Nursing Notes

Pain assessment P: Provokes/point. What causes the pain? Point to the pain? Q: Quality.
Is it dull, achy, sharp, stabbing, pressuring, deep, etc.? R: Radiation/relief. Does it radiate? What makes it better/worse? S: Severity/S&S. Rate pain on 110 scale. What S&S are associated with the pain (dizziness, diaphoresis, dyspnea, abnormal VS)? T: Time/onset. When did it start? Is it constant or intermittent? How long does it last? Sudden or gradual onset? Frequency? Nursing Care Assess pain: Use tools/scales Provide comfort: Positioning, rest Validate pts pain: Accept that pain exists Relieve anxiety/fears: Answer questions, provide support Teach relaxation techniques: Rhythmic breathing, guided imagery Provide cutaneous stimulation: Backrub, heat and cold therapy Decrease irritating stimuli: Bright lights, noise, room temp Use distraction (for mild pain): Soft music; encourage TV/reading Provide pharmacologic relief: Administer meds as ordered Evaluate pt response: Document; modify plan STANDARD PRECAUTIONS Perform hand hygiene before and after care and when soiled; most important way to prevent infection Use personal protective equipment (PPE) if touching, spilling, or splashing of blood or body fluids is likely; use gloves, gowns, mask, goggles, shields, aprons, head and foot protection Discard disposable items in fluid-impermeable bag and contaminated items in Biohazard Red Bag Do not recap used needles; dispose in sharps container Hold linen away from body; place in impermeable bag in a covered hamper; do not let hampers overflow Place lab specimens in a leak-proof transport bag without contaminating
the outside; label with biohazard sticker and patient information Institute procedure for accidental exposure: Wash area, report to supervisor, receive emergency care, seek referral for follow-up Receive hepatitis B vaccine Assign patient to private room if hygiene practices are unacceptable Avoid eating, drinking, touching eyes, applying makeup in patient areas Transmission-Based Precautions AIRBORNE Used for microorganisms that spread through air (droplet nuclei 5m [e.g., TB, measles, chicken pox]) Private room; negative air pressure room; door closed; high-efficiency disposable mask (replace when moist) or particulate respirator (e.g., for TB); transport patient with mask, teach to dispose soiled tissues in fluidimpervious bag at bedside DROPLET Used for microorganisms spread by large-particle droplets (droplet nuclei 5m, (e.g., pneumonia [streptococcal, mycoplasmal, meningococcal], rubella, mumps, influenza, adenovirus) Private room if available or cohort pts, mask when within 3ft of pt, door open, mask for pt when transporting, teach to dispose soiled tissues in fluid-impervious bag at bedside CONTACT Used for organisms spread by direct or indirect contact; methicillinresistant S. aureus (MRSA), vancomycin-resistant enterococcus (VRE), vancomycin intermediate-resistant S. aureus (VISA); enteric pathogens (e.g., E. coli, C. difficile), herpes simplex, pediculosis, hepatitis A and E, varicella zoster, respiratory syncytial virus Private room or cohort pts; gowns, gloves over-gown cuffs; dedicate equipment
Digoxin Brand Name: Lanoxin Toxicity: 2 Normal Range: 0.5-1.5 meq/L Indication: Congestive Heart Failure Classification: Cardiac Glycoside Mechanism of Action: Increase force of Myocardial Contraction Increase force of Cardiac Contraction Increase Cardiac Output Nursing Management: Check Apical Pulse Rate HR < 60bpm- Notify the Physician S/S: Anorexia Nausea and Vomiting Diarrhea Confusion Photophobia Xantopsia Antidote: DIGIBIND Lithium Brand Name: Lithane Toxicity: 2 Normal Range: 0.6-1.2 meq/L Indication: Bipolar Disorder (Anti-Manic) Mechanism of Action:
Decrease ACTH Decrease Norepinephrine Decrease Serotonin Nursing Management: Force Fluid (2-3 L) Increase Sodium Intake (4-10 g/daily to prevent dehydration) S/S: Anorexia Diarrhea Dehydration Hypothyroidism Fine Tremors Aminophylline/Theophylline Brand Names: Elixophyllin Toxicity: 20 Normal Range: 10-19meq/100ml Indication: COPD Classification: Bronchodilator Mechanism of Action: Bronchodilator- dilates the bronchial tree thereby allowing more air to enter the lungs. Nursing Management: Avoid Caffeine S/S: Tachycardia CNS excitability Irritability and Agitation Restlessness Tremors Dilantin/Phenytoin Toxicity: 20 Normal Range: 10-19 meq/L Classification: Anti-Convulsant Mechanism of Action: Suppresses the paroxysmal electrical activity that makes up focal lesions. Blocks post-tetanic potentiation (PTT). PTT is an important mechanism in the development of high frequency trains of impulses in excitatory brain circuits; the spread of this activity to adjacent neurons and propagation to distant neuronal aggregates results in uncontrolled spread of excitation of the whole brain leading to a tonic-clonic seizure. Nursing Management: It is only mixed with 0.9 plain NSS or NaCl to prevent crystals or precipitate. Given via: Sandwich Method Instruct client to avoid alcohol- CNS depression, may lead to
seizure. S/S: Gingival Hyperplasia Instruct client to massage his gums Hairy Tongue Ataxia (+) Rhombergs Test Nystagmus Acetaminophen Brand Name: Tylenol Toxicity: 200 Indication: Osteoarthritis Classification: Anti- Narcotic Analgesic Mechanism of Action: Acetaminophen is used for the relief of fever as well as aches and pains associated with many conditions. Relieves pain in mild arthritis but has no effect on the underlying inflammation, redness, and swelling of the joint. S/S: Jaundice Abdominal Pain Vomiting Antidote: Acetylceisteine Nursing Management: Prepare suction apparatus.

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Pain assessment P: Provokes/point. What causes the pain? Point to the pain? Q: Quality.

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