ticket in demerol

7/29/2019 Ticket in Demerol

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Ticket in skills lab 2

What are signs of Demerol (Meperidine, hydromorphone) toxicity?As

Demerol is metabolized by the body, a toxic byproduct called normeperidine is produced. This toxic

byproduct of Demerol can cause delirium as it accumulates in the systems of elderly patients. Signs of

delirium are acute confusion, disorientation, poor memory, agitation, difficulty sleeping, hallucinations and

extreme fear or anxiety.

Read more: http://www.livestrong.com/article/184097-warnings-about-demerol-injections/#ixzz2IXetJKXn

What are nursing interventions for the patient with confusion related to

Demerol toxicity?

Treatment of overdose: Naloxone HCI (Narcan) 0.2-0.8 mg IV, 02, IV fluids,

vasopressors (epi-pen)

How do you perform a wet to dry dressing? Wet to-dry dressings are used

only to debride wounds, as they cause tissue damage. Maceration (softening by the

action of liquid) of healthy tissue can occur with dressings that are always wet. Dry

dressings cause damage to granulating tissue if removed without first soaking the

gauze.

Preparation: Check physicians orders. Perform hand hygiene and gather

equipment. Identify client using two forms of identification. Explain procedure to

client. Provide privacy. Raise bed to HIGH position, and lower side rail nearest you.

Remove tape by pulling it toward the wound (rationale: this action prevents injury

to newly formed tissue). Don clean gloves. Remove wound packing by gently

grasping the gauze without touching the wound and tear it away at a right angle

from the wound surface. Place soi9led dressings in disposable bag. Remove gloves,and dispose of them in bag. Perform hand hygiene.

Procedure: Open packages of dressings making sure sterility is maintained. Pour

normal saline solution over dressings. Don sterile gloves. Pick up sterile gauze

dressings one at a time. Fluff each dressing, and place over wound (Rationale: If

packed tightly, dressing can prevent wound edges from contact with capillaries).

Place gauze in the wound, covering all exposed surfaces. Press gauze lightly into

depressions or cracks (Rationale: necrotic tissue is more prevalent in these areas).

Unfold a moist, sterile 4X8 (ABD pad) dressing into a single layer and place it on top

of wet dressings covering the wound area (not on skin). Place a dry 4X8 pad over

the dressing to hold it in place. Some protocols call for semi-occlusive dressing inplace of pad. Remove gloves, and place in plastic bag. Tape only the edges of the

dressing. Montgomery tapes may be used to prevent excessive skin irritation and

damage due to frequent dressing changes. Position client for comfort. Lower bed,

and raise side rail to UP position, if appropriate. Discard soiled material in

appropriate container. Perform hand hygiene. Observe wound for excessive

drainage or drying out of dressing between dressing changes. Remoisten dressing if
http://www.livestrong.com/article/184097-warnings-about-demerol-injections/#ixzz2IXetJKXnhttp://www.livestrong.com/article/184097-warnings-about-demerol-injections/#ixzz2IXetJKXn


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dry. (Rational: Unless excessive drainage occurs, or dressing dries out, dressings

are usually changed every 8 Hours. Provide client or family teaching regarding

wound care, if appropriate. Label dressing with date, time and initials.

Expected Outcome: Wound heals and skin is intact. Patient is free from infection.

Documentation: type of dressing change, assessment of the dressings that were

removed, condition of the wound, supplies used, clients response and how client

tolerated the procedure.

How would you change a central line dressing? Change every 72-96 hours

Procedure: Gather all necessary equipment: roll of tape, label, and central line

dressing kit. Check physicians orders. Verify patient by using 2 identifiers. Wash

hands. Check Explain procedure to the patient and/or significant other. Check for

providone-iodine or tape allergy. Organize supplies and equipment at bedside to

decrease the amount of time that site is open to air. Apply mask on yourself. (Don

gown if soiling is likely) Open central line kit. Place patient in supine position with

head turned away from catheter insertion site to decrease potential for

contamination by catheter insertion site to decrease potential for contamination by

patients secretions. Place a mask over the patients mouth and nose or sterile

drape over ventilated or trached patient. Don a pair of clean gloves. Remove

present dressing carefully to minimize trauma and prevent accidental dislodgment

of catheter. Discard soiled dressing in proper trash receptacle. Visually inspect the

skin and catheter site for signs of infection, leakage, or other mechanical problems.

Remove soiled gloves and don sterile gloves. Working in a circular motion from

insertion site outward to edge of dressing border cleanse skin, insertionsite, and

distal portion of catheter with: a) Providone-iodine scrub swabsticks X 3 to removebacteria and fungi b) Alcohol swabsticks X 3 to remove the betadine scrub c)

Betadine solution swabsticks x 3 to cover a 3 x 6 from site to periphery to provide

protective barrier against pathogens. Blot excess or pooled solution. Allow to dry.

Apply skin protective pad. Apply dressing tegaderm. Date, time and initial

dressing.

List signs/symptoms of hyperglycemia

1) High levels of sugar in the urine

2) Blood glucose >110

3) Frequent urination

4) Increased thirst

Medications which may be used during the simulation include:

Morphine Sulfate IVP prn


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Promethazine ivp prn

Ondansetron ivp prn

Enoxaprin sub q

Potassium Chloride 10 meq ivpb

Digoxin ivp

Famotidine ivp

Gentamycin 200 mg IVPB

Thiamine 100 mg PO

Glyburide 1.25 mg PO

Ceftazidime 2 grams IVPB

Nicotine Patch 21 mcg apply topically

Hydromorphone 2 mg IVP

Chlordiazepoxide hydrochloride 50 mg po prn

Lorazepam 0.5 mg IVP

Metocloparmide 10 mg IVP

Dexamethasone 4 mg IVP

Protonix 40 mg IVP

Morphine 6 mg IVP

Medications:

Medication

Route

Safe Dosage

Range

Classificat

ion

Mode of

Action

Why

given to

patient?

Nursing implications

Teaching

Side

Effects

Ceftazidime 2grams IVPB (akaCeptax, Fortaz,

Tazicef,Tazidime)

(IV/IM 1-2 g q8-12 hr X 5-10

Broadspectrumantibiotic

Killsbacterialcell wallsynthesis

Implications: Assessfor sensitivity topenicillin, othercephalosporins.Nephrotoxicity:increased BUN,creatinine; urineoutput; if decreasing,

Nausea,vomiting,diarrhea,anorexia


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days)

IV after diluting 1g/10mL sterileH20 for inj,shake, invert

needle, pushplunger, insertneedle throughstopper and keepin sol. Expelbubbles and giveover 3-5 min;may be dilutedfurther with 50-100 mL of normalsaline or D5W;run over -1 hr,

give through y-tube or 3-waystop-cock,discontinueprimary infduringadministration

notify prescriber; mayindicatenephrotoxicity. Bloodstudies: AST, ALT, CBC,Hct bilirubin, LDH, alkphos, Coombs testmonthly if patient is onlong-erm theraphy.Electrolytes: K, Na, Clmonthly if patient is onlong-term theraphyTeaching: If diabetic,to check bloodglucose. To report sorethroat, bruising,ble3eding, joint pain;may indicate blooddyscrasias (rare);diarrhea with mucus,blood, may indicatepseudomembranouscolitis. To reportpersistent diarrhea.

MedicationRoute

Safe DosageRange

Classification

Mode ofAction

Whygiven topatient?

Nursing implications

Teaching

SideEffects

Chlordiazepoxidehydrochloride 50mg po prn (aka

Librium)

Antianxiety

Adult: PO 5-10mg tid-qid

Administerw/food or milk for

Antianxiety

Gamma-

aminobutyric acid(GABA) is amajorinhibitorybrainchemicalthat blocksthe

To calmthe patientas the

patientmay bewithdrawing. Used totreatwithdrawal(hallucinations, acuteconfusion,

Assess B/P (lying,standing), pulse; ifsystolic B/P drops 20

mm Hg, hold product,notify prescriber

Hepatic studies: AST,ALT, bilirubin,creatinine, LDH, alkphos during long-ermtherapy

Dizziness,drowsiness,Orthostatic

hypotension, blurredvision


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GI symptoms.Crushed ifpatient in unableto swallowmedication whole

transmission of asignal fromone braincell toanother

This drugworks onGABA

restlessness, andhyperactivity of theautonomicnervoussystem(tachycardia,hypertension, fever)

I&O may indicaterenal dysfunction

Provide assistancew/ambulation

Teach: Product maybe taken with food. Notto use product foreveryday stress or uselonger than 4 mo,unless directed byprescriber. Not to takemore than prescribed.Avoid OTCpreparations

For overdose give:

flumazenil

Dexamethasone4 mg IVPAdult:Analphylacticshock IV 1-6mg/kg or IV 40mg q2-6 hrCerebral edema IV-10 mg, then4-6 mg IM

Undiluted directover 1 min orless or dilutedwith 0.9% NaClor F

Corticosteroid,synthetic

Decreasesinflammation

Inflammation,allergies,neoplasms, cerbraledema,septicshock,collagendisorders

Potassium, blood, urineglucose while on long-term therapy;hypokalemia andhyperglycemia.Weight daily; notifyprescriber of weeksgain >5 lb. I&O ration;be alert for decreasingurinary output,

increasing edema

Teach: That ID ascorticosteroid usershould be carried.Contact Prescriber ifsurgery, trauma, stressoccurs; dose may needto be adjusted. Notifyprescriber iftherapeutic response

decreases; dosageadjustment may beneeded. Not todiscontinue abruptly oradrenal crisis canresult. Symptoms:nausea, anorexia,fatigue, dizziness,

Depression,flushing,sweating,hypertension, diarrhea,nausea,abdominaldistention,increasedappetite


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dyspnea, weakness,joint pain

Digoxin ivp

A single initial

intravenous doseof 400 to 600mcg (0.4 to 0.6mg) of LANOXINInjection usuallyproduces adetectable effectin 5 to 30minutes thatbecomesmaximal in 1 to 4hours. Additional

doses of 100 to300 mcg (0.1 to0.3 mg) may begiven cautiouslyat 6- to 8-hourintervals untilclinical evidenceof an adequateeffect is noted.

The usualamount ofLANOXIN

Injection that a70-kg patientrequires toachieve 8- to 12-mcg/kg peakbody stores is600 to 1,000 mcg(0.6 to 1.0 mg).

Undiluted or 1mL ofproduct/4mL

sterile solution>5 min through

Y-tube or 3-waystopcock

Y site compatiblewith famotidine,morphine,potassium

Antidyshythmic

Inhibits thesodium-potassiumATPase,whichmakesmorecalciumavailableforcontractileproteins,

resulting inincreasedcardiacoutput

For mild tomoderateheart

failureSpecifically A-Fib

Listen to apical pulsefor 1 min before givingproduct; if pulse


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chloride

For toxicity: givedigoxin immuneFAB (Digibind)

Enoxaprin sub q

(Lovenox)

SUBCUT 30 mgbid given 12-24hr postop for7-10days, until DVTrisk is diminished

Anticoagulant,anthrombotic

Preventions of DeepVein

Thrombosis

Implications: Bloodstudies (Hct, CBC,coagulation studies,platelets, occult bloodin stools). For bleedinggums, petechiae,ecchymosis, blacktarry stools,hematuria-notifyprescriber

Hemorrhage,hypochromic anemia,thrombocytopenia,bleeding

Famotidine ivp

(Pepcid AC)

Adult: IV 20 mgq12 if unable totake PO

IV, direct Afterdiluting 2 mL ofproduct (10mg/ml) in salineto total volume of

5-10 mL; injectover 2 min topreventhypotension

H2-

histaminereceptorantagonist

Action:Competitively inhibitshistamineathistamineH2 receptorsite,

decreasinggastricsecretionwhilepepsinremains ata stablelevel

Ulcers,

refluxdiseasesorheartburn

Implications: Assess

for epigastric pain,abdominal pain, frankor occult blood inemesis, stools. Bloodcounts during therapy watch for decreasingplatelets. For bleeding,hematuria,hematuresis, occultblood in stools;abdominal pain

Headache,

dizziness,constipation, seizures inrenaldisease,dysrhythmias

Teach thatproductmust becontinued

forprescribedtime inprescribedmethod tobe effective;do notdouble dose.Reportbleeding,bruising,fatigue,

malaise.Avoidirritatingfoods


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MedicationRouteSafe DosageRange

ClassificationMode ofAction

Whygiven topatient?

Nursing implicationsTeaching

SideEffects

Gentamycin 200mg IVPB

Adult: IV Inf 3-6mg/kg/day individed dosesq8hr; dilute in50-200 mL 0.9%NaCl or D5Wgiven over 30min 1 hr

Antiinfective

Action:Interfereswithbacterialcellreproduction

Severesystemicinfectionsof CNS,respiratory, GI,urinarytract,bone, skin,softtissuescaused bysusceptible strainsofPseudomonas , E-coli,Staphylococcus,Klebsiella

Implications: Weighbefore treatment;calculation of dosageis usually based onideal body weight. I&0ratio, urinalysis dailyfor proteinuria, cells,casts; report suddenchange in urine output;toxicity is increased inpatients withdecreased renalfunction if high dosesare given.

Deafness,nausea,vomiting,anorexia,rash

Glyburide 1.25mg PO

Adult: 1.25-5 mg

initially, thenincreased todesired responseat weeklyintervals.

Administerw/breakfast, holddose if NPO toavoidhypoglycemia

Antidiabetic

Action:

CausesfunctioningB-cells inpancreas toreleaseinsulin,leading todrop inbloodglucoselevels; mayimprove

insulinbinding toinsulin

Increasebloodglucoselevels

Hypo/hyperglycemicreaction that can occursoon after meals; forsevere hypoglycemia.Blood glucose; A1clevels duringtreatment. Evaluatetherapeutic response

Teach: To use a bloodglucose meter fortesting while on thisproduct. Take productin morning to preventhypoglycemicreactions at night.

Headache,weakness,hypoglycemia

Hydromorphone2 mg IVP(Dilaudid)

Adult: 1-2 mg q4-

Opiateanalgesic

Action:Inhibits

To reducepain oruse toinhibit a

Assess respiratorydysfunction:respiratory depression,character, rate,

Respiratorydepression,Drowsiness,dizziness,


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6 hr prn

IV direct, dilutedwith 5 mL sterileH20 or NS; givethrough y-

connector or 3-way stopcock;give 2 mg orless/3-5 min

Treatment ofoverdose:Naloxone HCI(Narcan) 0.2-0.8mg IV, 02, IVfluids,vasopressors

ascendingpainpathwaysin CNS,increasespainthreshold,alters painperception

nonproductive cough

rhythm, notifyprescriber ifrespirations are


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over 10-20 min Rest andDigest

alcohol, other CNSdepressants that willenhance sedatingproperties of thisproduct

Morphine 6 mgIVP

Adult IV: 2.5-15mg diluted in 4-5mL h20; give 15or less over 4-5min

Overdosetreatment:Naloxone

(Narcan) 0.2-0.8mg IV o2, IVfluids,vasopressors

Opiateanalgesic

Action:Depressespainimpulsetransmission at thespinal cordlevel byinteracting

with opiodreceptors

To reducepatientpain

Avoid using MAOIs;Pain: location, type,character, give dosebefore pain becomessevere. Bowel status,I&Os, Respiratorydysfunction:depression, character,rate, rhythm, notifyprescriber ifrespirations are


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Adult:Habitrol-21mg/dayX4-8 wk;14 mg/dayx2-4wk; 7mg/dayx2-4 wkNicotrol: 15mg/dayx12 wk;10 mg/dayx2 wk;5 mg/dayx2wk

receptorsinperipheral,CNS

thehospital

prevent skin irritation

Teach: That patch is astoxic as cigarettes; tobe used only to detersmoking. Not to useduring pregnancy;birth defects mayoccur. To keep usedand unused system outof reach of childrenand pets. To stopsmoking immediatelywhen beginning patchtreatment

vertigo,insomnia

Ondansetron ivpprn

(Zofran)

Adult: IV/IM 4mg undilutedover >30 secprior to inductionof anesthesia

After diluting asingle dose in 50mL NS or D5W,0.45% NaCl or

NS; give over 15min.

Antiemetic

Action:

Preventsnausea,vomiting byblockingserotoninperipherally, centrally,and in thesmallintestine

To preventpatientsnausea

Assess: For absence ofnausea, vomitingduring chemotherapy.Hypersensitivityreaction: rash,bronchospasm. ForEPS: shuffling, gat,tremors grimacing,rigidity

Teach: Reportdiarrhea, constipation,rash, or changes inrespirations ordiscomfort at insertion

site. Headacherequiring analgesic iscommon

Headache,dizziness,drowsiness,fatigue, EPS,diarrhea,constipation, abdominalpain,musculoskeletal pain,woundsproblems,shivering ,fever,hypoxia,urinaryretention

PotassiumChloride 10 meqivpb

20 MEQ/hr whendiluted as 40mEq/1000 mL,max 150mEq/day

Never give IVbolus

Electrolyte,mineralreplacement

Action:Needed foradequate

transmission of nerveimpulsesand cardiaccontraction, renalfunction,intracellular ion

To bringpatientsPotassiumlevel to atleastminimumlevel 3.5

Assess: ECG forpeaking T waves,lowered R, depressedRST, prolonged P-Rinterval, widening QRScomplex,hyperkalemia; productshould be reduced or

discontinued.Potassium level duringtreatment (3.5-5). I&Oratio; watch fordecreased urinaryoutput; notifyprescriberimmediately. Cardiac

Bradycardia,cardiacdepression,dysrhythmias, arrest,peaking Twaves,lowered R

anddepressedRST,prolonged P-R interval,widenedQRScomplex,


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maintenance

status

Teach: To addpotassium-rich foodsto diet; bananas,orange juice,

avocados; wholegrains, broccoli,carrots, prunes, cocoaafter this medication isdiscontinued. Avoidtaking licorice in largeamounts-may causehypokalemia

nausea,vomiting,cramps,pain,diarrhea

Promethazine ivpprn

(Phenergan)

Adult:PO/IM/IV/RECT12.5-25 mg q4-6hr prn

Rapidadministrationmay causedecrease in B/P.

After diluting

each 25-50mg/9mL of NaClfor inj; give 25mg or less/2 min

Antihistamine, H1-receptor

antagonist

Action: Actson bloodvessels, GI,respiratorysystem bycompetingwithhistaminefor H1-receptor

site;decreasesallergicresponseby blockinghistamine

Given toreducemotion

sickness,rhinitis,allergysymptoms,sedation,nausea,preoperative andpostoperativesedation

I&O ratio; be alert forurinary retention,frequency, dysuria.

CBC during long-termtherapy. Respiratorystatus; rate, rhythm,increase in bronchialsecretions, wheezing,chest tightness. Avoiduse with out CNSdepressants

Dizziness,drowsiness,poor

coordination, neurolepticmalignantsyndrome,constipation, urinaryretention

Protonix 40 mgIVP

(Pantoprazole)

IV 40 mg/dayx7-

10 day

Reconstitutew/10mL 0.9%NaCl, furtherdilute with 80mLLR, D5, 0.9%NaCl (0.8 mg/ml),

ProtonPumpInhibitor

Action:suppressesgastricsecretionbyinhibitinghydrogen/potassiumATPaseenzyme

To reducepatientsgastroesophagealreflux

Assess: GI system;bowel sounds q8hr,abdomen for pain,swelling, anorexia.Hepatic studies: AST,

ALT, alk phos duringtreatment. For vit B12deficiency in thoselong term therapy

Teach: To reportsevere diarrhea;product may have atobe discontinued. That

Headache,diarrhea,abdominalpain, rash


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give over 15 min(

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