Pharmacology

According to the Joint Commission, required elements for medication titration orders
include the following: 1. medication name; 2. medication route; 3. initial or starting rate
of infusion (dose/min); 4. incremental units the rate can be increased or decreased; 5.
frequency for incremental doses (how often the dose (rate) can be increased or
decreased); 6. maximum rate (dose) of infusion; 7. objective clinical endpoint or patient
response. The nurse follows the titration prescription and does not make independent
determinations regarding the infusion.

A trough level should be drawn 30 minutes before the third or fourth dose. The other
answers are incorrect times to draw blood levels. Vancomycin is indicated for serious
gram–positive bacterial infections, so it is important to monitor dosage levels. The
typical trough level range for vancomycin is 10–20 µg/mL. The reference range for peak
levels is 25–50 µg/mL.

The nurse should verify the dosage strength (Right Dose) for the child before
administering. For this child (40 lbs = 18.2 kg) the dosage should be 1.5-1.8 mg/dose.
For procedural analgesia and sedation in children, morphine sulfate is given 0.08-0.1
mg/kg/dose IV, IM, or SC before the procedure and every 5-10 minutes as needed.
Peak effect is 15-30 minutes after IV administration and 30-60 minutes after IM
administration. Morphine sulfate is indicated for procedural analgesia because it is
reliable, predictable, and easily reversed with naloxone. NOTE: An average 4-year-old
weighs 40 pounds and is 40 inches tall.

Nadolol (Corgard) is a beta blocker used to treat hypertension and chest pain. It is
stored tightly closed at room temperature from 59 °F to 86 °F (15 °C to 30 °C), away
from heat, moisture, and light. Humulin N is a form of insulin. After it has been opened,
it is stored in the refrigerator or at room temperature below 86 °F. Humulin N must be
discarded within 31 days after opening. Ampicillin is a penicillin antibiotic. The liquid
suspension form should be stored in the refrigerator for up to 7 days. Epoetin alfa IV is
used with patients undergoing chemotherapy or suffering from anemia from serious
chronic diseases. It is stored in the refrigerator and should be protected from light.

Although neomycin is generally prescribed to treat infection, it is also prescribed for

patients with liver disease to kill intestinal bacteria. The bacteria produce ammonia
when breaking down protein. The diseased liver is unable to clear the ammonia, so
serum levels build and lead to hepatic encephalopathy. Neomycin does not affect pH or
prevent further liver damage.

5 mL = 1 teaspoon. The parent should give the child 1 teaspoon of amoxicillin every 8
hours. The parent should use a medication spoon or dropper to measure the dose, not
a household spoon. The nurse should educate the parent about completing the
prescription even if the child starts to feel better. 1 tablespoon = 3 teaspoons (15 mL),
which would be a triple dose.
The nurse should administer the dose, since it is within appropriate guidelines. The child
may safely receive 344-688 mg/day, in divided doses of 115-230 mg each. Amoxicillin
(20-40/kg/day) is the antibiotic of choice for treating acute otitis media in clients older
than 2 years who are not allergic to penicillin. Approximately 80% of children will have at
least one episode of acute otitis media. The 10 Rights of Medication Administration that
are applicable here: Right patient, right medication, right dose, right route, right time,
and right assessment.

Hypovolemia is corrected by expanding the intravascular compartment. An isotonic IV

solution will expand the intravascular compartment without affecting cells and tissues of
other fluid compartments. Hypertonic and colloid solutions would pull fluid into the
intravascular space but at the expense of other fluid compartments.

NPH insulin is an intermediate-acting insulin, usually given once or twice a day. The
peak effect of NPH insulin occurs 4–12 hours after administration, so the nurse should
start to monitor for signs of hypoglycemia at 10:00 a.m. Hypoglycemia (blood glucose
below 70 mg/dl) can have a rapid onset. Signs include shakiness, dizziness, anxiety,
confusion, sweating, chills, and clammy skin. The patient's pulse may increase. The
patient may complain of blurred vision, headache, fatigue, hunger, or nausea.

1 mcg = 0.001 mg. To convert 25 mcg, set up a proportion: 1/0.001 = 25/x. Cross-
multiply (0.001 × 25 = 0.025 mg) and then multiply by 52 kg = 1.3 mg per minute. In one
hour (60 min × 1.3 mg), the client should receive 78 mg.

The nurse should maintain the current heparin infusion rate. The reference range of
aPTT is 30-40 seconds. To obtain an aPTT result, an activator is added that speeds up
the clotting time and results in a narrower reference range. The aPTT is considered a
more sensitive version of the PTT and is used to monitor the patient’s response to
heparin therapy. Decreasing or increasing the infusion rate is not appropriate.
Protamine sulfate is a heparin antagonist, used to immediately reverse the action of
heparin. It is not indicated for this situation.

Common adverse effects of penicillin include rash; hives; itching; and swelling of the
face, lips, and tongue.

Procainamide is well-tolerated and is a first-line agent for the treatment of acute,

undiagnosed, wide-complex tachycardia. Procainamide blocks sodium channels and
also has an effect on potassium channels and so prolongs the effective refractory
period, decreases automaticity and slows conduction. The client's ECG should be
constantly monitored for cardiotoxicity: widening of QRS (> 50%) and prolonged QT
interval, as well as hypotension.

Potentiation is a type of drug interaction. Potentiation occurs when two drugs are taken
together and the action of one drug increases the action of the other, causing the
pharmacologic response to be greater for one of the drugs.
A teratogen is an agent that can disturb the development of the embryo or fetus. Taking
isotretinoin (Accutane) during pregnancy can cause birth defects of the brain and heart
as well as facial deformities. Before providing the client any instructions on taking this
medication, the nurse should determine whether the client might be pregnant. The client
should have a reliable birth control method. The capsules are swallowed whole with a
full glass of water. Unusual weight gain or weight loss are listed as rare or unknown
adverse reactions.

Basic Care and Comfort

A colostomy is created when the bowel is pulled through an opening in the abdominal
wall, creating a stoma through which intestinal contents will pass. A healthy stoma will
protrude about 2.5 cm with an open lumen at the top. The stoma should appear pinkish
red and moist. A dry, dusky, or reddish-purple stoma indicates ischemia. A narrowed,
flattened, or constricted stoma indicates stenosis. A concave and bowl-shaped stoma
has retracted. A retracted stoma can be difficult to care for. Complications include
problems maintaining appliance placement, leading to leakage and sore skin.

Stomatitis is irritation of the lips, mouth, tongue, and oropharynx, which occurs when
chemotherapy kills healthy cells that are rapidly dividing. It can impair nutrition, speech,
sleep, and the quality of life. Warm saline rinses are non-irritating and help eliminate
bacteria that can cause infection. Other nursing interventions include gentle oral
hygiene and administration of a topical analgesic as ordered by the physician.

Lotions, creams, and powders can soften the skin, making it more susceptible to
breakdown. The T-shirt and brace should fit snugly to avoid rubbing and irritating the
skin. The girl can stay active and perform specific exercises recommended by a
physical therapist.

Lacto-vegetarians can eat dairy products, soy, fruits, vegetables, lentils, grains, nuts,
and healthy fats. They do not eat eggs, poultry, fish, or meat.

Reduction of Risk Potential

Normal potassium levels are 3.5 to 5.0 mEq/L. Potassium levels below 3.5 mEq/L
indicate hypokalemia. The nurse should observe the client for muscle weakness, leg
cramps, shortness of breath, irregular heart rhythms, depression, confusion, and
lethargy. Elevated sodium levels (hypernatremia) result in rapid weight gain. Low
phosphate levels (hypophosphatemia) can cause slurred speech.

A sunken fontanelle is a sign of increasing dehydration. It is first noticed when

dehydration progresses from mild to moderate. Mild dehydration may be evidenced by
increased thirst and decreased urine output. Anuria (no urine output) is a sign of severe
dehydration.
A client is considered to have hypertension if even one of the parameters (either
diastolic or systolic) is elevated. This patient has stage 1 hypertension, defined as 120–
139 mmHg systolic or 80–89 mmHg diastolic. "Elevated blood pressure" replaces the
previously used term of prehypertension.

Infiltration occurs when IV fluid or medications leak into the surrounding tissue.
Extravasation is the leaking of vesicant drugs into the surrounding tissue. Extravasation
can cause severe local tissue damage, including blistering and necrosis, so the drugs
are rarely administered peripherally. Phlebitis is inflammation of a vein. Phlebitis
appears reddened and feels warm to the touch. Thrombosis is a clot in a vein.
Thrombosis feels warm and causes swelling and pain.

Stool that is to be tested must be examined while the specimen is fresh and warm. Ova
and parasites will not survive below body temperature. The feces can be collected with
a tongue blade from a bedpan or the toilet, and then placed in a non-sterile covered
container.
Partial thromboplastin time (PTT) is used to monitor and prescribe varying heparin
doses. The therapeutic range is 1.5 to 2.5 times the control time. HINT: The two Ts in
PTT resemble an H, and H stands for heparin. Prothrombin time (PT) is used to monitor
oral anticoagulant therapy, such as warfarin. CBC reports the total number of blood
cells. HbA1c is a value used for diabetic management and control.

Orthostatic or postural hypotension results when the patient’s blood pressure is not
maintained during position changes (i.e., from lying to either sitting or standing).
Orthostatic hypotension is defined as a decrease of more than 20 mmHg systolic or
more than 10 mmHg diastolic and a 10–20% increase in heart rate.

A gait belt is used for clients who may be weak or have balance issues. If the client
starts to fall, the nurse can control the fall by gently lowering the client onto the floor. A
cane is the least stable of these four options. Crutches are for transferring weight to the
upper body. A walker is for clients who need support when walking without assistance.

Bronchovesicular sounds are heard over the major bronchi. In this picture (an anterior
view), these sounds are heard around the sternum. Bronchial sounds are harsh, tubular
sounds heard over the trachea. Vesicular sounds are soft, low-pitched sounds produced
by air moving through the small bronchioles and alveoli.

External radiation therapy can cause the skin that is receiving the radiation to become
dry and itchy, and peel. The skin may appear sunburned and swollen. Special care is
necessary to avoid further irritation or permanent damage. Showers or baths should be
short, in lukewarm water. The patient must protect the skin from sun exposure. Loose
clothing prevents rubbing against the radiated areas. Moisturizing with approved
products helps relieve dry, itchy skin that could progress to infection.

Compartment syndrome occurs when excessive pressure builds up inside an enclosed

muscle space in the body. Compartment syndrome usually results from bleeding or
swelling after an injury. The dangerously high pressure in compartment syndrome
impedes the flow of blood to and from the affected tissues. About 75% of acute
compartment syndrome cases are the result of a broken leg or arm. Angelman
syndrome is a genetic disorder. Inflammatory myopathy is usually associated with
autoimmune disorders. Neuropathy is a nerve condition that causes numbness or
weakness.
This patient's magnesium level is elevated. (The normal range is 1.5–2.5 mEq/L.) Of
these four answer options, hypermagnesemia will have the most serious consequences.
The consequences of elevated magnesium include respiratory depression and heart
block. The patient's BUN level is also elevated. (The normal range is 7–22 mmol/L.) The
patient will need an evaluation, but this is not as critical as treating the
hypermagnesemia. The potassium level is within the normal range of 3.5–5.0 mEq/L.
The INR is within the normal range of 1.1 or lower.

After menopause, estrogen levels drop, resulting in a loss of calcium from the bones.
When bone mass is reduced, the entire skeletal structure can be jeopardized and the
risk of fractures increases. Obesity puts stress on the skeleton but doesn't necessarily
predispose it to fractures. Type 2 diabetes is not a risk factor. Lactose intolerance
means that some dairy products can cause intestinal distress, but calcium can be
obtained from other sources.

Inserting a nasogastric (NG) tube carries a risk of aspiration if the patient vomits. The
High Fowler's position keeps the head elevated to reduce the risk and facilitate the
insertion of the NG tube.

Physiological Adaptation
Diabetes mellitus does not cause third spacing. Third spacing occurs when too much
fluid moves from the intravascular space (blood vessels) into the interstitial or
"third" space – the nonfunctional area between cells. This can cause edema and
hypotension. Common sites are the abdomen, pleural cavity, and peritoneal cavity.

Inflammation caused by the hepatitis C virus can lead to cirrhosis or liver cancer, so the
patient should take steps to avoid further damage to the liver. People infected with the
hepatitis C virus should avoid alcohol and acetaminophen (Tylenol). They should also
get vaccinated for hepatitis A and B. Barrier protection should be used during sex, but
casual household contact is not a risk factor for transmission.

Kaposi sarcoma is an opportunistic disease that occurs as a result of

immunosuppression. Organ transplant patients can be at risk as well. The other
sarcomas do not have a known cause. Ewing sarcoma is a type of bone cancer that is
mostly diagnosed in teens and young adults. Synovial sarcoma begins in the cells
around the joints and tendons, anywhere in the body. Fibroblastic sarcoma develops in
the fibrous tissues, most commonly in the limbs, skin, and trunk of the body.

Second-degree heart block Type II is also called Mobitz II. With Mobitz Type II blocks,
the impulse is blocked in the bundle of His. Every few beats, there will be a missing
beat, but the PR interval will not lengthen. First-degree heart block is really a delay, not
a block. It is caused by a conduction delay at the AV node or bundle of His. This means
that the PR Interval will be longer than normal (over 0.20 sec.). With a third-degree
heart block, no atrial impulses are transmitted to the ventricles. As a result, the
ventricles generate an escape impulse, which is independent of the atrial beat. In most
cases, the atria will beat at 60–100 bpm, while the ventricles asynchronously beat at
30–45 bpm.

A client who receives peritoneal dialysis can expect a typical exchange cycle to last 30–
45 minutes, using 2–3 liters of dialysate solution. There are three phases: infusion (5–
10 minutes), dwell time (10 minutes), and drainage (10–30 minutes). During an
exchange, the client can read, talk, watch television, or sleep. The solution can remain
in the abdomen for a dwell time of 4–6 hours or longer. These are typical times; the
actual number of cycles and the dwell times will vary by client.
Ovarian cancer occurs more frequently in women over age 50. The disease has vague
early symptoms that are often ignored. One of the primary signs is abdominal bloating.
The woman may feel it, and it may look like a swollen belly to others. A woman may feel
full after eating just a few bites. She may also experience indigestion or nausea. The
other options are not related to ovarian cancer.
Crepitus is present when cartilage is lost. It is characterized by a popping or grating
sound, or sometimes the patient feels bone rubbing against bone secondary to loss of
cartilage. Decreased grip strength and bilateral joint swelling are more often seen in
rheumatoid arthritis. A stooped posture is seen in osteoporosis.

Pulmonary edema is the rapid accumulation of fluid in the tissues and air spaces of the
lungs. The symptoms of pulmonary edema include sudden dyspnea, the need to sit up
in order to breathe (orthopnea), cyanosis, pink frothy sputum, elevated pulse and blood
pressure, and severe anxiety. The other answer options are incorrect groups of
symptoms.

Cecilio