1.Insomnia
-Zolpidem (Ambien 5 mg po)- Can increase to 10 mg; however, don't forget the motto Start low, you can always increase the dose .
-Temazepam (Restoril) 7.5 - 15 mg po
-Benadryl 12.5 - 25 mg po. Drug of choice in COPD Use sedative drugs with extreme caution in COPD, and then very small dose
2.Death
- Check the following: Pupils - they should be dilated and not reactive Auscultate the heart and lungs Check for pain response. Sternal rub/supraorbital nerve
- Example of a note for the chart: -Called to evaluate a patient-in-asystole. Pupils were noted to be dilated and unresponsive to light. No heart or lung sounds where noted on auscultation. Patient had no response to noxious stimuli. The patient was pronounced dead at time on date.
- Call attending to notify them of death. Call family, if not aware yet.
- Get death certificate packet from nurse supervisor, and fill out precisely. Call coroner to notify them...nurse surpervisor should be able to help you with all this.
3.Shortness of Breath
4.Insulin Sliding Scale
Loose control:
BG ...... Insulin R SQ dose q 6
< 60 ..... give 1 amp D50 +- juice and Call H.O.
60 -150 ..... 0
151 - 200 .... 2u
201 - 250 .... 4u
251 - 300 .... 6-8u
301 - 350 .... 8-10u
351- 400.....10-12u
400+... give 12 units and call H.O.
Tight control:
< 60 ..... give 1 amp D50 +- juice and Call H.O.
60 -120 ..... 0
121 - 150 .... 2u
151 - 200 .... 4u
201 - 250 .... 6u
251 - 300 .... 8u
301- 350 .....10u
350 - 400 .....12u
400+... give 14 units, recheck in one hour, then call H.O.
5. Chest Pain
1. Ask the nurse? Why was the patient admitted? Have they tried anything? (SL nitro, morphine, PPI. . .)
2. Orders before getting there EKG now!!! Preferably before giving SL nitroglycerin; so, you can see if there are any ischemic changes. Nitro 0.4mg SL q5 minutes x3 O2 via NC, to keep sats >93 3.
3. Evaluate the Patient: Read the EKG If there is ST elevation, call for help (resident, cardiology)
4. Patient may need urgent intervention.
5. Is the chest pain getting better with the SL nitro?
- If not, consider starting a nitro drip.
- Written: Nitro gtt 50mg in 250 cc of D5W, start at 5cc/hr and titrate for pain.
- If you feel this is unstable angina, you should ask cardiology/attending if they want the patient on Heparin Protocol, Beta-Blocker.
6. If pain does get better with SL nitro, if not already written for, do the following:
- CPK with CK-MB and troponin now and q 6 hours x 3
- ASA 325 mg PO qd - 1st dose stat
- Nitro SL 0.4mg q5 min x3 for chest pain
- If not on beta-blocker, may be required
-BMP,Mg, phos level in the am.
- Consider CXR.
7. If you think this is GI (and you had better be sure): Try: GI Cocktail - Maalox 30 cc + Viscous Lido 10 cc + Donnatol 10 cc
6. Hypokalemia
Hypokalemia ** If the gut works, use it!** (oral is safer than IV) ** recheck BMP a couple hours after supplementation. ORAL: KCl 20-40 mEq PO (10 mEq will increase serum K by 0.1) IV REPLACEMENT (for severe hypokalemia, or unable to take PO): KCL 20 mEq in 250 cc NS over 2 hours CENTRAL LINE: KCL 40 mEq in 250 cc NS over 1 hour
7. Hyperkalemia
Repeat blood draw? (hemolysed?) -Get Stat ECG (check for peaked T's or arrythmias) -consider ABG (acidemia shifts K from intracellular to extracellular space in an effort to buffer the acid load. Once acidemia is corrected, the K may return to normal, or even become decreased) -Treat when K > 5.5 meq/l -Stop K containing fluids -Rehydrate -Correct coexisting low NA, Mg, Ca, and acidosis -Kayexelate 15-60g PO/PR -If ECG changes of hyperkalemia or K > 7 meq/l; start emergency Rx immediately, call resident -10% Ca gluconate: 10Ml over 2-5 min -Sodium bicarbonate 50ml 0ver 2 -5 min -Gluose/insulin: 50ml 50% dextrose + 10U regular insulin push -Kayexelate 15-60g PO/PR ECG Changes with hyperkalemia Tall peaked T waves Flattened P Prolonged PR interval Widening of QRS Sine wave: big trouble
8.Hypophospatemia
Severe (< 1.0) replace phos IV with sodium phospate (1.3 meq Na per mmol Phos) or potassium phosphate (1.5 meq K per mmol Phos) -Infuse 0.08-0.16 mmol/kg (elemental phos 2.5 - 5mg/kg)in 500cc of 1/2NS IV over 6 hours.
Mild/Mod (1.0 - 2.5) :Neutra-Phos 1-2 packets PO BID-TID
9.Hypertension
1. What to do first Check BP yourself in both arms Is the pt short of breath? Auscultate chest. Does pt have chest pain? Does pt have blurred vision, alt mental status? Consider checking optic fundi, stat CT head. 2. If BP > 180/110 and any of following call your resident immediately: Chest pain Pulmonary edema Encephalopathy (confusion) 3. If the BP > 180/110 and none of above: Vasotec 0.625 - 1.25 mg IV or Metoprolol 5mg IV or clonidine 0.1 - 0.3 mg PO - can give another dose in 1 hour if needed (beware of rebound HTN when stopped) 4. If the BP > 140/90 and < 180/110 PO medication only Give the patients scheduled BP medication early clonidine 0.1 mg PO
10.Constipation
Go see the patient to ensure no acute abdomen. Consider KUB. Meds: Colace 100 mg po Mg Citrate 120 ml PO Lactulose 15-30 ml PO Fleets enema/Soap suds enema
10.Nausea/vomiting
Phenergan (promethazine) 12.5-25 mg IM/IV Zofran (ondansteron) 4 mg IV (more expensive/effective)
10.Pain management
Very Severe - Morphine 2 mg IV - Demerol 50 mg PO/IM/IV * Severe - Demerol 25- 50 mg IM ***/+ Vistaril (hydroxyzine) 25 mg IM - Lortab (acetaminophen/hydrocodone) 7.5/500 1-2 tabs PO q 4-6 PRN Moderate - Darvocet N-100 (acetaminophen/propoxyphene 650/100) 1 PO q4 PRN - Tylenol #3 (acetaminophen/codein 300/30) 1-2 PO q4 PRN - Lortab 5/500 1-2 tabs PO q 4-6 PRN Mild - Tylenol 650 mg PO - Motrin 600-800 mg PO * DO NOT GIVE TO PTS IN RENAL FAILURE OR SEIZURE DISORDER
10.Falls
Fill out any required paperwork to document. Evaluate the patient x-ray or CT whatever is necessary (if anything). Write for fall precautions.
11.Hypotension
** Figure out why!!! -Sepsis - check temperature, WBC -Cardiogenic - check for medical history -Hypovolemic - check hemoglobin ** Give FLUID BOLUS of 250 cc NS (or more, depending on BP) and repeat according to response -If a patient has had recent surgery or is known to be a GI bleeder. . . Get a stat H+H Open fluids wide Type and cross, transfuse PRBC's (get blood consent prior)
12.Anuria
Examine for enlarged bladder, ask to see if nurse can find ultrasound/bladder scanner
-Flush/change urinary catheter
-Check creatinine for ARF
-NEVER give lasix
13. Oliguria
Give FLUID challenge NEVER give lasix
14.Sinus Tachycardia
15. Arrhythmias
Call your resident early.
Get vital signs!!!
Get an EKG - you cannot diagnose anything from a rhythm strip
- Check lytes + Ca, Mg, Phos
-V-TACH -Get STAT electrolytes and Mg level. -If patient is unstable (hypotension) - cardioversion -If sustained: lidocaine, procainamide or amiodarone; call resident/attending
-A-FIB -Cardiazem: Bolus with 0.25 mg/kg (if BP is ok) then start a drip. 125 mg in 100 cc D5W at 5 mg/hr-- titrate to keep HR between 80-100. Do not go higher than 15 mg/hr. -Digoxin: 0.25 mg bolus IV q6 hours, then maintenance dose is 0.125-0.25 mg qd (reduce loading and maintenance dose in renal failure).
-SVT -Adenosine 6 mg then 12 mg (can repeat 12 mg once) -Cardiazem: Bolus with 0.25 mg/kg (if BP is ok) then start a drip. 125 mg in 100 cc D5W at 5 mg/hr-- titrate to keep HR between 80-100. Do not go higher than 15 mg/hr.
15. Cortisol Stim Test
1. Check serum cortisol and ACTH levels
2. give cotrosyn 0.25mg IV x1
3. check cortisol levels after exactly 30 minutes
4. check cortisol levels after exactly 60 minutes
16. home Lasix sliding scale
1. weigh yourself daily
2. if weight increases by 2 pounds, double Lasix dose until normal weight
3. then resume normal dose
Disclaimer: Use this guide at your own risk! Verify all information before initiating treatment.