AP

Comprehensive Study Notes: Confidentiality, Patient Safety, Liver Cirrhosis, Cardiac & Respiratory Care, Pharmacology, Diet, Leadership, and Exam Strategy

Confidentiality, Boundaries, and Patient Information

  • Do not mix personal relationships with clinical care; do not accept patients via personal connections or social media (e.g., Facebook) to request care from a friend or family member. Maintain professional boundaries at all times.
  • Share only information that is pertinent to a patient’s care. Irrelevant personal details (e.g., nonessential data) should not be communicated to other disciplines (e.g., PT/OT) unless it directly impacts safety or treatment. For example, information like a patient’s gonorrhea status is not typically required for a left ankle fracture assessment; focus on pertinent safety events and health data (e.g., fractures).

Types of Patient Safety Events

  • Adverse event: an undesired experience or harm that occurs as a result of medical care or treatment (can involve the patient).
  • Near miss: an error detected in the process before it reaches the patient, e.g., a prescription written wrong that is caught before administration.
  • Sentinel event: a severe event causing death, permanent harm, or severe injury; systems-level investigation typically follows.

Illustrative Examples of Safety Events

  • Adverse event example (medication): patient received a different antihypertensive than prescribed (e.g., Norvasc instead of the intended drug). Nurse communicates with physician to hold the medication; monitor vitals (e.g., BP around midnight was 110/70) and next-morning readings (e.g., BP similar or changed) to assess harm.
  • Near miss example: prescription error identified before administration; corrected prior to giving the patient the drug.
  • Sentinel event example (line-related): a central line was left in place for weeks; follow-up labs showed redness at the insertion site, leukocytosis, and fever, indicating infection risk from a retained line.

Equity, Privacy, and Health Coverage Terms

  • Equity: everyone has a fair and just opportunity to access care, regardless of race, gender, socioeconomic status, etc.
  • Medicare and Medicaid: government programs that provide coverage; important to understand distinctions and appropriate referral or documentation.
  • Elder care terminology: for exam purposes, distinguish between age groups (elderly vs. younger) as context for treatment planning.

Liver Cirrhosis: Perfusion and Systemic Effects

  • Pathophysiology overview:
    • Portal hypertension contributes to ascites and varices; ammonia buildup due to reduced hepatic detoxification; impaired filtration and metabolism.
    • The liver’s multiple roles include synthesis of albumin and clotting factors, detoxification, metabolism of drugs, and ammonia clearance.
  • Key clinical signs/symptoms of liver cirrhosis:
    • Jaundice (bilirubin buildup)
    • Ascites (fluid accumulation; related to hypoalbuminemia)
    • Edema and fluid shifts due to reduced oncotic pressure from low albumin
    • Bruising and easy bleeding due to decreased clotting factor production
    • Anorexia and weight loss
    • Cognitive changes or confusion in advanced disease (hepatic encephalopathy) from ammonia buildup
  • Laboratory and physiological correlates:
    • Albumin: decreased production → edema/ascites; contributes to reduced oncotic pressure
    • Clotting factors: decreased synthesis → bleeding tendency
    • Ammonia: elevated due to impaired liver detoxification
    • Bilirubin: elevated → jaundice
  • Medication considerations in cirrhosis:
    • Many medications are metabolized by the liver; dose reductions or avoidance may be necessary
    • Avoid acetaminophen (Tylenol) to prevent hepatotoxicity; use alternatives when possible
  • Sodium and diet:
    • Sodium restriction is commonly advised to manage ascites and edema
  • Mental status and safety:
    • Hepatic encephalopathy can cause confusion and disorientation; assess orientation and risk of falls; reorientation strategies may help but addressing underlying cause is critical
  • Interventions and assessment reminders:
    • Elevate head of bed to optimize ventilation/comfort when appropriate, but be mindful of the overall clinical picture
    • When confusion or lethargy is present, notify the physician and assess for reversible triggers (infection, electrolyte disturbances, bleeding, or dehydration)

Cirrhosis-related Pharmacology and Safety Considerations

  • Pain and meds in liver disease:
    • Many drugs require dose adjustment; monitor for sedation, confusion, or worsening hepatic encephalopathy
  • Projected lab/clinical checks during care:
    • Monitor bilirubin, albumin, INR (clotting factors), ammonia, and hepatic encephalopathy signs

Respiratory and Airway Management (Asthma/COPD considerations)

  • Asthma basics:
    • Trigger: airway constriction; inflammation and hyperresponsiveness
    • Rescue inhaler: Albuterol (short-acting beta-agonist) for acute symptoms
    • Maintenance therapy: Inhaled corticosteroids and/or long-acting bronchodilators
    • Peak flow monitoring: track airway function at home to detect decline
  • Common inhaler-related principles:
    • Side effects of beta-agonists: tremors, jitteriness, tachycardia
    • If jitteriness or tachycardia is excessive, reassess therapy and consider alternatives
  • Home assessment concepts:
    • Peak flow readings help gauge severity and guide stepping up or down therapy

Cardiovascular Risk Factors and Right-Sided Heart Failure

  • Modifiable risk factors (things you can change):
    • Diet, physical activity, weight management, smoking cessation, blood pressure control, alcohol use, stress management, and glucose control (A1C)
  • Non-modifiable risk factors (things you cannot change):
    • Age, family history, gender
  • Right-sided heart failure: expected features (as part of data collection and assessment)
    • Peripheral edema, hepatomegaly, ascites, jugular venous distension (JVD)
    • Possible hepatosplenomegaly and systemic venous congestion
  • Cardiac rhythm understanding (example scenario from the lecture):
    • Complete heart block (third-degree AV block) can present with P waves present but no effective conduction to the ventricles (no QRS complexes) and bradycardia; management typically includes stopping activity, bed rest, and notifying physician for further intervention
    • If bradycardia or symptomatic block occurs, escalate to physician promptly

Pharmacology: Cardio-Pulmonary and GI Medications

  • Nitroglycerin (Nitro):
    • Sublingual administration; monitor blood pressure before and after each dose
    • Typical dosing in practice is up to 3 doses at 5-minute intervals if BP allows; BP must be measured prior to each dose
  • Blood pressure and heart rate considerations with antihypertensives:
    • Calcium channel blockers (pines): e.g., amlodipine (Norvasc); hold if systolic BP is too low
    • ACE inhibitors (e.g., Ramipril): monitor for hypotension and potential angioedema; hold if BP is low
    • Beta-blockers (e.g., metoprolol): monitor HR and BP; hold if HR or BP too low
  • Proton pump inhibitors (PPIs):
    • Omeprazole (Prilosec) and pantoprazole; used for GERD and ulcers; not directly related to the acute care cycle but relevant for chronic meds review
  • Diabetes medications:
    • Metformin: hold if renal function is impaired or during certain acute illnesses
    • Sulfonylureas (e.g., glipizide): risk of hypoglycemia; monitor blood glucose and adjust dosing
    • Insulin: rapid-acting/short-acting vs regular insulin for sliding-scale or scheduled dosing; adjust based on blood glucose
  • Diuretics and electrolyte considerations (in the context of cirrhosis and heart failure):
    • Careful electrolyte management; avoid giving IV fluids or electrolytes without explicit orders unless in emergency
  • Allergy considerations: ACE inhibitors and angioedema risk is a critical safety note

Preoperative, Postoperative Diet, and Pain Management

  • Postoperative diet progression:
    • Start with clear liquids, advance to full liquids, then to soft diet as tolerated
  • Pain management strategies (non-pharmacologic):
    • Ice, heat, guided imagery, massage, distraction, and other non-pharmacologic methods
  • Pain assessment: PQRST (Provocation/Palliation, Quality, Region/Radiation, Severity, Timing)
  • Special note: When a patient’s symptoms or pain changes, reassess and consider advancing with diet or analgesia appropriately

Critical Thinking Scenarios and Medication Safety

  • Critical thinking example: An elderly patient refuses Wellbutrin XL; a nurse practitioner (PM) cracks the tablet and feeds it in chocolate pudding, thereby violating extended-release integrity; extended-release forms require provider authorization for alternate administration routes or methods; crushing or altering extended-release formulations is inappropriate without explicit orders
  • Allergy and adverse reaction awareness:
    • ACE inhibitor–associated angioedema is a medical emergency; if suspected, discontinue and assess airway immediately
  • Case-derived safety questions:
    • Nitro contraindications and interactions (e.g., PDE5 inhibitors like Viagra) due to risk of severe hypotension
    • Before administering nitrates, obtain current BP and assess patient status
  • Time-out and patient identification:
    • Use name and date of birth (not room number) to identify patients
    • Conduct a time-out prior to procedures to verify correct patient, procedure, and site
    • Documentation of time-out and consent forms is essential; often three distinct steps are involved
  • Standard precautions and infection control:
    • Follow standard precautions consistently to reduce transmission risk
    • Adhere to sterile technique when appropriate; know which tasks require sterile handling (e.g., certain procedures) and when you can perform tasks under supervision
  • Medication administration safeguards:
    • You should not initiate the first bag of certain IV infusions (e.g., blood products, some electrolytes) without explicit orders; verify compatibility and order details; exceptions exist in emergencies
    • Antibiotics and other IV meds require orders; never administer without a physician/provider order unless an emergency protocol allows it
  • Diabetes medication safety in acute care:
    • Sliding-scale insulin dosing decisions depend on current blood glucose and clinical status
    • Typical approach: calculate units of insulin for elevated glucose; use appropriate type (rapid/short-acting) for correction
  • Safety in clinical reasoning questions:
    • When presented with a case (e.g., cirrhosis with ascites and confusion), consider the most appropriate action (e.g., notify physician) rather than adding unmentioned interventions (e.g., oxygen if not indicated by the scenario)

Leadership and Management Styles in Nursing

  • Autocratic leadership: decisive, one-person decision-making; appropriate in time-critical or safety-critical situations
  • Democratic leadership: collaborative, shared decision-making; uses group input for problem-solving
  • Practical application: select leadership style based on patient safety needs and urgency of the situation

Test-Taking Strategies and Exam Tips (From the Lecture Context)

  • When evaluating a vignette about liver cirrhosis with ascites and confusion, the safest action is to notify the physician rather than making assumptions about airway management or oxygen needs unless explicitly indicated
  • Expect questions on: patient safety, monitoring, standard precautions, and appropriate escalation of care; be prepared to differentiate between interventions that address the underlying issue versus those that do not

Quick Reference: Key Concepts and Formulas (LaTeX)

  • Glascow Coma Scale (GCS) concept: GCS = E + V + M
    • E: Eye opening (1–4)
    • V: Verbal response (1–5)
    • M: Motor response (1–6)
    • Typical maximum score: GCS_{ ext{max}} = 15
    • Note: The transcript included conflicting values (e.g., 50 or 80); remember the standard maximum is 15
  • Blood pressure and dosing reminders (conceptual, not a fixed equation): monitor before and after vasodilators or antihypertensives; adjust therapy based on current BP and patient tolerance
  • Postoperative diet progression (conceptual): Clear liquids → Full liquids → Soft diet
  • Insulin correction logic (conceptual): sliding-scale insulin dosing depends on current glucose and target ranges; exact units depend on institution protocol

Notes:

  • The transcript contains some garbled phrases and inconsistent numbers (e.g., GCS values, exact BP numbers, and drug names spelled loosely). The notes above preserve the core concepts, standard clinical reasoning, and safety practices that were covered, while aligning with typical clinical guidelines where the transcript provided hints that were unclear or inconsistent.
  • If you have access to the original slides or a cleaner transcript, I can refine these notes further and align each bullet with the exact slide references for your exam prep.