Brainstorm NCLEX-RN Updates

NCLEX-RN Topic 19: Clostridium difficile Infections

2010-02-04T18:15:00.000-08:00

Clostridium difficile [klo-STRID-ee-um dif-uh-SEEL] is a bacterium that causes diarrhea and more serious intestinal conditions such as colitis.

They are diseases that result from C. difficile infections such as Colitis, more serious instestinal conditions, sepsis, and rarely death.

C. difficile colonization
patient exhibits NO clinical symptoms
patient tests positive for C. difficile organism and/or its toxin
more common than C. difficile-associated disease

C. difficile-associated disease
patient exhibits clinical symptoms
patient tests positive for the C. difficile organism and/or its toxin

The risk for disease increases in patients with:

antibiotic exposure
gastrointestinal surgery/manipulation
long length of stay in healthcare settings
a serious underlying illness
immunocompromising conditions
advanced age

Stool culture for C. difficile: This is the most sensitive test available, but the one most often associated with false-positive results due to presence of non-toxigenic strains. Stool cultures for C. difficile also are labor intensive and require the appropriate culture environment to grow anaerobic microorganisms. Results are available within 48-96 hours of the test.
Antigen detection for C. difficile: These are rapid tests (<1 hr) that detect the presence of C. difficile antigen by latex agglutination or immunochromatographicassays. They must be combined with toxin testing to verify diagnosis.
Toxin testing for C. difficile*:
Enzyme immunoassay detects toxin A, toxin B, or both A and B. It is a same-day assay but less sensitive than the tissue culture cytotoxicity assay.
Tissue culture cytotoxicity assay detects toxin B only. This assay requires technical expertise to perform, is costly, and requires 24-48 hr for a final result. It does provide specific and sensitive results for C. difficile-associated disease.
C. difficile toxin is very unstable. The toxin degrades at room temperature and may be undetectable within 2 hours after collection of a stool specimen. False-negative results occur when specimens are not promptly tested or kept refrigerated until testing can be done.

TRANSMISSION

C. difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the C. difficile spores. C. difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item.

Symptoms include:

watery diarrhea (at least three bowel movements per day for two or more days)
fever
loss of appetite
nausea
abdominal pain/tenderness

C. difficile is generally treated for 10 days with antibiotics prescribed by your healthcare provider. The drugs are effective and appear to have few side-effects.

How is C. difficile-associated disease usually treated?

In 23% of patients, C. difficile-associated disease will resolve within 2-3 days of discontinuing the antibiotic to which the patient was previously exposed. The infection can usually be treated with an appropriate course (about 10 days) of antibiotics including metronidazole or vancomycin (administered orally). After treatment, repeat C. difficile testing is not recommended if the patients’ symptoms have resolved, as patients may remain colonized.

How can C. difficile-associated disease be prevented in hospitals and other healthcare settings?

Use antibiotics judiciously
Use Contact Precautions: for patients with known or suspected C. difficile-associated disease:
Place these patients in private rooms.If private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with C. difficile-associated disease.
Perform Hand Hygiene using either an alcohol-based hand rub or soap and water.
If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with C. difficile-associated disease; alcohol-based hand rubs may not be as effective against spore-forming bacteria.
Use gloves when entering patients’ rooms and during patient care.
Use gowns if soiling of clothes is likely.
Dedicate equipment whenever possible.
CONTINUE THESE PRECAUTIONS UNTIL DIARRHEA CEASES
Implement an environmental cleaning and disinfection strategy:
Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently.
Use an Environmental Protection Agency (EPA)-registered hypochlorite-based disinfectant for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: alcohol-based disinfectants are not effective against C. difficile and should not be used to disinfect environmental surfaces.)
Follow the manufacturer’s instructions for disinfection of endoscopes and other devices
Infection control practices in long term care and home health settings are similar to those practices taken in traditional health-care settings.

People in good health usually don’t get C. difficile disease. People who have other illnesses or conditions requiring prolonged use of antibiotics and the elderly are at greater risk of acquiring this disease. The bacteria are found in the feces. People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes. Healthcare workers can spread the bacteria to other patients or contaminate surfaces through hand contact.

If you are infected you can spread the disease to others. However, only people that are hospitalized or on antibiotics are likely to become ill. For safety precautions you may do the following to reduce the chance of spread to others:

wash hands with soap and water, especially after using the restroom and before eating;
clean surfaces in bathrooms, kitchens and other areas on a regular basis with household detergent/disinfectants.

What can I use to clean and disinfect surfaces and devices to help control C. difficile?

Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC’s “Guidelines for Environmental Infection Control in Health-Care Facilities.” Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of C. difficile. Consult the aforementioned guidelines for use conditions for generic sources of hypochlorite-based products (e.g., household chlorine bleach) for disinfection of environmental surfaces.

Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating C. difficile spores, but there are a number of registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions.

NCLEX-RN Topic 18: venlafaxine hydrochloride (Effexor XR)

2010-02-04T18:00:00.000-08:00

venlafaxine hydrochloride
(Effexor‡, Effexor, Effexor XR )

Pharmacologic Class: selective serotonin and norepinephrine reuptake inhibitor (SNRI)
Therapeutic Class: antidepressant

Indications:
Depression
Generalized anxiety disorder
Panic disorder
Social anxiety disorder
Adjust-a-dose: For patients with renal impairment, reduce daily amount by 25%. For those undergoing hemodialysis, reduce daily amount by 50% and withhold dose until dialysis is completed. For patients with hepatic impairment, reduce daily amount by 50%.
To prevent major depressive disorder relapse

Action
May increase the amount of norepinephrine, serotonin, or both in the CNS by blocking their reuptake by the presynaptic neurons.

Adverse reactions
CNS: headache, suicidal behavior, somnolence, dizziness, nervousness, insomnia, anxiety, tremor, abnormal dreams, paresthesia, agitation, asthenia.
CV: hypertension, tachycardia, vasodilation.
EENT: blurred vision.
GI: nausea, constipation, vomiting, dry mouth, anorexia, diarrhea, dyspepsia, flatulence.
GU: abnormal ejaculation, impotence, urinary frequency, impaired urination.
Metabolic: weight loss.
Skin: diaphoresis, rash.
Other: yawning, chills, infection.

Interactions
Drug-drug
MAO inhibitors (MAOIs), such as phenelzine, selegiline, tranylcypromine: May cause serotonin syndrome. Avoid using within 14 days of MAOI therapy.
Tramadol: May cause serotonin syndrome. Monitor patient closely.
Triptans: May cause serotonin syndrome (restlessness, hallucinations, loss of coordination, fast heartbeat, rapid changes in blood pressure, increased body temperature, hyperreflexia, nausea, vomiting, and diarrhea). Use cautiously and with increased monitoring at the start of therapy and with dose increase.
Drug-herb
Yohimbe: May cause additive stimulation. Urge caution.

Contraindications & cautions

Contraindicated in patients hypersensitive to drug or within 14 days of MAOI therapy.
Use cautiously in patients with renal impairment, diseases or conditions that could affect hemodynamic responses or metabolism, and in those with history of mania or seizures.
Use in third trimester of pregnancy may be associated with neonatal complications at birth. Consider the risk versus benefit of treatment during this time.

Nursing considerations

Alert: Closely monitor patients being treated for depression for signs and symptoms of clinical worsening and suicidal ideation, especially at the beginning of therapy and with dosage adjustments. Symptoms may include agitation, insomnia, anxiety, aggressiveness, or panic attacks.
Alert: Drug may increase the risk of suicidal thinking and behavior in children and adolescents with major depressive disorder or other psychiatric disorder.
Carefully monitor blood pressure. Drug therapy may cause sustained, dose-dependent increases in blood pressure. Greatest increases (averaging about 7 mm Hg above baseline) occur in patients taking 375 mg daily.
Monitor patient's weight, particularly underweight, depressed patients.

Patient teaching

If medication is to be stopped, inform patient who has received drug for 6 weeks or longer that drug will be stopped gradually by tapering dosage over a 2-week period as instructed by prescriber. Patient shouldn't abruptly stop taking the drug.
Alert: Warn family members to closely monitor patient for signs of worsening condition or suicidal ideation.
Warn patient to avoid hazardous activities that require alertness and good coordination until effects of drug are known.
Tell patient to avoid alcohol and to consult prescriber before taking other prescription or OTC drugs.
Advise woman of childbearing age to contact prescriber if she becomes pregnant or intends to become pregnant during therapy or if she's breast-feeding.

NCLEX-RN Topic 17: diclofenac sodium (Voltaren XR)/diclofenac potassium (Cataflam)

2010-02-04T17:53:00.000-08:00

diclofenac potassium
(Cataflam)

diclofenac sodium
(Fenac‡, Voltaren, Voltaren-XR, Voltaren Rapide†, Voltaren SR†)

Pharmacologic Class: NSAID
Therapeutic Class: antiarthritic; anti-inflammatory

Indications
Ankylosing spondylitis
Osteoarthritis
Rheumatoid arthritis

Action
May inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects.

Adverse reactions
CNS: anxiety, depression, dizziness, drowsiness, insomnia, irritability, headache, aseptic meningitis.
CV: heart failure, hypertension, edema, fluid retention.
EENT: tinnitus, laryngeal edema, swelling of the lips and tongue, blurred vision, eye pain, night blindness, epistaxis, reversible hearing loss.
GI: abdominal pain or cramps, constipation, diarrhea, indigestion, nausea, abdominal distention, flatulence, taste disorder, peptic ulceration, bleeding, melena, bloody diarrhea, appetite change, colitis.
GU: proteinuria, acute renal failure, oliguria, interstitial nephritis, papillary necrosis, nephrotic syndrome, fluid retention.
Hepatic: jaundice, hepatitis, hepatotoxicity.
Metabolic: hypoglycemia, hyperglycemia.
Musculoskeletal: back, leg, or joint pain.
Respiratory: asthma.
Skin: rash, pruritus, urticaria, eczema, dermatitis, alopecia, photosensitivity reactions, bullous eruption, Stevens-Johnson syndrome, allergic purpura.
Other: anaphylaxis, anaphylactoid reactions, angioedema.

Interactions
Drug-drug
Anticoagulants, including warfarin: May cause bleeding. Monitor patient closely.
Aspirin: May decrease effectiveness of diclofenac and increase GI toxicity. Avoid using together.
Beta blockers: May decrease antihypertensive effects. Monitor patient closely.
Cyclosporine, digoxin, lithium, methotrexate: May reduce renal clearance of these drugs and increase risk of toxicity. Monitor patient closely.
Diuretics: May decrease effectiveness of diuretics. Avoid using together.
Insulin, oral antidiabetics: May alter requirements for antidiabetics. Monitor patient closely.
Potassium-sparing diuretics: May enhance retention and increase level of potassium. Monitor potassium level.
Drug-herb
Dong quai, feverfew, garlic, ginger, horse chestnut, red clover: May cause bleeding based on the known effects or components. Discourage use together.
White willow: Herb and drug contain similar components. Discourage use together.
Drug-lifestyle
Sun exposure: May cause photosensitivity reactions. Advise patient to avoid excessive sunlight exposure.

Effects on lab test results
May increase ALT, AST, bilirubin, BUN, and creatinine levels. May increase or decrease glucose level.

Contraindications & cautions
Contraindicated in patients hypersensitive to drug and in those with hepatic porphyria or history of asthma, urticaria, or other allergic reactions after taking aspirin or other NSAIDs.
Avoid using during late pregnancy or breast-feeding.
Use cautiously in patients with history of peptic ulcer disease, hepatic dysfunction, cardiac disease, hypertension, fluid retention, or impaired renal function.

Nursing considerations
Because NSAIDs impair the synthesis of renal prostaglandins, they can decrease renal blood flow and lead to reversible renal impairment, especially in patients with renal or heart failure or liver dysfunction, in elderly patients, and in those taking diuretics. Monitor these patients closely.
Liver function test values may increase during therapy. Monitor transaminase, especially ALT, levels periodically in patients undergoing long-term therapy. Make first transaminase measurement no later than 8 weeks after therapy begins.
Because of their antipyretic and anti-inflammatory actions, NSAIDs may mask the signs and symptoms of infection.
Serious GI toxicity, including peptic ulcers and bleeding, can occur in patient taking NSAIDs, despite lack of symptoms.
Look alike-sound alike: Don't confuse diclofenac with Diflucan.

Patient teaching
Tell patient to take drug with milk, meals, or antacids to minimize GI distress.
Instruct patient not to crush, break, or chew enteric-coated tablets.
Advise patient not to take this drug with any other diclofenac-containing products (such as Arthrotec).
Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine, or stool; coffee-ground vomit; and black, tarry stool. Tell him to notify prescriber immediately if any of these occurs.
Teach patient the signs and symptoms of damage to the liver, including nausea, fatigue, lethargy, itching, yellowed skin or eyes, right upper quadrant tenderness, and flulike symptoms. Tell patient to contact prescriber immediately if these symptoms occur.
Advise patient to avoid consuming alcohol or aspirin during drug therapy.
Tell patient to wear sunscreen or protective clothing because drug may cause sensitivity to sunlight.
Warn patient to avoid hazardous activities that require alertness until it is known whether the drug causes CNS symptoms.
Tell pregnant woman to avoid use of drug during last trimester.
Advise patient that use of OTC NSAIDs and diclofenac may increase the risk of GI toxicity.

NCLEX-RN Topic 16: Selegine (Eldepryl, Zelapar)

2010-02-04T17:45:00.000-08:00

Eldepryl

Generic Name: selegiline (oral) (se LE ji leen)
Brand Names: Eldepryl, Zelapar

Eldepryl prevents the breakdown of a chemical in your brain called dopamine (DO pa meen). Low levels of this chemical are associated with Parkinson's disease.
Eldepryl is used together with other medicines to treat symptoms of Parkinson's disease.

IMPORTANT INFORMATION

There are many other medicines that can cause serious medical problems if you take them together with Eldepryl. Tell your doctor about all other prescription and over-the-counter medications you use, including vitamins, minerals, and herbal products.
While taking Eldepryl, do not drink alcohol or eat foods that are high in tyramine. Eating tyramine while you are using Eldepryl can raise your blood pressure to dangerous levels and cause life-threatening symptoms.
You should become very familiar with the list of foods to avoid while you are using Eldepryl.
Do not stop taking Eldepryl suddenly or you may have harmful side effects. Keep taking the medicine as prescribed. Talk with your doctor before stopping the medication.
You may have increased sexual urges, unusual urges to gamble, or other intense urges while taking this medication. Talk with your doctor if you believe you have any intense or unusual urges while taking Eldepryl.

Do not use Eldepryl if you are allergic to selegiline, or if you have used any of the following drugs within the past 14 days:
• cough or cold medicine that contains dextromethorphan;
• meperidine (Demerol), propoxyphene (Darvon, Darvocet), or tramadol (Ultram, Ultracet);
• methadone (Dolophine, Methadose); or
• other MAO inhibitors such as isocarboxazid (Marplan), tranylcypromine (Parnate), phenelzine (Nardil), rasagiline (Azilect), or transdermal selegiline (Emsam).

After you stop taking Eldepryl, you must wait at least 14 days before taking any of the medications listed above.
Before using this medicine, tell your doctor if you have kidney disease, liver disease, heart disease, high or low blood pressure, or a seizure disorder. If you have any of these conditions, you may not be able to use Eldepryl, or you may need a dosage adjustment or special tests during treatment.
FDA pregnancy category C. It is not known whether this medication is harmful to an unborn baby. Before you take Eldepryl, tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether selegiline passes into breast milk or if it could harm a nursing baby. Do not take Eldepryl without telling your doctor if you are breast-feeding a baby
Zelapar disintegrating tablets may contain phenylalanine. Talk to your doctor before using this form of selegiline if you have phenylketonuria (PKU).

NCLEX-RN Topic 15: VRE

2010-02-01T14:32:00.000-08:00

What is VRE (vancomycin-resistant enterococci)?

• Enterococci are bacteria that are normally present in the human intestines and in the female genital tract and are often found in the environment. These bacteria can sometimes cause infections.

• Vancomycin is an antibiotic that is often used to treat infections caused by enterococci. In some cases, enterococci have become resistant to vancomycin and are called vancomycin-resistant enterococci or VRE. Most VRE infections occur in people in hospitals.

What types of infections does VRE cause?

• VRE can live in the human intestines and female genital tract without causing disease (often called colonization). However, sometimes, it can be the cause infections of the urinary tract, the bloodstream or of wounds.

Are certain people at risk of getting VRE?

• The following persons are at an increased risk becoming infected with VRE:

• People who have been previously treated with the antibiotic vancomycin or other antibiotics for long periods of time.

• People who are hospitalized, particularly when they receive antibiotic treatment for long periods of time

• People with weakened immune systems such as patients in Intensive Care Units, or in cancer or transplant wards

• People who have undergone surgical procedures such as abdominal or chest surgery

• People with medical devices that stay in for some time such as urinary catheters or central intravenous (IV) catheters.

• People who are colonized with VRE

How common is VRE?

• Information collected by the Centers for Disease Control and Prevention during 2006 and 2007 showed that enterococci caused about 1 of every 8 infections in hospitals and only about 30% of these are VRE. VRE can be more common in certain groups of people such as those with weakened immune systems.

What is the treatment for VRE?

• People who are colonized (bacteria are present, but have no symptoms of an infection) with VRE do not usually need treatment.

• Most VRE infections can be treated with antibiotics other than vancomycin. Laboratory testing of the VRE can determine which antibiotics will work. For people who get VRE infections in their bladder and have urinary catheters, removal of the catheter when it is no longer needed can also help get rid of the infection.

How is VRE spread?

• VRE is often passed from person to person by the hands of caregivers.

o VRE can get onto a caregiver's hands after they have contact with other people with VRE or after contact with contaminated surfaces. VRE can also be spread directly to people after they touch surfaces that are contaminated with VRE. VRE is not usually spread through the air by coughing or sneezing.

How can I prevent the spread of VRE?

• If you or someone in your household has VRE, the following are some things you can do to prevent the spread of VRE:

• Keep your hands clean. Always wash your hands thoroughly after using the bathroom and before preparing food. Clean your hands after contact with persons who have VRE. Wash with soap and water (particularly when visibly soiled) or use alcohol-based hand rubs.

• Frequently clean areas of your home such as your bathroom that may become contaminated with VRE.

• Wear gloves if you may come in contact with body fluids that may contain VRE, such as stool or bandages from infected wounds. Always wash your hands after removing gloves.

• If you have VRE, be sure to tell healthcare providers caring for you that you have VRE so that they are aware of your infection. Healthcare facilities use special precautions to help prevent the spread of VRE to others.

NCLEX-RN Topic 14: MRSA

2010-02-01T14:30:00.000-08:00

What is MRSA (methicillin-resistant Staphylococcus aureus)?

• Some staph bacteria are resistant to antibiotics.

• MRSA is a type of staph that is resistant to antibiotics called beta-lactams.

o Beta-lactam antibiotics include methicillin and other more common antibiotics such as oxacillin, penicillin and amoxicillin.

• While 25% to 30% of the population is colonized with staph, approximately 1% is colonized with MRSA.

Who gets staph or MRSA infections?

• Staph infections, including MRSA, occur most frequently among persons in hospitals and healthcare facilities (such as nursing homes and dialysis centers) who have weakened immune systems.

• These healthcare-associated staph infections include surgical wound infections, urinary tract infections, bloodstream infections, and pneumonia.

What is community-associated MRSA (CA-MRSA)?

• Staph and MRSA can also cause illness in persons outside of hospitals and healthcare facilities.

• MRSA infections that are acquired by persons who have not been recently (within the past year) hospitalized or had a medical procedure (such as dialysis, surgery, catheters) are known as CA-MRSA infections.

• Staph or MRSA infections in the community are usually manifested as skin infections, such as pimples and boils, and occur in otherwise healthy people.

How common are staph and MRSA infections?

• Staph bacteria are one of the most common causes of skin infection in the United States and are a common cause of pneumonia, surgical wound infections, and bloodstream infections.

• The majority of MRSA infections occur among patients in hospitals or other healthcare settings; however, it is becoming more common in the community setting.

• Data from a prospective study in 2003, suggests that 12% of clinical MRSA infections are community-associated, but this varies by geographic region and population.

What does a staph or MRSA infection look like?

• Staph bacteria, including MRSA, can cause skin infections that may look like a pimple or boil and can be red, swollen, painful, or have pus or other drainage.

• More serious infections may cause pneumonia, bloodstream infections, or surgical wound infections.

Are certain people at increased risk for community-associated staph or MRSA infections?

• CDC has investigated clusters of CA-MRSA skin infections among athletes, military recruits, children, Pacific Islanders, Alaskan Natives, Native Americans, men who have sex with men, and prisoners.

o Factors that have been associated with the spread of MRSA skin infections include: close skin-to-skin contact, openings in the skin such as cuts or abrasions, contaminated items and surfaces, crowded living conditions, and poor hygiene.

How can I prevent staph or MRSA skin infections?

• Practice good hygiene:

1. Keep your hands clean by washing thoroughly with soap and water or using an alcohol-based hand sanitizer.

2. Keep cuts and scrapes clean and covered with a bandage until healed.

3. Avoid contact with other people’s wounds or bandages.

4. Avoid sharing personal items such as towels or razors.

Are people who are positive for the human immune deficiency virus (HIV) at increased risk for MRSA? Should they be taking special precautions?

• People with weakened immune systems, which include some patients with HIV infection, may be at risk for more severe illness if they get infected with MRSA.

• People with HIV should follow the same prevention measures as those without HIV to prevent staph infections, including practice good hygiene, cover wounds (e.g., cuts or abrasions) with clean dry bandages, avoid sharing personal items such as towels and razors, and contact their doctor if they think they have an infection.

Can I get a staph or MRSA infection at my health club?

• In the outbreaks of MRSA, the environment has not played a significant role in the transmission of MRSA.

• MRSA is transmitted most frequently by direct skin-to-skin contact.

o You can protect yourself from infections by practicing good hygiene (e.g., keeping your hands clean by washing with soap and water or using an alcohol-based hand rub and showering after working out); covering any open skin area such as abrasions or cuts with a clean dry bandage; avoiding sharing personal items such as towels or razors; using a barrier (e.g., clothing or a towel) between your skin and shared equipment; and wiping surfaces of equipment before and after use.

Are staph and MRSA infections treatable?

• Yes. Most staph and MRSA infections are treatable with antibiotics. If you are given an antibiotic, take all of the doses, even if the infection is getting better, unless your doctor tells you to stop taking it. Do not share antibiotics with other people or save unfinished antibiotics to use at another time.

• However, many staph skin infections may be treated by draining the abscess or boil and may not require antibiotics. Drainage of skin boils or abscesses should only be done by a healthcare provider.

• If after visiting your healthcare provider the infection is not getting better after a few days, contact them again. If other people you know or live with get the same infection tell them to go to their healthcare provider.

Is it possible that my staph or MRSA skin infection will come back after it is cured?

• Yes. It is possible to have a staph or MRSA skin infection come back (recur) after it is cured. To prevent this from happening, follow your healthcare provider’s directions while you have the infection, and follow the prevention steps after the infection is gone.

If I have a staph, or MRSA skin infection, what can I do to prevent others from getting infected?

• You can prevent spreading staph or MRSA skin infections to others by following these steps:

1. Cover your wound. Keep wounds that are draining or have pus covered with clean, dry bandages until healed. Follow your healthcare provider's instructions on proper care of the wound. Pus from infected wounds can contain staph, including MRSA, so keeping the infection covered will help prevent the spread to others. Bandages and tape can be discarded with the regular trash.

2. Clean your hands. You, your family, and others in close contact should wash their hands frequently with soap and water or use an alcohol-based hand sanitizer, especially after changing the bandage or touching the infected wound.

3. Do not share personal items. Avoid sharing personal items, such as towels, washcloths, razors, clothing, or uniforms, that may have had contact with the infected wound or bandage. Wash sheets, towels, and clothes that become soiled with water and laundry detergent. Use a dryer to dry clothes completely.

4. Talk to your doctor. Tell any healthcare providers who treat you that you have or had a staph or MRSA skin infection

NCLEX-RN Topic 13: Indomethacin (Indocin)

2010-01-19T19:26:00.000-08:00

indomethacin (Apo-Indomethacin†, Arthrexin‡, Indocid‡†, Indocid SR†, Indocin, Indocin SR, Novo-Methacin†)

Pharmacologic Class: NSAID
Therapeutic Class: nonopioid analgesic; antipyretic; anti-inflammatory

Indications & dosages

Moderate to severe rheumatoid arthritis or osteoarthritis, ankylosing spondylitis; Acute gouty arthritis; Acute painful shoulders (bursitis or tendinitis)

Adverse reactions

P.O. and P.R.

CNS: headache, dizziness, depression, drowsiness, confusion, somnolence, fatigue, peripheral neuropathy, psychic disturbances, syncope, vertigo.

CV: hypertension, edema.

EENT: hearing loss, tinnitus.

GI: nausea, anorexia, diarrhea, abdominal pain, peptic ulceration, GI bleeding, constipation, dyspepsia, pancreatitis.

GU: hematuria.

Hematologic: iron-deficiency anemia.

Metabolic: hyperkalemia.

Skin: pruritus, urticaria, Stevens-Johnson syndrome.

Other: hypersensitivity reactions.

GU: hematuria, proteinuria, interstitial nephritis.

Interactions

Drug-drug

Aminoglycosides, cyclosporine, methotrexate: May enhance toxicity of these drugs. Avoid using together.

Anticoagulants: May cause bleeding. Monitor patient closely.

Antihypertensives: May decrease antihypertensive effect. Monitor patient closely.

Antihypertensives, furosemide, thiazide diuretics: May impair response to both drugs. Avoid using together, if possible.

Aspirin: May decrease level of indomethacin. Avoid using together.

Aspirin, corticosteroids: May increase risk of GI toxicity. Avoid using together.

Bisphosphonates: May increase risk of gastric ulceration. Monitor patient for symptoms of gastric irritation or GI bleeding.

Diflunisal, probenecid: May decrease indomethacin excretion. Watch for increased indomethacin adverse reactions.

Digoxin: May prolong half-life of digoxin. Use together cautiously.

Dipyridamole: May enhance fluid retention. Avoid using together.

Lithium: May increase lithium level. Monitor patient for toxicity.

Penicillamine: May increase bioavailability of penicillamine. Monitor patient closely.

Phenytoin: May increase phenytoin level. Monitor patient closely.

Triamterene: May cause nephrotoxicity. Avoid using together.

Drug-herb

Dong quai, feverfew, garlic, ginger, horse chestnut, red clover: May cause bleeding. Discourage use together.

Senna: May inhibit diarrheal effects. Discourage use together.

White willow: Herb and drug contain similar components. Discourage use together.

Drug-lifestyle

Alcohol use: May cause GI toxicity. Discourage use together.

Effects on lab test results

May increase potassium level. May decrease hemoglobin level and hematocrit.

May increase liver function test values.

May cause positive direct Coombs test results.

Contraindications & cautions

Contraindicated in patients hypersensitive to drug and in those with a history of aspirin- or NSAID-induced asthma, rhinitis, or urticaria.

Contraindicated in pregnant or breast-feeding women and in neonates with untreated infection, active bleeding, coagulation defects or thrombocytopenia, congenital heart disease needing patency of the ductus arteriosus, necrotizing enterocolitis, or significant renal impairment. Suppositories are contraindicated in patients with history of proctitis or recent rectal bleeding.

Contraindicated in pregnant women.

Use cautiously in elderly patients, those with history of GI disease, and those with epilepsy, parkinsonism, hepatic or renal disease, CV disease, infection, and mental illness or depression.

Nursing considerations

Because of the high risk of adverse effects from long-term use, drug shouldn't be used routinely as an analgesic or antipyretic.

Sustained-release capsules shouldn't be used for acute gouty arthritis.

Give oral dose with food, milk, or antacid to decrease GI upset.

If ductus arteriosus reopens, a second course of one to three doses may be given. If ineffective, surgery may be needed.

Watch for bleeding in patients receiving anticoagulants, patients with coagulation defects, and neonates.

Because NSAIDs impair synthesis of renal prostaglandins, they can decrease renal blood flow and lead to reversible renal impairment, especially in patients with renal failure, heart failure, or liver dysfunction; in elderly patients; and in those taking diuretics. Monitor these patients closely.

Drug causes sodium retention; watch for weight gain (especially in elderly patients) and increased blood pressure in patients with hypertension.

Monitor patient for rash and respiratory distress, which may indicate a hypersensitivity reaction.

Because of their antipyretic and anti-inflammatory actions, NSAIDs may mask signs and symptoms of infection.

Serious GI toxicity (including peptic ulcers and bleeding) can occur in patient taking NSAIDs, despite lack of symptoms.

NSAIDs may cause increased risk of thrombotic events, MI, and stroke. Risk may be increased with duration of use and in patients with history of cardiovascular disease or risk factors of cardiovascular disease.

Monitor patient on long-term oral therapy for toxicity by conducting regular eye examinations, hearing tests, CBCs, and kidney function tests.

Patient teaching

Tell patient to take oral drug with food, milk, or antacid to prevent GI upset.

Alert patient that using oral form with aspirin, alcohol, other NSAIDs, or corticosteroids may increase risk of adverse GI reactions.

Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine, or stool; coffee-ground vomit; and black, tarry stool. Tell him to notify prescriber immediately if any of these occurs.

Tell patient to immediately report signs or symptoms of cardiac events, such as chest pain, shortness of breath, weakness, and slurred speech.

Warn patient to avoid hazardous activities that require mental alertness until CNS effects are known.

Tell patient to notify prescriber immediately if visual or hearing changes occur

NCLEX-RN Topic 12: alendronate sodium (Fosamax, Fosamax Plus D)

2010-01-19T19:16:00.000-08:00

alendronate sodium (Fosamax, Fosamax Plus D)
Therapeutic Class: bone resorption inhibitor

Indications & dosages
Osteoporosis in postmenopausal women; to increase bone mass in men with osteoporosis
To prevent osteoporosis in postmenopausal women

Adverse reactions

CNS: headache.

GI: abdominal pain, nausea, dyspepsia, constipation, diarrhea, flatulence, acid regurgitation, esophageal ulcer, vomiting, dysphagia, abdominal distention, gastritis, taste perversion.

Musculoskeletal: musculoskeletal pain.

Interactions

Drug-drug

Antacids, calcium supplements, many oral drugs: May interfere with absorption of alendronate. Instruct patient to wait at least 30 minutes after taking alendronate before taking other drug orally.

Aspirin, NSAIDs: May increase risk of upper GI adverse reactions with drug doses greater than 10 mg daily. Monitor patient closely.

Ranitidine (I.V. form): May increase availability of alendronate. Reduce dosage, as needed.

Drug-food

Any food: May decrease absorption of drug. Advise patient to take with full glass of water at least 30 minutes before food, beverages, or ingestion of other drugs.

Effects on lab test results

May decrease calcium and phosphate levels.

Contraindications & cautions

Contraindicated in patients hypersensitive to drug and in those with hypocalcemia, severe renal insufficiency, or abnormalities of the esophagus that delay esophageal emptying.

Use cautiously in patients with active upper GI problems (dysphagia, symptomatic esophageal diseases, gastritis, duodenitis, ulcers) or mild to moderate renal insufficiency.

Nursing considerations

Correct hypocalcemia and other disturbances of mineral metabolism (such as vitamin D deficiency) before therapy begins.

When used to treat osteoporosis, disease may be confirmed by findings of low bone mass on diagnostic studies or by history of osteoporotic fracture.

The recommended daily intake of vitamin D is 400 to 800 international units. Fosamax Plus D provides 400 international units daily when taken once weekly. Patients at risk for vitamin D deficiency, such as those who are chronically ill, nursing home bound, who have a GI malabsorption syndrome, or who are older than age 70, may require additional supplementation.

In Paget disease, drug is indicated for patients with alkaline phosphatase level at least two times upper limit of normal, for those who are symptomatic, and for those at risk for future complications from the disease.

Alert: Give drug with 6 to 8 ounces of water at least 30 minutes before patient's first food or drink of the day to facilitate delivery to the stomach. Don't allow patient to lie down for 30 minutes after taking drug.

Monitor patient's calcium and phosphate levels throughout therapy.

Look alike-sound alike: Don't confuse Fosamax with Flomax.

Patient teaching

Stress importance of taking tablet only with 6 to 8 ounces of water at least 30 minutes before ingesting anything else, including food, beverages, and other drugs. Tell patient that waiting longer than 30 minutes improves absorption.

Warn patient not to lie down for at least 30 minutes after taking drug to facilitate delivery to stomach and to reduce risk of esophageal irritation.

Advise patient to report adverse effects immediately, especially chest pain or difficulty swallowing.

Advise patient to take supplemental calcium and vitamin D if dietary intake is inadequate.

Tell patient about benefits of weight-bearing exercises in increasing bone mass. If applicable, explain importance of reducing or eliminating cigarette smoking and alcohol use

NCLEX-RN Topic 11: Performing Tracheostomy Care

2010-01-19T18:38:00.000-08:00

IMPLEMENTATION

➧Wash hands.
Prevents transmission of microorganisms.

➧ Perform tracheotomy suction.
Removes secretion to prevent occlusion of outer cannula by secretions.

➧ Allow patient to reoxygenate by breathing 100% oxygen, and pour the hydrogen peroxide and normal saline into sterile bowls. Place tracheotomy O2 collar over tracheotomy to ensure oxygen saturation.
Allows efficient and organized completion of tracheotomy care.

➧ Don sterile gloves; remove soiled dressing with forceps and discard in trash receptacle.
Prevents transmission of microorganisms.

➧ Keeping dominant hand sterile, remove oxygen source and inner cannula with nondominant hand; place cannula in hydrogen peroxide basin.
Hydrogen peroxide loosens the secretions.

➧ Place tracheotomy oxygen collar over outer cannula.
Maintains oxygenation of patient.

➧ Clean inner cannula using small brush.
Brush provides mechanical force to remove thick secretions.

➧ Rinse inner cannula with normal saline using nondominant nonsterile hand to pour saline.
Cleanses secretions and hydrogen peroxide from inner cannula.

➧ Replace inner cannula and secure locking mechanism. Reapply oxygen source.
Secures inner cannula and re-establishes oxygen supply. (Note: some tracheotomy devices do not have an inner cannula.)

➧ Cleanse outer cannula with a sterile cotton swab moistened with hydrogen peroxide.
Aseptically removes secretions from stoma site.

➧ Rinse stoma with cotton swab soaked in normal saline and dried with sterile 4X4s.
Rinses hydrogen peroxide from surface and dries surface, prohibiting a moist medium for microorganisms.

➧ Do not release all tracheotomy ties at the same time.
To prevent dislodgement of tracheotomy.

➧ Cut length adequate enough to wrap around the patient’s neck twice and cut ends on diagonal. Insert end of tie through eye of faceplate and pull through ipsilateral eye. Slide tie around neck to other eyelet and insert through second eyelet. Bring one tie around back of neck until ends meet. Tie ends securely allowing one finger breath between neck and tie.
Cutting ends on diagonal aids in insertion of tie through eyelet. One finger breath between neck and ties prevents ties from being too tight.

➧ Insert fresh tracheotomy dressing under clean ties and faceplate.
Absorbs drainage.

➧ Position patient comfortably and assess respiratory status.
Promotes comfort. Reassessment of airway patency and respiratory status ensures good patient outcomes and provides clues to whether further interventions are needed.

➧Wash hands.
Prevents transmission of microorganisms

NCLEX-RN Topic 10: Z-TRACK Method

2009-12-17T04:12:00.000-08:00

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!!!

2009-12-17T03:57:00.000-08:00

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

2009-12-16T04:42:00.000-08:00

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)

2009-12-14T17:26:00.000-08:00

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

2009-12-03T03:39:00.000-08:00

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.

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

2009-12-01T19:33:00.000-08:00

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

2009-12-01T19:12:00.000-08:00

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)

NCLEX-RN Topic 3: Peptic Ulcer Disease

2009-11-30T23:49:00.000-08:00

DUODENAL ULCER

Incidence:Age 30–60

Male: female _ 2–3:1

80% of peptic ulcers are Duodenal

Signs, Symptoms, and Clinical Findings
Hypersecretion of stomach acid
(HCl)

May have weight gain

Pain occurs 2–3 hours after a meal; Pain relieved by eating; often awakened between 1–2 AM; ingestion of food relieves pain

Vomiting uncommon

Hemorrhage less likely than with gastric ulcer, but if present melena more common than hematemesis More likely to perforate than gastric ulcers

Malignancy Possibility: Rare

Risk Factors: H. pylori, alcohol, smoking, cirrhosis, stress

GASTRIC ULCER

Incidence: Usually 50 and over

Male: female _ 1:1

15% of peptic ulcers are gastric

Signs, Symptoms, and Clinical Findings
Normal—hyposecretion of stomach acid (HCl)

Weight loss may occur

Pain occurs 1⁄2 to 1 hour after a meal; Pain is exacerbated by food; rarely occurs at night; may be relieved by vomiting; ingestion of food does not help, sometimes increases pain

Vomiting common

Hemorrhage more likely to occur than with duodenal ulcer; hematemesis more common than melena

Malignancy Possibility: Occasionally

Risk Factors: H. pylori, gastritis, alcohol, smoking, use of NSAIDs, stress

NCLEX-RN Topic 2: Dumping Syndrome

2009-11-30T23:45:00.000-08:00

Dumping syndrome: is a common complication of gastric resection when the pylorus is bypassed and is a postprandial problem of rapid dumping of food into the jejunum without proper mixing and duodenal digestion

ü Early manifestations: occur 15 to 30 minutes after eating and including vertigo, tachycardia, syncope, sweating, pallor, palpitations; believed to be caused by a rapid shift of extracellular fluid into the bowel to dilute the hypertonic chime thereby causing a decrease in blood volume

ü Late manifestations occur 2 to 3 hours postprandial and include epigastric fullness, distension, diarrhea, abdominal cramping, nausea and high pitched bowel sounds; these symptoms are caused by excessive release of insulin in response to a rapid rise in blood glucose due to high carbohydrate bolus entering the jejunum

ü Dumping syndrome can be minimized by a low-carbohydrate, high protein, high-fat diet; suggest also that client avoid drinking fluids and meals and lie down after eating; antispasmodics or sedatives may be ordered to delay gastric emptying

Billroth I (gastroduodenostomy): a partial gastrectomy where the distal portion of the stomach (including the antrum) is removed and the remainder is anastomosed to the duodenum; the gastrin producing cells in the antrum are removed as well as some of the parietal cells (acid pepsinogen secreting cells)

ü preoperative and postoperative care is the same as for any client having gastric surgery
ü dumping syndrome is a common complication of this procedure

Billroth II (gastrojejunostomy): a partial gastrectomy where the lower portion of the stomach is removed and the proximal remnant is anastomosed to the jejunum; used to treat gastric and duodenal ulcers

ü preoperative and postoperative care is the same as for any client having gastric surgery
ü dumping syndrome is a common complication of this procedure

NCLEX-RN Topic 1: Alport Syndrome

2009-11-30T04:01:00.000-08:00

Alport syndrome is a genetic disorder characterized by glomerulonephritis, endstage kidney disease, and hearing loss. Alport syndrome can also affect the eyes. The presence of blood in the urine (hematuria) is almost always found in this condition.

Alport Syndrome is an inherited disease of the kidney that can also affect the inner ear (cochlea) and eye. It is estimated to effect at least 1 in 5,000 people. It is caused by genetic mutations that affect the type IV collagen family of proteins. Type IV collagen is a major part of important tissue structures called basement membranes that are present in all tissues including the kidney, inner ear, and eye. Generally, Alport Syndrome affects boys more than girls because 80% of the time the disease is passed on by a mutation on the X chromosome (called X-linked Alport Syndrome).

Manifestations:

Hematuria which is usually microscopic
Brown, pink, or red urine (gross hematuria) for several days, associated with a cold or flu
Protein in the urine (proteinuria) and high blood pressure
Hearing loss
Anterior lenticonus may have a slow progressive deterioration of vision requiring patients to change the prescription of their glasses frequently. This condition may also lead to cataract formation
Some people with Alport Syndrome have abnormal pigment of the retina called dot-and-fleck retinopathy, but this does not result in any abnormalities of vision
Recurrent corneal erosion is another eye problem

Alport Syndrome Treatment

There is no treatment that has been proven to prevent the development of kidney failure in people with Alport Syndrome. It is very important for people with Alport Syndrome to be examined regularly by a Nephrologist, so that effects of kidney disease, such as hypertension (high blood pressure), can be identified early and treated. Regular hearing and vision evaluation is also important.

Medication

Data from studies suggest the benefits from angiotensin-converting enzyme (ACE) inhibitors in reducing proteinuria (protein in the urine) and progression of renal disease.

ACE inhibitors that have been used to treat Alport Syndrome patients include, but are not limited to:
Enalapril (Vasotec)
Fosinopril (Monopril)
Lisinopril (Zestril, Prinivil)

Quinapril (Accupril).

Angiotensin receptor blockers (ARBs) have also been used in patients with proteinuria as ARBs were shown to delay progression to kidney failure.

ARBs that have been used to treat Alport Syndrome patients include, but are not limited to:
Losartan (Cozaar)

Candesartan (Atacand).

NCLEX-RN Topics to be Posted Soon!

2009-08-29T06:16:00.000-07:00

NCLEX-RN topics will be posted soon on this blog site. Brainstorm NCLEX-RN students will have the privilege to see and read new nursing topics that will help them pass the NCLEX-RN exam.