to deliver care for people who dont like hospitals. During the interview, use information like this to demonstrate your interest in the organization. But dont simply say, I want to be hired because I want to be at a magnet hospital. Take it a step further, Steffel recommends, and explain why you want to be at a magnet hospital: because of the nurse support, the preceptor program, the internship, the transition training program, etc. This attention to detail shows the interviewer how serious you are about the position you are vying for. 6. Ask the right questions. Youre interviewing the organization just as much as were interviewing you, says Steffel, so you need to have questions prepared. Maybe there was something that the interviewer said during the interview that youd like to be clarified. Dont hesitate to ask. Now is the time to find out what wont work for your personalityrather than later, once youve signed the dotted line. Questions nurses should ask include the following: What is your orientation program like? Do you have a preceptor program? What is its duration? Do you allow time off for and/or pay for continuing ed? Do you have nurse educators, and how often are they available? How are performance evaluations done, and how frequently? Will I have to work weekends and holidays? Will I be on call? What is your retirement plan like? Will you contribute? Preparation at every level will set you apart from your competitionand may help you even enjoy the process. Read more Managing Your Career articles Goals of New Recommendations "The goal of an effective prevention program should be the elimination of CRBSI from all patient-care areas," write Naomi P. O'Grady, MD, from the National Institutes of Health in Bethesda, Maryland, and colleagues from HICPAC. "Although this is challenging, programs have demonstrated success, but sustained elimination requires continued effort. The goal of the measures discussed in this document is to reduce the rate to as low as feasible given the specific patient population being served, the universal presence of microorganisms in the human environment, and the limitations of current strategies and technologies." The new recommendations are addressed to healthcare personnel responsible for intravascular catheter insertion as well as those involved in surveillance and containment of infections in hospital, outpatient, and home healthcare settings. Multidisciplinary strategies and topics addressed in the updated guidelines include education, training, and staffing; selection of catheters and sites; peripheral catheters and midline catheters; central venous catheters (CVCs); hand hygiene and aseptic technique; maximal sterile barrier precautions; skin preparation; catheter site dressing regimens; patient cleansing; catheter securement devices; antimicrobial/antiseptic impregnated catheters and cuffs; systemic antibiotic prophylaxis; antibiotic/antiseptic ointments; antibiotic lock prophylaxis, antimicrobial catheter flush and catheter lock prophylaxis; anticoagulants; replacement of peripheral and midline catheters; replacement of CVCs, including peripherally inserted central catheters (PICCs) and hemodialysis catheters; umbilical catheters; peripheral arterial catheters and pressure-monitoring devices for adult and pediatric patients; replacement of administration sets; needleless intravascular catheter systems; and performance improvement. Recommendations Some of the specific recommendations include the following:

For peripheral and midline catheters, an upper-extremity site is preferred in adults. In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used.

Steel needles should be avoided when administering fluids and medications that might cause tissue necrosis if extravasation occurs. When the duration of intravascular therapy is likely to be more than 6 days, a midline catheter or PICC is preferred to a short peripheral catheter. The catheter insertion site should be evaluated daily, and peripheral venous catheters should be removed if signs of phlebitis develop. Risks and benefits of a central venous device to reduce infectious complications should be weighed against the risk for mechanical complications. In adult patients, use of the femoral vein for central venous access should be avoided. For nontunneled CVC placement, a subclavian site is preferred to a jugular or a femoral site. To avoid subclavian vein stenosis, the subclavian site should be avoided in hemodialysis patients and patients with advanced kidney disease. For patients with chronic renal failure, a fistula or graft instead of a CVC for permanent access for dialysis should be used. Ultrasound guidance by those fully trained in its technique should be used to place CVCs. A CVC should have the minimal number of ports or lumens essential for patient treatment. Any intravascular catheter that is no longer essential should be promptly removed. When adherence to aseptic technique cannot be ensured, such as for catheters inserted during a medical emergency, the catheter should be replaced as soon as possible (within 48 hours). Systemic antimicrobial prophylaxis before insertion or during use of an intravascular catheter is not routinely recommended to prevent catheter colonization or CRBSI.

Calculating Drug Dosages and Self-Test is a phenomenal site. It helped me pass my tests with 100%, which is what is required to pass dose calc at my school.

How to document disasters "If you didn't write it, you didn't do it." That may be the oldest and most tired clich in all of EMS and it is not exactly true. Likewise, "paint a picture & tell a story," is another biggie in documentation classes. I happen to agree with that one; unfortunately many providers are painting the wrong picture and telling the wrong story because they are not thinking about their audience. They are not considering who will be reading their report and why. Not to worry. I can fix it. Contrary to popular belief, patient care reports are not created for the singular purpose of feeding the voracious appetites of greedy lawyers. However, at feeding time, lousy documentation and your career make for a nice meal and there are plenty of sharks eager to take a big bite out of your assets. Know your audience Like every call, every report is unique. There is a specific series of events (or non-events) that must somehow be recorded in a way that both shows and tells the reader what happened, and clearly describes your reaction to it. At the same time, for better or worse, the reader will gather some insight about your appreciation of the circumstances that brought you to the scene, your assessment of everything, your understanding of associated protocols, and your application of technique. That is a boatload of information for one narrative and how you communicate it will depend on who will be reading it, and why. For example, the narrative for a fatal gunshot wound to the head that is left on scene for the medical examiner will look entirely different than that of a gunshot to the head that is transported and later

dies. While the outcome is the same, the audience is different and thus the documentation is different. Patient transports First and foremost, for patients who are transported, patient care reports are generated so future caregivers can know what happened before the patient came to them. The information is used to diagnose or rule out medical conditions; to identify medications taken and known drug allergies so as to prevent lethal combinations or anaphylactic nightmares; to guide advanced clinical assessments and treatment modalities, and the list goes on. If your prehospital documentation is inaccurate or incomplete, the easily avoidable can become an irreversible tragedy in the blink of an eye. The BIG Five 1) Write for Doctors, Nurses, and Allied Professionals 2) Organize as if the patient will become unconscious and unable to provide any information 3) Assume that the person reading your report knows nothing about anything that happened before the patient arrived in the ED 4) Make sure the reader knows WHEN you did what you did 5) Presume nothing and leave nothing [relevant] to the imagination Death in the field Then there is the issue of death in the field. Most systems have protocols that allow providers to withhold treatment and transport for the obviously dead. When called upon to document death in the field, you are not writing for the sake of future care, you are writing for medical examiners, homicide investigators, and possibly even criminal prosecutors (and criminal defense attorneys). While dead men tell no tales, your death-in-the-field documentation will speak volumes about what did or didn't happen; why that poor unfortunate is no longer an active participant in the game of life and whether you could have or should have done something about it. The BIG Five 1) Write for medical examiners, homicide detectives, and criminal justice attorneys 2) Organize as if you expect to see the report projected onto a giant screen in a courtroom 3) Assume that the person reading your report knows nothing about anything that happened while you were on the scene 4) Make sure the reader knows WHY you didn't treat or transport 5) Presume nothing and leave nothing [relevant] to the imagination

Patients not transported As I have said and continue to say, the calls in which there is a patient who refuses treatment and transport are the most dangerous calls of all. There are times when a patient refusal is acceptable, but the fact remains that the audience for your documentation is most likely to be a lawyer who wants something from you because something bad happened after you left. The BIG Five 1) Write for the Attorney who is suing you over this call (sad, but true) 2) Organize as if you expect to see the report projected onto a giant screen in a courtroom because it will be 3) Assume that the person reading your report (and the jury) knows nothing about anything that happened while you were on the scene 4) Make the reader understand WHY you didn't treat or transport 5) Presume nothing and leave nothing [relevant] to the imagination As you can see, knowing the audience for your documentation is as important as everything else an emergency provider has to do, perhaps more so if knowing the audience leads to greater diligence

and better care. It's Grad Time ~ 6 things your preceptor never wants to hear Contrary to nursing legend, preceptors arent villains. They want you to succeed, and, if given the chance, could be your best advocate. After all, most of them have volunteered for the job or have been identified by their manager as the type of person who would be able to help you best. When preceptor-new nurse relationships get to the point of intervention, its not always the preceptors fault . . . really. Sometimes, new nurses shut out their preceptor, saying things that demonstrate they dont want help, dont need help, or dont want to work at all. Kim Rapper, RN, a preceptor for many years, tells you what not to say to your preceptor so that your relationship stays healthy and beneficial to you: 1. I already know how to do that. The know-it-all attitudeand cutting off your preceptor in the midst of instructionwill keep you from learning all you can. You dont know it all, not even the most seasoned nurse does. Even if youve seen a procedure done 102 times, you can benefit from the reiteration. Every preceptor, even if his/her personality drives you crazy, has insights from which you can benefit. And if you listen and watch closely, you may pick up some simple strategy to master the skills you already possess. So, dont shut your preceptor out, and be open to new ways of doing things. 2. I cant do this! Most preceptors appreciate when a new nurse admits they dont know how to do something. But dont say, I cant. Its not the right word, because you will be doing it by the end of the orientation. Saying I cant suggests you dont care to learn. Instead, say, I dont know how to do this yet. I need your help. This demonstrates a willingness to learn. And it is completely appropriate; your preceptor needs to be in the room watching, helping, and coaching. No one should be doing something they feel they cant do or have never done before. Its in those instances that a good preceptor will be able to push youso, ultimately, you will be able to fly on your own.

3. Did you hear what so-and-so said? Cattiness and gossip are never appropriate. Its okay for a nurse to say to a preceptor, I dont feel comfortable with so-and-so nurse. But to come out and say things like, Did you hear what so-and-so did? chips away at your professional demeanor. Dont get me wrong, its okay for there to be differences. However, when your priority shifts from quality patient care to the Whos Who network, there is a problem. New nurses need to be socialized appropriately, and many preceptors take on that responsibility by inviting new nurses out to lunch and introducing them to the physicians. This needs to happen more frequently. If preceptors dont socialize new nurses into their peer group in a professional manner, then cattiness takes over. 4. If you dont put me on the day shift, Im going to quit! We had a new graduate make this demand. And, as you know, its an unrealistic one. New nurses are low on the totem pole, so expect to work the hard shifts. Most new grads start on the night shift; day shifts come with seniority. When you sign a contract, youre agreeing to work any shift. So its shocking to me that new grads start making demands when this is what theyve signed up for. However, if you are struggling with the night shift, seek support and advice from your preceptor on how to make nights work for the short-term; shes been there. Also remember that if you want to pick and choose your shifts, you have to stick with your hospital. At many hospitals, seniority is rewarded.

Thats why Ive stayed with the hospital I started with; now, more often than not, I get the shifts I request. 5. Id rather be doing Once I heard a new grad frequently and freely talk about changing her careerbecause nursing was beneath her aspirations. If nursing isnt what you expected, youve got to discuss that with your preceptor. But dont waste your time, or your preceptors time, if you know youre not going to stick with it. Nursing demands passion and a stick-with-it attitude. 6. Im doing it just for the money. These types are called appliance nurses. I made a commitment to myself when I was in nursing school that I would never keep doing this if it became just a job. That may not be something that everyone can do. But if you find you are seeing your job just as a paycheck, then maybe you need to take a step back. That may mean dumping some of your expectations of yourself. Or maybe you need to pursue activities that recharge you. For instance, I dabble in graphic arts, which rejuvenates me. When I go back to work, I do my nursing job much better because I want to, not because Im locked in. Ive learned you need to be able to do this job for the right reasons: to give the best possible patient care and make a difference in peoples lives.

[NEW] 2010 Guidelines CPR & ECC No longer A irway B reathing C irculation's now C A B with emphasis on compressions FIRST, i. e. no longer Look, Listen, Feel prior to compressions. So, Push Hard [at least 2"] & Push Fast [at least 100 x's/min].

Port-a-Caths ~ Use, Care, Accessing and Deaccessing Accessing the Implanted Port -To be done weekly if accessed, or monthly for routine maintenance 1. Assemble Supplies Betadine swabsticks Alcohol swabsticks Masks Sterile gloves Huber needle Prefilled 10 NSS syringe Prefilled 5 Heparin syringe 2 x 2 gauze 2. Wash hands with soap and water 3. Peel open one corner of the Huber needle package only; Extend end of extension tubing only out the opening 4. Attach 10cc NSS syringe to extension tube.

5. Prime tubing and needle with NSS 6. Place Huber needle package on a secure flat surface and peel back package open. Do NOT touch Huber needle until sterile gloves are on 7. Caregiver applies mask; the patient has the option of putting on a mask or turning their head away from the port area 8. Put on sterile gloves 9. Open alcohol swabsticks; prep site from center of port and work outward in a circular motion to include a 2-3 area; repeat using all three swabsticks 10. Allow alcohol to air dry and then repeat procedure with three Betadine swabsticks 11. Pick up Huber needle with NSS syringe attached; touch only the Huber needle as this is sterile and the syringe is not. 12. Fold wings of Huber needle back and hold securely; remove clear protective sheath from the needle.

PORT ACCESSING AND FLUSHING PROCEDURE 13. Locate and stabilize the port site with your thumb and index finger; creating a V shape. 14. Access the port by inserting the Huber needle at a 90 angle into the reservoir 15. Once accessed, the needle must not be twisted; excessive twisting will cut the septum and create a drug leakage path 16. Flush the port with 2-5cc NSS and then attempt to aspirate a blood return; this confirms proper placement; Do NOT aspirate an arterial port 17. Slowly inject the remaining 10cc NSS; observe for resistance, swelling or discomfort; if present, assess needle placement; if still present, remove the Huber and re-access or call the physician. 18. If this is a routine maintenance flush, close clamp, remove empty NSS syringe and attach Heparin filled syringe; Do NOT attempt to aspirate blood with the Heparin syringe

19. Flush with 5cc Heparin and close the clamp 20. Secure the port with your thumb and forefinger and pull the Huber needle straight out 21. Hold slight pressure with a 2 x 2 until bleeding, if any, stops; there should never be excessive bleeding 22. This procedure should be done every 4 weeks if port is not used Dressing the Port Site 1. If port is being used for continuous infusion, connect IV tubing after step 17 of the accessing procedure; if port is being used for intermittent infusion, apply clave clamp after step 19 of the accessing procedure 2. Port should be redressed once a week with needle change 3. Assemble Supplies CVC dressing kit Flat clean work surface 4. Wash hands with soap and water 5. Remove old dressing and deaccess port 6. Access port using the procedure described in A. 7. Open the package of 2 x 2s if extra padding is needed 8. Place one 2 x 2 under the wings to provide padding on the skin if Huber is not flush with chest 9. Tear a piece of Durapore tape approximately 3 long; split tape lengthwise; tape over Huber wings in a X format 10. Cover site with Tegaderm; this provides an occlusive dressing and allows the patient to bathe or shower without disturbing the dressing 11. Secure the extra tubing with tape to prevent catching on clothes http://www.horizonhealthcareservices...ort_access.pdf Different Types of Hubers: The new GRIPPER PLUS Safety Needle is used to deliver medications intravenously through a patient's implanted port. Its unique feature is a safety arm that is lifted to lock the needle into a protected position when de-accessing it from an implanted port. An audible click provides clinicians with confirmation that the de-accessed needle is in its locked safety position. The GRIPPER PLUS Safety Needle is safe for clinicians, comfortable for patients, and easy to use. It also allows institutions to comply with NIOSH / CDC criteria for sharps safety. The GRIPPER PLUS Safety Needle is based on the input of many clinicians and the design of the

familiar GRIPPER Huber needles, which are recognized as the gold standard in Huber needles. In the last five years, Deltec has sold over 10 million GRIPPER needles worldwide.

1: From behind the GRIPPER PLUS Safety Needle place fingers on each side of the base to stabilize it. With the other hand, place a finger on the tip of the safety arm.

2: Begin to lift the safety arm straight back. Notice that the needle comes out perfectly straight.

3: Continue lifting the safety arm until the needle "clicks" into the lock position. It is now safely out of the way, ready to be disposed of in a sharps container. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ LifeGuard's needle trap fully encapsulates the needle upon de-access. Compared to traditional needles and sharps, Lifeguard is designed for maximum control and safety with minor changes to technique.

Safeguard against Needlestick injuries Enhanced for Patient Comfort Designed for Maximum Control Easy to Use Minimum change to technique Large Grip Handle for Secure control

LifeGuard features:

Visual and audible confirmation of safety Colored safety handle for needle gauge confirmation Low profile design Height adjustable wings Needleless compatibility Easy to secure

LifeGuard Safety Needle will easily insert into all implanted ports and when de-accessing from the port it encapsulates the sharp point fully, preventing unnecessary needlesticks to clinicians and custodial staff. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Whether you're delivering chemotherapy, antibiotic therapy, or parenteral nutrition, the Surecan Safety Huber Needle's patented safety clip will automatically engage as you withdraw the needle from the base plate.

That's safety and compliance virtually assured. SURECAN Safety Huber Needle Features:

Passive design - no user activation needed Enables you to inject medication or withdraw blood from the Y-site with a simple luer connection when using available ULTRASITE Needle-free valve DEHP-free for compatibility with chemo drugs and lipids

Latex-free to avoid the risk of allergic reaction Conveniently color-coded by size (19, 20, and 22 gauge)

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Simple to use Robust safety mechanism Easy visibility of access site Small footprint Non-absorbent patient comfort pad Non-coring needle Latex free Best overall value SafeStep Huber Needle Set combines excellent safety Huber needle technologan affordable, simple to use product. SafeStep features ay in robust safety mechanism with a clear base for easy site visibility. It boasts a small footprint, one of the smallest available today! Its patient comfort pad is soft and supple for patient comfort during infusion. SafeStep is the best overall value for you, your nurses, and your patients! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MiniLoc Safety Infusion Set is Specialized Health Products premier safety Huber needle. MiniLoc is designed with an ultra-low profile, small footprint and enhanced angled tubing to facilitate dressing and help maintain dressing integrity.

MiniLocs specially lubricated needle reduces penetration and access forces during port access. Its needle forward design facilitates dual lumen port access. MiniLoc is latex free and features DEHP free tubing. MiniLocs ergonomic, integral wing design allows controlled, easy safety mechanism engagement. An audible click as well as tactile feel and a visual indicator confirm safety mechanism engagement

Let's Learn ABG's ~ Part I Normal pH of the blood is 7.35 to 7.45 Look at pH and determine if it is acidotic or alkalotic > 7.45 The pH is the best overall indicator in determining the acid-base status of the patient. Both acidosis and alkalosis can be of two different types: respiratory and metabolic. Respiratory acidosis or alkalosis is caused by various malfunctions of the lungs. Metabolic acidosis or alkalosis is caused by various metabolic disorders which result in an excessive build up or loss of acids or bases. Ok heres my basic first step interpretation: Ph interpretation. If Ph < 7.35, aciDotic. ( "D" for down, or less then). If Ph > 7.45, alKalotic ( "K" for Clouds, up, or greater then -- hey its close!) Bicarb is kidneys, metabolic. ( 22-26) PCo2 is lungs, respiratory. (35-45, same as the ph) Put them together, you get your answer :) The end! You got the Ph, right?? If its low, you're acidotic. If its high, your alkalotic. Now we need to figure out if its respiratory, or metabolic. So we look at the bicarb and the PCo2. If the Pc02 is normal ( 35-45), then it cannot be a respiratory problem. If the Pc02 is above or below normal, its a respiratory problem. If the bicarb is normal (22-26), then it cannot be a metabolic problem. if the bicarb is above or below normal, it is a metabolic problem. So the first part: Metabolic or Respiratory. ** We look at the bicarb and the PCo2. Which one is out of range? Now the second part: ** We look at the PH: Is the Ph high, or low? That gives you the answer to that. Then, we combine the two to get the answer.

Resp or Meta Acid or Alka ______________________________________________________________ Basic Geriatric Respiratory Assessment The objective of the pulmonary assessment of a geriatric patient is to check for the following:

Quality of respiratory efficiency; Gas exchange; and Presence of disease.

Respiratory Rate Normal respiratory rates for older patients are 12 to 18 breaths per minute for those living independently and 16 to 25 breaths per minute for those in long term-care. Tachypnea. A respiratory rate of 20 breaths per minute (or more than 25 breaths per minute for someone in a nursing home) indicates tachypnea. In such cases, look for the following:

Infection (especially pneumonia); COPD, the patient has air trapping and cannot empty the lungs. Congestive heart failure Pulmonary embolus Metabolic acidosis.

Bradypnea Bradypnea is a form of hypoventilation, in which the patient has a respiratory rate of less than 10 breaths per minute. Respiratory Effort Normal breathing is quiet and unlabored. If it is labored, it is important to note respiratory effort. In patients with pneumonia or acute abdomen, labored breathing prevents airway closure. Patients who have air hunger will often breathe with an open mouth. Audible Breath Sounds Pay attention to the breath sounds. Wheezing is an important clue to reactive airways or local obstruction. Coughing indicates lower airway irritation. Stridor implies partial airway obstruction. Respiratory Patterns Check for respiratory patterns and signs that indicate specific conditions. For example, inspiration interrupted by cough suggests pleuritic pain or inflammation. Chest Movement During Respiration The next part of the chest inspection is to observe the patient's chest movement during respiration. Use of Accessory Muscles Using accessory muscles implies that the forced expiratory volume is decreased to 30% of normal. In such cases, a sitting patient may lean forward with hands propped on the knees. Percussion Make sure your hands are warm before you begin percussion. Start at the back and check each side to compare the quality of the sensation. It is key to keep the wrist loose and the hand floppy. As you percuss, consider the characteristic of the structure you are percussing. One trick is to practice over a

table percussing from the center toward the legs. Notice how the percussion note feels firm when over the leg of the table. Close your eyes and practice until you can reliably stop over the leg. Sometimes an elderly patient is too ill to sit up and percussion must be accomplished with the patient in the lateral decubitus position. This position can add some artifacts of lung compression, producing dullness in the mid lung fields of both the dependent and upward lungs. Of note, the feel of the resonance may be more sensitive than the sound of the percussion note, especially in a noisy setting such as a crowded emergency room, where subtleties of sound are more difficult to appreciate. Basic Percussion Techniques 1. Light pat. Gently pat the back on each side starting at the apices and moving down to the diaphragm. 2. Direct percussion. Place your dominant hand on the skin and raise your forefinger and tap on the skin directly. 3. Indirect percussion Place your non-dominant hand on the skin and with your dominant middle finger tap the middle finger of your nondominant hand at the sistal interphalangeal joint. Dullness and Its Indications Dullness to percussion implies consolidation, pleural fluid, or pleural scarring. Auscultation Make sure that the listening area is quiet, and importantly, do not listen through the patient's clothing. Warm your stethoscope either by carrying it in your pants pocket or by vigorously rubbing it. One strategy is to place a rubber membrane on the bell and have the patient breath deeply with the mouth open. Make sure that your stethoscope bell is securely placed flat on the chest and that you are not breathing on your tubing. In fact, breathe on the tubing beforehand to appreciate the low-pitched rustling sound your breath produces. Be sure that your earpieces are securely in your ears to exclude environmental noise. Listen to at least 2 respiratory cycles at each location. All breath sounds should increase in pitch with inspiration and decrease with expiration. Begin at the bases and work up the back. Starting at the bases allows you to appreciate any basilar crackles secondary to atelectasis or early congestive heart failure. If you start at the apices and work down, such crackles might disappear by the time you get to the bases. If you hear additional noises make sure they are coming from the patient's chest and not from the skin, muscles, or other extraneous source. For example, body hair can produce a crackling sound that resembles dry cellophane crackles. Wheezes Wheezes are musical sounds that indicate airway obstruction, which when it occurs during expiration, suggests a source within the chest. Wheezing that occurs on inspiration suggests obstruction in the trachea (outside the chest). Hearing both inspiratory and expiratory wheezes is more concerning than hearing either alone. Crackles (Rales) Inspiratory crackles are common in elderly people. Note the location of expiratory crackles. Fixed crackles suggest fibrosis or pneumonia. Rhonchi Rhonchi are coarse flapping sounds that suggest fluid or mucus in an airway. Pleural Friction Rubs Pleural friction rubs are leathery, creaky sounds similar to the sound of slowly rubbing your palms together. They do not have a musical quality, like a wheeze does, but suggest 2 inflamed pleural surfaces rubbing together. They can occur on both inspiration and expiration, but they usually occur

with inspiration and tend to be localized. Hearing a pleural friction rub implies neoplasm, pulmonary infarction, pneumonia or tuberculosis. Signs of Pleural Inflammation Pain offers a clue to possible pleuritic inflammation. Pain from pleural irritation may also be referred to the shoulder. Demeanor and Posture Patients in respiratory distress may appear restless, agitated, or drowsy. The patient's eyes may be prominent. Patients in respiratory distress will often sit leaning forward using their accessory muscles. Patients who sit leaning forward with their legs dependent (Fowler's position) may have severe heart failure. Informed Consent Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention. In the communications process the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:

The patient's diagnosis, if known; The nature and purpose of a proposed treatment or procedure; The risks and benefits of a proposed treatment or procedure; Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance); The risks and benefits of the alternative treatment or procedure; and The risks and benefits of not receiving or undergoing a treatment or procedure.

In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention. This communications process, or a variation thereof, is both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states. Providing the patient relevant information has long been a physician's ethical obligation, but the legal concept of informed consent itself is recent. The first case defining informed consent appeared in the late 1950's. Earlier consent cases were based in the tort of battery, under which liability is imposed for unpermitted touching. Though battery claims occasionally occur when treatment is provided without consent, most consent cases generally center around whether the consent was "informed", i.e., whether the patient was given sufficient information to make a decision regarding his or her body and health care. It is important that the communications process itself be documented. Good documentation can serve as evidence in a court of the law that the process indeed took place. A timely and thorough documentation in the patient's chart by the physician providing the treatment and/or performing the procedure can be a strong piece of evidence that the physician engaged the patient in an appropriate discussion. A well-designed, signed informed consent form may also be useful, but an overly broad or highly detailed form actually can work against you. Forms that serve mainly to satisfy all legal requirements (stating for example that "all material risks have been explained to me") may not preclude a patient from asserting that the actual disclosure did not include risks that the patient unfortunately discovered after treatment.

At the other extreme, listing all of the risks may not be wise either. A comprehensive listing will be difficult for the patient to understand and any omission from the list will likely be presumed undisclosed. Medicare participating physicians must also be cognizant of CMS's requirements for informed consent. ________________________________________ When you find a pill lying about, or in an unmarked container, try this site for pill ID: Righthand side, best resources in the NAVIGATION brown box. You land on other sites, but the pill wizard is fantastic. has my fav free drug guide and compatability stuff online or PDA/Blackberry, but not all options are free. And for my 'Como se dice esto en Espanol' issues, I like

Encyclopedia of Nursing and Allied Health This is probably more of a resource for students, but is jam packed with useful information for all.

Insulin Chart ~ Types, Onset, Peaks, and Durations Types of Insulin Each type of insulin has an onset, a peak, and a duration time. The onset is how soon the insulin starts to lower your blood glucose after you take it. The peak is the time the insulin is working the hardest to lower your blood glucose. The duration is how long the insulin laststhe length of time it keeps lowering your blood glucose. Eat Right - Printable Patient Handouts The American dietetic association.The ADA Nutrition Care Manual is a valuable resource providing disease-specific information and evaluation, printable patient handouts, calculators that compute BMI/weight range, customization tools and much more.

The Land of ABG * A. The Last Name 1. First, look at her pH. (Normal = 7.35-7.45) 2. If her pH is < (less than) 7.35; her last name is ACIDOSIS. 3. If her pH is > (greater than) 7.45; her last name is ALKALOSIS. (Note: To be an absolutely perfect last name--her pH needs to be 7.40. So, keep in mind, that if her pH is 7.35-7.39--shes thinking about marrying into the ACIDOSIS family. If her pH is 7.41-7.45--shes thinking about marrying into the ALKALOSIS family.) B. The First Name Now that you know your patients last name, you would like to also learn her first name. 1. Look at her pH again. 2. If it is 7.35-7.45 (normal) then her first name is COMPENSATED. 3. If the pH is <7.35 or >7.45--then her first name is UNCOMPENSATED. C. The Middle Name Now that you know your patients first and last name, you would like to know her middle name. (Name Alert: These people are all related and you have many patients with the same first and last name. A middle name will give you more information to go on.) 1. First you need to look at the CO2 and HCO3. (Remember: Normal CO2 = 35-45. Normal HCO3 = 22-26) 2. The middle name will either be Respiratory or Metabolic. 3. If the CO2 is <35 or >45--her middle name is RESPIRATORY. 4. If the HCO3 is <22 or >26--her middle name is METABOLIC. D. The Family Feud 1. pH and HCO3 are "kissin cousins"--they like to go in the same direction. 2. But CO2 is the "black sheep"--pH runs the opposite direction when it sees him coming. Therefore: 3. Decreased pH with Decreased HCO3 = ACIDOSIS.

4. Increased pH with Increased HCO3 = ALKALOSIS. 5. Decreased pH with Increased CO2 = ACIDOSIS. 6. Increased pH with Decreased CO2 = ALKALOSIS. Peds Quiz ~ 25 questions/Instant Scoring Click this link to take the test live: 1.A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min.

You should immediately determine whether the patient has: A.stridor. B.delayed capillary refill time. C.weak pulses. D.the ability to tolerate oral feedings. 2.A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min. Abdominal breathing in this patient should be viewed as a: A.normal finding for a toddler. B.sign of impending respiratory failure. C.sign of decreased perfusion to the respiratory center. D.compensatory mechanism to increase the volume of air inhaled and respiratory rate. 3.A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min. The first step in treatment is to: A.administer a nebulizer treatment with a beta-agonist medication. B.administer humidified oxygen via blow-by method. C.suction the oropharynx for secretion. D.deliver bag-valve-mask ventilations.

4.A 6-year-old boy who was struck by a car while he was riding his bicycle is unresponsive and has pale, cool skin. Assessment reveals abrasions to his left shoulder and back and a swollen, deformed left thigh. He has a blood pressure of 74/62 mm Hg, a pulse of 152 beats/min, and respirations of 44 breaths/min. without increased work of breathing. What do these findings tell you about the patient s condition? A.He is unresponsive and his skin is cool because of a low body temperature from being outside B.His heart rate is fast because of pain in his shoulder and leg C.His respirations are fast because the impact affected the respiratory center in his brain D.His blood pressure is low because compensatory mechanisms for blood loss are failing 5.A 3-month-old infant who is extremely lethargic has had a cough, vomiting, and diarrhea for the past 3 days. Assessment reveals that he responds to pain, has mottled skin color, and a capillary refill time of 4 seconds. He has a blood pressure of 74/60 mm Hg, a pulse of 190 beats/min, and rapid, respirations without increased work of breathing at 60 breaths/min. The tachycardia in this infant is most likely due to: A.anxiety. B.hypovolemia. C.pneumothorax. D.swelling of the brain. 6.A 3-month-old infant who is extremely lethargic has had a cough, vomiting, and diarrhea for the past 3 days. Assessment reveals that he responds to pain, has mottled skin color, and a capillary refill time of 4 seconds. He has a blood pressure of 74/60 mm Hg, a pulse of 190 beats/min, and rapid, respirations without increased work of breathing at 60 breaths/min. The appropriate initial treatment is to: A.administer 100% oxygen by mask. B.administer dopamine intravenously. C.administer epinephrine via an intraosseous needle. D.perform endotracheal intubation. 7.Which of the following findings in a 2-year-old child assists in identifying the cause of a grand mal seizure? A.Fever B.Crackles in the lungs C.Abdominal tenderness D.Cardiac dysrhythmia 8.Activated charcoal is contraindicated in a patient who has ingested a toxic substance if: A.there is a history of abdominal surgery. B.there is a history of diarrhea or vomiting. C.the substance was corrosive. D.the substance was ingested approximately one hour ago.

9.A 10-year-old girl is unresponsive when she surfaces after diving into a quarry. Bystanders report that she was shaking all over as they pulled her out of the water. The first step in caring for this patient is to: A.stabilize her cervical spine to reduce the risk of further spinal injury. B.elevate her head to reduce the risk of aspiration. C.turn her on her side to allow any water to drain from her mouth. her mouth and insert an oropharyngeal airway to maintain a patent airway. 10.An 8-year-old boy fell 7 feet out of a tree, landing on his right arm and falling to his right side. He is crying and appears agitated. Assessment reveals that he has pale, warm skin, multiple abrasions on his right shoulder and hip, and a deformed right forearm. He has a blood pressure of 92/74 mm Hg, a pulse of 128 beats/min, and respirations of 32 breaths/min. What is the best approach to conducting the assessment of this patient? A.Telling him he must lie still or he may become paralyzed B.Exposing only those areas currently being assessed and then covering them C.Asking him if it is okay to listen to his lungs and touch his chest and stomach D.Asking him what hurts the most and begin by assessing that area of the body 11.An 8-year-old boy fell 7 feet out of a tree, landing on his right arm and falling to his right side. He is crying and appears agitated. Assessment reveals that he has pale, warm skin, multiple abrasions on his right shoulder and hip, and a deformed right forearm. He has a blood pressure of 92/74 mm Hg, a pulse of 128 beats/min, and respirations of 32 breaths/min. After completing your initial assessment, the first step in caring for this patient is to: A.manually stabilize the cervical spine to reduce the risk of spinal injury. B.initiate hyperventilation to reduce the accumulation of acids in the body. C.cover him with blankets to prevent heat loss. him in a position of comfort to decrease anxiety. 12.An 8-year-old boy fell 7 feet out of a tree, landing on his right arm and falling to his right side. He is crying and appears agitated. Assessment reveals that he has pale, warm skin, multiple abrasions on his right shoulder and hip, and a deformed right forearm. He has a blood pressure of 92/74 mm Hg, a pulse of 128 beats/min, and respirations of 32 breaths/min. What is the most likely cause for the abnormal appearance of this patient? A.Secondary brain injury B.Hypoxia C.Pain D.Hypothermia 13.What information is important to obtain about a child with smoke inhalation? A.Presence of windows or ventilation in the room B.Position of the patient when found C.History of recent cold symptoms

D.Location in the room where the patient was found 14.A 6-month-old infant who is being cared for by a babysitter is unresponsive and has warm, pink skin and respirations without increased work of breathing.. The babysitter appears anxious and frustrated and explains that the infant had been crying for hours and would not stop. The babysitter states, "I couldn t get her to stop crying. I tried everything. All of a sudden she got really quiet, and I couldn't wake her up. Please help her. I can't take her crying any more." The babysitter states that she does not think that the infant has been sick recently. The infant s altered level of consciousness is most likely due to: A.toxic exposure. B.shaken baby syndrome. C.seizures. D.respiratory failure. 15.An 18-month-old boy who reportedly fell down the stairs earlier in the day just isn t acting right, according to his caregivers. Assessment reveals multiple bruises on his thighs and back and a deformity of his right thigh. He is alert and crying. What is the best way to interact with the caregivers? A.Confront them by telling them you know that this injury could not have occurred from a fall; therefore, you are obligated to take him to the hospital. B.Ask them why they waited so long to call for help; the delay has made the child very sick; therefore, you will need to administer oxygen and establish an IV. C.Contact the local law enforcement agency to request that the caregiver be arrested while you transport the child. D.Explain that you are very concerned about the child s condition and that he needs to be examined at the hospital for a possible a broken leg. 16.A woman who is about to deliver a baby at home reports that the fluid was thick green when her bag of waters broke. The most important treatment of the newborn is to: A.vigorously dry and warm the baby. B.copiously suction the mouth and nose. C.administer oxygen by nasal cannula at 4 L/min. D.calculate the APGAR score. 17.Ascertaining the due date of a newborn during an impending delivery helps you to: A.assemble the correct size of equipment to care for the baby. B.decide whether the baby will be delivered at the scene or if there is time to transport the mother to the hospital. C.decide if an on-scene delivery is needed, particularly if the infant is premature, as the labor is often shorter for these infants. D.determine if meconium aspiration may have occurred. 18.Assessment of a newborn five minutes after delivery reveals cyanosis of the hands, feet, trunk, and face. Vital signs are pulse 160 beats/min and respirations 44 breaths/min. Treatment of this newborn includes:

A.initiating bag-valve-mask ventilations. B.performing intubation and positive pressure ventilation. C.applying free flow oxygen by mask at 5 L/min. D.reassessing the skin color in five minutes and then initiating oxygen therapy if needed. 19.An infant should be immediately evaluated by a physician if which of the following signs or symptoms are present? A.Use of abdominal muscles to breathe B.Temperature of 37 degrees (98.6 F) C.Acting fussier than normal D.Refuses a pacifier 20.A 3-year-old boy who has a tracheostomy has had difficulty breathing and coughing for 2 days because of increased secretions. He is on continuous oxygen. His mother states that his breathing is getting much worse. Assessment reveals that he is lethargic, has cool, mottled skin, and has copious secretions in the tracheostomy tube. Which of the following signs suggests significant obstruction of the tracheostomy tube? A.A slow heart rate and poor air exchange B.Irregular respirations and wheezing C.Crackles and decreased breath sounds D.Unequal chest rise and wheezing 21.During transport, what is the correct way to manage the respiratory status of a boy who is on a ventilator but also breathes on his own? A.Allow the patient to remain on the ventilator if he is not in respiratory distress B.Immediately deliver bag-valve-mask ventilations because you may not be familiar with the ventilator C.Switch the patient to oxygen by blow-by method because the ventilator will not work in the ambulance D.Decrease the flow rate as the oxygen in the ambulance is more potent and requires a lower flow rate 22.What is the danger of using a mask that is too large on a child who requires ventilatory assistance? A.Eye injuries may occur from the mask touching the globe B.It will be more difficult to obtain a seal for ventilation C.More pressure will need to be applied to obtain a mask seal, which may cause dislocation of the mandible D.If the mask extends across the eyes, it may exert pressure and stimulate the vagus nerve 23.What is the correct method to confirm proper placement of an endotracheal tube? A.Palpate for chest rise and fall over the anterior chest and abdomen B.Observe for gastric distention which indicates leakage of air around the tube in the trachea C.Auscultate the anterior chest and mid-abdominal area for the presence of bubbling or gurgling sounds D.Auscultate for bubbling or gurgling sounds over the epigastrium and breath sounds at the

midaxillary regions 24.When should the child s head be secured to the spine board during the immobilization procedure? A.After the body straps and lateral stabilization devices have been applied B.After the body straps have been applied, but before the lateral stabilization devices to ensure that the tape is applied tightly C.Before any straps or lateral stabilization devices have been applied D.If the child is quiet the head does not need to be secured once lateral stabilization devices are applied 25.Which of the following substances can be infused via an intraosseous needle? A.All medications and intravenous fluids B.All medications except sodium bicarbonate and dextrose C.Fluids or medications that are not acidic D.Only medications and fluids that have a neutral pH

__________________________________ CDC - Infectious Disease Guidelines Topic Sections Antibiotic and antimicrobial resistance Bacterial infections Diarrheal diseases Infection control, healthcare quality, and healthcare-related infections (on Division of Healthcare Quality Promotion site) Occupational exposure and health (on Division of Healthcare Quality Promotion site) Opportunistic infections Parasitic infections Sexually transmitted diseases Surveillance Travel and immigration Note: for SARS-related guidelines, please see the Severe Acute Respiratory Syndrome site Vaccination Viral infections ECG ~ 6 Second Strips Challenge yourself to identify rhythm strips ECG Encyclopedia

EKG Encyclopedia: The Virtual Pediatric Patient Available Cases

Case 1 - A cranky child Case 2 - A child with an abdominal mass Case 3 - An adolescent with leg pain Case 4 - A child with chronic constipation and pica Case 5 - A child with vomiting and diarrhea (Note this case is only available to users at the University of Iowa) Case 6 - A child with a sore throat Case 7 - A child with a fever Case 8 - A newborn with vomiting

http://www.virtualpediatrichospital....dsVPHome.shtml The Virtual Autopsy Ever had the urge to be a Medical Examiner? This site gives you 12 cases, their medical history & exam results ~ You try to pinpoint the cause of death. Traumatic Brain Injury Simulator The Neurotrauma Moulage is a traumatic brain injury simulator. It is designed to simulate a range of conditions affecting the management of the injured brain, and to encourage a greater understanding of the main tenets of traumatic brain injury management - especially the prevention of secondary injury. The initial stages of the moulage take you through the acute, emergency department management of the head injured patient. Once on the intensive care unit you are faced with various scenarios and you have to act to minimise brain ischaemia. You will not be presented with the next scenario until you've managed to get the brain back to it's calm, blue, oxygenated state as in the picture below! ECG Workshop ECG ROUNDS:Choose a case below CaseDescription A 75 year old man with dyspnea. What is the diagnosis? A 43 year old man with atypical chest pains. What is the diagnosis? A 58 year old female with chest pains. What is the diagnosis? A 75 year old woman with new onset of palpitations. What is the rhythm? A patient with chest pain and dyspnea. What is the rhythm? An elderly man with stroke. What interesting phenomena occurs?

Chest pain while visiting in the hospital. What's the diagnosis? Anorexia and dehydration. The EKG makes the diagnosis. Lidocaine may be hazardous to your health. A case of abnormal complexes. A 36 year old female with dyspnea after cocaine. What's the rhythm? A 29 year old female with palpitations. What's the rhythm? A 27 year old male with chest pain. What's the diagnosis? Is it ventricular or atrial? Interesting Rhythm and complexes. 52 yo male c/o chest pain. 74 y.o. male c/o weakness and dyspnea. Orientation to ICU/CCU We wrote this book to help new nurses and those orienting to ICU. They liked it so much they encouraged us to put it online for others to use...feel free to use these materials, but please give us attribution. Enjoy... feel free to copy them for any useful purpose. Thanks! Starting Out - New in the ICU Labs Pressors and Vasoactives Pacemakers Med Tips Arryhthmia Review Chest Tubes Blind Suctioning for Beginners Reading X-rays Perhipheral IV's for Beginners Intubations NG Tubes for Beginners Vents and ABGs Foleys for Beginners Pulmonary Embolisms ICP Monitoring Transfusions and Blood Two Interesting Situations PA-Lines Defibrillation Bedside Emergencies Heart Blocks Reading EKGs II What Nurses Really Do... Arterial Lines Sedation and Paralysis Central Lines

Reading 12-lead EKGs IABP Review Nutrition Help Calculating Medication Dosages - Includes test with instant scoring Calculating Medication Dosages This interactive study guide features Learning Outcomes, Matching Questions, Practice Questions, Know Your Labels, Case Studies, Student Success, a Link to the New York Times, and WebLinks, which will help you apply the concepts presented in this new exciting text. At the completion of each quiz section you may submit your answers to receive an instant score of your results.
Chapter 1: Review of Arithmetic for Medical Dosage Calculations Chapter 2: Safe and Accurate Drug Administration Chapter 3: Dimensional Analysis Chapter 4: Systems of Measurement for Dosage Calculations Chapter 5: Converting from One System of Measurement to Another Chapter 6: Calculating Oral Medications Doses Chapter 7: Syringes Chapter 8: Preparation of Solutions Chapter 9: Parenteral Medications Chapter 10: Calculating Flow Rates and Durations of Enternal and Intravenous Infusions Chapter 11: Calculating Flow Rates for Intravenous Medications Chapter 12: Calculating Pediatric Dosages Comprehensive Self-Test ECG: The Art of Interpretation This site gives you many valuable tools to enhance learning: Test yourself with "ECG Quizzes." Click on "Practice ECGs" to hone your skills. Choose "Flashcards" to quiz yourself on key terms. Look up vocabulary at "Online Glossary." Use "Web Links" as a resource for further online ECG information. NCLEX Sample Questions NCLEX Sample Questions 1. A nurse is working in an outpatient orthopedic clinic. During the patients history the patient reports, "I tore 3 of my 4 Rotator cuff muscles in the past." Which of the following muscles cannot be considered as possibly being torn?

A: Teres minor B: Teres major C: Supraspinatus D: Infraspinatus 2. A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention? A: A home health patient reports, "I am starting to have breakdown of my heels." B: A patient that received an upper extremity cast yesterday reports, "I cant feel my fingers in my right hand today." C: A young female reports, "I think I sprained my ankle about 2 weeks ago." D: A middle-aged patient reports, "My knee is still hurting from the TKR." 3. A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions? A: Patient may have a DVT. B: Patient may be exhibiting signs of dermatitis. C: Patient may be in the late phases of CHF. D: Patient may be experiencing anxiety after surgery. 4. A nurse is performing a screening on a patient that has been casted recently on the left lower extremity. Which of the following statements should the nurse be most concerned about? A: The patient reports, "I didnt keep my extremity elevated like the doctor asked me to." B: The patient reports, "I have been having pain in my left calf." C: The patient reports, "My left leg has really been itching." D: The patient reports, "The arthritis in my wrists is flaring up, when I put weight on my crutches." 5. A 93 year-old female with a history of Alzheimers Disease gets admitted to an Alzheimers unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse? A: Recommend the patient remain in her room at all times. B: Recommend family members bring pictures to the patients room. C: Recommend a speech therapy consult to the doctor. D: Recommend the patient attempt to walk pushing the w/c for safety. 6. A nurse is covering a pediatric unit and is responsible for a 15 year-old male patient on the floor. The mother of the child states, "I think my son is sexually interested in girls." The most appropriate course of action of the nurse is to respond by stating: A: "I will talk to the doctor about it." B: "Has this been going on for a while?" C: "How do you know this?" D: "Teenagers often exhibit signs of sexual interest in females." 7. A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is: A: Request a private evaluation of the females scalp from her parents. B: Contact the females parents about your observations. C: Observe the hairline and scalp for possible signs of lice. D: Contact the students physician. 8. A nurse is caring for a patient who has recently been diagnosed with

fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant? A: Transferring the patient to the shower. B: Ambulating the patient for the first time. C: Taking the patients breath sounds D: Educating the patient on monitoring fatigue 9. A nurse has been instructed to place an IV line in a patient that has active TB and HIV. The nurse should where which of the following safety equipment? A: Sterile gloves, mask, and goggles B: Surgical cap, gloves, mask, and proper shoewear C: Double gloves, gown, and mask D: Goggles, mask, gloves, and gown 10. A nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to use a quad cane. Which of the following is the most appropriate gait sequence? A: Place the cane in the patients left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence. B: Place the cane in the patients left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence. C: Place the cane in the patients right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence. D: Place the cane in the patients right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence. 11. A nurse has just started on the 7PM surgical unit shift. Which of the following patients should the nurse check on first? A: A 75 year-old female who is scheduled for an EGD in 10 hours. B: A 34 year-old male who is complaining of low back pain following back surgery and has an onset of urinary incontinence in the last hour. C: A 21 year-old male who had a lower extremity BKA yesterday, following a MVA and has phantom pain. D: A 27 year-old female who has received 1.5 units of RBCs. via transfusion the previous day. 12. A 64 year-old Alzheimers patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure? A: Secure the restraints to the bed rails on all extremities. B: Notify the physician that restraints have been placed properly. C: Communicate with the patient and family the need for restraints. D: Position the head of the bed at a 45 degree angle. 13. A 22 year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening? A: The patient is excited about being around family again. B: The patients suicide plan has probably progressed. C: The patients plans for the future have been clarified. D: The patients mood is improving. 14. A patient that has delivered a 8.2 lb. baby boy 3 days ago via c-section, reports white patches on her breast that arent going away. Which of the following medications may be necessary? A: Nystatin B: Atropine C: Amoxil

D: Loritab 15. A 13 year old girl is admitted to the ER with lower right abdominal discomfort. The admitting nursing should take which the following measures first? A: Administer Loritab to the patient for pain relief. B: Place the patient in right sidelying position for pressure relief. C: Start a Central Line. D: Provide pain reduction techniques without administering medication.

16. A 64 year-old male who has been diagnosed with COPD, and CHF exhibits an increase in total body weight of 10 lbs. over the last few days. The nurse should: A: Contact the patients physician immediately. B: Check the intake and output on the patients flow sheet. C: Encourage the patient to ambulate to reduce lower extremity edema. D: Check the patients vitals every 2 hours. 17. A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The nurse should do which of the following first? A: Check the patients chest x-ray results. B: Retake vitals including blood pressure. C: Perform a neurological screen on the patient. D: Request the physician on-call assess the patient. 18. A patient that has TB can be taken off restrictions after which of the following parameters have been met? A: Negative culture results. B: After 30 days of isolation. C: Normal body temperature for 48 hours. D: Non-productive cough for 72 hours. 19. A nurse teaching a patient with COPD pulmonary exercises should do which of the following? A: Teach purse-lip breathing techniques. B: Encourage repetitive heavy lifting exercises that will increase strength. C: Limit exercises based on respiratory acidosis. D: Take breaks every 10-20 minutes with exercises. 20. A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB? A: Chest x-ray B: Mantoux test C: Breath sounds examination D: Sputum culture for gram-negative bacteria

Answer Key 1. (B) Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis make up the Rotator Cuff. 2. (B) The patient experiencing neurovascular changes should have the highest priority. Pain following a TKR is normal, and breakdown over the heels is a gradual process. Moreover, a subacute ankle sprain is almost never a medical emergency. 3. (A) All of these factors indicate a DVT. 4. (B) Pain may be indicating neurovascular complication. 5. (B) Stimulation in the form of pictures may decrease signs of confusion. 6. (D) Adolescents exhibiting signs of sexual development and interest are normal. 7. (C) Observation of the students hair is the next step. 8. (A) Nursing assistants should be competent on all transfers. 9. (D) All protective measures must be worn, it is not required to double glove. 10. (A) The cane should be placed in the patients strong upper extremity, and left arm/right foot go together, for normal gait. 11. (B) The new onset of urinary incontinence may require additional medical assessment, and the physician needs to be notified. 12. (C) Both the family and the patient should have the need for restraints explained to them. 13. (B) The suicide plan may have been decided. 14. (A) Thrush may be occurring and the patient may need Nystatin. 15. (D) Do not administer pain medication or start a central line without MD orders. 16. (B) Check the intake and output prior to making any decisions about patient care. 17. (B) Dizziness can be a sign of hypotension, that may a contraindication with Morphine.

18. (A) Negative culture results would indicate absence of infection. 19. (A) Purse lip breathing will help decrease the volume of air expelled by increased bronchial airways. 20. (B) The Mantoux is the most accurate test to determine the presence of TB. The Auscultation Assistant ~ Heart Sounds & Breath Sounds to improve your skills Provides heart and lung sounds to help students improve their assessment skills.