Preparation Worksheets for NUR 445 Comprehensive Scenario PDF

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Pre-Simulation Worksheet NUR 445 Adult Health 3 Comprehensive Scenario In order to make the most out of the simulations, students need be prepared. Please read the learning outcome for each simulation, complete the following worksheet, and any associated tasks. What to wear and bring… 1. Wear your uniforms and dress as for clinical a. Hair put up b. One pair of stud earrings on the earlobes. c. No nose piercing or exposed tattoos d. Etc… 2. Bring a. Stethoscope b. Pre-work/medication templates c. Small pad of paper d. Pen/pencil Simulation Grade Criteria: Student signed up on SimIQ prior to simulation Pre-simulation work (brought to sim) Student arrived on time to simulation Reflection paper (graded using rubric)

____ / 1pt ____ / 8pts ____ / 1pt ____ / 20pts

TOTAL

____ / 30pts

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Comprehensive Scenario Learning outcomes Student will: 1. Prioritize nursing assessments and interventions for a patient presenting with heroin overdose and alcohol toxicity. 2. Synthesize the interactions between medications, diagnoses, and laboratory values. 3. Recognize appropriate and inappropriate provider orders. 4. Discuss nursing roles regarding genetics and genomics associated with substance addictions. Tasks: 1. Read one of the articles provided on BrightSpace on addictions and genetics/genomics. 2. Read in your textbook and class notes about to assessments, interventions, and treatment of a patient after a respiratory and cardiac arrest. Consider rhabdomyolysis, brain anoxia, and MODS. 3. Complete medication templates for the following medications and bring to your simulation. o Narcan o Escitalopram o Dexmethylphenidate o Guanfacine o Oxycodone/acetaminophen o Insulin (Humolog) o Piperacillin-tazopactam o Norepinephrine 4. Complete the pre-simulation worksheet and bring to your simulation.

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Comprehensive Scenario Worksheet What are the genetic predispositions to addiction and how does this influence nursing care? 

Increase in the proto-oncogene of cJUn, expression of the ENO2 CEBPB, FBK5 and PRKCB genes.

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This effects nursing care by knowing how a patient will tolerate opioids and how likely a patient is to become addicted to opioids.

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Family history of substance abuse increases risk of addiction.

Who is at risk for heroin addiction? 

Everyone – depends on your genetic make-up, environment, and family history

After a respiratory and cardiac arrest, what medical and/or nursing interventions could minimize brain damage? Provide oxygen, assess respiratory function, intubate the patient, decrease oxygen demand, monitor BP, monitor heart rate, monitor MAP, seizure precautions, prevent hypothermia

Which labs would the nurse expect the provider to order after a respiratory and cardiac arrest following an expected heroin overdose? ABGs, BMP, Troponin, PTT, INR, Creatinine, BUN, CK-MB, 12-lead ECG, X-Ray, CT, MRI, echocardiogram, pulmonary functions test What is rhabdomyolysis? Who is at risk to develop rhabdomyolysis? -Indicates muscle injury which release myoglobin and creatine-kinase (blood levels >5,000); clogs kidneys (intrarenal issue) -Diminished blood flow to cells and cell death release myoglobin -Increase creatine and waste products -Patient found down = increased risk of rhabdo d/t break down of tissue and muscle injury What is sepsis? What are the signs and symptoms of sepsis? -Systemic inflammatory response due to microorganisms entering body; Infection goes throughout the body not localized any more -Temperature – > 38 degrees Celsius or < 36 degrees Celsius -HR >90 -Respiratory Rate >20 -WBC > 12,000 or < 4,000 When should a sepsis protocols be initiated? ASAP- if infection is present and has s/s associated with sepsis lactate should be drawn and sepsis protocols should be activated What is included in a sepsis protocol? -Measure serum lactate, obtain blood cultures to administer antibiotics, administer broad spectrum antibiotic, administer fluids to treat hypotension, administer vasopressors for hypotension Goals: Fluid resuscitation, antibiotic admin, treating the underlying condition, infection prevention, maintain adequate oxygenation, increase tissue perfusion, increase cardiac output, pain control, glucose control, adequate nutrition, prevent DVT, prevent stress ulcers Name potential complications of sepsis? SIRS & MODS, respiratory failure, changes in LOC due to decreased perfusion and acidosis, cell hypoxia What is Continuous Veno-Venous Hemofiltration (CVVH) and when is it used? – Short term blood filtering done on patient who have renal dysfunction and are hemodynamically unstable. Used when kidneys are injured and need a break

4 Medication

Dosage/Route

Action

Indication

Side effects

Dexmethylphenidate (Focalin) – CNS stimulant

PO (Adults): 10 mg once daily, may be increased by 10 mg up to 40 mg/day; Patients currently taking methylphenidate —starting dose is 1/2 of the methylphenidate dose, up to 40 mg/day given as a single daily dose;

Produces CNS and respiratory stimulation with weak sympathomimeti c activity

Increased attention span in ADHD.

Behavioral disturbances, hallucinations, insomnia, mania, nervousness, thought disorder, abdominal pain, anorexia, angioedema

Guanfacine (Tenex) Antihypertensive

Hypertension: PO (Adults): 1 mg daily given at bedtime, may be increased if necessary at 3– 4 wk intervals up to 2 mg/day; may also be given in 2 divided doses.

Stimulates CNS alpha2adrenergic receptors, producing a decrease in sympathetic outflow to heart, kidneys, and blood vessels. Result is decreased BP and peripheral resistance, a slight decrease in heart rate, and no change in cardiac output.

Lowering of BP in hypertension.

Oxycodone/acetaminophe n (Percocet) Opioid analgesic

PO (Adults): Analgesic—2.5– 10 mg q 3– 6 hr as needed; if using combination products, acetaminophen dosage should not exceed 4 g/day

Bind to opiate receptors in the CNS. Alter the perception of and response to painful stimuli while producing generalized CNS depression.

Decrease in severity of moderate pain

Drowsiness, headache, weakness, depression, dizziness, fatigue, insomnia, constipation, dry mouth, erectile dysfunction

Confusion, dizziness, sedation, euphoria, hallucinations, headache, unusual dreams, hypotension, bradycardia

Nursing Considerations Monitor BP, pulse, and respiration before administering and periodically during therapy. Obtain a history (including assessment of family history of sudden death or ventricular arrhythmia), physical exam to assess for cardiac disease, and further evaluation (ECG and echocardiogram), if indicated. If exertional chest pain, unexplained syncope, or other cardiac symptoms occur, evaluate promptly. Hypertension: Monitor BP (lying and standing) and pulse frequently during initial dose adjustment and periodically during therapy. Report significant changes.

Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is 10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Dose may need to be decreased by 25–

5 50%. Initial drowsiness will diminish with continued use Insulin (Humalog)

Subcut (Adults): Initial dose range– 0.2– 0.6 units/kg/day. Usual maintenance range– 0.5– 1.2 units/kg/day.

Lowers blood glucose by: stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Inhibition of lipolysis and proteolysis, enhanced protein synthesis.

Control of hyperglycemi a in diabetic patients.

Piperacillin-tazobactam (Zosyn)

IV (Adults): Most infections—3.375 g q 6 hr. Nosocomial pneumonia—4.5 g q 6 hr. IV (Adults): Nosocomial pneumonia—4.5 g q 6 hr IV (Adults): Appendicitis and/or peritonitis —3.375 g q 6 hr.

Piperacillin: Binds to bacterial cell wall membrane, causing cell death. Spectrum is extended compared with other penicillins. Tazobactam: Inhibits betalactamase, an enzyme that can destroy penicillins

Death of susceptible bacteria

(Anti-infective)

Hypoglycemia, lipodystrophy, pruritus, erythema, swelling. allergic reactions including anaphylaxis

Assess for symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait)and hyperglycemia (confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; unusual thirst) periodically during therapy.

Seizures, diarrhea, pseudomembranou s colitis, pain phlebitis, toxic epidermal necrolysis, bleeding, leukopenia, neutropenia, thrombocytopenia

Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify health care professional immediately if these occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction. Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody

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stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy.

Norepinephrine (Levophed) Vasopressor

IV (Adults): 0.5– 1 mcg/min initially, followed by maintenance infusion of 2– 12 mcg/min titrated by BP response (average rate 2– 4 mcg/min, up to 30 mcg/min for refractory shock have been used).

Stimulates alpha-adrenergic receptors located mainly in blood vessels, causing constriction of both capacitance and resistance vessels. Also has minor betaadrenergic activity (myocardial stimulation)

Increased BP. Increased cardiac output.

Anxiety, dyspnea, arrhythmias, bradycardia, chest pain, hypertension, decreased urine output, renal failure

Assess for skin reactions (rash, fever, edema, mucosal erosions or ulcerations, red or inflamed eyes). Monitor patient with mild to moderate rash for progression. If rash becomes severe or systemic symptoms occur, discontinue piperacillin/tazobacta m. Monitor urine output and notify health care professional if it decreases to 30mL/ hr. Monitor BP every 2– 3 min until stabilized and every 5 min thereafter. Systolic BP is usually maintained at 80– 100 mm Hg or 30– 40 mm Hg below the previously existing systolic pressure in previously hypertensive patients. Consult physician for parameters. Continue to monitor BP frequently for hypotension following discontinuation of norepinephrine. ECG should be monitored continuously. CVP, intra-arterial pressure, pulmonary artery diastolic pressure, pulmonary capillary wedge pressure (PCWP), and cardiac output may also be monitored.

7 Escitalopram (Lexapro) SSRI

PO (Adults): Depression and GAD– 10 mg once daily, may be increased to 20 mg once daily after 1 wk.

Selectively inhibits the reuptake of serotonin in the CNS.

Narcan (Naloxone) Opioid analgesic

IV, IM, Subcut (Adults): Patients not suspected of being opioid dependent— 0.4 mg (10 mcg/kg); may repeat q 2– 3 min (IV route is preferred). Some patients may require up to 2 mg. Patients suspected to be opioid dependent —Initial dose should be increased to 0.1– 0.2 mg q 2– 3 min. May also be given by IV infusion at rate adjusted to patient’s response.

Competitively blocks the effects of opioids, including CNS and respiratory depression, without producing any agonist (opioidlike) effects.

Antidepressan t action

Neuroleptic malignant syndrome, suicidal thoughts, insomnia, diarrhea, nausea, SIADH, serotonin syndrom

Reversal of signs of opioid excess.

Ventricular arrhythmias, hypertension, hypotension, nausea, vomiting.

Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults older than24 yrs. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for next 4 wk, and on advice of health care professional thereafter. Monitor respiratory rate, rhythm, and depth; pulse, ECG, BP; and level of consciousness frequently for 3– 4 hr after the expected peak of blood concentrations. After a moderate overdose of a short half-life opioid, physical stimulation may be enough to prevent significant hypoventilation. The effects of some opioids may last longer than the effects of naloxone, and repeat doses may be necessary....