ATI Coach Pointers PDF

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Summary

Quick notes and pointers regarding med-surg, pharm, skills, and leadership. Just some good pneumonics to remember that are crucial...

Description

Latex Allergies: Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well.

Order of assessment: I-inspection P-palpation P-percussion A-auscultation

Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate.

Cane walking: C-cane O-opposite A-affected L-leg

Crutch walking: Remember the phase “step up” when picturing a person going up stairs with crutches. The good leg goes up first followed by the crutches and the bad leg. The opposite happens going down the stairs….OR “up to heaven…down to hell”

Delegation: RNs DO NOT delegate what they can EAT--evaluate, assess, teach

Helpful tool to remember Isolation Precautions: AIRBORNE: "My Chicken Hez TB" -Measles -Chicken pox

-Herpes zoster -TB Management: neg. pressure room, private room, mask, n-95 for TB. DROPLET: "SPIDERMAn" -Sepsis -Scarlet Fever -Strep -Pertussis -Pneumonia -Parvovirus -Influenza -Diphtheria -Epiglottitis -Rubella -Mumps -Adenovirus Management: Private room/mask CONTACT: "MRS WEE" -MRSA -VRSA -RSV -Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, and staphylococcus) -Wound infections -Enteric infections (Clostridium difficile) -Eye infections (conjunctivitis) Management: gown, gloves, goggles, private room

Here are some tips to help you remember some of your classifications: Antiemetics An antiemetic is a medication used in the treatment and/or prevention of nausea and vomiting. Remember generic names are our friend because meds in the same classification often have similar generic names but brand names can come and go.

Here are some common classes of antiemetics and their generic names – notice the similarities in the generic names: 5-HT3 receptor antagonists (serotonin antagonists) Dolasetron (Anzemet) Granisetron (Kytril , Sancuso) Ondansetron (Zofran) Tropisetron (Navoban) It’s ‘Tron’ to the rescue!

Dopamine antagonists Promethazine (Phenergan) Prochlorperazine (Compazine)

Metoclopramide (Reglan): Now this one is different in generic name because it can have some different side effects – watch for extra-pyramidal side effects with metoclopramide. Sometimes the generic names are not as helpful and you have to remember what meds fall under certain classes. Antihistamines and cannabinoids are used as antiemetics as well:

Erectile Dysfunction Agents Erectile dysfunction (ED) meds act by increasing nitric oxide which opens and relaxes the blood vessels of the penis causing increased blood flow (helping lead to getting and keeping an erection). Here is where the generic name is our friend again – meds in the same class often have similar generic names but brand names will come and go: Here are some common ED medsSildenafil (Viagra) Vardenafil (Levitra) Tadalafil (Cialis) Notice these end in ‘fil’. ‘Fil’ helps the nitric oxide to ‘fil’ the penis. While ‘Fil’ is a great guy (well-tolerated by most clients) he does have a few side effects – headache, flushing, back pain and muscle aches (with Levitra), temporary vision changes, including "blue vision" (with Viagra) and not all men can spend time with ‘Fil’. Men who have heart problems, uncontrolled blood pressure problems, history of stroke, or a health problem at can cause priapism can’t hang out with ‘Fil.’ Thrombolytic Agents

In order to truly appreciate this drug tip, you need to familiarize yourself with the Ghostbusters. If you haven’t heard the theme song, cue it up before reading further. We promise it will be worth it. PRIORITY POINT: If the Ghostbusters had a medication class of choice, this would be it! Thrombolytic Agents are CLOT BUSTERS. They work QUICKLY to restore circulation. As such, they increase a client’s risk for bleeding. Who you gonna call? Streptokinase (Streptase). Call right away! These medications must be administered within 4 to 6 hours of onset of symptoms. If there’s something strange in your neighborhood: Thrombolytic agents dissolve clots that have already been formed. These medications convert plasminogen to plasmin, which destroy fibrinogen and other clotting factors. What’s the goal? Restoration of circulation, as evidenced by relief of chest pain, and reduction of initial ST segment injury pattern as shown on ECG. What’s the risk? Increased bleeding. These medications should only be given while the client is closely monitored. Baseline platelet and blood counts (including aPTT, PT, and INR) shouldbe carefully assessed. Venipunctures and SQ and IM injections should be limited. After the clot has left the building: Administer beta blockers to decrease myocardial oxygen consumption and reduce the incidence and severity of reperfusion arrhythmias.

Insulins Insulins are used to manage diabetes mellitus, a chronic illness that results from an absolute or relative deficiency of insulin. There are various insulins that are available to manage diabetes. For each type of insulin, you will need to know the onset, peak, and duration. NCLEX questions may focus on when clients need to be assessed after insulin administration. Assessment should occur frequently, but especially during the PEAK of insulin action, as this is when hypoglycemia is most likely to occur. Signs and symptoms ofabrupt-onset hypoglycemia include tachycardia, palpations, diaphoresis, and shakiness. Gradual onset hypoglycemia may manifest with headache, tremors, or weakness. We’ll CLIMB TO THE PEAK…starting FAST and ending SLOW. FASTEST: Rapid acting insulins:Lispro (Humalog). ONSET: Less than 15 minutes. PEAK: 30 minutes to 1 hour. DURATION: 3 to 4 hours. FAST: Short acting insulins: Regular (Humulin R). ONSET: 30 minutes to 1 hour. PEAK: 2 to 3 hours. DURATION: 5 to 7 hours.

SLOW: Intermediate-acting insulins: NPH insulin (Humulin N). ONSET: 1 to 2 hours. PEAK: 4 to 12 hours. DURATION: 18 to 24 hours. SLOWEST: Long-acting insulins: Insulin glargine (Lantus). ONSET: 1 hour PEAK: None DURATION: 10 to 24 hours. Many students look for ways to more easily remember all of the ranges associated with insulin. It is helpful to think generally rather than trying to recall all exact numbers when memorizing this information, and, if you can only remember one thing about each insulin, CLIMB TO THE PEAK. Pick one number from each time frame (onset, peak, duration) to help reduce the values that you’re trying to memorize. Remember that onset, peak, and duration build sequentially as you move from one type of insulin to another, so it may be helpful to remember, for example, that onset times go from 15 minutes, to 30 minutes, to 1 hour (trend: all onsets are less than an hour). Peak times go from 30 minutes, to 2 hours, to 4 hours (trend: even numbers). Finally, duration goes from 3 hours, to 5 hours, to 24 hours. If you always organize your thoughts by O.P.D.(onset, peak, and duration), starting FAST (rapid acting) and ending SLOW (long acting) when studying the different types of insulin, these tips will be helpful. The key is consistency…looking at values in the same order every time.

Here is some additional information in this content area below-

To remember right sided versus left side heart failure symptoms (HEAD/CHOP) Right sided (HEAD) H- Hepatomegaly E- Edema (Bipedal) A- Ascites D- Distended Neck Vein Left sided (CHOP) C- Cough H- Hemoptysis O- Orthopnea

P- Pulmonary Congestion (crackles/ rales)

Here is a chart comparing the two:

Right side heart failure

Left side heart failure

Jugular vein distention

Dyspnea, orthopnea (shortness of breath while lying down), nocturnal dyspnea

Ascending dependent edema (legs, ankle, sacrum) Abdominal distention, ascites Fatigue and weakness

Fatigue Displaced apical pulse (hypertrophy) S3 heart sound (gallop)

Nausea and anorexia

Pulmonary congestion (dyspnea, cough, bibasilar crackles)

Polyuria at rest (nocturnal)

Frothy sputum (can be blood tinged)

Liver enlargement and tenderness

Altered mental status

Weight gain

Manifestation of organ failure such as oliguria (decrease in urine output)

How I remember the routes of transmission for Hepatitis.... If it has a VOWEL (A or E) it comes from the BOWEL- - all others are blood transmission. Thyroid disorders and analogy with Tigger and Eeyore (silly, but it works) Tigger has hyperthyroidism: bouncing around (tremors, excitability. Nervousness, irritability)--> weight loss as he is always moving, tachycardic as he never stops moving, everything is heightened: sweating, more frequent bowel movements, increased appetite, can't sleep, fatigued, increased sensitivity to heat

Eeyore has hypothyroidism: everything is slowing down: constipation, weight gain, puffy face, slowed heart rate, depression, increased sensitivity to cold Hypoglycemia:TIRED T-achycardia I-rritability R-estless

E-xcessive Hunger D-iaphoresis/ Depression

Traction: T- Temperature (Extremity, Infection) R - Ropes hang freely A - Alignment C - Circulation Check (5 P's) T- Type & Location of fracture I - Increase fluid intake O - Overhead trapeze N - No weights on bed or floor

The HYPERKALEMIA "Machine" - Causes of Increased Serum K+ M - Medications - ACE inhibitors, NSAIDS A - Acidosis - Metabolic and respiratory C - Cellular destruction - Burns, traumatic injury H - Hypoaldosteronism, hemolysis I - Intake - Excessive N - Nephrons, renal failure E - Excretion – Impaired

MURDER Signs and Symptoms of Increased Serum K+ M - Muscle weakness U - Urine, oliguria, anuria R- Respiratory distress D - Decreased cardiac contractility E - ECG changes R - Reflexes, hyperreflexia, or areflexia (flaccid)

HYPERNATREMIA "You Are Fried" F - Fever (low grade), flushed skin R - Restless (irritable) I - Increased fluid retention and increased BP E - Edema (peripheral and pitting) D - Decreased urinary output, dry mouth

Can also use this one: SALT S = Skin flushed A = Agitation L = Low-grade fever T = Thirst

S/S of Hyponatremia: SALT LOSS S tupor/coma A norexia, N&V L ethargy T endon reflexes decreased

L imp muscles (weakness) O rthostatic hypotension S eizures/headache S tomach cramping

Blood Compatibility Compatible Plasma Types

Patient Type

Compatible Red Cell Types

A

A, O

A, AB

B

B, O

B, AB

O

O

O, A, B, AB

AB

AB, A, B, O

AB

RhD Positive

RhD Positive

RhD Negative

RhD Negative

RhD Positive

RhD Negative

RhD Negative

Acute kidney injury

(FFP & Cryoprecipitate)

RhD Positive RhD Negative

Nephrotic syndrome

Episode of kidney failure or Changes in glomerulus kidney damage that causes What is it? that leads to leaking of build up of waste products large amounts of protein in blood

Glomerulonephritis Inflammation that leads to leaking of RBCs and mild amount of protein

Causes

Diseases and disorders that can cause decreased blood flow to kidneys, direct damage to kidney, or blockage of the urinary tract

Tends to affect pediatric population Glomeruli changes – can be from disease process like HF, DM

Tends to affect pediatric population Post streptococcal infection “HAD STREP”

Dependent on cause** Swelling SOB Signs and Confusion symptoms Chest pain Nausea Oliguria

Massive proteinuria

Hypertension

Frothy, foamy urine

Antistreptolysin titer positive

Hypoalbuminemia Edema – not just in face, but will progress to extremities and abdomen

Decreased GFR Swelling in eyes/face

Hyperlipidemia

Tea colored urine from hematuria

Weight gain

Recent strep infection Elevated BUN and creatinine

Fatigue

Proteinuria Meds Treatment

Dependent on cause

Prednisone

Meds

Possible dialysis

Furosemide

Antihypertensives

Albumin How to Interpret an ABG? The first value a nurse should look at is the pH to determine if the patient is in normal range, above, or below. If a patient’s pH > 7.45, the patient is alkalotic. If the pH < 7.35, then the patient is acidotic. Next, examine the PaCO2. This will determine if the changes in the blood gas are due to the respiratory system or metabolically driven. In combination with the HCO3, the nurse will be able to fully comprehend the blood gas. Below is a chart that contains the different values and determining if the patient is suffering from a respiratory or a metabolic component. This will enable the medical team to treat the patient adequately.

pH CO2 HCO3 Respiratory acidosis

↓

↑

Normal

Respiratory alkalosis

↑

↓

Normal

Respiratory acidosis with metabolic compensation ↓

↑

↑

Respiratory alkalosis with metabolic compensation ↑

↓

↓

The acronym ROME is used to help nurses remember the relationship between pH and CO2. Respiratory Opposite Metabolic Equal The CO2 is the respiratory component of the blood gas: if the CO2 is low and the pH is high then the patient would have respiratory alkalosis. These two values move in opposite directions. On the other hand, the HCO3 is the metabolic component of the blood gas. If the HCO3 is low and the pH is high then the patient is in metabolic acidosis. These two values move in the same direction. There are many different ways to remember how to analyze an arterial blood gas. It’s a nurse’s responsibility to be able to identify key components in order to be prepared for the next step. Asking the help of more senior clinical nurses and respiratory therapists will allow novice nurses to master this skill. To remember signs and symptoms of Cushing's: Remember the mnemonic: “STRESSED” (remember there is too much of the STRESS hormone CORTISOL) S= Skin fragile T= Truncal obesity with small arms R= Rounded face (appears like moon), Reproductive issues amennorhea and ED in male(due to adrenal cortex’s role in secreting sex hormones) E= Ecchymosis, Elevated blood pressure S= Striae on the extremities and abdomen (Purplish) S= Sugar extremely high (hyperglycemia) E= Excessive body hair especially in women…and Hirsutism (women starting to have male characteristics), Electrolytes imbalance: hypokalemia D= Dorsocervical fat pad (Buffalo hump), Depression Signs & Symptoms of Addison’s Disease Remember the phrase: “Low STEROID Hormones” (remember you have low production of aldosterone & cortisol which are STEROID hormones) S= Sodium & Sugar low (due to low levels of cortisol which is responsible for retention sodium and increases blood glucose), Salt cravings

T = Tired and muscle weakness E = Electrolyte imbalance of high Potassium and high Calcium R = Reproductive changes…irregular menstrual cycle and ED in men O = lOw blood pressure (at risk for vascular collapse)….aldosterone plays a role in regulating BP I = Increased pigmentation of the skin (hyperpigmentation of the skin) D = Diarrhea and nausea, Depression

Remember the 7L's for hypokalemia 1. 2.

Lethargy (confusion) Low, shallow respirations (due to decreased ability to use accessory muscles for breathing)

3.

Lethal cardiac dysrhythmias

4.

Lots of urine

5.

Leg cramps

6.

Limp muscles

7.

Low BP & Heart

Causes of Hypocalcemia Remember “Low Calcium” Low parathyroid hormone due. This is due to the destruction or removal parathyroid gland (any surgeries of the neck ex: thyroidectomy you want to check the calcium level) Professors love to ask this on an exam. Oral intake inadequate (alcoholism, bulimia etc.) Wound drainage (especially GI System because this is where calcium is absorbed) Celiac’s & Crohn’s Disease cause malabsorption of calcium in the GI track Acute Pancreatitis Low Vitamin D levels (allows for calcium to be reabsorbed)

Chronic kidney issues (excessive excretion of calcium by the kidneys) Increased phosphorus levels in the blood (phosphorus and calcium do the opposite of each other) Using medications such as magnesium supplements, laxatives, loop diuretics, calcium binder drugs Mobility issues

Signs & Symptoms of Hypocalcemia Remember “CRAMPS” Confusion Reflexes hyperactive Arrhythmias (prolonged QT interval and ST interval) Note: definitely remember prolonged QT interval…another major test question Muscle spasms in calves or feet, tetany, seizures Positive Trousseau’s! You will see this before Chvostek’s sign or before tetany. This sign may be positive before other manifestations of hypocalcemia such as hyperactive reflexes. Signs of Chvostek’s (nerve hyperexcitability of the facial nerves. To elicit this response you would tap at the angle of the jaw via the masseter muscle and the facial muscles on the same side of the face will contract momentarily (the lips or nose will twitch).

Types of kidney rejection:

Cause

Manifestations

Treatment

An antibody-mediated response causing small blood clots to form in the Hyperacute transplanted kidney that occlude vessels and result in massive cellular destruction. Not reversible

Fever, hypertension, pain at the transplant site.

Immediate removal of the donor kidney.

Acute

Oliguria, anuria, low grade Involves increased

Cause vasculitis in the donor

fever, hypertension, kidney, and cellular destruction tenderness over the starts with inflammatory that transplanted kidney, causes lysis of the donor lethargy, azotemia, and kidney fluid retention.

Chronic

Blood vessel injury from overgrowth of the smooth muscle of the blood vessels causing fibrotic tissue to replace normal tissue resulting in a nonfunctioning donor kidney.

doses of immunosuppressive medications.

Gradual return of Conservative until azotemia, fluid retention, dialysis is required. electrolyte imbalance, and fatigue.

Delegation Tips 

Nurses need to delegate fittingly and review that clients receive safe, quality care by the assigned personnel.



The delegating nurse reviews the following factors when assigning tasks and nursing activities: Individual client needs, facility policies, job descriptions, the specific state nurse practice act and professional standards.



RNs are responsible for the supervision of client care tasks delegated to licensed practical nurses (LPNs) and to unlicensed assistive personnel (UAPs).



The RN must be knowledgeable about the applicable state nurse practice act and regulations



LPNs may delegate to other LPNs and UAP.



LPNS and UAPs care for stable clients

Examples of tasks that can be delegated by the RN To LPNs Reinforcement of client teaching

To UAP Activities of daily living (ADLs)

Monitoring client clinical manifestations Bathing, Grooming, Dressing, Toileting, Ambulating, Feeding (without swallowing after the initial RN assessment and concerns), Positioning, Bed making evaluation Tracheostomy Care

Specimen Collection

Suctioning

Intake and output

Reviewing patency and placement of a nasogastric tube Enteral feeding administ...