FUNDAMENTALS : LAB VALUES ü IF DOES NOT WORK = THE SUGAR WILL GO

HIGH
TOPIC OUTLINE
1 DIABETIC LABS
2 KIDNEY LABS & URINE ANALYSIS HYPOGLYCEMIA VS HYPERGLYCEMIA
3 LIVER LABS
4 TOP 5 TOXIC DRUG LEVELS
GLUCOSE LEVEL
DIABETIC LABS BELOW 70 HYPOGLYCEMIA
ABOVE 115 HYPERGLYCEMIA

NORMAL LAB VALUES : DIABETIC LABS

HYPOGLYCEMIA VS HYPERGLYCEMIA
GLUCOSE 70 – 115 mg/dL
HYPOGLYCEMIA HYPERGLYCEMIA
FASTING GLUCOSE ¯ 100 mg/dL
LOW SUGAR HIGH SUGAR
HEMOGLOBIN A1C (HgBA1C) ¯ 6.5 %
70 OR LESS OVER 115
HgBA1C 6.5+ HgBA1C 6.5+
DIABETES: DIAGNOSTIC LABS
“LOW BRAIN FUNCTION” “BLOOD IS TURNED TO MUD”
HYPOGLY BRAIN WILL DIE

HYPOGLYCEMIA

Ø MOST DEADLY!! = CAUSE BRAIN DEATH

Ø “Hypogly brain might DIE”

SIGNS AND SYMPTOMS

Ø HEMOGLOBIN A1C (HgBA1C) CRITICAL SIGNS

ü long 2-3 months sugar audit 1 Cool
ü best used to see if patient is being compliant 2 Pale “PALLOR”
with controlling their blood sugars the long 3 Sweaty “diaphoretic” “clammy”
term 4 Nervous “anxious” “trembling”
ü BELOW 6: CONTROLLED AND FIXED
ü ABOVE 6.5: REVISE KEY WORDS:
H HEADACHE
DIABETES COMPLIANCE I IRRITABILITY
Type 1 Diabetes Insulin
W WEAKNESS
Type 2 Diabetes Diet & Exercise
A ANXIETY & TREMBLING NCLEX TIP
S SWEATY “DIAPHORESIS” NCLEX TIP
Ø GLUCOSE “GTT TOLERANCE” TEST
H HUNGER NCLEX TIP
ü when we give an 8 ounce drink of syrupy
glucose to see if insulin is doing its job by
putting the sugar into the cell

DRGB 1
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ALCOHOL

Ø a NO in any disease!
Ø lowers sugar

INSULIN PEAK TIMES

Ø patients are MOST AT RISK for low sugar

Ø PEAK TIME = GIVE A PLATE OF FOOD

TREATMENTS

Ø FIRST TREATMENT: GIVE SUGAR

A - AWAKE
CAUSES A - ASK THEM TO EAT

CAUSES WHAT TO EAT

1 EXERCISE ü juice
2 ALCOHOL NCLEX TIP ü soda
3 INSULIN PEAK TIMES NCLEX TIP ü crackers
ü low fat milk
EXERCISE ü NOT HIGH FAT MILK OR PEANUT BUTTER
(fat slows down sugar absorption)
WATCH OUT:
S - SLEEP
DIABETIC ATHLETES WHO EXERCISE: S - STAB WITH DEXTROSE IV (IV D50)
GIVE EXTRA GLUCOSE ü Reassess sugar every 15 minutes after giving
insulin
KEY WORDS:

bicyclist, swimmers, runners KEY WORD IF ASLEEP:

NOT ALERT OR UNAROUSABLE OR ONLY

AROUSABLE TO PAINFUL STIMULI

DRGB 2
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HYPERGLYCEMIA STEROIDS

Ø body tries to get rid of all these thick syrup Ø -sone ending drugs
Ø prednisone
SIGNS AND SYMPTOMS Ø steroids increase the sugar

SIGNS AND SYMPTOMS

PolyUria frequent urination
too much urine
tries to urinate it all
PolyDypsia increased thirst
too much drinking fluid
body tries to dilute all that sugar
PolyPhagia hunger
too much plates
excess hunger as cells starve since
insulin is not doing its job to get
sugar inside the cells

HORMONE THERAPY

Ø estrogen

CHRONIC: HgBA1C 6.5+

Ø DIET SIMPLE SUGAR

CAUSES
DIET
ü white bread
ACUTE: 115 OR MORE
ü soda
ü candy
CAUSES (4 S’s)
ü NO fiber
1 SEPSIS
2 STRESS
TREATMENTS
3 SKIP INSULIN
4 STEROIDS
Ø INSULIN
ü to put that sugar into the cells
ü increase insulin with the four S causes
SEPSIS
ü patient is not on insulin FOREVER
ü one the S’s STOPS = INSULIN STOPS
Ø infection #1 cause NCLEX TIP

STRESS KEY WORD:

Ø surgery, hospital stay NCLEX TIP IF SUGAR IS STILL HIGH AFTER INSULIN
(CRITICAL):
SKIP INSULIN CALL DOCTOR OR HCP

Ø skipping insulin doses

DRGB 3
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URINE OUTPUT 30 ml/hr or LESS =

KIDNEY DISTRESS

HYDROGEN IONS

Ø VERY ACIDIC!!!
Ø RENAL FAILURE:
ü failed washer machines
QUESTIONS
ü retain more waste & acid in the body (since it
can’t be washed out)
3 COMMON EXAM QUESTIONS
ü acid builds up in the blood and end up in
METABOLIC ACIDOSIS (pH < 7.35)
Q1: A client with type 1 diabetes is only responsive to painful
ü in turn, damages the MUSCLES, BONES &
stimuli with a blood sugar of 42, what is the first action taken
KIDNEYS
by the nurse?
• Repeat the blood sugar assessment
• Give Dextrose IV Push
• Call the HCP (Doctor)
• Clock out for lunch-dis too much...

Q2: Which medication could cause risk for hyperglycemia?

• Labetalol
• Albuterol
• Spironolactone
• Prednisone

QUESTIONS
Q3: The non diabetic client is admitted for a kidney infection
that has now turned septic. The blood sugars have increased
COMMON TEST QUESTION
from 150 to 225. What is the best answer to give a family
member who is asking why insulin is used?
Q1: List of clients MOST at risk for Metabolic Acidosis? SATA.
• The client now has type 2 diabetes because of the
• Renal Failure
infection
• Pyelonephritis
• Insulin is given to control the hypoglycemia
• Patient waiting for hemodialysis
• High sugar is common during infection and stress
• Hyperventilation related to anxiety attack
to the body, the insulin will help lower the sugar
• Child with diarrhea x 2 days
until the infection resolves
• Be QUIET & let me do my job
METABOLIC = KIDNEYS AND BODY
Pyelonephritis: Kidney Infection
Hemodialysis: process where we use a kidney machine to
KIDNEY LABS & URINE ANALYSIS
filter/wash the blood from kidneys
Diarrhea: poop out all alkaline, leaving them with an acidic
NORMAL LAB VALUES : RENAL LABS body

HYDROGEN IONS ACIDIC

UREA (BUN)
UREA (BUN) 10 – 20 MAX
Ø BLOOD UREA NITROGEN
CREATININE OVER 1.3 = BAD KIDNEY
Ø By-product of protein waste
Ø after the body consumes the nutrients it needs from
proteins

DRGB 4
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Ø HIGH BUN = BODY IS DRY CREATININE

Ø MOST CRITICAL KIDNEY LAB VALUE TO ASSESS

KIDNEY FUNCTION
Ø one to know for all nursing examinations/tests

OVER 1.3 = BAD KIDNEY

Ø waste product produced by the muscles coming from

the normal everyday wear and tear

Ø "protein bar wrapper"

ü the trash that the body needs to toss out

Ø HIGH CREATININE = HIGH KIDNEY IMPAIRMENT

ü kidneys are getting clogged up with muscle
waste and impairing its function to wash the
blood

UREA: PATHOPHYSIOLOGY

Ø starts as ammonia and to be sucked in the liver and be

broken down into urea
Ø then it is pushed into the blood before it is excreted by
the kidneys (from the body into the potty) MEMORY TRICKS

C – CREATININE
C - CRITICAL KIDNEY LAB
C- CLOGGING

DRGB 5
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CASES THAT DOESN’T MATCH URINE COLOR

STUDY TIP FOR PHARMA & LAB VALUES:
DI DIURESING A LOT OF FLUID
ALWAYS FOCUS ON THE MAX RANGES!! LIGHT URINE, DRY BODY
mainly focus how drugs of values will harm SIADH STOP URINATING
the patient DARK URINE, FLUID-FILLED BODY

SPECIFIC GRAVITY

NORMAL LAB VALUES : URINE ANALYSIS

SPECIFIC GRAVITY 1.003 – 1.030

Ø weight of the urine

MEMORY TRICKS

LIGHT URINE SG ¯ 1.003

QUESTIONS
LOW AND LIQUIDY “DILUTE”
COMMON NCLEX QUESTION BODY

Q1: Client with infected toe due to diabetes is scheduled for

cardiac catheterization with contrast, which lab value should
the nurse report to the provider?
• Blood Urea Nitrogen level of 19 DARK URINE SG ­ 1.030
• Blood glucose of 155
• Creatinine level of 1.9 HIGH LABS = DRY BODY
• White blood cell count of 14,500

CREATININE OVER 1.3 = BAD KIDNEY!

Contrast: Kills the kidneys
INFECTION = HIGH WBC

HEMATURIA (RBC)
URINE ANALYSIS
Ø BLOOD IN THE URINE
COLOR

URINE
LIGHT URINE HYDRATED
DARK URINE DEHYDRATED

DRGB 6
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CAUSES URINE CULTURE & SENSITIVITY TEST

ü Kidney Stones
ü Bladder Cancer Ø CULTURE: identifies the bacteria
ü Trauma (Surgery/ Procedure – Prostate) Ø SENSITIVITY: which antibiotic is the bacteria most
sensitive to, to best kill it

Ø take a STEROID URINE SAMPLE

KEY NUMBER:
WBC “LEUKOCYTES”
OVER 10,000 ORGANISMS/mL = UTI

Ø general infection
Ø UTI, Kidney Infection
ü client complain of “burning” during urination

PROTEIN & GLUCOSE

INDICATION
HIGH PROTEIN NEPHROTIC SYNDROME
HIGH GLUCOSE DIABETES

NITRITES - PYELONEPHRITIS

Ø kidney infection
Ø KIDNEY INFECTION = NITRITES

DRGB 7
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QUESTIONS

COMMON NCLEX QUESTION

Q1: Client with history of diabetes… which does the nurse

suspect?

SIGNS AND SYMPTOMS

HEPATIC ENCEPHALOPATHY

Ø cloudy toxic brain from high levels of ammonia in that

protein

• Dehydration (low fluid intake) & possible UTI

HIGH SPECIFIC GRAVITY = BODY IS DRY

HIGH GLUCOSE = DIABETES ASTERIXIS
LEUKOCYTES WBC = INFECTION
Ø twitching extremities in the arms and legs
KAPLAN QUESTION

Q1: Procedure for collecting a sterile urine specimen from a

foley bag? ORDER SEQUENCE.

MENTAL STATUS CHANGES

MENTAL STATUS CHANGES

ü Confusion
ü Bizarre behavior
ü Sleepiness
1. Clamp drainage tube below the port
2. Wait 15-30 minutes
3. Scrub the port using an antiseptic swab
4. Attach a sterile, needleless access device to
aspirate a specimen via the port

LIVER LABS

CIRRHOSIS

DRGB 8
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KEY ASSESSMENTS NCLEX TIP Þ ALL SIGNS WILL BE PRESENT FOR CLIENTS WITH LIVER
1 Assess hand movements with arms extended FAILURE NOT SPECIFIC TO HEPATIC ENCEPHALOPATHY
2 Assess mental status with those from previous shifts
3 Assess recent blood draws for ammonia levels QUESTIONS

TOP MISSED NCLEX QUESTION

Q1: Which assessments would indicate if a client with cirrhosis

has progressed to hepatic encephalopathy? SATA.
• Ask the client for their date of birth, name, date
and location
• Tell the client to extend their arms
• Compare ammonia blood levels with that of
previous shifts

Asking personal details: mental status

Extend client's arms: assess for muscle twitching
Ammonia Levels: should not go higher
HIGHER AMMONIA = MORE HEPATIC ENCEPHALOPATHY

SAUNDERS QUESTION

Ø HE NOT ASSESSING THE FOLLOWING: Q1: A client with cirrhosis.. shows signs of hepatic
1. SKIN FOR THINNING BLOOD VESSELS (SPIDER encephalopathy. The nurse should plan a dietary consultation
VEINS) to limit… which ingredient?
• Protein

PROTEIN: has the Ammonia waste

AMMONIA: protein wrapper/ waste around the protein which
causes hepatic encephalopathy

LAB VALUES: LIVER FAILURE LABS (NCLEX TIP)

HIGH AMMONIA Hepatic Encephalopathy

2. EYES AND BODY FOR JAUNDICE ALBUMIN LOW (¯ 3.5)

CALCIUM LOW
LOW PLATELETS

BILIRUBIN HIGH

COAGUALATION PANEL CLOTTING TIME HIGH

HIGH PT, PTT, INR

ALT & AST ELEVATED

DRGB 9
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COAGULATION PANEL

Ø coagulation factors
Ø HIGH PT, PTT, INR
ü a higher risk for bleeding
ü bruising is very common with these clients

ALBUMIN

Ø low albumin
Ø low calcium
CALCIUM: binds to albumin
Ø low platelets

ALT & AST

BILIRUBIN
Ø ALT: Alanine transaminase
Ø not scooping up bilirubin by the bile Ø AST: Aspartate transaminase
Ø causing body to be JAUNDICE Ø common for any liver disease client
ü cirrhosis
ü hepatitis

TIONS

DRGB 10
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QUESTIONS 3 Wear long sleeved clothes and cotton gloves

4 Trim fingernails short
TOP MISSED NCLEX QUESTION
QUESTIONS
Q1: Which blood lab values are expected to be elevated in a
client with worsening liver cirrhosis? SATA. TOP MISSED NCLEX QUESTION
• Ammonia
• Bilirubin Q1: A client with worsening liver failure presents to the med-
• Prothrombin Time (PT) surg floor… which assessment findings should the nurse
• Albumin expect? SATA.
• Calcium • Enlarged abdomen from ascites
• Bruise marks on the skin
• Fatigue and possible confusion
• Sclera that appears yellow
• Reports of itchy skin

Ascites: abdomen filled with fluid

DIAGNOSTICS

LIVER BIOPSY
PRURITIS
Ø can be taken to analyze tissues
Ø itchy skin
Ø toxins and bile salts build up under the skin, this causes Ø AFTER PROCEDURE:
major itching ü lay on the RIGHT SIDE to prevent bleeding
Ø the recycling detox filter (liver) is broken, so the body is ü put pressure on anything that is bleeding
naturally filling up with waste products ü put pressure on the liver to prevent bleeding

KEY POINTS NCLEX TIP

1 Apply a cool moist cloth to affected areas (not a hot
shower/bath)
2 Apply moisturizing cream over unbroken skin

DRGB 11
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INTERVENTIONS

ASCITES

Ø A – Ascites
A – Abdominal Fluid
ü from portal hypertension where fluid overflows
into the peritoneal cavity
Ø Paracentesis
ü pokes the abdomen with a needle to drain the
fluid

NURSING INTERVENTIONS
1 Empty the bladder NCLEX TIP
2 Vital Signs (Monitor for BP – can go to a shock)
3 Measure abdominal circumference & weight NCLEX TIP
EFFECT OF ALBUMIN IV
Measure how much fluid was taken out in the abdomen
1 INCREASED BP & BOUNDING PULSES
4 HOB UP – High fowlers position (keep fluid in one place
2 Vital Signs (Monitor for BP – can go to a shock)
& help drainage)
3 Measure abdominal circumference & weight NCLEX TIP
Measure how much fluid was taken out in the abdomen
QUESTIONS
4 HOB UP – High fowlers position (keep fluid in one place
& help drainage)
HESI QUESTION

INCREASED BP & BOUNDING PULSES

Q1: A nurse is assisting with a paracentesis for a patient with
ascites caused by cirrhosis. Which action should the nurse
Ø fluid gets drawn out of the abdomen and into the blood
take first?
vessels

• Have the patient empty their bladder

ALBUMIN IV

Ø treat hypoalbuminemia
ALBUMIN: attracts water, transports drugs, and binds
to calcium
ü attracts water like a magnet, to bring fluid
back into the vascular spaces = help decrease
ascites

DRGB 12
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Ø once inside the blood vessels we give -ide ending Ø Low Sodium & Fluid
diuretics to drain fluid from the body and into the potty. ü get low swelling with that ascites
Ø NO ALCOHOL
ü it can worsen scarring of the liver

HOW TO KNOW IF ALBUMIN HAS BEEN EFFECTIVE?

ü Assess vital signs! NCLEX TIP
Ø MALNUTRITION: provide ORAL CARE before meals to
must remain within normal limits
wake up those taste buds
= ALBUMIN HAS BEEN EFFECTIVE

Ø ALBUMIN EFFECTIVENESS does not depend on the

QUESTIONS
reduction of abdominal circumference with ascites
Ø It does not RESOLVE muscle tremors and twitching in
HESI QUESTION
the arms and legs

Q1: The nurse is caring for a patient with severe liver cirrhosis
and imbalanced nutrition. Which nursing intervention would
NURSING CARE
prevent malnutrition in this patient?
• Provide oral care before meals
DIET

Ø LOW PROTEIN = LOW AMMONIA

ü prevents hepatic Encephalopathy
BLEED RISK

Ø from low coagulation factors

DRGB 13
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NURSING CARE PHARMACOLOGY

ü Soft toothbrush
ü Electric razor NEOMYCIN
ü Monitor blood in stools
Ø used to decrease ammonia-producing bacteria

LACTULOSE
ESOPHAGEAL VARICES
LACTULOSE
ü Lose the ammonia via
ü Loose bowels
ü Lose potassium (Hypokalemia)

Ø AVOID VALSALVA MANEUVER NORMAL WHAT TO EXPECT?

ü NO bearing down (during bowel movements) ü Low potassium
ü any pressure can pop the esophagus ü Explosive diarrhea

Ø NO new NGT NASOGASTRIC TUBE ü DON’T STOP GIIVNG THE DRUG

ü no pressure inside the esophagus loose stools
ü esophagus is like an overfilled water balloon low potassium
waiting to explode with all that blood. ü MONITOR POTASSIUM

DRGB 14
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QUESTIONS

KAPLAN QUESTION

Q1: Lactulose:
• Monitor for hypokalemia

MECHANISM OF ACTION

Ø looses the bowels to lessen ammonia levels

HOW TO EVALUATE LACTULOSE EFFECTIVENESS?
ü 2-3 soft stools per day
MEMORY TRICKS
ü Ammonia levels decrease
ü Cognition improved
L Laxative for
“Improved mental status” NCLEX TIP

A Ammonia decreasing levels

C Cognition returns
“improved mental status” NCLEX TIP

INDICATION

LACTULOSE
ü decrease ammonia levels with cirrhosis patients
ü treats Hepatic Encephalopathy
TEST TIPS
Ø helps the body poo out all that ammonia (massive
explosive diarrhea) Ø IMPROVED MENTAL STATUS IS THE ONLY INDICATOR
Ø LACTO – LOSE (help lose ammonia via loose bowels) THAT LACTULOSE IS EFFECTIVE
Ø DIARRHEA and LOOSE STOOLS are NOT indicators that
AMMONIA ammonia levels are decreasing

Ø decrease via the BOWEL not urine since it is not a

diuretic

DRGB 15
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TOP 5 TOXIC DRUG LEVELS

5 TOXIC DRUG LEVELS

1 LITHIUM
2 DIGOXIN
3 THEOPHYLLINE
4 PHENYTOIN
5 KIDNEY KILLERS

TOXIC DRUG LEVELS

LITHIUM OVER 1.5

SIGNS
DIGOXIN OVER 2.0 ü Extreme thirst
ü Excessive urination
THEOPHYLLINE OVER 20 ü Vomiting ; Diarrhea

PHENYTOIN OVER 20
PHARMACOLOGY (LITHIUM)

KIDNEY KILLERS CREATININE OVER 1.3 = DEAD KIDNEY

THERAPEUTIC RANGE: 0.6 – 1.2 mEq/L

THERAPEUTIC RANGE INDICATION

LITHIUM 0.6 – 1.2 mEq/L LONG TERM TREATMENT FOR

ü Bipolar
DIGOXIN 0.5 – 2.0 ng/mL ü Schizoaffective disorder

THEOPHYLLINE 10 – 20 mcg/mL
MEMORY TRICKS

PHENYTOIN 10 – 20 mcg/dl
LITHIUM BATTERY
KIDNEY KILLERS 0.6 – 1.2 mEq/L lithium last for a long time

BIPOLAR - BATTERY
LITHIUM

Ø for bipolar and mental health disorders

KEY POINT:

Þ TOXICITY OVER 1.5 mEq/L

ü HIGHEST RISK FOR TOXICITY:
clients with decreased renal function!
TOP SIGNS LEADING TO TOXICITY
KIDNEY: washing blood from medications
and waste
DEHYDRATION = MORE CONCENTRATION OF LITHIUM
CAUTIOUS PATIENT WITH:

DRGB 16
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o Kidney Disease
INCREASE FLUID & SODIUM (NA+)
o Old Age (Naturally have decreased
kidney function)
Ø lithium lets go with the fluid
KEY KIDNEY SIGNS

Þ CREATININE OVER 1.3 = BAD KIDNEY!

Þ URINE 30 ml / hr or LESS = KIDNEY IN DISTRESS!
Þ S/S = TINNITUS
Tinnitus: ringing of the ears, indicates kidney malfunction
Ototoxicity

CONTRAINDICATION

KEY POINTS!

DO NOT GIVE LITHIUM:

ü DEHYDRATION
ü LOW SODIUM “HYPONATREMIA” BELOW 135 mEq/L
ü DO NOT LIMIT SODIUM OR WATER INTAKE

Ø always question DOCTOR'S RIGHTS if the patient has

KEY POINTS: LITH low sodium or dehydration
L LEVELS OVER 1.5 mEq/L = TOXIC!
I INCREASE FLUID & SODIUM (NA+)
T TOXIC SIGNS
H HOLD NSAIDS (IBUPROFEN, NAPROXEN)

LEVELS OVER 1.5 mEq/L = TOXIC!

Ø blood levels are drawn easily to maintain therapeutic

dose (take up to 3 weeks)!

Ø sodium swells the body with water, we need to avoid the

toxicity

QUESTIONS

COMMON TEST QUESTION

Q1: HIGHEST RISK FOR TOXICITY?

QUESTIONS • A patient with STOMACH FLU (Diarrhea &
Vomiting)
COMMON TEST QUESTION

Q1: Is lithium at Therapeutic Level?

• IF YES, CONTINUE AT CURRENT DOSE

DRGB 17
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TOXIC SIGNS

WHEN TO REPORT TO THE HCP!

ü REPORT EXCESSIVE URINATION AND EXTREME THIRST!!!
ü VOMITING AND DIARRHEA
ü NEUROMUSCULAR EXCITABILITY

REPORT EXCESSIVE URINATION AND EXTREME THIRST!!!

KEY WORDS:

Þ DUE TO MASSIVE DEHYDRATION! Ø lead to more dehydration and toxicity!

ü LOW SODIUM = REPORT TO HCP!
ü AVOID DEHYDRATION
PATIENT TEACHING
ü Teach patient to drink water 1-3 L/day
ü Limit Diuretics & Diuretic-containing products
*furosemide & hydrochlorothiazide
*coffee, colas, tea
*more fluid in and less fluid out!
ü No anticholinergic medications
*IPRATROPIUM: respiratory med that dries
your body VOMITING AND DIARRHEA
PIUM = YOU CAN’T PEE WITH THEM!
Ø which can add more dehydration & toxicity

NEUROMUSCULAR EXCITABILITY

NEUROMUSCULAR EXCITABILITY
ü TREMORS
ü MYOCLONIC JERKS
ü HORSE HAND TREMOR
ü ATAXIA
ü CONFUSION
ü AGITATION

DRGB 18
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IF PT WANTS TO TAKE IT: NEEDS FURTHER

TEACHING!

INTERVENTION
Þ USE
Ø INCREASE FLUIDS!! ACETAMINOPHEN (TYLENOL) INSTEAD!
ü #1 INTERVENTION!

HOLD NSAIDS

Ø Ibuprofen, Naproxen
Ø really bad for the entire body, especially the kidneys!

COMMON EXPECTED SIDE EFFECTS

Ø DO NOT NEED TO REPORT!

SIDE EFFECTS
1 DRY MOUTH & THIRST
2 DROWSINESS & FATIGUE
3 WEIGHT GAIN

DRY MOUTH & THIRST

KEY POINT:

Þ NSAIDS (Ibuprofen)
ü decrease renal blood flow increasing risk for
TOXICITY

PATIENT EDUCATION: TEACH PATIENT TO USE

ü ICE CHIPS
ü GUM
ü SUGARLESS CANDY
ü DRINK PLENTY OF FLUIDS
ü DO ORAL HYGIENE
ü AVOID TAKING!!!

DRGB 19
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DIGOXIN

Ø cardiac glycoside for Atrial fibrillation

Ø LOWERS HEART RATE (negative conotropic)
Ø no blood pressure effects only heart rate effects
Ø DIGOXIN DIGS FOR A DEEPER CONTRACTION
DROWSINESS & FATIGUE
ü increase contractility inside the heart
ü FOR SYSTOLIC HF
ü squeezed heart failure

DIGOXIN
ü NO ORTHOSTATIC HYPOTENSION
ü NO SLOW POSITION CHANGES

PATIENT EDUCATION: TEACH PATIENT TO

ü AVOID DRIVING & HAZARDOUS ACTIVITIES UNTIL
CONDITION IMPROVES

TOP SIGNS OF TOXICITY

SIGNS OF TOXICITY
ü NAUSEA AND VOMITING
ü VISION CHANGES “DIFFICULTY READING”

WEIGHT GAIN

PATIENT EDUCATION: TEACH PATIENT

ü PROPER DIET & EXERCISE
ü DECREASE APPETITE
ü IF PATIENT HAS WEIGHT LOSS: INDICATES ANOREXIA &
MILD GI UPSET

DRGB 20
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TOXICITY (OVER 2.0)

SIGNS OF TOXICITY
ü VISION CHANGES
ü NAUSEA & VOMITING
ü ANOREXIA
ü DIZZINESS / LIGHTHEADEDNESS

Ø NOTIFY HCP ASAP!!! NCLEX TIP

KEY WORDS:

Þ VISION CHANGES:
PHARMACOLOGY (DIGOXIN)
Ø fuzziness
Ø blurred vision
Ø digs for a deeper contraction
Ø color changes
Ø lowers/decreases heart rate
Ø difficulty reading

DIGOXIN = A TOXIN (VERY TOXIC)

KEY POINT:

TREATMENTS: PRIORITY INTERVENTIONS Þ TOXICITY OVER 2.0 mEq/L

ü HIGHEST RISK FOR DIGOXIN TOXICITY:
KEY POINTS: ATP older clients with decreased kidney function!
A APICAL PULSE (BELOW 60) KIDNEY: washing blood from medications
T TOXICITY (OVER 2.0) and waste
P POTASSIUM LEVEL (BELOW 3.5) broken kidneys = can’t wash the drug out of
the blood
APICAL PULSE (BELOW 60)
KEY KIDNEY SIGNS
Ø check heart rate for a full 60 seconds
Ø heart rate below 60 is very risky! Þ CREATININE OVER 1.3 = “no pee pee”
Ø we don’t give the drug digoxin Ø normal: 0.6 – 1.2
Ø kidney injury!
Ø risk for toxicity for any drugs

Þ MONITOR VERY CLOSELY PATIENTS:

Ø ELDERLY
Ø RENAL FAILURE PATIENTS

POTASSIUM LEVEL (BELOW 3.5)

Ø check for potassium level!

Ø ¯ 3.5 K+ = increase risk for digoxin toxicity
Ø digoxin do not cause low potassium like diuretics
Ø this does not waste potassium
ü do not need to eat more green leafy veggies or
melons NCLEX TIP

Ø APICAL PULSE
ü LEFT SIDE
ü Midclavicular 5th Intercostal Space

DRGB 21
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PHARMACOLOGY (THEOPHYLLINE)
COMMON TEST QUESTION
KEY POINTS: 3 T’s
Q1: Which patient is MOST AT RISK for Digoxin Toxicity? T TOXIC! OVER 20 (mcg/mL) NCLEX TIP!
• A client on Potassium-Wasting Diuretics (-ide)
T TONIC CLONIC SEIZURES
• Kidney Failure clients
T TACHYCARDIA & DYSRHYTHMIAS NCLEX TIP

TOXIC! OVER 20 (mcg/mL)

THEOPHYLLINE
Ø need FREQUENT BLOOD DRAWS

Ø a bronchodilator for asthma and COPD clients

Ø Methylxanthines
Ø THERAPEUTIC RANGE: 10 – 20 mcg/mL

TONIC CLONIC SEIZURES

Ø SEVERE TOXICITY 1ST PRIORITY

Ø REPORT SIGNS OF TOXICITY

TOP SIGNS OF TOXICITY

SIGNS OF TOXICITY
ü ANOREXIA
SIGNS OF TOXICITY
ü NAUSEA & VOMITING
ü SEIZURES
ü RESTLESSNESS
ü INSOMNIA
SEIZURES

DRGB 22
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TACHYCARDIA & DYSRHYTHMIAS PHENYTOIN

QUESTIONS Ø brand name: Dilantin

Ø an anticonvulsant for seizures
HESI QUESTIONS

Q1: Patient education in patient on Theophylline?

• Teach patient to AVOID beta blockers that lower
the heart rate while on Theophylline

BETA BLOCKERS: blocks the effects of Theophylline

Q2: Nursing intervention on patient having tachycardia with

theophylline?
• ALERT HCP of tachycardia BEFORE giving the next
dose

TOP SIGNS OF TOXICITY

SIGNS OF TOXICITY
ü ATAXIA – UNSTEADY GAIT
ü HAND TREMORS
ü SLURRED SPEECH

KEY TEACHING POINTS

2 DRUGS THAT INCREASE TOXICITY RISK NCXLEX TIP
ü Climetidine (H2 blocker – heart burn)
ü Ciprofloxacin (ABX - Antibiotic)
ü TAKE IN AM
ü AVOID CAFFEINE (ANY STIMULANTS)
ü STOP TAKING BEFORE CARDIAC STRESS TEST
*can augment the test

DRGB 23
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PHARMACOLOGY (PHENYTOIN)
REPORT TO HCP!
ü OVER 20 – TOXIC RISK
INDICATION
HOLD MED
NOTIFY HCP!
Ø long term protection against seizures
ü epilepsy
ü other long term chronic seizure disorders

KEY WORDS:

Þ LONG TERM
Ø lasts longer in the body
Ø patients can get very TOXIC ü ROUTINE BLOOD TESTS
“blood levels monitored routinely”
check the THERAPEUTIC RANGE of the drug
monitor for liver function

ANY DRUG THAT CAN CAUSE TOXICITY = CAN AFFECT THE

LIVER HEAVILY

MEMORY TRICKS

Phenytoin = phenyTOXIC

QUESTIONS

HESI QUESTIONS

KEY POINT:
Q1: When to hold Phenytoin drug?
• Hold med for level higher than 20
Þ 10-20 mcg/dl THERAPEUTIC RANGE
ü BELOW 10 – SEIZURE RISK
OVER 20 = VERY TOXIC!

DRGB 24
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ADVERSE EFFECTS
Q2: When to take phenytoin? ü SUICIDAL IDEATIONS
• Take phenytoin at the same time daily because of ü SKIN RASH – “new” “painful” = PRIORITY!!!
the narrow therapeutic index *Stevens Johnson Syndrome
*report to HCP immediately

TOXICITY

Ø NCLEX TIPS!

EARLY SIGNS TO REPORT TO HCP

ü ATAXIA
ü HAND TREMOR
ü SLURRED SPEECH

ATAXIA

Ø unsteady gait EXPECTED SIDE EFFECTS

Ø gait disturbance
Ø CNS DEPRESSANTS = LOW AND SLOW VITALS!
Ø DO NOT STOP THE DRUG!

SIDE EFFECTS
ü BRADYCARDIA & HYPOTENSION
ü GINGIVAL HYPERPLASIA NCLEX TIP!
*overgrowth of gum tissue around the teeth
*resulting in big gums that bleed easily

SLURRED SPEECH

Ø having trouble forming sentences

PATIENT TEACHING: GINGIVAL HYPERPLASIA

ü Teach patient good dental hygiene with soft bristle
toothbrush
ü Regular dentist visits & follow up visits

QUESTIONS

ATI QUESTION

Q1: Patient teaching when taking Phenytoin?

• Teach patient to inform dentist that they are taking
phenytoin
OTHER ADVERSE EFFECTS

DRGB 25
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OVER 20 = VERY TOXIC! TAKE FOLIC ACID, CALCIUM & VITAMIN D

HESI QUESTION
ü Phenytoin decreases folic acid absorption and
Q1: Nursing intervention when taking Phenytoin? decreases bone density
• Perform or assist with oral care every shift
• Skin rash, fatigue & dyspnea are PRIORITY!

ANY TYPE OF SKIN RASH = INDICATION OF STEVENS

JOHNSON SYNDROME (VERY DEADLY!)

KAPLAN QUESTION

Q1: Statements requiring immediate intervention:

• "I noticed a rash on my stomach last week"
• "Lately I find myself thinking about driving off a
cliff"

QUESTIONS

PATIENT TEACHING
KAPLAN QUESTION

PATIENT EDUCATION
Q1: Patient education when taking Phenytoin?
1 NO ORAL CONTRACEPTIVES
• Encourage foods such as milk, cantaloupe and kale
2 NO STOPPING ABRUPTLY
3 TAKE FOLIC ACID, CALCIUM & VITAMIN D
These are foods HIGH IN FOLATE & VITAMIN D

NO ORAL CONTRACEPTIVES

Q2: Which statement requires further teaching?

Ø Phenytoin deactivates the pill = ACCIDENTAL
• "If I start having adverse effects I will stop this med
PREGNANCY
immediately"
ü teach patient to use alternative birth control (IUD)

NEVER STOP DRUG ABRUPTLY OR IMMEDIATELY!

WE ALWAYS TAPER OFF

ADMINISTRATION

ü importance of phenytoin with tube feeding

ü it can decrease the absorption and cause
seizures
NO STOPPING ABRUBTLY
ADMINISTRATION
ü this goes for any drug acting on the BRAIN ü STOP TUBE FEEDING FOR 1-2 HRS BEFORE AND AFTER
ADMINISTRATION PRIORITY!

STOP TUBE FEEDING FOR 1-2 HRS BEFORE AND AFTER

ADMINISTRATION

ü tube feedings can interfere with the absorption

and decrease phenytoin effectiveness

DRGB 26
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ANTICONVULSANT: LEVETIRACETAM

ü prevent and treat seizures (HIGH RISK)

HIGH RISK FOR SEIZURES THAT CAN INCREASE

INTRACRANIAL PRESSURE
ü BRAIN TUMORS
ü BRAIN SURGERY
ü BRAIN TRAUMA

TUBE FEEDINGS

ü Flush with 30 – 50 mL tap water before and

after the drug is given
ü Normal Saline is NOT REQUIRED

ü PREFERRED OVER PHENYTOIN

ü due to minimal drug to drug interactions

PHENYTOIN IV ADMINISTRATION

Ø ALWAYS flush the IV with Normal Saline before and

after giving this drug

BIG SIDE EFFECTS

SIDE EFFECTS
ü LOW AND SLOW BODY
ü DROWSINESS
ü FATIGUE

KEY POINT: MAJOR ADVERSE EFFECTS

Þ Gums typically bleed = normal because of the gum ADVERSE EFFECTS

growth ü SUICIDAL THOUGHTS
ü NOT THE FACE! ü STEVENS-JOHNSON SYNDROME
no need to use an electric shaver
SUICIDAL THOUGHTS
Þ NO Metallic taste
ü for METRONIDAZOLE ü REPORT ANY KEY WORD!
ü New anxiety
Þ NO Photosensitivity ü New agitation
ü Depression

DRGB 27
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ü Mood changes ü can cause drowsiness and fatigue: common

during first 46 weeks when starting the
medication

KIDNEY KILLERS
STEVENS=JOHNSON SYNDROME
CREATININE OVER 1.3 = DEAD KIDNEY
ü REPORT! Ø CT Contrast
ü Skin Rash Ø Antibiotics: Vancomycin & Gentamicin
ü Blistering ü IT’S A SIN TO GIVE A -MICIN
ü Muscle Join Pain ü SUPER BUGS
ü Conjunctivitis

Ø HIGHEST RISK FOR TOXICITY

ü clients with broken kidneys or broken filters
ü Decreased renal function = increased toxicity
PATIENT TEACHING ü Creatinine OVER 1.3 = BAD KIDNEY!
Renal Failure
PATIENT EDUCATION Old Age
1 DRIVING Ø Kills the kidneys and ears when they are toxic
2 NO STOPPING ABRUPTLY
BIG GUN ANTIBIOTICS
3 TAKE FOLIC ACID, CALCIUM & VITAMIN D
1 GLYCOPEPTIDES CLASS
2 AMINOGLYCOSIDES CLASS
DRIVING
3 TAKE FOLIC ACID, CALCIUM & VITAMIN D
ü get permission from HCP & follow
transportation dept. guidelines

DRGB 28
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GLYCOPEPTIDES CLASS

GLYCOPEPTIDES CLASS
ü VANCOMYCIN

AMINOGLYCOSIDES CLASS

GLYCOPEPTIDES CLASS
ü TOBRAMYCIN
ü GENTAMICIN
ü NEOMYCIN

NURSING INTERVENTION
KEY WORDS:
NURSING INTERVENTION
ü MONITOR DRUG CONCENTRATION IN THE BLOOD Þ REPORT SIGNS OF TOXICITY
ü GENTAMICIN ü EAR DAMAGE “Ototoxicity”
ü NEOMYCIN monitor for hearing and balance changes
Vertigo (loss of balance) NCLEX TIP
MONITOR DRUG CONCENTRATION IN THE BLOOD Ataxia – inability to walk
Tinnitus (ringing of the ears) NCLEX TIP
KEY POINT
ü KIDNEY DAMAGE “Nephrotoxicity”
TOO HIGH KIDNEYS DIE
REPORT / NOTIFY HCP
TOO LOW INFECTION GROW
o increasing BUN & Creatinine
o CREATININE OVER 1.3 = BAD
KIDNEY
o BUN OVER 20 = NOT GOOD
o URINE OUTPUT 30 ml/hr or LESS =
KIDNEY DISTRESS

KEY POINT:

Þ PEAK & TROUGH

ü CHECK 15 – 30 MINUTES BEFORE “next dose” or
“administration”
draw and review levels
range must be between 10 – 20

ü REPORT AND HOLD!

Vancomycin OVER 20
too high = kidneys will die!

DRGB 29