Pharmacological and Parenteral Therapies.

WHAT IS IT?

Cirrhosis is chronic, irreversible liver disease. Inflammation and fibrosis (scarring) of liver cells (hepatocytes) form scar tissue in the liver. This scar tissue blocks blood flow through the liver and stops the liver from working properly.

Quick Concept: Because the sick liver cannot do its jobs, toxins, fluid, and pressure build up throughout the body.

Impaired liver function:

• •Impaired protein metabolism
• •Increased drug toxicity (the liver cannot break down drugs)
• •Decreased clotting factors, increased ammonia levels, increased bilirubin levels
• •Increased LFTs (liver function tests): ALT, AST, ALP
• •Impaired blood sugar regulation

Complications:

• •Hepatic encephalopathy: increased ammonia causes brain tissue swelling
• •Bleeding risk: decreased clotting factors
• •Portal hypertension: blocked blood flow raises pressure in the portal vein and backs up into GI (gastrointestinal) circulation
• •Esophageal varices: dilated, thin veins in the esophagus from portal hypertension that can rupture and bleed (life-threatening emergency)

ASSESSMENT

• •Malaise (feeling unwell) and general fatigue
• •Anorexia (loss of appetite)
• •Increased bilirubin: jaundice (yellow skin) with scleral icterus (yellow eyes), dark urine, clay-colored stools
• •Impaired protein metabolism: edema (swelling), ascites (fluid in the belly), increased ammonia leading to hepatic encephalopathy (disorientation, altered LOC, asterixis or flapping hand tremor)
• •Pain in the RUQ (right upper quadrant of the abdomen)
• •Hepatomegaly (enlarged liver)
• •Splenomegaly (enlarged spleen)
• •Portal hypertension: hemorrhoids, varicose veins, esophageal varices that can cause massive GI bleed and vomiting blood
• •Impaired coagulation: anemia, bleeding, easy bruising

MANAGEMENT

Medications:

• •Analgesics (pain relievers)
• •Vitamin K for clotting factors
• •Antacids to decrease esophagus irritation
• •Lactulose to decrease ammonia levels
• •Blood products if bleeding
• •Diuretics (water pills) to remove fluid

Procedures and care:

• •Paracentesis to drain abdominal fluid
• •Dietary restrictions: fluid restriction, decreased protein intake, decreased sodium (Na) intake

Esophageal varices:

• •Endoscopy to cauterize, clip, or band varices to prevent bleeding
• •Sengstaken-Blakemore OR Minnesota tube: balloon inflated in the esophagus to put pressure on bleeding varices

WHAT IS IT?

Pancreatitis is inflammation of the pancreas. It happens when the pancreas digests itself (autodigestion) after long-term damage. Acute pancreatitis occurs suddenly, and most clients recover fully. Chronic pancreatitis is usually due to long-standing alcohol abuse with loss of pancreatic function.

CAUSES

• •Alcohol abuse
• •Gallbladder disease
• •Obstruction of the ducts
• •Hyperlipidemia (high blood fats)
• •Peptic ulcer disease (PUD)

ASSESSMENT

• •Abdominal pain with sudden onset, in the mid-epigastric area and left upper quadrant
• •N/V (nausea and vomiting)
• •Weight loss from malabsorption
• •Abdominal tenderness
• •Abnormal labs: increased WBC (white blood cells), bilirubin, ALP (alkaline phosphatase), amylase, lipase
• •Cullen's sign: bruising and edema (swelling) around the umbilicus (belly button)
• •Turner's sign: flank bruising, a sign of pancreatic autodigestion or retroperitoneal hemorrhage (bleeding behind the abdominal cavity)
• •Steatorrhea: fatty, foul-smelling stools

MANAGEMENT

• •Suppress pancreatic secretions with NPO (nothing by mouth) diet and NG (nasogastric) tube insertion to decompress the stomach
• •IV hydration
• •TPN (total parenteral nutrition, IV feeding) for prolonged exacerbations to provide adequate nutrition
• •ERCP (endoscopic retrograde cholangiopancreatography) to remove gallstones: a camera is inserted to visualize the common bile duct

Surgery:

• •Whipple: remove a portion of the pancreas (for a mass or tumor)
• •Pancreatectomy: remove the pancreas, which requires insulin, glucagon, and pancreatic enzyme supplementation
• •Cholecystectomy: if the source is gallbladder disease

Medications for pain and to control symptoms:

• •Analgesics, H2 blockers, proton pump inhibitors, insulin, and anticholinergics

WHAT IS IT?

A blood transfusion gives a client blood products through an IV. There are four types of products: packed red blood cells (PRBCs), cryoprecipitate, fresh frozen plasma, and platelets. The product must match the donor type by ABO type, Rh status, and special antibodies.

PRODUCT TYPES

• •PRBCs (also called a "unit of blood"): given for anemia
• •FFP (fresh frozen plasma): contains clotting factors
• •Platelets: given for thrombocytopenia (low platelets) and often before a procedure for clients with platelets less than 50. Re-check 1 hour post-transfusion.
• •Cryoprecipitate: contains fibrinogen, commonly used for hemorrhage and DIC (disseminated intravascular coagulation)

PROCEDURE

Prepare to transfuse:

• •Type and crossmatch/screen
• •Pre-transfusion vitals
• •Materials: special blood IV tubing, 0.9% normal saline, access to emergency medications

Begin transfusion:

• •Independent double-check completed by two RNs
• •Start the infusion at a slow rate for the first 10 to 15 minutes
• •Monitor for reaction

ASSESSMENT

• •Transfusion reactions most commonly occur in the first 10 to 15 minutes
• •Symptoms: pruritus (itching), rash, fever, chills, low back pain, anxiety
• •Reactions present similarly to anaphylaxis and can occur up to 24 hours after transfusion
• •Delayed reactions: caused by antibody mismatch, can be potentially fatal, occur in clients who have had transfusions before or have undetectable antibodies below the screening threshold
• •Post-transfusion: redraw CBC (complete blood count)

MANAGEMENT

For a transfusion reaction:

• •Immediately STOP the transfusion and SAVE the blood product for the lab
• •Treatment is similar to anaphylaxis: notify provider, give antihistamines (diphenhydramine), give acetaminophen
• •Consider furosemide for fluid overload and to maintain kidney function
• •Monitor airway patency
• •Maintain IV access
• •Report to the blood bank

WHAT IS IT?

Thrombocytopenia is a decrease in circulating platelets (less than 100,000/mL). Platelets help the blood clot, so when they are low the person bleeds easily. Causes include aplastic anemia (decreased production), autoimmune disorders (increased destruction), and medications such as heparin-induced thrombocytopenia, cytotoxic drugs, and some antibiotics.

ASSESSMENT

Abnormal labs:

• •Low platelet count
• •Low hemoglobin (Hgb) and hematocrit (Hct)

Bleeding (not enough platelets to clot):

• •Petechiae (tiny red or purple spots on the skin)
• •Epistaxis (nosebleed)
• •GI (gastrointestinal) bleeding: hematemesis (vomiting blood), melena (black tarry stool), occult (hidden) blood in the stool
• •Hematuria (blood in urine)
• •Hemoptysis (coughing up blood)

MANAGEMENT

• •Platelet transfusions

Bleeding precautions:

• •Avoid invasive procedures
• •Use a soft-bristled toothbrush
• •Avoid medications that interfere with clotting (for example aspirin, heparin)

WHAT IS IT?

This chart maps donor blood types to patient (recipient) blood types.

TABLE

Donor blood types listed: O-, O+, B-, B+, A-, A+, AB-, AB+

Patient (recipient) blood types listed: O-, O+, B-, B+, A-, A+, AB-, AB+

• •[source fragment unclear, verify at source: the chart's specific donor-to-recipient matches were not legible in the source]

WHAT IS IT?

This card covers how to treat burn injuries. Burns cause fluid loss and a high risk of infection, so early care focuses on replacing fluid, controlling pain, fighting infection, and healing the wound.

ASSESSMENT

• •On arrival to the ED or hospital, determine the total body surface area (TBSA) burned
• •1st and 2nd degree burns are very painful
• •3rd and 4th degree burns may be painless due to nerve damage
• •Impaired temperature regulation
• •Hypovolemia from third spacing or capillary leak (fluid leaks out of vessels), so the client will have high heart rate and low blood pressure

MANAGEMENT

Fluid resuscitation:

• •Parkland Burn Formula: 4 x TBSA (%) x kg
• •Give half over 8 hours
• •Give half over 16 hours
• •Titrate to urine output 30 to 50 mL/hr
• •Assess for edema (swelling)

Other interventions:

• •Administer antibiotics
• •Aggressive wound care
• •Pain management, typically with opioid analgesics, PCA (patient-controlled analgesia) if able
• •Optimize nutrition intake to promote healing; may require an NG (nasogastric) tube for feeds or a PICC (peripherally inserted central catheter) line for TPN (total parenteral nutrition, IV feeding)

Skin grafting:

• •Autologous: taken from healthy tissue on the client
• •Allogeneic: from another human donor
• •Meshed and stretched over the wound

WHAT IS IT?

Meningitis is inflammation of the membranes around the brain and spinal cord. It is caused by a virus, bacteria, fungus, or protozoa.

Quick Concept: CSF (cerebrospinal fluid) is analyzed to make the diagnosis and shows cloudy fluid, increased WBC (white blood cells), and decreased glucose.

ASSESSMENT

• •Fever
• •Altered level of consciousness
• •Nuchal rigidity (neck stiffness)
• •Kernig's sign: severe stiffness of the hamstrings makes the client unable to straighten the leg when the hip is flexed to a 90-degree angle
• •Brudzinski's sign: severe neck stiffness causes the client's hips and knees to flex when the neck is flexed
• •Lethargy
• •Increased intracranial pressure
• •Photophobia (sensitivity to light)
• •Seizures

MANAGEMENT

• •Place in droplet isolation
• •Analgesics (pain drugs)
• •Antibiotics: consider the blood-brain barrier

WHAT IS IT?

Pneumonia is an inflammatory condition of the lungs that primarily affects the alveoli, which may fill with fluid or pus. It can be infectious (bacterial or viral) or noninfectious (aspiration).

DIAGNOSIS

• •Chest X-ray
• •Sputum culture to identify the organism

ASSESSMENT

Viral:

• •Low-grade fever
• •Nonproductive cough
• •WBCs normal to low elevation
• •Chest X-ray shows minimal changes
• •Less severe than bacterial

Bacterial:

• •High fever
• •Productive cough
• •WBCs elevated
• •Chest X-ray shows infiltrate
• •More severe than viral

Both:

• •Chills
• •Rhonchi/wheezes
• •Sputum production

MANAGEMENT

Medications:

• •Antibiotics
• •Analgesics
• •Antipyretics

Nursing actions:

• •Supplemental O2
• •Assess and maintain the respiratory status
• •Encourage activity as soon as possible
• •Instruct on chest expansion exercises: incentive spirometry; turn, cough, deep breathe
• •Encourage 3 L/day of fluids unless contraindicated, to thin secretions

WHAT IS IT?

This card is a chart of blood type compatibility, showing for each blood type who it can receive from and who it can donate to.

TABLE

Blood type -> can receive from / can donate to

• •[source fragment unclear, verify at source: only the column headings were present; the specific blood type mappings were not legible in the source]

WHAT IS IT?

Hypocalcemia is a low level of calcium in the blood. Calcium is needed for nerves, muscles, and the heart, so low levels cause muscle and nerve problems.

CAUSES (LOW CALCIUM)

• •Low parathyroid hormone (after any neck surgery: check the calcium level)
• •Oral intake inadequate (alcoholism, bulimia, etc.)
• •Wound drainage (especially GI, gastrointestinal, system)
• •Celiac's and Crohn's disease (malabsorption of calcium)
• •Acute pancreatitis
• •Low vitamin D levels
• •Chronic kidney issues (excessive excretion)
• •Increased phosphorus levels in the blood
• •Using certain medications (magnesium supplements, laxatives, loop diuretics, calcium binder drugs)
• •Mobility issues

ASSESSMENT (CRAMPS)

• •Confusion
• •Reflexes: hyperactive
• •Arrhythmias (abnormal heart rhythms)
• •Muscle spasms in calves or feet, tetany (involuntary muscle contractions), seizures
• •Positive Trousseau's sign (happens before Chvostek's sign and tetany)
• •Signs of Chvostek's

WHAT IS IT?

Hypomagnesemia is a low magnesium (Mg) level in the blood.

CAUSES (mnemonic: LOW MAG)

• •Limited intake of Mg (starvation)
• •Other electrolyte issues (hypokalemia, hypocalcemia)
• •Wasting Magnesium through the kidneys (loop and thiazide diuretics; cyclosporine)
• •Malabsorption issues (Crohn's and celiac diseases, "-prazole" drugs, diarrhea/vomiting)
• •Alcohol (stimulates the kidneys to excrete Mg)
• •Glycemic issues (diabetic ketoacidosis, insulin administration)

ASSESSMENT (mnemonic: TWITCHING)

• •Trousseau's sign (positive due to hypocalcemia)
• •Weak respirations
• •Irritability
• •Torsades de pointes, Tetany (seizures)
• •Cardiac changes, Chvostek's sign
• •Hypertension, Hyperreflexia
• •Involuntary movements
• •Nausea
• •GI issues (decreased bowel sounds and motility)

WHAT IS IT?

This card uses the memory aid HHOP for treating a sickle cell crisis.

MANAGEMENT (HHOP)

• •Heat
• •Hydration
• •Oxygen
• •Pain medications

WHAT IS IT?

This card lists the steps for using a metered dose inhaler correctly.

STEPS

1. Shake the inhaler well before use (3 to 4 times).

2. Remove the cap.

3. Breathe out, away from the inhaler.

4. Bring the inhaler to your mouth, place it between your teeth, and close your mouth around it.

5. Start to breathe slowly. Press the top of the inhaler once and keep breathing in slowly until you have taken a full breath (3 to 5 seconds).

6. Remove the inhaler from your mouth and hold your breath for about 10 seconds, then breathe out.

WHAT IS IT?

This card pairs common drugs and toxins with their antidotes.

TABLE

• •Warfarin: Vitamin K
• •Benzodiazepines: Flumazenil
• •Heparin: Protamine Sulfate
• •Opioids: Naloxone
• •Anticholinergics: Physostigmine
• •Beta Blockers: Glucagon
• •Methotrexate: Folinic Acid (Leucovorin)
• •Tricyclic antidepressants: Sodium Bicarbonate
• •Digoxin: Digoxin Immune Fab (Digibind)

WHAT IS IT?

This card is a reference table of insulin types with their onset, peak, and duration.

TABLE

• •Rapid acting: lispro (Humalog), aspart (NovoLog) - onset less than 15 min, peak 1 h, duration 3 h
• •Short acting (clear): regular (Novolin R / Humulin R) - onset 1 h, peak 2 h, duration 4 h
• •Intermediate (cloudy): isophane (NPH) - onset 4 h, peak 8 h, duration 12 h
• •Long acting: glargine (Lantus) - slow absorption, no peak, duration 24 h

WHAT IS IT?

High alert medications carry a higher risk of causing serious harm to the patient if used in error. They need extra checks.

HIGH ALERT MEDICATIONS

• •Insulin
• •Opiates and narcotics
• •Injectable potassium chloride (or phosphate) concentrate
• •IV coagulants (heparin)
• •Sodium chloride solutions greater than 0.9%

WHAT IS IT?

Narrow therapeutic range drugs have a small gap between a helpful dose and a toxic dose, so they need close monitoring. This card lists them plus key facts on several specific drugs.

NARROW THERAPEUTIC RANGE DRUGS

• •Gentamicin
• •Vancomycin
• •Warfarin
• •Lithium
• •Digoxin
• •Theophylline
• •Methotrexate
• •Phenytoin
• •Insulin
• •Ciclosporin

KEY DRUG FACTS

Tuberculosis drugs (mnemonic: RIPE): Rifampicin, Isoniazid, Pyrazinamide, Ethambutol

• •Rifampicin: causes red-orange tears and urine
• •Ethambutol: causes problems with vision, liver problem
• •Isoniazid: can cause peripheral neuritis (nerve inflammation); take vitamin B6 to counter it

Monoamine oxidase inhibitors (MAOIs):

• •Tyramine-rich foods may cause severe hypertension (high BP) in patients taking MAOIs
• •Tyramine-rich foods: aged cheese, chicken liver, avocados, bananas, meat tenderizer, salami, bologna, Chianti wine, and beer

Pyridium:

• •Urinary tract analgesic (pain reliever) and spasmolytic
• •Not an anti-infective
• •Turns urine bright orange

Nitroglycerine patch:

• •Administered up to three times with intervals of five minutes

Morphine:

• •Contraindicated in pancreatitis because it causes spasms of the Sphincter of Oddi
• •Meperidine (Demerol) should be given instead

Clozapine:

• •A significant toxic risk is blood dyscrasia (blood cell disorder)

Digoxin:

• •Assess pulse for a full minute; if less than 60 bpm, hold the dose
• •Check digitalis and potassium levels

Haloperidol adverse effects:

• •Drowsiness, insomnia, weakness, headache
• •Extrapyramidal symptoms: akathisia, tardive dyskinesia, dystonia

Aluminum hydroxide:

• •Treats GERD (acid reflux) and kidney stones
• •WOF (watch out for): constipation

Hydroxyzine:

• •Treats anxiety and itching
• •WOF (watch out for): dry mouth

Midazolam:

• •Given for conscious sedation
• •WOF (watch out for): respiratory depression and hypotension (low BP)

WHAT IS IT?

This card covers patient teaching for amiodarone, including what to do about a missed dose and what to watch for.

NURSING CONSIDERATIONS

• •Take a missed dose any time in the day, or skip it entirely.
• •Do not take a double dose.
• •Watch for (WOF): diaphoresis (sweating), dyspnea (shortness of breath), lethargy.

WHAT IS IT?

Warfarin (Coumadin) is an anticoagulant (blood thinner). This card covers key nursing teaching points.

NURSING CONSIDERATIONS

• •Stress the importance of taking the prescribed dosage and keeping follow-up appointments
• •WOF (Watch Out For): signs of bleeding, diarrhea, fever, rash

WHAT IS IT?

This card covers administration considerations for phenytoin (a seizure medication).

NURSING CONSIDERATIONS

• •Enteral (tube) feedings: stop the feeding 1-2 hours before and after giving phenytoin, because enteral feedings decrease its absorption.
• •Flush with 30-50 mL of NaCl (normal saline) before and after giving phenytoin.
• •WOF means "Watch Out For."