Monthly Archives: August 2012

Maternal/Child Health (OB): Fetal and Maternal Assessment Techniques

I. ULTRASOUND (US)

  • used during first trimester to assess: # of fetuses, gestational age, uterine abnormalities, fetal cardiac movement and rhythm
  • used during second and third trimester to assess: size-date discrepancies, amniotic fluid volume, uterine anomalies, amniocentesis results, gestational age, fetal viability, placenta location and maturity
  • nursing implications: patient may need to maintain a full bladder prior to US if in the first or second trimester for the uterus to be observable (not needed for transvaginal US)
  • no known complications

II. CHORIONIC VILLI SAMPLING (CVS)

  • at 8 to 12 weeks gestation, a small piece of villi is removed guided under an US
  • determines genetic diagnosis in the first trimester
  • nursing implications: lithotomy position, patient may feel sharp pain when catheter inserted
  • complications: spontaneous abortion

III. AMNIOCENTESIS

  • at 14-16 weeks, amniotic fluid sample removed from uterus
  • used to assess: genetic diagnosis, fetal lung maturity, fetal well-being
    genetic disorders: trisomies, metabolic disorders, neural tube defects
    fetal lung maturity: L:S ratio (2:1) and presence of prostaglandins (PG) after 35 weeks is most accurate determination
    fetal well-being: bilirubin delta optical density, meconium may indicate fetal distress
  • nursing implications: supine position, use of Betadine to sterilize site, label samples, monitor FHR 1 hour after procedure; ***if amniocentesis is done in early pregnancy, bladder must be FULL; it done in late pregnancy, bladder must be EMPTY to prevent puncture
  • complications: spontaneous abortion, fetal injury, infection

IV. ELECTRONIC FETAL MONITORING (EFM)

  • variables of EFM:
    – contractions – duration, frequency, intensity
    – baseline fetal heart rate (FHR) – 110-160, measured over 10 minutes
  • variability: absent, minimal (< 5 bpm) , moderate (6-25 bpm), marked (>25 bpm)
  • VEAL CHOP
  • warning signs: absent or minimal FHR, bradycardia (< 110), tachycardia (>160), variable decelrations
  • emergent signs: severe variable decelrations (FHR <70, lasting > 30-60s), late decelerations

V. NONSTRESS TEST (NST)

  • assesses fetal response to movement which can determine fetal well-being in high-risk pregnancies
  • healthy “reactive” sign: fetus responds to movement by a fetal heart rate (FHR) acceleration of 15 beats, lasting 15 seconds after movement, occuring twice in a 20 minute period
  • nursing implications: apply fetal monitor, give handheld event marker to mother and instruct her to push button whenever she heels movement, it may also be recorded on FHR strip, *if there is not fetal movement, assume that the fetus is sleeping and stimulate it through sound or palpation or have mother move it and begin test again

VI. CONTRACTION STRESS TEST (CST) or OXYTOCIN CHALLENGE TEST (OCT)

  • assesses fetal response to low oxygen supply during induction of contractions (through nipple stimulation or Oxytocin)
  • nonreassuring “bad” sign: late decelerations = placental insufficiency!
  • contraindications: rupture of membranes (ROM), prematurity, hydramnios, multiple gestation, placenta previa, previous uterine classical scar
  • nursing implications: place external monitors of abdomen (ultrasound and tocodynanometer); record a 20 second baseline strip to determine reactivity (fetal well being) and presence/absence of contractions; for nipple stimulation, have patient use warm wet washcloths to roll nipple of one breast for 10 minutes and rol both if contractions don’t start within 10 minutes; oxytocin infused if no contractions after nipple stimulation
  • complications: hyperstimulation or tetany (contractions over 90 seconds OR contractions with less than 30 seconds in between) R/T overstimulating nipples
  • REMEMBER: a NEGATIVE test = GOOD (fetal well being)

VII. BIOPHYSICAL PROFILE (BPP)

  • ultrasound used to evaluated fetal health by assessing:
    1.) fetal breathing movements (FBM)
    2.) gross body movements (GBM)
    3.) fetal tone (FT)
    4.) reactive fetal heart rate (nonstress test)
    5.) qualitative amniotic fluid volume (AFV)
  • each variable = 2 points for a normal response; 0 points for an abnormal (either 2 OR 0)
  • nursing implications: prepare, inform, provide support; teach patient that a LOW score = fetal compromise and needs to be assessed further
  • a score of 8-10 = fetal well-being

VIII. FETAL PH BLOOD SAMPLING

  • determiens true acidosis when nonreassuring fetal heart rate is noted (tachycardia not related to maternal variables, decreased variability not related to nonasphyxial causes, severe variable decels unresponsive to treatment, late decels)
  • only performed in intrapartum period
  • sample taken from the presenting part (breech or scalp) when membranes have ruptured and cervix dilated to 2-3cm
Image Source: #1, #2, #3, #4, #5, #6, #7,
Content derived from HESI Comprehensive Review for the NCLEX-RN Examination.

Management: What Can the Licensed Vocational Nurse (LVN) Do and Not Do?

LVNs CAN:

  • CAN make focused assessments
  • CAN administer some IVPB, PO, IM, subcut, ID, suppository, eye/ear/nose medications
  • CAN perform dressing changes
  • CAN catheterize
  • CAN help with basic hygiene
  • CAN employ clinical problem solving
  • CAN observe a patient intervention (eg: pursed-lip breathing, incentive spirometer)
  • CAN teach standardized information (eg: how to apply a nicotine patch)
  • CAN collect data about a patient’s response to certain medications
  • CAN reinforce teaching

LVNs CANNOT:

  • CANNOT make initial or comprehensive assessments
  • CANNOT administer IV push medications, antineoplastics, strong antibiotics, experimental medications
  • CANNOT hang blood
  • CANNOT do initial teaching

*** Please NOTE: the scope of practice for the LVN/LPN varies from state to state and also depends on their facility’s policies and procedures. Refer to your state’s Board of Nursing (BON) for a more detailed description of the scope of practice for licensed nurses. 

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Psych Medications: Antidepressants


I. Selective Serotonin Re-uptake Inhibitors
SSRIs (Lexapro, Celexa, Prozac, Paxil, Zoloft, Luvox)

  • [Luv Zolo Proz, Lexa Cel Pax] “Love solo pros. Lexa sells packs.”
  • SSRIs are FIRST LINE for depression
  • has fewer side effects than TCAs or MAOIs
  • no anticholinergic side effects, usual S&S include nausea, insomnia, sexual dysfunction

II. Atypical Antidepressants (new generation) (Cymbalta, Desyrel, Effexor, Remeron, Wellbutrin, Pristiq)

  • [Cymba Des Well Effex. Remer is imPrist] “Cymba does well effects. Rem is impressed.”
  • DESYREL can also be used for insomnia
  • EFFEXOR and CYMBALTA may cause HTN
  • CYMBALTA also used for neuropathic pain
  • WELLBUTRIN also used for smoking cessation

III. Tricyclic Antidepressants (Elavil, Anafranil, Norpramin, Tofranil, Vivactil, Pamelor, Sinequan)

  • Sounds like female names: Ela, Ana, Pam, Viv …; some end in -FRANIL or -IL
  • may take about 1-3w for effect and 6-8w for max response
  • have strong ANTICHOLINERGIC EFFECTS, so use with caution in elderly patients or patients with constipation, glaucoma or BPH
  • these medications also have strong CARDIOTOXIC effects
  • NORPRAMINE has low anticholinergic effects, which would be appropriate for the above
  • once daily dosing at bedtime helps to promote sleep through sedation effects and reduce daytime sleepiness
  • check the patient for HOARDING, especially if they are at RISK FOR SUICIDE

IV. Monamine Oxidase Inhibitors (MAOIs) (Nardil, Marplan, Parnate, EMSAM-patch)

  • [PaNaMA] or [No Popular Meds (N.P.M.)]
  • only used as a 2nd or 3rd choice for treatment of depression b/c of dietary restrictions and SE
  • dietary restriction of foods high in TYRAMINE (dried fruits, almost all cheeses, processed meats, soy products, avocados)
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Critical Care: Emergency Medications

I. SODIUM CHANNEL BLOCKERS – ↓ conduction velocity in the atria, ventricles, His-Purkinje

  • Class 1A: Norpace/disopyramide, Pronestyl/procainamide, Quinora/quinidine
    – action: delays repolarization
    – effect on EKG: wide QRS, prolonged QT
  • Class 1B: Xylocaine/lidocaine, Mexitil/mexiletine, Dilantin/phenytoin
    – action: accelerates repolarization
    – effect on EKG: little to no effect
  • Class 1C: Tambocor/flecainide, Rythmol/propafenone
    – action: decreases impulse conduction
    – effect on EKG: pronounced prodysrhythmic actions, wide QRS, prolonged QT

II. BETA ADRENERGIC BLOCKERS

  • Tenormin/atenolol, Coreg/carvedilol, Brevibloc/esmolol, Lopressor/metropolol, Betapace/sotalol
    action: ↓ automaticity of SA node, ↓ conduction velocity of AV node,  atrial and ventricular contractility
    effect on EKG: bradycardia, prolonged PR, AV block

III. POTASSIUM CHANNEL BLOCKERS

  • Cordarone/amiodarone, Bretylol/bretylium, Tikosyn/dofetilide, Corvert/ibutilide, Betapace/sotalol
    action: delay repolarization, resulting in prolonged action potential and refractory period
    effect on EKG: prolonged PR and QT, wide QRS, bradycardia

IV. CALCIUM CHANNEL BLOCKERS

  • Cardizem/diltiazem, Calan/verapamil
    action: ↓ automaticity of SA node, delay AV node conduction, ↓ myocardial contractility
    effect on EKG: bradycardia, prolonged PR, AV block

V. OTHER

  • Adenocard/adenosine, Lanoxin/digoxin, Magnesium
    action: ↓ conduction through AV node, ↓ automaticity of SA node
    effect on EKG: prolonged PR, AV block
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Content derived from Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 8th Edition.

Critical Care: Mechanical Ventilator Basics

I. MODES OF VENTILATION

  • Controlled: ventilator does the work of breathing (WOB) FOR the patient
  • Assist-control: patient and ventilator share WOB, patient initiates a spontaneous breath and a tidal volume is delivered
  • Synchronized Intermittent Mandatory Ventilation (SIMV): patient receives a preset tidal volume at a preset frequency, synchronous with the patient’s own breathing; patient can still breathe spontaneously in between ventilator breaths
  • Pressure support ventilation (PSV): positive airway pressure (PAP) applied during inspiration; patient must be able to initiate a spontaneous breath
  • Pressure-control inverse ratio ventilation (PC-IRV): prolonged PAP applied to increase inspiratory time and decrease expiratory time; normal inspiration/expiration (I:E) ratio is 1:2, with PC-IRV it is reversed to 2:3, 3:1, 4:1, etc1

II. VENTILATOR SETTINGS

  • Rate (f) – number of breaths per minute (usual: 6-20)
  • Tidal volume (Tv) – volume of air delivered with each breathe (usual: 6-10 mL/kg)
  • Fraction of Inspired Oxygen (FiO2) – oxygen concentration (usual: 21%-100%)
  • Positive End-Expiratory Pressure (PEEP) – positive pressure applied at the end of expiration (usual 5 cm H2O)
  • Pressure support – positive pressure applied to keep airway open and facilitate inspiration (usual: 6-18 cm H2O)
  • I:E ratio – inspiration:expiration ratio (usual: 1:2, 1:1.5), if IMV desired – 2:1, 3:1

III. VENTILATOR ALARMS

  • High pressure alarm: kinking of the tubing, patient biting on endotracheal (ET) tube, secretions pooling in tubing, patient “fighting” the ventilator, bronchospasms, pulmonary edema
  • Low pressure alarm: air leak from tube, ET tube cuff has deflated, total or partial extubation,

IV. PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA (VAP)

  • Head-of-bed (HOB) elevated at minimum, 30-45 degrees
  • NO routine changes of ventilator circuit tubing
  • Use of an ET tube with dorsal lumen to facilitate suctioning
  • Hand hygiene

V. WEANING PARAMETERS

  • Negative Inspiratory Force (NIF) = 20-30
  • Minute ventilation (Ve) = < 10 L/min
  • Pressure of carbon dioxide (PaCO2) = 35-45 (or within normal limits [COPD patients])
  • Pressure of oxygen (PaO2) = 60+
  • Fraction of inspired oxygen (FiO2) = 50% or less
  • Positive end-expiratory pressure (PEEP) = < 5
  • Pressure support ventilation (PSV) = 10 or less

VI. COMPLICATIONS OF MECHANICAL VENTILATION

  • Decreased cardiac output due to increase intrathoracic pressure resulting from high PEEP
  • Barotrauma/volutrauma due to over distension of the lungs from high inspiratory pressures or high PEEP; can lead to pneumothorax
  • Hypo/hyperventilation which can lead to acid base imbalances
  • Ventilator-associated pneumonia (VAP)
  • Fluid and electrolyte imbalances due to low cardiac output, low kidney perfusion
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Content derived from Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 8th Edition.

Critical Care: Heart Blocks

**With heart blocks, the AV node is sick. Therefore the P-R INTERVAL will be abnormal.

I. FIRST DEGREE HEART BLOCK

  • HEART RATE: Variable
  • RHYTHM: Regular
  • P WAVES: Normal
  • P-R INTERVAL: consistently longer than 0.20 seconds
  • QRS WIDTH: Usually normal
  • INTERVENTIONS: Continue to monitor, IV, O2

II. SECOND DEGREE HEART BLOCK, TYPE I (WENCKEBACH, MOBITZ I)

  • HEART RATE: Variable
  • RHYTHM: Irregular
  • P WAVES: Normal; # of P’s > # of QRS
  • P-R INTERVAL: progressive lengthening on consecutive beats until you drop one QRS
  • QRS WIDTH: Usually normal, absent when blocked
  • INTERVENTIONS: Continue to monitor, IV, O2

III. SECOND DEGREE HEART BLOCK, TYPE II (MOBITZ II)

  • HEART RATE: Variable, slow
  • RHYTHM: Irregular
  • P WAVES: Normal; # of P’s > # of QRS
  • P-R INTERVAL: consistent when it happens, absent with blocked beats
  • QRS WIDTH: Usually normal, absent when blocked
  • INTERVENTIONS: transcutaneous pacemaker; *closely monitor, as it may lead to complete heart block!

IV. THIRD DEGREE (COMPLETE) HEART BLOCK

  • HEART RATE: Variable, slow
  • RHYTHM: Regular
  • P WAVES: Normal; # of P’s > # of QRS
  • P-R INTERVAL: Random
  • QRS WIDTH: Wide
  • INTERVENTIONS: transcutaneous pacemaker; may then need permanent pacemaker
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Critical Care: Atrial Rhythms

I. PREMATURE ATRIAL CONTRACTIONS (PACs)

  • HEART RATE: Variable
  • RHYHTM: Irregular
  • P WAVES: Abnormal configuration, 1:1 ratio
  • P-R INTERVAL: Variable, may be shorter
  • QRS WIDTH: Usually normal
  • INTERVENTIONS: Continue to monitor, check pulse

II. PAROXYSMAL/SUPRAVENTRICULAR TACHYCARDIA (P/SVT)

  • HEART RATE: 100-300
  • RHYTHM: Regular
  • P WAVES: Abnormal, may be hidden
  • P-R INTERVAL: Variable, may be hidden
  • QRS WIDTH: Usually normal
  • INTERVENTIONS: Continue to monitor, may use vagal maneuvers and adenosine, cardioversion if other measures are ineffective

III. ATRIAL FIBRILLATION

  • HEART RATE: Atrial – >350, Ventricular – depends on AV block
  • RHYTHM: Irregular
  • P WAVES: Fibrillatory waves, “scribble”
  • P-R INTERVAL: Absent
  • QRS WIDTH: Usually normal
  • INTERVENTIONS: Prevent clots with anticoagulants, rate control with calcium channel blockers

IV. ATRIAL FLUTTER

  • HEART RATE: Atrial – 250-300, Ventricular – depends on AV block
  • RHYTHM: Atrial – regular, Ventricular – varies with AV
  • P WAVES: “Sawtooth” flutter waves
  • P-R INTERVAL: Absent
  • QRD WIDTH: Usually normal
  • INTERVENTIONS: Prevent clots with anticoagulants, rate control with calcium channel blockers
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Critical Care: Sinus Rhythms

I. NORMAL SINUS

  • HEART RATE: 60-100
  • RHYTHM: Regular
  • P WAVES: Normal
  • P-R INTERVAL: Normal
  • QRS WIDTH: Normal
  • INTERVENTIONS: Continue to monitor, check pulse

II. SINUS BRADYCARDIA

  • HEART RATE: <60
  • RHYTHM: Regular
  • P WAVES: Normal
  • P-R INTERVAL: Normal
  • QRS WIDTH: Normal
  • INTERVENTIONS: Symptomatic? (low BP, pale, dizzy) – may need atropine; otherwise, monitor and check pulse

III. SINUS TACHYCARDIA

  • HEART RATE: >100
  • RHYTHM: Regular
  • P WAVES: Normal
  • P-R INTERVAL: Normal
  • QRS WIDTH: Normal
  • INTERVENTIONS: Determine causes (anxiety? pain?); may need beta blockers, calcium channel blockers, analgesics or antipyretics as appropriate

IV. SINUS ARRHYTHMIA

  • HEART RATE: Variable
  • RHYTHM: Irregular
  • P WAVES: Normal
  • P-R INTERVAL: Normal
  • QRS WIDTH: Normal
  • INTERVENTIONS: Continue to monitor, check pulse
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Critical Care: Ventricular Rhythms, Asystole, PEA

I. PREMATURE VENTRICULAR CONTRACTIONS (PVCs)

  • HEART RATE: Variable
  • RHYTHM: Irregular
  • P WAVE: Normal
  • P-R INTERVAL: Normal
  • QRS WIDTH: Wide
  • INTERVENTIONS: Monitor; watch for sequences of PVCs which may lead to VTac

II. VENTRICULAR TACHYCARDIA (VTac)

  • HEART RATE: > 100
  • RHYTHM: Regular
  • P WAVES: None
  • P-R INTERVAL: None
  • QRS WIDTH: Wide
  • INTERVENTIONS: Check for pulse: if none, proceed to CPR & shock; otherwise, monitor; may need antidysrhythmics (Amiodarone, Procainamide)

III. VENTRICULAR FIBRILLATION (VFib)

  • HEART RATE: Variable, rapid
  • RHYTHM: Irregular
  • P WAVES: None
  • P-R INTERVAL: None
  • QRS WIDTH: Wild
  • INTERVENTIONS: EMERGENCY! Proceed to defibrillation, CPR & ACLS measures

IV. ASYSTOLE

  • NO heart rate; NO P waves, P-R intervals or QRS complexes
  • INTERVENTIONS: Check for causes*DO NOT shock!

V. PULSELESS ELECTRICAL ACTIVITY (PEA)

  • Any organized rhythm (other than VTac, VFib, asystole) with NO PULSE
  • INTERVENTIONS: First, CPR, intubation & ACLS measures; then look for causes
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Critical Care: Phases of Burn Care

PHASES OF CARE FOR THE BURN PATIENT:

  • Pre-hospital Phase
  • Emergent Phase
  • Acute Phase
  • Rehab Phase

I. PRE-HOSPITAL PHASE – primary concerns are ABC’s (airway, breathing, circulation)

  • Remove from the burn source
  • Check patency of airway and for adequate ventilation
  • Check for adequate circulation
  • Treat as needed – flush the skin for chemical injuries, remove clothing, 100% O2 for carbon monoxide poisoning
  • Prevent hypothermia – only cool for < 10 minutes

II. EMERGENT PHASE – main concerns are hypovolemic shock and edema

  • Airway management: may need intubation R/T edema or swelling of the airway, 100% humidified O2
  • Fluid resuscitation: 2 large bore IVs if 15% burn, central line if 30% burn
    Parkland (Baxter) Formula: 4 mL X kg X % Total Body Surface Area Burned (TBSAB)
    1/2 total in 1st 8 HRS
    1/4 total in 2nd 8 HRS
    1/4 total in 3rd 8 HRS
    Example: For a 70 kg patient with 50% TBSAB → 4 mL X 70 kg X 50 TBSAB = 14,000 mL in 24 hrs
    1/2 total in 1st 8 hrs = 7000 mL (875 mL/hr) ← to calculate, just divde 7000 mL/8 hrs
    1/4 total in 2nd 8 hrs = 3500 mL (437.5 mL/hr)
    1/4 total in 3rd 8 hrs = 3500 mL (437.5 mL/hr)
  • Wound care: debridement, escharatomies (an incision on the skin to relieve pressure due to edema), multiple dressing changes, room needs to be kept warm (85 degrees F), may need artificial skin
  • Pain management: analgesics, nonsystemic antimicrobial agents (Silverlon, Acticoat, Silvadene, Sulfamylon), thromboembolism prophylaxis (Lovenox), tetanus immunization
  • Nutrition: assess gastric residuals frequently, bowel sounds q8h, feedings usually started slowly at 20-40 mL/hr; may give calcium-containing supplements and milkshakes; supplemental vitamins in the emergent phase, iron in the acute phase

III. ACUTE PHASE

  • Wound care: debridement, topical antimicrobial creams (silver sulfadiazine, silver-impregnated dressings)
  • Excision and grafting: after 1-2 days, wound exicsion performed – important to maintain blood conservation and observe for circulation problems, coverage achieved with cultured epithelial autografts (grow skin from the patient’s own cells) or artificial skin
  • Pain management: 2 kinds of pain – background pain and treatment-induced pain, will need continuous IV opioids, around-the-clock management and may be even anxiolytics to potentiate pain relief, patient-controlled analgesia may also be used
  • Physical therapy: maintain joint function and prevent contractures, best times to perform active/passive range-of-motion exercises are during and after wound cleansing; patient’s with neck burns should sleep without pillows or neck dangling off the bed to hyperextend the neck

IV. REHAB PHASE

  • Range of motion exercises
  • Pressure bandages: used to keep scars flat, never worn over unhealed wounds
  • Relieve itching
  • Psychological support: patient may have permanent disfigurement due to scarring, assess for coping skills and family support
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Content derived from Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 8th Edition.