NCLEX-RN Topic 10: Z-TRACK Method

Implementation



➧Wash hands.


Prevents transmission of microorganisms.


➧ Prepare syringe with ordered medication adhering to the five rights of drug administration.


Reduces risk of drug error. Proper preparation of drug.


➧ Change needle after medication has been drawn up, and pull plunger back 0.3 mL.


Prevents irritation and staining of skin and subcutaneous tissues when needle is inserted into skin; airlock prevents back seepage of medication through the tissues.


➧ Identify patient by reading identification bracelet and addressing patient by name.


Confirms identity of the patient.


➧ Explain procedure and purpose of medication to be given.


Decreases anxiety and promotes cooperation.


➧ Verify allergies listed on medication record.


Alerts nurse to possible allergic reactions.


➧ Provide privacy.


Reduces embarrassment.


➧ Don gloves.


Prevents contact with body fluids.


➧ Assist patient into the prone position.


Prone position facilitates identification of anatomic landmarks and promotes relaxation of gluteal muscles.


➧ Outline injection site by identification of anatomical landmarks of dorsogluteal site, and information on locating anatomical landmarks).


Prevents nerve injury.


➧ Clean skin with alcohol, and remove needle cap.


Prevents transfer of microorganisms.


➧ Pull skin 1 to 1/2 inches laterally away from midline with nondominant hand, and rest the heel of the hand on the skin while maintaining traction.


Retracts the skin and subcutaneous tissue from muscle, forming a tract that prevents back seepage of medication into subcutaneous tissues.


Allows fingers to support syringe barrel to provide stability of needle while aspirating.


➧ Observe for the rise of the air bubble to the top of syringe and quickly insert needle at 90-degree angle.


Minimizes pain upon needle insertion, facilitates needle entering muscle mass, and ensures that air clears the needle to seal drug in muscle tissue.


➧ Pull plunger back to aspirate for blood return.


Determines if inadvertent insertion into blood vessel has occurred.


➧ If blood returns, remove the needle, assess and clean site with alcohol pad, apply Band-Aid, and discard medication.

Repeat steps 1–14.


If no blood, return slowly inject medication, and hold needle in place for 10 seconds.


Blood return indicates intravascular injection.


Medication contaminated with blood must be discarded.


Provides adequate absorption time, and prevents leakage of medication back into subcutaneous tissues.


➧ Release the skin while removing needle at the same angle of insertion.


Avoids a direct track between muscle and subcutaneous tissue and skin that would allow the drug to be displaced causing irritation and pain.


➧ Dispose of needle in sharps container; do not recap.


Prevents accidental needle stick.


➧ Do not massage the insertion area; may place alcohol pad or Band-Aid over the site.


Massage will increase the possibility of drug displacement into the tissues.


➧ Reposition patient, raise side rails, and lower bed. Place call bell within reach.


Maintains safety, comfort, and communication.


➧Wash hands


Prevents transfer of microorganisms.


➧ Document administration on medication record.


Prevents accidental re-medication, and serves as a legal record.


➧ Re-check site in 15 to 30 minutes.


Verifies that no seepage of drug has occurred

NCLEX-RN Topic 9: QUICK, EASY ways to remember important clinical facts!!!

QUICK, EASY ways to remember important clinical facts!!!

 To remember the meaning of myasthenia gravis …


...think of grave muscle weakness.






To remember the progression of ARDS, think of …


Assault to the pulmonary system
Respiratory distress
Decreased lung compliance
Severe respiratory failure.




To remember the progression of signs and symptoms of Lyme disease, remember LIME …


Lesions, lymph node swelling, like the flu (Stage 1)
Innervation problems, such as meningitis and peripheral neuropathy (Stage 2)
Movement problems, such as arthritis (Stage 3)
Everything else, such as myocarditis and arrhythmia (Stage 3).




When combining insulins, to remember which to draw first, think of “clear before cloudy.”


Who doesn’t prefer a clear day to a cloudy one?






Remember this jingle when converting inches to centimeters …

“ 2.54, that’s 1 inch and no more.”






To remember which drugs can be given safely through an endotracheal tube, think


of ALE…


Atropine
Lidocaine
Epinephrine.




To remember which drug should be inhaled FIRST, think about your ABCs…


A Bronchodilator comes before a Corticosteroid.






When using an IN-LINE nebulizer, remember to…


connect it to the IN-SPIRATORY side of the ventilatory circuit

NCLEX-RN Topic 8: THERAPEUTIC DIET FOR SPECIFIC CONDITIONS

THERAPEUTIC DIET FOR SPECIFIC CONDITIONS

n AGE – CLEAR LIQUID
n AGN – LOW NA , LOW CHON
n ADDISON’S – HIGH NA , LOW K
n ANEMIA , PERNICIOUS – HIGH CHON , VIT. B.
n ANEMIA SICKLE CELL – HIGH FLUID
n GOUT – PURINE RESTRICTED
n ADHD AND BIPOLAR – FINGER FOODS
n BURN – HIGH CAL. HIGH CHON
n CELIAC – GLUTEIN FREE
n CHOLECYSTITIS; Cholelithiasis, Choledocholithiasis, Cholangitis – HIGH CHON, HIGH CARB, LOW FAT
Low-fat diet to avoid stimulating the gallbladder, which constricts to excrete bile with subsequent pain; calories principally from carbohydrate foods in acute phases; of weight loss is indicated, calories may be reduced to 1000 to 1200; postoperatively clients may take fat-restricted diets initially but progress to regular diets

n CHF – LOW NA , LOW CHOL.
n CROHNS aka Regional Enteritis aka granulomatous colitis – HIGH CHON AND CHO, LOW FAT
n CYSTIC FIBROSIS – HIGH CAL., HIGH NA
n LITHIASIS----ACID ASH FOR ALK. STONES------ALK. ASH FOR ACID STONES
n(1) Calcium stones: low-calcium diet (400 mg daily), achieved by eliminating dairy products; if phosphate involvement, limit high-phosphorus foods (e.g., dairy products, meat); if oxalate involvement, avoid oxalate-rich foods (e.g., tea, almonds, cashews, chocolate, cocoa, beans, spinach, rhubarb); because calcium stones have an alkaline chemistry, an acid ash diet can be used to create an acidic urinary tract, which is less conducive to their formation; encourage whole grains, eggs, cranberry juice, and limit milk, vegetables, fruit; provide riboflavin, vitamins A and C, and folic acid supplements
n
n(2) Uric acid stones: uric acid is a metabolic product of purines; limit purine foods
n(e.g., meat (especially organ meats], meat extracts, and to a lesser extent whole grains and legumes); alkaline-ash diet because the stone composition is acid
n
n(3) Cystine stones (rare): low methionine because methionine is the essential amino acid from which the nonessential amino acid cystine is formed; limit protein foods (meat, milk, eggs, cheese); alkaline-ash diet, because the stone is an acid composition

n DECUBITUS ULCERS – HIGH CHON , HIGH VIT C
n DIARRHEA – HIGH K AND NA
Diverticulosis and Diverticulitis - High-fiber diet after acute phase; Bowel rest: NPO or low-residue diet during initial acute phase; Addition of bran to everyday foods; Avoid intake of seeds and foods with small seeds such as berries and figs
n DUMPING SYNDROME – HIGH FAT, HIGH CHON, DRY, LOW CARBOHYDRATE
n HEPATIC ENCEPHALOPATHY-LOW CHON
n HEPATITIS – HIGH CHON,HIGH CAL.
n HIRSPRUNGS – LOW RESIDUE, HIGH CHON AND CHO
n CIRRHOSIS – LOW CHON
nClients with ascites are fluid-restricted to prevent further accumulation of ascitic fluid
nDiet restrictions include low sodium intake to prevent further ascitic fluid accumulation and decreased protein intake
nProvide small frequent meals
nLifestyle changes include dietary restrictions, abstinence from alcohol, fluid restrictions; suggest nutrition consultation
nTeach client to reduce intake of foods that are high in sodium; canned and frozen foods, highly processed cheeses, potato chips, etc. must be avoided
n MENIERE’S - LOW NA
n MI AND HPN – LOW CHOL.,FATS,NA
n HYPERTHYROIDISM- HIGH CAL. AND CHON
n HYPOTHYROIDISM – LOW CAL. LOW CHOL, LOW SAT. FAT
n NEPHROTIC SYNDROME – LOW NA, HIGH CHON , HIGH CAL.
Hepatitis - Diet therapy - High protein to heal liver tissue; total should approximate 75 to 100g; High carbohydrate to meet energy needs and restore glycogen reserves; total should be300 to 400g; Moderate fat to make food palatable; total should be 100 to 150g; High calorie to meet increased energy needs for disease process, tissue regeneration, and to spare protein for healing; total should be 2500 to 3000; Vitamins A and E when steatorrhea is present; mineral supplements of calcium and zinc

n HYPERPARATHYROIDISM – LOW CALCIUM
n HYPOPARATHYROIDISM – HIGH CA, LOW PHOSPHORUS
n OSTEOPOROSIS – HIGH CALCIUM AND HIGH VIT. D
n PANCREATITIS – LOW FAT
nDiet regulated according to the client’s condition: nothing by mouth; parenteral administration of fluids and electrolytes, total and peripheral parenteral nutrition; diet low in fats and proteins, with restriction of stimulants such as caffeine and alcohol
n PUD – HIGH FAT, HIGH CARB. LOW CHON
n No foods have been determined to be ulcerogenic but some foods aggravate active PUD (coffee, cola, tea, chocolate, foods high in sodium and spicy food) and these should be avoided in the acute phase; even decaffeinated coffee stimulates coffee stimulates gastrin release
n PKU – LOW CHON / PHENYLALANINE
nTreatment is dietary, restricting phenylalanine intake to 20-30 mg/kg body weight
nKeep phenylalanine serum levels 2-8 mg/dl
nUse Lofenalac formula for infants and later

n PIH – HIGH CHON
n RENAL FAILURE (ACUTE) – moderate/LOW CHON,HIGH CARB
moderate/low CHON (to decrease workload of the kidney) and high carbohydrate; After the diuretic phase, the patient is placed on a high-protein, high-calorie diet

Chronic Renal Failure
***moderate to low protein CHON, high carbohydrates, low potassium, and low phosphorous; Very low protein (20 g); minimal essential amino acids make body use its own excess urea nitrogen to synthesize the nonessential amino acids needed for tissue protein production

n LOW NA (OLIGURIC PHASE)
n HIGH CHON , HIGH CAL AND RESTRICTED FLUID (DIURETIC PHASE)
n RENAL FAILURE (Chronic) – LOW CHON , LOW NA , LOW K
Ulcerative Colitis - Diet therapy may include a low-residue diet or in severe cases nothing by mouth to rest the bowel: TPN will be ordered in severe cases; Avoid foods that exacerbate symptoms: raw vegetables, raw fruits, whole-grain breads and cereals, seeds, nuts, popcorn, and any highly spiced or hot.

NCLEX-RN Topic 7: sumatriptan succinate (IMITREX)

sumatriptan succinate (Imitrex)

Indications & dosages
Acute migraine attacks (with or without aura)

Action
May act as an agonist at serotonin receptors on extracerebral intracranial blood vessels, which constricts the affected vessels, inhibits neuropeptide release, and reduces pain transmission in the trigeminal pathways.

Adverse reactions
CNS: dizziness, vertigo, drowsiness, headache, anxiety, malaise, fatigue.
CV: atrial fibrillation, ventricular fibrillation, ventricular tachycardia, coronary artery vasospasm, transient myocardial ischemia, MI, pressure or tightness in chest.
EENT: discomfort of throat, nasal cavity or sinus, mouth, jaw, or tongue, altered vision.
GI: abdominal discomfort, dysphagia, diarrhea, nausea, vomiting, unusual or bad taste (nasal spray).
Musculoskeletal: myalgia, muscle cramps, neck pain.
Respiratory: upper respiratory inflammation and dyspnea (P.O.).
Skin: diaphoresis, flushing, tingling, injection site reaction.
Other: warm or hot sensation, burning sensation, heaviness, pressure or tightness, tight feeling in head, cold sensation, numbness.

Interactions
Drug-drug
Ergot and ergot derivatives, other 5-HT1 agonists: May prolong vasospastic effects. Don't use within 24 hours of sumatriptan therapy.
MAO inhibitors: May reduce sumatriptan clearance. Avoid using within 2 weeks of MAO inhibitor. Use injection cautiously and decrease sumatriptan dose.
SSRIs: May cause weakness, hyperreflexia, and incoordination. Monitor patient closely if use together can't be avoided.
Drug-herb
Horehound: May enhance serotonergic effects. Discourage use together.

Effects on lab test results: May increase liver enzyme levels.


Contraindications & cautions

Contraindicated in patients with hypersensitivity to drug or its components; those with history, symptoms, or signs of ischemic cardiac, cerebrovascular (such as stroke or transient ischemic attack), or peripheral vascular syndromes (such as ischemic bowel disease); significant underlying CV diseases, including angina pectoris, MI, and silent myocardial ischemia; uncontrolled hypertension; or severe hepatic impairment.
Contraindicated within 24 hours of another 5-HT agonist or drug containing ergotamine and within 2 weeks of MAO inhibitor.

Nursing considerations

Use cautiously in woman who is or may become pregnant.
Use cautiously in patient with risk factors for coronary artery disease (CAD), such as postmenopausal women, men older than age 40, or patients with hypertension, hypercholesterolemia, obesity, diabetes, smoking, or family history of CAD.
Alert: When giving drug to patient at risk for CAD, give first dose in presence of other medical personnel. Rarely, serious adverse cardiac effects can follow administration.
Alert: Combining drug with an SSRI or a selective serotonin-norepinephrine reuptake inhibitor (SNRI) may cause serotonin syndrome. Symptoms include restlessness, hallucinations, loss of coordination, fast heart beat, rapid changes in blood pressure, increased body temperature, hyperreflexia, nausea, vomiting, and diarrhea. Serotonin syndrome may occur when starting or increasing the dose of drug, SSRI, or SNRI.>
After subcutaneous injection, most patients experience relief in 1 to 2 hours.
Redness or pain at injection site should subside within 1 hour after injection.
Look alike-sound alike: Don't confuse sumatriptan with somatropin.

Patient teaching

Inform patient that drug is intended only to treat migraine attacks, not to prevent them or reduce their occurrence.
If patient is pregnant or may become pregnant, tell her not to use drug but to discuss with prescriber the risks and benefits of using drug during pregnancy.
Tell patient that drug may be taken any time during a migraine attack, as soon as signs or symptoms appear.
Review information about drug's injectable form, which is available in a spring-loaded injector system for easier patient use. Make sure patient understands how to load the injector, give the injection, and dispose of used syringes.
Alert: Tell patient to tell prescriber immediately about persistent or severe chest pain. Warn him to stop using drug and to call prescriber if he develops pain or tightness in the throat, wheezing, heart throbbing, rash, lumps, hives, or swollen eyelids, face, or lips.

NCLEX-RN Topic 6: Metered Dose Inhaler (MDI) and Purpose of SPACER

A MDI (or inhaler) is a device that contains asthma medicine. It delivers the medicine into the lungs. The MDI needs to be used in a certain way, or it will not work.

***A spacer is a plastic tube with a mask that connects to the MDI. The spacer helps more of the medicine get into the lungs where it can help your child. If your child uses the MDI without a spacer, a lot of the asthma medicine can stick to the tongue and throat instead of going to the lungs. This "wastes" the medicine and decreases it’s usefulness.

***Attached to the mouthpiece, spacers hold the discharged, premeasured cloud of medication in a chamber until the patient breathes in. Spacers are recommended for young children and older adults who have trouble coordinating breathing and activating the MDI. For these groups, a MDI is especially recommended for use with inhaled steroids because it reduces the amount of drug deposited in the mouth and throat thereby reducing unwanted side effects.

Follow the directions from your child’s therapist, nurse or doctor closely. Read the directions on the medicine, MDI and spacer labels carefully before use. Your child’s doctor will give you specific instructions for your child. Some general guidelines for you to follow include:
1. Wash your hands well.
2. Have your child sit up straight or stand to use the MDI.
3. Remove the cap from the inhaler.
4. Shake the inhaler well before using it each time. If it is a new inhaler or has not been used in several days, follow the manufacturer instructions for priming the inhaler.
5. Attach the inhaler to the spacer.
6. Cover your child’s mouth and nose with the mask. If your child fights the mask, have another person gently hold his arms.
7. Press the inhaler to spray the medicine into the spacer.
8. Keep the mask in place until your child takes 6 or 7 deep breaths. If counting breaths is a problem, slowly count to 10. The number of breaths needed to remove all the medicine can vary based on the size of the child. Small babies may need to take 6 – 10 breaths to empty the spacer. 9. Remove the mask.
10. If your child’s doctor has told you to give two puffs, wait at least one minute, shake the MDI and repeat steps 6 – 9.

OR

There are several basic steps for using an inhaler:

1. Before using any MDI, read the product's instructions carefully. Remember that MDIs are not all alike. If you have any questions, call your doctor, nurse or pharmacist for help.
2. Remove the cap and look inside to see that nothing is blocking the mouthpiece.
3. Hold the inhaler upright with the mouthpiece at the bottom and shake it.
4. Tilt your head back slightly and breathe out fully.
5. Place the inhaler with the mouthpiece in the position that is correct for you. Close your lips on the inhaler or hold it 1 to 2 inches from your open mouth.
6. Press down on the inhaler to release the medication as you start to breathe in.
7. Breathe in slowly and steadily. Take 3 to 5 seconds for each breath.
8. Hold your breath for 10 seconds to allow the medication to settle in the lungs.
9. Breathe out slowly.
10. Repeat puffs as directed.
11. If a steroid inhaler is used, rinse the mouth after use.

Many inhalers come with a dose counter. If it does not have one, it is important that you keep track of how much you use. Here are a few ways that may help:

The most accurate way is to count the number of doses your child uses each day and mark it on the calendar. Compare the number of doses used with the number of doses on the canister – most canisters tell you how many doses it contains. (For example, if your child uses 3 puffs each day from a 200-puff canister, get it refilled in 60-65 days). Be sure to mark what day that you start using a new inhaler on the calendar so you can keep track of the number of doses left.

Place a blank label on the inhaler. Place a "" on the label after each puff until you reach the number of puffs listed on the canister label.

Write a refill date on the canister each time you get a new MDI at the drug store. If your child uses about the same number of doses each day, you’ll know to get a refill at the same time each month. This only works if your child does not use the inhaler for extra rescue doses.

Do NOT float your canister in water to see if it sinks or floats – this is NOT accurate and may lead to not having medicine when your child needs it.

Be sure to refill your prescription before the canister runs out. An inhaler never feels like it is getting empty. You must keep up with the number of puffs used, including puffs used to prime the inhaler.

Rinse the spacer and mask as needed with warm, running water. Clean them once a week with warm water and soap. Allow the spacer and mask to air dry between uses.

Do not clean or dry the inside of the spacer with a cloth or fabric. This can create an electric charge on the inside of the spacer. The charge will decrease the amount of medicine that goes to your child’s lungs.

The mouthpiece (boot) holding the canister must be rinsed with warm running water once a week, do not soak it. When placing the canister back into the dried boot, it must be primed with one puff (refer to manufacturer’s instructions).

NCLEX-RN Topic 5: Plavix

Plavix keeps the platelets in your blood from coagulating (clotting) to prevent unwanted blood clots that can occur with certain heart or blood vessel conditions.

Plavix is used to prevent blood clots after a recent heart attack or stroke, and in people with certain disorders of the heart or blood vessels.

Plavix keeps your blood from coagulating (clotting) to prevent unwanted blood clots that can occur with certain heart or blood vessel conditions. Because of this drug action, Plavix can make it easier for you to bleed, even from a minor injury. Contact your doctor or seek emergency medical attention if you have bleeding that will not stop.

You may also have bleeding on the inside of your body, such as in your stomach or intestines. Call your doctor at once if you have black or bloody stools, or if you cough up blood or vomit that looks like coffee grounds. These could be signs of bleeding in your digestive tract. Avoid drinking alcohol while taking Plavix. Alcohol may increase your risk of bleeding in your stomach or intestines.

If you need to have any type of surgery or dental work, tell the surgeon or dentist ahead of time that you are using Plavix. You may need to stop using the medicine for at least 5 days before having surgery, to prevent excessive bleeding.

While you are taking Plavix, do not take aspirin or other NSAIDs (non-steroidal anti-inflammatory drugs) without your doctor's advice. NSAIDs include ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn), diclofenac (Voltaren), diflunisal (Dolobid), etodolac (Lodine), flurbiprofen (Ansaid), indomethacin (Indocin), ketoprofen (Orudis), ketorolac (Toradol), mefenamic acid (Ponstel), meloxicam (Mobic), nabumetone (Relafen), piroxicam (Feldene), and others.

Do not use Plavix if you are allergic to clopidogrel, or if you have any active bleeding such as a stomach ulcer or bleeding in the brain (such as from a head injury).


Take Plavix exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label.

Take this medication with a full glass of water.

Plavix can be taken with or without food.

Because Plavix keeps your blood from coagulating (clotting) to prevent unwanted blood clots, it can also make it easier for you to bleed, even from a minor injury. Contact your doctor or seek emergency medical attention if you have bleeding that will not stop.

If you need to have any type of surgery or dental work, tell the surgeon or dentist ahead of time that you are using Plavix. You may need to stop using the medicine for at least 5 days before having surgery, to prevent excessive bleeding.

To be sure this medication is not causing harmful effects, your blood will need to be tested on a regular basis. Do not miss any scheduled visits to your doctor.

Store Plavix at room temperature away from moisture and heat.

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at your next regularly scheduled time. Do not take extra medicine to make up the missed dose.

SIDE EFFECTS:

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Stop using Plavix and call your doctor at once if you have any of these serious side effects:
· nosebleed or other bleeding that will not stop;
· black, bloody, or tarry stools;
· coughing up blood or vomit that looks like coffee grounds;
· chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;
· sudden numbness or weakness, especially on one side of the body;
· sudden headache, confusion, problems with vision, speech, or balance; or
· pale skin, easy bruising or bleeding, weakness, fever, and urinating more or less than usual.
Less serious Plavix side effects may include:
· stomach pain;
· runny or stuffy nose, cough, sore throat; or
· mild headache or dizziness.

NCLEX-RN Topic 4: Tyramine Rich Foods to Avoid When Taking MAOIs

FOODS (CONTAINING TYRAMINE) TO AVOID WHEN TAKING MAOIS

• Mature or aged cheeses or dishes made with cheese, such as lasagna or pizza. All cheese is considered aged except cottage cheese, cream cheese, ricotta cheese, and processed cheese slices.
• Aged meats such as pepperoni, salami, mortadella, summer sausage, beef logs, and similar products. Make sure meat and chicken are fresh and have been properly refrigerated.
• Italian broad beans (fava) pods or banana peel. Banana pulp and all other fruits and vegetables are permitted.
• All tap beers and microbrewery beer. Drink no more than two cans or bottles of beer (including non-alcoholic beer) or 4 ounces of wine per day.
• Sauerkraut, soy sauce or soybean condiments, or marmite (concentrated yeast)