NRNP6566KNOWLEDGECHECKWEEK8
QUE
STI
ON1
A7
7y earoldma nf
ellandsu f
fer
edal acer
ati
onacros
sh i
supp e
rri
ghtli
p.Th
eAPRNdeci
dest
o
ut
il
i
zeab loc
kforp a
inc ontr
olwh i
chs u
tur
ingthela
cera
tion.Whatty
peofbl
ocka
ndwh at
medi
c a
tionwoul
db eapp
ro p
riat
eforthi
spati
ent
?
F
oruppe rl
iplacer
ati
on,a
ni n
fraorb
ital
n er
veblockcanbeused.Theanest
heti
cofc hoic
eisp l
ain
l
i
docain
eb uti
fther
eareprof
useb l
eedingexter
n a
ll
y,ep
inephr
inecanbeaddedforb e
tterhemod y
namic
c
ontr
ol.On ceanest
hesi
aisachieved,i
rri
gat
eth eare
awithsal
ine.
Lidoca
ine2%s houldbeu se
da sner
ve
b
loc
ksf orintr
aora
landsuperf
icia
lprocedures
. Addi
ngepin
ephri
nep r
oduce
svasoc onst
ric
ti
on .Thedo
se
f
orl
idoca i
newithepi
nephr
ineis7mg /kgwithama xi
mumd oseof500mg
QUE
STI
ON2
A1
3yearoldgi
rl
isev a
luat
edinurg
entc a
ref
oralargewoundonherl
eftf
orear
m.Shec ompla
insof
se
verepai
n,i
scrying,
andisroc
kingonth
eb edduetopain
.TheAPRNisplanni
ngonh owto
r
epairt
hel
acera
tionandisconsi
deri
ngut
il
izi
ngketamin
eforp
rocedur
alsedat
ion.
Wh atar
ethe
ben
efit
sandri
sksofthisdr
ug?Wh atmon
itor
ingwouldbei
ndi
cate
difuti
l
ized?
Ket
amineh a
ss ev
e r
a l
a dva
ntagesoverothersed at
ivesforprocedur
alsedat
ion.Accordi
ngtoBuck(2016)
,the
us
eo fket
amineresu l
tsinonl
ymi ni
ma l
r e
sp i
rator
yd epress
ionwi t
hpre
servedore x
a g
gerat
edp h
aryngea
land
l
ary
ngealref
lexes
. I
ta l
soresul
tstonorma lorsligh
tlyincr
easedmu scl
etonewi t
hmi n
orincr
easeinBP,hear
trat
e
an
dc ardi
acoutput(Buck,2016)
.Additi
onally
, i
tisrapidact
inga sananest
he t
icwit
ha nal
gesi
cproper
ti
es.Some
pot
enti
all
yli
fe-
thr
e a
ten i
ngadverseef
fectsh avebeena ssoci
a t
edwithket
ami ne,
alt
houghrare.
Theseincl
ude
l
ary
ng os
pasm, a
pn ea,i
mp ai
redcard
iacfunc t
ion,inc
rea s
edin t
racr
ani
alpre
ss ur
ea n
dd ia
betesi
nsipi
dussothe
pa
tie
n t
sshouldbec aref
ull
ymon i
tor
edf orthese(Buc k,201
6) .
Re
fer
enc
e
Bu
ck,
M.L
.(2
016
).Ke
tami
nei
nfu
sion
sforp
edi
atr
ics
eda
tiona
nda
nal
ges
ia.
Ped
iat
ri
c
Ph
arma
cot
her
apy
,22
(6)
.ht
tps
://
med
.vi
rgi
ni
a.
edu
/pe
dia
tri
cs/
wp-
c
ont
ent
/up
loa
ds/
sit
es/
237
/20
15/
12/
Jun
e16
_Ke
tami
ne_
Ped
Pha
rma
co.
pdf
QUE
STI
ON3
A6
6yearoldwomenint
heI
CUi
sdi
agn
ose
dwi
thd
eli
ri
um.
Wha
twou
ldb
eth
ebe
sta
ppr
oac
hto
t
rea
tin
gh erd
eli
ri
um?
, Bar
kleyandMy e
rs(20 18),
treati
ngtheund e
rly
ingme di
calcondit
ioniscruci
a l
toresol
vi
ngd el
i
ri
u ma sfail
uretodo
somayleadtolong-
te r
mc ogniti
veimp a
irment.Al
thoughsedati
ve sanda nt
ipsy
choti
csma ybea dmini
ster
e d,
ef
for
tsmu stbema detor edu
cea nxi
etyanda gi
tat
ionbykee p
ingt hemcomf or
tabl
e,mainta
ini
ngn ormalsl
e ep
pat
ter
n s
,andfre
quen treori
ent
a t
ion(Barkl
ey&My ers,201
8).Ac utepsyc
h ot
icme d
icati
onsli
kelorazepam,
ol
anzapine
,andHaldo l
ca nbeo rde
redforthosewithdemen t
ia(Ba r
kl
ey&My er
s,2018)
.Ifpat
ientisluc
id,oral
quet
iapi
ne,ol
anzapi
n e,r
isperdone,andhaloper
idolca
nb egiveninlowd oses(Bar
kley&My er
s,201 8)
.Me di
cal,
neu
rologi
ca n
dp sy
ch i
atr
icc onsul
tat
ionsshouldbema deaswe ll
.
Re
fer
enc
e
Ba
rkl
ey,
T.W.
,&My
ers
,C.
M.(
201
5).
Pra
cti
cec
ons
ide
rat
io
nsf
ort
hea
dul
t-
ger
ont
ol
ogya
cut
e
c
aren
urs
epr
act
it
io
ner(
2nde
d.)
.We
stHol
l
ywood
,CA:
Bar
kl
ey&As
soc
iat
es.
QUE
STI
ON4
A6
6ye
arol
dma
nisa
dmi
redt
oth
eICUwi
thr
esp
ira
tor
ydi
st
res
san
dbi
l
ate
ral
pne
umon
ia.
Heh
asah
ist
oryofa
CVA2y
ear
sag
owi
thr
igh
the
mip
leg
iaa
nda
pha
sia
.Cu
rre
ntv
it
alss
ign
sar
eT9
8.8HR1
15BP1
70/
99.
RR3
2.
Ox
yge
nsa
tur
ati
oni
s90
%onan
onr
ebr
eat
herma
sk.
Thep
ati
entwe
igh
s70k
g.Th
eNPd
eci
dest
ope
rfor
ma
r
api
dse
que
ncei
ntu
bat
ion
.Wh
atme
dic
ati
onsa
ndd
ose
swou
ldb
eap
prop
ria
tef
ort
hisp
ati
ent
?
Forrapi
ds e
qu e
n c
eint
ubat
ion,i
nduct
ionagentth
atcou l
db eus
ediset
omidat
e0.3
mg /k
gIV(
2 0
mgfor
t
h i
sp at
ie
nt).Theneur
omuscul
arbloc
k i
ngagenttha
tc oul
db euse
disr
ocur
onium1-1
.2mg/k
gIV(70
mgf ort
hispati
ent)
.Succ
inyl
chol
in
eisn oti
ndic
atedforthosewit
hhi
st
oryofst
rok
eov e
r72hour
s.
QUE
STI
ON5
Ap
ati
entre
ceiv
ingpr
op of
olforb
ron
ch os
copyi
ntheI
CUb ec
omesunre
spons
ivet
over
bal
ortac
-
t
il
esti
mu l
ati
on.
Hisp ul
seoxi
meterrea
ds85%.
Wh ata
cti
ons
h ou
ldtheNPtak
etoi
mprov
ethe
pa
tie
nt’
soxygenat
ion?
Prop
ofoli
sshorta
cti
ng.
Whenrespi
rat
orydep
ressi
onoc
cur
sasshownbydecr
eas
e dl
eve
lof
c
onsc
iousnessandd
e c
rease
doxyg
ens a
tur
ati
on,d
iscon
tin
ueth
edri
pan
dp rov
idev
ent
il
ator
y
a
ssi
st
a nc
ethrou
ghab agval
vemask.
I
ntr
eat
ingp
rop
ofol
tox
ici
ty
,th
efi
rs
tst
ept
opr
eve
ntwor
sen
ingc
ond
iti
onsi
stod
isc
ont
inu
eth
epr
opof
ol
i
nfu
sion
.Ift
hep
ati
ents
ti
ll
requ
ire
sse
dat
ioni
nth
edu
etoot
herf
act
orsa
not
herc
las
sofs
eda
tiv
esh
oul
d
b
esu
bst
it
ute
d.Th
epa
tie
nts
hou
ldt
henb
ehe
mod
yna
mic
all
yst
abi
l
ize
d.I
nse
ver
eca
ses
,pa
tie
ntsma
y
r
equ
irea
dva
nce
dca
rdi
ore
spi
rat
oryl
i
ket
hisp
ati
ent
,su
ppo
rts
ucha
sex
tra
cor
por
eal
memb
ran
ous
QUE
STI
ON1
A7
7y earoldma nf
ellandsu f
fer
edal acer
ati
onacros
sh i
supp e
rri
ghtli
p.Th
eAPRNdeci
dest
o
ut
il
i
zeab loc
kforp a
inc ontr
olwh i
chs u
tur
ingthela
cera
tion.Whatty
peofbl
ocka
ndwh at
medi
c a
tionwoul
db eapp
ro p
riat
eforthi
spati
ent
?
F
oruppe rl
iplacer
ati
on,a
ni n
fraorb
ital
n er
veblockcanbeused.Theanest
heti
cofc hoic
eisp l
ain
l
i
docain
eb uti
fther
eareprof
useb l
eedingexter
n a
ll
y,ep
inephr
inecanbeaddedforb e
tterhemod y
namic
c
ontr
ol.On ceanest
hesi
aisachieved,i
rri
gat
eth eare
awithsal
ine.
Lidoca
ine2%s houldbeu se
da sner
ve
b
loc
ksf orintr
aora
landsuperf
icia
lprocedures
. Addi
ngepin
ephri
nep r
oduce
svasoc onst
ric
ti
on .Thedo
se
f
orl
idoca i
newithepi
nephr
ineis7mg /kgwithama xi
mumd oseof500mg
QUE
STI
ON2
A1
3yearoldgi
rl
isev a
luat
edinurg
entc a
ref
oralargewoundonherl
eftf
orear
m.Shec ompla
insof
se
verepai
n,i
scrying,
andisroc
kingonth
eb edduetopain
.TheAPRNisplanni
ngonh owto
r
epairt
hel
acera
tionandisconsi
deri
ngut
il
izi
ngketamin
eforp
rocedur
alsedat
ion.
Wh atar
ethe
ben
efit
sandri
sksofthisdr
ug?Wh atmon
itor
ingwouldbei
ndi
cate
difuti
l
ized?
Ket
amineh a
ss ev
e r
a l
a dva
ntagesoverothersed at
ivesforprocedur
alsedat
ion.Accordi
ngtoBuck(2016)
,the
us
eo fket
amineresu l
tsinonl
ymi ni
ma l
r e
sp i
rator
yd epress
ionwi t
hpre
servedore x
a g
gerat
edp h
aryngea
land
l
ary
ngealref
lexes
. I
ta l
soresul
tstonorma lorsligh
tlyincr
easedmu scl
etonewi t
hmi n
orincr
easeinBP,hear
trat
e
an
dc ardi
acoutput(Buck,2016)
.Additi
onally
, i
tisrapidact
inga sananest
he t
icwit
ha nal
gesi
cproper
ti
es.Some
pot
enti
all
yli
fe-
thr
e a
ten i
ngadverseef
fectsh avebeena ssoci
a t
edwithket
ami ne,
alt
houghrare.
Theseincl
ude
l
ary
ng os
pasm, a
pn ea,i
mp ai
redcard
iacfunc t
ion,inc
rea s
edin t
racr
ani
alpre
ss ur
ea n
dd ia
betesi
nsipi
dussothe
pa
tie
n t
sshouldbec aref
ull
ymon i
tor
edf orthese(Buc k,201
6) .
Re
fer
enc
e
Bu
ck,
M.L
.(2
016
).Ke
tami
nei
nfu
sion
sforp
edi
atr
ics
eda
tiona
nda
nal
ges
ia.
Ped
iat
ri
c
Ph
arma
cot
her
apy
,22
(6)
.ht
tps
://
med
.vi
rgi
ni
a.
edu
/pe
dia
tri
cs/
wp-
c
ont
ent
/up
loa
ds/
sit
es/
237
/20
15/
12/
Jun
e16
_Ke
tami
ne_
Ped
Pha
rma
co.
QUE
STI
ON3
A6
6yearoldwomenint
heI
CUi
sdi
agn
ose
dwi
thd
eli
ri
um.
Wha
twou
ldb
eth
ebe
sta
ppr
oac
hto
t
rea
tin
gh erd
eli
ri
um?
, Bar
kleyandMy e
rs(20 18),
treati
ngtheund e
rly
ingme di
calcondit
ioniscruci
a l
toresol
vi
ngd el
i
ri
u ma sfail
uretodo
somayleadtolong-
te r
mc ogniti
veimp a
irment.Al
thoughsedati
ve sanda nt
ipsy
choti
csma ybea dmini
ster
e d,
ef
for
tsmu stbema detor edu
cea nxi
etyanda gi
tat
ionbykee p
ingt hemcomf or
tabl
e,mainta
ini
ngn ormalsl
e ep
pat
ter
n s
,andfre
quen treori
ent
a t
ion(Barkl
ey&My ers,201
8).Ac utepsyc
h ot
icme d
icati
onsli
kelorazepam,
ol
anzapine
,andHaldo l
ca nbeo rde
redforthosewithdemen t
ia(Ba r
kl
ey&My er
s,2018)
.Ifpat
ientisluc
id,oral
quet
iapi
ne,ol
anzapi
n e,r
isperdone,andhaloper
idolca
nb egiveninlowd oses(Bar
kley&My er
s,201 8)
.Me di
cal,
neu
rologi
ca n
dp sy
ch i
atr
icc onsul
tat
ionsshouldbema deaswe ll
.
Re
fer
enc
e
Ba
rkl
ey,
T.W.
,&My
ers
,C.
M.(
201
5).
Pra
cti
cec
ons
ide
rat
io
nsf
ort
hea
dul
t-
ger
ont
ol
ogya
cut
e
c
aren
urs
epr
act
it
io
ner(
2nde
d.)
.We
stHol
l
ywood
,CA:
Bar
kl
ey&As
soc
iat
es.
QUE
STI
ON4
A6
6ye
arol
dma
nisa
dmi
redt
oth
eICUwi
thr
esp
ira
tor
ydi
st
res
san
dbi
l
ate
ral
pne
umon
ia.
Heh
asah
ist
oryofa
CVA2y
ear
sag
owi
thr
igh
the
mip
leg
iaa
nda
pha
sia
.Cu
rre
ntv
it
alss
ign
sar
eT9
8.8HR1
15BP1
70/
99.
RR3
2.
Ox
yge
nsa
tur
ati
oni
s90
%onan
onr
ebr
eat
herma
sk.
Thep
ati
entwe
igh
s70k
g.Th
eNPd
eci
dest
ope
rfor
ma
r
api
dse
que
ncei
ntu
bat
ion
.Wh
atme
dic
ati
onsa
ndd
ose
swou
ldb
eap
prop
ria
tef
ort
hisp
ati
ent
?
Forrapi
ds e
qu e
n c
eint
ubat
ion,i
nduct
ionagentth
atcou l
db eus
ediset
omidat
e0.3
mg /k
gIV(
2 0
mgfor
t
h i
sp at
ie
nt).Theneur
omuscul
arbloc
k i
ngagenttha
tc oul
db euse
disr
ocur
onium1-1
.2mg/k
gIV(70
mgf ort
hispati
ent)
.Succ
inyl
chol
in
eisn oti
ndic
atedforthosewit
hhi
st
oryofst
rok
eov e
r72hour
s.
QUE
STI
ON5
Ap
ati
entre
ceiv
ingpr
op of
olforb
ron
ch os
copyi
ntheI
CUb ec
omesunre
spons
ivet
over
bal
ortac
-
t
il
esti
mu l
ati
on.
Hisp ul
seoxi
meterrea
ds85%.
Wh ata
cti
ons
h ou
ldtheNPtak
etoi
mprov
ethe
pa
tie
nt’
soxygenat
ion?
Prop
ofoli
sshorta
cti
ng.
Whenrespi
rat
orydep
ressi
onoc
cur
sasshownbydecr
eas
e dl
eve
lof
c
onsc
iousnessandd
e c
rease
doxyg
ens a
tur
ati
on,d
iscon
tin
ueth
edri
pan
dp rov
idev
ent
il
ator
y
a
ssi
st
a nc
ethrou
ghab agval
vemask.
I
ntr
eat
ingp
rop
ofol
tox
ici
ty
,th
efi
rs
tst
ept
opr
eve
ntwor
sen
ingc
ond
iti
onsi
stod
isc
ont
inu
eth
epr
opof
ol
i
nfu
sion
.Ift
hep
ati
ents
ti
ll
requ
ire
sse
dat
ioni
nth
edu
etoot
herf
act
orsa
not
herc
las
sofs
eda
tiv
esh
oul
d
b
esu
bst
it
ute
d.Th
epa
tie
nts
hou
ldt
henb
ehe
mod
yna
mic
all
yst
abi
l
ize
d.I
nse
ver
eca
ses
,pa
tie
ntsma
y
r
equ
irea
dva
nce
dca
rdi
ore
spi
rat
oryl
i
ket
hisp
ati
ent
,su
ppo
rts
ucha
sex
tra
cor
por
eal
memb
ran
ous
