CT or MRI? What's the difference?

"Difference between CT Scan and MRI" by KJ OM

https://www.youtube.com/watch?v=8mUaXmFi6Hc




And a super cool VOX vid on the power of the MRI:
"Life Looks Really Different Through an MRI Machine" by VOX

https://www.youtube.com/watch?v=l8xTVfs4FQ0

Garner's Critical Care Class RX List

Here's the list of medications in alphabetical order to make looking things up in the drug book easier:

Adenosine

Amiodarone

Atropine

Calcium Gluconate

Dobutamine

Dopamine

Epinephrine

Glucagon

Ibutilide 

Isoproterenol

Lidocaine

Magnesium

Nitroglycerin

Nitroprusside

Norepinephrine
Vasopressin


A few of us will be working on completing these Med Cards, so this list will be edited as we go.

Adenosine (Adenocard)

Class: antidysrhythmic

Action: slows conduction at AV node, interrupts reentry, restores normal sinus with PSVT.

Dose:

>50kg, IV bol: 6 mg + 20 mL saline flush.  May repeat 12mg q1-2 min

child, infant, neonate <50kg, IV bol: 0.1mg/kg up to 0.3mg/kg/dose

Pharmacokinetics: ½ life 10 seconds

Adverse effects: Severe hypotension, atrial/ventrical tachydysrhythmias, AV block, cardiac arrest, bronchospasms with asthmatics.  Seizures.

Common side effects: flushing, palpitations, sweating, hypotension, dyspnea.

Nursing considerations:

Will interact with ginger (toxicity), dig, verapamil (v-fib)

Monitor EKG, vitals—expect transient dysrhythmia. 

Monitory resp status—d/c if respiration status are negatively impacted. 

Seizure precautions.

TX for OD: Defib + vasopressor + theophylline.

Amiodarone

Class: antidysrhthmic

Action: prolongs action potential and refractory period=increases PR and QT intervals, decreases sinus rate, decreases peripheral vascular resistance.

Dose:

IV 150 mg rapid loading over 10 min, then 360 mg over 6 hrs, then maintenance 540 mg over 18 hrs.

PO loading 800-1600mg/day for 3 weeks, then 400mg/day

Pharmacokinetics: peak 2-7 hr, onset 1-3 weeks

Adverse effects: sinus arrest, AV block, hepatotoxicity, pulmonary fibrosis/toxicity, ARDS, dyspnea with neonates.

Common side effects: n/v, rash, photosensitivity, phlebitis.

Nursing considerations:

grapefruit interaction (toxicity)

TX for OD: O2, vent, EKG, Dopamine (circulatory depression), diazepam/thiopental/isoproterenol

Atropine

Class: antidysrhythmic, anticholinergic (parasympatholytic) antimuscarinic

Action: blocks Ach at parasympathetic neuroeffector sites=blocks vagal stimulation in the heart=increases C.O., HR, dries secretions

Dose: Adult: IV Bol 0.5-1mg q3-5min max 3 mg; Child: IV bol 0.01mg/kg up to 0.4 mg or 0.3 mg/m^2 q4-6hr, minimum of 0.1 mg to avoid paradoxical rxt.  Max 0.5mg dose

Pharmacokinetics: peak 2-4 min

Adverse effects: tachycardia, coma, paralytic ileus,

Common side effects: h/a, dizziness, involuntary mov’t, confusion, psychosis, flushing, angina, urinary retention

Nursing considerations: con’t EKG for PAC, PVC, eye pain, assess I&O, bladder distension, hypertension (esp inc. intraocular pressure pain), bronchodilation.

TX for OD: O2 vent, ECK, dopamine for circulatory depression, diazepam or thiopental for seizures, additional antidysrhythmics if tachydysrhythmias develop.

Calcium Gluconate

Class: calcium electrolyte replacement

Action: used to maintain nervous, muscular, skeletal function, enzymre rxn, cardiac contractility, coagulation of blood, endocrine secretory, exocrine glands

Dose: IV: 0.5-2 g @ 0.5 ml/min of 10% sol’n, max 3g.

Pharmacokinetics: onset immediate, duration 0.5-2hr.

Adverse effects: Cardiac arrest, short QT, heart block, dysrhythmias, coma, extravasation

Common side effects:Drowsiness, lethargy, HA/N/V--toxicity

Nursing considerations: Assess EKG changes, CVP, PAWP, hypocalcemia (tetany), hypercalcemia, seizure precautions.

Tx for OD: none listed

Dobutamine

Class: adrenergic direct-acting B1-agonist=cardiac stimulant

Action: increases cardiac contractility, increases C.O. WITHOUT increasing HR.

Dose: adult and child IVF 2-40 mcg/kg/min

Pharmacokinetics: Onset 1-2 min, peak 10 min.

Adverse effects: PVC, palp, tachycardia, angina, s/s O2 deprivation,

Common side effects: muscle cramps, dyspnea, NV heartburn

Nursing considerations: medication is a sulfite derivative, first correct hypovolemia, check for and treat decreased oxygenation or perfusion.  EKG and PCWP and CVP.

Tx for OD: reduce, D/C, B-blocker, lidocaine or propranolol for severe ventricular tachydysrhythmias.

Dopamine

Class: adrenergic/catecholamine

Action: causes increased cardiac output, acts on B1 and A-receptors=vasoconstriction, renal and mesenteric vasodilation, positive inotropic effects=increased C.O. USED FOR CARDIOGENIC, SEPTIC SHOCK

Dose:  Adult 2-50 mcg/kg/min up—titrate by 5-10 mcg/kg/min increments.

Pharmacokinetics: onset 5 min, duration <10min.

Adverse effects: palpitations, angina, ectopic beats, wide QRS complex, tachycardia, hypertension

Common side effects: n/v/d, ha, feelings of anxiety, dyspnea

Nursing considerations: MONITOR FOR EXTRAVASATION.

Tx for OD: D/C IV, give short acting a-adrenergic blocker

Epinephrine

Class: catecholamine, bronchodilator, nonselective adrenergic agonist, vasopressor

Action: B1 and B2 adrenergic agonist=bronchodilation/bronchovasodilation, cardiac and CNS stimulation vasoconstriction of A-receptors at high doses

Dose: Adult: 0.3 mg IM

Pharmacokinetics: onset 1-5 min

Adverse effects: cerebral hemorrhage

Common side effects: palpitation, tachydysrhythmias, increased T wave, anorexia, n/v, sweating, tremors.

Nursing considerations: Do not used with MAOI or tricyclicsàhypertensive crises. 

Tx for OD: Administer a/b blockers.

Glucagon

Class:

Action:

Dose:

Pharmacokinetics:

Adverse effects:

Common side effects:

Nursing considerations:

Tx for OD:

Ibutilide 

Class: antidysrhythmic

Action: prolongs action potential and refractory period—AIDS WITH A-FIB/FLUTTER

Dose: >60kg IVF 1mg over 10 min, may repeat after 10 min; <60kg IVF0.01 mg/kg over 10 min, may repeat after 10 min.

Pharmacokinetics: half life 6 hr

Adverse effects: sinus arrest, CHF, polymorphic ventricular tachycardia/torsades de pointes, prolongued QT interval

Common side effects: hypotension, bradycardai, undle branch block, AV block, syncope.

Nursing considerations: EKG of minimum 4 hr to check for dysrhythmias.  D/C as soon as atrial fib/flutter ceases.  QT interval is rate dependent=increased chances of ectopic foci

Isoproterenol

DISCONTINUED BY FDA  http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Overview&DrugName=ISOPROTERENOL%20HYDROCHLORIDE

Lidocaine

Class:

Action: treats VF or pulseless VTach—given after d-fib and epi or vasopression

Dose: 1-1.5 mg/kg IV over 2-3 min, may repeat with 0.5-0.75 mg/kg over 2-3 min in 5-10 min up to 3 mg/kg.

Pharmacokinetics:

Adverse effects:

Common side effects:

Nursing considerations:

Tx for OD:

Magnesium

Class:

Action:

Dose:

Pharmacokinetics:

Adverse effects:

Common side effects:

Nursing considerations:

Tx for OD:

Nitroglycerin

Class:

Acion:

Dose:

Pharmacokinetics:

Adverse effects:

Common side effects:

Nursing considerations:

Tx for OD:

Nitroprusside

Class:

Acion:

Dose:

Pharmacokinetics:

Adverse effects:

Common side effects:

Nursing considerations:

Tx for OD:

Norepinephrine

Class:

Acion:

Dose:

Pharmacokinetics:

Adverse effects:

Common side effects:

Nursing considerations:

Tx for OD:

Vasopressin

Class:

Acion:

Dose:

Pharmacokinetics:

Adverse effects:

Common side effects:

Nursing considerations:

Tx for OD:

Auscultation

https://www.youtube.com/watch?v=V3HNQING3xs

Thank God For Khan Academy: EKG Strips

"SupraVentricular TachyCardia" by KhanAcademyMedicine

https://www.youtube.com/watch?v=eCrQDI1OAeU

https://www.khanacademy.org/science/health-and-medicine/circulatory-system-diseases/dysrhythmias-and-tachycardias/v/electrical-conduction-in-heart-cells

Ever Wondered How to do (or instruct) a Testicular Self-Exam?

Here's a great, straight forward, and surprisingly unblurred video, courtesy of the Aussie rugby team, Wolverines,  and two MD's on how to do a testicular self-exam.  Fair warning, there is NO BLURRING, and it is definitely NSFW.

Youtube: Jaw Thrust Maneuver

"Spinal Injury- Jaw Thrust" by ProCPR

https://www.youtube.com/watch?v=PdkgnRCoci4

Youtube: Applying C-Spine Collar

"C-Spine Injury-Collar Application" by Oxford Medical Videos

https://www.youtube.com/watch?v=hHHy1mc7sqY

Nasopharyngeal Swab Procedure

https://www.youtube.com/watch?v=TFwSefezIHU

Pneumonia Breath Sound Assessment Video

Sorry for the terrible quality of the video, but the information is so great.  Watch it anyway:
https://www.youtube.com/watch?v=NYzV33W10fI

Pediatric Urine Collector

Here are several links for pediatric urine collection:

Applying a Pediatric Urine Collector
NEJM Catheterization of the Urethra in Girls

ATI: Medication Administration for Pediatrics

These equations are taken from the RN ATI portal videos.




Client Weight Formula for Maintaining Daily Fluid Balance:  When running 0.9 NS IV for pediatric fluid maintenance, use this formula:

The sum of:

100 ml/kg for the first 10 kg

50 ml/kg for the second 10 kg

20 ml/kg for the remaining kg

Example: Calculate the fluid required for a 98 lb child.  Round to the ten.
 98lb / (2.2 lb/kg) = 44.54 kg  <--I noticed that for the ATI, they rounded this to 44.5 kg right away.
1st 10 kg= 10 kg x 100 ml/kg = 1000 mL
2nd 10 kg = 10 kg x 50 ml/kg= 500 mL
remaining weight = 44.5 kg - 20 kg = 24.5 kg; 24.5 kg x (20ml/kg)= 490 mL
volume required to maintain daily fluid balance for a 98 lb child is: 1000 mL +500 mL + 490 mL=1549mL






Calculating Body Surface Area:  Sometimes, a doctor will prescribe medication by BSA (body surface area) when precise administration is required, such as with highly toxic medications.  The formula is:

http://dailymed.nlm.nih.gov/dailymed/archives/image.cfm?archiveid=19085&type=img&name=norvir-equation.jpg

Example: Calculate the BSA for a child weighing 9.5 kg and 74.5 cm.  Round to the hundredth.


Sqrt ( (9.5kg x 74.5 cm)/3600)
=Sqrt (707.75 kgcm/3600)
=Sqrt (0.1965972...kgcm)
=0.4433m^2
=0.44m^2

The Nebulous Concept Known As The Nursing Diagnosis

THE MAJORITY OF NURSING STUDENTS WHEN FACED WITH WRITING ACTUAL* NURSING DIAGNOSIS FOR A CAREPLAN:

Currently we're in peds rotation and our clinical instructor (who loves nursing diagnosis) gave us a case study and then asked us to identify two "actual" nursing diagnosis.  Our class collectively froze.

For some reason, no one really knows how to create a nursing diagnosis.  Or at least, I've never met anyone who could clearly and concisely explain the etiology section of the nursing diagnosis.  I've had several clinical instructors try to explain it, only to pause, then say some variation of "You don't need to worry about that.  You don't have to do it in real life.  And if you ever do, there are drop down options on the computer."

And no, I have not yet found a nursing diagnosis book that illuminated my poor, confused soul.  The best book I've come across is the Handbook of Nursing Diagnosis by Carpenito (which I only just discovered after being in school for 1.5 years and it is a huge step up from the books I've been using before).  If you have a better book, I encourage you to post the title and author(s) in the comments section, because (sweet Mary mother of Jesus) we all need help when it comes to this.  As it is, I'm not claiming any of this is correct, but I'll do my best to recreate the process my instructor went through with us.

Before I jump into reenacting constructing a nursing diagnosis, let me try to review the skeleton of the nursing diagnosis.  You will need:

1) NANDA nsg dx label--this list updates year to year, so you'll have to find the most updated version.  Usually the diagnosis is either actual or potential (although our professor mentioned wellness and syndrome diagnosis--which I'm not familiar with).

2) Etiology--pathophysiological, treatment related, situational, social, spiritual, maturational, environmental.  Etiology is the most difficult part of the nursing diagnosis as most people won't be able to see beyond the medical diagnosis (they're so beautifully succinct).  It's hard to write an inference that is related to, yet cohesive and separate from the symptoms.  Ask yourself what are the factors that caused this problem?

For example, constipation is a diagnosis, but decrease intake of fiber, decrease intake of fluids, decreased ambulation, (age related/drug related) decrease in peristalsis all result in constipation, so any of those could be your etiology.

Any time you feel tempted to stick a medical diagnosis in right after the R/T, stop yourself, move your pen over two inches and write "secondary to __insert medical diagnosis here_," then go back and write the etiology of the medical diagnosis.

For example, if you are tempted to write "anxiety R/T agoraphobia" shift over and write "anxiety R/T __________________________secondary to agoraphobia."  Then ask yourself, what is it about this patient that sets of his or her agoraphobia?  Is it fear of humiliation?  Fear of bodily harm? Uncertainty of surroundings?  Overwhelming feelings of fear?  What etiology do the symptoms suggest?  All of those could be secondary to the medical diagnosis of agoraphobia.

3) S/S--this should be the easiest part--the signs and symptoms are the evidence with which you use to select your label and infer your etiology.

When you string those three things together, you get a structure like this:

NANDA approved nsg diagnostic label R/T etiology (that is NOT the medical diagnosis--don't be afraid to let this be as long as you need it to be, a whole sentence if necessary) AEB s/s that relate to the actual diagnostic label.




Here's the case study we were presented with:

I like to work in the reverse of the diagnosis construction.  I look at my symptoms, gather my diagnosis if there is one, and (as I recently discovered) etiologies.

SYMPTOMS:
-swelling/inflammation
-pain
-purulent drainage
-tender to touch
-slight red streaks extending from cuticle up the finger

DX:
-cellulitis

NURSING DIAGNOSIS LABELS:
-We know she has infection, but that's not on the NANDA approved list, so we can't use that one. I don't know why it's not on the list.  (Our professor said "it's because now we have a medical diagnosis for what kind of infection, and we can't prevent the infection..." which doesn't make any sense to me, but, alright, whatever.)
-We know that she's been gouging her cuticles out and biting them, so there's bound to be some kind of impaired skin integrity.
-We know that she's in acute pain.
-We know that the mother allowed the child to get this sick, so there is some kind of deficient knowledge.

ETIOLOGIES:
-We already have a medical diagnosis (cellulitis), so we know that at least one of the nursing diagnosis will be "______________secondary to cellulitis" to treat the medical diagnosis.  Drawing a blank?  So did we.  As our professor said "what caused the cellulitis?"  In other words, what was the etiology?  Layman's terms: biting cuticles, and poking cuticles with pens or pencils.  Fancy terms: tissue destruction.

Usually, I'd write the nursing diagnosis based on priority.  In this case, pain would be a priority because it's unlikely I'd get much compliance from a child in pain.  So here's my attempt at a nursing diagnosis for pain.  (Yes, I made up some s/s.)
Acute pain R/T nerve stimulation from swelling secondary to cellulitis AEB child flinching when finger is touched, stating "it hurts," and indicating 4/10 pain.


*Actual as in not a "risk for."

They always told us in clinical to do an abdominal SQ injection at least 1 inch away from the umbilicus, but they never explained why:

Also, I was always nervous about dorsal gluteal injections until I saw this video.