N249 Syllabus Spring 2013
Transcript of N249 Syllabus Spring 2013
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NAPA VALLEY COLLEGEASSOCIATE DEGREE PROGRAM
IN NURSING
NURS 249 – NURSING IN
HEALTH ALTERATIONS IV
SPRING 2013
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NAPA VALLEY COLLEGEASSOCIATE DEGREE PROGRAM IN NURSING
Course Information ................................................................................................................... 1Course Description .......................................................................................................... 2Course Outcomes............................................................................................................ 5
Unit I – Nursing Care of Children with Acute, Complex Illness ............................................. 6
Unit II – Alterations in the Nervous/Sensory System ........................................................... 11
Unit III – Alterations in the Integumentary System ............................................................... 17
Unit IV – Alterations in Cellular Growth/Immunity ................................................................ 22
Unit V – Alterations in the Endocrine/Metabolic System ...................................................... 29
Seminars .................................................................................................................................. 34Helping children adapt to the hospital environment........................................................ 35
Organizing Client Care .................................................................................................. 36Head Injury & Spinal Cord Injury.................................................................................... 41Chronic Neurologic Alterations ...................................................................................... 44Epilepsy / Seizure Disorders Across the Lifespan .......................................................... 46Ethical Cases & Legal Cases ........................................................................................ 55Burn and Inhalation Injury .............................................................................................. 58Shock, Shock/MODS ..................................................................................................... 61Prioritizing Care ............................................................................................................. 64Using Nursing Process to Care for Clients Diagnosed with Cancer ............................... 65Complimentary and/or Alternative Medicine................................................................... 66Multidisciplinary Care for Clients with Cancer ................................................................ 67Rectal Cancer Care ................................................………………………………………..68
Cancer Presentation and Paper..................................................................................... 74Endocrine Case Studies ................................................................................................ 77Endocrine Disorders……………………………………………………… .......................... 81
Acute Liver Failure / Acute on Chronic Liver Failure ...................................................... 84 Alcoholic Liver Disease and ETOH Withdrawal 88 Assertive Behavior and Evaluation ................................................................................ 89Delegating Nursing Care ............................................................................................... 91Evaluating Performance ……………………………………………………………………..92
Skills Lab ................................................................................................................................. 93Peripheral Infusion Therapy ........................................................................................... 94
Assumption of Risk Form............................................................................................... 98
Clinical Guidelines – Medical/Surgical ................................................................................. 99Kaiser Driving Directions ........................................................................................... ..100Guidelines ……………..…………………………………………………………………… ... 101Clinical Preparation and Written Assignments ............................................................. 102Student Evaluation by RN…………………………………………………………………...103Clinical Self Evaluation ................................................................................................ 104Medication Assignment Form ...................................................................................... 105
Specialty Rotation Guidelines .............................................................................................. 106ICU .............................................................................................................................. 107ER ............................................................................................................................... 108
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Oncology Outpatient .................................................................................................... 109Radiation Therapy ....................................................................................................... 110Cardiac Catheterization Lab ........................................................................................ 111Outpatient Surgery ...................................................................................................... 112ER – Ambulance Team ............................................................................................... 113Clinical Experience in a Community Agency ................................................................ 114Student Evaluations in Specialty Rotations .................................................................. 115
Clinical Evaluation Tool – Medical/Surgical ........................................................................ 116
Pediatric Clinical Guidelines ................................................................................................ 125Directions to Sutter/Sacramento Clinical Site............................................................... 126Directions to: Children’s Hospital, Oakland ................................................................. 127Guide for Health History & Interview of Child and Family ............................................. 128Child Data Base .......................................................................................................... 129Lab Values & Diagnostic Tests .................................................................................... 131Medication Assignment Form ...................................................................................... 132Nursing Care Plan ....................................................................................................... 134Student Evaluation – Pediatric Rotation ....................................................................... 136
Clinical Evaluation Tool – Pediatrics ................................................................................... 137
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COURSE INFORMATION
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NAPA VALLEY COLLEGEASSOCIATE DEGREE PROGRAM IN NURSING
COURSE NUMBER AND TITLE: NURS 249 Nursing in Health Alterations IV
COURSE DESCRIPTION: Focus is on the application of the nursing process for clientswith multiple complex health alterations. The student functions
in the roles of manager and provider of care.
PREREQUISITES: NURS 246; 247; NURS 248245 Advanced Placement LVN/Paramedic Bridge (asapplicable)
NUMBER OF HOURS: Total Credit: 7 unitsClass: 4 units (72 hours of lecture/seminar)Clinical/Lab: 3 units (162 clinical hours)
NOTE: Clinical hours include Medical-Surgical and Pediatricclinical rotations, orientation hours associated with these
rotations and Simulation hours as follows:
M/S Clinical 104.0M/S Simulation 6.5Pediatrics Clinical 45.0Pediatric Simulation 6.5
Theory ClassesMonday 0800-1200Thursday 1000-1200
SeminarMonday 10-12
Clinical HoursPer assigned facility
REQUIRED TEXT / ONLINE Syllabus NURS 249
2011-2013 ADN Student HandbookRESOURCES:
Ackley, B. J., & Ladwig, G. B. (2011) Nursing diagnosishandbook: A guide to planning care. (9th ed.). St. Louis:Mosby.
Ball, J.W., & Bindler, R.C., (2012). Pediatric nursing: Caringfor children (5th ed.). New Jersey: Prentice-Hall
Ball, J.W.,& Bindler, R. C., (2012). Clinical skills manual forpediatric nursing. (5th ed.). New Jersey: Prentice-Hall.
Castillo, S. (2009). Strategies, techniques and approaches tothinking. (4th ed.). Philadelphia: W.B. Saunders.
Ebersole, O., & Hess, P. (2009). Geriatric nursing & healthyaging. St. Louis: Mosby. (3rd ed.)
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Elkin, M. K., Perry, A. G., & Potter, P. A. (2012). Nursing
interventions & clinical skills. (5th ed.) St. Louis: Mosby.
Hogstel, M. O., & Curry, L. C. (2005). Practical guide to healthassessment throughout the lifespan. (4th ed.) Philadelphia: F.
A. Davis.
Lewis, S. M., Hertkemper, M., & Dirksen, S. R. (2011).Medical-surgical nursing assessment & management ofclinical problems. (8th ed.) St. Louis: Mosby.
Nursing Skills Online course to accompany FundamentalsOf Nursing
Ogden, S. J. (2007). Calculation of drug dosages.(8th ed.) St.Louis: Mosby
Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing
(7th ed.). St. Louis: Mosby.
Purnell, L.D., (2009). Guide to culturally competent healthcare. (2nd ed.)Philadelphia: F.A. Davis
DRUG REFERENCEOPTIONAL TEXT Ackley, B. J. & Ladwig, G. B., 2011. Nursing Diagnosis
Handbook: An Evidence Based Guide. (9th ed) St. Louis:Mosby Elsevier
Deglin, J. H., & Vallerand, A. H. (2011). Davis drug guide fornurses. (12th ed.). Philadelphia: F.A. Davis.
Elkin, M. K., Perry, A.G., & Potter, P. A. (2007), NursingInterventions and Clinical Skills. (4th ed) St. Louis: Mosby
Evolve/Reach HESI Ticket for online
Gahart, B. L., & Nazareno, A. R. (2013), IntravenousMedications. (29th ed) St. Louis: Mosby
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher L., &Camera, I.M. (2011). Medical-Surgical Nursing Assessment &Management of Clinical Problems. (8th ed) St. Louis: MosbyElsevier
Mosby’s 2011 Nursing Video Skills 3.0 DVDs
Skidmore-Roth. (2013) Mosby’s nursing drug reference.(26thEdition) St. Louis: Mosby.
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Whitehead, D.K., Weiss, S.A., & Tappen, R.M. (2010).Essentials of Nursing Leadership and Management. (5th ed)Philadelphia: F. A. Davis Company
TEACHING METHODS: The theory portion of this course is taught primarily by lecture,class discussion, small group discussion, and seminars both in
person and on-line. The clinical portion includes simulationand demonstrations in addition to the in hospital clinicalrotations.
EVALUATION: To successfully complete this course, the student must achieve:
1. A minimum of 90.00% on the Drug Calculation CompetencyExam. Student may retest once and must have a minimumof 90%.
2. A cumulative average of a grade of C (75.00%). This will
include all tests, papers, and presentations
3. A satisfactory summative clinical performance evaluation inboth Pediatric and Adult Medical-Surgical Clinical.
4. A satisfactory preparation for and participation in seminars.
5. A satisfactory completion of all written assignments on boththe theory and clinical components of the course.
6. A satisfactory background clearance.
7. Up-to-date health records and CPR card.
8. Satisfactory attendance (see below)
Class/Seminar Attendance:
Regular attendance in all classes is important for satisfactoryacademic progress. The Napa Valley College attendanceregulations make provisions for a limited number of unavoidableabsences. However, a student who is absent for as many timesas a class meets each week will have exhausted this provision.
An instructor may request verification of those absences.Further absences may cause the instructor to drop the studentfrom the class. An alternative assignment (for seminar), due atthe beginning of the next class will be given to students who areabsent. Students will be graded on participation, preparationand compilation of assignments.
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NAPA VALLEY COLLEGEASSOCIATE DEGREE PROGRAM IN NURSING
Course Outcomes
NURS 249 – Nursing in Health Alterations IV
I. Use the nursing process for the care of clients with multiple complex alterations in health
II. Practice in accordance with safe, ethical, and legal guidelines in the Nurse Practice Act, ANA Code of Ethics and Nurse Practice Standards
III. Collaborate with clients and the interdisciplinary team using informatics and therapeuticcommunication to promote client-centered care
IV. Evaluate theory, quality monitors, and evidence-based knowledge for decision making toguide nursing practice and client outcomes
V. Manage client-centered care for clients with multiple complex alterations in health incollaboration with client and interdisciplinary team
VI. Demonstrate consistent commitment to continued professional growth and self-development
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UNIT I – NURSING CARE OFCHILDREN
WITH ACUTE, COMPLEX ILLNESS
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UNIT I – NURSING CARE OF CHILDREN WITH ACUTE, COMPLEX ILLNESSRELATED ACTIVITES – ASSIGNMENTS
REVIEW:
Physical and psychosocial developmental tasks, fears, nutrition, and play/activities for each
age group: infant, toddler, pre-school child, school-age child and adolescent CPR for infants and children
NURS 141, Unit II Health
Videos on Pediatric Assessment
Age-Specific Learning Resource Guide, NURS 141
Ball, J.W., Bindler, R.C., & Cowen, K. (2012), Principles of Pediatric Nursing: Caring forChildren. (5th ed) New Jersey: Pearson Education, Inc. Hall
o Chapter 1 – Nurse’s Role in Care of the Child (Hospital, Community, & Home) o Chapter 6 – Introduction to Health Promotion and Health Maintenanceo Chapter 10 – Nursing Considerations for the Child in the Communityo Chapter 12 – Nursing Considerations for the Child with a Chronic Conditiono Chapter 13 – The Child with a Life Threatening Condition and End of Life Careo Chapter 14 – Infant, Child, and Adolescent Nutritiono Chapter 15 – Pain Assessment and Managemento Chapter 17 – Assessment and Management of Social and Environmental Influences
on Children
READ:
Ball, J.W., Bindler, R.C., & Cowen, K. (2012), Principles of Pediatric Nursing: Caring forChildren. (5th ed) New Jersey: Pearson Education, Inc. HallChapter 11, The Hospitalized Child
WEB RESOURCES:
Iannelli, V Helping Your Child In An Emergency. Would you know what to do? (2006, June 14). About.com Guidehttp://pediatrics.about.com/cs/pediatricadvice/a/emergencies.htm
Roadmap to Teen Health. This counseling tool has been developed by the American Academy ofNurse Practitioners (Supported by an educational grant from Merck)http://www.aanp.org/images/documents/educadtion/RoadmapToTeenHealthFlipchart.pdf
Roadmap to Teen Health PowerPointhttp://www.aanp.org/education/education-toolkits
Safety Matter Pediatric Medication Guide from the American Academy of Nurse Practitioners and
National Association of Pediatric Nurse PractitionersThis flipchart is supported by an educational grant from McNeil Consumer Healthcare.http://www.aanp.org/images/documents/education/safetymatterspediatricmedicationguide.pdf
SEMINAR:
Helping children adapt to the hospital environment
http://pediatrics.about.com/cs/pediatricadvice/a/emergencies.htmhttp://pediatrics.about.com/cs/pediatricadvice/a/emergencies.htmhttp://www.aanp.org/images/documents/educadtion/RoadmapToTeenHealthFlipchart.pdfhttp://www.aanp.org/images/documents/educadtion/RoadmapToTeenHealthFlipchart.pdfhttp://www.aanp.org/education/education-toolkitshttp://www.aanp.org/education/education-toolkitshttp://www.aanp.org/images/documents/education/safetymatterspediatricmedicationguide.pdfhttp://www.aanp.org/images/documents/education/safetymatterspediatricmedicationguide.pdfhttp://www.aanp.org/images/documents/education/safetymatterspediatricmedicationguide.pdfhttp://www.aanp.org/education/education-toolkitshttp://www.aanp.org/images/documents/educadtion/RoadmapToTeenHealthFlipchart.pdfhttp://pediatrics.about.com/cs/pediatricadvice/a/emergencies.htm
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Theory Objectives Content Outline Lab/Clinical ObjectivesThe student will (be able
to):The student will (be able
to):
1. Describe how clientcentered care, teamwork
& collaboration,evidenced basedpractice, qualityimprovement, safety, andinformatics are used inthe nursing care ofchildren with acute,complex illnesses
2. Describe the healthcareneeds of the children ofthe 21st century.
3. Describe the leadingcause of death, accidentand injury in children ateach developmentallevel.
4. Identify factors thatinfluence the nursingcare of children and theirfamilies.
5. Describe some barriersto healthcare of children.
6. Describe how ANAstandards of MaternalChild Nursing contributeto quality of care forchildren and theirfamilies.
I. Nursing Care of Children with Acute,Complex Illness
A. Healthcare needs of children
B. Mortality
C. Morbidity1. Developmental characteristics
that lead to accidents2. Characteristics of accident
prone children3. Prevention4. School and community
agencies available
D. Influencing factors1. Type of family group
2. Cultural heritagea. Prevalent health problems
in specific culturesb. Influence on health
behaviors3. Socioeconomic status4. Environment
5. Concept of time
E. Barriers to care
F. Quality of care ANA standards
G. Nursing process, guide to care,assessment, and nursingapproach
1. Adapt the nursingprocess to provide care
for children of all agesand their families.
2. Use informationtechnology andcommunicationtechniques, play therapyand age specificteaching strategies tominimize the stress ofillness andhospitalization and to
provide anticipatoryguidance for the childand family.
3. Provide client-centeredcare that is comfortable,safe, and accurate tochildren and theirfamilies.
4. Use effective measuresto assess, intervene and
evaluate pain.
5. Use legal reportingrequirements of thenurse
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Theory Objectives Content Outline Lab/Clinical ObjectivesThe student will (be able
to):The student will (be able
to):
7. Identify how nursingprocess guides the
nursing care of the childand their family in avariety of settings.
8. Describe the care of achild with a lifethreatening illness orinjury.
9. Describe methods offeeding and commonproblems the nurse willsolve in providingadequate nutrition for thechild of any age.
10. Explain principles andnursing responsibilities in
medication administration& pre & post-operativecare.
11. Describe assessmentand management ofacute and chronic painand treatment.
12. Describe the use oftherapeutic play toexpress feelings in
children of any age.
13. Develop teachingstrategies to be used inproviding healthpromotion activities forany age group.
H. Child with life threatening illness,
injury1. Child’s experience 2. Family experience3. Stressors4. Crisis5. Common reactions6. Nursing care7. Case management
I. Nutrition1. Dietary patterns
2. Formula feedings3. Special diets4. Gavage
J. Principles and nursingimplications1. Medication Administration
a. Calculating dosagesb. Techniques of
administrationc. IV administration
2. Pre- and post-operative care
3. Management of pain
K. Therapeutic play1. Types2. Age-specific activities
L. Learning style, teachingstrategies
1. Infant2. Toddler3. Pre-School child
4. School age child5. Adolescent
M. Treatments/Procedures1. Oxygen administration2. Apnea monitors3. Telemetry4. Resuscitation5. Heel sticks
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Theory Objectives Content Outline Lab/Clinical ObjectivesThe student will (be able
to):The student will (be able
to):
14. Describe the care of thechild who requires
hospital care.
15. Compare the nursingresponsibilities for thecare of children in avariety of settings:
outpatient clinics, home,long term care, hospital,emergency room,intensive care.
6. Restraints7. Transportation
N. Care in a variety of settings1. Outpatient clinic2. Acute care3. Emergency room4. Intensive care5. Home6. Long term care
O. Legal & Ethical Issues1. Informed consent
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UNIT II – ALTERATIONS IN THENERVOUS/SENSORY SYSTEM
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UNIT II – ALTERATIONS IN THE NERVOUS/SENSORY SYSTEMRELATED ACTIVITES – ASSIGNMENTS
REVIEW:
Normal structure and function of the nervous/sensory system
NURS 141 – Assessment and Health Promotion of the Nervous/Sensory System
Lewis, S. L., Heitkemper, M. M., & Dirksen, S. R., O’Brien, D.G., & Bucky L. (2011). Medical-
Surgical Nursing Assessment & Management of Clinical Problems. (8th
ed) St. Louis: MosbyElsevier
o Chapter 56 – Nervous System
Ball, J.W. & Bindler, R.C. (2012), Pediatric Nursing: Caring for Children. (4th ed) NewJersey: Pearson Prentice Hall
o Chapter 5 – Pediatric Assessment
READ:
Lewis, S. L., Heitkemper, M. M., & Dirksen, S. R., O’Brien, D.G., & Bucky L. (2011). Medical-Surgical Nursing Assessment & Management of Clinical Problems. (8 th ed) St. Louis: MosbyElsevier
o Chapter 57 – Acute Intracranial Problems
o Chapter 58 – Strokeo Chapter 59 – Chronic Neurologic Problemso Chapter 61 – Peripheral Nerve & Spinal Cord Problems
Ball, J.W. & Bindler, R.C. (2012), Pediatric Nursing: Caring for Children. (4th ed) NewJersey: Pearson Prentice Hall
o Chapter 26 – Alterations in Neurologic Function
CLINICAL EXPERIENCES:
Provide Pre and Post education for a client having a CT or MRI.
Observe a specialist in neurology perform a neurologic exam.
Assist with a lumbar puncture/ interpret the results.
Care for clients with head / spinal injury Care for clients with long term or permanent neurologic deficits.
Present a case in post-conference for a client with neurologic injury using SBAR Format.Include in your nursing care plan evidence of patient centered care and teamwork andcollaboration.
Visit an acute rehabilitation center. Discuss the philosophy of rehabilitation with a rehabnurse.
SEMINARS:
Head Injury
Spinal Cord Injury
Epilepsy / Seizures Across the Lifespan
Chronic Neurological Deficits
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Unit II – Alterations in the Nervous/Sensory System
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Theory Objectives Content Outline Lab Clinical Objectives
The student will (be able to): The student will (be able to
1. Describe how clientcentered care, teamworkand collaboration, evidencebased practice, qualityimprovement, safety and
informatics are used in thenursing care of clients withalterations in thenervous/sensory system.
2. Describe how alterations inthe nervous/sensorysystem can lead to illness.
3. Describe the cause andclinical course of acute andchronic alterations in the
nervous/sensory system.
4. Compare chronicneurologic conditions foralterations in motorfunction, muscle tone,respiratory difficulty,disorders of locomotion,emotion and emotioncontrol, and sensory loss.
5. Identify populations at risk
for alterations in thenervous/sensory system.
6. Describe health promotionand prevention ofalterations or complicationsin the nervous/sensorysystem.
7. Explain the medical andsurgical management ofthe client with acute or
chronic alterations in thenervous/sensory system.
8. Describe the action, useand the implications fornursing of medicationsused in the management ofnervous/sensoryalterations.
9. Explain the difference in
I. Alterations in Nervous/Sensory System
Meningitis
Guillain Barré Syndrome
Multiple Sclerosis (MS)
Parkinson’s (PD)
Myasthenia Gravis (MG)
Epilepsy
Encephalopathy (All Forms)
Hydrocephalus
Cerebral Palsy
Intracranial HemorrhageEpiduralSubduralSubarachnoidIntracerebral
TraumaFractures
ConcussionContusionCoup-contra coupEpidural / Subdural
HerniationSupratentorialInfratentorial or SubtentorialUncal
Management of Increasing IntracranialPressure
TumorsPrimary, metastaticBrain, Spinal cord
Spinal Cord InjurySpinal ShockNeurogenic Shock
Autonomic dysreflexia
1. Perform a neurologicassessment according tothe guidelines given you.
2. Recognize signs of
impending myasthenic orcholinergic crisis and takeeffective actions.
3. Apply the nursing processin planning for and caringfor a client with deficits inneurologic function.
4. Delegate interventions foneurologic clients to teammembers according to
their experience level.
5. Institute measures topreserve function at theoptimum level and prevenfurther injury.
6. Provide nursing care for aclient with an actual orpotential problem ofsensory deprivation.
7. Identify support systemsavailable to the client.
8. Identify factors that mayimpede rehabilitation.
9. Identify psychosocialreactions to neurologicalterations present.
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Theory Objectives Content Outline Lab Clinical Objectives
The student will (be able to): The student will (be able to
cholinergic crisis andmyasthenic crisis.
10. Distinguish betweenhemorrhagic and ischemicstroke as to stroke
patterns, usual age group,onset of symptoms,medications, stages ofrecovery and nursinginterventions.
11. Explain the difference insymptoms and theirduration with transientischemic attacks (TIA), anda completed stroke.
12. Explain the nursing carebefore, during and afterdiagnostic tests of thenervous/sensory system.
13. Explain rationale forsignificant findings from aninterview and physicalassessment of a client withalterations in thenervous/sensory system.
14. Explain the progression ofsymptoms withsupratentorial herniation.
15. Given several assessmentsof a client, state whetherthe client’s condition isimproving or not.
16. Differentiate between theearly and late signs ofincreasing intracranial
pressure and the signs thatindicate herniation isoccurring.
17. Choose the most importantnursing action to take whenan assessment indicateschange in status isoccurring.
18. Identify nursing diagnoses
Diagnostic Tests
CTMRILP, CSFEEG (electroencephalography)EMG (electromyogram)Tensilon test
Neurologic Assessment
Neuro Specific Tests on Physical Examand equipment used
Cranial Nerve Assessment (12)LOCGlasgow Coma ScaleCognitive functionMotor functionSensory functionCerebellar functionCranial nervesReflexesVital signs
Pharmacology
AEDsCarbamazepine (Tegretol)Lamotrigine (Lamictal)Phenytoin (Dilantin)Fosphenytoin (Cerebyx)Gabapentin (Neurontin)Levetiracetam (Keppra)Topiramate (Topamax)
Diazepam (Valium)Lorazepam (Ativan)
Midazolam (Versed)
Mannitol (Osmitrol)Dexamethasone (Decadron)Methylprednisolone (SoluMedrol)
Levodopa (Sinemet)Benztropine (Cogentin)Ropinirole (Requip)
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Theory Objectives Content Outline Lab Clinical Objectives
The student will (be able to): The student will (be able to
to be used for alteration inthe nervous/sensorysystem.
19. Describe with rationalesnursing care planning,
interventions andevaluation of clients with analteration in thenervous/sensory system.
20. Describe nursinginterventions with rationalethat will assist a client withchronic neuralgic deficits tomaintain optimum healthand function as long aspossible.
21. Identify priorities in themanagement of the multi-trauma client.
22. Identify which nursinginterventions for thenervous/sensory client canbe delegated to a unitassistant or LVN.
23. State when and why the
nurse will increase ordecrease stimuli in theclient’s environment.
24. Predict the effect of stresson clients withdegenerative neurologicalterations.
25. Describe the nursingmanagement of majorphysical and psychosocial
problems for clients withspinal cord injury (SCI)during shock and afterrecovery from shock.
26. Identify the overall goals ofrehabilitation.
27. Identify ways for the familyto be included in therehabilitative process.
Interferon beta 1a and 1b (Betaserson / Avonex)
Glatiramer (Copaxone)
Mycophenolate (Cellcept)
IVIG
Rocephin, Vanco, Zosyn, Acyclovir
Pyridostigmine (Mestinon)Edrophonium (Tensilon)
rtPA (Alteplase)
Baclofen (Lioresal)
Legal/Ethical
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Theory Objectives Content Outline Lab Clinical Objectives
The student will (be able to): The student will (be able to
28. Identify statements that canbe made to a paraplegicclient regarding sexuality.
29. Outline essential content to
be included in clienteducation.
30. Describe home careservices to SCI clients.
31. Explain ethical/legal issuesrelated to care of clientswith nervous/sensoryalterations.
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UNIT III – ALTERATIONS IN THEINTEGUMENTARY SYSTEM
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UNIT III – ALTERATIONS IN INTEGUMENTARY SYSTEMRELATED ACTIVITES – ASSIGNMENTS
REVIEW:
Structure and function of the skin.
Assessment of clients with integumentary alterations. Nursing care of clients with integumentary alterations.
The assessment of the integumentary system.
Initiating a peripheral IV infusion.
Fluid and electrolytes.
READ:
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher L., & Camera, I.M. (2011). Medical-Surgical Nursing Assessment & Management of Clinical Problems. (8 th ed) St. Louis: MosbyElsevier
o Chapter 25 – Burns, pgs. 472-495o Chapter 67 – Shock, pgs. 1717-1743
Ball, J.W., Bindler, R.C., & Cowen, K. (2012), Principles of Pediatric Nursing: Caring forChildren. (5th ed) New Jersey: Pearson Education, Inc. Hall
o Chapter 31 – Alterations in Skin Integrity, Burns, pgs. 1055-1065o Chapter 21 – Alterations in CV Function, Shock, pgs. 637-644
Current internet resources
AV MATERIALS:
NV 246 – Critical Care: Emergency Burn Treatment
CASE STUDIES:
Case Study: Burn Trauma
Hypovolemic shock
CLINICAL EXPERIENCE:
Management of a client with multi-system failure related to an alteration in theintegumentary system.
Teach client and family methods of burn prevention.
Use the Rule of Nines and TBSA to determine extent of a burn injury.
SEMINARS:
Burn / Inhalation Injury
Delegating Nursing Care
Shock, Shock/MODS
Evaluating Performance
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Theory Objectives Content Outline Lab/Clinical Objectives
The student will (be able to): The student will (be able to):1. Describe how client
centered care, teamworkand collaboration,evidenced based practice,quality improvement,safety, and informatics are
used in the nursing careof clients with alterationsin the integumentarysystem
2. Identify differentcategories of burns andthe alterations in theintegumentary system thatcould result.
3. Identify risk factors withpotential complicationsdue to an alteration in theintegumentary systemrelated to a burn injury.
4. Summarize the phases ofcare a client with analteration in theintegumentary system,due to a burn injury, will
experience.
5. Specify how the nursingprocess can be used toeffectively manage theoutcome of a client withalterations in theintegumentary system dueto a burn injury.
6. Explain the classificationsystems and diagnostic
tests used to determinethe severity of a burninjury.
7. Describe potentialcomplications, treatmentand rationale formanaging the care of a
III. Alterations in the IntegumentarySystem
A. Categories of burns1. Thermal2. Chemical3. Electrical4. Radiation5. Inhalation
B. Risk factors with complications1. Location of burn2. Pre-existing disorders3. Trauma4. Age
C. Burn phases1. Pre-hospital care2. Emergent3. Acute4. Rehabilitation
D. Nursing Process1. Assessment2. Diagnosis3. Planning4. Implementation5. Evaluation
E. Classification and Diagnostic tests1. Depth2. Extent
3. Rule of Nines4. TBSA5. Laboratory tests
F. Potential complications1. Fluid and electrolyte
imbalances2. Shock3. Renal failure4. Hypothermia
1. Compose a teaching planfor a burn client and familyabout the four differentcategories of burns.Include at least onepreventative measure for
each category.
2. Delegate the care of aburn client based on yourassessment andknowledge of potentialcomplications and riskfactors.
3. Make a list of agencies orresources in yourcommunity available to
your client in therehabilitative phase of aburn injury.
4. Formulate a plan of carefor a client with analteration in skin integrityin each of the phases of aburn injury.
5. Calculate the extent of aburn injury by applying the
Rule of Nines and TBSAclassifications.
6. Manage the care of aclient who has developeda complication due to analteration in theintegumentary system.
7. Prioritize your nursingdiagnoses using Maslow’shierarchy of needs to
manage the care of aclient who has analteration in theintegumentary system.
8. Explain to a client that hasan alteration in theintegumentary system theimportance of reporting
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client with alterations inthe Integumentary systemdue to a burn injury.
8. Develop nursingdiagnoses and outcomecriteria for the client withan alteration in the
integumentary system dueto a burn injury.
9. Explain the potential forfluid imbalance andnutrition requirements ineach of the phases ofburn injury.
10. Summarize the impactthat alterations in theintegumentary system,(burns), can have on otherbody systems.
11. Describe pharmacologicalinterventions used fortreating the client with an
alteration in theintegumentary systemrelated to a burn injury.
12. Identify different woundcare considerations andoptions for a client with analteration in theintegumentary systemrelated to a burn injury.
13. Explain legal and ethicalissues related to the careof a client with analteration in theintegumentary systemrelated to a burn injury.
14. Describe the nursing
5. Septic shock
G. Nursing Diagnosis1. Fluid volume deficit2. Pain3. Self-care deficit4. Altered nutrition
5. High risk for infection6. High risk for impaired mobility7. Anxiety8. Knowledge deficit
H. Fluid imbalances & nutritionalrequirements1. Emergent2. Acute3. Rehabilitation
I. Body systems
1. Cardiovascular2. Respiratory3. Renal4. Endocrine5. Gastrointestinal
J. Pharmacological interventions1. Pain management2. Topical antimicrobials3. Antibiotics4. Tetanus5. Sedatives
K. Wound Care & Options1. Infection control2. Hydrotherapy3. Debridement4. Wound coverings
L. Legal & Ethical issues1. Cost of care2. Trained personnel3. Right to life4. Emotional support
M. MODS1. Events
a. SIRSb. Organ dysfunctionc. DIC
2. Mechanisms
significant weightchanges.
9. Manage the care of theclient who has multi-system failure.
10. Start peripheral IV usingguidelines taught in skillslab.
11. Manage the care of aclient who has a complexwound care regime due toan alteration in the
integumentary system.
12. Describe the process forreporting a legal or ethicalissue to a client or familymembers in the healthcare facility where you areassigned.
13. Identify assessment datathat suggests a client isdeveloping MODS.
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management of the clientwith Multiple OrganDysfunction Syndrome(MODS).
a. Change in circulatingvolume
b. Tissue hypoxiac. Myocardial depressiond. Hypermetabolism
3. Early signs & symptomsa. Temperature
b. Heart Ratec. Respiratory Rated. WBC
4. S & S of organ failurea. Respiratoryb. Neurosensoryc. Renald. CVe. GIf. Liver
5. Progressiona. Adult
b. Child6. Prevention7. Nursing process
a. Assessment/earlydetection
b. Planning(1) Prevent/treat
infection(2) Nutrition/
metabolicsupport
(3) Maintain tissue
oxygenation(4) Support forindividualorgans
c. Collaboration
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UNIT IV – ALTERATIONS INCELLULAR GROWTH/IMMUNITY
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UNIT IV – ATERATIONS IN CELLULAR GROWTH/IMMUNITYRELATED ACTIVITES – ASSIGNMENT
REVIEW:
A & P of the Immune System
Mechanisms of Immunity
NURS 142
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher L., & Camera, I.M. (2011). Medical-Surgical Nursing Assessment & Management of Clinical Problems. (8th ed) St. Louis: MosbyElsevier
o Chapter 7 – Community Based Nursing & Home Care, pgs. 85-93o Chapter 11 – End of Life & Palliative Care, pgs. 151-164
READ:
Potter, P. A. & Perry, A. G. (2009). Fundamentals of Nursing. (7th ed.) St. Louis: MosbyElsevier
o Chapter 7 – Caring for the Cancer Survivor, pgs. 84-94
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher L., & Camera, I.M. (2011). Medical-
Surgical Nursing Assessment & Management of Clinical Problems. (8th
ed) St. Louis: MosbyElsevier
o Chapter 14 – Genetics, Altered Immune Response & Transplantation, pgs. 206-234o Chapter 16 – Cancer, pgs. 260-300
Ball, J.W. & Bindler, R.C. (2012), Pediatric Nursing: Caring for Children. (4th ed) New Jersey:
Pearson Prentice Hallo Chapter 23 – Alterations in Cellular Growth, pgs. 837-901
Guidelines for Detection of Cancer, American Cancer Society.o http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/america
n-cancer-society-guidelines-for-the-early-detection-of-cancer
SELECTED WEBSITES:
www.guidelines.gov
www.cancer.org
www.supersibs.org
CLINICAL EXPERIENCES:
Care for adults with cancer of the colon, lung, breast, bowel, prostate.
Care for children with leukemia, brain, bone and soft-tissue tumors.
Find out what services are in this community for the care of cancer clients.
Discuss alternative methods used to increase faith and hope.
SEMINARS:
Health Promotion in the Community –Oral Presentation/Paper
Using Nursing Process to care for clients diagnosed with cancer
Multidisciplinary Care for clients with cancer
Rectal Cancer
http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancerhttp://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancerhttp://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancerhttp://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancerhttp://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancerhttp://www.guidelines.gov/http://www.guidelines.gov/http://www.cancer.org/http://www.cancer.org/http://www.supersibs.org/http://www.supersibs.org/http://www.supersibs.org/http://www.cancer.org/http://www.guidelines.gov/http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancerhttp://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer
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Theory Objectives Content Outline Lab/Clinical Objectives
The student will (be able to): The student will (be ableto):
1. Describe how clientcentered care, teamworkand collaboration,
evidenced basedpractice, qualityimprovement, safety, andinformatics are used inthe nursing care of clientswith alterations in cellulargrowth/immunity.
2. Describe how alterationsin the immune system orin cell growth can lead toillness.
3. Describe the cause,symptoms and clinicalcourse for alterations inthe immune system.
4. Identify populations atrisk for alterations in theimmune system.
5. Explain the significanceof a depressed immune
system.
6. Describe healthpromotion & prevention ofalterations orcomplications in theimmune system.
7. Explain the medical andsurgical management ofthe client with alterationsin the immune system.
8. Describe the action, useand the implications fornursing for medicationsused in the managementof alterations of theimmune system orcellular growth.
A. Alterations in Cellular Growth/Immunity1. Exaggerated response
a. Anaphylaxis
2. Misdirected responsea. Autoimmune response
(1) Organ specific(2) Systemic (Generalized Lupus
Erythematosis) (SLE)b. Graft rejection
3. Deficient response(Immunodeficiency)a. Natural deficit
(1) Inherited severe combinedimmunodeficiency disease(SCID)
(2) Ageb. Acquired deficit
(1) AIDS(a) Opportunistic infections(b) Urgent care(c) Kaposi’s Sarcoma
(2) Malnutrition(3) Stress(4) Pathologic(5) Artificial(6) Radiation(7) Medications
4. Proliferative responsea. Incidence and mortalityb. Characteristics of malignancy
(1) Normal cells(2) Cancer cells
c. Characteristics of malignancy(1) Infiltration(2) Metastasis(3) Classification(4) Phases
(a) In situ(b) Localized
(c) Invasive(d) Metastatic
(5) Types(6) Method of spread(7) Sties of metastasis(8) Result if untreated(9) Differences in children(10) Grading and staging(11) Complications of cancer
1. Implement measures todecrease the risk ofinfection.
2. Prepare the client forand care for them afterdiagnostic tests.
3. Plan, implement andevaluate care for clientreceiving cancertherapy.
4. Assess clients forpresence of
complications or toxicside effects of cancertherapy.
5. Apply principles of painmanagement used inclients with cancer.
6. Assess clientsexperiencing a changein body image.
7. Formulate someoutcomes related to thenursing diagnoses ofclients with cancer.
8. Implement measures tomaintain adequate fluidand nutritional status.
9. Support client/familiesin grief process.
10. Use therapeuticcommunication to helpa client expressfeelings about theirexperience.
11. Develop and carry out agroup health educationprogram about the
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Theory Objectives Content Outline Lab/Clinical Objectives
The student will (be able to): The student will (be ableto):
9. Explain rationale forsignificant findings froman interview & physical
assessment of a clientwith an alteration in theimmune system.
10. Describe with rationalenursing care planning,interventions & evaluationof clients with analteration in the immunesystem.
11. Identify body sites of
cancer incidence andmortality in men andwomen.
12. Compare benign andmalignant cells for growthrate, spread andrecurrence.
13. Describe ways cancerspreads through the bodyand what happens if not
treated.
14. Describe classification ofcancer by staging andgrading.
15. Describe prevention andearly detection measuresand nursing care forcancer of the lung,breast, colon, uterus,skin.
16. Describe early detectionand nursing care forchildhood cancers:leukemia, brain, bone andsoft tissue tumors.
17. Explain the nursing carebefore, during and after
(a) Hypercalcemia(b) Spinal cord compression(c) Superior vena cava
compression(d) Hyperuricemia(e) Effusions(f) Sepsis(g) Renal failure(h) Hyperkalemia(i) Tumor Lysis Syndrome
B. Risk Factors1. Heredity2. Environment3. Demographics4. Geography
5. Cultural practices6. Psychologic factors7. Iatrogenic8. Diet9. Stress10. Chronic irritation11. Socioeconomic status
C. Prevention and Early Detection1. Detection
a. ACS warning signsb. Additional signs in children
2. Screening
a. Cultural factors(1) Hispanic(2) African American(3) Asian(4) American Indian
b. ACS guidelines for persons ataverage risk(1) Melanoma(2) Breast cancer(3) Colon(4) Uterus(5) Lung
c. Preventiond. Late signs
D. Nursing Assessment of Alterations in theImmune System1. Significant findings
E. Diagnostic Studies1. Tumor markers2. Serum enzymes3. Uric acid
seven warning signs ofcancer or someprevention or screening
methods.
12. Coordinate teaching,referrals and dischargeplanning with otherhealthcare teammembers.
13. Demonstrateresponsibility andaccountability infunctioning as a
member of thehealthcare team in thiscommunity.
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Theory Objectives Content Outline Lab/Clinical Objectives
The student will (be able to): The student will (be ableto):
diagnostic tests of theimmune system or thoseused to detect abnormal
cell growth.
18. Describe the rationale,side effects and toxiceffects of traditional andcurrent treatments forcancer.
19. Describe the impact ofhope on the immunesystem.
20. Explain the role of thenurse related tocomplimentary,alternative and/orunproven methods ofcancer therapy.
21. Summarize psychosocialalterations for clientsdiagnosed with cancerand clients undergoingtherapy.
22. Formulate a list ofpotential nursingdiagnoses when caringfor clients with alterationsin the immune system.
23. Evaluate the quality ofinformation available onthe Web for professionalsand clients.
24. Explain ethical/legalissues related to care ofclients with immunesystem alterations.
4. Cytology5. Hormonal Receptor Assays6. X-ray
7. Biopsy8. Endoscopy9. Bronchoscopy10. Thoracentesis11. Lymphangiogram12. Anergy Panel
F. Nursing Care Planning, Implementationand Evaluation1. Current treatment modalities
a. Preference – Sensitive cancerdecisions
b. Shared decision –making
approachc. Chemotherapy
(1) Classic / Conventional /Cytoxic(a) Alkylating agents(b) Plant alkaloids(c) Antimetabolites(d) Antitumor antibiotics(e) Hormones(f) Corticosteroids
(2) Cytoprotectants/ Antidotes(3) New Age/Cytostatic
(a) Monoclonal Antibodies(b) Small molecules(c) Biologic response modifiers(d) Hormones(e) Vaccines
(4) Approaches(a) Combination(b) Adjuvant(c) Palliative
(5) Schedule(6) Routes(7) OSHA guidelines
b. Radiation(1) Targeted therapy(2) Internal(3) External
c. Surgeryd. Blood componentse. Bone marrow and stem cell
transplantf. Nutrition
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Theory Objectives Content Outline Lab/Clinical Objectives
The student will (be able to): The student will (be ableto):
g. Medications (other)h. Pain managementi. Marijuana use
j. Supportive therapy(1) Therapeutic communication
(a) Cultural values(b) Elements of a comforting
(healing) response.(2) Palliative care(3) Hospice
k. Complementary therapies2. Coping mechanisms3. Hope4. Questionable methods of cancer
treatment (Quackery)
5. Rehabilitation6. Life after cancer
(a) Sequelae(1) Late effects(2) Long-term effects
(b) Interview/assessment(c) Childhood cancer survivors
7. Essential components of survivorshipcare
8. Alternative/complimentary therapya. Nurse role
G. Toxic Effects of Chemotherapy and
Radiation1. Cancer related fatigue & sleep
alterations2. Targeted therapy side effects3. Cytotoxic chemotherapy
(a) Agranulocytosis(b) Depressed bone marrow(c) Bleeding tendencies(d) Anemia(e) Nausea/vomiting(f) Stomatitis(g) Alopecia
(h) Constipation/Diarrhea(i) Extravasation(j) Immunosuppression(k) Other systemic effects(l) Sexual/reproductive effects(m) Infertility(n) Psychosocial effects
H. Safe Environment for Family and Nurse(OSHA)
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Theory Objectives Content Outline Lab/Clinical Objectives
The student will (be able to): The student will (be ableto):
I. Psychosocial Impact1. Confront diagnosis2. Develop strength
3. Maintain connectionsJ. Nursing DiagnosesK. TeachingL. Discharge Planning
1. Symptom prevention or control2. Community agencies3. Support groups4. Referrals5. Role of family/community
M. Legal/Ethical Issues1. Principles
a. Autonomy
b. Beneficencec. Fidelityd. Sanctity of lifee. Veracity
2. Trendsa. Alternative medicine
(1) Implications for care(2) No FDA guidelines
b. With HIV(1) Client vs. hcw(2) Confidentiality vs. disclosure(3) Mandatory vs. voluntary
testingc. With cancer, terminal illness
(1) Pain control(2) Euthanasia, mercy
killing
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UNIT V – ALTERATIONS IN THEENDOCRINE/METABOLIC SYSTEM
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UNIT V – ALTERATIONS IN THE ENDOCRINE/METABOLIC SYSTEMRELATED ACTIVITES – ASSIGNMENTS
Review:
NURS 141 on endocrine system.
Normal function of endocrine system including synthesis, releasing mechanisms, targetorgans, effect of hormones, negative feedback, renin-angiotensin-aldosterone-axis.
Major physiological functions of the liver.
Lewis, S. L., Heitkemper, M. M., & Dirksen, S. R., O’Brien, D.G., & Bucky L. (2011). Medical-Surgical Nursing Assessment & Management of Clinical Problems. (8 th ed) St. Louis: MosbyElsevier
o Chapter 39 – Gastrointestinal Systemo Chapter 48 – Endocrine Systemo Chapter 49 – Diabetes Mellitus
Read:
Lewis, S. L., Heitkemper, M. M., & Dirksen, S. R., O’Brien, D.G., & Bucky L. (2011). Medical-Surgical Nursing Assessment & Management of Clinical Problems. (8 th ed) St. Louis: MosbyElsevier
o Chapter 49 – Diabetes Mellitus . 1242-1246 Acute Complicationso Chapter 50 – Endocrine Problemso Chapter 44 – Liver, Pancreas, & Biliary Tract Problems
Ball, J.W. & Bindler, R.C. (2008), Pediatric Nursing: Caring for Children. (4th ed) New Jersey:Pearson Prentice Hall
o Chapter 29 – Alterations in Endocrine & Metabolic Functiono Chapter 24 – Alterations in GI Function, Viral Hepatitis
Seminars:
Legal-Ethical
Assertive Behavior
Endocrine Alterations / Endocrine Case Studies
Acute Liver Failure / Acute on Chronic Liver Failure
Alcoholic Liver Disease and ETOH Withdrawal
Hypofunction Hyperfunction
Pancreas / Diabetes / Hypoglycemia Pancreas/Diabetes / DKA, HHS
Adrenal Gland / Addison’s Disease Adrenal Gland / Cushing’s Syndrome
Thyroid /Hypothyroid/ Myxedema Coma Thyroid / Hyperthyroid / Thyroid Storm
Pituitary Growth Hormone /Hypopituitarism Pituitary Growth Hormone / Acromegaly
Pituitary Decreased ADH / Diabetes Insipidus Pituitary Increased ADH / SIADH
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Unit V – Alterations in the Endocrine/Metabolic System
31
Theory Objectives Content Outline Lab/Clinical Objectives
The student will (be able to): The student will (be able to):
1. Describe how clientcentered care, teamworkand collaboration,evidence based practice,quality improvement,
safety and informatics areused in the nursing careof clients with alterationsin theendocrine/metabolicsystem.
2. Delineate the major healthproblems, risk factors, andmedical or surgicalinterventions in alterationsof the endocrine system.
3. Predict the long-termeffects ofdeficits/excesses ofhormones on the clientincluding effects on growthand development.
4. Explain the expectedeffects, side effects andcomplications ofcorticosteroid therapy.
5. Explain the significance ofdiagnostic lab studiesfrequently ordered toevaluate the endocrinesystem.
6. Explain rationale forassessment findings of allbody systems when aclient has an alteration inthe endocrine system.
7. Explain the medical andsurgical management ofthe client with an alterationin the endocrine system.
8. Describe the action, useand the implications fornursing of drugs used inthe medical managementof endocrine alterations.
See Table Previous Page
Potential Complications
PC: Addisonian CrisisPC: Electrolyte imbalancePC: Thyroid StormPC: Cardiac Arrhythmias
Endocrine Diagnostic Studies /Labs
CT Scan and MRIRadioactive Iodine Uptake (RAI)
Serum and Urine Sodium / OtherElectrolytes / Osmolarity /Osmolality
TSH, T3, T4CortisolSuppression / Stimulation Tests
1. Apply nursing processin planning and caring fora client with a hormonalimbalance.
2. Develop a client centeredindividualized nursingcare plan (includingcultural, ethnic practices,psychosocial and learningneeds) for a client with anendocrine/metabolicalteration.
3. Set priorities for actionsusing the problem solvingprocess.
4. Implement effectivenursing interventions forclients withendocrine/metabolicalterations.
5. Evaluate the expectedoutcomes of the nursingintervention and revisecare plan.
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Theory Objectives Content Outline Lab/Clinical Objective
The student will (be able to): The student will (be able
9. Formulate outcome criteriabased on identified nursingdiagnoses.
10. Describe with rationalenursing care planning,interventions andevaluation of clients withan alteration of theendocrine system.
11. Identify priorities in themanagement of clientswith alterations in theendocrine system.
12. Develop a teaching planfor a client with analteration in the endocrinesystem.
13. Identify resourcesavailable to clients andtheir families in dealingwith alterations in theendocrine system.
14. Explain some of the legal
and ethical issues relatedto the care of clients withan alteration in theendocrine system.
15. Describe how alterationsin the liver can lead toillness.
16. Compare Hepatitis A, B, Cand D.
Pharmacology Categories
Hormone replacement
“Anti-glandular” medications Corticosteroids
Drug Therapy for Chronic ViralHepatitis
Drug Therapy for Cirrhotics
Use of Steroids
Expected effectsSide effects, complications
Alterations in Liver Function Acute Liver Failure / Acute on ChronicLiver Failure
CirrhosisCompensated vs DecompensatedSymptoms of Hepatic DecompensationPortal HypertensionThird spacing – AscitesEsophageal Variceal BleedingSBPJaundiceHepatic Encephalopathy
Hepatitis – General
ClassificationsMode of transmissionMarkersWhen infective /risks of transmissionClinical characteristicsPreventive/post exposure therapyPrognosis
Risk Factors
Alcohol, chemicalsDrug overdoseIatrogenicIVDU, others
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Theory Objectives Content Outline Lab/Clinical Objectives
The student will (be able to): The student will (be able to)
17. Identify factors that placeclients at risk for liverfailure.
18. Explain the significance of
the results of diagnosticstudies ordered to evaluateclients with alterations inliver function.
19. Explain rationale forassessment findings of allbody systems when aclient has liver failure.
20. Explain the medical andsurgical management of
the client with an alterationin the metabolic system(liver).
21. Describe the action, useand implications for nursingof drugs used in themedical management ofclients with alterations inthe liver.
22. Formulate outcome criteria
based on identified nursingdiagnoses.
23. Describe with rationalenursing care planning,interventions andevaluation of clients withan alteration of the liver.
24. Identify priorities in themanagement of clients withalterations in the liver.
25. Identify resources availableto clients and their familiesin dealing with alterationsin the liver.
26. Explain some of the legaland ethical issues relatedto the care of clients withan alteration in the liver.
Diagnostic Lab
ALT (SGPT) AST (SGOT) Alkaline phosphatase
GGTCholesterolHepatitis markersH&HWBCPlateletsBlood Ammonia
AlbuminPT/INRBilirubinDirect (conjugated)Indirect (unconjugated)
Medical/Surgical Management
Liver BiopsyEndoscopyBlakemore-Sengstaken tubeSurgicalShunts - TIPS
Medications
1. Vasopressin
2. Diuretics3. Antibiotics4. Neomycin5. Lactulose6. Fresh blood
Nutrition
Transmission Precautions
Risks of Alcohol Withdrawal
Legal/Ethical
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SEMINARS
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SEMINAR: HELPING CHILDREN ADAPT TO THE HOSPITAL ENVIRONMENT
OBJECTIVES:
1. Identify the major biologic, psychosocial, cognitive, and social developments for children.
2. Discuss the development and relationships of personality, cognitive, language, moral, spiritualand self-concept.
3. Describe the role of play in the growth and development of children.4. Describe guidelines for communication and interviewing.5. Describe nursing strategies to promote optimal nutritional/fluid balance.6. Describe pain management strategies.
PREPARATION:
1. Divide into groups.2. Choose one of the following hospitalized children to present:
8-month-old with diarrhea and dehydration Toddler with Cystic Fibrosis
5-year-old with leukemia
Fifth-grader with diabetes
Pregnant 15-year-old
PRESENTATION: Time allotted is 20 minutes for A and B
A. For the age group selected:1. Provide description of disease process, signs and symptoms, statistics, and nursing
implications.
2. Bring a game or project and give rationale for choice.3. Identify gross and fine motor development.4. Identify cognitive and social development.5. Identify anticipatory guidance for injury prevention and safety.6. Cite resources (APA format) during the presentations and make available to participants.
B. For the age group selected:1. Plan a lunch menu (suggest bring sample food items, poster or a collage).2. Identify dietary requirements from each of the food groups.3. Identify fluid requirements (oral and parenteral). Provide example and calculations.4. Identify anticipatory guidance for nutritional requirements and discharge instructions.5. Cite resources (APA format).
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SEMINAR: ORGANIZING CLIENT CARE
Using the nursing unit below, complete the following process for organizing client care:
1. Establish a philosophy for the care of children in your unit.
2. Write specific outcome statements for each client and for each team member.3. Write 1-2 high priority nursing diagnoses, identify what client is at risk for and how to prevent
it.4. Consider if room assignments are appropriate.5. List all of the activities in the care of each client for the shift.6. Identify all general or routine unit activities that will occur during the shift, i.e. refill water
pitchers, stock cabinets, etc.7. Identify any major concerns for the day that will influence your assignment.8. Make assignments according to usual job descriptions and Nurse Practice Act.9. Identify delivery care model.
TEAM MEMBERS
Jean RN, worked on unit for 2 years, very capable
Paul UA, worked on unit for 1 year, prefers younger children
Sue RN, 2 years’ experience
Allen Child life therapist will make rounds
Kathy RN, Head Nurse, experienced pediatric nurse
QUESTIONS:
1. Are room assignments satisfactory? What changes would you make, if any?
2. What changes might you make if Melissa was developmentally delayed?
3. A client care conference is scheduled for today at 1:30. Choose a client to present. What will
be the issues/concerns, priorities, and plans?
4. According to the Nurse Practice Act, what is the role of the nurse?
5. What are the standards of competent performance? (Title 16 Section 1443.5)
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NURSING UNIT
You are Kathy the shift lead today 7-3:30 pm for this group of 10 clients on a pediatrics unit.
Private rooms:
Susan Age 11, appendectomy admitted to OR last night and transferred from PACU at 3 am
Patrick Age 14 months, admitted yesterday with croup with blow-by oxygen and IV steroids,would probably be discharged tomorrow
Russell Age 14, cystic fibrosis, fourth hospitalization this year, critically ill, prognosis guarded;Parents at bedside, 2 younger children at home, RT scheduled at 9 am
Laura Age 6 months, with failure to thrive (FTT), birth weight 7 lbs., currently weighs 10lbs., gained 3 ounces in last 24 hours
Shane Age 2 years, diarrhea from salmonella
Stephanie Age 13 with anorexia nervosa
Sharing rooms:
Tony Age 4, osteomyelitis left great toe and bottom of foot, on multiple IV antibiotics, dailywound packing and wet to dry dressing bid
Peter Age 5, asthma exacerbation
Tonya Age 9, fell off bicycle, suffered concussion, going home today
Melissa Age 6, cerebral palsy, had bilateral heel cord lengthening 2 days ago, in casts,discharge planning in progress.
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WORKSHEETS
UNIT PHILOSOPHY:
OUTCOMES FOR ALL CLIENTS:1. SUSAN2. PATRICK3. RUSSELL4. LAURA5. SHANE6. STEPHANIE7. TONY8. PETER
9. TONYA10. MELISSA
GOALS FOR TEAM MEMBERS:KATHY, RN CHARGEJEAN, RNPAUL, UA
ALLEN, CHILD LIFE THERAPISTSUE, RN
UNIT ACTIVITIES (REFILL WATER PITCHERS, STOCK CABINETS, ETC.):
DELIVERY CARE MODEL:
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LUNCH TIMES: BREAK TIMES:
STAFF CLIENT NURSINGDIAGNOSES
OUTCOMES ACTIVITIES COMMENTS
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UNIT II SEMINAR: HEAD INJURY
Bobby, 17 years old, falls off the roof of his house and hits his head on the pavement. He isunconscious for about 5 minutes. Upon awakening, he is able to walk into the house. After 30minutes he begins to be confused and irritable. He complains of a headache with nausea and
vomiting. He arrives at the ER after about 90 minutes. In the ER, Bobby was able to move all ofhis extremities and was combative and confused. His pupils were equal at 3mm and reactive tolight. GCS of 10.
ER Assessment:GCS drops to 7 and he is comatose. An ET tube was placed and an orogastric tube was inserted.He was admitted to the unit.
1. What is the significance of a GCS of 7? What is the significance of a GCS of 3 ?
2. What neurologic parameters would you continue to monitor on admission?
3. How would the nurse recognize the early signs of increasing intracranial pressure?
4. What further assessments were indicated when his condition deteriorated?
5. What other complications could occur? How could you prevent them? What interventionswould help to decrease mortality and failure to rescue?
6. Which initial assessment findings would lead you to suspect epidural hematoma?
7. Describe the pathophysiology of an epidural bleed.
8. What is meant by “uncal” herniation?
9. Were the symptoms described the classical symptoms described in the text?
10. Why were pupil changes ipsilateral and motor changes contralateral?
11. Why did he need the ET tube and an orogastric tube?
12. Explain the normal homeostatic regulatory mechanisms that maintain normal intracranialpressure.
13. Describe the nursing management of Bobby and his head injury. Name the desiredoutcomes and why your nursing measures work.
14. Why might mannitol be ordered?
15. What measures can the nurse take to control the environment for Bobby?
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16. When a client is completely sedated and paralyzed or in a barbiturate coma, what are theadvantages and disadvantages for the client and nurse?
17. What is the significance of a Cushing reflex?
18. What does the family of a critically head injured client need from the nurse?
19. What is the nurse’s role when providing interdisciplinary care to the client and family?
20. If the client survives this injury and is able to be discharged home, what instructions shouldthe family receive about Post Traumatic Brain Injury (PTBI)?
21. List six nursing diagnoses that apply to this client.
22. What is the most common cause of head injury?
23. What is the morbidity and mortality within your community?
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UNIT II SEMINAR: SPINAL CORD INJURY
Respond to the following case scenario.
A 19 year old college student is brought to the unit after a rock climbing accident. He fell 30 feet tothe ground. He was found lying in a supine position, unable to move any extremities andcomplaining of neck pain. He is alert and oriented, his conversation is appropriate. He complainsthat he cannot feel his arms or legs. His pupils are equal and reactive to light. VS are BP 110/72,HR 82, R 18 Paramedics apply a surgical collar, place him on a backboard, immobilize his headand transport him to the hospital.
An assessment in the emergency room reveals that his sensory perception ends at an imaginaryline across his chest about 3 inches above the nipple line. He has some sensation in his arms andcan raise his shoulders but not his arms. His lower extremities are flaccid. VS are BP 94/55, HR64, RR 24, shallow. O2 sat is 92% on room air. Temp is 102 degrees F. Color is dusky, skin warmand dry. No history of neurological or metabolic disease.
X-ray revealed a fractured vertebra, decreased lung expansion upon inhalation. Blood tests werenormal except pH = 7.25.
Methylprednisolone (Solu-medrol) 30mg/kg IV was given over a period of one hour. An infusion of5.4mg/kg/hr. was then started to continue for 23 hours. Protonix was also ordered. Tongs wereplaced, with 20 pounds of weight.
He is on a Stryker frame, is receiving oxygen at 4 liters via nasal cannula with peripheral IV 0.9 NSat 42 ml/hr.
He was transferred to the trauma unit. Hgb and Hct were normal. Blood sugar was 562mg/dL, was
repeated and was accurate. Ketones were negative. Blood alcohol was normal.
One week later his vital signs are normal. There is no change in arm strength or sensation. He hasmarked spasms and exaggerated stretch reflexes in his lower extremities. He has urinaryincontinence and a Foley catheter is required.
1. How many spinal cord injured clients are living in the US? What is the initial hospitalizationand average lifetime cost?
2. Why did his heart rate and blood pressure fall during this emergency? Why was hisbreathing rapid and shallow? Why was the blood pH below normal?
3. What other clinical examination findings were present and why?
4. What is your interpretation of the elevated blood glucose in a person with no history ofmetabolic disease? What would you anticipate the doctor ordering? Why would Protonix beordered?
5. Explain the pathophysiology of spinal shock.
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6. For what treatment/interventions will you set up?
7. How long might this shock last?
8. One week after the injury, his signs and symptoms had changed. Explain these findings?
9. Why did he suffer from urinary incontinence?
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UNIT II SEMINAR: Chronic Neurologic Alterations
Parkinson’s Disease John Smith, age 67, an African-American gentleman is seen in a clinic. His chief complaint istremors that have progressively gotten worse over the last six months. His handwriting has also
become almost illegible. His wife describes him as depressed, with a blank look on his face andslowed speech. An assessment reveals tremors, movement of the thumb and index finger in acircular movement; shuffling gait, fatigue, drooling, rigidity during ROM, voice weak and soft,constipation, difficulty moving from sitting to standing position, and unable to perform rapidalternating movements. He is admitted for adjustment of his medications. When discharged, hewill be receiving carbadopa/levodopa 25/100 bid PO and Benadryl 25 mg PO qhs.
1. Mr. Smith was diagnosed with Parkinson’s disease. What data was collected that supportsthis diagnosis?
2. What additional information could be used to confirm that diagnosis?
3. What are the nursing considerations for Mr. Smith?
4. Develop 2 nursing diagnoses from the data provided and explain.
5. Describe the process of medication reconciliation. Identify questions you would want toknow have been answered.
6. Develop a teaching plan (outcomes and content) for a community group that providesinformation that will increase knowledge about PD and its management.
Outcomes1.
2.3.4.
Content
Guillain BarréClient, age 60 became ill and was admitted to the hospital 5 days later. He had been running afever, had chills, abdominal discomfort and sinus congestion and fatigue. While in hospital, he hadlab tests, x-rays and an MRI. After 2 days he had sudden bilateral lower extremity paralysis andwas diagnosed with GB. His past medical history was not significant. He did have mild COPD. He
is married and has 3 children
1. What specific assessments would the nurse make immediately?
2. What is in this client’s history that suggests GB?
3. What is the likely progression and prognosis for this client?
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4. Discuss the purpose the nursing implications of each of the medical therapies that might beprescribed.a. Immune-related treatments – corticosteroids, IVIG, plasmapheresis
b. Meds – Protonix, LMWH, Lexapro, Restoril
5. What complications would you observe for and how could you prevent them?
Myasthenia Gravis A 30 year old woman is admitted with muscle weakness in the face that has been getting worseover the past 2 months. She says her jaws get tired as she chews, and swallowing has becomedifficult. She notices that she has diplopia after reading for a while. Her assessment reveals ptosisof the eyelids, mild muscle weakness that is progressive as movement continues. An EEG revealsprogressive weakness. Her symptoms are reversed in 40 seconds after an IV dose of Tensilon, anacetylcholinesterase inhibitor (anticholinesterase). She is diagnosed with MG and started onpyridostigmine bromide and prednisone. When her symptoms become severe she undergoesplasmapheresis. She uses atropine as needed to decrease nausea, abdominal cramps andsalivation which she experiences as side effects of the anticholinesterase.
1. Why is she experiencing difficulty chewing and swallowing?
2. How do anticholinesterase medications improve skeletal muscle function?
3. Why is atropine beneficial in treating side effects experienced?
4. How does the corticosteroid benefit the client?
5. Why does plasmapheresis help her?
6. Why is she at increased risk for respiratory failure?
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UNIT II SEMINAR: Epilepsy / Seizure Disorders Across the Lifespan
Group One Case Study Febrile SeizureMinimum # of Students 5
Objectives:
1. Demonstrate how a focus on the QSEN competencies of Safety, Teamwork and Collaboration,Evidence Based Practice, Quality Improvement and Informatics enable the nurse to provide PatientCentered Care.
2. Demonstrate appropriate teaching to the patient and family after a child presents to theEmergency Room with a febrile seizure.
Primary Method: Role playing
Additional Methods: Utilization of Web Resources
Present this case to the class with each student assuming a role:
Narrator: Reads the case study to the class. Keeps track of time (15”) for presentation.Summarizes the important points and demonstrates QSEN Competency by providing additionalEvidence Based Information found in a web search.
Registered Nurse #1 You have taken the History / Performed the Physical Exam (The PE isnormal). Tell the class what questions you asked and why when taking the history. State thefindings for each body system examined on your head to toe assessment (all are normal). Describehow you approached the patient from the QSEN Competency of Safety during the exam.
Mother Age 18, did not graduate from high school but working on GED- Develop questions to ask
the nurse after the H&P is completed about what is happening to your child and why. Show awillingness to learn to assume role of a participant as a valued member of the Team using theQSEN competency of Teamwork and Collaboration.
Registered Nurse #2 Answers mother’s questions. Describes lumbar puncture procedure for thepediatric patient. Research guidelines for lumbar puncture taking into consideration the QSENcompetency of Quality Improvement.
Case Manager / Discharge Nurse : Reviews with mother the results of the examination and theinformation the physician has already given the mother (all lab tests are normal and LP is normal)Child may go home: what to expect, how to care for child. Discuss how both the mother would usethe QSEN Competency of Informatics to assist her in communicating with her health care provider
after discharge and also enhancing her understanding of the discharge advice. Provide one webbased resource for the mother.
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Case Study
You are working in the Emergency Room. A 7-month-old boy is brought in by his mother @ 4 PM.She states he had a runny nose and fever for 2 days . His pediatrician saw him @ 10 AM todayand diagnosed URI. He received Tylenol, no antibiotics. Later in the afternoon while sitting on herlap he began to stare and had a generalized tonic-clonic seizure. The entire episode lasted about 5
minutes she thinks. He fell asleep after the seizure and was brought to the ER.
PMH: Normal development (describe this)
Vital Signs T 102 F, HR 124, R 30 BP 90/50
Wt 7.9 Kg (50%) Ht 66.5 cm (50%) HC 44 cm (50%)
Labs have been drawn and the physician has asked for assistance performing a Lumbar Puncture
Teaching Points:
The most common type of seizure in the pediatric age group, febrile seizures are usually benign.Though associated with fever, there is no evidence of intracranial infection or defined cause.Febrile seizures are triggered more by how fast the temperature increases than the absolute heightof the temperature.
Children have a higher susceptibility to seizure activity in the brain -- a lower seizure threshold --because of their age and the immaturity of their body's immune system. Complicated by a rapidlyrising fever and possibly the general condition of health, a febrile seizure may occur.
A family history of epilepsy has not been shown to be a risk factor for first febrile seizures but afamily history of febrile seizure is a risk factor, together with male sex and the height of the
temperature (usually > 102F).
Several other factors may increase the risk of seizure: chronic maternal ill health, parental fertilityproblems, breech birth, Caesarean birth, small birth weight, developmental delay, and cerebralproblems may increase the incidence of febrile seizures. Smoking and drug intake (including anti-epileptic drugs) during pregnancy can further increase the risk.
Febrile seizures are age dependent, are rare before 9 months and after 5 years with the peak age9-20 months. They are most commonly generalized tonic-clonic (aka “Grand Mal”) with a duration ofusually less than 5 minutes and no greater than 15 minutes. Risk of recurrence is 35-50% withmost recurrences within 6-12 months. The diagnosis of Febrile Seizure is one of exclusion – ie.,other potentially serious illnesses must be ruled out before this diagnosis is made. The American
Academy of Pediatricians strongly recommends that a Lumbar Puncture be performed if the child is< 12 months.
Although seizures look different, they have certain things in common: During a seizure, a clientmay stop breathing, generally only for only a few seconds. Although some can last as long as 3-5minutes, most seizures only last 1-2 minutes. The brain almost always stops the seizures safelyand naturally.
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Few things are more frightening to parents than to witness their child having a seizure. 10% ofambulance calls are for children having seizures but most seizures resolve in the pre-hospitalsetting. Words parents might use to describe a seizure include a “fit”, an “attack”, a “spell”, or a“convulsion
Febrile Seizure Management What Advice Should I give to Parents?
http://www.cks.nhs.uk/febrile_seizure/management/detailed_answers/advice_for_parents Inform parents about the nature of febrile seizures:
o Although short-lasting seizures are frightening to watch, they are not harmful to thechild, do not cause brain damage, and will not cause the child to die.
o The child may be sleepy for up to an hour after the seizure.o Febrile seizures are not the same as epilepsy. Epilepsy may develop later, but this is
rare — the chance is about 1 in 50 for children who have had one simple febrileseizure. No treatment is available to reduce this risk.
Advise parents on the future management of a fever. Explain that controlling fever does notprevent recurrence but does make the child more comfortable if they are distressed.
Explain that febrile seizures may recur — about 1 in 3 children will have another febrileseizure.
Explain that immunization is still advised after a febrile seizure even if, as rarely happens,the febrile seizure followed an immunization.
Advise parents or caregivers looking after a feverish child at home:o To encourage their child to drink more fluids and consider seeking further advice if
they detect signs of dehydration.o How to identify a non-blanching rash.o To check their child during the night.o To keep their child away from nursery or school while the child's fever persists, and
to notify the school or nursery of the illness. Explain that the aim of controlling fever is to ease symptoms and to prevent
dehydrationo Do not use antipyretic drugs with the sole aim of reducing body temperature or of
preventing febrile seizureso Consider acetaminophen or ibuprofen if the child is distressed or unwello Do not over- or under-dress a child with fevero Tepid sponging, fanning and cold bathing are not recommended].o Ensure an adequate fluid intake
Explain how to manage a recurrent seizure. Parents should:o Place the child in the recovery position on a soft surface, lying semi-prone with the
face turned to the side. This prevents the inhalation of vomit, keeps the airway open,and prevents the child from injury.
o Not force anything into the child's mouth.o Note the time that the seizure started, and stay with the child.o Telephone their HCP for advice if the seizure has stopped and has lasted for less
than 5 minutes. Request an urgent ambulance if the seizure continues for more than 5 minutes. Febrile seizures have an excellent outcome and population studies show normal intellect
and behavior even after complex seizures is important because the anxiety and fearexperienced by parents whenever their child develops a fever can potentially interfere withdaily family life
The risk of epilepsy after a febrile seizure is small. There is NO evidence of:
o Subsequent impaired intelligence or poorer academic achievement
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o An increased risk of neurological deficits, such as hemiplegiao An increased risk of death, even in children who have febrile status epilepticus.
Acetaminophen and ibuprofen are useful in relieving the discomfort of a febrile child.However rigorous attempts to lower temperature should not be attempted as no evidenceexists that antipyretics reduce the number of febrile seizures .
There is evidence to suggest that immunizations DO NOT increase the risk of recurrent
febrile seizures.
Group Two Epilepsy School-Aged Child and School Administration of Diastat4-5 Students
Objectives:
1. Increase knowledge of the Nurse Practice Act and medication administration guidelines forlicensed personnel.
2. Consider the legal and ethical ramifications of lay people and UAPs in a school setting
administering medications.
Method: Moderate a discussion with the class covering the following topics (each student in thegroup takes at least one topic):
1. Summarize background information about new legislation passed in the State of CaliforniaJanuary 2012 (see below and add any information you might find)
2. Describe Diastat administration (find a protocol using web based resources).
3. Present the viewpoint of the advocates of this legislation (See below and using web basedresources find out if there has been additional legislative action)
4. Present the viewpoint of nursing leaders about this legislation as it relates to the NursePractice Act (see below and review the July 25th Agenda Item Summary).
5. Summarize the Position Paper of the NASN – “Emergency Medication” (Posted onBlackboard). Lead discussion for/against this position paper. Summarize key points.
Background Information Adapted from: http://www.ocregister.com/articles/school-322987-diastat-nursing.html
SB161 is a state bill that allows non-licensed school personnel to administer an anti-convulsionmedication to students in an emergency. Gov. Jerry Brown signed the bill into law Oct. 7, 2011despite fierce opposition from nursing unions and their allies, and it took effect Jan. 1, 2012.
SB 161 authorizes public schools in California to offer voluntary, optional Diastat training to schoolemployees. Parents of children with a Diastat prescription must request that their child's schooloffer this training to employees, and no employee can be forced or coerced to participate, accordingto the new law.
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The legislation was proposed after the state Board of Registered Nursing declared in September2009 that no one but a registered nurse could lawfully administer Diastat. Many local schoolsstopped training laypeople to administer Diastat. But some local schools continued to trainlaypeople in the intervening years, using outside resources such as Diastat training courses offeredby the Epilepsy Alliance of Orange County. Now, with the law clarified, advocates hope moreschool districts will embrace the new legislation when it formally goes into effect Jan. 1.
"I imagine it will happen rapidly," Cabanillas said. "My gut feeling is most school districts will behappy to go back to the way it used to be."
Proponents of SB161
Gianna DeLorenzo, age 9, has frequent seizures because of a genetic disease called tuberoussclerosis complex. Her parents, Pat and Aina, were vocal advocates for passage of SB161.Pat DeLorenzo said he feels "extremely relieved" at the passage of SB 161. Though Gianna has afull-time nurse at her school, Missio