Medical Surgical Nursing

Medical-Surgical Nursing Communication Strategies - A. Assess client for hearing deficits or hearing loss B. Determine whether the client understands questions C. Take time to ask yes/no questions if the client is having difficulty communicating D. Observe client's nonverbal communication cues (grimacing indicating pain, fear in a child) E. When possible, provide continuity of care by assigning the same nurse F. Encourage presence of family members to reassure client Primary prevention - Intended to reduce health risks and increase healthy behaviors e.g. Providing immunizations, teaching nutrition classes, and requiring smoke-free zones Secondary prevention - Intended to detect disease (through screening) and treat the disease as early as possible e.g. Colonoscopy allows colon cancer to be detected so that an intervention can be initiated as early as possible Tertiary prevention - Intended to prevent disability and complications and to provide for a peaceful death. Tertiary prevention includes rehabilitation e.g. Rehabilitation after a stroke or hip replacement surgery, hospice care Herbal medication: Bitter orange - Application: Weight reduction Mechanism of action: CNS stimulant catecholaminergic Side effects: High BP and tachycardia in healthy adults with normal BP Drug interaction: It can interact with many drugs Efficacy: Unproven Herbal medication: Black cohosh - Application: Alleviate hot flashes of menopause Mechanism of action: Acts on neurotransmitter systems; binds with serotonin receptor subtypes Side effects: No evidence of severe side effects Herbal medication: Echinacea - Application: Reduction in duration of common cold Mechanism of action: Stimulation of immune cell function and cytokine production Side effects: Allergic reactions Drug interaction: Potential inhibition of CYP450 isoforms Efficacy: Proven Herbal medication: Ephedra - Application: Reduction of fatigue; weight reduction Mechanism of action: CNS stimulation; CNS stimulant catecholaminergic Side effects: Excessive adrenergic stimulation, HTN, MI, stroke, extensive CNS stimulation, agitation, sleep disturbances, psychosis Drug interaction: Synergistic interaction with methylxanthines, synergistic interaction with monoamine oxidase inhibitors (MAOIs), inhibition of antihypertensive effects Efficacy: Proven Herbal medication: Garlic - Application: Reduction of hyperlipidemia Mechanism of action: HMG-CoA reductase inhibitor Side effects: Odor, diaphoresis, bleeding Drug interactions: Potentiation of anticoagulant and antiplatelet medications, decreased plasma levels of protease inhibitor drug saquinavir Herbal medication: Ginger - Application: Treatment of nausea in motion sickness and pregnancy Mechanism of action: Serotonin antagonist Side effects: No major adverse side effects Drug interaction: Potential potentiation of anticoagulant antiplatelet drugs (controversial) Efficacy: Proven Herbal medication: Gingko - Application: Enhancement of mental performance Mechanism of action: Vasodilator Side effects: No major adverse side effects Drug interaction: Synergistic interaction with other stimulants (e.g. caffeine) Efficacy: Unproven Herbal medication: Ginseng - Application: Treatment of erectile disfunction; reduction of fatigue; enhancement of mental performance Mechanism of action: Antiandrogen Side effects: No major adverse side effects Drug interaction: No consistent reports Efficacy: Supportive Herbal medication: Hoodia gordonii (aka Hoodia, Veldkos, Slimming cactus, Trichocaulon gordonii, Stapelia gordonii) - Application: Weight reduction Mechanism of action: P57, the main ingredient cannot actively reach the brain to suppress the appetite Side effects: May be mildly toxic (confirmed in mice but not humans), increased heart rate, possible hepatotoxic as evidenced by increase in alkaline phosphatase (ALP) in healthy women Efficacy: Unproven Herbal medication: Kava - Application: Treatment of anxiety Mechanism of action: Modulatory effect at GABA receptors Side effects: Hepatotoxicity Drug interaction: Inhibition of CYP4502EI, potentiation of other sedatives (benzodiazepines), inhibition of effects of levodopa in Parkinson disease clients Efficacy: Proven Herbal medication: Red yeast rice - Application: Reduction of hyperlipidemia Mechanism of action: Precise mechanism of action unknown, Lovastin is principal active ingredient, 7 other HMG-CoA reductase inhibitors (statins) Side effects: Unknown adverse effects Drug interaction: Unknown Efficacy: Partly understood Herbal medication: Saw palmetto - Application: Relief of benign prostate hypertrophy Mechanism of action: Antiandrogen Side effects: None Drug interaction: No major interactions reported Efficacy: Unproven Herbal medication: Soy - Application: Therapeutic for menopausal vasomotor symptoms, prevention of breast cancer, prevention of osteoporosis Mechanism of action: Phytoestrogens help balance wildly fluctuating hormone levels, structurally similar to estradiol (major endogenous estrogen) Side effects: Can provoke asthma, gastrointestinal disturbance Drug interaction: Dangerous interaction with MAOI inhibitors leading to serotonin syndrome, inhibition of actions of tamoxifen Efficacy: Proven Herbal medication: Soy protein - Application: Reduction of hyperlipidemia Mechanism of action: Unknown Herbal medication: St. John's wort - Application: Depression Mechanism of action: Inhibition of norepinephrine, dopamine, and serotonin reuptake Side effects: Mania in bipolar clients, photosensitivity Drug interactions: Serotonin syndrome when combined with selective serotonin reuptake inhibitors or tricyclic antidepressants, reduced plasma concentrations of many drugs such as oral contraceptives, statins, warfarin Efficacy: Proven Pneumonia: Nursing Assessment - A. Tachypnea: shallow respirations, often with use of accessory muscles B. Abrupt onset of fever with shaking and chills (not reliable in older adults) C. Productive cough with pleuritic pain D. Rapid, bounding pulse E. In older adults, symptoms include: confusion, lethargy/melaise, anorexia, rapid respiratory rate, tachycardia F. Pain and dullness to percussion over the affected lung area G. Bronchial breath sounds, crackles; Pt. with pneumonia changes the letter "E" to "A" when heard with stethoscope over lungs; Tactile fremitus (chest vibrations when the pt. says "99") H. Chest radiograph indication of infiltrates with consolidation or pleural effusion I. Elevated white blood cell (WBC) count J. Arterial blood gas (ABG) indication of hypoxemia K. On pulse oximetry, a drop in O2 saturation Pneumonia: Nursing Plans and Interventions - A. Assess sputum for volume, color, consistency, clarity and distinct odors like Pseudomonas B. Assist client to cough productively by: deep breathing every 2 hours, using humidity to loosen secretions, suctioning the airway, chest physiotherapy C. Provide fluids up to 3 L/day unless contraindicated D. Assess lung sounds before and after coughing E. Assess rate, depth, and pattern of respirations regularly (assess for accessory muscles) F. Monitor ABGs (PO2 80 mm Hg; PCO2 45 mm Hg) G. Monitor O2 saturation H. Assess skin color I. Assess mental status, restlessness, irritability J. Administer humidified O2 as prescribed K. Monitor temp. regularly L. Provide adequate rest periods M. Encourage at-risk groups to get pneumonia nd annual flu shots (healthy adults develop protection within 2-3 weeks) Antiinfectives: Penicillins - Drugs: Procaine penicillin G, Benzathine penicillin, Penicillin V Indications: Antiinfectives, used primarily for gram-positive infections Adverse reactions: allergic reactions, anaphylaxis, phlebitis at IV site, diarrhea, GI distress, superinfection Nursing implications: Use with caution in clients allergic to cephalosporins, monitor for allergic reactions, observe clients for at least 30 min after parental administration, oral penicillin G should be taken on an empty stomach, probenecid decreases renal excretion, thereby resulting in an increased blood level of the drug, alters contraceptive effectiveness Antiinfectives: Semisynthetic - Drugs: Oxacillin sodium, Naficillin sodium, Cloxacillin sodium, Dicloxacillin sodium Indications: Antiinfectives, used primarly for gram-positive infections Adverse reactions: allergic reactions, anaphylaxis, superinfection, phlebitis at IV site, diarrhea, GI distress Nursing implications: Cannot be used in clients allergic to pencillin, use with caution in clients allergic to cephalosporins, monitor for super infection (sore mouth, vaginal discharge, diarrhea, cough) Antiinfectives: Antipseudomonal Penicillins and Combinations - Drugs: Ampicillin, Ticarcillin + clavulunate, Piperacillin + tazobactam, Ampicillin + sulbactam Indications: Antiinfectives, broad spectrums Adverse reactions: Similar to penicillin, ampicillin rash Nursing implications: Contraindicated in client allergic to penicillin (see Penicillin) Antiinfectives: Tetracyclines - Drugs: Tetracycline HCl, Doxycycline hyclate Minocycline Indications: Antiinfectives Adverse reactions: Hypersensitivity reactions, photosensitivity Nursing implications: Decrease the effectiveness of oral contraceptives, avoid concurrent use of antacids (milk products), inspect IV site frequently, monitor for superinfections, avoid exposure to sunlight during use, avoid use in pregnant clients and children under 8 yrs (can cause yellow-brown discoloration of teeth and growth retardation) Antiinfectives: Aminoglycosides - Drugs: Gentamicin sulfate, Tobramycin sulfate, Amikacin sulfate, Miscellaneous agents (Vancomycin hydrochloride, Metronidazole) Indications: Antiinfectives, used with gram-negative bacteria Adverse reactions: Neuromuscular blockade, nephrotoxicity, ototoxicity Nursing implications: Monitor renal function, BUN, creatinine, and I&O, monitor for ototoxicity (headache, dizziness, hearing loss, tinnitus), monitor for superinfection, peak and trough levels required, monitor for vancomycin serum drug concentrations Antiinfectives: Cephalosporins - Drugs: First Generation: Cefazolin, Cephalexin Second Generation: Cefaclor, Cefamandole, Cefuroxime, Cefoxitin, Cefotetan, Cefroprozil Third Generation: Cefotaxime, Ceftriaxone, Cefdinir, Cefixime, Cefpodoxime, Ceftibuten (Cedax) Fourth Generation: Cefepime Indications: Antiinfectives Adverse reactions: Allergic reactions, thrombophlebitis, GI distress, superinfection Nursing implications: Use with caution in clients allergic to penicillin and cephalosporins (see Penicillins) Antiinfectives: Carbapenems - Drugs: Imipenem, Meropenem, Ertapenem Indications: Treatment of severe or high-risk bacterial infections, reserved for known or suspected multidrug resistant bacterial infections Antiinfectives: Monobactam - Drugs: Aztreonam Indications: Pseudomonas aeruginosa + many otherwise resistant organisms, most effective against gram-negatives Adverse reactions: Phlebitis, pseudomembranous colitis, CNS changes, EEG changes, headache, diplopia, hypotension Nursing implications: Monitor renal and hepatic function (especially in older adults), carefully monitor for diarrhea, assess motor sensory function and cardiac rhythm Antiinfectives: Macrolides - Drugs: Clarithyromycin, Azithromycin, Erythromycin Indications: Clarithyromycin (PO): URI, including streptococci; as adjunct treatment for Helicobacter pylori, Clarithyromycin (IV): gram-negative and gram-positive organisms Adverse reactions: Pseudomembranous colitis, phlebitis: a vesicant, superinfections, dizziness, dyspnea Nursing implications: Give Clarithyromycin XL with food, space monoamine oxidase inhibitors (MAOI) 14 days before start and after end of Clarithyromycin, report diarrhea, abdominal cramping (all macrolides), monitor liver and renal labs, PO clarithromycin give on an empty stomach Antiinfectives: Fluoroquinolones - Drugs: Ciprofloxacin, Levofloxacin, Moxifloxacin Indications: Used to treat respiratory infections, UTIs, skin, bone, and joint infections; has been used as conjunctive treatment for TB and AIDS Adverse reactions: Superinfections, CNS disturbances, arroyos (sluggish pupillary reaction to light) and cataracts possible with ciprofloxacin, ciprofloxacin: a vesicant Nursing implications: Prompt onset, crosses placenta and in breast milk, can lower seizure threshold, monitor liver, renal and blood counts, safety for children unknown, many drug-drug interactions Antiinfectives: Lincosamides - Drug: Clindamycin Indications: Soft tissue infections caused by streptococci, staphylococci, and anaerobes, infections resistant to penicillins and cephalosporins, used in penicillin- and erthyromycin-senstive clients Adverse reactions: Agranulocytosis, pseudomembranous colitis, superinfections Nursing implications: Periodic liver, renal, and blood count monitoring, report diarrhea immediately Antiinfectives: Streptogramin - Drug: Quinupristin/dalfopristin Indication: Life-threatening VRE (Vancomycin-resistant enterococci) Adverse reactions: Arthralgia (pain in joints), myalgia (pain in muscle), severe vesicant, pseudomembranous colitis, nausea/vomiting, diarrhea, rash, pruritus Nursing indications: Incompatible with any saline solutions of heparin, functionally related to both macrolides and lincosamides, monitor total bilirubin, many drug-drug interactions Antiinfectives: Oxazolidinone - Drug: Linezolid Indication: Life-threatening VRE (Vancomycin-resistant enterococci) and MRSA Adverse reactions: GI disturbances, headache, pancytopenia, pseudomembranous colitis, superinfections Nursing implications: Monitor renal and liver labs and blood count, may exacerbate HTN (especially if pt. ingests foods with tyramine [MAOI-like properties]), report diarrhea immediately HESI Hint for Pneumonia: Hydration - -Thins out mucus trapped in bronchioles and alveoli, facilitating expectoration -Is essential for client experiencing fever -Is important because 300 to 400 mL of fluid is lost daily by the lungs through evaporation HESI Hint: Pneumonia Preventives for Older Adults - -Annual flu vaccinations -Pneumococcal vaccination at age 65 or older and younger clients who are at high risk -Avoiding sources of infection and indoor pollutants (dust, smoke, and aersols) -No smoking HESI Hint: Pneumonia Preventives for Immunosuppressed and Debilitated Persons - -Annual flu vaccinations -Pneumonia vaccination -Avoid infections -Sensible nutrition -Adequate fluid intake -Appropriate balance of rest and activity HESI Hint: Pneumonia Preventives for Comatose and Immobile Persons - -Elevation of head of bed at least 30 degrees for feeding and for 1 hour after feeding -Turn frequently HESI Hint: Pneumonia Preventives for Patients with Functional or Anatomic Asplenia - -Flu and pneumonia vaccinations Normal ABG values: Blood Gas - 7.35-7.45 Normal ABG values: PCO2 - 35-45 mm Hg Normal ABG values: PO2 - 80-100 mm Hg Normal ABG values: HCO3- - 21-28 mEq/L Chronic Bronchitis - Pathophysiology: Chronic sputum with cough production on a daily basis for a minimum of 3 months in each of 2 consecutive years, chronic hypoxemia (cor pulmonale), increase in mucus/cilia production, increase in bronchial wall thickness (obstructs air flow), reduced responsiveness of respiratory center to hypoxemic stimuli Precipitating factors: Higher incidence in smokers Assessment: Generalized cyanosis, "blue-bloaters", right-sided heart failure, distended neck veins, crackles, expiratory wheezes Nursing plan and interventions: Lowest FiO2 possible to prevent CO2 retention, monitor for S&S of fluid overload, maintain PaCO2 between 55 and 60, baseline ABGs, teach pursed-lip breathing and diaphragmatic breathing, teach tripod position, administer bronchodilators and antiinflammatory agents Emphysema - Pathophysiology: Reduced gas exchange surface area, increased air trapping (increased AP diameter), decreased capillary network, increased work, increased O2 consumption Precipitating factors: Cigarette smoking, environmental and/or occupational exposure, genetic Assessment: "pink-puffers", barrel chest, pursed-lip breathers, distant, quiet breath sounds, wheezes, pulmonary blebs on radiograph Nursing plans and interventions: Lowest FiO2 possible to prevent CO2 retention, monitor for S&S of fluid overload, maintain PaCO2 between 55 and 60, baseline ABGs, teach pursed-lip breathing and diaphragmatic breathing, teach tripod position, administer bronchodilators and antiinflammatory agents Asthma - Pathophysiology: Narrowing or closure of the airway due to a variety of stimulants Precipitating factors: Mucosal edema, V/Q abnormalities, increased work of breathing, beta blockers, respiratory infection, allergic reaction, emotional stress, exercise, environmental or occupational exposure, reflux esophagitis Assessment: Dyspnea, wheezing, chest tightness, assess precipitating factors, medication history Nursing plans and interventions: Administer bronchodilators, administer fluids and humidification, education (causes, medication regimen), ABGs, ventilatory patterns, C-PAP and Bi-PAP Chronic Airflow Limitation: Nursing Plans and Interventions - A. Teach client to sit upright and bend slightly forward to promote breathing (tripod position) B. Teach diaphragmatic and pursed-lip breathing. Teach prolonged expiratory phase to prevent bronchiolar collapse and prevent air trapping C. Administer O2 at 1-2 L D. Pace activities to conserve energy E. Maintain adequate dietary intake (small, frequent meals; favorite foods; dietary supplements) *Continuation of smoking tobacco = increase vitamin C *COPD = increase magnesium and calcium *Monitor magnesium and phosphate F. Provide adequate fluid intake (min. 3 L) G. Fluids should be taken IN-BETWEEN meals H. Smoking cessation is IMPERATIVE Serum calcium levels - 9-11 mg/dL Phosphorous levels - 3-4.5 mg/dL HESI Hint for Chronic Airflow Limitation: Health Promotion - -Eating consumes energy needed for breathing. Offer mechanically soft diets, which do not require as much chewing and digestion. Assist with feeding if needed. -Prevent secondary infections; avoid crowds, contact with persons who have infectious diseases, and respiratory irritants (tobacco smoke) -Teach client to report any change in characteristics of sputum -Encourage client to hydrate well (3 L/day) and decrease caffeine due to diuretic effects -Obtain immunizations when needed (flu and pneumonia) HESI Hint: O2 delivery - 4 L/min = must bubble through some type of water solution so it can be humidified 1-4 L/min = given by mask or nasal prongs, oropharynx and nasal pharynx provide adequate humidification Nursing Skills for a Respiratory Client: Suctioning (Tracheal) - -Suction when adventitious breath sounds are heard, when secretions are present at the endotracheal tube, and when gurgling sounds are noted -Use aseptic/sterile technique throughout the procedure -Wear mask and goggles -Advance catheter until resistance is felt -Apply suction only when withdrawing catheter (gently rotate catheter when withdrawing) -Never suction for more than 10 to 15 seconds, and pass the catheter only three or fewer times -Oxygenate with 100% O2 for 1-2 min before and after suctioning to prevent hypoxia Nursing Skills for a Respiratory Client: Ventilator Setting Maintenance - -Verify that alarms are on -Maintain settings and check often to ensure that they are specifically set as prescribed by health care provider -Verify functioning of ventilator at least every 4 hours Nasal cannula - Low O2 flow for low O2 concentrations (good for COPD) Simple face mask - Low flow, but effectively delivers high O2 concentrations; cannot deliver 40% O2 Nonrebreather mask - Low flow, but delivers high O2 concentrations (60% to 90%) Partial rebreather mask - Low-flow O2 reservoir bag attached; can deliver high O2 concentrations Venturi mask - High-flow system; can deliver exact O2 concentration C-PAP mask - Continuous positive airway pressure. CPAP is an effective treatment for obstructive sleep apnea. Bi-PAP - Bilevel Positive Airway Pressure Nursing Skills for a Respiratory Client: Pulse Oximetry - -Easy measurement of O2 saturation -Should be 90% ideally above 95% -Noninvasive, fastens to finger, toe, or earlobe -No nail polish -Must have good peripheral perfusion to be accurate Nursing Skills for a Respiratory Client: Tracheostomy Care - -Aseptic technique (remove inner cannula only from stoma) -Clean nondisposable inner cannula with H2O2; rinse with sterile saline in accordance with hospital policy -4 x 4 gauze dressing is butterfly folded after inner cannula is inserted Nursing Skills for a Respiratory Client: Respiratory Isolation Technique - -Mask is required for anyone entering the room -Private room is required with negative air pressure -Client must wear mask if leaving room Nursing Skills for a Respiratory Client: Proper Use of an Inhaler with Spacers - -Have client exhale completely -Grip mouthpiece (in mouth) only if client has a spacer; otherwise, keep mouth open to bring in volume of air with misted medication. While inhaling slowly, push down firmly on the inhaler to release the medication -Use bronchodilator inhaler before steroid inhaler -Wait at least 1 min between puffs (inhaled doses) -After steroid inhaler use, patient must perform oral care to prevent fungal infections Bronchodilators and Corticosteriods: Adrenergics and Sympathomimetics - Drugs: Epinephrine, Isoproterenol HCl, Albuterol, Isoetharine, Terbutaline, Salmeterol, Metaproterenol (inhaled), Levalbuterol Indications: Bronchodilator Adverse reactions: Anxiety, increased heart rate, nausea, vomiting, urinary retention Nursing implications: Check heart rate, monitor for urinary retention (especially in men over 40), instruct proper use of the inhaler, use bronchodilator before steroid inhaler, may cause sleep disturbance Bronchodilators and Corticosteriods: Methylxanthine - Drugs: Aminophylline (IV), Theophylline (PO) Indications: Bronchodilator Adverse reactions: GI distress, sleeplessness, cardiac dysrhythmias, hyperactivity, tachycardia Nursing implications: Administer oral forms with food, avoid foods containing caffeine, check heart rate, instruct proper use of inhaler, monitor therapeutic range (10-15 ug/mL or 10-20 mcg/mL), crosses placenta Bronchodilators and Corticosteriods: Corticosteroids - Drugs: Prednisone (PO), Solu-Medrol (IV), Beclomethasone dipropionate (inhaled), Budesonide (inhaled), Fluticasone (inhaled), Triamicinolone (inhaled), Flunisolide (inhaled), Mometasone (inhaled) Indications: Antiinflammatory Adverse reactions: Cardiac dysrhythmias occur with long-term steroid use Nursing implications: Instruct in proper use of inhaler, encourage oral care after use Bronchodilators and Corticosteriods: Anticholinergics - Drugs: Ipratropium, Tiotropium Indications: Bronchodilator, control of rhinorrhea Adverse reactions: Dry mouth, blurred vision, cough Nursing implications: Do no exceed 12 doses in 24 hours (ipratropium) Bronchodilators and Corticosteriods: Combination Products - Drugs: Fluticasone + salmeterol, Ipratropium + albuterol, Budesonide + formoterol *See individual drugs for info Bronchodilators and Corticosteriods: Phosphodiesterase 4 Inhibitors - Drug: Roflumilast Indication: Reduced lung inflammation in severe COPD Adverse reactions: Insomnia, weight loss, depression Nursing implications: Many drug-drug interactions Cancer of the Larynx - Characterized by hoarseness and/or voice characteristics, palpable jugular nodes, pain when swallowing, unexplained earache, and changes in mouth or tongue (white, gray, dark brown, or black and may appear patchy) HESI Hint: Cancer of the Larynx (1) - Air entering the lungs is humidified along the nasobronchial tree. This natural humidifying pathway is gone for the client who has had a laryngectomy. If the air is not humidified before entering the lungs, secretions tend to thicken and become crusty HESI Hint: Cancer of the Larynx (2) - A laryngectomy tube has a larger lumen and is shorter than a tracheostomy tube. Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks (for first 24 hrs) HESI Hint: Cancer of the Larynx (3) - Fear of choking is very real for laryngectomy clients. They cannot cough as they could earlier because the glottis is gone. Teach the glottal stop technique to remove secretions (take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube) Pulmonary Tuberculosis - Communicable lung disease caused by an infection by Mycobacterium tuberculosis bacteria HESI Hint: Tuberculosis Test - Tuberculosis Skin Test (TST) (Mantoux); A positive TB skin test in a healthy client is exhibited by an induration 10 mm or greater in diameter 48 to 72 hours after the skin test. Anyone who has received a bacillus Calmette-Guerin (BCG) vaccine will have a positive skin test and must be evaluated with an initial chest radiograph. A health history with signs and symptoms form may be filled out annually until signs and symptoms arise; then another radiograph is required. Chest x-rays are required on new employment; employer may require an x-ray every 5 years depending on exposure risk. *CDC guidelines indicate that the QuantiFeron-TB Gold test, a new blood test, is more reliable for TB skin testing. Nucleic acid amplification (NAA) testing may be recommended when a client has signs and symptoms of TB. Drug Therapy for Tuberculosis (TB): First-Line Drugs - Drug: Isoniazid (INH) Mechanism of action: Interferes with DNA metabolism of tubercle bacillus Side effects: Nausea, vomiting, abdominal pain, peripheral neuritis *Rare SEs: neurotoxicity, optic neuritis, and hepatotoxicity Comments: Metabolism primarily by liver and excretion by kidneys; pyridoxine (vitamine B6) administration during high-dose therapy as prophylactic measure; use as single prophylactic agent for active TB in individuals whose PPD converts to positive; ability to cross blood-brain barrier; drug interaction with alcohol, Antabuse, and phenytoin Drug Therapy for Tuberculosis (TB): First-Line Drugs (con't) - Drug: Rifampin Mechanisms of Action: Has broad-spectrum effects, inhibits RNA polymerase of tubercle bacillus Side effects: Hepatitis, febrile reaction, GI disturbance, peripheral neuropathy, hypersensitivity, *orange body secretions* Comments: Used in conjunction with at least one other antitubercular agent; low incidence of SEs; suppression of effect of birth control pills; *possible orange urine*; increases metabolism of digoxin and oral hypoglycemics Drug Therapy for Tuberculosis (TB): First-Line Drugs (con't) - Drug: Ethambutol Side effects: Skin rash, GI disturbance, malaise, peripheral neuritis, optic neuritis Comments: Side effects uncommon and reversible with discontinuation of drug; most common use as substitute drug when toxicity occurs with isoniazid or rifampin HESI Hint: TB Teaching - Drug therapy is usually long-term (6 months or longer). It is essential that the client take the medications as prescribed for the entire time. Drug Therapy for Tuberculosis (TB): First-Line Drugs (con't) - Drug: Rifapentine Side effects: Red discoloration of body fluids and tissues HESI Hint: Teaching Points for Rifampin - Reduces effectiveness of oral contraceptives; client should use other birth control methods during treatment; gives body fluids orange tinge; stains soft contact lenses HESI Hint: Teaching Points for Isoniazid (INH) - Increased phenytoin levels HESI Hint: Teaching Points for Ethambutol - Vision check before starting therapy and monthly thereafter; may have to take for 1 to 2 years HESI Hint: Teaching Points for Combination Drug Therapy - Teach rationale for combination drug therapy to increase compliance. Resistance develops more slowly if several anti-TB drugs given, instead of just one drug at a time HESI Hint: Lung Tumors - Some tumors are so large that they fill entire lobes of the lung. When removed, large spaces are left. Chest tubes are not usually used with these clients because it is helpful if the mediastinal cavity, where the lung used to be, fills up with fluid. This fluid helps to prevent the shift of remaining chest organs to fill the empty space. Chest tubes - 1. Keep all tubing coiled loosely below chest level, with connections tight and taped 2. Keep water seal and suction control chamber at the appropriate water levels 3. Monitor the fluid drainage, and mark the time of measurement and the fluid level 4. Observe for air bubbling in the water seal chamber and fluctuations (tidaling) 5. Monitor the client's clinical status 6. Check position of the chest drainage system 7. Encourage the client to breathe deeply periodically 8. Do not empty collection container. Replace unit when full 9. Do not strip or milk chest tubes 10. Chest tubes are not routinely clamped. If the drainage system breaks, place the distal end of the chest tubing connection in a sterile water container at a 2-cm level as an emergency water seal 11. Maintain dry occlusive dressing HESI Hint: Chest Tubes - If the chest tube is accidentally dislodged from the client, the nurse should cover with a dry sterile dressing taped on three sides. If an air leak is noted, tape the dressing on three sides only; this allows air to escape and prevents the formation of a tension pneumothorax. Notify the healthcare provider HESI Hint: NCLEX-RN Content on Chest Tubes - Fluctuations (tidaling) in the fluid will occur if there is no external suction. These fluctuating movements are a good indicator that the system is intact; they should move upward with each inspiration and downward with each expiration. If fluctuations cease, check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in client's position, because expanding lung tissue may be occluding the tube opening. When a chest tube is connected to suction, continuous bubbling is an indication of an air leak Lung Volumes and Capacities -