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Ticket in skills lab 2
What are signs of Demerol (Meperidine, hydromorphone) toxicity?As
Demerol is metabolized by the body, a toxic byproduct called normeperidine is produced. This toxic
byproduct of Demerol can cause delirium as it accumulates in the systems of elderly patients. Signs of
delirium are acute confusion, disorientation, poor memory, agitation, difficulty sleeping, hallucinations and
extreme fear or anxiety.
Read more: http://www.livestrong.com/article/184097-warnings-about-demerol-injections/#ixzz2IXetJKXn
What are nursing interventions for the patient with confusion related to
Demerol toxicity?
Treatment of overdose: Naloxone HCI (Narcan) 0.2-0.8 mg IV, 02, IV fluids,
vasopressors (epi-pen)
How do you perform a wet to dry dressing? Wet to-dry dressings are used
only to debride wounds, as they cause tissue damage. Maceration (softening by the
action of liquid) of healthy tissue can occur with dressings that are always wet. Dry
dressings cause damage to granulating tissue if removed without first soaking the
gauze.
Preparation: Check physicians orders. Perform hand hygiene and gather
equipment. Identify client using two forms of identification. Explain procedure to
client. Provide privacy. Raise bed to HIGH position, and lower side rail nearest you.
Remove tape by pulling it toward the wound (rationale: this action prevents injury
to newly formed tissue). Don clean gloves. Remove wound packing by gently
grasping the gauze without touching the wound and tear it away at a right angle
from the wound surface. Place soi9led dressings in disposable bag. Remove gloves,and dispose of them in bag. Perform hand hygiene.
Procedure: Open packages of dressings making sure sterility is maintained. Pour
normal saline solution over dressings. Don sterile gloves. Pick up sterile gauze
dressings one at a time. Fluff each dressing, and place over wound (Rationale: If
packed tightly, dressing can prevent wound edges from contact with capillaries).
Place gauze in the wound, covering all exposed surfaces. Press gauze lightly into
depressions or cracks (Rationale: necrotic tissue is more prevalent in these areas).
Unfold a moist, sterile 4X8 (ABD pad) dressing into a single layer and place it on top
of wet dressings covering the wound area (not on skin). Place a dry 4X8 pad over
the dressing to hold it in place. Some protocols call for semi-occlusive dressing inplace of pad. Remove gloves, and place in plastic bag. Tape only the edges of the
dressing. Montgomery tapes may be used to prevent excessive skin irritation and
damage due to frequent dressing changes. Position client for comfort. Lower bed,
and raise side rail to UP position, if appropriate. Discard soiled material in
appropriate container. Perform hand hygiene. Observe wound for excessive
drainage or drying out of dressing between dressing changes. Remoisten dressing if
http://www.livestrong.com/article/184097-warnings-about-demerol-injections/#ixzz2IXetJKXnhttp://www.livestrong.com/article/184097-warnings-about-demerol-injections/#ixzz2IXetJKXn7/29/2019 Ticket in Demerol
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dry. (Rational: Unless excessive drainage occurs, or dressing dries out, dressings
are usually changed every 8 Hours. Provide client or family teaching regarding
wound care, if appropriate. Label dressing with date, time and initials.
Expected Outcome: Wound heals and skin is intact. Patient is free from infection.
Documentation: type of dressing change, assessment of the dressings that were
removed, condition of the wound, supplies used, clients response and how client
tolerated the procedure.
How would you change a central line dressing? Change every 72-96 hours
Procedure: Gather all necessary equipment: roll of tape, label, and central line
dressing kit. Check physicians orders. Verify patient by using 2 identifiers. Wash
hands. Check Explain procedure to the patient and/or significant other. Check for
providone-iodine or tape allergy. Organize supplies and equipment at bedside to
decrease the amount of time that site is open to air. Apply mask on yourself. (Don
gown if soiling is likely) Open central line kit. Place patient in supine position with
head turned away from catheter insertion site to decrease potential for
contamination by catheter insertion site to decrease potential for contamination by
patients secretions. Place a mask over the patients mouth and nose or sterile
drape over ventilated or trached patient. Don a pair of clean gloves. Remove
present dressing carefully to minimize trauma and prevent accidental dislodgment
of catheter. Discard soiled dressing in proper trash receptacle. Visually inspect the
skin and catheter site for signs of infection, leakage, or other mechanical problems.
Remove soiled gloves and don sterile gloves. Working in a circular motion from
insertion site outward to edge of dressing border cleanse skin, insertionsite, and
distal portion of catheter with: a) Providone-iodine scrub swabsticks X 3 to removebacteria and fungi b) Alcohol swabsticks X 3 to remove the betadine scrub c)
Betadine solution swabsticks x 3 to cover a 3 x 6 from site to periphery to provide
protective barrier against pathogens. Blot excess or pooled solution. Allow to dry.
Apply skin protective pad. Apply dressing tegaderm. Date, time and initial
dressing.
List signs/symptoms of hyperglycemia
1) High levels of sugar in the urine
2) Blood glucose >110
3) Frequent urination
4) Increased thirst
Medications which may be used during the simulation include:
Morphine Sulfate IVP prn
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Promethazine ivp prn
Ondansetron ivp prn
Enoxaprin sub q
Potassium Chloride 10 meq ivpb
Digoxin ivp
Famotidine ivp
Gentamycin 200 mg IVPB
Thiamine 100 mg PO
Glyburide 1.25 mg PO
Ceftazidime 2 grams IVPB
Nicotine Patch 21 mcg apply topically
Hydromorphone 2 mg IVP
Chlordiazepoxide hydrochloride 50 mg po prn
Lorazepam 0.5 mg IVP
Metocloparmide 10 mg IVP
Dexamethasone 4 mg IVP
Protonix 40 mg IVP
Morphine 6 mg IVP
Medications:
Medication
Route
Safe Dosage
Range
Classificat
ion
Mode of
Action
Why
given to
patient?
Nursing implications
Teaching
Side
Effects
Ceftazidime 2grams IVPB (akaCeptax, Fortaz,
Tazicef,Tazidime)
(IV/IM 1-2 g q8-12 hr X 5-10
Broadspectrumantibiotic
Killsbacterialcell wallsynthesis
Implications: Assessfor sensitivity topenicillin, othercephalosporins.Nephrotoxicity:increased BUN,creatinine; urineoutput; if decreasing,
Nausea,vomiting,diarrhea,anorexia
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days)
IV after diluting 1g/10mL sterileH20 for inj,shake, invert
needle, pushplunger, insertneedle throughstopper and keepin sol. Expelbubbles and giveover 3-5 min;may be dilutedfurther with 50-100 mL of normalsaline or D5W;run over -1 hr,
give through y-tube or 3-waystop-cock,discontinueprimary infduringadministration
notify prescriber; mayindicatenephrotoxicity. Bloodstudies: AST, ALT, CBC,Hct bilirubin, LDH, alkphos, Coombs testmonthly if patient is onlong-erm theraphy.Electrolytes: K, Na, Clmonthly if patient is onlong-term theraphyTeaching: If diabetic,to check bloodglucose. To report sorethroat, bruising,ble3eding, joint pain;may indicate blooddyscrasias (rare);diarrhea with mucus,blood, may indicatepseudomembranouscolitis. To reportpersistent diarrhea.
MedicationRoute
Safe DosageRange
Classification
Mode ofAction
Whygiven topatient?
Nursing implications
Teaching
SideEffects
Chlordiazepoxidehydrochloride 50mg po prn (aka
Librium)
Antianxiety
Adult: PO 5-10mg tid-qid
Administerw/food or milk for
Antianxiety
Gamma-
aminobutyric acid(GABA) is amajorinhibitorybrainchemicalthat blocksthe
To calmthe patientas the
patientmay bewithdrawing. Used totreatwithdrawal(hallucinations, acuteconfusion,
Assess B/P (lying,standing), pulse; ifsystolic B/P drops 20
mm Hg, hold product,notify prescriber
Hepatic studies: AST,ALT, bilirubin,creatinine, LDH, alkphos during long-ermtherapy
Dizziness,drowsiness,Orthostatic
hypotension, blurredvision
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GI symptoms.Crushed ifpatient in unableto swallowmedication whole
transmission of asignal fromone braincell toanother
This drugworks onGABA
restlessness, andhyperactivity of theautonomicnervoussystem(tachycardia,hypertension, fever)
I&O may indicaterenal dysfunction
Provide assistancew/ambulation
Teach: Product maybe taken with food. Notto use product foreveryday stress or uselonger than 4 mo,unless directed byprescriber. Not to takemore than prescribed.Avoid OTCpreparations
For overdose give:
flumazenil
Dexamethasone4 mg IVPAdult:Analphylacticshock IV 1-6mg/kg or IV 40mg q2-6 hrCerebral edema IV-10 mg, then4-6 mg IM
Undiluted directover 1 min orless or dilutedwith 0.9% NaClor F
Corticosteroid,synthetic
Decreasesinflammation
Inflammation,allergies,neoplasms, cerbraledema,septicshock,collagendisorders
Potassium, blood, urineglucose while on long-term therapy;hypokalemia andhyperglycemia.Weight daily; notifyprescriber of weeksgain >5 lb. I&O ration;be alert for decreasingurinary output,
increasing edema
Teach: That ID ascorticosteroid usershould be carried.Contact Prescriber ifsurgery, trauma, stressoccurs; dose may needto be adjusted. Notifyprescriber iftherapeutic response
decreases; dosageadjustment may beneeded. Not todiscontinue abruptly oradrenal crisis canresult. Symptoms:nausea, anorexia,fatigue, dizziness,
Depression,flushing,sweating,hypertension, diarrhea,nausea,abdominaldistention,increasedappetite
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dyspnea, weakness,joint pain
Digoxin ivp
A single initial
intravenous doseof 400 to 600mcg (0.4 to 0.6mg) of LANOXINInjection usuallyproduces adetectable effectin 5 to 30minutes thatbecomesmaximal in 1 to 4hours. Additional
doses of 100 to300 mcg (0.1 to0.3 mg) may begiven cautiouslyat 6- to 8-hourintervals untilclinical evidenceof an adequateeffect is noted.
The usualamount ofLANOXIN
Injection that a70-kg patientrequires toachieve 8- to 12-mcg/kg peakbody stores is600 to 1,000 mcg(0.6 to 1.0 mg).
Undiluted or 1mL ofproduct/4mL
sterile solution>5 min through
Y-tube or 3-waystopcock
Y site compatiblewith famotidine,morphine,potassium
Antidyshythmic
Inhibits thesodium-potassiumATPase,whichmakesmorecalciumavailableforcontractileproteins,
resulting inincreasedcardiacoutput
For mild tomoderateheart
failureSpecifically A-Fib
Listen to apical pulsefor 1 min before givingproduct; if pulse
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chloride
For toxicity: givedigoxin immuneFAB (Digibind)
Enoxaprin sub q
(Lovenox)
SUBCUT 30 mgbid given 12-24hr postop for7-10days, until DVTrisk is diminished
Anticoagulant,anthrombotic
Preventions of DeepVein
Thrombosis
Implications: Bloodstudies (Hct, CBC,coagulation studies,platelets, occult bloodin stools). For bleedinggums, petechiae,ecchymosis, blacktarry stools,hematuria-notifyprescriber
Hemorrhage,hypochromic anemia,thrombocytopenia,bleeding
Famotidine ivp
(Pepcid AC)
Adult: IV 20 mgq12 if unable totake PO
IV, direct Afterdiluting 2 mL ofproduct (10mg/ml) in salineto total volume of
5-10 mL; injectover 2 min topreventhypotension
H2-
histaminereceptorantagonist
Action:Competitively inhibitshistamineathistamineH2 receptorsite,
decreasinggastricsecretionwhilepepsinremains ata stablelevel
Ulcers,
refluxdiseasesorheartburn
Implications: Assess
for epigastric pain,abdominal pain, frankor occult blood inemesis, stools. Bloodcounts during therapy watch for decreasingplatelets. For bleeding,hematuria,hematuresis, occultblood in stools;abdominal pain
Headache,
dizziness,constipation, seizures inrenaldisease,dysrhythmias
Teach thatproductmust becontinued
forprescribedtime inprescribedmethod tobe effective;do notdouble dose.Reportbleeding,bruising,fatigue,
malaise.Avoidirritatingfoods
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MedicationRouteSafe DosageRange
ClassificationMode ofAction
Whygiven topatient?
Nursing implicationsTeaching
SideEffects
Gentamycin 200mg IVPB
Adult: IV Inf 3-6mg/kg/day individed dosesq8hr; dilute in50-200 mL 0.9%NaCl or D5Wgiven over 30min 1 hr
Antiinfective
Action:Interfereswithbacterialcellreproduction
Severesystemicinfectionsof CNS,respiratory, GI,urinarytract,bone, skin,softtissuescaused bysusceptible strainsofPseudomonas , E-coli,Staphylococcus,Klebsiella
Implications: Weighbefore treatment;calculation of dosageis usually based onideal body weight. I&0ratio, urinalysis dailyfor proteinuria, cells,casts; report suddenchange in urine output;toxicity is increased inpatients withdecreased renalfunction if high dosesare given.
Deafness,nausea,vomiting,anorexia,rash
Glyburide 1.25mg PO
Adult: 1.25-5 mg
initially, thenincreased todesired responseat weeklyintervals.
Administerw/breakfast, holddose if NPO toavoidhypoglycemia
Antidiabetic
Action:
CausesfunctioningB-cells inpancreas toreleaseinsulin,leading todrop inbloodglucoselevels; mayimprove
insulinbinding toinsulin
Increasebloodglucoselevels
Hypo/hyperglycemicreaction that can occursoon after meals; forsevere hypoglycemia.Blood glucose; A1clevels duringtreatment. Evaluatetherapeutic response
Teach: To use a bloodglucose meter fortesting while on thisproduct. Take productin morning to preventhypoglycemicreactions at night.
Headache,weakness,hypoglycemia
Hydromorphone2 mg IVP(Dilaudid)
Adult: 1-2 mg q4-
Opiateanalgesic
Action:Inhibits
To reducepain oruse toinhibit a
Assess respiratorydysfunction:respiratory depression,character, rate,
Respiratorydepression,Drowsiness,dizziness,
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6 hr prn
IV direct, dilutedwith 5 mL sterileH20 or NS; givethrough y-
connector or 3-way stopcock;give 2 mg orless/3-5 min
Treatment ofoverdose:Naloxone HCI(Narcan) 0.2-0.8mg IV, 02, IVfluids,vasopressors
ascendingpainpathwaysin CNS,increasespainthreshold,alters painperception
nonproductive cough
rhythm, notifyprescriber ifrespirations are
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over 10-20 min Rest andDigest
alcohol, other CNSdepressants that willenhance sedatingproperties of thisproduct
Morphine 6 mgIVP
Adult IV: 2.5-15mg diluted in 4-5mL h20; give 15or less over 4-5min
Overdosetreatment:Naloxone
(Narcan) 0.2-0.8mg IV o2, IVfluids,vasopressors
Opiateanalgesic
Action:Depressespainimpulsetransmission at thespinal cordlevel byinteracting
with opiodreceptors
To reducepatientpain
Avoid using MAOIs;Pain: location, type,character, give dosebefore pain becomessevere. Bowel status,I&Os, Respiratorydysfunction:depression, character,rate, rhythm, notifyprescriber ifrespirations are
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Adult:Habitrol-21mg/dayX4-8 wk;14 mg/dayx2-4wk; 7mg/dayx2-4 wkNicotrol: 15mg/dayx12 wk;10 mg/dayx2 wk;5 mg/dayx2wk
receptorsinperipheral,CNS
thehospital
prevent skin irritation
Teach: That patch is astoxic as cigarettes; tobe used only to detersmoking. Not to useduring pregnancy;birth defects mayoccur. To keep usedand unused system outof reach of childrenand pets. To stopsmoking immediatelywhen beginning patchtreatment
vertigo,insomnia
Ondansetron ivpprn
(Zofran)
Adult: IV/IM 4mg undilutedover >30 secprior to inductionof anesthesia
After diluting asingle dose in 50mL NS or D5W,0.45% NaCl or
NS; give over 15min.
Antiemetic
Action:
Preventsnausea,vomiting byblockingserotoninperipherally, centrally,and in thesmallintestine
To preventpatientsnausea
Assess: For absence ofnausea, vomitingduring chemotherapy.Hypersensitivityreaction: rash,bronchospasm. ForEPS: shuffling, gat,tremors grimacing,rigidity
Teach: Reportdiarrhea, constipation,rash, or changes inrespirations ordiscomfort at insertion
site. Headacherequiring analgesic iscommon
Headache,dizziness,drowsiness,fatigue, EPS,diarrhea,constipation, abdominalpain,musculoskeletal pain,woundsproblems,shivering ,fever,hypoxia,urinaryretention
PotassiumChloride 10 meqivpb
20 MEQ/hr whendiluted as 40mEq/1000 mL,max 150mEq/day
Never give IVbolus
Electrolyte,mineralreplacement
Action:Needed foradequate
transmission of nerveimpulsesand cardiaccontraction, renalfunction,intracellular ion
To bringpatientsPotassiumlevel to atleastminimumlevel 3.5
Assess: ECG forpeaking T waves,lowered R, depressedRST, prolonged P-Rinterval, widening QRScomplex,hyperkalemia; productshould be reduced or
discontinued.Potassium level duringtreatment (3.5-5). I&Oratio; watch fordecreased urinaryoutput; notifyprescriberimmediately. Cardiac
Bradycardia,cardiacdepression,dysrhythmias, arrest,peaking Twaves,lowered R
anddepressedRST,prolonged P-R interval,widenedQRScomplex,
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maintenance
status
Teach: To addpotassium-rich foodsto diet; bananas,orange juice,
avocados; wholegrains, broccoli,carrots, prunes, cocoaafter this medication isdiscontinued. Avoidtaking licorice in largeamounts-may causehypokalemia
nausea,vomiting,cramps,pain,diarrhea
Promethazine ivpprn
(Phenergan)
Adult:PO/IM/IV/RECT12.5-25 mg q4-6hr prn
Rapidadministrationmay causedecrease in B/P.
After diluting
each 25-50mg/9mL of NaClfor inj; give 25mg or less/2 min
Antihistamine, H1-receptor
antagonist
Action: Actson bloodvessels, GI,respiratorysystem bycompetingwithhistaminefor H1-receptor
site;decreasesallergicresponseby blockinghistamine
Given toreducemotion
sickness,rhinitis,allergysymptoms,sedation,nausea,preoperative andpostoperativesedation
I&O ratio; be alert forurinary retention,frequency, dysuria.
CBC during long-termtherapy. Respiratorystatus; rate, rhythm,increase in bronchialsecretions, wheezing,chest tightness. Avoiduse with out CNSdepressants
Dizziness,drowsiness,poor
coordination, neurolepticmalignantsyndrome,constipation, urinaryretention
Protonix 40 mgIVP
(Pantoprazole)
IV 40 mg/dayx7-
10 day
Reconstitutew/10mL 0.9%NaCl, furtherdilute with 80mLLR, D5, 0.9%NaCl (0.8 mg/ml),
ProtonPumpInhibitor
Action:suppressesgastricsecretionbyinhibitinghydrogen/potassiumATPaseenzyme
To reducepatientsgastroesophagealreflux
Assess: GI system;bowel sounds q8hr,abdomen for pain,swelling, anorexia.Hepatic studies: AST,
ALT, alk phos duringtreatment. For vit B12deficiency in thoselong term therapy
Teach: To reportsevere diarrhea;product may have atobe discontinued. That
Headache,diarrhea,abdominalpain, rash
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give over 15 min(