150 Study Guide

• These notes cover intravenous fluids, electrolyte balance, and other key medical concepts from the provided text.

Intravenous Fluids

• Hypertonic fluids (3% or 5% sodium chloride and dextrose) have a high sodium content.
• They draw water out of cells and are used to correct severe hyponatremia and cerebral edema.
• Rapid infusion of hypertonic fluids can damage the myelin sheath of nerve cells, leading to osmotic demyelination syndrome, seizures, confusion, or coma.
• Hypotonic fluids (0.45% sodium chloride and D5W) move fluid into cells.
• They treat cellular dehydration, hypernatremia, and promote urine output.
• Isotonic fluids (normal saline (0.9%) and lactated ringers) treat hypovolemia, raise blood pressure, and address acute blood loss and electrolyte imbalances in burn/trauma patients.

Osmosis, Filtration, and Diffusion

• Osmosis is the movement of water molecules from a solution with high concentration to a solution with lower concentration through a cell's partially permeable membrane.
• Filtration is the movement of fluid between interstitial and vascular spaces driven by high pressure, moving from high to low pressure.
• Diffusion is the movement of electrolytes and particles through the cell membrane, from high to low concentration, allowing for glucose regulation.

Electrolyte Balances

• Potassium imbalances affect the heart.
• Sodium imbalances affect neurological function.
• Calcium imbalances affect muscles and bones.
• Magnesium imbalances affect heart health.
• Treatments and nursing care/education are necessary for both hyper- and hypo conditions.

Hyponatremia

• Signs/Symptoms include behavioral changes from brain swelling and acute confusion (especially in older adults). Low risk of seizure, coma, and death
• Treatment involves increasing sodium intake: 0.9% NS for fluid deficit, hypertonic (3%) solution for severe cases, and conivaptan for fluid excess.
• Nursing care focuses on patient safety, skin protection, and monitoring for fluid overload.

Hypernatremia

• Signs/Symptoms include short attention span with normal or decreased fluid, agitation with fluid overload, and lethargy or coma.
• Treatment includes 0.9% NS and D5 in 0.45% or diuretics.

Hypokalemia

• Signs/Symptoms include irregular heartbeat (dysrhythmias), a weak, thready pulse, and ECG changes.
• Treatment involves increasing potassium intake (orally or IV, given slowly - never push) and spironolactone.
• Nursing care focuses on fall risk reduction due to muscle weakness and increasing dietary potassium.

Hyperkalemia

• Signs/Symptoms include skipped heartbeats and palpitations.
• Treatment involves patiromer and kayexalate (to excrete potassium in GI tract).
• Nursing care includes stopping K+ infusions, limiting dietary potassium, cardiac monitoring, and educating about diet, drugs, and symptoms to prevent recurrence.
• Critical Rescue: If HR below 60 or T wave spikes.

Hypocalcemia

• Signs/Symptoms include muscle spasms (calf or foot), tingling/numbness, positive Trousseau and Chvostek signs, easy fractures, and decreased height.
• Treatment involves calcium and vitamin D replacement.
• Nursing care focuses on increasing calcium and vitamin D intake, reducing stimuli, and preventing injury with fragile bones.

Hypercalcemia

• Signs/Symptoms include severe muscle weakness and decreased deep tendon reflexes.
• Treatment involves IV 0.9% NS, loop diuretics (furosemide), phosphorus, and NSAIDs.
• Nursing care includes decreasing calcium intake, monitoring ECG, and considering possible dialysis.

Hypomagnesemia

• Signs/Symptoms include increased risk for hypertension, atherosclerosis, hypertrophic left ventricle, and dysrhythmias.
• Treatment involves IV magnesium sulfate.
• Nursing/Education involves avoiding overtreatment, managing the specific problem, and stopping loop diuretics.

Hypermagnesemia

• Signs/Symptoms include low HR, peripheral vasodilation, hypotension, and cardiac arrest (severe).
• Treatment involves NS and furosemide (for normal kidney function).
• Nursing/Education involves reducing magnesium levels and using magnesium-free IV fluids.

Dietary Education for Electrolyte Balance

• High sodium foods: processed or preserved items (canned, pickled).
• Low sodium foods: fresh fish, poultry, fresh fruits, and vegetables.
• High potassium foods: bananas, avocados, oranges, potatoes, and spinach.
• Low potassium foods: eggs, bread, and cereal grains.
• High calcium foods: dairy (milk, cheese, yogurt).
• Low calcium foods: fruits, veggies, eggs, and lean meat.
• High magnesium foods: avocados, dark chocolate, and nuts.

Sodium Polystyrene Sulfonate (Kayexalate)

• It is a liquid oral drug used to help the body get rid of extra potassium.

Fluid Balance Monitoring

• Weighing patients helps determine fluid balance; weigh every morning before any intake and after first urination using the same flat scale.
• Teach patients to weigh daily after voiding and notify PCP if a >2 lbs gain in one day or >5 lbs in a week or rapid weight loss unexpectedly

Obesity and Gastric Bypass Surgery

• Guidelines for having: Do not respond to nutrition/exercise adjustments, have a BMI of 40 or > OR BMI of 35 or > with other health risk factors.
• Reasons for not being able to have surgery: if the patient is not alert/oriented, lacks sufficient strength/mobility, unable to comply with diet, has heart/lung risks, impaired mental capacity, no support, or substance abuse issues.
• Complications include nutritional/vitamin deficiencies, blood clots, bowel obstructions, hernias, and dumping syndrome.

Dumping Syndrome

• It causes food to move too quickly from the stomach to the small intestine.
• Symptoms: nausea, vomiting, abdominal cramping, bloating, dizziness, and sweating.
• Prevention: eat small, frequent meals (6-8/day), avoid sugar/processed/high-fat foods, increase fiber/protein, avoid liquids with meals, chew well, and relax for 30 minutes after eating.
• Treatment: dietary adjustments, antidiarrheal agents, or surgical intervention.

Type II Diabetes and Insulin

• Reasons a Type II diabetic may need insulin for a short period: pregnancy, illness, surgery, poor glucose control, or when multiple antidiabetic medications are insufficient.
• Medications that can raise glucose levels: corticosteroids and antibiotics during acute illnesses.

Type II Diabetes and Decreasing Glucose

• Best way for a Type II diabetic to decrease glucose levels: reduce risk factors via proper exercise (30 minutes/5 days a week of moderate-intensity aerobic activity, resistance training twice a week), and diet (veggies, fruits, whole grains, avoid sugar, Mediterranean diet, high-fiber).

Type 1 Diabetes

• Causes: beta cells are destroyed and cannot produce insulin, typically in childhood.
• Treatment: synthetic insulin used in all T1DM to attempt to replicate normal insulin release patterns (baseline and post-eating).
• Education: refrigerate insulin, avoid sunlight/extreme temperatures, keep in-use insulin at room temp, roll don't shake, and inspect for changes, only use syringe once
• Sick days: take insulin as usual, test glucose and urine ketones every 3-4 hours, report increased glucose (>240 consistently and ketones and any N/V/D to the provider, take supplemental doses of insulin every 3-4 hours, soft food 6-8 times a day, take liquids, if unable to retain oral fluids may need hospitalization to avoid DKA or coma
• Exercise: take BG before and after exercise, if <100 or >250 with ketones DO NOT EXERCISE, carbohydrate snack before exercise
• Monitor at home/how often: check BG before every meal and before bed, know symptoms of hyper/hypoglycemia, periods of illness, before and after exercise

Parathyroid Disorders

• Hypo: low calcium, muscle spasms, positive Trousseau and Chvostek signs, osteoporosis, treat with vitamin D and IV calcium gluconate.
• Hyper: high calcium, muscle weakness, kidney stones, calcium deposits, bone lesions, treat with cinacalcet and bisphosphonates/parathyroidectomy

Dehydration

• Complications: weak peripheral pulse, decreased BP, risk for falling, flat neck veins, poor skin turgor, dry/scaly skin, low output, muscle weakness, dysrhythmia, possible confusion with decreased alertness.
• Treatment: fluid replacement (IV or orally), antidiarrheal drugs (if diarrhea is a symptom).

Constipation

• Complications: hemorrhoids, rectal prolapse, bowel obstruction, perforation.
• Treatment: laxatives, stool softeners, enemas (may cause dependence), increased fluid/fiber intake, and increased activity.
• Purpose for NG tube: to decompress the stomach, remove fluid/gas, relieve pain/N/V, allow bowel to rest
• Food: NPO until AFTER peristalsis, then introduce foods SLOWLY; more food can cause feces and block the intestine.
• Education: report abdominal pain, distention, N/V, follow-up appointments, increase fiber/fluids/activity.
• NEVER feed in a salem sump (NG) because there are little holes all throughout and the feed will go into lungs

Intussusception

• It involves a twist of the bowel in children causing vomiting, severe abdominal pain in waves, stool is red currant jelly, distention
• Care: get MRI/CT, review labs, and get a history
• Treatment: barium/air enema to push bowel back in place, open/laparoscopic surgery, rebalance electrolytes, and antibiotics
• Education: rest, increase fluids, call PCP if fever, constant belly pain, vomiting

Anaphylaxis

• Causes: drugs/contrast, food allergies, insect bites.
• Signs/Symptoms: wheezing, low BP, swelling, itching, nausea, and redness.
• Treatment: establish airway, give EPI IM (repeat 3x every 5-15 mins, can be given IV if not working IM), recumbent position if breathing allows, apply oxygen, antihistamine IV/IM, corticosteroids, IV NS, nebulized albuterol, and monitor pulse ox.
• Education: avoid known allergies, wear a medical bracelet, notify healthcare personnel about allergies, carry epi/anaphylaxis kit.

Angioedema

• Causes: latex, insects, peanuts, shellfish, vancomycin/penicillin, NSAIDs, or ACEIs.
• Complications: face and throat swelling, airway obstruction.
• Treatment: ensure airway, stop drugs (IV), give oxygen or intubation/tracheostomy, drug therapy.
• Education: know allergies, be aware of symptoms.

Urinary Retention

• Signs/Symptoms: increased urine volume, distention, difficulty starting urination, and feeling the need to pee despite having just done so.
• Treatment: bladder scan, catheter, medications, and urethral stents/dilations.
• Education: avoid holding urine, drink plenty of water, and watch urination habits.

Fractures

• Kids bones are more bendy than adult bones
• Spiral/Rib fractures: consider abuse, which are caused by a twisting motion.
• Growth plate injuries: weakest point of long bones, affects future bone growth. Common site of injury
• Frequency: femoral shaft (young adults), distal forearm (children), rib (older adults).
• Healing time: kids heal faster than adults: neonatal (2-3), early (4), later (6-8), adolescence (8-12) weeks; adults are 4-6 weeks up to a year
• Treatment for kids: ensure nutrients for healing and bone regrowth, TREAT FIRST THEN CALL 911, oxy and tylenol if severe
• Treatment for adults: CALL 911 TREAT THEN AIRWAY, given fentanyl, hydromorphone and acetaminophen then NSAIDS
• Both: reduction and immobilization, hourly neuro checks for first 24 hours, then every 1-4, elevate above the heart, ice for 30 minutes first 24-48 hours, check for 1 finger in between the cast and skin*, during reduction nurses monitor EtCO2 if <30 do a sternal rub Splints are preferred; fiberglass casts are best

Fractures and Traction

• Weights are used to keep the extremity stretched to prevent muscle spasms and can be in skin or skeletal form.
• Ensure to perform cleaning care and document drainage,DONT REMOVE WEIGHT
• Surgical intervention: ORIF- cut open and reduce bone directly with metal pins or rods, external- used for open fracture with rods connected to the external frame and give IV then oral antibiotics
• Assessment of Fractures: pain and point of tenderness, pallor, pulselessness, paraesthesia ((distal to site)), paralysis ((distal to site)) and pressure.
• Main concern: assessment and evaluation of neurovascular disfunction; assess neurovascular frequently for 24 hours, elevate elevate and ice for 24-48 hrs ice for 30 mins, no ice for 30 mins*
• Ensure you can fit one finger in between the cast

Complications of Fractures

• Hypercoagulability (natural response).
• Osteomyelitis (bone or soft tissue infection) is common with Staph or MRSA, treat with IV antibiotics for 2 weeks, oral for 3-4 weeks.
• VTE (DVT/PE): Use blood clot medication, DVT clot in deep veins (legs), PE travels to lungs, more prevalent in pelvic, femur, spinal or lower legs fractures
• Fat Embolism: Travels from the yellow bone marrow into the blood stream, occurs 24-48 after the injury; hypoxia, headache and MEALS rash.

Acute Compartment Syndrome

• Acute Compartment Syndrome increased capillary and venous pressure (externally if cast can cause); plasma leaks into interstitial space.
• Edema: Severe pain and perfusion decreased.
• Treatment: Fasciotomy (cut into fascia and open wound) or remove cast and fasciectomy.
• Treatment: Pt applies variety of objects (smooth, rough, sharp) to desensitize area.
• Post op care for fractures is use IV ketorolac to decrease inflation and pain, assess for drainage ( color or odor etc), make sure its draining (cleat), normal

Amputations

• Health promotion includes adhering to diabetic management, maintaining a healthy weight, exercising regularly, and avoiding smoking/risky vehicles. Ensure skin and ensure skin color are normal and warm
• Treat acute/persistent pain, especially phantom (beta blockers (for pain), gabopentin for sharp pain, antispasmodic (baclofen) In coordination with pt/OT turn the pt every 2 hours, promote mobility and pt in prone position every 3-4 hours for 20-30 minutes to promote self esteem
• Complications: Hemorrhage, infection, phantom limb pain, flexion contractors ( hip or keen MUST BE TREATED, keep prone position 3-4 hours for 20-30 mins*) if an emergency keep the limb in a dry waterproof bag in ice

Multiple Sclerosis (MS)

• It is an autoimmune disorder that demyelination of myelin sheath and get plaques that build up where sheath used to be, nerve impulses weaken that occurs in 20-50 with women and in colder climates
• Relapse remitting MS (RRMS)- MOST COMMON- have symptoms then resolve, and relapse with new symptoms (BEST ONE TO HAVE)
• Secondary (SPMS)- steadily progressive w/in 10 years of RRMS diagnosis
• Primary (PPMS)-progressive disability w/out acute attack or remission (40-60 years of age)
• Exacerbation of MS- from emotional changes, muscle spasms, fatigue.
• Affect mobility- muscle spasticity, intention tremors, fatigue, double vision and vertigo that prevents mobility.
• Treatment: help with mobility aspect) baclofen or tizanidine to lessen spasticity paresthesia- carbamazepine or tricyclic antidepressant
• Treatment (exercise program for ROM with PT/OT), avoid body temp elevating and hard exercise, plan activities to save energy and decrease stress, speech therapist if needed Complications are decreased mobility, decreased vision, impaired immunity.