Assess Merged PDF

STUDENT NURSE ASSESSMENT SHEET
Room #: ________________ | Age & Gender: ________________ | Today’s Date: ________________

MD/PA/NP/Team: ______________________ ________________________ | Nurse: ________________ |
Admit Date: ________________ | Admitting Diagnoses: ________________________________________ |
Vital Signs: [ Time: ________ ] | HR – ________ | B/P – ________ | RR – ________ | Temp – ________ |
SPO2 – ________ @ ________ via ________ | Pain – ________ [ Numerical/Wong-Baker/FLACC ] [ Location: ________________ ]
[ Type – Acute/Chronic/Sharp/Dull/Aching/Burning ] | Reassessed Score – ________ [ Time: ________ ] |
Health Maintenance: Reason for Admission (Patient’s Own Words): ________________________________________ |

Perception of Health – Good/Fair/Poor | Substance Use – Tobacco/ETOH/Drug Use/None [ Describe:
________________________________________ ] | Code Status – Full/DNR/DNI/CMO | Advanced Directive – Y/N | Living Will – Y/N |
Psychosocial: WNL - Cooperative, normal and appropriate affect; denies SI/HI; denies hallucinations and delusions. |
Primary Language: ________________ | Marital Status – Single/Married/Divorced/Widowed | Lives – Alone/With Spouse/
With Family/Assisted Living/Nursing Home | Mood: ________________ | Affect - Appropriate/Inappropriate/Congruent/Incongruent/
Normal/Blunted/Exaggerated | Behavior - Cooperative/Uncooperative/Withdrawn/Lethargic/Agitated/Combative | SI/HI – Y/N |
Hallucinations & Delusions – Y/N [ Type – Auditory/Olfactory/Visual ] |
Safety: Fall Risk – Low/Medium/High [ Score: ____ ] | Fall Precautions – Y/N | ID Bracelet On – Y/N | Oriented to Unit – Y/N |
Bed Low – Y/N | Nonskid Footwear – Y/N | Call Light Available – Y/N | Side Rails – 2/3/4 | Assist to Ambulate – None/1 Person/2
People/Unable to Ambulate | Restraints – Y/N [ Type: ________________ ] | C/O – Y/N [ Type: ________________ ] |
HEENT: WNL – Full head & neck ROM; trachea midline; non-palpable lymph nodes; eyes clear and white; ear auricles and
canals intact without masses/lesions/redness or drainage; nasal septum intact; moist pink mucus membranes; no sensory deficits. |
Full Head/Neck ROM – Y/N | Nuchal Rigidity – Y/N | Trachea Midline – Y/N | Palpable Lymph Nodes – Y/N
[ Describe: ________________________ ] | Eyes: [ Sclera – White/Yellow ] [ Conjunctiva – Clear/Cloudy/Pink ] | Vision Loss - Y/N
[ Describe: ________________ ] | Photophobia – Y/N | Contacts/Glasses - Y/N | Ears: [ Auricles: Intact/Masses/Lesions ] [ Canals:
Clear/Redness/Swelling/Lesions/Drainage ] [ Describe: ________________ ] | Hearing Loss - Y/N [ HOH – Left/Right/Both ]
[ Deaf – Y/N ] | Tinnitus – Y/N | Vertigo – Y/N | Hearing Aid - Y/N | Nose: [ Septum: Intact/Deviated ] | Loss of Smell - Y/N |
Epistaxis - Y/N | Mouth: [ Mucus Membranes – Dry/Moist/Pink/Pale/Lesions ] | Loss of Taste – Y/N | Dysphagia - Y/N | Dentures – Y/N |
Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Neurological: WNL – GCS 15; RASS 0; AAO X 3; speech clear; PERRLA; facial movements symmetrical;
reflexes present (not Babinski). | GCS – ________ | RASS – ________ | LOC – Alert/Confused/Disoriented/Lethargic/Stupor/Coma |
Oriented – Person/Place/Time | Speech – Clear/Slurred/Difficulty Forming Words/Difficulty Following Commands/Non-Verbal |
Pupils – [ OS – Fixed/Round/Irregular/Reactive/Nonreactive ] [Size: ____ ] [ OD – Fixed/Round/Irregular/Reactive/Nonreactive ]
[Size: ____ ] | Facial Movement Symmetry – Symmetrical/Nonsymmetrical [ Describe: ________________ ] | Gag Reflex – Present/Absent |
Swallow – Present/Active | Corneal – Present/Absent | Babinski – Present/Absent |
Respiratory: WNL – Patent airway; respirations even and unlabored; lung sounds clear bilaterally; denies SOB/dyspnea;
SPO2 > 93% without supplemental oxygen; no tracheostomy or ventilator support; no chest tubes. | Appears in Acute Respiratory
Distress – Y/N | Respiratory Effort & Quality – Labored/Unlabored/Shallow/Deep | Lung Sounds – Clear/Course/Diminished/Crackles/
Wheezing/Rhonchi/Stridor/Friction Rub [ Location – Left/Right/Bilateral/Anterior/Posterior/LUL/LLL/RUL/RLL/Bases ]
[ Describe: ________________________________________________________ ] | Nasal Flaring – Y/N | Retractions – Y/N |
SOB/Dyspnea – Y/N | Cough – None/Productive/Non-Productive [ Sputum – Clear/White/Yellow/Green/Pink/Red/Brown ] [ Quantity –
Scant/Moderate/Copious ] [ Consistency – Thin/Thick/Foamy ] | O2 – Y/N [ Type/Amount - ________ via ________ ] |
Tracheostomy – Y/N [ Describe (Condition, Drainage, Type & Size): ________________________________________________________ ] |
ET Tube – Y/N [ Describe (Size, Position & Vent): ________________________________________________________ ] |
Chest Tube – Y/N [ Location: ________________ ] [ Condition: ________________ ] [ Describe (Treatments):
________________________________________________ ]
Cardiovascular: WNL – Regular apical pulse (S1, S2, no murmur); stable B/P; afebrile; denies angina/chest pain; cap. refill < 3 sec.;
unremarkable neck veins; no edema; positive peripheral pulses; no arterial line. | Heart: Apical Pulse - ________ [ Regular/Irregular ] |
Heart Sounds – [ Murmur – Y/N ] [ Rub – Y/N ] [ Gallup – Y/N ] [ Muffled – Y/N ] | Vital Signs Stable – Y/N | Chest Pain/Angina – Y/N |
Cap. Refill - ____ Sec. | Neck Veins - Distended/Unremarkable | Edema – [ ____ ] [ Location: LA/RA/LL/RL ] | Peripheral Pulses – L. Radial [
____ ] R. Radial [ ____ ] L. Post. Tibial [ ____ ] R. Post. Tibial [ ____ ] L. Dorsalis Pedis [ ____ ] R. Dorsalis Pedis [ ____ ] | Telemetry – Y/N
Rate – ________ Rhythm – ________________________ Box # – ________ | Arterial Line – Y/N [ Describe (Waveform, Condition):
________________________________________________________ ] |

Integumentary: WNL – Skin is warm, dry and intact, color and tone are consistent with ethnicity;
no surgical incisions, rashes, eczema, ulcers or lesions. | Overall Skin Condition: Temp -
Cool/Warm/Hot | Moisture - Dry/Moist/Diaphoretic | Turgor – Elastic/Loose/Tight | Color -
Erythema/Pallor/Cyanosis/Jaundice/Ashen/Mottled [ Describe: ________________ ] | Tone - Consistent
with Ethnicity – Y/N | Integrity - Intact/Torn | Wounds: Y/N [ Stage: I/II/III/IV/Unstageable ] [ Size:
____________ ] [ Locations (Illustrate On Figure): ________________________ ] Dressings - Y/N [
Type: Sterile/Non-Sterile/Dry/Wet-Dry/Other ] [ Describe: ________________________ ] | IV
Lines/Tubes/Drains: [ Line #1: PIV/CVC/PICC/Port/Arterial/Triple Lumen] [Other: ________________
] [ Location: ________________ ] [Condition: ________________ ] [ Line #2:
PIV/CVC/PICC/Port/Arterial/Triple Lumen/] [Other: ________________ ] [ Location:
________________ ] [Condition: ________________ ] [ Drain Type: JP/Penrose/Wound-Vac] [Other Drain Type: ________________ ]
[Location: ________________ ] [ Condition: ________________ ] [ Describe (Treatments):
________________________________________________ ] | [ Other Skin Conditions (Illustrate On Figure): ____________________________ ] |
Gastrointestinal: WNL – Abdomen soft and non-distended and non-tender; active bowel sounds; denies N/V/D or constipation; continent of
stool. | Abdomen - Soft/Firm/Flat/Protuberant/Distended | Bowel Sounds - Normal/Hypoactive/Hyperactive/Absent | Diet - NPO/Soft/Clear
Liquid/Liquid/Regular/Advance As Tolerated [ Type: ________________ ] | Strict I&O - Y/N | Nausea/Vomiting/Diarrhea - N/V/D | Tube
feeding – Y/N [ Via: TPN/G Tube/ J Tube/NG Tube] [ Type: ________________ ] [Rate: ________ gtts/min or mL/hr] | Feces: [ Color:
________________ ] [ Consistency – Liquid/Loose/Formed/Hard ] [Describe (Size/Amount): ________________________ ] [Date of Last
BM: ________ ] | Flatus – Y/N | Constipation - Y/N | Continent - Y/N |
Genitourinary: WNL – Empties bladder without dysuria; bladder is non-distended after voiding; urine clear/yellow; no vaginal/penile
discharge; urine output avg. > 30 mL/HR; continent of urine. | Urine – [ Color: ________________ ] [ Appearance:
Clear/Cloudy/Hematuria/Abnormal Sediment ] [ Odor: Y/N ] [ Amount: ________ mL ( ____ AM/PM - ____ AM/PM) ] | Genital
Discharge – Y/N [ Color: ________ ] | Continent – Y/N | Catheterized – Y/N [ Type: Foley/Straight/Suprapubic/Condom ] |
Dysuria – Y/N | Urinary Hesitancy/Difficulty – Y/N |
Activity/Exercise: Absence of swelling and tenderness and normal ROM on all joints; no prosthesis required; no muscle weakness;
independent in ADLs & self-care. | Movement/ROM – Full/Limited/None | Muscle Weakness – Generalized/Left Sided/Right Sided |
Prosthesis – LA/RA/LL/RL/Other | Gait – Even (Normal)/Ataxic/Parkinsonian (Shuffling)/Scissor/Pigeon/High Stepping/Spastic/Myopathic
(Waddling) | Use of Assistive Devices – Walker/Wheelchair/Cane/Other. | ADLs/Self-Care – Self/Partial Assist/Full Assist | Position in Bed -
Decoriticate/Deceberate/Orthopenic/Fetal/Fowler/Semi-Fowler/Supine |
Rest & Comfort: WNL – Patient denies pain. Patient sleeps and rests comfortably. | Avg. Hours Sleep/Night – ________ |
Disturbances/Issues – Y/N [ Describe (Pain, Environment, Psychosocial Issues etc.): ________________________________________________ ] [
Sleep Aids: _________________________________ ] [ Nursing Interventions: ________________________________________________ ] |
Improved Sleep/Rest – Y/N |




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Highlights from the 2017 Guideline for the Prevention, Detection,
Evaluation and Management of High Blood Pressure in Adults
A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
New blood pressure targets and treatment recommendations: For years, hypertension was classified as a blood pressure (BP) reading of 140/90 mm Hg or
higher, but the updated guideline classifies hypertension as a BP reading of 130/80 mm Hg or higher. The updated guideline also provides new treatment
recommendations, which include lifestyle changes as well as BP-lowering medications, as shown in Table 1.
TABLE 1. Classification of BP
BP Category Systolic BP Diastolic BP Treatment or Follow-up

Normal <120 mm Hg and <80 mm Hg Evaluate yearly; encourage healthy lifestyle changes to maintain normal BP
Elevated 120-129 mm Hg and <80 mm Hg Recommend healthy lifestyle changes and reassess in 3-6 months
Hypertension: 130-139 mm Hg or 80-89 mm Hg Assess the 10-year risk for heart disease and stroke using
stage 1 the atherosclerotic cardiovascular disease (ASCVD) risk calculator
• If risk is less than 10%, start with healthy lifestyle recommendations and
reassess in 3-6 months
• If risk is greater than 10% or the patient has known clinical cardiovascular
disease (CVD), diabetes mellitus, or chronic kidney disease, recommend
lifestyle changes and BP-lowering medication (1 medication); reassess in
1 month for effectiveness of medication therapy
–– If goal is met after 1 month, reassess in 3-6 months
–– If goal is not met after 1 month, consider different medication
or titration
–– Continue monthly follow-up until control is achieved
Hypertension: ≥140 mm Hg or ≥90 mm Hg Recommend healthy lifestyle changes and BP-lowering medication (2
stage 2 medications of different classes); reassess in 1 month for effectiveness
• If goal is met after 1 month, reassess in 3-6 months
• If goal is not met after 1 month, consider different medications or titration
• Continue monthly follow-up until control is achieved
TABLE 2. Hypertensive Crises: Emergencies and Urgencies (See Section 11.2 of 2017 Hypertension Guideline)
Hypertensive Systolic BP Diastolic BP Treatment or Follow-up

Crises
Hypertensive >180 mm Hg and/ >120 mm Hg Many of these patients are noncompliant with antihypertensive therapy and
urgency or do not have clinical or laboratory evidence of new or worsening target organ
damage; reinstitute or intensify antihypertensive drug therapy, and treat
anxiety as applicable
Hypertensive >180 mm Hg + and/ >120 mm Hg Admit patient to an intensive care unit for continuous monitoring of BP
emergency target organ damage or + target organ and parenteral administration of an appropriate agent in those with new/
damage progressive or worsening target organ damage (see Tables 19 and 20 in the
2017 Hypertension Guideline)
Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler
SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in
adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published online ahead of print November 13, 2017]. Hypertension. doi: 10.1161/HYP.0000000000000065.
© 2017 American Heart Association
Pharmacologic recommendations:
The updated guideline recommends BP-lowering The new Hypertension Guideline changes
medication for those with stage 1 hypertension
with clinical CVD or a 10-year risk of ASCVD
the definition of hypertension, which is now
10% or greater, as well as for those with stage 2 considered to be any systolic BP measurement
hypertension. For stage 2, the recommendation is
2 BP-lowering medications in addition to healthy of 130 mm Hg or higher—or any diastolic BP
lifestyle changes, which is a more aggressive
treatment standard—previous guidelines
measurement of 80 mm Hg or higher.
recommended starting patients on only 1 BP-
lowering medication. Hypertensive urgency vs hypertensive • Record all readings accurately; use a
The guideline also updates the recommen- emergency: Hypertensive urgencies are associ- monitor with built-in memory and bring
dations for specific populations. Because black ated with severe BP elevation in otherwise it to all clinic appointments.
adults are more likely to have hypertension stable patients without acute or impending For clinical decision-making, base the
than other groups, 2 or more antihypertensive change in target organ damage or dysfunction. patient’s BP on an average from readings
medications are recommended to achieve a Hypertensive emergencies are severe elevations on 2 or more occasions.
target of less than 130/80 mm Hg in this group, in BP associated with evidence of new or
and thiazide-type diuretics and/or calcium worsening target organ damage. Treatment recommendations: The
channel blockers are more effective in lowering updated guideline presents new treatment
Focus on accurate measurements: To ensure recommendations, which include lifestyle
BP alone or in multidrug regimens. Morbidity accurate measurements, make sure the
and mortality attributed to hypertension are changes as well as BP-lowering medications.
instrument you are using is properly calibrated. These lifestyle changes can reduce systolic BP
more common in black and Hispanic adults The updated guideline also stresses the basic
compared with white adults. by approximately 4 to 11 mm Hg for patients
processes for accurately measuring BP, including with hypertension, with the biggest impacts
For adults starting a new or adjusted drug some simple yet critical actions before and being changes to diet and exercise.
regimen to treat hypertension, follow up during measurements. For accurate in-office
with them each month to determine how well measurements, do the following: • In addition to promoting the DASH diet,
they are following and responding to their which is rich in fruits, vegetables, whole
• Have the patient avoid smoking, caffeine,
prescribed treatment until their BP is under grains, and low-fat dairy products, the
or exercise within 30 minutes before
control.2-4 For a full list of medications, see updated guideline recommends reducing
measurements; empty his or her bladder;
Table 18 in the 2017 Hypertension Guideline. sodium intake and increasing potassium
sit quietly for at least 5 minutes before
Emphasis on cardiovascular disease: The intake to reduce BP. However, some patients
measurements; and remain still during
updated guideline provides recommendations may be harmed by excess potassium, such
measurements.
for patients with clinical CVD and makes as those with kidney disease or who take
• Support the limb used to measure BP, certain medicines. See Table 15 in
new recommendations for using the
ensuring that the BP cuff is at heart level the 2017 Hypertension Guideline for
ASCVD risk calculator:
and using the correct cuff size; don’t take the more information.
• Use BP-lowering medication for primary
measurement over clothes.
prevention of CVD in adults with no history • Each patient’s ideal body weight is the best
of CVD and an estimated 10-year ASCVD • Measure in both arms and use the higher goal, but as a rule, expect about a 1 mm Hg
risk less than 10% and a systolic BP of 140 reading; an average of 2 to 3 measurements BP reduction for every 1 kg reduction in
mm Hg or greater or a diastolic BP of 90 mm taken on 2 to 3 separate occasions will body weight.
Hg or greater.5-9 minimize error and provide a more
• Recommendations for physical activity
accurate estimate.
• Use BP-lowering medications for secondary include 90 to 150 minutes of aerobic
prevention of recurrent CVD events in For more information about accurate
and/or dynamic resistance exercise per week
measurements, see Tables 8 and 9 in the 2017
patients with clinical CVD and an average and/or 3 sessions per week of isometric
Hypertension Guideline.
systolic BP of 130 mm Hg or greater or a resistance exercises.
diastolic BP of 80 mm Hg or greater and Focus on self-monitoring: Office BPs are often • For patients who drink alcohol, aim for
for primary prevention in adults with an higher than ambulatory or home BPs, so the
reducing their intake to 2 or fewer drinks
estimated 10-year risk of ASCVD of 10% updated guideline emphasizes having patients
daily for men and no more than 1 drink daily
monitor their own BP for hypertension diagnosis,
or greater with an average systolic BP of 130 for women.
treatment, and management. Patients should
mm Hg or greater or average diastolic BP of
follow these steps: New targets for comorbidities: For patients
80 mm Hg or greater.5,10-17
• Use the same validated instrument at the with comorbidities, the updated guideline
No prehypertension: The updated guideline same time when measuring at home to more generally recommends prescribing BP-lowering
eliminates the term prehypertension and instead accurately compare results. medications in patients with clinical CVD
uses the term elevated BP for a systolic BP of • Position themselves correctly, with the and new stage 1 or stage 2 hypertension to
120 to 129 mm Hg and a diastolic BP of less than target a BP of less than 130/80 mm Hg (this
bottom of the cuff directly above the bend of
80 mm Hg. was previously less than 140/90 mm Hg). The
the elbow.
guideline recommends different follow-up
More hypertension patients: Because the new • Optimally, take at least 2 readings 1 minute intervals based on the stage of hypertension, type
definition of hypertension is lower (130/80 mm apart each morning before medication and of medication, level of BP control, and presence
Hg), more people will be classified as having
each evening before supper. Ideally, obtain of target organ damage.
hypertension. However, most of these new
patients can prevent hypertension-related health weekly readings 2 weeks after a treatment
problems through lifestyle changes alone. change and the week before a clinic visit. To download the full version of the 2017
Hypertension Guideline, please visit
http://professional.heart.org/hypertension.
P a t i e n t E d u c a t i o n S e r i e s
By Elizabeth Hanes, BSN, RN
Freelance writer • Albuquerque, N.M.
> Deep vein thrombosis

What’s a deep vein thrombosis?
A deep vein thrombosis, or DVT, is a blood clot that forms
important to call 911 right away so you can get immedi-
ate treatment.
in one of the deep veins in your body, usually in one of
your legs. A blood clot is a clump of blood cells that How is a DVT treated?
forms into a solid mass over time. A DVT may be danger- A DVT is usually treated by a medicine called an
ous because it can break off and move through your anticoagulant (commonly known as a “blood thinner”).
bloodstream to your lungs, causing a pulmonary embo- Anticoagulants, like heparin and warfarin, slow down the
lism, or PE. A PE can block blood flow and cause lung clotting process and help prevent a blood clot from getting
damage or even death. bigger. They also help prevent the formation of new clots.
Am I at risk for a DVT? What can I do to avoid getting a DVT?

If you’re not very active, you’re at risk for a DVT. People You can make several lifestyle changes to reduce your
who are paralyzed, and anyone who’s confined to a bed chances of getting a DVT. To reduce your risk:
for any reason, has an increased chance of getting a DVT. • Quit smoking. Your healthcare provider can help you
Dehydration can increase your risk of getting a DVT put together a stop-smoking program that will work best
because it makes the blood thicker, and blood tends for you.
to clot when it thickens. Other risk factors for a DVT • Lose weight if you’re overweight, exercise regularly, and
include: eat a healthy diet. Consult your healthcare provider for
• heart failure help creating a healthy eating and exercise plan.
• active cancer • Drink plenty of water or other noncaffeinated, non-
• chemotherapy alcoholic beverages every day so you don’t become
• recent trauma or injury dehydrated.
• birth control medicines • Wear special support stockings, called compression
• obesity stockings, if your healthcare providers advises.
• major surgery • Avoid long periods of inactivity. Don’t sit for long
• smoking periods at one time. When you’re traveling on a plane,
• traveling more than 4 hours by car, plane, train, bus, train, or car, get up and walk around at least once
or bus without walking around every hour. This is especially important if the trip lasts
• genetic disorders. longer than 4 hours. ■
How will I know if I have a DVT? RESOURCES

Symptoms of a DVT in one of your legs include swelling, Mayo Clinic. Blood clots. http://www.mayoclinic.com/health/blood-clots/
MY00109.
redness, warmth, and tenderness or pain. Contact your
Medline Plus. Blood clots. http://www.nlm.nih.gov/medlineplus/ency/
healthcare provider if you have any of these symptoms article/001124.htm.
because you may need immediate treatment. National Blood Clot Alliance. Stop the clot. http://www.stoptheclot.org.
If a clot travels to your lung, you may experience Pai M, Douketis JD. Patient information: deep vein thrombosis (DVT).
UpToDate. 2013. http://www.uptodate.com.
sudden shortness of breath, chest pain, a fast heart-
beat, or cough. If you have any of these symptoms, it’s DOI-10.1097/01.NURSE.0000431944.08030.90
This patient-education guide has been adapted for the 5th-grade level using the Flesch-Kinkaid formula. It may
be photocopied for clinical use or adapted to meet your facility’s requirements. Selected references are available
upon request.
www.Nursing2013.com August l Nursing2013 l 43
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CE 1.5 HOURS
Continuing Education
Venous
Thromboembolism:
Updated Management
Guidelines
A review of what’s new, what’s the same, and the implications for nursing practice.
ABSTRACT: Venous thromboembolism (VTE) is a leading cause of death and disability worldwide. Each year,
more than 10 million cases of VTE are diagnosed; studies suggest there are as many as 900,000 cases per year
in the United States. The condition is estimated to cost the U.S. health care system between $7 billion and
$10 billion annually. In February 2016, the American College of Chest Physicians released the 10th edition of
the Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. After providing an
overview of VTE pathophysiology, risk factors, signs, symptoms, and key clinical assessments, this article de-
tails recommendations from the new guideline, which incorporates the most up-to-date treatment options
for patients with VTE. The authors highlight key changes from the 2012 guideline, particularly those related
to nursing practice, patient education, care coordination, patient adherence, medication costs, follow-up ap-
pointments, and diagnostic testing.
Keywords: care coordination, embolism, non–vitamin K oral anticoagulants, patient education, treatment
guidelines, venous thromboembolism
V
enous thromboembolism (VTE) is a leading most common medical complication related to hos-
cause of worldwide death and disability and pitalization and extended length of stay and the third
a growing public health concern. In the United most common cause of excess hospital charges and
States, there is no national surveillance system for high mortality rates.5 During 2007–2009, a discharge
VTE, so the national incidence is unclear. Estimates diagnosis of VTE was recorded for roughly 550,000
of U.S. incidence vary from 300,000 to 900,000 cases adult hospitalizations per year.6 Because it is a con-
per year,1-4 with as many as 100,000 to 300,000 cases dition associated with health care, VTE has received
ending in death.4 attention from the U.S. Surgeon General, the Joint
VTE, which includes both deep venous thrombosis Commission, the Centers for Medicare and Medicaid
(DVT) and pulmonary embolism (PE), is the second Services, the National Quality Forum, and the Agency
38 AJN ▼ May 2017 ▼ Vol. 117, No. 5 ajnonline.com

By Sarah Hudson Roberts, DNP, MSN, RN, and Sherry Motes Lawrence, DNP, MSN, RN
for Healthcare Research and Quality in the form

of calls to action, new quality and performance mea-
sures, information sheets, consensus standards, and
guides to quality improvement.2, 6-8 Despite this focus,
the number of secondary diagnoses of VTE in hospi-
talized patients has continued to rise and a 2011 ret-
rospective analysis of U.S. health care claims data
estimated that the incidence of VTE would more than
double from 950,000 cases in 2006 to 1.82 million
in 2050.9
Hospital stays for VTE place a considerable eco-
nomic burden on the U.S. health care system,10-12 with
total health care costs, including the treatment of acute
and recurrent VTE as well as the treatment of resulting
complications, estimated to be between $7 billion and
$10 billion per year.11 In 2011, mean hospital charges
were $30,051 for DVT and $37,006 for PE, while
the mean length of stay was 4.7 days for patients
with DVT and 5.1 days for patients with PE.12
In February 2016, the American College of
Chest Physicians published the 10th edition of the
Antithrombotic Therapy for VTE Disease: CHEST
Guideline and Expert Panel Report (CHEST Guide- In this venogram of the lower leg, the red arrow points to a filling
line).13 This guideline incorporates the most up-to- defect associated with deep vein thrombosis. Image © O’Connor
date treatment options for patients with VTE and MB, et al. Cases J 2009; licensee BioMed Central.
includes some noteworthy changes to the 2012 9th
edition guideline (see Table 113). These include the
following13:
• the recommended use of non–vitamin K oral an- proposed by the 19th-century German physician
ticoagulants (NOACs) over warfarin for initial Rudolf Virchow as a triad of vascular abnormalities:
and long-term treatment of VTE in patients with- hypercoagulability, endothelial injury, and altered ve-
out cancer nous blood flow. These abnormalities may result from
• a reversal of the recommendation to routinely use medical conditions or therapies, traumatic injury, sur-
compression stockings to prevent postthrombotic gical procedures, dehydration, or reduced or restricted
syndrome activity.
• new treatment recommendations for patients with DVT most commonly develops in the lower ex-
isolated subsegmental PE tremities, though the study of a U.S. multicenter regis-
Drawing largely from this guideline, this article pro- try of patients with confirmed DVT found that 11%
vides an overview of VTE pathophysiology, risk fac- of the patients had developed upper-extremity DVT.18
tors, signs and symptoms, and key clinical assessments, Rarely, DVT develops in cerebral, pelvic, and mesen-
with an emphasis on nursing practice, patient educa- teric veins. It is critically important to identify the size
tion, care coordination, patient adherence, medication and exact location of lower-extremity DVT because
costs, follow-up appointments, and diagnostic testing. thrombi in the proximal veins of the leg, defined as the
popliteal vein and those above it, are strongly associ-
VTE PATHOPHYSIOLOGY ated with PE if left untreated. While thrombi located
Venous stasis, as can occur with immobilization or in the distal lower-extremity veins are less likely to
prolonged bed rest, is a well-established risk factor result in PE, up to 15% of distal thrombi enlarge
for developing VTE. In fact, when patients are hos- and extend into the proximal deep veins if left un-
pitalized for an acute medical illness, their risk of de- treated.19
veloping VTE increases by a factor of eight.14 There PE, an obstruction within a pulmonary artery, is
are, however, numerous other risk factors, both mod- most commonly caused by a thrombus but can also
ifiable and nonmodifiable (see Risk Factors for VTE be caused by air, fat, or a tumor. The mechanical ob-
Development 15-17). struction within the pulmonary vasculature can cause
DVT is the initial presentation in two-thirds of pulmonary hypertension and ultimately right heart
patients with VTE.1 The etiology of DVT was first failure. In response to rising pulmonary pressures,
ajn@wolterskluwer.com AJN ▼ May 2017 ▼ Vol. 117, No. 5 39

compensatory mechanisms activated by the sympa- inflammation that accompanies venous obstruction.
thetic nervous system release chemical mediators that A thorough assessment of the affected extremity may
cause vasoconstriction, further reducing blood flow reveal superficial venous dilation as well. Any of these
through the pulmonary vasculature and creating a symptoms should be evaluated in the context of the
ventilation–perfusion mismatch. The resulting hypo- patient’s current medical condition and circumstances.
perfusion and hypoxemia cause both pulmonary and The most frequently reported symptoms of PE are
cardiac ischemia and potentially tissue infarction. dyspnea and pleuritic pain. Other PE signs and symp-
Early recognition and appropriate treatment of PE toms include coughing, palpitations, anxiety, wheez-
maximize patients’ chances of survival. ing, bloody sputum, and unilateral extremity pain.
Assessment may reveal unilateral extremity swelling,
CLINICAL PRESENTATION fever, hemoptysis, pleural effusion, altered mental
Common signs and symptoms of DVT include uni- status, and hypoxia. Differences have been noted in
lateral swelling of the affected limb in conjunction symptoms reported by women and men, with women
with warmth, tenderness, and redness from the more likely to report anxiety, shortness of breath, and
Table 1. Major Changes in Guideline Recommendations for the Management of VTE13
Prior Current
Category Recommendation Recommendation Evidence Supporting This Change
Choice of Warfarin for NOACs Risk reduction is similar with NOACs.
long-term patients without over warfarin for Risk of bleeding is less with NOACs.
anticoagulants cancer patients without Greater convenience for patients with
cancer NOACs
Use of aspirin for Not addressed Aspirin recom- Moderate-quality evidence that use of
extended therapy mended for patients aspirin reduces recurrent VTE by about
discontinuing NOAC 33%
therapy and for those
who decline NOAC
therapy
Use of compres- Recommended Not recommended No evidence to support the use of
sion stockings to compression stockings to prevent
prevent post- postthrombotic syndrome
thrombotic
syndrome
Treatment of Not addressed Clinical surveillance After subsegmental PE, which is small
subsegmental PE over anticoagulation and usually originates from an isolated
in patients with no DVT, the risk of recurrence is less than
proximal DVT and with a larger PE.
low risk of recurrence
Outpatient Recommended Outpatient treatment Treatment with a NOAC facilitates outpa-
treatment of early discharge recommended for tient treatment for select patients. A NOAC
acute PE (after five days) carefully selected pa- that does not require bridge therapy
tients should be selected to aid in this process.
Management of Not addressed For patients on oral Low-quality evidence supports the use of
recurrent VTE anticoagulant ther- LMWH for a short period because the risk
while on antico- apy, switch to LMWH of recurrent VTE decreases over time.
agulant therapy for one month. For
patients on LMWH,
increase dosage by
25% to 33%.
DVT = deep venous thrombosis; LMWH = low-molecular-weight heparin; NOAC = non–vitamin K oral anticoagulant; PE = pulmonary embolism;
VTE = venous thromboembolism.

calf pain, and men less likely to report signs and symp-
toms of PE or DVT.20 Risk Factors for VTE
Development15-17
CLINICAL ASSESSMENT
When DVT is suspected, screen the patient using •• Metabolic, endocrine, or respiratory disorders
a DVT probability scale, such as the Wells Score.21 •• Hypercoagulable states, including genetic
(See Table 2.21) If the patient receives a Wells score of thrombophilia
2 or higher, diagnostic testing, starting with a D-dimer •• Active malignancy or cancer treatment
laboratory test, should be performed as soon as pos-
•• Advanced age
sible.22, 23
•• Hypertension
The D-dimer test identifies the presence of the
small fibrin fragments produced when the body •• Elevated triglyceride levels and low levels of
tries to break down blood clots. While the presence high-density lipoprotein cholesterol
of D-dimer fragments in the blood may suggest the •• Previous VTE or first-degree relative with VTE
presence of a blood clot, the test is not specific enough •• Recent surgery or trauma
to serve as a diagnostic criterion because D-dimer •• Pregnancy
fragments are also associated with inflammation, •• Estrogen use (oral contraceptives or hormone
pregnancy, trauma, surgery, and infection. For this replacement therapy, for example)
reason, the D-dimer test is most often used to exclude, •• Limited mobility
rather than to confirm, the diagnosis of DVT.24 A neg- •• Severe obesity
ative D-dimer test indicates that the likelihood of DVT •• Venous stasis, as can occur with immobiliza-
is low. The primary noninvasive tool used to diagnose tion or prolonged bed rest
DVT is venous-compression ultrasonography, which •• Dehydration
has a sensitivity of 97% and a specificity of 94% in
•• Inpatient status with acute medical illness
correctly identifying proximal lower-extremity vein
•• Varicose veins with phlebitis
thrombosis.24 Treatment can be started immediately
upon ultrasonographic confirmation of a thrombus, •• Presence of multiple medical comorbidities
though if findings are inconclusive or inconsistent with VTE = venous thromboembolism.
clinical assessment, venography should be considered.25
When PE is suspected, screen the patient using a
probability tool, such as the Wells Criteria for Pul-
monary Embolism (available online at www.mdcalc. Choice of anticoagulant therapy. The expert
com/wells-criteria-pulmonary-embolism).26 If proba- panel agreed that current evidence supports the use
bility screening suggests a likelihood of PE, diagnos- of anticoagulant therapy in treating PE or proximal
tic testing should be initiated as soon as possible. As DVT. For patients with cancer who develop VTE,
with DVT testing, a D-dimer blood test can be per- low-molecular-weight heparin (LMWH) continues
formed to rule out the presence of PE.26 Diagnostic to be recommended as the primary treatment over
imaging includes multidetector computed tomogra- any of the oral agents, including warfarin and the
phy angiography (MDCTA), which is highly sensi- NOAC medications—dabigatran and edoxaban,
tive in detecting PE and, when used in conjunction which must be combined with LMWH in the acute
with D-dimer measurement, can safely rule out PE in phase of treatment, and apixaban and rivaroxaban,
patients without high clinical probability, eliminating which need not be combined with LMWH. For pa-
the need for compression ultrasonography in such tients without cancer who develop VTE, new recom-
cases. If MDCTA scanning is unavailable or cannot mendations support the use of NOAC medications
be used because of patient sensitivity, a ventilation– over warfarin for both initial and long-term treat-
perfusion scan can be performed, though this has a ment, but do not recommend any NOAC over an-
lower sensitivity in identifying PE, particularly in pa- other. Research has shown that NOAC medications
tients with preexisting pulmonary conditions.27 perform as well as warfarin in preventing recurrent
VTE—and with less risk of bleeding, most notably
UPDATED GUIDELINE RECOMMENDATIONS intracranial bleeding.28, 29 Although warfarin has a spe-
The 10th edition of the CHEST Guideline did not cific reversal agent, warfarin doesn’t have a lower risk
change previous recommendations regarding which of a fatal bleeding event than the NOAC medications,
patients should and should not receive extended anti- with rivaroxaban and apixaban having the lowest
coagulation therapy; however, several recommenda- bleeding risk compared with either LMWH plus war-
tions concerning VTE prevention and treatment were farin or unfractionated heparin plus warfarin.28, 29 The
reversed or modified.13 Except as otherwise cited, the choice of anticoagulant is also influenced by comorbid
discussion in this section is based on this report by conditions and patient preference. LMWH is the pan-
Kearon and colleagues. el’s recommended therapy for VTE associated with

pregnancy because the oral anticoagulants have been an elevated D-dimer level have about twice the risk
shown to cross the placental barrier. of recurrent VTE than patients who have a negative
Duration of anticoagulant therapy. When an anti- D-dimer test, men have a 75% higher risk of recur-
coagulant is prescribed, the panel recommends three rence than women, and together the two factors may
months as the minimum course of treatment. A deci- have greater predictive significance.
sion to extend anticoagulant therapy beyond three The use of antiplatelet therapy, including aspirin,
months should not be made lightly, as it usually im- in the treatment of VTE has not been addressed in
plies that the treatment will continue indefinitely. If previous guidelines. Extended aspirin therapy has
the VTE was associated with surgery or another tran- been found to reduce the recurrence of VTE without
sient risk factor, the panel recommends discontinuing significantly raising the risk of bleeding.30 While the
treatment at the end of three months. Isolated, distal panel does not view aspirin as an acceptable substitute
DVT, however, may require no anticoagulant therapy. for warfarin or a NOAC, it recommends that patients
For patients who develop a first unprovoked proxi- who discontinue or decline traditional anticoagulant
mal DVT or PE or a second unprovoked VTE and therapy receive aspirin therapy unless its use is contra-
have a low to moderate risk of bleeding, extended an- indicated.
ticoagulant therapy, with no scheduled stop date, is The risk of developing recurrent VTE decreases
recommended. If the bleeding risk is considered high, over the course of anticoagulant therapy. The develop-
further risk stratification is in order. Any patients ment of recurrent VTE while receiving anticoagulant
prescribed extended anticoagulant therapy should be therapy at therapeutic doses is rare and should prompt
reassessed periodically. diagnostic reevaluation, evaluation of adherence, and
D-dimer levels. The panel recommends that consideration of undiagnosed active malignancy. Fol-
D-dimer levels be measured in all patients who have lowing these assessments, the guideline panel recom-
received anticoagulant therapy about one month after mends prescribing a short-term (usually one-month)
discontinuing treatment. While there are no specific course of LMWH and then resuming oral anticoag-
recommendations regarding continuing therapy on ulant therapy. Any ongoing treatment that would in-
the basis of D-dimer levels or patient sex, both fac- crease the likelihood of VTE, such as hormone therapy
tors may influence the decision. Patients who have or chemotherapy, may be discontinued.
Table 2. Wells Clinical Model for Predicting Pretest Probability of DVT 21, a
Clinical Characteristic Score

Active cancer (patient receiving treatment for cancer within the previous 6 months or currently 1
receiving palliative treatment)
Paralysis, paresis, or recent plaster immobilization of the lower extremities 1
Recently bedridden for 3 days or more, or major surgery within the previous 12 weeks requiring 1
general or regional anesthesia
Localized tenderness along the distribution of the deep venous system 1
Entire leg swollen 1
Calf swelling at least 3 cm larger than that on the asymptomatic side (measured 10 cm below tib- 1
ial tuberosity)
Pitting edema confined to the symptomatic leg 1
Collateral superficial veins (nonvaricose) 1
Previously documented DVT 1
Alternative diagnosis at least as likely as DVT −2
DVT = deep venous thrombosis.
a
A score of 2 or higher indicates that the probability of DVT is likely; a score of less than 2 indicates that the probability of DVT is unlikely. In
patients with symptoms in both legs, the more symptomatic leg is used.
Reprinted from Wells PS, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003;349(13):1227–35. Copy-
right © 2003 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

DVT management varies with thrombi location routine use of compression stockings did not reduce
and patient symptoms. If thrombosis is limited to the the incidence of postthrombotic syndrome. While the
muscular veins of the calf and the patient is not at risk current guideline does not recommend routine use
for extension and has no severe symptoms, the risk of of compression stockings to prevent postthrombotic
anticoagulation may outweigh the potential benefits. syndrome, it acknowledges that these stockings may
For these patients, the panel recommends serial ultra- reduce symptoms in affected patients.
sonographic imaging for two weeks over anticoagula- Upper-extremity DVT. The panel also recom-
tion therapy unless imaging reveals extension, in which mended that upper-extremity DVT, like lower-
case anticoagulation therapy should be initiated and extremity DVT, be treated with anticoagulant therapy
continued for at least three months. Since roughly rather than thrombolysis, unless the patient is “most
15% of untreated distal thrombi extend into the prox- likely to derive benefit” from thrombolysis because
imal veins of the leg, patients with distal DVT should she or he has
be either monitored by ultrasound or treated with • had severe symptoms for fewer than 14 days.
anticoagulation therapy. Factors that increase the • a thrombus involving most of the subclavian and
risk of thrombotic extension include axillary veins.
• size of the thrombus (greater than 5 cm in length, • a low risk of bleeding.
greater than 7 mm in diameter, or involving mul- • good functional status.
tiple veins). • life expectancy of at least one year.
• a markedly positive D-dimer test. For patients with upper-extremity DVT who receive
• inpatient status. thrombolysis, catheter-directed thrombolysis is pre-
• active cancer. ferred over systemic thrombolysis. After undergoing
• location of the thrombus near proximal veins. thrombolysis, the guideline recommends that patients
• history of VTE. receive anticoagulant therapy at the same dosage and
• no reversible provoking factor. duration as patients who did not undergo thrombolysis.
Since roughly 15% of untreated distal thrombi extend

into the proximal veins of the leg, patients with distal DVT
should be either monitored by ultrasound or treated
with anticoagulation therapy.
The current guideline does not recommend catheter- Management of PE. The advances in computed
directed thrombolysis, using such agents as tissue tomography pulmonary angiography have increased
plasminogen activator or streptokinase, to dissolve a the diagnosis of PE that is confined to the subseg-
thrombus unless the patient is developing venous mental pulmonary arteries. Current evidence sug-
gangrene. It further recommends against using an in- gests that subsegmental PE is usually small, having
ferior vena cava filter in patients who are receiving originated from a small, isolated thrombus. Based
anticoagulant therapy. on low-quality evidence, the guideline recommends
Postthrombotic syndrome is a common complica- that patients with subsegmental PE but no proximal
tion of DVT. Between 23% and 60% of patients di- DVT and little risk of recurrent VTE receive ultra-
agnosed with DVT develop postthrombotic syndrome sound surveillance of the lower extremities but no
within two years of DVT onset.31, 32 Signs and symp- anticoagulant treatment, and that those with proxi-
toms include edema, skin discoloration, pain, and in mal DVT or a high risk of recurrent VTE receive
severe cases, ulceration. The pain and swelling caused anticoagulant therapy.
by this syndrome can substantially affect quality of Outpatient treatment of PE. Patients who have
life. While earlier versions of this guideline recom- no identified risk factors for bleeding and are both
mended the use of compression stockings to prevent hemodynamically stable and expected to adhere
the development of postthrombotic syndrome, the to the prescribed therapy should be offered the op-
current guideline cited a more recent, large, multi- tion of home treatment or early discharge, rather
center, placebo-controlled study, which found that than the standard five days of inpatient treatment.

A screening tool, such as a simplified Pulmonary as rivaroxaban or apixaban, is best suited to outpa-
Embolism Severity Index (PESI), can help clinicians tient treatment.
identify patients for whom home treatment would The updated recommendations support the use
be appropriate. The simplified PESI helps clinicians of systemic thrombolysis only for patients with acute
evaluate such patient data as age, oxygen saturation PE who are not at high risk for bleeding and are ex-
level, heart rate, blood pressure, and medical history in periencing hypotension (systolic blood pressure below
order to estimate the severity of PE.33 Patients with a 90 mmHg for more than 15 minutes). The longer the
score of 0 would be considered “low risk” and may duration of hypotension or other signs of shock, the
be suitable candidates for home treatment.33 The panel greater the indication for systemic thrombolysis. If the
recognized the value of screening tools such as the sim- patient’s condition deteriorates with routine anticoag-
plified PESI, but emphasized that, though screening ulation therapy, the need for systemic thrombolysis
tools aid in clinical decision making, they do not re- should be reevaluated.
place clinical judgement. PE treatment with a NOAC The expert panel notes that the role of catheter-
that does not require LMWH in the acute phase, such directed thrombolysis in the treatment of PE is
Table 3. Non–Vitamin K Oral Anticoagulants Used to Treat Acute VTE 34-38
Generic (Trade) Name Drug Category Antidote Precautions

Dabigatran (Pradaxa) Direct thrombin Idarucizumab •• Not recommended for patients with mechanical heart valves
inhibitor (Praxbind) •• Not recommended for patients with liver disease
•• Can be used in patients with renal impairment with dose
adjustments
•• Avoid use in patients with renal failure; dosing recommenda-
tions cannot be provided for patients with a creatinine clear-
ance < 15 mL/min or for those receiving dialysis treatment
•• Strict medication adherence is critical
•• Discontinue at least 24 hours before invasive or surgical
procedures; can be restarted after the procedure as soon as
medically appropriate
Rivaroxaban (Xarelto) Factor Xa None •• Not recommended for patients with mechanical heart valves
inhibitor •• Can be used in patients with renal impairment with dose
adjustments
•• Avoid in patients with liver disease
adequate hemostasis established
Apixaban (Eliquis) Factor Xa None •• Not recommended for patients with mechanical heart valves
inhibitor •• Can be used in patients with renal impairment with dose
adjustments
Edoxaban (Savaysa) Factor Xa None •• Not recommended for patients with mechanical heart valves
inhibitor and moderate to severe mitral stenosis
•• Not recommended for patients with liver disease
•• Can be used in patients with renal impairment with dose
adjustments
VTE = venous thromboembolism.

s upported only by low-quality evidence. In general,
systemic thrombolysis is recommended over catheter- Patient Teaching Points
directed thrombolysis unless the patient has failed a
trial of systemic thrombolysis or is unlikely to sur- Current Treatment
vive the few hours necessary for the thrombolysis •• Importance of medication adherence
to be effective. In such situations, if the requisite ex- •• Importance of follow-up appointments
pertise and resources are available to perform the •• What to do if you miss a dose of a NOAC
procedure, the panel recommends catheter-assisted •• Signs and symptoms of bleeding to report to
thrombus removal—that is, mechanical interven- your health care provider:
tion, with or without catheter-directed thromboly- oo Increased bruising
sis. The panel determined that patients who have oo Overt bleeding
developed chronic thromboembolic pulmonary hy- oo Dizziness, feeling faint
pertension may receive some benefit after undergo- oo Increased shortness of breath
ing a pulmonary artery thromboendarterectomy by oo Intolerance of cold
an experienced surgical team, but emphasized that
patient selection requires careful evaluation by spe- Preventing VTE Recurrence
cialists in pulmonary hypertension diagnosis and •• Stay hydrated
management. •• Avoid oral contraceptives and hormonal therapy
•• Exercise, stay active
MEDICATION CONSIDERATIONS •• Perform leg exercises during travel
The introduction of NOACs in the 10th edition •• Symptoms to report to your health care pro-
guideline represents a major change in anticoagula- vider that may indicate recurrence:
tion therapy for VTE. To provide safe and effective oo Swelling of one extremity
patient care, it is important for nurses to know about oo Calf pain
warfarin, LMWH, and the various NOACs used in oo Numbness or tingling of one extremity
VTE treatment (see Table 334-38), and to be familiar
oo Acute shortness of breath
with the benefits and risks associated with each.
NOAC advantages. NOACs have the following oo Pleuritic chest pain
advantages over warfarin: oo Palpitations
• Since food does not affect their metabolism, they oo Wheezing
produce a predictable anticoagulant effect with oo Bloody sputum
no need for dietary restrictions. oo Anxiety
• They are given in fixed doses, requiring no rou-
NOAC = non–vitamin K oral anticoagulant; VTE = venous thromboem-
tine international normalized ratio (INR) moni- bolism.
toring.39
• They are as effective as warfarin, cause fewer
bleeding complications, and are more conve-
nient to administer.39 50-mL vials, each containing 2.5 g. When adminis-
Unlike NOACs, warfarin has a slow onset of ac- tering idarucizumab, it is important to keep the fol-
tion; when initiated to treat VTE, warfarin must be lowing steps in mind35:
overlapped with a rapidly acting parenteral anticoag- • Do not mix with other medications.
ulant bridge therapy for at least five days.40 With their • Once the solution has been removed from the vial,
rapid onset of action, rivaroxaban and apixaban readministration should begin within an hour.
quire no anticoagulation bridge therapy.40 Without • The iv line must be flushed with a 0.9% sodium
the need for bridge therapy, initiating NOAC therapy chloride injection solution before infusion.
is simpler than warfarin therapy, and it may reduce • No other infusion should be administered through
hospital length of stay, number of hospital admissions, the same iv access.
and cost. • Dabigatran treatment can be reinitiated 24 hours
Reversal of anticoagulant effect. One of the main after idarucizumab administration.
concerns with NOAC treatment is the lack of anti- Dosing schedules. Nonadherent patients should
dotes should bleeding occur or should the patient re- not be prescribed short-acting NOACs because missed
quire an invasive surgical procedure.40, 41 Currently, doses can be more harmful than missed doses of war-
the only NOAC with an antidote is dabigatran for farin, which has a half-life of several days.40 Patients
which idarucizumab, a humanized monoclonal anti- who prefer once-daily medications can be prescribed
body fragment, can be used to reverse the anticoagu- rivaroxaban and edoxaban (dabigatran and apixaban
lant effect.34, 35 require twice-daily dosing).
Idarucizumab administration. The recommended Comorbid conditions. Patients with upper gastro-
dose of idarucizumab is 5 g, provided as two separate intestinal symptoms may have better outcomes with

rivaroxaban or apixaban than with dabigatran. Up • nonpharmacologic methods for preventing recur-
to 10% of patients prescribed dabigatran develop rent VTE.
dyspepsia, which can lead to early discontinuation.40 Successful VTE management is a collaborative pro-
In the updated CHEST Guideline, LMWH remains cess that includes health care providers, their patients,
the anticoagulant of choice for patients with malignan- and their caregivers. Patients who are actively involved
cies and for those with mechanical heart valves.13, 42 in their health care and follow their prescribed plans of
Promoting adherence. The effectiveness of VTE care have improved health outcomes and lower health
treatment depends on patients taking their medica- care costs. While NOACs may reduce the overall costs
tions as prescribed. Nurse-led anticoagulation clinics associated with treating VTE, there are challenges as-
can play an important role in improving care coordi- sociated with their use. Nurses play a pivotal role in
nation and reducing ED visits and hospitalizations.43-45 ensuring that these new anticoagulants improve pa-
The personalization of dosage routines and the use tient outcomes through
of text-messaged and e-mailed patient reminders • ensuring that patients have a voice in their medi-
can be beneficial.46, 47 Smartphone medication adher- cation selection.
ence applications are another strategy for improving • developing effective patient education programs.
adherence.48 Although routine INR monitoring is • follow-up in the outpatient setting. ▼
not required with NOAC treatment for VTE, peri-
odic, scheduled patient follow-up is necessary to en- For four additional continuing nursing education
sure safe and effective treatment. Follow-up visits activities on the topic of venous thromboembolism,
allow nurses to reinforce patient education and fos- go to www.nursingcenter.com/ce.
ter a long-term trusting relationship with the pa-
tient. When patients feel safe, they are more likely
to be forthcoming when discussing adherence issues Sarah Hudson Roberts and Sherry Motes Lawrence are assis-
and missed doses. Encourage patients to bring their tant professors at the University of South Alabama College of
Nursing in Mobile. Contact author: Sarah Hudson Roberts,
prescriptions to follow-up appointments so pill sroberts@southalabama.edu. The authors and planners have dis-
counts may be used as a measure of medication ad- closed no potential conflicts of interest, financial or otherwise.
herence, and consider incorporating adherence into
written treatment contracts.49 Patients may need to REFERENCES
be reminded that over-the-counter medications, such 1. Beckman MG, et al. Venous thromboembolism: a public
as aspirin and other nonsteroidal antiinflammatory health concern. Am J Prev Med 2010;38(4 Suppl):S495-S501.
drugs, are linked to an increased risk of bleeding. Pa- 2. Maynard G. Preventing hospital-associated venous thrombo-
tient education, emphasizing the need for strict ad- embolism: a guide for effective quality improvement. Rock-
ville, MD: Agency for Healthcare Research and Quality; 2016
herence to prescribed NOAC treatment, should be
Aug. AHRQ Publication No. 16-0001-EF. https://www.ahrq.
ongoing. gov/sites/default/files/wysiwyg/professionals/quality-patient-
Financial implications. Practical issues may affect safety/patient-safety-resources/resources/vtguide/vteguide.pdf.
NOAC use in the outpatient setting. The preauthori- 3. Raskob GE, et al. Surveillance for deep vein thrombosis and
zation requirements of some insurance companies, pulmonary embolism: recommendations from a national work-
variable patient copays, and high cost of the drugs shop. Am J Prev Med 2010;38(4 Suppl):S502-S509.
may present financial barriers for some patients, 4. Wendelboe AM, et al. The design and implementation of a
which may in turn contribute to medication nonad- new surveillance system for venous thromboembolism using
herence. Before prescribing NOACs, health care pro- combined active and passive methods. Am Heart J 2015;
170(3):447-54.e18.
viders should verify insurance coverage and patient
5. Geerts WH, et al. Prevention of venous thromboembolism:
copays. If the patient is eligible for financial assistance
American College of Chest Physicians evidence-based clinical
through a pharmaceutical company’s patient assis- practice guidelines (8th edition). Chest 2008;133(6 Suppl):
tance program, arrangements should be made before 381S-453S.
the treatment is prescribed.41 6. Centers for Medicare and Medicaid Services. Overview.
Patient education should be provided upon dis- Hospital-acquired condition (HAC) reduction program.
charge and reinforced throughout treatment (see n.d. https://www.qualitynet.org/dcs/ContentServer?c=Page&
Patient Teaching Points). In addition to oral instruc- pagename=QnetPublic%2FPage%2FQnetTier2&cid=
tions, written educational materials should be pro- 1228774189166.
vided to patients and caregivers for home use. Ensure 7. Joint Commission. Venous thromboembolism. 2016. https://
www.jointcommission.org/venous_thromboembolism.
that patients understand the
• rationale for drug treatment. 8. Office of the Surgeon General. The Surgeon General’s call to
action to prevent deep vein thrombosis and pulmonary em-
• importance of medication adherence in achieving bolism. Rockville, MD; 2008. Publications and reports of
therapeutic anticoagulation. the Surgeon General.
• consequences of nonadherence, including risk of 9. Deitelzweig SB, et al. Prevalence of clinical venous thrombo-
recurrent VTE. embolism in the USA: current trends and future projections.
• signs and symptoms of recurrence. Am J Hematol 2011;86(2):217-20.

2.0
ANCC
CONTACT HOURS
Caring for adults with

impaired physical mobility
By Ann Crawford, PhD, RN, CNS, CEN, CPEN,
and Helene Harris, MSN, RN
THE WORD MOBILITY is associated with physical move-

ment, including both simple gross motor movements and
more complex fine motor movements, along with associ-
ated coordination of those movements. Physical mobility
requires sufficient muscle strength and energy, along with
adequate skeletal stability, joint function, and neuromuscu-
lar synchronization.1 Anything that disrupts this integrated
process can lead to impaired mobility or immobility.
This article describes reasons mobility may be impaired,
the hazards of limited mobility or immobility, and nursing
interventions to mitigate complications.
Who’s at risk?
Though anyone can develop impaired mobility, those with
acute or chronic diseases, traumatic injury, or chronic pain
have a greater risk of experiencing altered mobility and its
associated complications.1 Disease processes directly affecting
mobility include disorders of the central and peripheral ner-
vous systems, musculoskeletal disorders, and neuromuscular
disorders. Nervous system diseases that can impair mobility
include cerebral palsy, multiple sclerosis, and Parkinson dis-
ease. Musculoskeletal disorders impairing mobility include
muscular dystrophy, osteoarthritis, and rheumatoid arthritis.
Other disorders that can impair mobility include con-
genital deformities such as osteochondrodysplasia and
diseases that contribute to fatigue such as heart failure and
KUPICOO /iSTOCK
chronic obstructive pulmonary disease.1,2 Traumatic or-

thopedic, head, and spinal injuries are especially likely to
impair mobility.
36 l Nursing2016 l Volume 46, Number 12 www.Nursing2016.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Chronic pain related to various Multiple hazards social interaction, further exacerbat-
medical disorders, surgical proce- Impaired mobility has negative con- ing the effects of isolation.1,3,4
dures, and traumatic injuries can sequences for virtually all body sys- Assess the patient’s ability to am-
also have a significant effect on an tems. If prolonged, immobility leads bulate and the amount of assistance
individual’s ability to move. Malnu- to deconditioning and loss of func- (including use of assistive devices)
trition and nutritional deficiencies tion (see Hazards of immobility). required. Several assessment tools
complicate or delay healing and The psychosocial effects of immo- are available; for some common
recovery, prolonging immobility bility are manifested by mood and af- examples, see Tools for assessing im-
impairments.1 fect changes. Patients with impaired paired mobility. Because impaired
Injuries related to falls can also mobility may experience boredom, mobility increases the risk of falls,
affect mobility. Musculoskeletal and anxiety, grieving, anger, and altered use a valid fall assessment tool to
other changes associated with ag- verbal/nonverbal communication determine the patient’s fall risk.
ing, such as decreased bone density, patterns. The change in mobility
decreased muscle mass, loss of pe- status may also alter the patient’s Nursing assessments
ripheral vision, and dementia can body image, leading to decreased related to mobility
combine to make older adults more self-esteem and a sense of powerless- Because mobility issues are directly
prone to falls and traumatic injury.1 ness. The patient may withdraw from related to musculoskeletal disorders,
Hazards of immobility1,3,4
Body system Immobility effects Potential complications
Cardiovascular • decreased systemic vascular resistance causing venous • orthostatic hypotension
pooling in extremities • thrombus formation
• decreased cardiac output
Respiratory • decreased strength of respiratory muscles • atelectasis
• diminished lung expansion • hypoxemia
• hypoventilation • pneumonia
• impaired gas exchange • pulmonary edema
• decreased cough reflex • thrombus formation
• pulmonary secretion pooling • pulmonary embolism
• blood redistribution and fluid shifts within the lung tissue
Integumentary • decreased delivery of oxygen and nutrients to tissues • skin breakdown
• tissue ischemia due to pressure between bed or chair and • abrasions/excoriation
bony prominences • pressure ulcers
• inflammation over bony prominences • infection
• friction and shearing of skin during movement
Musculoskeletal • reduced muscle mass • fatigue
• decreased muscle strength • decreased stability and
• decreased endurance balance
• shortening and tightening of connective tissue • muscle atrophy
• impaired joint mobility • joint contractures
• impaired calcium metabolism • foot drop
• osteoporosis
• falls
• pathologic fractures
Gastrointestinal • decreased peristalsis • constipation
• anorexia • fecal impaction
• decreased fluid intake • ileus
• increased intestinal gas • flatulence
• altered swallowing ability • abdominal distension
• nausea/vomiting
• heartburn, indigestion
• aspiration
• malnutrition.

a thorough assessment of this system
and its effect on the patient’s mobil- Tools for assessing impaired mobility
ity status is essential. Assess muscle Some examples of mobility assessment tools include the following.
bulk, tone, and muscle strength and • The Timed Up and Go (TUG) Test assesses mobility, balance, walking ability, and
coordination. fall risk.8 An observer assesses postural stability, gait, stride length, and sway as
Immobility can negatively affect the patient rises from sitting position in a chair, walks three meters, returns to
tissue perfusion, so also perform a the chair, and sits back down. Scores are based on time required to complete
thorough cardiovascular assess- the exercise. Patients requiring 12 or more seconds to complete the task have a
ment, including heart sounds, BP, higher fall risk.
apical and peripheral pulses, and • The Modified Elderly Mobility Scale (MEMS) tests motor function of older adults
with varying functional levels.9 It consists of eight categories of function, includ-
capillary refill time. Assess for the
ing position changes (lying, sitting, standing), ambulation, gait, functional reach,
presence of lower extremity edema.
and climbing stairs. Scores are based on the time required to complete the
Assessment of the respiratory sys- tasks and the degree of assistance needed. Higher scores in these areas indi-
tem should include lung sounds, chest cate a higher level of function.
wall movement and symmetry, and • The Functional Movement Screen (FMS) appraises a patient’s movement pat-
rate, depth and effort of respirations. terns to identify body asymmetries, weaknesses, and muscle and joint stiffness
Nursing assessment of the gastroin- that could potentially result in pain or injury.10 The FMS is comprised of seven
testinal system includes auscultating exercise tests of motor ability along with three tests designed to screen for joint
bowel sounds and palpating the abdo- problems. The patient receives a score from 0 to 4 on each exercise test, with
men for distension or discomfort. total score comparisons of the right and left sides. Higher scores (14 to 16)
To evaluate genitourinary prob- correlate with less risk of injury.
lems, assess for the presence of • The Mobility Scale for Acute Stroke (MSAS) was developed to explicitly distin-
urinary tract abnormalities such as guish between the lower levels of mobility seen in patients with acute strokes
in the first 2 weeks following stroke onset.11 It measures six mobility-related
suprapubic pain, dysuria, urgency, or
activities related to balance, body positioning changes, and ambulation/gait.
frequency, and urinary incontinence.
Each activity is graded on a 1-to-6 scale. Higher scores indicate a higher level
of functioning.
Nursing interventions • The Functional Independence Measure (FIM) is used to assess basic activities
While many interventions depend on of daily living, such as self-care needs, to identify overall independence during
the underlying cause of the patient’s specific functional tasks.12 It has two subscales, motor function and socio-
immobility, the nursing interventions cognitive functioning. The motor subscale includes 13 items that the patient
in this article will focus on aspects of would usually perform daily, including eating, grooming, bowel and bladder
care related to mobility itself. management, transfers, ambulation/movement, and stair climbing. The socio-
To avoid or minimize complica- cognitive portion looks at areas of comprehension such as expression, social
tions of immobility, mobilize the interaction, problem-solving, and memory.
patient as soon as possible and to
the fullest extent possible. Mobiliza- appropriate fall prevention strategies Pain can be a major deterrent to
tion efforts such as dangling, sitting, as indicated, such as hourly round- mobility. Monitor the patient’s level
and early ambulation, depend on ing to address patient needs. Encour- of pain by using a valid pain intensity
the patient’s unique circumstances age the patient to perform activities rating scale and provide nonpharma-
during hospitalization, such as the of daily living (ADLs) as indepen- cologic and pharmacologic pain man-
illness/disease process, procedures dently as possible and to participate agement interventions as prescribed.
performed, and surgery type.5 For in physical therapy prescribed to Along with medications (ranging
example, early mobilization may oc- improve mobility. Perform range-of- from nonsteroidal anti-inflammatory
cur from 24 to 36 hours for a patient motion exercises (active or passive drugs to opioids), consider employing
following an acute ischemic stroke. depending on the patient’s ability nonpharmacologic measures such as
A patient undergoing a cardiac cath- and clinical status).3,4 positioning, splinting, and heat/cold
eterization may be mobilized within Collaborate with other healthcare application, to reduce musculoskeletal
a few hours following the procedure, professionals for patient education discomfort. Document the patient’s
while a patient undergoing total knee and care planning; for example, response to therapy, including any ad-
arthroplasty may begin mobilizing physical therapists for safe ambula- verse reactions or drug interactions.2,4
24 hours following the surgery.5 tion plans, occupational therapists Orthostatic hypotension is defined
Monitor vital signs before and for ADLs, and dietitians for healthy as a drop in systolic BP of 20 mm Hg
after physical activity. Institute meal planning.4,6 or more or in diastolic BP of 10 mm
www.Nursing2016.com December l Nursing2016 l 39

Hg or more within 3 minutes of • reassessing the potential and de- such as sodium, potassium, magne-
standing.7 If orthostatic hypotension gree of risk of pressure ulcer devel- sium, and calcium.
is suspected, measure the patient’s opment daily. Debilitated patients are more sus-
vital signs while he or she is supine, • inspecting the patient’s skin daily. ceptible to infection, so monitor for
sitting, and standing. Graduated • treating dry skin with moisturizers. signs such as fever and leukocytosis.3,4
compression stockings can help im- • optimizing nutrition and hydration. Ask the patient to report any nau-
prove venous return. Anticoagulants • using pressure-redistribution sea, vomiting, or abdominal pain.
may be prescribed to help prevent surfaces. Because immobility can increase
venous thromboembolism.3,4 • minimizing exposure of the skin to the risk of constipation, monitor
Encourage adequate fluid intake moisture due to incontinence, per- bowel movements for regularity
to liquefy pulmonary secretions, and spiration, or wound drainage.3,4 and characteristics. Encourage fluid
teach the patient deep breathing and intake and a high fiber diet, unless
coughing exercises to prevent atelec- Ongoing assessment contraindicated, to help prevent
tasis. Monitor SpO2 levels and provide and nursing care constipation.
supplemental oxygen as prescribed to Nutritional status affects both the When documenting I&O, note
maintain adequate oxygenation. patient’s potential for developing amount and characteristics of urine.
Position the patient with the head immobility-related complications Lab test results, including urine osmo-
of the bed elevated 30 to 45 degrees and the patient’s ability to regain lality and specific gravity and blood
unless medically contraindicated; mobility. Monitor the patient’s food urea nitrogen, can help determine the
turn and reposition the patient every consumption and portion sizes, dai- patient’s fluid volume status.2-4
2 hours. Besides supporting respira- ly weights, intake and output (I&O), Monitor the patient’s emotional
tion, proper positioning and repo- and activity level. As needed, assist status every shift, and be attuned to
sitioning helps protect the skin and the patient with meals, discuss food any behavioral or mood changes. Of-
minimize the potential for break- preferences with the patient/family, fer support and empathy, and allow
down. Additional interventions for and consult a dietitian. Monitor lab the patient to express his or her feel-
preventing pressure ulcers include: values related to nutrition, such as ings in a nonjudgmental manner. Any
• conducting a pressure ulcer admis- serum albumin, serum protein, identified concerns should be reported
sion assessment for all patients. blood glucose, and key electrolytes and monitored to ensure the patient’s
continued psychological health.3,4
Research supports early mobility Patient teaching

Clark, Lowman, Griffin, Matthews, and Reiff (2013) studied the effectiveness of an Adherence to recommended pre-
early mobilization program in a trauma and burns ICU.13 They identified a decrease vention and treatment strategies
in pulmonary and cardiovascular complications, such as pneumonia and deep vein can make a significant difference in
thrombosis, when they implemented the program and concluded that early mo- whether the patient will regain mo-
bilization was safe and effective. They added that the medical community, includ- bility or develop immobility-related
ing healthcare providers, nurses, physical therapists, and hospital administrators, complications. Educate patients and
should promote a culture where early mobilization for hospitalized patients is the their families regarding the risks of
standard of care.
impaired mobility and the impor-
Similarly, Havey, Herriman, and O’Brien (2013) identified that bedrest and
tance of maintaining the highest level
immobility in patients following abdominal surgery contributed to increased fa-
tigue, decreased body muscle mass, and decreased pulmonary function.14 They
of physical activity possible. Discuss
emphasized the importance of early mobilization to decrease these negative the importance of turning and repo-
physical effects. sitioning to maintain skin integrity
Institutions need to look at the financial and organizational implications of and explain that passive and active
implementing some form of mobility program to prevent or minimize the effects range-of-motion exercises will help
of immobility. Clark et al. (2013) and Knoblauch et al. (2013) both report that the patient maintain joint flexibility,
implementing early mobilization programs doesn’t increase costs and may be muscle strength, and muscle mass.
associated with decreased lengths of stay for patients.13,15 Kalisch et al. (2013) Discuss fall prevention tech-
identified that mobilizing hospitalized patients not only provides physical benefits niques. For example, teach patients
for them but psychological and social value as well. In addition, organizational
to change positions slowly to avoid
outcomes related to mobility programs offer positive reasons for providing nursing
orthostatic hypotension.
and medical interventions that will promote optimal mobility for patients suffering
from immobility issues.5
Stress the importance of optimal
nutrition in the healing process; the

patient and family should under- incorporating appropriate assessment 9. Lewis C, Shaw K. Move it or lose it: a look at
the MEMS. ADVANCE for Phys Ther Rehab Med.
stand that meals high in protein and skills, early mobilization efforts, and 2013;24(11):8.
nutrients are beneficial for healing. proper prevention strategies, the 10. Nuzum T. Understanding the functional
Also inform patients about the im- nurse can help patients recover their movement screen (FMS): a tool to avoid injuries.
2014. http://theraplus.org/understanding-functional-
portance of adequate fluid intake to former degree of mobility and flex- movement-screen-fms-tool-avoid-injuries.
help prevent both urinary tract infec- ibility in support of an optimal qual- 11. Simondson JA, Goldie P, Greenwood KM. The
tions and constipation. ity of life. ■ mobility scale for acute stroke patients: concurrent
validity. Clin Rehabil. 2003;17(5):558-564.
The psychological impact due
12. Sears PT. Physical therapy: the Functional
to impaired mobility and immobil- REFERENCES Independence Measurement. 2016. http://
ity can be devastating. Provide the 1. Giddens J, Scheller J. Mobility. In: Jean Giddens, physicaltherapy.about.com/od/Physical-Therapy-
ed. Concepts for Nursing Practice. St Louis, MO: For-Seniors/a/Functional-Independence-
patient and family with information Mosby Elsevier; 2013:239-247. Measurement.htm.
about support groups and commu- 2. Burton MA, Ludwig LJM. Fundamentals of 13. Clark DE, Lowman JD, Griffin RL, Matthews
HM, Reiff DA. Effectiveness of an early
nity resources as appropriate for any Nursing Care: Concepts, Connections, & Skills.
mobilization protocol in a trauma and burns
Philadelphia, PA: F.A. Davis; 2015.
identified physiological, psychoso- intensive care unit: a retrospective cohort study.
3. Amidei C. Mobilisation in critical care: a concept Phys Ther. 2013;93(2):186-196.
cial, spiritual, and financial needs.2-4 analysis. Intensive Crit Care Nurs. 2012;28(2):73-81.
14. Havey R, Herriman E, O’Brien D. Guarding the
4. Ignatavicius D, Workman M. Medical-Surgical gut: early mobility after abdominal surgery. Crit Care
Nursing: Patient-Centered Collaborative Care. 7th ed.
Keep patients on the move St. Louis, MO: Elsevier; 2013.
Nurs Q. 2013;36(1):63-72.
Immobility and its complications 5. Kalisch BJ, Lee S, Dabney BW. Outcomes of
15. Knoblauch DJ, Bettis MA, Lundy F, Meldrum C.
Financial implications of starting a mobility protocol
have been shown to have the poten- inpatient mobilization: a literature review. J Clin in a surgical intensive care unit. Crit Care Nurs Q.
Nurs. 2014;23(11-12):1486-1501.
tial to cause physical disability and 2013;36(1):120-126.
6. Nursing interventions and rationales.
emotional suffering for patients, as Impaired physical mobility. 2013. http://
Ann Crawford is a professor at the College of Nursing,
well as to increase healthcare costs nursinginterventionsrationales.blogspot. University of Mary Hardin-Baylor in Belton, Tex. Now
com/2013/07/impaired-physical-mobility.html. retired, Helene Harris was formerly a clinical educator
for facilities and communities. (See in the Central Texas Veterans Health Care System in
7. Bickley LS. Bates’ Guide to Physical Examination.
Research supports early mobility.) A 11th ed. Philadelphia, PA: Wolters Kluwer/ Temple, Tex.
comprehensive understanding of Lippincott Williams & Wilkins; 2012. The authors and planners have disclosed no potential
8. Centers for Disease Control and Prevention. The conflicts of interest, financial or otherwise.
the concept of mobility is critical to Timed Up and Go (TUG) test. https://www.cdc.
providing optimal patient care. By gov/steadi/pdf/tug_test-a.pdf. DOI-10.1097/01.NURSE.0000504674.19099.1d
> For more than 118 additional continuing education articles related to
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1.5 1.5
CONTACT HOURS CONTACT HOURS
Reversal agents for

oral anticoagulants
Abstract: For more than half a century, warfarin, a vitamin K antagonist, has been
the anticoagulant of choice. However, direct oral anticoagulants are rapidly gaining
in popularity, which poses the need for efficacious reversal agents. This review article
summarizes the strategies and agents used to reverse oral anticoagulants.
By Carrie L. Griffiths, PharmD, BCCCP; Mark L. Vestal; Spencer J. Livengood;

and Samantha Hicks, MSN, ACNP, CCRN
nticoagulation therapy is indicated in patients who However, warfarin has many reversal options, such as
A have had a venous thromboembolism, atrial fibril-
lation (AF), mechanical valve replacement, and
phytonadione (vitamin K), fresh frozen plasma (FFP), and
prothrombin complex concentrate (PCC). These reversal
other coagulation disorders (antiphospholipid antibody agents allow warfarin to be an alternative option for patients
syndrome, Factor V Leiden). Since 2010, when the first direct at an increased risk of bleeding, and recent guidelines still
oral anticoagulant was approved by the FDA, antithrom- recommend it for certain patients.1 This article reviews key
botic therapy has shifted away from the mainstay of therapy, points regarding available oral anticoagulants (warfarin,
the vitamin K antagonist, due to recent guideline recom- dabigatran, rivaroxaban, apixaban, edoxaban), available
mendations in antithrombotic therapy.1 reversal agents (vitamin K, FFP, PCC, idarucizumab), and a
In AF, a CHADS2 score or CHA2DS2-VASc score (an new reversal agent (andexanet alfa), which is currently in
updated version), is used to determine the patient’s stroke phase III clinical trials.
risk and need for anticoagulation therapy.2 Several studies
have shown a lower bleeding risk with direct oral antico- ■ Oral anticoagulants
agulants (DOACs) over warfarin.3-6 Therefore, clinicians Warfarin
are considering these agents more often for their patients. Approved by the FDA in 1954, warfarin is indicated for
In addition to their improved safety and efficacy profile, prophylaxis and treatment of venous thrombosis, pulmo-
DOACs do not require monitoring and have fewer drug nary embolism, thromboembolic complications associated
interactions than warfarin. with AF and/or cardiac valve replacement, and reduction
DOACs do not require monitoring, so it is difficult to in the risk of death due to recurrent myocardial infarction
determine if the drugs are subtherapeutic, therapeutic, or and stroke. It works by inhibiting the synthesis of vitamin
supratherapeutic. This has led to a need for effectual antidotes K–dependent clotting factors II, VII, IX, and X and the
in the case of an emergency.1 Currently, only one reversal agent anticoagulant proteins C and S, ultimately leading to an
(idarucizumab for dabigatran) has been approved by the FDA, anticoagulant effect.7
leaving other DOACs such as rivaroxaban, apixaban, and Although warfarin is an effective anticoagulant, manag-
edoxaban without reversal agents. ing therapy with warfarin is challenging due to the individual
Keywords: andexanet alfa, apixaban, dabigatran, direct oral anticoagulants, edoxaban, fresh frozen plasma, idarucizumab, phytonadione,
prothrombin complex concentrate, reversal agents, rivaroxaban, vitamin K, warfarin
www.tnpj.com The Nurse Practitioner • November 2017 9

Reversal agents for oral anticoagulants
variations in dosage requirements that can result in over/ Apixaban

under-anticoagulation. In addition, warfarin has a narrow Approved by the FDA in 2012 for the treatment of nonval-
therapeutic range, which must be monitored closely to vular AF needing anticoagulation, apixaban exerts its phar-
prevent adverse reactions (such as bleeding). Warfarin’s macologic effect by binding to free and bound factor Xa in
concentrations can also be affected by vitamin K–containing the body, thus preventing clot formation and platelet activa-
tion. Renal excretion accounts for 27%
of apixaban elimination. This makes
Since the first DOAC was approved, apixaban a viable option in patients
antithrombotic therapy has shifted away from the with kidney impairment, although
clinical judgment should be employed.
mainstay of therapy, the vitamin K antagonist. Apixaban is currently approved for risk
reduction of stroke and systemic embo-
lism in nonvalvular AF and treatment
foods and other medications, such as amiodarone, flucon- of DVT and PE, risk reduction to prevent recurrence of DVT
azole, and others.8 However, even though warfarin interacts and PE after initial treatment, and prophylaxis of DVT after
with many foods and medications, it is still commonly used hip or knee replacement surgery.13
for anticoagulation.9
Edoxaban
Dabigatran A factor Xa inhibitor, edoxaban was approved by the FDA
A direct thrombin inhibitor, dabigatran was approved by in 2015 for nonvalvular AF and is the newest factor Xa
the FDA in 2010 for nonvalvular AF and was the first inhibitor to be approved. Like rivaroxaban and apixaban,
DOAC used as an alternative to the vitamin K antagonist.10 it exerts its pharmacologic effect by binding directly to free
This oral prodrug converted by serum esterase works by and clot-bound factor Xa without requiring cofactors (an-
binding to both fibrin-bound and unbound thrombin, tithrombin), thus preventing thrombus formation and
which ultimately negates the conversion of fibrinogen platelet activation. Currently, edoxaban is indicated for
(factor I) to fibrin (factor Ia), preventing the formation of reduction of stroke and systemic embolism in patients with
a thrombus.3,10 nonvalvular AF and treatment of DVT and PE after 5 to 10
Currently, dabigatran is indicated for stroke and sys- days of treatment with a parenteral anticoagulant.14
temic embolism prophylaxis in nonvalvular AF, treatment Consult the manufacturer’s prescribing label for com-
of deep vein thrombosis (DVT) and pulmonary embolism plete prescribing information including dose recommenda-
(PE) in patients who were previously treated with a paren- tions and dose adjustments for each drug.7,11-14
teral anticoagulant for 5 to 10 days, risk reduction to prevent
recurrence of DVT and PE in patients who were previously ■ Reversal agents
treated, and prophylaxis of DVT and PE in patients under- Phytonadione (vitamin K)
going hip replacement surgery, which was approved by the Vitamin K reverses the anticoagulant effect of warfarin
FDA in 2014.11 by promoting hepatic production of the vitamin K–
dependent clotting factors II, VII, IX, and X. By promot-
Rivaroxaban ing hepatic production of the vitamin K–dependent
A factor Xa inhibitor, rivaroxaban was approved by the clotting factors, administering exogenous vitamin K I.V.
FDA in 2011 for nonvalvular AF and venous thromboem- or orally expedites the reduction of the international
bolism and was the first factor Xa inhibitor to be ap- normalized ratio (INR). Between the two routes of ad-
proved. 10 It exerts its pharmacologic effect by binding ministration, I.V. vitamin K causes a faster reduction in
directly to free and clot-bound factor Xa, without requir- the INR within 6 to 8 hours after administration com-
ing cofactors (antithrombin), thus preventing thrombus pared with oral vitamin K, which causes a reduction
formation and platelet activation. Currently, rivaroxaban within 24 to 48 hours.15
is indicated for risk reduction of stroke and systemic em- The reduction in INR achieved after 24 to 48 hours is
bolism in nonvalvular AF, treatment of DVT and PE, risk similar between the I.V. and oral routes. Therefore, there is
reduction to prevent recurrence of DVT and PE in patients no advantage to using the I.V. route when the need for war-
who were initially treated for DVT or PE, and prophy- farin reversal is not urgent. The I.M. and subcutaneous
laxis of DVT and PE in patients undergoing knee or hip routes of administration are not recommended in patients
replacement surgery.12 requiring warfarin reversal due to erratic absorption; the
10 The Nurse Practitioner • Vol. 42, No. 11 www.tnpj.com

risk of anaphylaxis is a concern when vitamin K is admin- exert their effects within the body. PCCs are indicated for
istered via the I.V. route.15,16 reversal of vitamin K antagonists, such as warfarin.18
The American College of Chest Physicians (ACCP) has The 3-PCC contains the factors II, IX, and X; 4-PCC
specific recommendations that describe when vitamin K contains a combination of coagulation factors II, VII, IX, X,
administration is appropriate.16 First, the ACCP recommends and proteins C and S. Both of these products are indicated
against the routine use of vitamin K for warfarin reversal in for patients requiring reversal of vitamin K antagonist due
patients with an INR between 4.5 and 10 and no bleeding; to acute major bleeding. The administration of PCC causes
there is no advantage to administering vitamin K in this thrombotic or thromboembolic events in some patients
situation. Instead, warfarin should be withheld in these treated with PCC. Vitamin K must be administered to pa-
patients until the INR declines. Second, administering oral tients receiving 4-PCC in order to maintain adequate factor
vitamin K and withholding warfarin are recommended for levels in the body following administration when reversing
patients with an INR greater than 10 and no bleeding. Fi- warfarin.19
nally, in the presence of bleeding regardless of INR, a slow The risk of a thromboembolic event must be weighed
I.V. dose of vitamin K as well as withholding warfarin are against the risk of acute bleeding in patients receiving
recommended.15,16 4-PCC. Dosing of 4-PCC is given as a single dose based on
Overall, vitamin K is effective in the complete rever- the patient’s weight and INR.19
sal of warfarin within 24 to 48 hours. Per the ACCP, in- PCCs are currently being studied as potential options
tervention with vitamin K is not indicated when the INR for reversal of DOACs; however, the use of PCCs is cur-
is 10 or less unless the patient has significant bleeding or rently off-label.18 A meta-analysis by da Luz and colleagues
16
requires urgent surgery. Administering vitamin K can concluded that PCCs partially reverse DOACs and should
result in the patient being refractory to warfarin when be considered as treatment options in case of severe bleeding
warfarin is reinitiated. Therefore, the
lowest possible dose of vitamin K
should be used to reverse warfarin to Administering vitamin K can result in the
avoid further complications.15
patient being refractory to warfarin when
FFP warfarin is reinitiated.
Prepared from single units of whole
blood or plasma, FFP is a widely used
agent that reverses warfarin in the event of serious bleeding for DOACs without a reversal agent. Studies for reversal of
and elevated INR. Within FFP, all of the clotting factors, DOACs are limited and it is strongly encouraged to look at
plasma proteins, electrolytes, physiologic anticoagulants risks versus benefit (such as thrombosis) with PCC before
(protein C, protein S, antithrombin, tissue factor pathway considering using it as a reversal for these agents.20
inhibitor), and added anticoagulants exist, allowing FFP to
reverse coagulopathies caused by warfarin. 17 Dosing is Idarucizumab
based on the patient’s weight (10 mL/kg to 20 mL/kg), To date, dabigatran is the only DOAC with an FDA-approved
which produces a 20% to 30% increase in plasma levels of reversal agent. Idarucizumab, a humanized monoclonal
clotting factors.15 antibody fragment, was approved by the FDA in 2015 as the
FFP carries risks, including disease transmission, fluid reversal agent for dabigatran.21 Due to promising results in
overload, and transfusion reactions, such as hypersensitiv- clinical trials, idarucizumab received accelerated approval
ity reactions. It must be blood group–specific because it from the FDA, which allowed it to come to market sooner
contains isohemagglutinins. FFP has to be thawed before (see Reversal agents for oral anticoagulants).22
use, which could delay treatment in the event of an emer- Idarucizumab, a humanized monoclonal antibody frag-
gency.15 FFP is not effective to reverse the effects of DOACs ment, binds to dabigatran and its metabolites (affinity ap-
and should not be used with reversal of DOACs.10 proximately 350 times higher than dabigatran for thrombin),
thus neutralizing and reversing dabigatran’s anticoagulant
PCC effect.23 Because the mechanism of dabigatran differs from
PCCs are typically composed of varying amounts of factors other DOACs, idarucizumab will only reverse the effects of
II, VII, IX, and X. Frequently used formulations of PCC dabigatran and should not be used to reverse other DOACs.
include 3-factor PCC (3-PCC) and 4-factor PCC (4-PCC). Currently, FDA indications of idarucizumab include patients
Both products require activation by the clotting cascade to treated with dabigatran when the reversal of anticoagulant

effects is warranted for emergency surgery/urgent proce- elevated coagulation parameters, it may be warranted to
dures, and/or life-threatening/uncontrolled bleeding.21 administer another dose of idarucizumab, but the safety
Two methods of administration may be used. The first and efficacy of readministration have not been established.21
is a continuous infusion by hanging the vials, and the second Third, few reports in clinical trials have noted a hy-
method is providing bolus injections by injecting both vials persensitivity reaction, and the risk of reaction should
consecutively via syringe.21 Once the solution has been always be considered. However, it is important to always
drawn up via syringe for bolus injections, idarucizumab determine the risk versus benefit when deciding if a
must be administered within 1 hour. A preexisting I.V. line patient should receive idarucizumab. Finally, if patients
may be used for administration, but the line must be flushed with the condition of hereditary fructose intolerance
with sterile 0.9% sodium chloride injection prior to infu- have had a previous reaction to sorbitol, it is important
sion, and no other infusion should be administered via the to note that idarucizumab contains 4 g of sorbitol as an
same I.V. line.21 excipient and should be considered when administering
Idarucizumab has four warnings that should be con- idarucizumab.21,22
sidered before administration. First, reversing dabigatran During the phase III clinical trial, the Reversal Effects
exposes patients to risk of developing a thrombus due to of Idarucizumab on Active Dabigatran (RE-VERSE AD)
the underlying disease (AF). To reduce this risk, restarting study, efficacy and safety of idarucizumab were established.
anticoagulation should be considered as soon as medi- In the RE-VERSE AD study, patients age 18 or older who
cally appropriate, and dabigatran may be reinitiated in a had uncontrollable and/or life-threatening bleeding (group
patient as early as 24 hours after administration of idaru- A) or who required a surgery or other invasive procedures
cizumab. that could not be delayed for 8 hours (group B) received
Second, in a small number of patients in clinical trials, idarucizumab. The primary endpoint was the percentage
elevation of coagulation parameters (activated partial reversal of the anticoagulant effect of dabigatran, which was
thromboplastin time and/or ecarin clotting time [ECT]) determined within 4 hours after the infusion of idaruci-
has been observed after the administration of idarucizumab on the basis of the measurement of dilute thrombin
zumab (between 12 and 24 hours post administration). If time (dTT) or ECT by a central lab (dTT and ECT were
there is reappearance of clinically relevant bleeding with chosen as markers of idarucizumab’s percentage reversal
Reversal agents for oral anticoagulants1,15,18,19,23,27
Anticoagulant Reversal agent Mechanism of action Important facts

Warfarin Vitamin K Cofactor for hepatic synthesis Recommended when a patient is bleeding or
of factors II, VII, IX, and X has an INR >10
FFP Repletes all plasma proteins May transmit diseases; must be blood type–
and clotting factors specific because FFP contains isohemaggluti-
nins; may cause fluid overload, which could be
problematic in patients with heart failure
3-PCC Repletes vitamin K–dependent Must coadminister vitamin K with dose; some
clotting factors II, IX, and X products contain heparin and are contraindi-
cated in patients with heparin-induced throm-
bocytopenia (HIT); refer to package insert for
dosing, as this depends on the product
4-PCC Repletes vitamin K–dependent Dose is determined by the patient’s predose
clotting factors II, VII, IX, X as INR and body weight; must coadminister vita-
well as proteins C and S min K with dose; preferred over FFP in cases
of major bleeding; contains heparin and is
contraindicated in patients with HIT
Dabigatran Idarucizumab Binds to and reverses dabiga- Must administer both vials in package for com-
tran and its metabolites plete reversal of dabigatran
Rivaroxaban Andexanet alfa Binds to and reverses effects Currently in phase III clinical trials and pending
of factor Xa inhibitors FDA approval
Apixaban
Edoxaban
12 The Nurse Practitioner • Vol. 42, No. 11 www.tnpj.com

effect because these markers are highly correlated with the trauma or surgery. Currently, there are no approved agents
concentrations of unbound dabigatran). Of note, dTT and for the reversal of factor Xa inhibitors. Andexanet alfa is a
ECT may not be readily available. Many different secondary new agent seeking FDA approval that completely reverses
endpoints were evaluated, but the major secondary endpoint direct and indirect factor Xa inhibitors, such as rivaroxaban,
was hemostasis restoration.23 apixaban, edoxaban, and enoxaparin.25
To provide idarucizumab to patients as soon as possible, Andexanet alfa is a recombinant modified human factor
an interim analysis from the RE-VERSE AD study was pub- Xa decoy protein, which exerts its effects by binding to factor
lished in June 2015. Overall, idarucizumab completely re- Xa inhibitors and preventing their anticoagulant effects
versed the anticoagulant effect of dabigatran in 90 patients within the body. Administration in clinical trials has in-
within minutes of administration. Among the 68 patients cluded a bolus dose followed by a 2-hour infusion of andex-
who had elevated dTT and 81 who had elevated ECT, the anet alfa. Because andexanet alfa has not yet been approved
medium maximum percentage reversal was 100% (95% for use, the dosing and administration information have not
confidence interval [CI], 100 to 100), which was evident on been established.25
the first sample taken after the first infusion of idaruci- Andexanet alfa is currently undergoing a third phase
zumab. Therefore, since the interim results indicated that III clinical trial to test its effectiveness in the reversal of
idarucizumab was an effective reversal agent for dabigatran, these agents in direct and indirect factor Xa inhibitors.
idarucizumab received accelerated approval from the FDA Two additional phase III trials showing the effi cacy of
in October 2015, which was contingent upon the results of andexanet alfa have already been completed. The AN-
the full cohort analysis.23 NEXA-A trial only tested the reversal agent’s effectiveness
In August 2017, the full cohort analysis of the RE- in apixaban, whereas the ANNEXA-R trial showed its
VERSE AD study was published, which continued to show effectiveness when reversing rivaroxaban.26 The apixaban
that idarucizumab was an effective and safe reversal agent and rivaroxaban trials did not report any thromboem-
for dabigatran. Among the 503 patients in the trial, 461 bolic events caused by the administration of the reversal
patients (91.7%, 276 in group A and 185 in group B) had agent.26
an elevated ECT or a prolonged dTT at study entry. With- One patient was reported to have an anaphylactic reac-
in 4 hours after administering idarucizumab, 100% (95% tion upon administration.26 While the last phase III trial
CI 100 to 100) of dabigatran’s anticoagulant effect was has not yet been completed, a preliminary analysis has been
reversed based on the ECT and dTT measurement. Fur- recently published. This analysis reported andexanet alfa
thermore, unbound (active) dabigatran concentrations to be effective in the rapid reversal of factor Xa agents in
remained less than 20 ng/mL (a level that produces little or 67 patients. However, 12 of the 67 patients (18%) reported
no anticoagulant effect) for the majority of patients for 24 having thrombotic events after being treated with andex-
hours. Of note, reemergence of levels greater than 20 ng/ anet alfa.25
mL occurred in 114 of 497 patients (23%), but only 10
patients experienced recurrent or continuous bleeding. ■ Conclusion
Regarding restoration of hemostasis, in group A, 134 pa- Prescribing of DOACs is on the rise due to their efficacy and
tients (98 patients had intracranial bleeding and could not safety that has been seen in many clinical studies, and the
be assessed) had confirmed bleeding cessation within 24 need for effective antidotes is warranted. Currently, the only
hours, and the median investigator-reported time to ces- FDA-approved reversal agent for a DOAC is idarucizumab
sation of bleeding was 2.5 hours. for dabigatran, which leaves the factor Xa inhibitors rivar-
In group B, 197 patients underwent urgent procedures, oxaban, apixaban, and edoxaban without effective reversal
and normal intraoperative hemostasis was reported in 184 agents. However, andexanet alfa has shown efficacy in the
patients (93.4%). Regarding safety, 117 patients (23.3%; reversal of factor Xa inhibitors and is currently in phase III
66 in group A and 51 in group B) had serious adverse clinical trials.27
events within 5 days of idarucizumab administration.
However, no consistent pattern developed, and the major- REFERENCES
ity of events were due to worsening of their underlying 1. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease:
CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315-352.
conditions.24
2. Odum LE, Cochran KA, Aistrope DS, Snella KA. The CHADS2 versus the
new CHAD2DS2-VASc scoring systems for guiding antithrombotic treatment
■ Andexanet alfa of patients with atrial fibrillation: review of the literature and recommenda-
tions for use. Pharmacotherapy. 2012;32(3):285-296.
Patients taking factor Xa inhibitor anticoagulants are at an 3. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in
increased risk of bleeding in emergency situations, such as patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139-1151.

P a t i e n t E d u c a t i o n S e r i e s
> Taking warfarin safely

What is warfarin and how does it work?
Warfarin is a prescription medicine that helps stop
abnormal blood clots from forming or growing larger
pink or brown urine, red or dark-colored stool, heavier-
than-normal menstrual bleeding or abnormal vaginal
bleeding, a nosebleed, or coughing up or vomiting
in blood vessels. Because clots can block blood blood or material that looks like coffee grinds. Also call
flow, they can cause a heart attack, brain attack your healthcare provider or 911 if you have a severe
(stroke), and other serious problems. headache, a fever or illness that gets worse, dizziness or
While you’re taking warfarin, you must have regu- weakness, chest pain, or trouble breathing, or if you
lar blood tests to make sure you’re getting enough have new pain or color or temperature changes in any
warfarin to stop harmful clots but not so much that part of your body, such as your toes. Go to a hospital
your blood won’t clot when it should (for example, emergency department if you hit your head to make
when you cut yourself). sure you don’t have any bleeding in your brain.
How do I take warfarin? Do I have to change my diet?

Because warfarin increases your risk for bleeding, you Eat a normal balanced diet, and don’t make changes
must take it exactly as your healthcare provider tells in your diet without first talking to your healthcare
you. You’ll have to get a blood test called a PT/INR at provider. Foods rich in vitamin K (dark green or
least once a month, sometimes more often. (PT/INR leafy vegetables such as broccoli and spinach) can
stands for prothrombin time and international nor- change the effects of warfarin in your body. You
malized ratio.) The amount of warfarin you take may don’t have to avoid these foods, but try to keep the
change depending on test results. amount you eat the same every week. Don’t drink
Follow these guidelines when taking warfarin: alcohol, and avoid drinking cranberry juice or eating
• Take warfarin at the same time each day. cranberry products because they can affect how
• If you miss or forget a dose, call your healthcare warfarin works in your body.
provider for advice. Don’t take a double dose.
• Don’t take warfarin if you’re pregnant or may How can I reduce my risk of bleeding?
become pregnant; if you want to breastfeed, you Because you may bleed easily, take these precautions:
need to discuss it with your healthcare provider first. • Clean your teeth gently with a soft-bristle toothbrush
• Tell all your other healthcare providers, including and waxed floss.
your dentist, that you’re taking warfarin. If you need • Shave with an electric razor instead of a razor blade,
surgery, medical tests, or dental procedures, you may or use hair-removing cream.
have to stop taking warfarin temporarily. • Take care not to cut yourself when using knives and
• Talk to your healthcare provider before you take any other sharp objects.
new medicine, including over-the-counter drugs, • Don’t walk barefoot, and avoid activities that have a
herbal supplements, and vitamins. risk of injury, such as contact sports.
• Call your healthcare provider right away if you have If you start bleeding, apply constant pressure until
any signs of unusual bleeding or bruising such as the bleeding stops. If it doesn’t stop in 10 minutes, call
bleeding from a cut that doesn’t stop, bleeding gums, your healthcare provider or 911 for help. ■
®
This patient-education guide has been adapted for the 5th-grade level using the Flesch-Kincaid and SMOG
formulas. It may be photocopied for clinical use or adapted to meet your facility’s requirements. Selected
references are available upon request.
58 | Nursing2010 | April www.Nursing2010.com

Letter From the Editor
What Is Professionalism?
Catherine L. Witt, MS, NNP-BC
I
have often heard nurses use the phrase “I just may not like. They include honest evaluation of your
want to be treated like a professional.” Often professional practice. They include using resources
it is in conjunction with activities such as wisely, not just supplies, but your time. They include
punching a time clock or issues like break times or environmental health as part of nursing practice.2
pay scales. Once I heard it around a complaint about A professional demonstrates those behaviors as
mandatory education requirements. Is this what defined by the profession. How many have actually
being treated like a professional is about? What do taken the time to read the Neonatal Nurses Scope
we mean when we say that? and Standards of Practice or know what the stan-
dards actually are? How many do we actually live up
Merriam-Webster defines professionalism as a. of, to? The first 6 standards of nursing practice, which
relating to, or characteristic of a profession; b. have to do mostly with patient care, are perhaps eas-
engaged in one of the learned professions; c. (1) ier. We are used to doing assessments, making a plan
characterized by or conforming to the technical or of care, identifying desired outcomes, and evaluating
ethical standards of a profession (2) exhibiting a the care to see if it worked. The others, the standards
courteous, conscientious, and generally businesslike
of professional performance, are perhaps harder. Not
manner in the workplace.1
many want to participate in quality improvement
committees. Only a few attend professional confer-
As nurses, we have standards that have been
ences or read the latest research during their down
developed by our professional organization, with
time. Most of us avoid self-reflection and an honest
input from members. These standards outline what
appraisal of our own practice; and if forced to obtain
nurses are held accountable for. NANN has recently
peer reviews, we try to pick our friends. We some-
updated the Scope and Standards of Practice for
times avoid sharing information with the new gradu-
Neonatal Nurses. The book describes the standards
ate nurse. We forget the difference between profes-
that nurses, and neonatal nurses in particular, are
sional, therapeutic relationships, and friendships, not
expected to uphold. It also describes how to uphold
only with our patients but sometimes with our
the standards—what it means in practical terms to
coworkers. We complain that we do not like research
meet the standards outlined.
and that it is too hard to read. We are often not fis-
Nursing standards of practice do not just include
cally responsible and do not always use our down-
nursing process—assessing the patient, determining
time productively. We expect leadership from others,
the patient’s issues and desired outcomes, and devel-
but not from ourselves.
oping, implementing, and evaluating a plan of care.
A recent article talks about professional comport-
They also include things like ethical practice. They
ment. The authors define professional comportment as
include education, not just nursing school but ongo-
behavior that is dignified, competent, and conscious,
ing, to keep up with current knowledge and changes
and includes caring and compassion.3 It includes com-
in practice. They include contributing to quality, to
mitment to the profession, respect for others, and col-
ensuring that care in your unit is the best it can be.
laboration. In some ways, comportment is really about
They include communication, leadership, and col-
good manners and doing a job well. Without comport-
laboration. This means collaborating not only with
ment, a unit becomes an unpleasant place to work. We
other healthcare team members but with the new
all prefer to work with colleagues who are committed,
graduate nurse on your unit, the students who need
are easy to get along with, and are compassionate, not
preceptors, and the person on the other shift you
only toward their patients, but toward their cowork-
ers. Professional comportment incorporates the nurs-
The author declares no conflict of interest. ing standards that we are accountable for.
Copyright © 2013 by The National Association of Professionalism has nothing to do with time clocks.
Neonatal Nurses It has to do with how we hold ourselves and our peers
DOI: 10.1097/ANC.0b013e3182a4a5af accountable to being the best we can be, not only for
Advances in Neonatal Care • Vol. 13, No. 5 • pp. 303-304 303
Copyright © 2013 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
ANC200425.indd 303 13/08/13 7:49 PM

NCLEX-RN Cram Sheet by
2019 Update
This NCLEX-RN cram sheet or cheat sheet can help you prepare as it contains condensed facts about the nurse licensure exam itself and key nursing information. When your time to
take the NCLEX comes, you can write or transfer these vital information from your head to a blank sheet of paper provided by the testing center.
Please download only at Nurseslabs.com as we continually update this cram sheet.
1. TEST INFORMATION 2. NCLEX QUESTION TYPES 3. VITAL SIGNS
• Six hours – the maximum time allotted for the NCLEX is 6 • Multiple-Choice –These questions provide you with data Heart rate 80 – 100 bpm
hours. about client situation and given four options to choose Respiratory rate 12-20 rpm
• Take breaks – Take breaks if you need a time out or from. Most common question type. Blood pressure 110-120/60 mmHg
need to move around. First optional break is offered after • Fill-in-the-Blank – This format is usually used for Temperature 37 °C (98.6 °F)
2 hours of testing, next is offered after 3.5 hours of testing. medication calculation or computing an IV flow rate. Type
All breaks count to your allotted six hours. only a number for your answer in the box. Rounding an 4. HEMATOLOGY VALUES
• 75/265 – the minimum number of question you can answer should be done at the end of the calculation or as
answer is 75 and a maximum of 265. Of the 75 questions, what the question specifies. Type in the decimal point if
RBCs 4.5 – 5.0 million per mm3
60 will be scored question and the remaining 15 are necessary.
WBCs 4,500 – 11,000 per mm3
pretest or unscored questions. • Multiple-Response – You’ll be asked to select all the
Neutrophils 60 – 70%
• Read the question and answers carefully – do not jump option that relate to the information asked by the question.
Lymphocytes 20 – 25%
into conclusions or make wild guesses. Read the entirety There may be two or more correct answers and no partial
Monocytes 3 – 8%
of the question including its choices before selecting your credit is given for correct selection.
Eosinophils 2 – 4%
final answer. • Ordered-Response – In this format, you’ll be asked to Basophils 0.5 – 1%
• Look for keywords – avoid answers with absolutes like use the computer mouse to drag and drop your nursing Platelets 150,000– 400,000 per mm3
always, never, all, every, only, must, except, none, or no. actions in order or priority. Based on the information Hemoglobin (Hgb) 12 – 16 gm (F);
• Don’t read into the question – Never assume anything presented, determine what you’ll do first, second, third, 14 – 18 gm (M).
that has not been specifically mentioned and don’t add and so forth. Directions are provided with the question. Hematocrit (Hct) 37 – 47 (F);
extra meaning to the question. • Figure or Hotspot – A picture or graphic will be 40 – 54 (M)
• Eliminate answers that are clearly wrong or incorrect presented along with a question. This could contain a
– to increase your probability of selecting the correct chart, a table, or an illustration where you’ll be asked to
point or click on a specific area. Figures may also appear 5. SERUM ELECTROLYTES
answer!
• Watch for grammatical inconsistencies – Subjects and along with a multiple-choice question.
verbs should agree. If the question is an incomplete • Chart/Exhibit – A chart or exhibit is presented along with Sodium 135 – 145 mEq/L
sentence, the correct answer should complete the a problem. You’ll be provided with three tabs or buttons Potassium 3.5 – 5.0 mEq/L
question in a grammatically correct manner. that you need to click to obtain the information needed to Calcium 8.6–10 mg/dL
• Rephrase the question – putting the question into your answer the question. Chloride 98 – 107 mEq/L
own words can pluck the unneeded info and reveal the • Graphic Option – In this format, options are pictures Magnesium 1.2 – 2.6 mg/dL
core of the stem. rather than text. Each option is preceded by a circle that Phosphorus 2.7-4.5 mg/dL
• Make an educated guess – if you can’t make the best you need to click to represent your answer.
answer for a question after carefully reading it, choose the • Audio – In this format, you’ll be required to listen to a 6. ACID- BASE BALANCE
answer with the most information. sound to answer the question. You’ll need to use the
• New question types – New question types are added on headset provided and click on the sound icon for it to play. Use the ABG Tic-Tac-Toe Method for interpreting. Learn about
the test. These questions are found on the Special You’ll be able to listen to the sound as many times as the technique at: (https://bit.ly/abgtictactoe).
Research Section of the test, which pops up after the necessary.
pH 7.35 – 7.45
candidate finishes the exam. These do not count toward • Video – This will require viewing of an animation or video HCO3 22 – 26 mEq/L
your score and are testing out the feasibility of the test clip to answer the accompanying question. Pco2 35 – 45 mmHg
question, not the test-taker. PaO2 80–100 mmHg
SaO2 >95
Notice: Please download this NCLEX-RN Cram Sheet only at Nurseslabs.

We are continually updating the cram sheet with new info and you can only be assured to get the latest and updated version by downloading it from our site.
Thank you! The link is: https://nurseslabs.com/nclex-cram-sheet/
7. CHEMISTRY VALUES 10. THERAPEUTIC DRUG LEVELS 13. UNIT CONVERSIONS
Glucose 70 – 110 mg/dL Acetaminophen (Tylenol) 10-20 mcg/mL 1 teaspoon (t) 5 ml

BUN 7-22 mg/dL Carbamazepine (Tegretol) 4 – 10 mcg/mL 1 tablespoon (T) 3 t (15 ml)
Serum creatinine 0.6 – 1.35 mg/dL Digoxin (Lanoxin) 0.5 – 2.0 ng/mL 1 oz 30 ml
LDH 100-190 U/L Gentamycin (Garamycin) 5 – 10 mcg/ml (peak), 1 cup 8 oz
Protein 6.2 – 8.1 g/dL <2.0 mcg/ml (valley) 1 quart 2 pints
Albumin 3.4 – 5.0 g/dL Lithium (Eskalith) 0.5 – 1.2 mEq/L 1 pint 2 cups
Bilirubin <1.0 mg/dL Magnesium sulfate 4 – 7 mg/dL 1 grain (gr) 60 mg
Total Cholesterol 130 – 200 mg/dL Phenobarbital (Solfoton) 15 – 40 mcg/mL 1 gram (g) 1,000 mg
Triglyceride 40 – 50 mg/dL Phenytoin (Dilantin) 10 – 20 mcg/dL 1 kilogram (kg) 2.2 lbs
Uric acid 3.5 – 7.5 mg/dL Salicylate 100 – 250 mcg/mL 1 lb 16 oz
CPK 21-232 U/L Theophylline (Aminophylline) 10 – 20 mcg/dL Convert C to F multiply by 1.8 then add
Tobramycin (Tobrex) 5 – 10 mcg/mL (peak), 32
8. URINE TEST NORMAL VALUES 0.5 – 2.0 mcg/mL (valley) Convert F to C: subtract 32 then divide
Valproic Acid (Depakene) 50 – 100 mcg/ml by 1.8
Vancomycin (Vancocin) 20 – 40 mcg/ml (peak), 14. MATERNITY NORMAL VALUES
Color Pale yellow 5 to 15 mcg/ml (trough)
Odor Specific aromatic odor, similar to
ammonia 11. CARDIAC MARKERS • Fetal Heart Rate: 120 – 160 bpm
Turbidity Clear • Variability: 6 – 10 bpm
pH 4.5 – 7.8 Creatinine kinase (CK) 26 – 174 units/L • Amniotic fluid: 500 – 1200 ml
Specific gravity 1.016 to 1.022 • CK-MB 0%-5% of total • Contractions: 2 – 5 minutes apart with duration of < 90
Glucose <0.5 g/day • CK-MM 95%-100% of total seconds and intensity of <100 mmHg.
Ketones None • CK-BB 0%
• AVA: The umbilical cord has two arteries and one vein.
Protein None Troponin I <0.6 ng/mL (> 1.5 ng/mL
Bilirubin None indicates MI)
Casts None to few Troponin T > 0.1-0.2 ng/mL indicates MI 15. APGAR SCORING
Crystals None Myoglobin <90 mcg/L; elevation indicates
MI
Bacteria None or <1000/mL
Atrial natriuretic peptides (ANP)
• Appearance, Pulses, Grimace, Activity, Reflex Irritability.
22 – 27 pg/mL
RBC <3 cells/HPF Brain natriuretic peptides (BNP) • Done at 1 and 5 minutes with a score of 0 for absent, 1 for
< 100 pg/mL
WBC < 4 cells/HPF decreased, and 2 for strongly positive.
Uric Acid 250–750 mg/24 hr • Scores 7 and above are generally normal, 4 to 6 fairly low,
12. ANTICOAGULANT THERAPY
and 3 and below are generally regarded as critically low.
9. NORMAL GLUCOSE VALUES
Sodium warfarin 10 – 12 seconds (control). The
16. EPIDURAL ANESTHESIA: STOP
(Coumadin) PT antidote is Vitamin K.
Glucose, fasting 70 – 110 mg/dL INR (Coumadin) 0.9 – 1.2
Glucose, monitoring 60 – 100 mg/dL Heparin PTT 30 – 45 seconds (control). The • STOP is a treatment for maternal hypotension after an
Glucose tolerance test, oral antidote is protamine sulfate. epidural anesthesia.
• Baseline fasting 70 – 110 mg/dL APTT 3 – 31.9 seconds • Stop infusion of Pitocin.
• 30-min fasting 110 – 170 mg/dL Fibrinogen level 203 – 377 mg/dL • Turn the client on her left side.
• 60-min fasting 120 – 170 mg/dL • Oxygen therapy.
• 90-min fasting 100 – 140 mg/dL • Push IV fluids, if hypovolemia is present.
• 120-min fasting 70 – 120 mg/dL
Glucose, 2-hour <140 mg/dL
postprandial
SOURCE: https://nurseslabs.com/nclex-cram-sheet/
17. PREGNANCY CATEGORY OF DRUGS • Antihistamines – block the release of histamine. • Amiodarone (Cordarone) – WOF diaphoresis, dyspnea,
• Antihypertensives – lower blood pressure and increases lethargy. Take missed dose any time in the day or to skip
blood flow. it entirely. Do not take double dose.
• Category A – No risk in controlled human studies
• Anti-infectives – used for the treatment of infections, • Warfarin (Coumadin) – WOF for signs of bleeding,
• Category B – No risk in other studies. Examples: diarrhea, fever, or rash. Stress importance of complying
• Bronchodilators – dilates large air passages in asthma
Amoxicillin, Cefotaxime. with prescribed dosage and follow-up appointments.
or lung diseases (e.g., COPD).
• Category C – Risk not ruled out. Examples: Rifampicin • Methylphenidate (Ritalin) – Treatment of ADHD. Assess
• Diuretics – decreases water/sodium from the Loop of
(Rifampin), Theophylline (Theolair). for heart related side-effects and reported immediately.
Henle.
• Category D – Positive evidence of risk. Examples: Child may need a drug holiday because the drug stunts
• Laxatives – promotes the passage of stool.
Phenytoin, Tetracycline. growth.
• Miotics – constricts the pupils.
• Category X – Contraindicated in Pregnancy. Examples: • Dopamine – Treatment of hypotension, shock, and low
• Mydriatics – dilates the pupils.
Isotretinoin (Accutane), Thalidomide (Immunoprin), etc. cardiac output. Monitor ECG for arrhythmias and blood
• Narcotics/analgesics – relieves moderate to severe pain.
• Category N – Not yet classified pressure.
• Rifampicin – causes red-orange tears and urine.
20. RULE OF NINES
18. DRUG SCHEDULES • Ethambutol – causes problems with vision, liver problem.
• Isoniazid – can cause peripheral neuritis, take vitamin B6
• For calculating Total Body Surface Area (TBSA) for burns: to counter.
• Schedule I – no currently accepted medical use and for
research use only (e.g., heroin, LSD, MDMA). • Head and neck: 9%
• Schedule II – drugs with high potential for abuse and • Upper limbs: 18% (9% each) 22. DEVELOPMENTAL MILESTONES
requires written prescription (e.g., Ritalin, hydromorphone • Anterior torso: 18%
(Dilaudid), meperidine (Demerol), and fentanyl). • Posterior torso: 18%
• Legs: 36% (18% each) • 2 – 3 months: able to turn head up, and can turn side to
• Schedule III – requires new prescription after six months side. Makes cooing or gurgling noises and can turn head
or five refills (e.g., codeine, testosterone, ketamine). • Genitalia: 1%
to sound.
• Schedule IV – requires new prescription after six months • 4 – 5 months: grasps, switch and roll over tummy to back.
(e.g., Darvon, Xanax, Soma, and Valium). 21. MEDICATIONS Can babble and can mimic sounds.
• Schedule V – dispensed as any other prescription or • 6 – 7 months: sits at 6 and waves bye-bye. Can
without prescription (e.g., cough preparations, Lomotil, recognize familiar faces and knows if someone is a
• Digoxin (Lanoxin) – Assess pulses for a full minute, if
Motofen). stranger. Passes things back and forth between hands.
less than 60 bpm hold dose. Check digitalis and
potassium levels. • 8 – 9 months: stands straight at eight, has favorite toy,
19. MEDICATION CLASSIFICATIONS • Aluminum Hydroxide (Amphojel) – Treatment of GERD plays peek-a-boo.
and kidney stones. WOF constipation. • 10 – 11 months: belly to butt.
• Antacids – reduces hydrochloric acid in the stomach. • Hydroxyzine (Vistaril) – Treatment of anxiety and itching. • 12 – 13 months: twelve and up, drinks from a cup. Cries
• Antianemics – increases blood cell production. WOF dry mouth. when parents leave, uses furniture to cruise.
• Anticholinergics – decreases oral secretions.
• Anticoagulants – prevents clot formation, • Midazolam (Versed) – given for conscious sedation.
• Anticonvulsants – used for management of seizures Watch out for (WOF) respiratory depression and
and/or bipolar disorders. hypotension.
• Antidiarrheals – decreases gastric motility and reduce
water in bowel.
23. CULTURAL CONSIDERATIONS
• African Americans – May believe that illness is caused by supernatural causes and seek advice and remedies form faith healers; they are family oriented; have higher incidence of high blood
pressure and obesity; high incidence of lactose intolerance with difficulty digesting milk and milk products.
• Arab Americans – May remain silent about health problems such as STIs, substance abuse, and mental illness; a devout Muslim may interpret illness as the will of Allah, a test of faith; may rely on
ritual cures or alternative therapies before seeking help from health care provider; after death, the family may want to prepare the body by washing and wrapping the body in unsewn white cloth;
postmortem examinations are discouraged unless required by law. May avoid pork and alcohol if Muslim. Islamic patients observe month long fast of Ramadan (begins approximately mid-October);
people suffering from chronic illnesses, pregnant women, breast-feeding, or menstruating don’t fast. Females avoid eye contact with males; use same-sex family members as interpreters.
• Asian Americans – May value ability to endure pain and grief with silent stoicism; typically family oriented; extended family should be involved in care of dying patient; believes in “hot-cold” yin/yang
often involved; sodium intake is generally high because of salted and dried foods; may believe prolonged eye contact is rude and an invasion of privacy; may not without necessarily understanding;
may prefer to maintain a comfortable physical distance between the patient and the health care provider.
• Latino Americans – May view illness as a sign of weakness, punishment for evil doing; may consult with a curandero or voodoo priest; family members are typically involved in all aspects of
decision making such as terminal illness; may see no reason to submit to mammograms or vaccinations.
• Native Americans – May turn to a medicine man to determine the true cause of an illness; may value the ability to endure pain or grief with silent stoicism; diet may be deficient in vitamin D and
calcium because many suffer from lactose intolerance or don’t drink milk; obesity and diabetes are major health concerns; may divert eyes to the floor when they are praying or paying attention.
• Western Culture – May value technology almost exclusively in the struggle to conquer diseases; health is understood to be the absence, minimization, or control of disease process; eating utensils
usually consists of knife, fork, and spoon; three daily meals is typical.
24. COMMON DIETS
• Acute Renal Disease – protein-restricted, high-calorie, • COPD – soft, high-calorie, low-carbohydrate, high-fat, • Pancreatitis – low-fat, regular, small frequent feedings;
fluid-controlled, sodium and potassium controlled. small frequent feedings tube feeding or total parenteral nutrition.
• Addison’s disease – increased sodium, low potassium • Cystic Fibrosis – increase in fluids. • Peptic ulcer – bland diet
diet. • Diarrhea – liquid, low-fiber, regular, fluid and electrolyte • Pernicious Anemia – increase Vitamin B12 (Cobalamin),
• ADHD and Bipolar – high-calorie and provide finger replacement found in high amounts on shellfish, beef liver, and fish.
foods. • Gallbladder diseases – low-fat, calorie-restricted, regular • Sickle Cell Anemia – increase fluids to maintain
• Burns – high protein, high caloric, increase in Vitamin C. • Gastritis – low-fiber, bland diet hydration since sickling increases when patients become
• Cancer – high-calorie, high-protein. • Hepatitis – regular, high-calorie, high-protein dehydrated.
• Celiac Disease – gluten-free diet (no BROW: barley, rye, • Hyperlipidemias – fat-controlled, calorie-restricted • Stroke – mechanical soft, regular, or tube-feeding.
oat, and wheat). • Hypertension, heart failure, CAD – low-sodium, calorie- • Underweight – high-calorie, high protein
• Chronic Renal Disease – protein-restricted, low-sodium, restricted, fat-controlled • Vomiting – fluid and electrolyte replacement
fluid-restricted, potassium-restricted, phosphorus- • Kidney Stones – increased fluid intake, calcium-
restricted. controlled, low-oxalate
• Cirrhosis (stable) – normal protein • Nephrotic Syndrome – sodium-restricted, high-calorie,
• Cirrhosis with hepatic insufficiency – restrict protein, high-protein, potassium-restricted.
fluids, and sodium. • Obesity, overweight – calorie-restricted, high-fiver
• Constipation – high-fiber, increased fluids
25. POSITIONING CLIENTS
• Asthma – Orthopneic position where patient is sitting up • Post thyroidectomy – low or semi-Fowlers, support • Spinal Cord Injury – immobilize on spine board, with
and bent forward with arms supported on a table or chair head, neck and shoulders. head in neutral position. Immobilize head with padded C-
arms. • Thoracentesis – sitting on the side of the bed and leaning collar, maintain traction and alignment of head manually.
• Post Bronchoscopy – flat on bed with head over the table (during procedure); affected side up (after Log roll client and do not allow client to twist or bend.
hyperextended. procedure). • Liver Biopsy – right side lying with pillow or small towel
• Cerebral Aneurysm – high Fowler’s. • Spina Bifida – position infant on prone so that sac does under puncture site for at least 3 hours.
• Hemorrhagic Stroke – HOV elevated 30 degrees to not rupture. • Paracentesis – flat on bed or sitting.
reduce ICP and facilitate venous drainage. • Buck’s Traction – elevate foot of bed for counter-traction. • Intestinal Tubes – place patient on right side to facilitate
• Ischemic Stroke – HOB flat. • Post Total Hip Replacement – don’t sleep on operated passage into duodenum.
• Cardiac Catheterization – keep site extended. side, don’t flex hip more than 45-60 degrees, don’t elevate • Nasogastric Tubes – elevate HOB 30 degrees to prevent
• Epistaxis – lean forward. HOB more than 45 degrees. Maintain hip abduction by aspiration. Maintain elevation for continuous feeding or
• Above Knee Amputation – elevate for first 24 hours on separating thighs with pillows. 1hour after intermittent feedings.
pillow, position on prone daily for hip extension. • Prolapsed cord – knee-chest position or Trendelenburg. • Rectal Exam – knee-chest position, Sim’s, or dorsal
• Below Knee Amputation – foot of bed elevated for first • Cleft-lip – position on back or in infant seat to prevent recumbent.
24 hours, position prone daily for hip extension. trauma to the suture line. While feeding, hold in upright • During internal radiation – patient should be on bed rest
• Tube feeding for patients with decreased LOC – position. while implant is in place.
position patient on right side to promote emptying of the • Cleft-palate – prone. • Autonomic Dysreflexia – place client in sitting position
stomach with HOB elevated to prevent aspiration. • Hemorrhoidectomy – assist to lateral position. (elevate HOB) first before any other implementation.
• Air/Pulmonary embolism – turn patient to left side and • Hiatal Hernia – upright position. • Shock – bed rest with extremities elevated 20 degrees,
lower HOB. • Preventing Dumping Syndrome – eat in reclining knees straight, head slightly elevated (modified
• Postural Drainage – Lung segment to be drained should position, lie down after meals for 20-30 minutes (also Trendelenburg).
be in the uppermost position to allow gravity to work. restrict fluids during meals, low fiber diet, and small • Head Injury – elevate HOB 30 degrees to decrease
• Post Lumbar puncture – patient should lie flat in supine frequent meals). intracranial pressure.
to prevent headache and leaking of CSF. • Enema Administration – position patient in left-side lying • Peritoneal Dialysis when outflow is inadequate – turn
• Continuous Bladder Irrigation (CBI) – catheter should (Sim’s position) with knees flexed. patient side to side before checking for kinks in the tubing.
be taped to thigh so legs should be kept straight. • Post supratentorial surgery (incision behind hairline) • Myelogram Water-based dye – semi Fowler’s for at least
• After myringotomy – position on the side of affected ear – elevate HOB 30-45 degrees. 8 hours.
after surgery (allows drainage of secretion). • Post infratentorial surgery (incision at nape of neck) – • Myelogram Oil-based dye – flat on bed for at least 6-8
• Post cataract surgery – patient will sleep on unaffected position patient flat and lateral on either side. hours to prevent leakage of CSF.
side with a night shield for 1-4 weeks. • Increased ICP – high Fowler’s. • Myelogram Air dye – Trendelenburg
• Detached retina – area of detachment should be in the • Laminectomy – back as straight as possible; log roll to
dependent position. move and sand bag on sides.
26. COMMON SIGNS AND SYMPTOMS
• Pulmonary Tuberculosis (PTB) – low-grade afternoon • Tetany – hypocalcemia, [+] Trousseau’s sign; Chvostek • Glaucoma – tunnel vision.
fever. sign. • Retinal Detachment – flashes of light, shadow with
• Pneumonia – rust-colored sputum. • Tetanus – Risus sardonicus or rictus grin. curtain across vision.
• Asthma – wheezing on expiration. • Pancreatitis – Cullen’s sign (ecchymosis of the • Basilar Skull Fracture – Raccoon eyes (periorbital
• Emphysema – barrel chest. umbilicus), Grey Turner’s sign (bruising of the flank). ecchymosis) and Battle’s sign (mastoid ecchymosis).
• Kawasaki Syndrome – strawberry tongue. • Pyloric Stenosis – olive like mass. • Buerger’s Disease – intermittent claudication (pain at
• Pernicious Anemia – red beefy tongue. • Patent Ductus Arteriosus – washing machine-like buttocks or legs from poor circulation resulting in impaired
• Down syndrome – protruding tongue. murmur. walking).
• Cholera – rice-watery stool and washer woman’s hands • Addison’s disease – bronze-like skin pigmentation. • Diabetic Ketoacidosis – acetone breathe.
(wrinkled hands from dehydration). • Cushing’s syndrome – moon face appearance and • Pregnancy Induced Hypertension (PIH) – proteinuria,
• Malaria – stepladder like fever with chills. buffalo hump. hypertension, edema.
• Typhoid – rose spots in the abdomen. • Grave’s Disease (Hyperthyroidism) – Exophthalmos • Diabetes Mellitus – polydipsia, polyphagia, polyuria.
• Dengue – fever, rash, and headache. Positive Herman’s (bulging of the eye out of the orbit). • Gastroesophageal Reflux Disease (GERD) – heartburn.
sign. • Intussusception – Sausage-shaped mass. • Hirschsprung’s Disease (Toxic Megacolon) – ribbon-
• Diphtheria – pseudomembrane formation. • Multiple Sclerosis – Charcot’s Triad: nystagmus, like stool.
• Measles – Koplik’s spots (clustered white lesions on intention tremor, and dysarthria. • Herpes Simplex Type II – painful vesicles on genitalia
buccal mucosa). • Myasthenia Gravis – descending muscle weakness, • Genital Warts – warts 1-2 mm in diameter.
• Systemic Lupus Erythematosus – butterfly rash. ptosis (drooping of eyelids). • Syphilis – painless chancres.
• Leprosy – leonine facies (thickened folded facial skin). • Guillain-Barre Syndrome – ascending muscles • Chancroid – painful chancres.
• Bulimia – chipmunk facies (parotid gland swelling). weakness. • Gonorrhea – green, creamy discharges and painful
• Appendicitis – rebound tenderness at McBurney’s point. • Deep vein thrombosis (DVT) – Homan’s Sign. urination.
Rovsing’s sign (palpation of LLQ elicits pain in RLQ). • Angina – crushing, stabbing pain relieved by NTG. • Chlamydia – milky discharge and painful urination.
Psoas sign (pain from flexing the thigh to the hip). • Myocardial Infarction (MI) – crushing, stabbing pain • Candidiasis – white cheesy odorless vaginal discharges.
• Meningitis – Kernig’s sign (stiffness of hamstrings radiating to left shoulder, neck, and arms. Unrelieved by • Trichomoniasis – yellow, itchy, frothy, and foul-smelling
causing inability to straighten the leg when the hip is NTG. vaginal discharges
flexed to 90 degrees), Brudzinski’s sign (forced flexion of • Parkinson’s disease – pill-rolling tremors.
the neck elicits a reflex flexion of the hips). • Cytomegalovirus (CMV) infection – Owl’s eye
appearance of cells (huge nucleus in cells).
27. MISCELLANEOUS TIPS
• Delegate sterile skills (e.g., dressing change) to the RN or • When patient is in distress, administration of medication is • Para is the number of pregnancies that reached viability,
LPN. rarely the best choice. regardless of whether the fetus was delivered alive or
• Where non-skilled care is required, delegate the stable • Always check for allergies before administering antibiotics. stillborn. A fetus is considered viable at 20 weeks’
client to the nursing assistant. • Neutropenic patients should not receive vaccines, fresh gestation.
• Assign the most critical client to the RN. fruits, or flowers. • Lochia rubra is the vaginal discharge of almost pure
• Clients who are being discharged should have final • Nitroglycerine sublingual is administered up to three times blood that occurs during the first few days after childbirth.
assessments done by the RN. with intervals of five minutes. • Lochia serosa is the serous vaginal discharge that
• The Licensed Practical Nurse (LPN) can monitor clients • Morphine is contraindicated in pancreatitis because it occurs 4 to 7 days after childbirth.
with IV therapy, insert urinary catheters, feeding tubes, causes spasms of the Sphincter of Oddi. Demerol should • Lochia alba is the vaginal discharge of decreased blood
and apply restraints. be given. and increased leukocytes that’s the final stage of lochia. It
• Assessment, teaching, medication administration, • Never give potassium (K+) in IV push. occurs 7 to 10 days after childbirth.
evaluation, unstable patients cannot be delegated to an • Infants born to an HIV-positive mother should receive all • In the event of fire, the acronym most often used is RACE.
unlicensed assistive personnel. immunizations of schedule. (R) Remove the patient. (A) Activate the alarm. (C)
• Weight is the best indicator of dehydration. • Gravida is the number of pregnancies a woman has had, Attempt to contain the fire by closing the door. (E)
regardless of outcome. Extinguish the fire if it can be done safely. 6
• Before signing an informed consent form, the patient • Beneficence is the duty to do no harm and the duty to do • People with obsessive-compulsive disorder realize that
should know whether other treatment options are good. There’s an obligation in patient care to do no harm their behavior is unreasonable, but are powerless to
available and should understand what will occur during and an equal obligation to assist the patient. control it.
the preoperative, intraoperative, and postoperative • Nonmaleficence is the duty to do no harm. • A significant toxic risk associated with clozapine
phases; the risks involved; and the possible • Tyramine-rich food, such as aged cheese, chicken liver, (Clozaril) administration is blood dyscrasia.
complications. The patient should also have a general avocados, bananas, meat tenderizer, salami, bologna, • Adverse effects of haloperidol (Haldol) administration
idea of the time required from surgery to recovery. In Chianti wine, and beer may cause severe hypertension in include drowsiness; insomnia; weakness; headache; and
addition, he should have an opportunity to ask questions. a patient who takes a monoamine oxidase inhibitor. extrapyramidal symptoms, such as akathisia, tardive
• The first nursing intervention in a quadriplegic client who • Projection is the unconscious assigning of a thought, dyskinesia, and dystonia.
is experiencing autonomic dysreflexia is to elevate his feeling, or action to someone or something else. • Hypervigilance and déjà vu are signs of posttraumatic
head as high as possible. • Sublimation is the channeling of unacceptable impulses stress disorder (PTSD
• Usually, patients who have the same infection and are in into socially acceptable behavior.
strict isolation can share a room. • Repression is an unconscious defense mechanism
• Veracity is truth and is an essential component of a whereby unacceptable or painful thoughts, impulses,
therapeutic relationship between a health care provider memories, or feelings are pushed from the consciousness
and his patient. or forgotten.
NCLEX ONLINE RESOURCES
• NCLEX-RN Official Website – (https://www.ncsbn.org/nclex.htm)

• NCLEX-RN Practice Questions – Over 2,100 free sample questions (https://nurseslabs.com/nclex-practice-questions/)
• 20 NCLEX Tips and Strategies Every Nursing Students Should Know (https://nurseslabs.com/20-nclex-tips-strategies-every-nursing-students-know/)
• 12 Tips to Answer NCLEX Select All That Apply (SATA) Questions (https://nurseslabs.com/tips-answer-select-apply-questions-nclex/)
• 5 Principles in Answering Therapeutic Communication Questions – great tips on how to answer TheraCom questions (https://nurseslabs.com/5-principles-answering-therapeutic-
communication-questions/)
• 11 Test Taking Tips & Strategies For Nurses (https://nurseslabs.com/11-test-taking-tips-strategies/)
• Nursing Bullets – collection of bite-sized nursing information, great for reviews! (https://nurseslabs.com/tag/nursing-bullets/)
• NCLEX Daily – Facebook page that posts daily questions for NCLEX (https://www.facebook.com/nclexdaily)
RECOMMENDED NCLEX BOOKS
• Saunders Comprehensive Review for the NCLEX-RN by Silvestri, 6th edition (http://amzn.to/1MhSw3C)
• Saunders Q & A Review for the NCLEX-RN Examination by Silvestri, 6th edition (http://amzn.to/1J6gOhO)
• Saunders 2014-2015 Strategies for Test Success – Passing Nursing School and the NCLEX Exam by Silvestri, 3rd edition (http://amzn.to/1F45gJ8)
• Saunders Q&A Review Cards for the NCLEX-RN Examination by Silvestri, 2nd edition (http://amzn.to/1Ahi5yB)
• Davis’s NCLEX-RN Success by Lagerquist, 3rd edition (http://amzn.to/1zbKboZ)
• Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Exam by Nugent et al., 20th edition (http://amzn.to/1ytMYIR)
• Kaplan NCLEX RN 2013-2014 Edition: Strategies, Practice, and Review (http://amzn.to/171hdQR)
• Lippincott’s NCLEX-RN Questions and Answers Made Incredibly Easy, 5th edition (http://amzn.to/1vpd6Et)
• Lippincott’s NCLEX-RN Alternate-Format Questions, 5th edition (http://amzn.to/19dEEIz)

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Student Nurse Assessment Sheet © 2011 cjcsoon2brn

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Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Room #: ________________ | Age & Gender: ________________ | Today’s Date: ________________

Health Maintenance: Reason for Admission (Patient’s Own Words): ________________________________________ |

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Room #: ________________ | Age & Gender: ________________ | Today’s Date: ________________

Health Maintenance: Reason for Admission (Patient’s Own Words): ________________________________________ |

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Room #: ________________ | Age & Gender: ________________ | Today’s Date: ________________

Health Maintenance: Reason for Admission (Patient’s Own Words): ________________________________________ |

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Room #: ________________ | Age & Gender: ________________ | Today’s Date: ________________

Health Maintenance: Reason for Admission (Patient’s Own Words): ________________________________________ |

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Room #: ________________ | Age & Gender: ________________ | Today’s Date: ________________

Health Maintenance: Reason for Admission (Patient’s Own Words): ________________________________________ |

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Student Nurse Assessment Sheet © 2011 cjcsoon2brn

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

BP Category Systolic BP Diastolic BP Treatment or Follow-up

Hypertensive Systolic BP Diastolic BP Treatment or Follow-up

> Deep vein thrombosis

Am I at risk for a DVT? What can I do to avoid getting a DVT?

How will I know if I have a DVT? RESOURCES

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for Healthcare Research and Quality in the form

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Table 1. Major Changes in Guideline Recommendations for the Management of VTE13

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Clinical Characteristic Score

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Since roughly 15% of untreated distal thrombi extend

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Table 3. Non–Vitamin K Oral Anticoagulants Used to Treat Acute VTE 34-38

Generic (Trade) Name Drug Category Antidote Precautions

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Caring for adults with

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