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@nurseconnect

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Diabetic Ketoacidosis (DKA): The Basics
Common Drugs Part II
For all medication series click here
Common Drugs Part I
For all medication series click here

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me: immune system why do i have a fever
immune system: well the bacteria can’t survive outside 37 degrees for long so i thought i’d raise the temperature to kill them off!
me:Â
immune system:
me:Â
immune system:
me: we also can’t survive outside 37 degrees for long
immune system:
"Rules To Teach Your Son”
1. Never shake a man’s hand sitting down. 2. Don’t enter a pool by the stairs. 3. The man at the BBQ Grill is the closest thing to a king. 4. In a negotiation, never make the first offer. 5. Request the late check-out. 6. When entrusted with a secret, keep it. 7. Hold your heroes to a higher standard. 8. Return a borrowed car with a full tank of gas. 9. Play with passion or don’t play at all… 10. When shaking hands, grip firmly and look them in the eye. 11. Don’t let a wishbone grow where a backbone should be. 12. If you need music on the beach, you’re missing the point. 13. Carry two handkerchiefs. The one in your back pocket is for you. The one in your breast pocket is for her. 14. You marry the girl, you marry her family. 15. Be like a duck. Remain calm on the surface and paddle like crazy underneath. 16. Experience the serenity of traveling alone. 17. Never be afraid to ask out the best looking girl in the room. 18. Never turn down a breath mint. 19. A sport coat is worth 1000 words. 20. Try writing your own eulogy. Never stop revising. 21. Thank a veteran. Then make it up to him. 22. Eat lunch with the new kid. 23. After writing an angry email, read it carefully. Then delete it. 24. Ask your mom to play. She won’t let you win. 25. Manners maketh the man. 26. Give credit. Take the blame. 27. Stand up to Bullies. Protect those bullied. 28. Write down your dreams. 29. Take time to snuggle your pets, they love you so much and are always happy to see you. 30. Be confident and humble at the same time. 31. Call and visit your parents often. They miss you. 32. In all things lead by example not explanation. - Big Rick
IV Initiation Tips
Consider the key factors!
The patient's medical history and current medical state If the patient is critically ill or if they could “go south” quickly, vein preservation is crucial. These patients are most likely to require rapid administration of fluid and/or rapid access to a vein for bloodwork in an emergency setting. Ensure that IV access is obtained from the most distal site first and moving upward with alternating sites as required. Patients with a history of multiple hospitalizations or chronic illness where IV access has been an ongoing requirement often know their veins very well and will not hesitate to tell you what areas never work!! Although their insight is incredibly useful, always assess BOTH arms regardless before making your decisionÂ
Age, body size and weight, skin and vein condition, level of activity If possible, try to initiate the IV on the non-dominant arm to reduce the risk of losing the IV during patient activity. Confused patients who are prone to pulling at tubes are often “tricked” by IVs that are placed in hidden spots like the ventral forearm with a light sleeve to cover the area. Remember it is never appropriate to cover an IV site with gauze and tape, you should always be able to quickly assess the site especially during continuous infusion. Elderly patients lose subcutaneous tissue as they age, their distal veins are frail and roll easily and are prone to blowing. These patients will also experience worse complications if infiltration or phlebitis occurs at a distal site. The general rule that I use for the elderly is to try to find the straightest distal vein that is available, usually in the forearm. Obese patients may not have veins that are visible. Practicing identifying veins by touch first may help you to improve your IV access skills on heavier patients where visualizing veins is challenging.
The type of IV fluid or medication to be infused IV fluid or medications with a high osmolality or low pH will require a larger vein that can tolerate the infusion Vesicant medications cause tissue necrosis and can damage surrounding tendons and ligaments in the hands/distal forearm. These medications should ideally be administered at a more proximal site with a larger IV. It is also important to ensure that there is adequate blood flow around the IV site to carry fluids and medications into circulation, especially if they are vesicants. Consider this: Vancomycin has a pH of ~3.9. Lemon juice has a pH of 2.5-3. When administering Vanco through a peripheral IV, not only does the site have to be large enough to tolerate the drug, but there has to be enough bloodflow AROUND the catheter to carry the drug into circulation and prevent local damage.
The expected duration of I.V. therapy If the patient is expected to receive IV therapy for less than one week, start with the most distal site in the upper extremities and move upward. This is extremely important for vein preservation and keeps vein selection high if IV access is lost. If the patient is expected to receive IV therapy for longer than a week, and/or requires frequent blood work and intermittent IV meds but has poor venous access, discuss the option of a central line/peripherally inserted central line as a more appropriate alternative with the medical team and/or venous access support team at your work
Your level of experience - If the patient’s veins are a level 4 or 5, consider observing a more experienced nurse insert the IV until you have become more comfortable with your skills, or have them guide you through vein selection.
Consider the vein level! The lower, the better.
Consider where NOT to poke!
NEVERÂ place an IV in:
Veins below (DISTAL to) a previous I.V. infiltration or phlebitic area
Areas of skin inflammation, disease, bruising, or breakdown
An arm affected by a radical mastectomy, edema, blood clot, or infection
An arm with an arteriovenous shunt or fistula.
Avoid veins in the wrist for venipuncture as they run in close proximity to nerves. The cephalic vein on the lateral (thumb) side of the lower forearm/wrist is right next to the radial nerve, I always avoid this site and consider it a last resort for this reason.
Avoid valves. Where two veins conjoin into one there will be valves. Valves can also be visualized as distinct bumps along a straight vein during vein engorgement. You cannot pass an IV catheter through a valve. It will be met with resistance and it will be painful for the patient.
Consider appropriate gauging!
24- to 22-gauge for children and elderly patients
24- to 20-gauge for medical patients and postoperative surgical patients
18-gauge for surgical patients and for rapid blood administration. Blood can be infused through smaller-gauge catheters, but the flow rate will be slower.
16-gauge for trauma patients and those requiring large volumes of fluid rapidly.
Consider useful techniques!
Warm the arms for 3-5 minutes prior to searching for a vein
Position the arm at or below the level of the heart to encourage blood flow
Use a blood pressure cuff in the elderly. The tightness of a tourniquet can actually blow a punctured vein and a cuff is much more pressure sensitive against the skin of these patients
Use moist compresses or rub the site to encourage blood flow
When cleaning the site, apply good pressure, this can really help you to visualize the vein better immediately prior to puncturing it
Stabilize the vein throughout the IV insertion. Pull downward on the skin distal to the puncture site with your non-dominant hand and maintain that stabilization UNTIL THE CATHETER IS IN. Before puncturing the skin, make sure you are stabilizing far enough down the arm or hand that you can get a low enough angle to go into the vein and not through it.
Insert the catheter with the needle bevel up at a low angle. When blood return is observed, lower the angle level to the arm and advance the unit slightly to confirm placement. Blood return should continue during advancement, at which point the catheter should advance smoothly while the needle is retracted.
Learn to insert the IV holding it with your thumb and middle finger. This eventually allows you to advance the catheter with your index finger while retracting the needle with your thumb and middle finger.
Once the IV is in, follow the two T rule: Transparent Dressing and Tourniquet. As soon as the dressing has secured the site the tourniquet should come off.
It is okay to instruct the patient to clench their fist during IV initiation, this helps with venous filling. However this should be avoided if the IV site is being used to draw blood on insertion (often seen in ED) and should always be avoided with blood work. Fist clenching can result in inaccurate lab results due to hemolysis and excessive local muscle contraction.
AST and ALT are increased in liver disease. In alcoholic liver disease, AST is increased more than ALT because alcohol damages the mitochondria, which contain AST. If the pt has nonalcohilic liver disease, but AST is greater than ALT, it suggests progression to advanced fibrosis or cirrhosis.
ALP (alkaline phosphatase) is increased in cholestasis (gallbladder isn’t moving, e.g., in biliary obstruction), infiltration disorders, and bone disease.
GGT is increased in liver and biliary disease (like ALP) and is associated with alcohol use.
So if the pt has increased ALP, it could mean he has bone disease or liver disease. If GGT is increased, then it’s liver disease because GGT is not found in bone.
Or like when your hands are the tiniest bit sweaty.Â

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Why don’t we need annual paps?
Off-shoot question to your HPV post. What is the benefit of doing paps every 2-3 years instead of annually? Logically one would locate a cancer if one were testing annually. Does this change have something to do with the Gardasil vaccine? @death-by-puppies-and-chocolate
So when the powers that be make cancer screening guidelines, they have to balance benefits, harms, and cost to get to a test that is effective, worth the price, and doesn’t hurt folks. With paps, we can definitely catch cancers if we do them annually, but many studies around the world have shown that annual testing leads to more unnecessary and potentially harmful extra tests.
To explain: a pap test alone does not test for HPV. It’s taking a scraping of cells from the cervix and looking for signs of cell damage caused by HPV. The longer HPV lingers, the more potential damage it can cause. Typically it takes the body about 8 months to clear an HPV infection, but 10% of the time it takes more than 2 years to clear it. It doesn’t really lie dormant because infection is always asymptomatic anyway (except when you get warts, but that’s more of a sign than a symptom). In general, the younger you are, the easier you clear the infection. It also usually takes 10-20 years for cervical cancer to show up after initial infection, so there’s usually a good bit of time after infection to catch cell changes and remove the affected cells before they turn into cancer. Â
Lots more info and sources after the jump…
The cell changes we see are graded on a spectrum from normal to cancer. Recommendations on what to do with abnormal test results are based on age and the result and the guideline is about 30 pages long so I’m not going to go into it here. But let’s say you’re 24 and you’re going in for a pap. The standard in the US is to only test for HPV if the pap is abnormal (for women 21-30). So your pap comes back positive for low grade dysplasia. Your HPV test comes back negative for high-risk cancer causing strains of the virus. Knowing what we know about how cervical cancer comes to be, we can reliably say that your body has already probably cleared the HPV infection and those low-grade changes on your pap are likely to resolve on their own unless you get infected with HPV again. And since it takes a long time for those low grade changes to become cancer, we can safely hold off on retesting you for another 3 years. Now if your HPV was positive, we would test you again in a year to make sure that virus isn’t still hanging around causing problems and to make sure those low grade changes haven’t progressed to high grade.
So now when we add HPV testing to the pap, we can get a better idea of how likely the changes in the cells are to get worse. Tons of huge studies have also shown that our ability to catch cancers improves when we add HPV testing to the Pap. We also decrease unnecessary testing. Twenty years ago in the US, the patient scenario described above would have gone differently. That patient would have gone back for pap smears every 6 months to a year and likely would have gone on to have a colposcopy (where we find what specific part of the cervix is affected and take a biopsy of it to be sure there isn’t anything worse in there than what the pap showed) or even a LEEP (where a large chunk of the cervix is removed). We now know that those extra procedures, which are painful and expensive and could potentially cause problems in future pregnancies, were also unnecessary. That patient would have probably cleared the changes on her own, and if she didn’t we would have still caught it before it became cancer but we would have caused her less pain and trauma in the process. Thus, paps every 3 years for ages 21-30.
Testing is spaced out to every 5 years after the age of 30 and we typically stop testing at 65. If most HPV infections occur in your 20s and 30s, and they take 10-20 years to cause cancer, then it stands that by the time you reach 65, if you’ve had nothing but normal paps for the previous 10 years, it’s extremely unlikely that you will get cervical cancer before you are about 80 unless you start having a lot of new sexual partners in your old age. And by 80 you may already be dead or you may opt to not be treated. This method catches over 95% of cervical cancers.
Sources:
National Cancer Institute: Understanding Cervical Changes: Next Steps After an Abnormal Screening Test
ASCCP Consensus guidelines for managing abnormal cervical cancer screens
Mandelblatt JS, Lawrence WF, Womack SM, et al. Benefits and Costs of Using HPV Testing to Screen for Cervical Cancer. JAMA. 2002;287(18):2372–2381. doi:10.1001/jama.287.18.2372
Smith-McCune K. Choosing a Screening Method for Cervical Cancer: Papanicolaou Testing Alone or With Human Papillomavirus Testing. JAMA Intern Med. 2014;174(7):1027–1028. doi:10.1001/jamainternmed.2014.1368
Stout NK, Goldhaber-Fiebert JD, Ortendahl JD, Goldie SJ. Trade-offs in Cervical Cancer PreventionBalancing Benefits and Risks. Arch Intern Med. 2008;168(17):1881–1889. doi:10.1001/archinte.168.17.1881
this is an easy to follow flow chart on when to call an ambulance for a seizure.
god. they need to make one of these for vomiting and diarrhea to keep people out of my ER.
Common Drugs Part II
For all medication series click here
Acute Myocardial Infarction
Superficial atherosclerotic fatty streaks are formed in the coronary arteries of children and develop into elevated plaques by the third and fourth decades of life. By the fifth and sixth decades of life, the plaques further develop into complex, ulcerated, and hemorrhagic plaques. The culmination of plaque development includes rupture or intraplaque hemorrhage and subsequent coronary artery occlusion and myocardial infarction. Atherogenesis occurs more rapidly when endothelial injury occurs through damage by hypertension, elevated LDLs, high cholesterol, diabetes, and smoking. Signs and Symptoms: Chest pain: retrosternal tightness, squeezing sensation, occassionally described as a “dull ache”. Pain usually occurs at rest, unlike angina pectoris. Pain is more severe than angina pectoris and builds up rapidly. Radiation to the left shoulder is commonly experienced Diaphoresis, weakness, dizziness, nausea, vomiting Abdominal discomfort (most common in inferior wall MIs) ECG Changes: Classic Evolution: Peaked T waves, to ST segment elevation, T wave inversion, Q wave development Â
Confirmatory Evidence: Elevation of CK-MB fraction for 3 days Scintigraphic studies and echocardiography may be performed to explore the extent of MI damage
Treatment: • Supplementary Oxygen - Administered during initial hours of treatment • Morphine Sulfate - Excellent analgesic & anxiolytic. Used for pain relief, and preload- & afterload-reducing properties • Thrombolytic Therapy (streptokinase, APSAC, reteplase, or t-PA) -  Thrombolytics are administered to reduce the extent of infarction. Administered only when the following criteria are met: A: Typical chest pain suggestive of MI is present B: ECG changes confirm presence of MI C: Other causative diseases of symptoms have been ruled out Considered the cornerstone of treatment for MI. The benefits of thrombolytic therapy are greatest within the first 3 hours of MI • Heparin Therapy - Initiated concomitantly with thrombolytic therapy, typically continued for 24-48 hours. Maintains thrombolytic-induced coronary artery patency effectively • β-Blockade (Metoprolol) - Contraindicated with hypotension, bradycardia, left ventricular dysfunction, or AV block. It is incredibly effective in treatment of reflex tachycardia and hypertension, used to limit the extent of infarction • Nitroglycerin - Used for pain relief, and pre-load reducing properties • Warfarin - Indicated in the presence of severe left ventricular dysfunction for prevention of mural thrombosis • Aspirin - Administered at the time of infarct and continued every day following. Reduces chance of rethrombosis and recurrent MI Post-Myocardial Infarction: • Stress ECG test before discharge • Discharge medications: aspirin, β-blockers, possibly an acetylcholinesterase inhibitor depending on size of infarct and use of thrombolytic therapy • Exercise regimen - patients are often recommended a gradual increase in activity levels over a period of 6 to 8 weeks post-discharge • Return to work within 8 weeks • Sexual intercourse can resume within 4-6 weeks, or when the patient can climb 2-3 flights of stairs
Therapeutic Drug Levels (some may vary)
Amikacin: 15 to 25 mcg/mL . Aminophylline: 10 to 20 mcg/mL . Amitriptyline: 120 to 150 ng/mL . Carbamazepine: 5 to 12 mcg/mL . Cyclosporine: 100 to 400 ng/mL (12 hours after dose) . Desipramine: 150 to 300 ng/mL . Digoxin: 0.8 to 2.0 ng/mL . Disopyramide: 2 to 5 mcg/mL . Ethosuximide: 40 to 100 mcg/mL . Flecainide: 0.2 to 1.0 mcg/mL . Gentamicin: 5 to 10 mcg/mL . Imipramine: 150 to 300 ng/mL . Kanamycin: 20 to 25 mcg/mL . Lidocaine: 1.5 to 5.0 mcg/mL . Lithium: 0.8 to 1.2 mEq/L . Nortriptyline: 50 to 150 ng/mL . Phenobarbital: 10 to 30 mcg/mL . Phenytoin: 10 to 20 mcg/mL . Primidone: 5 to 12 mcg/mL . Procainamide: 4 to 10 mcg/mL . Quinidine: 2 to 5 mcg/mL . Sirolimus: 4 to 20 ng/mL (12 hours after dose; varies with use) . Tacrolimus: 5 to 15 ng/mL (12 hours after dose) . Theophylline: 10 to 20 mcg/mL . Tobramycin: 5 to 10 mcg/mL . Valproic acid: 50 to 100 mcg/m

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The Medical Terminology “Cheat Sheet” Every Healthcare Pro Needs [Infographic]
Cancer Therapy
Radiation therapyÂ
Uses ionising radiation to destroy tumour cells. Â
either external beam radiotherapy (e.g x-ray) or brachytherapy (e.g. palladium103).Â
radiation directly damages the DNA of the targeted cells.
ChemotherapyÂ
Cytotoxic drugs interfere with cell division.Â
not specific for cancer cells, but adversely target cancer cells due to increased proliferation periods, and decreased ability to repair DNAÂ
Most chemotherapies are given in combination with other drugs or regimens like total body irradiation and ASCT.
ImmunotherapyÂ
use of antibodies that specifically target the cancer - or the induction of the immune system to attack the tumour (vaccine like strategies, cytokines, graft-vs-tumour).
Herceptin is a monoclonal antibody used in the treatment of breast cancer. Â The antibodies are raised to HER2 (human epidermal growth factor receptor 2).
SurgeryÂ
If the cancer has metastasised complete excision is usually impossible. Â
Not always possible depending on location and size.
Examples of surgical procedures for cancer include mastectomy for breast cancer or prostatectomy for prostate cancer.
Hormonal therapyÂ
cancer growth inhibited by either blocking hormone function (e.g. breast and prostate cancer) or supplying additional hormones (e.g. prolactinomas). Â
Angiogenesis inhibitorsÂ
reducing the blood supply to the tumour.
Bevacizumab is a monoclonal antibody to VEGF (vascular endothelial growth factor).
Enzyme inhibitorsÂ
Certain cancers exist due to excess activity of a certain enzyme.
Imatinib is used in chronic myeloid and acute lymphoblastic leukaemia where the cancer is a result of constitutively active tyrosine kinase (as a result of the Philadelphia chromosome bcr-abl).  This fusion protein leads to unregulated cell division.
Future therapy - Genetic alterationsÂ
Works on the principle that cancer cells have poorer DNA repair mechanisms.Â
 Altering gene expression through mutations, epigenetic alterations or inhibitors of gene products may be beneficial.
If breast cancer is caused by mutations in the tumour suppressor genes BRCA1 or BRCA2 - inhibition of PARP1 leads to cancer cell death.