POINTS TO REMEMBER

I. Cardiac Arrest CPR A. Determine unresponsiveness a. shake and shout "are you okay?" b. call for help 1. Position the client, if no evidence of trauma (if trauma, see section III of this lesson) 2. Open the airway a. head-tilt, chin lift b. jaw thrust (if spinal injury suspected) 3. Assess for breathing: look, listen and feel 4. Give rescue breaths a. assess if breaths go into lungs by chest movement b. if air does not go in, reposition airway (see #3 above) c. if air still does not go in, check for foreign body i. abdominal thrust (Heimlich manueuver ii. do not proceed until airway and rescue breathing established d. when airway is clear, check for abscence of pulse e. begin chest compressions i. be sure client is on a firm surface ii. hand position is critical two finger-widths above xiphoid lower one-half of sternum iii. for adult, 1.5 to 2 inch compression depth iv. two rescuers, 80 to 100 compressions per minute v. one rescuer, 80 compressions per minute f. alternate compressions and breaths i. one and two rescuers, 15 compressions to two breaths g. reassess cardiopulmonary status after one minute and every few minutes thereafter

B. Early defibrillation 3. In adults, the arrhythmia most correctable is ventricular fibrillation if treated promptly 4. Before starting CPR for ventricular fibrillation, call for help E. Airway with simultaneous cervical spine immobilization 1. Must use jaw thrust 2. Do not use head-tilt chin-lift: it could injure neck F. Breathing 1. Look, listen and feel for respirations 2. Follow CPR procedure G. Circulation 1. Assess pulses a. carotid pulse: BP at least 60 b. femoral pulse: BP at least 70 c. radial pulse: BP at least 80 2. Stop any active, visible bleeding 3. After initial assessment, start large-bore IVs H. Airway with simultaneous cervical spine immobilization 1. Must use jaw thrust 2. Do not use head-tilt chin-lift: it could injure neck I. Breathing 1. Look, listen and feel for respirations 2. Follow CPR procedure J. Circulation 1. Assess pulses a. carotid pulse: BP at least 60 b. femoral pulse: BP at least 70 c. radial pulse: BP at least 80 2. Stop any active, visible bleeding 3. After initial assessment, start large-bore IVs K. Airway with simultaneous cervical spine immobilization 1. Must use jaw thrust 2. Do not use head-tilt chin-lift: it could injure neck L. Breathing 1. Look, listen and feel for respirations

2. Follow CPR procedure M. Circulation 1. Assess pulses a. carotid pulse: BP at least 60 b. femoral pulse: BP at least 70 c. radial pulse: BP at least 80 2. Stop any active, visible bleeding 3. After initial assessment, start large-bore IVs III. Trauma Care A. Airway with simultaneous cervical spine immobilization Must use jaw thrust Do not use head-tilt chin-lift: it could injure neck B. Breathing 1. Look, listen and feel for respirations 2. Follow CPR procedure C. Circulation 1. Assess pulses a. carotid pulse: BP at least 60 b. femoral pulse: BP at least 70 c. radial pulse: BP at least 80 2. Stop any active, visible bleeding 3. After initial assessment, start large-bore IVs Disability: brief neurological exam 1. Level of consciousness 2. Pupil response to light 3. Ability to move extremities 4. Ability to move against resistance Expose 1. Undress client 2. Inspect for injuries or deformities Fahrenheit 1. Take temperature 2. Maintain warmth a. warm blankets b. warming lights Get vitals 1. Pulse 2. Respiratory rate 3. Blood pressure History and head-to-toe full assessment 1. How did injury occur - mechanism of injury 2. Client's medical history 3. Full body system assessment Inspect the back 1. Roll the client over - log roll with help 2. Inspect for injuries or deformities 1. 2.

A.

B.

C.

D.

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F.

CPR

Early defibrillation is the key to successful resuscitation for many adults. Continually reassess during CPR to see if the client regains a pulse or begins breathing. Reassess to see that the chest moves and pulses are palpable during CPR. SHOCK In shock, the first hour of treatment is most critical. Early detection is key. There are different ways to categorize shock. Basically, shock presents three potential problems: 1. Not enough fluid in the blood vessels (hypovolemia) OR 2. Fluid has moved outside the vessels, so cannot be pumped to the organs (distributive) OR 3. Heart cannot pump fluid that is present (cardiogenic) Shock and Temperature In septic shock, the skin and body temperature may increase. In other shock states, body and skin temperature will decrease. Shock and Heart Signs Early stages of shock activate the sympathetic nervous system. So in early stages, the client will not always be hypotensive. Bradycardia is a very late sign in shock.

Another late sign is cardiac arrhythmia (other than sinus tachycardia). Arrhythmias reflect less perfusion of the coronary arteries and myocarditis. As the myocardium receives less perfusion, heart pumps less. Because less blood perfuses the brain, level of consciousness drops. Shock and Urinary Output Average adult urinary output is 0.5 to 1.0 ml/kg/hr. Less than 35 ml/hour reflects decreased renal blood flow. Acute renal failure can result. Shock and Respiration As blood flow to lungs decreases, less gas exchange will occur. When tissues receive less oxygen, they produce more lactate and metabolic acidosis sets in. Metabolic acidosis increases risk of cardiac arrhythmias. For a client in shock, body cells receive less oxygen and nutrients. Thus treatment aims at increasing both available oxygen and volume of blood in vessels (unless the heart has failed). Medications can improve tone of blood vessels (inotropes) or treat the cause of shock (corticosteroids, antibiotics). When treating a trauma client, you must quickly assess ABCs. After you know the client is breathing and has a pulse, vital signs can wait while you stop any bleeding and start other interventions (such as starting IVS). Don't rely only on the vital sign numbers. Head and Spine Injury If client has head injury, the most important assessment is level of consciousness; next is pupil response to light. Changes in vitals are very late sign.

With trauma clients, assume spine is injured until proven otherwise. While you open the airway, you must keep cervical spine immobile.

SAFE AND EFFECTIVE CARE ENVT. Safety Safety is the primary concern when caring for clients.Falls are the most frequent cause of injury for elderly clients in acute care. Know the institution's plan for fire drills and evacuation. Know the emergency phone number for reporting fire. Know locations of all fire alarms, exits, and extinguishers. ARCE: Activate fire alarm, Rescue clients, Contain fire by closing doors and windows, Extinguish flames with an appropriate fire extinguisher In a fire, never use an elevator - use stairs in emergency exit Turn off all oxygen supplies in the area of the fire. In a fire, close all doors and windows. In a power failure, only certain electrical outlets access the emergency generators. Know which ones they are. Know your agency's policy for cleaning up a biohazardous spill. Safety devices are used only as a last resort. Use the least restrictive immobilizing device. Poisons Never induce vomiting unless instructed to do so by a poison center or health care provider. If you suspect someone has taken poison, take the poisonous substance with you to the emergency room. Infection Infection control with the use of standard precautions, transmission precautions and medical and surgical asepsis decreases the spread of infection. The major sites for nosocomial infections are urinary and respiratory tracts, blood, and wounds. All nosocomial infections that occur in hospitals must be tracked and recorded by risk management. The single most effective way to prevent infection is hand washing. Handwashing is the most effective method of preventing infection; friction is the most important variable. Standard precautions are used for contact with all body fluids except sweat. Standard precautions are used for all clients, and transmission precautions are used for all clients with transmittable organisms. Special (N95) respirator masks are necessary to care for clients under airborne precautions who have tuberculosis. Protective (neutropenic) isolation is used for clients with immunosuppression and low white blood counts.

Cardiovascular and Respiratory agents

1. Cardiac glycosides a. action: makes heart beat slower but stronger i. improves pumping ability of heart ii. increases force of heart's contraction iii. decreases rate of contraction iv. increases cardiac output b. examples i. digitoxin (Crystodigin) ii. digoxin (Lanoxin) c. use i. congestive heart failure ii. atrial flutter iii. atrial fibrillation d. contraindications i. ventricular tachycardia ii. ventricular fibrillation iii. second and third degree heart block e. adverse side effects i. gastrointestinal effects such as nausea and vomiting, diarrhea, and anorexia ii. bradycardia iii. xanthopsia iv. muscle weakness v. dysrhythmia f. nursing interventions i. before giving glycoside, check apical pulse and heart rhythm. Report if < 60 bpm ii. establish baseline data such as vital signs, electrolytes, clinical symptoms, creatinine clearance test iii. monitor for drug toxicity in children - cardiac arrhythmias in adults - visual disturbances, nausea and vomiting, anorexia older clients more prone to toxicity iv. monitor drug levels therapeutic range 0.8 to 2.0 ng/ml toxic range > two ng/ml diuretics may increase chance of toxicity g. monitor intake and output h. client teaching i. take medication as prescribed ii. teach client how to take and record pulse daily iii. identify and report signs of toxicity for atrial fibrillation: take pulse and report if below 60 or above 100 or changes in rhythm daily weights: report two pound increase Antihypertensives a. action: dilates peripheral blood vessels b. examples i. hydralazine HCL (Apresoline) ii. enalapril maleate (Vasotec) iii. reserpine (Serpasil) iv. prazosin HCL (Minipress) v. methyldopa (Aldomet) vi. clonidine (Catapres) c. use: hypertension d. contraindications i. heart block ii. children e. adverse side effects i. orthostatic hypotension ii. dizziness iii. bradycardia iv. tachycardia v. sexual dysfunction vi. deterioration in renal function vii. agranulosis

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nursing interventions i. monitor vital signs and blood pressure, sitting and standing ii. monitor for hearing changes, renal functioning iii. if hypotension, closely monitor client iv. encourage intake of foods high in vitamin B v. teach client low sodium diet change positions slowly take medication as instructed avoid hazardous activities protect medication from heat and light

3.

Thrombolytics a. action: binds with plasminogen to dissolve thrombi (clots) in coronary arteries within four to six hours of myocardial infarction. Activates conversion of plasminogen to plasmin. Plasmin is able to break down clots (fibrin). b. examples i. streptokinase (Streptase) ii. urokinase (Abbokinase) c. uses i. myocardial infarction ii. deep venous thrombosis iii. pulmonary emboli d. contraindications i. active bleeding ii. cerebral embolism/thrombosis/hemorrhage iii. recent intraarterial diagnostic procedure or surgery iv. recent major surgery v. neoplasms of the CNS vi. severe hypertension e. adverse side effects i. bleeding ii. allergic reactions:urticaria, itching, flushing, headache f. nursing interventions i. monitor for bleeding ii. monitor coagulation studies iii. monitor for allergic reactions iv. keep available: aminocaproic acid (fibrinolysis inhibitor) Lipid-lowering agents (antilipemic) a. action and use: lower LDL levels by reducing the synthesis of cholesterol and/or triglycerides. Use: primary hypercholesterolemia b. examples i. cholestyramine (Questran) ii. atorvastatin (Lipitor) iii. colestipol (Colestid) iv. nicotinic acid (Niacin) c. contraindications: i. hypersensitivity ii. pregnancy/lactation iii. active liver disease d. adverse side effects i. skin flushing ii. gastric upset iii. niacin: temporary, intense flushing of face, neck and ears iv. reduced absorption of fat-soluble vitamins v. disruption of liver function vi. muscle tenderness or weakness (rhabdomyolysis) e. nursing interventions i. monitor cholesterol levels ii. monitor liver function tests iii. teach client blood work and eye exams will be necessary during treatment to report blurred vision, severe GI symptoms, or headache about low-cholesterol high-fiber diet to report muscle weakness or tenderness

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iv. with cholestyramine, colestipol: Give other medications (e.g., such as thiazide diuretics, digoxin, warfarin, and certain antibiotics) one hour before or four hours after administration of cholestryramine and colestipol, so that they will not react with bile-acid-binding resins Antianginals a. nitrates i. ii. iii. iv. v.

examples: nitroglycerin, isosorbide dinitrate (Isordil) action: dilate arterioles which lowers peripheral vascular resistance (afterload) uses: treatment and prevention of acute chest pain caused by myocardial ischemia adverse effects: postural hypotension, headache, flushing, dizziness contraindications hypersensitivity severe anemia hypotension hypovolemia vi. nursing Interventions monitor for orthostatic hypotension monitor for tolerance with long term use administer every five minutes but not more than three tablets in 15 minutes if pain not relieved after 15 minutes and three tablets, notify physician immediately instruct client take pulse before taking medication take oral preparations without food when to seek medical attention not to chew or swallow sublingual tabs make position changes slowly carry drug so that it is always within reach but avoid exposure to body heat and light replace drug approximately every six months avoid alcohol ingestion b. beta-adrenergic blocking agents i. examples: propranolol (Inderal), metoprolol (Lopressor) ii. action: inhibit sympathetic stimulation of beta receptors in the heart decreases heart rate and force of myocardial contraction thus decreasing myocardial oxygen consumption iii. uses: reduces frequency and severity of acute anginal attacks, dysrhythmias iv. side effects: blood dyscrasias, hypotension, GI disturbances, flushing of the skin v. contraindications hypersensitivity cardiogenic shock cardiac failure vi. nursing interventions weigh daily. Report weight gain of five pounds or greater monitor ECG if using for dysrhythmia administer on an empty stomach protect injectable solution from light instruct client take pulse before taking drug not to discontinue medication abruptly avoid hazardous activities if drowsiness occurs make position changes slowly take drug at same time each day c. calcium channel blockers i. examples: verapamil (Isoptin), nifedipine (Adalat), diltiazem (Cardizem) ii. action: prevent the movement of extracellular calcium into the cell resulting in coronary and peripheral artery dilation iii. uses: stable angina, dysrhythmias, hypertension iv. side effects: headache, drowsiness, dizziness, GI disturbances, flushing of the skin v. contraindications: hypersensitivity vi. nursing interventions monitor chest pain monitor ECG if used for dysrhythmia administer with food instruct client increase fluids to counteract constipation take pulse before taking drug

avoid hazardous activities until stabilized on drug limit caffeine consumption avoid alcohol change position slowly

Hypotension and shock b. natural and synthetic catecholamines c. examples: epinephrine, dopamine (Intropin), dobutamine (Dobutrex) d. actions: increase cardiac output, (+) inotrope, (+) chronotrope e. uses: dopamine and dobutamine: hypovolemic and cardiogenic shock, epinephrine: anaphylactic shock f. adverse effects: dysrhythmias, hypotension, tissue necrosis if extravasation occurs. Tremors, anxiety, dizziness with epinephrine g. contraindications i. hypersensitivity ii. ventricular fibrillation iii. tachydysrhythmias iv. safety in children not known h. nursing interventions i. correct hypokalemia before administering ii. monitor vital signs frequently iii. monitor ECG continuously during administration iv. administer with infusion pump v. start drug slowly and increase according to health care provider's orders vi. monitor injection site for extravasation vii. protect solution from light viii. do not use discolored solution ix. stop the drug gradually 1. Anticoagulants a. action: disrupt the blood coagulation process, thereby suppressing the production of fibrin b. examples i. heparin: parenteral administration ii. coumadin (Warfarin): oral administration c. use i. pulmonary embolism ii. deep vein thrombosis iii. myocardial infarction iv. atrial fibrillation d. adverse side effects i. allergic responses such as chills, fever and urticaria ii. use cautiously if client tends to bleed (hemophilia, peptic ulcer) iii. GI disturbances- nausea and vomiting, diarrhea, abdominal cramps e. contraindications i. hemophilia ii. leukemia iii. peptic ulcer iv. blood dyscrasias f. nursing interventions i. heparin: monitor APTT (activated partial thromboplastin time) normal 40 seconds at therapeutic levels, APTT increases by a factor of 1.5 to 2 ii. coumadin - monitor PT (prothrombin time) normal 12 seconds INR (International normalized ratio) two to three iii. do baseline blood studies before therapy iv. have antidote ready heparin: protamine sulfate coumadin: vitamin K v. monitor client for symptoms of hemorrhage such as increased pulse, decreased BP vi. avoid salicylates (such as aspirin) vii. avoid IM injections viii. teach client take medication at same time every day wear medical alert jewelry: wearer takes anticoagulants use a soft toothbrush do not use a straight razor; use an electric razor avoid alcohol and smoking

report any signs of bleeding, red or black bowel movements, headaches, rashes, red or pink-tinged urine, sputum avoid trauma blood levels of the anticoagulant may be monitored do not take over-the-counter (OTC) medications withou

Bronchodilators i. action: i. dilate air passages in the lungs, specific action dependent on type of drug. ii. increase heart rate iii. act on the autonomic nervous system j. examples i. beta-adrenergic: abuterol (Proventil, Ventolin), metaproterenol (Alupent) ii. xanthines: aminophylline, theophylline (Theo-Dur) acts on bronchial smooth muscle iii. epinephrine HCL (Adrenalin) - increases the rate and strength of cardiac contraction through the sympathetic nervous system iv. isoproterenol HCL (Isuprel) - increases the heart rate by stimulating the beta-adrenergic blocking agent of the sympathetic nervous system k. use i. bronchospasms ii. asthma l. adverse effects i. dizziness ii. tremors iii. anxiety iv. palpitations v. gastric disturbances vi. headache vii. tachycardia viii. dysrhythmias m. contraindications i. hypersensitivity ii. narrow angle glaucoma iii. tachydysrhythmias iv. severe cardiac disease n. nursing interventions i. monitor theophylline levels (normal ten to 20 mcg/dl) ii. monitor intake and output, and vital signs iii. monitor EKG, vital signs during therapy iv. teach clients take medication as prescribed only report adverse effects stop smoking during therapy take with meals avoid OTC drugs The dosage of medication needed for a therapeutic effect can vary with age, weight, gender, health status and environmental factors. Most drugs produce a mixture of therapeutic and adverse effects. Medications require a written order from a physician or a nurse practitioner legally permitted to prescribe them. Because most drugs are metabolized in the liver, it is especially susceptible to drug induced injury. The nurse is responsible to judge independently before giving a prescribed medication. The route of administration will be chosen to achieve a certain therapeutic action, at a certain speed. Medications interact with foods, and that interaction can block or slow therapeutic action People metabolize medications differently, depending on age, gender, body size, health status, drug tolerance, cumulative effect of medication, and genetics. Inhalers are most effective when their users know the right technique. Teach the technique and then test how well the client uses it. Medications are especially likely to cause hypotension in elderly people. There are two types of drug dependence: psychic and physical. Psychic dependence implies a craving to use the drug periodically. Physical dependence implies physical symptoms when the drug is withheld.

HEALTH PROM AND MAINTENANCE Before Birth Early and regular antepartal (before-birth) care is critical. First trimester health directly influences the development of organs in embryo and fetus. To identify risks, nurses need both subjective (client's) and objective (the nurse's own) assessment data. Prescribed medications, over-the-counter drugs, alcohol and tobacco may lead to problems for the fetus and woman. Pregnancy diet must include increased calcium, protein, iron and folic acid. If the client's situation warrants, suggest ways to adapt activity, employment, and travel. It is helpful if the woman can have the same support person throughout pregnancy and birthing classes. Labor Maintain safety and asepsis (sterilize instruments; wear gown, gloves, mask) through the labor and birth process to reduce risks to mother and fetus/newborn. Ideally, same caregivers stay through all stages of labor. Recognize urgent signs and act promptly. Constantly assess and analyze problems to prioritize actions. Reinforce the childbirth preparation techniques practiced by the couple during pregnancy. Effective teaching during labor must be flexible. Mother will have shorter attention span, increasing discomfort, and emotional responses to labor. Promote privacy of the woman and support person as much as possible. Respect the cultural and religious beliefs of the woman and partner. Involve the family in the birth process as noted in their birth plan or special requests. Provide for the woman's needs and comfort. Communicate caring and concern to the woman and her family through therapeutic techniques. Document assessments, changes in condition and care as promptly as possible. Postpartum Teach (by demonstration and praise) self assessment and care. Start soon after birth. The newborn is first of all a family member. Share your assessments and plans with parents; welcome their input. Respect culture and religious beliefs of the family. Praise the parent's skills. Media and pamphlets are useful teaching aids if the parent has a chance to discuss them. Visits and Teachings Mothers are discharged quickly, so you must teach accordingly. Home visits and follow-up telephone calls let the nurse and parents discuss adaptations, questions and concerns. Postpartum teaching should include women's health promotion. The adolescent mother benefits from developmentally appropriate teaching and referral to community resources, including parenting classes. Growth and Development Normally proceed in a regular fashion from simple to complex and in cephalocaudal and proximodistal patterns. Are orderly, directional, predictable, interdependent and complex processes. Are unique to individuals and their genetic potential. Occur through conflict and adaptation. Growth and development are impacted by genetics, environment, health status, nutrition, culture, and family structures and practices. Growth should be measured and evaluated at regular intervals throughout childhood. Deviations from normal growth and development should be thoroughly investigated and treated as quickly as possible. In the care of children, key concepts are anticipatory guidance and prevention of disease. Major developmental tasks of infancy are: increase in mobility, separation, and establishment of trusting relationships. In both toddlerhood and adolescence, hallmarks are development of independence and further separation. Children and adolescents grow rapidly, so nurses must stress optimum nutrition and give anticipatory guidance related to nutrition. In children over one year of age, the leading cause of death is injuries. Elder Adults Elder adults must adjust to lessening physical and cognitive abilities. Over 85% have some type of chronic disease. When elder adults experience cognitive changes, check for possible substance abuse or polypharmacy. Cognitive impairment can be acute and reversible, or it can be chronic and irreversible. Up to 60% of older adults have some impairment in performance of activities of daily living. Some physiologic changes are a normal part of the aging process and do not signal disease. Elder adults need more time to complete tasks.

 Age is a weak predictor of survival in traumatic injury and critical illness. Health Risks in Elder Adults Major health problems typically include cardiovascular, cerebrovascular, and respiratory diseases; diabetes; and cancer. The elder adult will change social roles, and these changes may affect psychological health, leading to depression. Elder adults need the same nutrition as other adults, but more bulk and fiber, calcium, and vitamins C and A. Contraindications for estrogen replacement therapy include hypertension thrombophlebitis cardiac dysfunction family history of breast or uterine cancer Elder adults clear drugs from kidney and liver more slowly; so medications have longer half-lives, and they can bring on side effects and toxicity at lower doses. Health Promotion: Health Assessment Measure vital signs when the client is at rest Compare both sides of the body for symmetry Assess the systems related to the clients major complaint first Offer rest periods if client becomes tired Culture and religious beliefs may play a role in observed differences Warm hands and equipment such as stethoscope before touching client Tell client what you are going to do before touching client Normal variations exist among clients and there is a range of normalcy for all physical findings Maintain the clients privacy throughout the examination Control for environmental factors which may distort findings Check equipment prior to exam for functioning Consider growth and developmental needs when assessing specific age groups Integrate client teaching throughout the exam Vasculature Compare blood pressure in arms left versus right Compare blood pressure with client lying, sitting and standing Lungs - Airway Anemic patients may never become cyanotic Polycythemic patients may be cyanotic, even when oxygenation is normal Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology. Cyanosis indicates decreased available oxygen. Etiology can be either peripheral or central in origin. Wheezes indicates narrowing/inflammatory process of lower airways Stridor harsh sound produced near larynx by vibration of structures in upper airway. Classic "barky cough" Crackles or rales adventitious sounds, usually on inspiration and indicating inflammation Breast Breast tissue shrinks with menopause Teach client breast self examination Abdomen - Reproductive System Auscultation should be performed before palpation to prevent distortion of bowel sounds Tightening of abdominal muscles hinders accuracy of palpation and auscultation Warm hands before touching clients abdomen. Men breathe abdominally; women breathe costally. Auscultate all four quadrants for bowel sounds Auscultate abdomen between meals Musculoskeletal Older adults walk with smaller steps and need a wider base of support Neurological Glasgow Coma Score not valid in patients who have used alcohol or other mind-altering drugs possibly not valid in patients who are hypoglycemic, in shock, or hypothermic (below 34C) should be compared to total of 10 when client is intubated Reflexes are normally less brisk or even absent in older clients Reflex response diminishes in the lower extremities before the upper extremities are affected Absent reflexes may indicate neuropathy or lower motor neuron disorder Hyperactive reflexes suggest an upper motor neuron disorder Teaching client and family Teaching-learning process mirrors the nursing process Select teaching strategies that are compatible with the clients learning style, age, culture, level of education Client teaching should be multi-sensory

Always confirm the clients understanding of the information presented Teaching must be geared to the level of the learner Repeat key information and summarize main points at intervals Explain medical terminology in lay terms Determine the clients learning style and gear teaching methods to using that style Sequence information the way the client will use it Be concrete and use the simplest words and the shortest sentences when teaching low literacy clients, or any client under stress