Important Facts Nurses Should Know

Therapeutic Drug Levels
Here are some of the therapeutic blood levels that are important for the nurse to be aware of when taking the NCLEX® exam:
- Digoxin: 0.5–2.0 ng/ml
- Lithium: 0.6–1.5 mEq/L
- Dilantin: 10–20 mcg/dl
- Theophylline: 10–20 mcg/dl

Vital Signs
Here are some of the normal ranges for vital signs:
- Heart rate: 80–100 beats per minute
- Newborn heart rate: 100–180 beats per minute
- Respiratory rate: 12–20 respirations per minute
- Blood pressure: systolic = 110–120 mm Hg; diastolic = 60–90 mm Hg
- Newborn blood pressure: systolic = 65 mm Hg; diastolic = 41 mm Hg
- Temperature: 98.6 +/–

Anticoagulant Therapy
These are the tests to be done for the client taking anticoagulants and their control levels. Remember that the therapeutic range is 1.5–2 times the control:
- Coumadin (sodium warfarin) PT/Protime: 12–20 seconds.
- International normalizing ratio (INR): 2–3.
- The antidote for sodium warfarin is vitamin K.
- Heparin and heparin derivatives partial thromboplastin time (PTT):

30–60 seconds.
- The antidote for heparin is protamine sulfate.

Intrapartal Normal Values
Here are some of the normal ranges to remember when caring for the client during the intrapartal period:
- Fetal heart rate: 120–160 beats per minute
- Variability: 6–10 beats per minute
- Contractions:
- Frequency of contractions: every 2–5 minutes
- Duration of contractions: less than 90 seconds
- Intensity of contractions: less than 100 mmHg
- Amniotic fluid amount: 500–1200 ml

Standard Precautions
Standard precautions are a set of guidelines for the nurse to take when caring for the client. These precautions protect the nurse from transmitting the disease to another client or to herself:
- Gloves should be worn when there is a chance of contact with blood and body fluids, when handling other potentially infected material, and when performing vascular access procedures.
- Gloves should be changed after each client contact and between contact procedures with the same client.
- Masks and protective eyewear should be worn when there is a likelihood of splashes or when body fluids might become airborne.
- Gloves and aprons should be worn during procedures in which there is the likelihood of splashes of blood or body fluids.
- Hand washing should be done immediately after contact with body flu- ids or other potentially infected material and as soon as gloves are removed.
- Needles and sharps should be disposed of in sharps containers. No recapping, bending, or breaking of needles should occur.
- Mouth-to-mouth resuscitation should be performed using a mouthpiece or other ventilation device.
Body fluids likely to transmit blood-borne disease include blood, semen, vaginal/ cervical secretions, tissues, cerebral spinal fluid, amniotic fluid, synovial fluid, pleural fluid, peritoneal fluid, and breast milk. Body fluids not likely to transmit blood-borne disease unless blood is visible include feces, nasal secretions, sputum, vomitus, sweat, tears, urine, and saliva (the exception is during oral surgery or dentistry).

Airborne Precautions
Examples of infections caused by organisms suspended in the air for prolonged periods of time are tuberculosis, measles (rubella), and chickenpox.
Place these clients in a private room. Healthcare workers should wear a
HEPA mask or N-95 mask when dealing with such clients. These mask contain fine fibers and filter out particles, preventing them from passing through to the healthcare worker.

Droplet Precautions
Infections caused by organisms suspended in droplets that can travel 3 feet, but are not suspended in the air for long periods of time are influenza, mumps, pertussis, rubella (German measles), diphtheria, pneumonia, scarlet fever, streptococcal pharyngitis, and meningitis. Place the client in a private room or in a room with a client who has the same illness. The clients should be no closer than 3 feet away from one another. Caregivers should wear a mask, and the door can remain open.

Contact Precautions
Infections caused by organisms spread by direct contact include RSV, scabies, colonization with MRSA, and VRE. Place the client in a private room or with a client with the same condition. Caregivers should wear gloves when entering the room and wear gowns to prevent contact with the client. Hands should be washed with an antimicrobial soap before leaving the client’s room.
Equipment used by the client should remain in the room and should be disinfected before being used by anyone else. The client should be transported only for essential procedures; during transport, precautions should be taken to prevent disease transmission.

Chemoprophylaxis After Occupational Exposure to HIV
Should the nurse be exposed to HIV, several interventions should be taken immediately. These interventions involve the use of several antiviral medications.

Interventions in the Event of HIV Exposure


Revised Life Support Guidelines (American Heart Association)
Frequently the American Heart Association releases guidelines for the care of the client experiencing dysrrhythmias. In this section, we discuss these guidelines and the correct method of performing cardiopulmonary resuscitation.

Basic Life Support—Adult
Basic life support can save the life of a client experiencing a life-threatening arrhythmia. These guidelines include
- Rescue breathing and bag-mask ventilation—Deliver mouth-to- mouth ventilations slowly over 2 full seconds with the least volume needed to make the chest rise.
- Bag-mask devices—If using a bag-mask device with oxygen supplement of at least 40%, deliver smaller tidal volume (6–7 ml/kg) over 1–2 seconds. Measure effectiveness by assessing chest expansion and oxygen saturations.
- Pulse checks—In addition to standard pulse checks, professional res- cuers should assess for signs of circulation, including evidence of normal breathing or any movement in response to the two rescue breaths given.
- Adult CPR—If there’s just one rescuer, perform chest compressions at a rate of 100/minute (the same rate for children). Because there is an interruption for ventilations, you won’t actually give 100 compressions/minute.
- Chest compressions—During CPR, the rescuer should perform two compressions to one ventilation. He should pause 2 seconds for each ventilation. After the airway is secured, he should switch to a ratio of five compressions to one ventilation.
- Chest-compression-only CPR—This is recommend if the rescuer is unable or unwilling to perform rescue breathing.
- In-hospital defibrillation—AHA recommends that all healthcare providers who might need to perform CPR should receive equipment, education, and authorization to perform defibrillation (AHA defines early defibrillation in a hospital or ambulatory healthcare facility as a shock-collapse interval of less 3 minutes).

Basic Life Support—Infants and Children
Basic life support is somewhat different for infants and children from that of adults. These differences include
- Phone fast versus phone first—Perform CPR for 1 minute before activating emergency medical services (EMS), except when the child is at high risk for cardiac arrhythmias and is in cardiac arrest. In that case, the rescuer should phone first to get a defibrillator on the way.
- Pulse check—For infants under 1 year of age, use brachial artery. For children, check the carotid artery. Assess for other signs of circulation, including normal breathing, coughing, and movement.
- Rescuer breathing/bag-mask—During infant rescue breathing, the rescuer should cover both the infant’s nose and mouth with his own mouth.
- Chest compressions—AHA now recommends the two thumb encir- cling hands technique instead of the two finger technique previously used.
If only one rescuer is present, two fingers should be used to provide chest compressions while the other hand is used to support the infant’s head.

Treatment of Acute Coronary Syndromes—AHA and ACLS

Guidelines
Frequently there are changes in the protocol for treatment of clients experiencing acute coronary syndromes. Changes in this treatment include
- A 12 lead ECG is useful in making a diagnosis of a myocardial infarction.
- Aspirin (100–325 mg) should be taken as soon as the symptoms begin.

Do not take the enteric-coated form.
- Prefibrinolytic therapy is recommended if transport to the hospital is prolonged or if more than 1 hour has passed between the onset of chest pain and the notification of an ACLS provider. For clients who are (candidates for recombinant tissue plasminogen activator (rtPA), AHA does not recommend giving rtPA 3 hours after the onset of symptoms.)

Drug Changes Currently in Use
These current drugs are being used to treat ventricular fibrillation and ventricular tachycardia. If the client is found to be in ventricular fibrillation, the immediate priority is to defibrillate, followed by CPR. An airway is inserted to facilitate proper ventilation, and an IV with a large-gauge needle is begun to provide IV medications and treat shock. Here are some things to remember about drugs used to treat ventricular fibrillation and ventricular tachycardia:
- Only one antiarrhythmic per client except for rare cases—New evi- dence suggests that lidocaine and epinephrine might not be as reliable as previously thought and might actually worsen the client’s condition.
- Lidocaine—This can suppress ventricular tachycardia associated with acute myocardial ischemia and infarction after they occur, but prophylactic use is contraindicated.
- Amiodarone—This has been shown to outperform other antiarrhyth- mic drugs, and AHA recommends it as a first-line antiarrythmic for shock refractory VT/VF. Amiodarone is recommended over lidocaine and adenosine as the initial treatment for wide complex tachycardia in hemodynamically stable clients.
- Procainamide—This is recommended before lidocaine and adenosine.
- Aminodarone and sotalol—These are recommended for the treatment of stable monomorphic and polymorphic VT.
- Epinephrine—A high dose (0.1 mg/kg) is no longer recommended for treating cardiac arrest. Clients who received high doses of epinephrine for cardiac arrest and survive have more complications after resuscitation than those who receive standard doses.
- Vasopressin (arginine vasopressin)—This adrenergic alternative to epinephrine is used for promoting the return of spontaneous circulation after cardiac arrest.
- Magnesium—This is recommended only for the treatment of hypo- magnesemia and torsades de pointes.
- Bretylium—This is no longer recommended for VT/pulseless or ven- tricular fibrillation. AHA has removed bretylium from ACLS treatment algorithms and guidelines because of the high incidence of adverse reactions and the availability of safer drugs.

Defense Mechanisms Often Used by Clients during Stressful Situations
The guide, 'Caring for the Client with Psychiatric Disorders,' discussed the client with psychosis and neurosis.
We also examined defense mechanisms used by the client to help him cope with stressors. Here is a quick reference to some of these defense mechanisms:
- Compensation—The development of attributes that take the place of more desirable ones
- Conversion reaction—The development of physical symptoms in response to emotional distress
- Denial—The failure to regard an event or feeling
- Displacement—The transference of emotions to another other than the intended
- Projection—The transferring of unacceptable feelings to another person
- Rationalization—The dismissal of one’s responsibility by placing fault on another
- Reaction formation—The expression of feelings opposite to one’s true feelings
- Regression—The returning to a previous state of development in which one felt secure
- Repression—The unconscious forgetting of unpleasant memories
- Sublimation—The channeling of unacceptable behaviors into behaviors that are socially acceptable
- Suppression—The conscious forgetting of an undesirable memory

Nutrition Notes
It is important for the nurse to be aware of different diets used in the disease processes we have discussed.

Dietary and Nutrition Notes to Remember:
A quick reference to help you remember the diets.

(contd.)


Immunization Schedule
It is important for the nurse to be aware of the recommended immunization schedule for various age groups.

Recommended Childhood and Adolescent Immunization Schedule UNITED STATES • 2005