NUR 283 Comprehensive 1 Study Guide 2024 - Galen College of Nursing, Exams of Nursing

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For patients prescribed digoxin monitor apical pulse rate for one full minute. Recognize and report changes (irregular rate with early or extra beats). Teach to withhold dose and notify health care professional if pulse rate is <60 bpm in an adult, <70 bpm ina child, or <90 bpm in an infant. Gl effects include anorexia (usually the first manifestation of toxicity), nausea, vomiting, and abdominal pain. CNS effects include fatigue, weakness, vision changes (blurred vision, yellow- green or white halos around objects). Teach the patient to monitor for these effects and report to the provider if they occur. One of the scenarios this week is about IV infiltration. When caring for a patient that develops IV phlebitis manifestations, what are appropriate nursing actions? For any peripheral IV, if the site is red and swollen upon assessment the next action is to remove the IV. Phlebitis/infiltration from the IV requires the nurse to document in the medical record as well as complete an incident report. Document objectively a description of the facts and your actions. Do not document in the medical record that an incident report was completed. The incident report is for the risk management department in the organization. Again, only document the facts and nursing actions taken. Do not state in the medical record that you completed an incident report. For older adults a 19 or 20g is indicated due to fragile skin. Protect the skin of older adults with IV insertion by using a soft cloth between the tourniquet and skin or a blood pressure cuff inflated 10 to 15 cm (4 to 6 in) above the insertion site to compress only venous blood flow. Interventions for patients with digoxin toxicity: * Monitor VS * Stop digoxin and potassium-wasting diuretics immediately. * Monitor K+ levels. For levels less than 3.5 mEq/L, administer potassium IV or by mouth. Do not give any further K+ if the level is greater than 5.0 mEq/L or AV block is present. * Treat dysrhythmias with phenytoin or lidocaine. ¢ Treat bradycardia with atropine. * For excessive toxicity, activated charcoal, cholestyramine, or digoxin immune Fab can be used to bind digoxin and prevent absorption.