Ultimate Nursing Bundle

Normal intervals (adult)

5-step routine

1. Look at the patient first. Pulse, BP, LOC, symptoms. Treat the patient, not the monitor.
2. Rate: atrial and ventricular.
3. Rhythm: regular or irregular? (march out the R–R intervals).
4. P waves: present? upright? one per QRS? any P without a QRS?
5. PR and QRS: measure. Constant or changing PR? Narrow or wide QRS?

5-lead placement

• White: right arm (below right clavicle). Black: left arm.
• Green: right lower chest/abdomen. Red: left lower chest/abdomen.
• Brown (chest): V1, 4th intercostal space, right sternal border (or as ordered).

Sinus arrhythmia

Rate varies with breathing (speeds up on inspiration, slows on expiration). Normal in children and young adults. No treatment.

Sinus arrest / pause

SA node fails to fire: a flat gap with no P, QRS or T. Report long pauses (e.g., >3 sec) and symptoms; may need a pacemaker (sick sinus syndrome).

Pulseless electrical activity (PEA)

The monitor shows an organized rhythm (it may even look normal) but there is no palpable pulse.

Treatment: same as asystole: CPR, epinephrine as soon as possible, find and fix the cause (Hs and Ts). Not shockable.

Compare at a glance

Defibrillation vs. cardioversion

If the patient goes into VF during cardioversion: turn sync off and defibrillate.

Key ACLS drugs

When to start medication

• Everyone with elevated BP or hypertension: lifestyle changes.
• Stage 2: start medication; often 2 drugs, preferably in a single combined pill.
• Stage 1: start medication if the person has heart disease, diabetes, CKD or a PREVENT 10-year cardiovascular risk ≥7.5%; otherwise lifestyle for 3–6 months, then medication if BP stays ≥130/80.
• Target: <130/80 for most adults (lower systolic, toward 120, if tolerated).

First-line drug classes

Thiazide-type diuretic (chlorthalidone, HCTZ) · ACE inhibitor or ARB (never both together) · long-acting dihydropyridine CCB (amlodipine).

Pregnancy: avoid ACE inhibitors and ARBs; use labetalol, extended-release nifedipine, or methyldopa.

Lifestyle (each lowers systolic BP)

Severe hypertension: urgency vs. emergency

Without new organ damage: resume or adjust oral meds and arrange close follow-up. Lower gradually.

Hypertensive emergency = severe BP plus acute target-organ damage: brain (headache, confusion, seizure, stroke), eyes (vision change), heart (chest pain, pulmonary edema), aorta (dissection), kidneys (↓ urine output, ↑ creatinine).

• ICU; arterial line; IV titratable drug (nicardipine, clevidipine, labetalol, esmolol).
• Lower BP by no more than 25% in the first hour, then to ~160/100–110 over the next 2–6 h, then toward normal over 24–48 h.
• Exceptions: aortic dissection (rapidly to systolic <120), severe preeclampsia, acute stroke (special targets).

Acute decompensated HF

• High Fowler's; oxygen to keep SpO₂ ≥90% (non-invasive ventilation if needed).
• IV loop diuretic; monitor urine output, K⁺, Mg²⁺, creatinine, BP.
• Vasodilators (nitroglycerin) if BP allows.
• Strict I&O, daily weight, lung sounds.
• Avoid: NSAIDs, diltiazem/verapamil (in HFrEF), thiazolidinediones (pioglitazone).

Teaching for home

• Weigh daily: same time, same scale, after voiding, before breakfast, similar clothing.
• Report a gain of >1 kg (2–3 lb) in a day or 2 kg (5 lb) in a week, or worse breathlessness, swelling, or needing more pillows.
• Limit sodium (commonly <2–3 g/day); fluid limits only if ordered.
• Take meds even when feeling well; check BP/pulse as taught.
• Stay active (cardiac rehab); flu, COVID and pneumococcal vaccines.

Recognize it

• Pressure, squeezing or heaviness in the chest; may spread to arm, jaw, neck, back; sweating, nausea, dyspnea.
• Women, older adults and people with diabetes often have atypical symptoms: fatigue, dyspnea, nausea, epigastric discomfort.
• 12-lead EKG within 10 minutes of arrival.
• High-sensitivity troponin at arrival and repeated (rises within hours; stays up 1–2 weeks).

Which leads, which artery

Inferior MI: get right-sided leads. A right ventricular infarct is preload-dependent: avoid nitrates and diuretics; give IV fluids for hypotension.

After PCI (cardiac cath)

• Check site, distal pulses, color, temperature and sensation as per protocol (e.g., every 15 min at first).
• Radial: compression band, release per protocol; no BP or blood draws on that arm.
• Femoral: keep leg straight and HOB low as ordered. Back or flank pain + hypotension → retroperitoneal bleed: report now.
• Contrast: hydrate; watch urine output and creatinine.

Discharge teaching

• Dual antiplatelet therapy (usually 12 months): never stop without the cardiologist; bleeding precautions.
• Chest pain at home: stop, sit, take 1 SL nitroglycerin. If not better or worse after 5 min, call emergency services; may repeat every 5 min, max 3.
• Keep nitroglycerin in its original dark glass bottle; carry it always.
• Cardiac rehab; stop smoking; heart-healthy diet; sex is usually safe once able to climb 2 flights of stairs, as cleared.

Lipid values (adults)

Some guides reverse the HDL numbers by sex. It's women ≥50, men ≥40.

Risk factors

Tests

• Stress test: avoid caffeine 12–24 h before; some meds (e.g. beta blockers) may be held as ordered.
• Cardiac cath: check allergies, kidney function, anticoagulants; metformin may be held around contrast if kidney function is poor.
• Lipid panel: fasting not always required; follow the lab's instructions.

Hemorrhagic stroke

• Usually sudden severe headache ("worst of my life"), vomiting, ↓ LOC.
• Lower systolic BP (commonly to ~140); reverse anticoagulants.
• ICP care: HOB 30°, head midline, avoid straining, coughing and hip flexion; seizure precautions.
• No thrombolytics, antiplatelets or anticoagulants.

Right vs. left hemisphere

Practice (cover the answers)

Signs of hypoxia

A newly restless or confused patient: check oxygenation before giving a sedative.

Oxygen safety

• No smoking, candles, or open flames; post "oxygen in use".
• Secure cylinders upright in a stand or cart.
• Water-based lubricant only on lips and nares (no petroleum jelly).
• Avoid prolonged high FiO₂ (oxygen toxicity); give the lowest FiO₂ that meets the target.

Incentive spirometer

1. Sit upright; exhale normally.
2. Seal lips around the mouthpiece.
3. Inhale slowly and deeply to raise the piston.
4. Hold the breath 3–5 seconds, then exhale.
5. Repeat 10 times every hour while awake; cough afterwards (splint incisions).

Suctioning (adult)

• Suction only when needed (secretions heard or seen, ↓ SpO₂, ↑ airway pressure).
• Pre-oxygenate; sterile technique for artificial airways.
• Wall pressure ~100–150 mmHg; apply suction only while withdrawing.
• Each pass ≤10–15 seconds; limit passes; reoxygenate between.
• Stop for bradycardia, dysrhythmia or desaturation.

Acute exacerbation

• SABA ± ipratropium (nebulizer or MDI with spacer).
• Systemic corticosteroid (e.g., prednisone 40 mg daily for 5 days).
• Antibiotics if sputum becomes purulent or ventilation is needed.
• Controlled oxygen 88–92%; ABG.
• BiPAP for hypercapnic respiratory acidosis (pH ≤7.35, PaCO₂ >45).

Nursing and teaching

• Smoking cessation: the single most effective intervention.
• Pursed-lip breathing (in through nose, out slowly through pursed lips, exhale twice as long); huff coughing.
• Upright or tripod position; pace activities; pulmonary rehab.
• High-calorie, high-protein small frequent meals; rest before eating.
• Fluids ~2–3 L/day to thin secretions unless restricted (e.g., HF).
• Vaccines: influenza yearly, COVID-19, pneumococcal, RSV, Tdap, zoster.

Acute exacerbation

• SABA (albuterol) repeated, e.g., every 20 min in the first hour; add ipratropium if severe.
• Systemic corticosteroid early (oral prednisone or IV).
• Oxygen to SpO₂ 93–95% adults (94–98% children).
• IV magnesium sulfate for severe attacks not responding.
• No sedatives. Prepare for intubation if tiring.

Inhaler technique

• MDI: shake; breathe out; seal lips (spacer preferred); press once and breathe in slowly over 3–5 s; hold ~10 s; wait 30–60 s between puffs.
• Dry powder inhaler: don't shake; don't breathe into it; breathe in fast and deep.
• Rinse mouth and spit after a steroid inhaler (prevents thrush).
• Two inhalers: bronchodilator first, then the steroid.

Assessment

• Fever, chills, productive cough, pleuritic chest pain, dyspnea, tachypnea.
• Crackles; bronchial breath sounds, dullness and ↑ tactile fremitus over consolidation.
• Older adults: may present with confusion, falls, no fever.
• Chest X-ray; sputum and blood cultures before antibiotics (don't delay antibiotics in sepsis).
• CURB-65 severity: Confusion, Urea (BUN >19 mg/dL), RR ≥30, BP <90 systolic or ≤60 diastolic, age ≥65.

Care and prevention

• Antibiotics on time; oxygen to target; fluids unless restricted.
• HOB ≥30°; turn, cough, deep breathe; incentive spirometer; early mobility.
• Aspiration precautions: swallow screen, sit at 90° to eat, chin tuck, oral care.
• Vaccines: pneumococcal (PCV20 or PCV21, or PCV15 + PPSV23) for all adults ≥50 and younger adults with risk conditions; yearly influenza; COVID-19; RSV for older or high-risk adults. Updated

VAP prevention bundle

• HOB 30–45° unless contraindicated.
• Daily sedation interruption + spontaneous breathing trial.
• Oral care with toothbrushing. Updated Routine chlorhexidine mouthwash is no longer recommended (SHEA 2022).
• Subglottic suction tubes for longer ventilation; drain tubing condensate away from the patient.
• Early mobility; DVT and stress-ulcer prophylaxis as indicated.

Complications

• VAP; barotrauma or pneumothorax (sudden high pressures, absent breath sounds, ↓ SpO₂).
• Hypotension from positive pressure.
• Stress ulcers, DVT, muscle weakness, pressure injury at lips.
• Delirium: screen daily.

After extubation

High Fowler's, oxygen, cough and deep breathe; watch for stridor (airway edema: report now); swallow assessment before eating.

Do

• Keep the unit upright and below chest level.
• Keep tubing free of kinks and dependent loops.
• Check dressing, insertion site, crepitus (subcutaneous air), breath sounds, SpO₂.
• Keep at bedside: sterile water and an occlusive dressing (and clamps if policy).
• Encourage coughing, deep breathing, incentive spirometry, pain control.

Don't

• Don't clamp routinely (risk of tension pneumothorax): only briefly to find a leak, to change the unit, or if ordered.
• Don't strip or milk the tubing routinely.
• Don't lift the unit above the chest.

Tidaling stopped?

Either the lung has re-expanded (good: confirm with X-ray), or the tube is kinked, clotted or blocked (check).

Pneumothorax types

• Spontaneous: tall thin young adults, smokers, lung disease.
• Open (sucking chest wound): cover with a vented or 3-sided occlusive dressing.
• Tension: air trapped with each breath → shift of the mediastinum. Tracheal deviation away from the affected side, absent breath sounds, JVD, hypotension, severe distress. Emergency: needle decompression, then chest tube.
• Hemothorax: blood in the pleural space.

Prevention

• Early ambulation; ankle pumps and leg exercises.
• Sequential compression devices (not on a leg with a known clot).
• Pharmacologic prophylaxis: enoxaparin or SC heparin as ordered.
• Hydration; avoid crossing legs, pillows under knees, tight garments.

Normal changes

• Blood volume ↑ 40–50% → physiologic anemia (Hgb <11 g/dL in 1st/3rd trimester or <10.5 in 2nd is anemia).
• HR ↑ 10–15/min; BP dips in 2nd trimester.
• Supine hypotension: uterus compresses the vena cava → place on her left side (or wedge under right hip).
• hCG maintains the corpus luteum (and progesterone) early in pregnancy. It's the hormone pregnancy tests detect. It does not feed the fetus.

Severe-range BP: treat within 30–60 min

If BP stays ≥160 systolic or ≥110 diastolic for 15 min:

• Labetalol IV (avoid in asthma, heart block)
• Hydralazine IV
• Nifedipine immediate-release oral

Goal: lower to ~140–150/90–100, not to normal (protect placental blood flow). Delivery is the cure; betamethasone if birth is likely before 34 weeks.

Eclamptic seizure

1. Call for help; stay; note the time.
2. Turn on her side; protect from injury. Don't restrain; nothing in the mouth.
3. After: airway, suction, oxygen; magnesium sulfate as ordered.
4. Assess the fetus (expect bradycardia during the seizure) and watch for abruption.

HELLP

RUQ or epigastric pain, nausea, vomiting, malaise. It can occur with normal-looking BP. Labs: hemolysis (↑ LDH, ↑ bilirubin), ↑ AST/ALT, platelets <100,000. Risks: liver rupture, DIC, abruption. Treatment: stabilize, magnesium, deliver.

Cervix and fetal position

• Dilation 0–10 cm; effacement 0–100% (thinning).
• Station: −5 to +5; 0 = at the ischial spines (engaged).
• Most common position: LOA (left occiput anterior). Posterior (OP) → back labor.
• Contraction frequency = start of one to start of the next; duration = start to end of one.
• Tachysystole: >5 contractions in 10 min, averaged over 30 min.

True vs. false labor

Rupture of membranes

• Check the FHR right away after rupture (cord prolapse risk).
• Note fluid COAT: Color (clear normal; green = meconium), Odor (foul = infection), Amount, Time.
• Nitrazine paper turns blue (alkaline amniotic fluid); ferning under the microscope.
• Rupture >18 h → infection risk: monitor temperature.

Induction and augmentation

• Bishop score ≥8 = favorable cervix. Lower → cervical ripening first.
• Misoprostol (PGE1) or dinoprostone (PGE2), or a balloon catheter. No misoprostol with a previous cesarean or uterine scar (rupture risk). Start oxytocin ≥4 h after the last misoprostol dose.
• Oxytocin (high-alert): infusion pump, piggybacked into the main line at the port closest to the patient. Titrate per protocol. Stop it for tachysystole with an abnormal FHR or a Category III tracing. Watch for water intoxication (headache, confusion, ↓ urine).

Preterm labor (<37 weeks)

• Tocolytics delay birth ~48 h to allow steroids and transfer: nifedipine; indomethacin (<32 wk, ≤48 h); terbutaline (short-term only: boxed warning against prolonged or oral use).
• Betamethasone 12 mg IM × 2 doses 24 h apart (24 0/7–33 6/7 wk; considered from 22 wk and in selected late-preterm cases) for fetal lung maturity.
• Magnesium sulfate before 32 wk for fetal neuroprotection.

Three categories

• Category I (normal): baseline 110–160, moderate variability, no late or variable decels (early decels and accels may be present).
• Category II (indeterminate): everything that is not I or III. Evaluate, resuscitate, re-evaluate.
• Category III (abnormal): absent variability with recurrent lates, recurrent variables, or bradycardia; or sinusoidal. Prepare for rapid delivery.

First actions

1. Fundal massage (support the lower uterus above the pubic bone with the other hand).
2. Call for help; activate the hemorrhage protocol.
3. Empty the bladder (a full bladder pushes the uterus up and to the right).
4. Two large-bore IVs; fluids; oxygen; legs raised.
5. Labs: CBC, type and crossmatch, coagulation, fibrinogen.
6. Uterotonics and TXA as ordered; keep counting blood loss.

If bleeding continues

Uterine balloon tamponade, uterine artery embolization, compression sutures, hysterectomy. Massive transfusion protocol (red cells, plasma, platelets, fibrinogen/cryo).

Hematoma

Severe perineal or rectal pain and pressure, swelling, signs of blood loss with little visible bleeding.

Breastfeeding

• Feed on demand, 8–12 times in 24 h.
• Good latch: wide open mouth, lips flanged out, much of the areola in the mouth, audible swallowing, no ongoing pain.
• Enough milk: by day 5+, ≥6 wet diapers and 3–4 yellow stools a day; weight regained by 10–14 days.
• Engorgement: feed often, cold packs after feeds, supportive bra.

Mood after birth

Before discharge

• Rh immune globulin within 72 h if she is Rh-negative and the baby is Rh-positive.
• MMR if not rubella-immune (avoid pregnancy for 1 month; breastfeeding is fine); Tdap if not given.
• Contraception: progestin-only methods can start anytime; combined estrogen methods not before 3 weeks (later if breastfeeding or VTE risk).
• Warning signs: chest pain or SOB, seizure, thoughts of harming self or baby, soaking a pad in an hour, red swollen leg, temp ≥100.4°F (38°C), severe headache or vision change.

DIC labs

↓ platelets, ↓ fibrinogen, prolonged PT/aPTT, ↑ D-dimer. Bleeding from IV sites, gums, petechiae. Treat the cause; blood products.

Hypoglycemia

At risk: infant of diabetic mother, small or large for dates, preterm, cold stress. Signs: jitteriness, poor feeding, floppy, apnea, high-pitched cry, temperature instability, seizures (or none). Check glucose early per protocol; feed; 40% dextrose gel to the cheek; IV dextrose if severe or persistent.

Jaundice

Within the first 24 h = pathologic: report now. Physiologic jaundice appears after 24 h and peaks day 3–5. Phototherapy: eye shields, maximum skin exposure, turn, feed often, monitor temperature and hydration. Treat by hour-specific bilirubin thresholds (AAP 2022).

Keeping baby warm and safe

• Dry immediately; skin-to-skin; hat; warm room. Heat loss: evaporation, conduction, convection, radiation.
• Safe sleep: on the back, firm flat surface, own sleep space in the parents' room, nothing soft in the crib, no smoking, avoid overheating.
• Cord: dry cord care: keep clean and dry, fold the diaper below the stump; falls off in ~10–14 days. Report redness, odor or drainage.
• Rear-facing car seat required for discharge; back seat, harness snug at the armpits.

Pain assessment

Non-drug comfort: breastfeeding or sucrose for infants during procedures, skin-to-skin, distraction, topical anesthetic before needles.

Safe dosing

• Doses are weight-based (mg/kg): weigh in kilograms and record kg only.
• Calculate the safe dose range and compare it with the order before giving.
• Never exceed the adult maximum dose.
• Oral liquids: use an oral syringe or the device supplied, never a kitchen spoon. Check the concentration.

Example: 22 lb child → 10 kg. Acetaminophen 15 mg/kg = 150 mg. Liquid 160 mg/5 mL → 150 ÷ 160 × 5 = 4.7 mL.

Development: the nursing angle

Tet spell (hypercyanotic episode)

1. Knee-chest position (older children squat): ↑ systemic resistance, more blood to the lungs.
2. Keep calm; parent holds the child.
3. Oxygen.
4. Morphine, IV fluids, and other drugs as ordered.

Duct medicines

• To close a PDA (preterm): indomethacin, ibuprofen, or acetaminophen.
• To keep it open in duct-dependent defects: prostaglandin E1 (alprostadil) infusion. Watch for apnea, fever, flushing, low BP.

Heart failure in infants

• Tachypnea and sweating during feeds, poor feeding, poor weight gain, tachycardia, hepatomegaly, irritability. (Peripheral edema is less common than in adults.)
• Small frequent feeds; higher-calorie formula or fortified breast milk; tube feeds if tiring; rest; daily weight.
• Digoxin: count the apical pulse for 1 full minute; hold and notify per parameters (commonly infant <90–110, child <70); vomiting or poor feeding can be early toxicity. Furosemide: watch K⁺.

Kawasaki disease (acquired)

• Fever ≥5 days + features: red eyes without discharge, red cracked lips and "strawberry tongue", rash, swollen hands and feet then peeling, a large neck lymph node.
• Danger: coronary artery aneurysms (echocardiograms).
• Treatment: IVIG + aspirin (one of the few times aspirin is used in children).
• Delay live vaccines (MMR, varicella) ~11 months after IVIG. Report flu or chickenpox exposure while on aspirin (Reye's syndrome).

Breathing

• Pulse present but not breathing well: 1 breath every 2–3 sec (20–30/min).
• With an advanced airway during CPR: 1 breath every 2–3 sec, compressions continuous.
• Just enough to make the chest rise. Over-ventilation is harmful.

Calling for help and the AED

• Alone, unwitnessed arrest: give 2 min of CPR first, then call and get the AED (likely respiratory cause).
• Sudden witnessed collapse: call and get the AED first (likely cardiac).
• AED: pediatric pads or dose attenuator for children <8 years if available; otherwise use adult pads (front and back if they would touch).

Croup (laryngotracheobronchitis)

• Usually parainfluenza virus; 6 months–3 years.
• Barking, seal-like cough, hoarse voice, inspiratory stridor; worse at night.
• Dexamethasone single dose (oral or IM) for all severities.
• Nebulized epinephrine for stridor at rest; observe 2–4 h after (symptoms can return).
• Keep the child calm, on the parent's lap. Mist therapy isn't proven.

Epiglottitis: airway emergency

• Sudden high fever, toxic look; the 4 Ds: drooling, dysphagia, dysphonia (muffled voice), distress; tripod position.
• Do not put anything in the mouth or examine the throat (no tongue blade, no throat swab): it can cause complete obstruction.
• Keep upright and calm; emergency airway equipment at the bedside; intubation in a controlled setting; IV antibiotics.
• Rare now thanks to the Hib vaccine.

Foreign-body aspiration

Sudden cough, choking or wheeze in a toddler, often one-sided decreased breath sounds. Prevent: no nuts, whole grapes, hard candy, popcorn or small toys for under 4s; cut food small.

Oral rehydration (mild–moderate)

• ORS 50 mL/kg (mild) or 100 mL/kg (moderate) over 3–4 h, in small frequent sips (5 mL every 1–2 min by spoon or syringe).
• Replace ongoing losses (~10 mL/kg per loose stool).
• Continue breastfeeding and normal diet once rehydrated.
• Avoid juice, soda and sports drinks (too much sugar).

IV fluids

• Severe dehydration or shock: 10–20 mL/kg isotonic bolus (normal saline or lactated Ringer's); reassess and repeat.
• Maintenance (Holliday-Segar): 100 mL/kg/day for the first 10 kg + 50 mL/kg/day for the next 10 kg + 20 mL/kg/day for each kg above 20.
• Example, 25 kg: 1,000 + 500 + 100 = 1,600 mL/day (~65 mL/h).
• Isotonic maintenance fluids are now preferred (lower risk of hyponatremia). Updated
• Add potassium only after the child voids.

Lungs: airway clearance every day

• Chest physiotherapy, oscillating vest or PEP device, huff coughing, exercise: usually 1–2+ times a day.
• Usual order: bronchodilator → hypertonic saline → dornase alfa → airway clearance → inhaled antibiotic (e.g., tobramycin) → inhaled steroid if used.
• Airway clearance before meals (or 1 h after) to avoid vomiting.
• Infection control: people with CF keep ≥6 ft (2 m) apart from each other (cross-infection); contact precautions in hospital.

Pancreas and nutrition

• Pancreatic enzymes (pancrelipase) with every meal and snack, at the start of eating.
• Swallow capsules whole, or open and sprinkle beads on a small amount of acidic soft food (applesauce). Don't crush or chew the beads; don't mix with milk.
• Adjust dose to stools (fewer greasy stools = right dose).
• High-calorie, high-protein, high-fat (unrestricted fat) diet, individualized (some people on modulators now gain too much weight); extra salt in hot weather, fever or exercise.
• CF-specific fat-soluble vitamins A, D, E, K.

Complications

CF-related diabetes (yearly screening from age 10) · distal intestinal obstruction · liver disease · low bone density · pneumothorax · hemoptysis · depression and anxiety (screen).

Therapeutic drug levels

Coagulation targets

Timing

• Trough: just before the next dose (lowest level).
• Peak: at a set time after the dose (e.g., 30 min after an IV infusion ends).
• High trough = toxicity risk; low peak = not effective.

Teaching for every BP drug

• Change position slowly; sit before standing; dangle legs.
• Don't stop suddenly (especially beta blockers, clonidine).
• Keep a home BP log; report dizziness or fainting.
• Avoid NSAIDs and decongestants (raise BP; NSAIDs harm kidneys with ACEi/ARB + diuretic).
• Limit alcohol and salt; take as prescribed even when feeling well.

Special situations

• Pregnancy: labetalol, extended-release nifedipine, methyldopa. No ACE inhibitors, ARBs, ARNI.
• Diabetes or CKD with protein in urine: ACE inhibitor or ARB preferred.
• Asthma: avoid non-selective beta blockers.
• Gout: thiazides can trigger attacks; losartan lowers uric acid.
• Angioedema history: no ACE inhibitors or ARNI.

Amiodarone

For VT/VF and atrial fibrillation. Long half-life (weeks to months).

• Lungs: pulmonary toxicity (cough, dyspnea): baseline chest X-ray and lung tests.
• Thyroid: hypo- or hyperthyroidism (it contains iodine): check TSH.
• Liver tests; eyes (corneal deposits, optic neuropathy); skin (photosensitivity, blue-gray color).
• Bradycardia, QT prolongation; IV can cause hypotension.
• Raises warfarin and digoxin levels: doses need lowering.

Nitrates

• Sublingual tablet or spray: 1 dose every 5 min, max 3; call emergency services if pain isn't better 5 min after the first dose.
• Store tablets in the original dark glass bottle.
• Patch/ointment: rotate sites, remove the old one, wear gloves; plan a nitrate-free period (usually 10–12 h overnight) to prevent tolerance.
• Headache (expected; acetaminophen), hypotension, dizziness.
• Never with PDE-5 inhibitors (sildenafil, vardenafil within 24 h; tadalafil within 48 h).

Antiplatelets

After a coronary stent: never stop antiplatelets without the cardiologist (stent thrombosis).

Thrombolytics

Alteplase (stroke, STEMI, massive PE); tenecteplase (stroke, STEMI); reteplase (STEMI only). Dissolve existing clots.

Contraindications (examples): active bleeding, any prior brain hemorrhage, recent stroke, surgery or trauma, brain tumor, severe uncontrolled BP, bleeding disorder.

Nursing: place IV lines before; avoid IM injections and new punctures; neuro checks; watch for bleeding (gums, IV sites, urine, stool, neuro change). Stroke timing: within 4.5 h of last known well.

Mixing NPH and regular in one syringe

1. Inject air into NPH (cloudy). Don't draw up.
2. Inject air into regular (clear) and draw up the regular dose.
3. Then draw up the NPH dose.

Giving insulin

• Subcutaneous: abdomen (fastest, ≥2 in from the umbilicus), back of arms, thighs, buttocks.
• Rotate sites within an area (lumps of fat called lipohypertrophy cause erratic absorption).
• Pens: prime 2 units; hold the needle in for ~10 sec.
• High-alert: independent double check per policy; always use "units", never "U".
• Storage: unopened in the fridge (don't freeze); in-use pen or vial at room temperature for the time on the label (often 28 days).

Hypoglycemia (<70 mg/dL)

Signs: shaky, sweaty, fast heartbeat, anxious, hungry, headache, confused, irritable → seizures, coma. Beta blockers can hide the warning signs.

1. Awake and can swallow: 15 g fast carbohydrate (4 oz/120 mL juice or regular soda, glucose tablets).
2. Recheck in 15 min; repeat if still <70.
3. Once normal: a snack or meal with protein and carbohydrate.
4. Can't swallow or unconscious: glucagon (IM, SC or nasal) or IV dextrose; turn on the side.

In the hospital

• Typical target for most inpatients: 140–180 mg/dL.
• Basal + mealtime + correction insulin is preferred over sliding-scale insulin alone. Updated
• NPO: basal insulin is usually continued (often at a reduced dose): clarify with the prescriber; hold mealtime insulin.
• DKA drip: regular insulin IV; check K⁺ first (don't start if K⁺ <3.3: replace K⁺ first). Give SC basal insulin 1–2 h before stopping the drip.

Morning highs

Dawn phenomenon: early-morning hormone surge raises glucose (2–3 AM glucose normal or high). Somogyi effect: night-time low followed by a rebound high (2–3 AM glucose low). Check a 2–3 AM glucose to tell them apart.

Targets (individualized)

Nursing points

• Before contrast scans: check metformin and kidney function.
• Before surgery: ask about SGLT2 inhibitors and GLP-1 RAs (both may need holding per protocol).
• Teach foot care, eye exams yearly, kidney checks (urine albumin), BP and cholesterol control.
• Watch for hypoglycemia when combining sulfonylureas or insulin with other agents.

Vancomycin monitoring Updated

For serious MRSA infections, current guidelines (2020) recommend dosing by AUC (area under the curve) 400–600, not trough levels alone. If your facility uses troughs, draw the trough just before the next dose.

C. diff treatment Updated

Fidaxomicin is preferred; oral vancomycin is an acceptable alternative (IDSA/SHEA 2021). Metronidazole only if neither is available. Stop the causing antibiotic if possible; contact precautions; soap and water; no antidiarrheal drugs unless ordered.

Antifungals

• Nystatin: swish and swallow 4–5×/day; remove dentures first.
• Fluconazole: QT, liver; ↑ warfarin and many drug levels.
• Amphotericin B: fever, chills, rigors (premedicate as ordered), nephrotoxicity, low K⁺ and Mg²⁺. Lipid forms are less toxic.

Antivirals

• Acyclovir / valacyclovir: herpes and shingles; hydrate (kidney crystals with IV); doesn't cure herpes.
• Oseltamivir: influenza; most effective within 48 h of symptoms; also for prevention. (Baloxavir: single dose.)
• HIV: treatment for everyone diagnosed, daily adherence; PrEP before exposure; PEP within 72 h after exposure.

Teach for all antidepressants

• Full effect takes 4–6 weeks (some improvement may come in 1–2 weeks).
• Don't stop suddenly (discontinuation symptoms): taper.
• Boxed warning: increased suicidal thoughts in people under 25, especially early on or after dose changes. As energy returns before mood lifts, a person may act on a plan: monitor closely.
• Avoid alcohol; no St. John's wort.

MAOI diet and drug rules

Avoid tyramine: aged cheese, cured, smoked or fermented meats (salami, pepperoni), tap or draft beer, soy sauce, sauerkraut, kimchi, fava beans, overripe or spoiled food, yeast extracts.

Hypertensive crisis: severe occipital headache, stiff neck, chest pain, palpitations, sweating.

Never combine with SSRIs, SNRIs, TCAs, meperidine, tramadol, dextromethorphan, linezolid, St. John's wort. Wait 14 days after stopping an MAOI (and 5 weeks after fluoxetine before starting one).

Lithium

• Level 0.6–1.2 mEq/L; toxic >1.5. Draw ~12 h after the last dose.
• Keep sodium intake and fluids normal and steady (2–3 L/day). Low sodium or dehydration (vomiting, sweating, heat) → toxicity.
• Raise levels: NSAIDs, ACE inhibitors/ARBs, thiazides.
• Expected: fine tremor, thirst, frequent urination, weight gain. Long-term: hypothyroidism, kidney effects.
• Toxicity: vomiting, diarrhea, coarse tremor, confusion, ataxia, seizures.
• Teratogenic (heart defect): plan pregnancy with the prescriber.

Other mood stabilizers

• Valproate: liver toxicity, pancreatitis, low platelets, weight gain; major birth defects (avoid in pregnancy).
• Carbamazepine: SJS (HLA-B*1502 testing in Asian ancestry), low blood counts, low sodium; weakens birth control pills.
• Lamotrigine: rash → SJS: must be increased slowly; report any rash.

Anxiolytics

• Benzodiazepines (lorazepam, diazepam, alprazolam, chlordiazepoxide): sedation, falls (avoid in older adults where possible), dependence, withdrawal seizures if stopped suddenly. Boxed warning: with opioids → respiratory depression and death. Antidote: flumazenil. Used for alcohol withdrawal.
• Buspirone: no dependence; takes 2–4 weeks; not for "as needed" use.

ADHD medications

• Stimulants (methylphenidate, amphetamines): appetite and weight loss, insomnia (give early in the day), ↑ HR and BP, growth monitoring, misuse risk (controlled drug).
• Non-stimulants: atomoxetine (suicidal thoughts warning), viloxazine, guanfacine, clonidine (sedation, low BP).

Acetaminophen

• Max 4 g/day in healthy adults (some labels and older adults: 3 g); ≤2 g/day with liver disease or regular alcohol use. It's the preferred pain reliever in cirrhosis at these lower doses.
• Hidden acetaminophen in combination products (cold remedies, hydrocodone/APAP): add them up.
• Overdose may look fine at first; liver failure in 2–3 days. Antidote: acetylcysteine.

NSAIDs (ibuprofen, naproxen, ketorolac, celecoxib)

• Take with food; GI bleeding (black stools, coffee-ground vomit); a PPI may be added.
• Kidney injury (especially with dehydration, ACEi/ARB + diuretic); ↑ BP; ↑ heart attack and stroke risk.
• Ketorolac: max 5 days. Avoid NSAIDs from ~20 weeks of pregnancy unless prescribed.
• Some people with asthma react (aspirin-exacerbated respiratory disease).

Opioids

• morphine, hydromorphone, oxycodone, hydrocodone, fentanyl, methadone, tramadol.
• Assess sedation before respirations: increasing sleepiness comes before respiratory depression (use a sedation scale such as POSS).
• Naloxone: dilute and titrate IV in small doses (e.g., 0.04–0.4 mg) for over-sedation; 4 mg nasal in the community. Watch for return of sedation and for withdrawal and pain.
• Constipation doesn't go away: start a stimulant laxative (senna) with the opioid; softener alone isn't enough.
• Nausea, itching, urinary retention, orthostasis, confusion in older adults.
• Morphine: active metabolites build up in kidney failure (hydromorphone or fentanyl preferred). Avoid meperidine (seizures).
• Tramadol: seizures, serotonin syndrome.

New non-opioid option New

Suzetrigine (approved 2025) blocks pain signals in peripheral nerves (NaV1.8) for moderate-to-severe acute pain, without opioid sedation or addiction risk. Many interactions (CYP3A); avoid grapefruit.

Multimodal analgesia

Combine acetaminophen + NSAID + regional techniques + non-drug methods to reduce opioid needs.

Cold, allergy and cough products

• First-generation antihistamines (diphenhydramine, chlorpheniramine): sedation, anticholinergic effects; avoid in older adults. Second-generation (loratadine, cetirizine) cause less drowsiness.
• Decongestants (pseudoephedrine): raise BP and HR; avoid in uncontrolled hypertension. Nasal sprays (oxymetazoline): max ~3 days (rebound congestion). Oral phenylephrine is ineffective as a decongestant (FDA advisory committee 2023; FDA proposed removing it in 2024).
• Dextromethorphan: serotonin syndrome with SSRIs/MAOIs.
• Benzonatate: swallow whole (chewing numbs the throat; dangerous for young children).
• No OTC cough and cold medicines for children under 4 (US labeling).

Systemic corticosteroids (short-term)

• Prednisone, methylprednisolone for exacerbations.
• Take in the morning with food.
• High glucose (check in diabetes), insomnia, mood changes, fluid retention, increased appetite.
• Longer courses: taper (see Endocrine).

Inhaler order

Bronchodilator first, then the steroid. Same medicine: wait 30–60 sec between puffs.

Laxatives

H. pylori

Combination therapy for 14 days: a PPI + antibiotics (often bismuth quadruple therapy: PPI, bismuth, tetracycline, metronidazole). Bismuth turns stools and tongue black (harmless). Test for cure afterwards.

IBD

Aminosalicylates (mesalamine), steroids, immunomodulators, and biologics (infliximab, adalimumab, vedolizumab, ustekinumab): screen for TB and hepatitis B before biologics; no live vaccines.

Gout

• Acute flare: NSAIDs, colchicine (diarrhea is a toxicity sign; lower doses now used), or steroids.
• Prevention (lower uric acid): allopurinol (first-line), febuxostat. Allopurinol can be started during a flare with anti-inflammatory cover. Stop and report any rash (SJS); HLA-B*5801 testing for some ancestries.
• Fluids 2–3 L/day; limit alcohol (especially beer), organ meats, shellfish, sugary drinks.

Osteoporosis

• Bisphosphonates (alendronate, risedronate): first thing in the morning with a full glass of plain water, empty stomach, stay upright 30 min before food or other drugs (esophagitis). Rare jaw osteonecrosis (dental check) and thigh fractures.
• Denosumab: injection every 6 months; low calcium; don't stop without a plan (rebound spine fractures).
• Anabolic: teriparatide, abaloparatide, romosozumab (heart risk).
• Calcium + vitamin D; weight-bearing exercise; fall prevention.

Parkinson's disease

• Carbidopa-levodopa: most effective. Nausea, orthostatic hypotension, dyskinesias, "wearing-off". High-protein meals reduce absorption: spread protein through the day. Dark urine and sweat. Never stop suddenly (NMS-like reaction).
• Dopamine agonists (pramipexole, ropinirole): sleep attacks, impulse-control problems (gambling, shopping).
• MAO-B inhibitors (selegiline, rasagiline); amantadine; anticholinergics (avoid in older adults).
• Avoid: metoclopramide, haloperidol (worsen symptoms).

Myasthenia gravis

• Pyridostigmine: take on time, 30–60 min before meals (helps chewing and swallowing).
• Myasthenic crisis (too little drug or illness) vs. cholinergic crisis (too much: SLUDGE, bradycardia, small pupils). Both cause weakness and respiratory failure: airway first; atropine for cholinergic crisis.
• Newer: complement inhibitors and FcRn blockers (e.g., efgartigimod).
• Avoid drugs that worsen MG: aminoglycosides, fluoroquinolones, magnesium, some beta blockers.

Alzheimer's disease

• Cholinesterase inhibitors (donepezil, rivastigmine patch, galantamine): nausea, bradycardia, syncope; donepezil at bedtime (vivid dreams → morning).
• Memantine: moderate–severe disease; dizziness.
• Anti-amyloid antibodies for early disease: donanemab (IV every 4 weeks), lecanemab (IV, or weekly subcutaneous autoinjector). MRI monitoring for ARIA (brain swelling or bleeding): headache, confusion, vision change. APOE ε4 carriers are at higher risk. New

Blood transfusion