Category Archives: Junior II

Medical-Surgical: Left versus Right Heart Failure

LEFT HEART FAILURE

  • left = “lungs” = respiratory symptoms
  • blood backs up into the lungs due to failure of the left side of the heart
  • classic symptoms: dyspnea, crackles in lungs

RIGHT HEART FAILURE

  • blood backs up into the periphery due to failure of the right side of the heart
  • classic symptoms: edema, jugular vein distention (JVD), hepatomegaly, splenomegaly
Image source.

Medical-Surgical: Diabetes Mellitus

Diabetes Mellitus (DM), otherwise known as diabetes, is a “group of diseases characterized by high blood glucose levels that result from defects in the body’s ability to produce and/or use insulin” (American Diabetes Association [ADA], 2012).

Types of Diabetes

  • Type I – autoimmune destruction of insulin-producing beta cells; present at birth; may also be referred to as insulin-dependent DM
  • Type II – characterized as insulin resistance or decreased ability of pancreas to produce insulin; occurs later in life; may also be referred to as non-insulin-dependent DM
  • Gestational – present during pregnancy

How is DM diagnosed?

  • less than 100 mg/dL = normal
  • 100 to 126 mg/dL impaired fasting glucose (IFG) = prediabetes
  • greater than 126 mg/dL = diabetes
  • two hour oral glucose test > 200 with glucose load of 75g
  • diagnosis of DM must be confirmed on a subsequent day with FBS, TFG or 2 hour glucose tolerance test

Glycosylated hemoglobin, also known as A1C, measures glucose control over the past 3 months.

How do we manage DM?

  • Nutrition:
    – For Type I DM, insulin doses are balanced with usual food intake and exercise. Patient must be consistent with the timing of insulin administration and amount of food consumed (especially carbohydrates [CHO]).
    – For Type 2 DM, initial dietary management aimed at decreasing calories, fats and simple sugars. Weight loss may help improve glycemic control (recommended weight loss of 5-7%).
  • Exercise may help decrease insulin resistance, lower blood glucose levels directly, improve circulation and muscle tone
    a caution about exercise and DM: AVOID exercise if hyperglycemia is present WITH ketosis
    – exercise lowers blood glucose levels for about 48 hours after activity
    – patients should exercise for 1 hour after a meal or have a 10-15g CHO snack
    – patients must check their blood glucose before, during and after exercise
    *do NOT exercise if blood glucose is less than 100
  • Drug therapy:
    – insulin: given subcutaneously or IV (only Regular can be given IV); different types of insulin with different onsets and peaks**; abdomen is highest rate of absorption followed by the arm, thigh then buttocks
    – oral agents: sulfonylureas, meglinitides, metformin

**Insulin types, peaks, onsets and durations

Complications of DM

  • Hypoglycemia
    – caused by too much insulin or by too much exercise compared to the amount of food eaten
    – BG < 70 mg/dL
    – symptoms: “wet and shaky” – cold sweats, weakness, irritability, pallor, increased HR, confusion, fatigue
    – treatment: give a fast acting CHO; when symptoms improve, give a long lasting CHO; Glucagon injection also given
  • Diabetic Ketoacidosis
     defined as a profound deficiency in insulin leading to an extremely elevated BG level 
    most likely occurs in type I DM, but can occur in type II DM during stress or illness
    – symptoms: polyuria, dry mouth, thirst, restlessness, sunken eyeballs, Kussmaul respirations, CNS changes, fruity breath, ketonuria
    – treatment: 1.) low dose regular insulin (0.1 units) in normal saline (NS) IV; 2.) when BG reaches 250, glucose is added to the IV to prevent hypoglycemia; 3.) replace electrolytes; 4.) prevent cerebral edema and monitor VS, I&O and cardiac status
  • Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
    – 
    a life-threatening syndrome that occurs mainly in type II DM and leads to an extremely elevated BG level
    – symptoms: polyuria, dehydration; but NO ketones
    – treatment: 1.) rapid replacement of fluid via IV NS or 1/2NS; 2.) administer regular insulin via IV; 3.) when BG reaches 250, glucose is added to the IV to prevent hypoglycemia; 4.) replace electrolytes and monitor VS, I&O and cardiac status

Complications associated with insulin therapy

  • Allergy – now rare due to use of human insulin
  • Lipodystrophy – occurs if the same injections sites are used subsequently; hypertrophy may also occur is a site is not used for 6 months; this is also rare with human insulin
  • Somogyi effect – body abnormally overreacts to hypoglycemia occurring at night or during sleep by increasing BG levels; elevated BG noted on morning BG checks and is associated with undetected hypoglycemia during sleep; treatment with less insulin
  • Dawn phenomenon – hyperglycemia is present in the morning due to counter-regulatory hormones released in the predawn hours; treatment by adjusting timing of insulin or increasing insulin
Content Sources:
American Diabetes Association.
Medical-Surgical Nursing: Assessment and Management of Clinical Problems.
Diabetes Self-management.
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Psych Medications: Mood Stabilizers

Anti-manic and Mood Stabilizing drugs (Lithium, Depakote, Lamictal, Tegretol, Trileptal)

  • LITHIUM is the drug of choice for controlling manic episodes
  • lithium has a narrow therapeutic index (~0.6-1.2), familiarize yourself with the different LEVELS OF TOXICITY
  • normal SE of lithium include fine tremors, mild thirst, mild nausea and general discomfort – if they persist, may indicate toxicity
  • remember that DEHYDRATION (excess nausea, diarrhea, sweating, diuretics) may cause lithium TOXICITY
  • SE of toxicity include coarse tremors, persistent GI upset, confusion, muscle irritabbility, ECG changes, incoordination
  • lithium level of > 2.5 may = DEATH
  • Tegretol may cause agranulocytosis – monitor WBCs
  • Lamictal may cause Steven-Johnson’s – monitor platelets
  • Depakote may cause hepatotoxicity and thrombocytopenia – monitor LFTs and platelets
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Psych Medications: Benzodiazepines

Benzodiazepines/Non-benzodiazepine Anxiolytics (Ativan, Klonopin, Valium, Xanax, Librium, Buspar, Inderal)

  • [Val and Xan the Klo Ind the Bus] “Val and Xan the Klown In the Bus”
  • benzos increase GABA, have rapid onset
  • few drug interactions, but can interact with other CNS depressants (alcohol) and manifest as sedation or death
  • there is potential for ABUSE, be cautious when giving to patients with history of substance abuse
  • benzos must be tapered to lessen S&S of withdrawal (fatigue, irritability, insomnia, tremors)
  • BUSPAR is a special drug: takes a while to work, so often is taken with a benzo while waiting for therapeutic effect; no potential for abuse; high cost
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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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Medical-Surgical: Cushing’s vs Addison’s Disease

CUSHING’S 

  • think moon face, buffalo hump, truncal obesity – a “cushy” appearance
  • HIGH in everything, EXCEPT potassium – hypernateremia, hypertension, hyperglycemia, hypokalemia

ADDISON’S 

  • think bronze skin, weight loss, decrease appetite
  • LOW in everything, EXCEPT potassium – hyponatremia, hypotension, hypoglycemia, hyperkalemia
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Psychiatric/Mental Health: The Basics

The focus of this psychiatric/mental health nursing is usually around 4 main concepts:

  • therapeutic communication
  • safety
  • medications
  • specific psychiatric disorders

Therapeutic communication:
Communication is vital to the general nursing field, not just in psych, but it is especially important when interacting with a patient in the psychiatric setting. Much of the techniques learned in assessment applies such as reflection, active listening, empathy, etc. However, it is important to first look at the overall patient situation and determine which statement is most appropriate. For example, for a patient who is suicidal, you would want to ask more direct questions even if they seem very blunt such as “have you thought about harming yourself?”

Safety:
Recall that in the model Maslow’s Hierarchy of Needs, the care of the patient follows a stairstep priority list starting with physiological needs, followed by safety, emotional needs, self esteem. In psych, safety is always the priority. Consider interacting with an escalating angry patient. First step would  be to escort other patients away from the angry patient. Think about a patient who just told you he wants to kill himself. First thing would be to remove all objects that he could use to harm himself, such as ropes, bedsheets, even coke cans. Safety of the patient, other patients and nurse is crucial in these settings.

Medications:
Medications aren’t administered by students during the clinical shift, however, it is important for us as nurses to know the ins and outs of psych medications. There are several classes of medications covered in this course:

  • Antidepressants – Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclics (TCAs), Monoamine Oxidase Inhibitors (MAOIs) and Atypicals
  • Antipsychotics – Conventionals and Atypicals
  • EPS drugs
  • Benzodiazepeines and related anxiolytics
  • Mood Stabilizers – Lithium, antiseizure medications
  • ADHD meds
  • Alzheimer’s agents
  • Herbals
  • Hypnotics
It isn’t enough to simply know what kind of drug it is, but also what is the specific name. Prozac is a SSRI, Geodon is an atypical antipsychotic.  There are several techniques to memorize the different drug names. I’ve seen pictures, acronyms and color coding. Once you know the different names and correlating class of drug, know their mechanism of action. Majority of these drugs work on neurotransmitters in the brain which in turn may produce the therapeutic effect as needed to relieve symptoms. Knowing the side effects is especially important. Some of these medications produce very uncomfortable side effects which may contribute to noncompliance. Teaching patients how to manage the side effects and administering the appropriate treatment is a critical part of medication administration.

Psychiatric Disorders:
There are several different psychiatric disorders covered in this coursed, including:

  • Schizophrenia
  • Anxiety disorders
  • Addictions
  • Depression
  • Bipolar disorder
  • Somatoform, Factitious, Dissociative disorders
  • Cognitive disorders
  • Personality disorders
  • Child/Adolescent disorders
  • Eating disorders

Alongside, there are other topics including death and dying, abuse, crisis intervention, etc. For each of the psych disorders, concentrate on the manifestations of the disorder, medications and relevant treatments, role of the nurse in caring for this particular patient, appropriate diagnoses and outcomes and patient teaching in managing their illness.

Whether you’re interested in working in the field of psychiatric nursing or not, the skills learned in this course may apply to all fields of nursing. Whether you’re working in critical care or general med/surg, there is a high possibility that some patients you meet may have comorbid psychiatric problems. Viewing the patient holistically includes addressing mental health and a efficient nurse is one who is competent in not only the medical, but the emotional and mental aspects of nursing care.

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Medical-Surgical Nursing: The Basics

Med/Surg is like the meat and potatoes of nursing, with Foundations being the dinner plate and Assessment being the mashed potatoes. It’s important to get a grasp of the general med/surg content, concentrating on:

  • pathophysiology of certain conditions and clinical manifestations
  • nursing interventions R/T the pathophys
  • related medications and treatment options
  • patient teaching

The Lewis textbook does a great job of organizing the content in a comprehensive and flowing manner. The chapters begin with basic pathophys related to a certain disease process followed by clinical manifestations. By now, much of the terminology used should be familiar post-Foundations. It’s important to differentiate specific clinical manifestations with a specific disease, because there are quite a few that overlap with other conditions. For example, nausea and vomiting may be a common symptom amongst several GI conditions, but a symptom like pain relieved by food is more specific to duodenal ulcers (as opposed to gastric ulcers).

Once you’re familiar with the clinical manifestations of the disease, relevant diagnoses and outcomes are important to address those symptoms. It’s also important to recognize what symptom that diagnosis addresses and if they match. For example, the diagnosis Ineffective airway clearance is more relevant to excess mucus in the airway as opposed to Ineffective breathing pattern which is more relevant to labored breathing. Remember, as nurses we don’t necessarily treat the disease, rather we treat the symptoms.

Following that, knowing the role of the nurse and responsibilities in the collaborative care is critical. A simple way to study for this is by linking the pathophy with the clinical manifestations and then link that to a specific nursing intervention. For example, a patient with COPD often displays dyspnea (difficulty breathing). The pathophysiology behind that is chronic inflammation of the airway and excess mucus. As a nurse, what are some interventions you can do? Let’s start with the obvious – oxygen. Assuming there is a standing order, the nurse would apply oxygen to the patient (FYI: patients with COPD should never be given oxygen more than 2-3 liters/minute as it may cause them to stop breathing!). Alright, so give the patient oxygen, what else is relevant? How about raising the head of the bed to allow for the lungs to expand? Often times a test question will ask for a priority intervention. In this case, what is the one action that the nurse can do immediately? It usually would be raising the head of the bed. Once envision in your mind yourself as the nurse caring for this patient, it may help facilitate the way you study for this course.

In addition, patient teaching is important. What does the patient need to know about self care before he or she is discharged? Using the above COPD example, I could teach the patient to take his/her medications regularly, turn/cough/deep breathe to facilitate lung clearance and pursed-lip breathing to prevent air trapping.

The exams for Med/Surg focus mainly on nursing care with some assessment and patient teaching. When reading the question, picture that patient in your mind. It’s important to differentiate real world from NCLEX world. Often times, these questions are in a setting where you have as much time as you have and can only do one thing in the room before leaving. Remember to identify positive from negative questions, as well as priority questions. What can the nurse do immediately? Before I call the doctor, what information have I gathered? If the question does not have any assessment findings/information in the root of the question, usually you would need to assess first.

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“Reviews & Rationales”

Photobucket Photobucket

These supplemental reads were recommended by a nurse graduate YouTuber. She expressed how beneficial these books where in reviewing & emphasizing the material of the corresponding topics. They come in a variety of topics that cover from Pre-Nursing to Senior II. According to reviews on Amazon.com, many buyers recommend these reads as it has helped them during their courses.

I just ordered the Medical-Surgical & Mental Health R&R books to try them out. It couldn’t hurt to consider them if you’d want to spend a little extra. I personally have found them to be great as additional abbreviated material alongside the textbook material from the theory class. Below are the estimated, minimum, used prices.

Pre-Nursing:
Prentice Hall Nursing Reviews & Rationales: Anatomy & Physiology: Amazon ($14)
Prentice Hall Nursing Reviews & Rationales: Pharmacology: Amazon ($20)
Prentice Hall Nursing Reviews & Rationales: Pathophysiology: Amazon ($20)

Junior I:
Prentice Hall Nursing Reviews & Rationales: Nursing Fundamentals: Amazon ($15)
Prentice Hall Nursing Reviews & Rationales: Health Assessment: Amazon ($20)
Prentice Hall Nursing Reviews & Rationales: Fluid, Electrolyte, Acid-Base Balance: Amazon ($20)

Junior II:
Prentice Hall Nursing Reviews & Rationales: Medical-Surgical Nursing: Amazon ($20)
Prentice Hall Nursing Reviews & Rationales: Mental Health Nursing: Amazon ($18)

Senior I:
Prentice Hall Nursing Reviews & Rationales: Child Health Nursing: Amazon ($17)
Prentice Hall Nursing Reviews & Rationales: Maternal-Newborn Nursing: Amazon ($20)

Senior II:
Prentice Hall Nursing Reviews & Rationales: Nursing Leadership & Management: Amazon ($12)

Images from amazon.com

Care Plans

A care plan is an outline of the care that is expected to be provided to a patient based on their clinical picture. A well constructed care plan consists of the following:

  1. a holistic approach, taking into consideration psychosocial and socioeconomic concerns
  2. focuses on interventions to relieve or minimize a current health problem
  3. has mutually set goals and parameters that are SMART (Specific, Measurable, Action-oriented, Relevant, Time-bound)

NURSING DIAGNOSES
Nursing diagnoses are clinical judgments set based on a patient’s response to actual or potential health problems. The following is a typical set up of a nursing diagnosis:

(nursing diagnosis) related to (medical diagnosis or primary complaint) as evidence by (signs & symptoms)
Example: Acute pain R/T abdominal incision AEB grimacing, rating of pain 6/10.

The North American Nursing Diagnosis Association-International (NANDA-I) is the main organization for defining standard nursing diagnoses. It is important to note the different between a NURSING and a MEDICAL diagnosis.

A MEDICAL diagnosis focuses on the primary complaint, disease or illness.
A NURSING diagnosis focuses on the patient’s response to actual or potential health problems.

There are four types of nursing diagnoses as defined by NANDA-I:

  • Actual diagnosis – an existing health problem
  • Potential diagnosis – a “risk for” problem
  • Health promotion/Wellness diagnosis – readiness to enhance well-being and self health
  • Syndrome diagnosis – a cluster of nursing diagnoses that are better addressed together

In nursing school, take the time to construct these efficiently. These care plans are meant to train you to think like a nurse. What is the patient’s background? What is your plan of action? What are several nursing diagnoses you can associate with this patient? What is your priority intervention? All of these questions need to be answered once you begin your shift as an RN in the real world.

Content Source: #1, #2.