:)One of my classmates, before, asked me in YM the type of situation which somehow happened not only in the hospital — where I am working — but definitely occurred no matter how you mastered to monitor your patient. The question is, “If your patient got 50ng/dl after getting the patient’s blood glucose level. At that moment, happened to be the scheduled time for the next insulin dose or oral hypoglycemic agent (any of the two). Will you give the next dose?

The answer would be NO.

Your independent nursing action in this situation would be to let the patient eat simple carbohydrates: in the form of candies or orange juices.  You are not going to give OHA or insulin for the time being since they are compelled to make your blood glucose run to normal level or at least make your blood sugar be lowered. Record and report the findings should you omit the next dose to the attending physician.

Bookmark It

Hide Sites

Musculoskeletal - Upload a Document to Scribd

Bookmark It

Hide Sites

There will be a Basic Life Support with First Aid Training for only Php 700 this coming October 2 - 3 2008 (thursday and friday) 8:30AM - 5PM and Professional Cardiopulmonary Resuscitation with Automatic External Defibrillator and Oxygen Administration on October 04, 2008 (saturday) for only Php  1000. But if you’ll attend both trainings it’ll only be 1500 instead of 1700.00 as part of special training package. If you’re interested pls contact CELI Bigfoot Ramos  now at 4128811 loc.826/824 and look for Desiree. Hurry limited slots only.

Bookmark It

Hide Sites

Patient X presents with extensive destruction of knees, subcutaneous nodules, and exquisite pain in the metatarsophalangeal joint? Biopsy shows needle-like crystals. What is the diagnosis? gouty arthritis.

Assessment Findings

1. Severe pain in the involved joints, initially the big toe.

2. Swelling and inflammation of the joint

3. TOPHI - yellowish-whitish irregular deposits in the skin that break open and reveal a gritty appearance.

4. PODAGRA - big toe

5. Fever, malaise

6. Body weakness and headache

7. Renal stones

LABORATORY DIAGNOSIS

Even if the clinical appearance strongly suggests gout, the diagnosis should be confirmed by needle aspiration of acutely or chronically inflamed joints or tophaceous deposits. During acute gouty attacks, strongly birefringent needle- shaped MSU (Monosodium Urate) crystals with negative elongation are largely intracellular. Synovial fluid cell counts are elevated from 2000 to 60,000/µL. Effusions appear cloudy due to leukocytes, and large amounts of crystals occasionally produce a thick pasty or chalky joint fluid. Bacterial infection can coexist with urate crystals in synovial fluid; if there is any suspicion of septic arthritis, joint fluid must also be cultured. MSU crystals can often be demonstrated in the first metatarsophalangeal joint and in knees not acutely involved with gout. Arthrocentesis of these joints is a useful technique to establish the diagnosis of gout between attacks. Serum uric acid levels can be normal or low at the time of the acute attack, since lowering of uric acid with hypouricemic therapy or other medications limits the value of serum uric acid determinations for the diagnosis of gout. Despite these limitations, serum uric acid is almost always elevated at some time and can be used to follow the course of hypouricemic therapy. A 24-h urine collection for uric acid is valuable in assessing the risk of stones, in elucidating overproduction or underexcretion of uric acid, and in deciding which hypouricemic regimen to use. Excretion of 800 mg of uric acid per 24 h on a regular diet suggests that causes of overproduction of purine should be considered. Urinalysis, blood urea nitrogen, serum creatinine, white blood cell (WBC) count, and serum lipids should be obtained because of possible pathologic sequelae of gout and other associated diseases requiring treatment.

® Elevated levels of uric acid in the blood

• Uric acid stones in the kidney
• (+) urate crystals in the synovial fluid

As a summary:

• Elevated levels of uric acid in the blood
• Uric acid stones in the kidney
• (+) urate crystals in the synovial fluid

RADIOGRAPHIC FEATURES:

Cystic changes, well-defined erosions described as punched-out lytic lesions with overhanging bony edges [Martel’s sign, or G sign (G for gout)], associated with soft tissue calcified masses are characteristic radiographic features of chronic tophaceous gout. However, similar radiographic signs can also be observed in erosive osteoarthritis, destructive apatite arthropathies, and rheumatoid arthritis.

Medical management

1. Allupurinol- take it WITH FOOD : Rash signifies allergic reaction

2. Colchicine: For acute attack

3. Probenecid: For uric acid excretion in the kidney
TREATMENT

Acute Gouty Arthritis The mainstay of treatment during an acute attack is the administration of an anti-inflammatory drug such as colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or glucocorticoids depending on the age of the patient and comorbid conditions. Both colchicine and NSAIDs may be quite toxic in the elderly, particularly in the presence of renal insufficiency and gastrointestinal disorders. In elderly patients, one may favor the use of intraarticular glucocorticoid injections for attacks involving one or two larger joints or ice pack applications along with lower oral doses of colchicine for gouty synovitis affecting small joints. Colchicine given orally is a traditional and effective treatment, if used early in the attack, in at least 85% of patients. One tablet (0.6 mg) is given every hour until relief of symptoms or gastrointestinal toxicity occurs, or a total of four to eight tablets may be given in accordance with the age of the patient. The drug must be stopped promptly at the first sign of loose stools, and symptomatic treatment must be given for the diarrhea. Intravenous colchicine is sometimes used and can reduce, though not eliminated, the gastrointestinal side effects. Intravenous colchicine is most reliable for pre- or postoperative prophylaxis in 1- to 2-mg doses when patients cannot take medications orally. Life-threatening colchicines toxicity and sudden death have been described with the administration of 4 mg/d intravenously. The intravenous dose for acute gouty arthritis is 1 to 2 mg given slowly through an established venous line over 10 min in a soluset, and two additional doses of 1 mg each may be given at 6-h intervals, but the total dose should never exceed 4 mg. NSAIDs are affective in 90% of patients, and the resolution of signs and symptoms usually occurs in 5 to 7 days. The most effective drugs are those with a short half-life and include indomethacin, 25 to 50 mg tid, ibuprofen, 800 mg tid, or diclofenac, 50 mg tid. Cyclooxigenase-2 highly selective inhibitors are probably equally effective but with less short-term gastrointestinal toxicity. Oral glucocorticoids such as prednisone, 30 to 50 mg/d as the initial dose and tapered over 5 to 7 days, a single intravenous dose of methylprednisolone, 7 mg of betametasone, or 20 to 40 mg of intraarticular triamcinolone acetonide have been equally effective. ACTH as an intramuscular injection of 40 to 80 IU in a single dose or every 12 h for 1 to 2 days is effective in patients with acute polyarticular refractory gout or with a contraindication for using colchicine or NSAIDs.

Hypouricemic Therapy Attempts to normalize serum uric acid to <300µmol/L (5.0 mg/dL) to prevent recurrent gouty attacks and eliminate tophaceous deposits entail a commitment to long-term hypouricemic regimens and medications that generally are required for life. Hypouricemic therapy should be considered when the hyperuricemia cannot be corrected by simple means (control of body weight, low-purine diet, increase in liquid ingestion, limitation of ethanol intake, and avoidance of diuretic use). The decision to initiate hypouricemic therapy is usually made taking into consideration the number of acute attacks, family history of gout, presence of MSU tophaceous deposits, uric acid excretion >800 mg per 24 hours, presence of uric acid stones, and risk for acute uric acid nephropathy during chemotherapy for myeloproliferative disorders. Uricosuric agents, such as probenecid, can be used in patients with good renal function who underexcrete uric acid, with 600 mg in a 24-hour urine sample. Urine volume must be maintained by ingestion of 1500 mL of water every day. Probenecid can be started at a dosage of 200 mg twice daily and increased gradually as needed up to 2 g in order to maintain a serum uric acid level 300µmol/L (5 mg/dL). Probenecid is the drug of choice to treat elderly patients with hypertension and thiazide dependence; however, probenecid is not effective with a renal creatinine clearance _1 mL/s. These patients may require allopurinol or benzbromarone, which is another uricosuric drug that is effective in patients with renal failure and who are receiving diuretics. Allopurinol is the best drug to lower serum urate in overproducers, stone formers, and patients with advanced renal failure. It can be given in a single morning dose, 300 mg initially and increasing up to 800 mg if needed. In most patients, it is not necessary to start at a lower dose; however, in patients with renal failure, the dosage should be adjusted depending on the serum creatinine concentration in order to minimize side effects. Patients with frequent acute attacks may require lower initial doses to prevent exacerbations. Toxicity of allopurinol has been recognized increasingly in patients with renal failure who use thiazide diuretics and in those patients allergic to penicillin and ampicillin. The most serious side effects include skin rash with progression to life-threatening toxic epidermal necrolysis, systemic vasculitis, bone marrow suppression, granulomatous hepatitis, and renal failure. Urate-lowering drugs should not be initiated during acute attacks. This is especially important in patients who have refractory acute arthritis or who had a flare-up previously with hypouricemic drugs. Colchicine prophylaxis in doses of 0.6 mg one to two times daily is usually continued, along with hypouricemic therapy, until the patient is normouricemic and without gouty attacks for 3 months. However, prophylactic colchicine treatment may be necessary as long as tophi are present. Recombinant urate oxidase uricase can be used in the short-term prophylaxis and treatment of chemotherapy-associated hyperuricemia in patients with lymphoproliferative and myeloproliferative disorders.

Drug-Induced Gouty Arthritis

Diuretics, aspirin, cytotoxics, cyclosporine, alcohol, ethambutol

Nursing Intervention

1. Provide a diet with LOW purine

Avoid Organ meats, aged and processed foods

STRICT dietary restriction is NOT necessary

2. Encourage an increased fluid intake (2-3L/day) to prevent stone formation

3. Instruct the patient to avoid alcohol

4. Provide alkaline ash diet to increase urinary pH

5. Provide bed rest during early attack of gout

6. Position the affected extremity in mild flexion

7. Administer anti-gout medication and analgesics

Bookmark It

Hide Sites

TUBERCULOSIS

Agent:

• Mycobacterium Tuberculosis (human)
• Mycobacterium Africanum (human)
• Mycobacterium bovis (animal, cattle)

Transmission:

• Airborne, droplet
• Direct invasion through mucous membrane (rare)
• Ingestion of contaminated unpasturized milk

Communicability: As long as bacilli are present in the sputum

Susceptibility: 6-12 months after exposure

• Common among children below 3 y.o., adolescents, young adults and old age
• HIV infected patient, under weight, diabetics and substance abusers

Signs and Symptoms:

• Cough more than 2 weeks
• Loss of appetite and loss of weight
• Afternoon fever and night sweats
• Chest and back pain
• Hemoptysis

Diagnostic Exam:

• Sputum Exam (early morning sputum, 3x negative result = rule out)
• Chest X-ray
• Sputum, gastric culture
• Physical exam - TB symptomatics
• Mantoux Test - read after 48-72 hours: 10 mm or more = (+)

30mm or higher = suggestive of secondary infection

Treatment:

Category I:

• New pulmonary TB cases with (+) sputum exam
• Sputum (-) with chest x-ray of moderate to far advance TB
• Extra pulmonary TB (e.g. TB meningitis, intestinal TB, etc.)

A.      Intensive Phase (2 months)

• Rifampicin 450 mg
• Isoniazid (INH) 300 mg
• Pyrazinamide (PZA) 500 mg (2 tabs)
• Ethambutol 400 mg (2 tabs)

* Sputum exam if (+) add 1 month intensive treatment

B.      Maintenance Phase (4 months)

• Rifampicin
• Isoniazid

Category II:

• Relapses
• Failures
• Others (Resistant Cases)

A.      Intensive Phase (2 months)

• Rifampicin 450 mg
• Isoniazid 300 mg
• Pyrazinamide 500 mg (2 tabs)
• Ethambutol 400 mg (2 tabs)
• Streptomycin SO₄ 1gm (IM)

B.      Intensive Phase (1 month)

• Rifampicin
• INH
• PZA
• Ethambutol

* Sputum Exam: if (+) add 1 month of RIPE

C.      Maintenance Phase (5 months)

• Rifampicin
• Isoniazid
• Ethambutol

Category III:

• New TB cases who are sputum (-)
• New serious extrapulmonary TB cases

A.      Intensive Phase (2 months)

• Rifampicin 450 mg
• Isoniazid 300 mg
• Pyrazinamide 500 mg

B.      Maintenance Phase (2 months)

• Rifampicin
• Isoniazid

Contraindications/Complications:

• PZA (Pyrazinamide) - gouty arthritis
• Streptomycin Sulfate - pregnant women, can cause deafness and ringing of ears
• INH (Isoniazid) - cause peripheral neuritis
• Rifampicin - not indicated to patient with liver and renal damage; can cause red-orange urine

Other treatment programs:

• SR: Standard Regimen

(INH and Streptomycin)

• SCC: Short Course Chemotherapy

(Rifampicin, INH, PZA)

• DOTS: Direct Observed Treatment Short Course

(taking anti TB drugs under direct supervision of health worker)

Prevention:

1.       BCG vaccination

2.       IEC (Public Education)

3.       Improve social conditions

4.       Active, passive case finding and treatment

Bookmark It

Hide Sites

Sample Nurse Practice Tests 2 

1. Cells in the pancreas that secrete glucagon and insulin are which of the following?

• a.  A and B cells
• b.  acinar cells
• c.  D cells 
• d. pancreatic D1 cells
• e. pancreatic polypeptide cells

2. A 57-year-old female patient has suffered a major stroke and as a result is in a coma. The attending neurologist is very concerned because the patient is developing ataxic breathing. The pneumotaxic center and apneustic centers of the brain are located in which of the following?

• a. diencephalon
• b. midbrain 
• c.  pons
• d.  spinal cord
• e.  telencephalon

3. A 14-year-old boy presents with weight loss and diarrhea. His tongue becomes sore and blistery after eating oatmeal or rye bread, which leads to the diagnosis of celiac disease. The boy and his parents are advised to be sensitive to symptoms of tetany and paresthesias, since they can occur as a consequence of malabsorption of which of the following?

• a. calcium
• b. carbohydrates
• c. fat
• d. iron
• e. water

4. Lack of oxygen (hypoxia) will cause reflex vasoconstriction in the circulation supplying which of the following organs?

• a. brain
• b. heart muscle
• c. kidney
• d. lungs
• e. skeletal muscle

5. A patient with newly diagnosed schizophrenia is given chlorpromazine. It is a drug that has amongst other effects moderate anticholinergic activity. As a consequence, which of the following is an expected side effect of this medication?

• a. bradycardia
• b. decreased GI sphincter tone
• c.  dry mouth
• d.  emptying of urinary bladder
• e. increased GI motility

6. Which of the following statements concerning total body energy storage is correct?

• (A) Most of the body’s energy store is held as carbohydrate.
• (B) Most of the body’s energy store is held as lipid.
• (C) Most of the body’s energy store is held as plasma glucose.
• (D) Most of the body’s energy store is held as protein.
• (E) Total body’s energy storage approximately equals resting metabolic rate.

7. Heparin is a rapidly acting, potent anticoagulant that has many important clinical uses.Which of the following is an action of heparin?

• (A) activates prothrombin
• (B) acts with antithrombin to inhibit thrombin activity
• (C) decreases prothrombin time
• (D) inhibits calcium action
• (E) promotes vitamin K activity

8. Following an automobile accident a patient suffers a pelvic fracture and significant internal blood loss resulting in hemorrhagic shock. Which of the following organs has the largest specific blood flow (blood flow per gram of tissue) under resting conditions and is especially vulnerable during the shock phase?

• (A) brain
• (B) heart muscle
• (C) kidneys
• (D) skeletal muscle
• (E) skin

9. A 68-year-old woman presents with sleep disturbances and memory loss. After careful analysis, she is diagnosed with early stages of Alzheimer’s disease. Her pharmacological treatment plan includes acetylcholine esterase inhibitors. One week after starting treatment, the woman’s daughter calls in, reporting that her mom has developed new symptoms that might be related to her new medicine. Which of the following is a likely side effect of the drug?

• (A) dry mouth
• (B) forgetting to urinate
• (C) muscle weakness
• (D) nausea and diarrhea
• (E) vertigo

10. A 52-year-old woman has had rheumatoid arthritis for many years. She now comes to you complaining of the development in the past few months of redness, burning, and itching of her eyes and a dry mouth, making swallowing difficult. This newly developing condition gives the patient a greatly increased risk for which of the following?

• (A) esophageal carcinoma
• (B) leukemia
• (C) lymphoma
• (D) melanoma
• (E) pleomorphic adenoma

Bookmark It

Hide Sites

Case Study Psychiatric Nursing 101

A 29-year-old man is brought to the emergency center in a drunken stupor. He is accompanied by his wife, who states that he hasn’t been himself at all for the past few months. According to his wife, he was evaluated for depression by his personal physician about 3 months ago and started on an SSRI. He responded quite well to this therapy over the subsequent 2 months. He started feeling so good and so energetic that he stopped taking his medication. He found that he needed less and less sleep, to the point where he is now only sleeping 2-3 hours a day. He has been showering his wife with very expensive gifts and has hit the maximum limit on all of their credit cards. He has been extremely romantic and more interested in sexual relations than at any time before. He has also started drinking heavily and has passed out drunk more than once. His work has suffered, and his boss said that he is in danger of being fired if things don’t straighten out. Other than being drunk, his physical examination and blood tests are normal. He is admitted to the psychiatric unit with a diagnosis of bipolar disorder and started on lithium.

• What is the mechanism of action of lithium?
• What are the common side effects of lithium?
• What is the mechanism of lithium-induced polyuria?

Mechanism of action of lithium: Not entirely known but may be related to inhibition of membrane phospholipid turnover with a reduction in key second messengers, important in the overactivity of catecholamines thought to be related to mood swings characteristic of bipolar disorder.

Common side effects of lithium: Nausea, vomiting, diarrhea, tremor, edema, weight gain, polydipsia, and polyuria.

Mechanism of lithium-induced polyuria: Renal collecting tubule becomes resistant to antidiuretic hormone.

Bookmark It

Hide Sites

ß-Blockers

• Examples:  Propranolol, metoprolol, atenolol, nadolol, timolol, pindolol, esmolol, labetalol

•  Toxicity: Impotence, exacerbation of asthma, cardiovascular adverse effects (bradycardia, AV block, Congestive Heart Failure), CNS adverse effects (sedation, sleep alterations)

Bookmark It

Hide Sites

Acetyl Salicylic Acid (Aspirin) Overdose

Acute and chronic (elderly with renal insufficiency)

Important Assessment:

• hyperventilation (central stimulation of respiratory drive)
• increased anion gap (AG) metabolic acidosis (increased lactate)
• tinnitus, confusion, lethargy
• coma, seizures, hyperthermia, non-cardiogenic pulmonary edema, circulatory collapse
• ABG’s possible:
  • respiratory alkalosis
  • metabolic acidosis
  • respiratory acidosis

Management

• decontamination
• 10:1 charcoal:drug ratio
• whole bowel irrigation (useful if enteric-coated ASA)
• close observation of serum level, serum pH
• alkalinization of urine
• may require K supplements for adequate alkalinization
• consider hemodialysis when:
  • severe metabolic acidosis (intractable)
  • level continues to increase
  • end organ damage (unable to diurese)

to view the complete list of antidote just click here

Bookmark It

Hide Sites

Antipsychotics (neuroleptics)

formerly called major tranquilizers. Used to relieve psychotic symptoms ( delusions, hallucinations, and looseness of association)

Common Medications: Thioridazine, haloperidol, fluphenazine, chlorpromazine

Mechanism of action: Most antipsychotics block dopamine D2 receptors (excess dopamine effect connected with schizophrenia). Also acts as antiemetic, anticholinergic and histaminic effects.

Contraindications: hypersensitivity, glaucoma, convulsive disorder, pregnancy and lactation, elderly clients.

Indications: schizophrenia, psychosis

Toxicity:

Pseudoparkisonism-tremor: mask-like faces, drooling

Akathisia: restlessness

Dystonia: grimacing, torticoilis, intermittent muscle spasms

Tardive Dyskinesia: Stereotypic oral - facial movements probably due to dopamine receptors sensitization results of long-term antipsychotic use. , usually irreversible

Seizure

Extrapyramidal system side effects, sedation, endocrine side effects, and side effects arising from blocking muscarinic, alpha, and histamine receptors.

Neuroleptic malignant syndrome: rigidity, autonomic instability or hyperactivity, hyperpyrexia (treat with dantrolene and dopamine agonists)

Nursing Mnemonics: Ultimate 4 (U4)

Evolution of EPS side effects

4 h acute dystonia

4 d akinesia

4 wk akathisia

4 mo tardive dyskinesia (often irreversible)

Bookmark It

Hide Sites