323 Final PDF

323 final  Fluid and electrolytes Types of solutions : Uses: Hypotonic - half NS 0.45.% Cerebral edema, hyponatermia, hypovolemia Isotonic - normal saline and lactated ringer's Surgery, burns, blood loss Hyperton...

323 final  Fluid and electrolytes Types of solutions : Uses: Hypotonic - half NS 0.45.% Cerebral edema, hyponatermia, hypovolemia Isotonic - normal saline and lactated ringer's Surgery, burns, blood loss Hypertonic - 3% saline DKA, hypernatermia, sick cell Hypovolemi U Hypervolemi a S. a High BP Low BP Rapid weight gain Dry mouth Edema rapid weight loss Increased urine output Law ruin output JUD Confusion lethargy Bounding pulse SOB Crackles Dedicated LOC Normal electrolytes levels Potassium 3.5 - 5 Calcium 9 - 11 Sodium 135 - 145  Potassium - Potassium PUMPS the heart Immediately think cardiac monitor IV insulin LOWERS potassium, SQ insulin does NOT lower potassium Potassium BURNS - it is a vesicant - produces blistering Foods – avocado, fish, banana, OJ, raisins, dried fruits, meat, milk, fruits, veggies, salt substitutes Hyperkalemia Signs/symptoms – Change in ECG (wide QRS, prolonged PR, no P waves), muscle weakness and cramping leg pain progressing to areflexia, slow pulse, low BP, diarrhea, abdominal cramping, nausea, oliguria Causes – kidney failure (most common), use of salt or potassium supplements, receiving old blood, cell destruction, acidosis, hypoxia, exercise, catabolic state, use of potassium-sparing diuretics Treatment: ◦ cardiac monitor, give Kayexalate (either orally or as an enema), calcium gluconate, glucose & insulin IV (helps move potassium into cells by exchanging Na ions for K ions), teach pt to avoid foods high in potassium (ie. meats, dairy, bananas, OJ, avocados, broccoli, potatoes, spinach), stop potassium in IV fluids, diuretics (ie. Lasix) if kidneys are functioning, may need dialysis if critically high Hypokalemia Causes – ◦ excessive vomiting, suctioning, dehydration, vomiting, diarrhea, medications (diuretics, laxatives, insulin all cause increased potassium loss), alkalosis (causes exchange of H+ for K+), beta adrenergic stimulation, rapid cell building (ie. B12 or erythropoietin to increase RBCs), aldosterone Signs/symptoms – ◦ weakness, nausea, vomiting, dysrhythmias (ST depression, change in T waves, increase in U waves), constipation, low BP, increased pulse, increased digoxin toxicity, muscle weakness and paralysis, muscle cramping, rhabdomyolysis, hyperglycemia, diuresis, decreased peristalsis can even lead to paralytic ileus ◦ Treatment – for slightly low levels encourage foods high in potassium (fruit juice, citrus fruits, dried fruits, bananas, nuts, veggies), cardiac monitor, watch for digitalis toxicity, stop giving HCTZ, Lasix, cortisone, be very careful if they have renal disease (urine output must be at least 600 mL/day) must have good urine output (>600 ml/day) before giving any potassium supplements, (urine output about 30 ccs and hour to give potassium) never give potassium IV push, always must be diluted and given as a drip at 10 mEq/hr max put on ECG monitoring, assess IV site often Sodium - think NEURO/LOC Hyponatremia ISOtonic Symptoms: Confusion, headaches Seizures (can progress to coma) Abd cramps, n/v Hypernatremia Calcium Hypocalcemia Hypercalcania Numbness Kidney tingling stones Medications with calcium  ABG’s Normal levels 7.3 Respiratory ! PH 7.4 CO 53 54 Alkalosis U Acidosi 2 HCO 52 52 S. s 3 Remember 2 ROME 6 PH above 7.45 PH below 35 Respiratory Coa below 35 Coa above 45 Opposite HCO3 normal or low HCO3 normal or Metabolic high Equal Metabolic Alkalosis U Acidosi Metabolic acidosis s S. Caused by PH below 7.35 PH above 7.45 DKA CO2 normal or low Coa normal or high Diarrhea HCO3 below 22 HC03 above 26 Renal failure GI fistula Starvation Respiratory acidosis Respiratory alkalosis Caused by Caused by Metabolic alkalosis COPD Liver failure Caused by Pneumonia Hyperventilation Vomiting Atelectasis NG suctioning Pulmonary edema Diuretics Hypokalmeia  Anemia IDA Sickle cell B12 deficiency Signs and Signs and symptoms Signs and symptoms symptoms GI tract : Low Oz Sore, red, beefy tongue Fatigue Pain (Glossitis) Lethargy SOB Anorexia Irritable Jaundice Nausea, vomiting Pale Vision issues Abdominal pain Tachycardia Organ failure Spoon nails Acute chest syndrome Neuromuscular: Weakness Paresthesia Of feet and hands Interventions Ataxia Interventions Oral iron ferrous Reduced sensation HOP sulfate / iron Muscle weakness Hydration supplement Impaired thought process Oxygen Take w/ vitamin C to Pain increase absorption Hydroxyurea Take w/ empty stomach Stool may be tarry or black.  Blood transfusion Verify order, patient’s identity, patient’s blood type, consent Two licensed personnel at bedside for verification Start infusion slowly Monitor patient closely for first 15 minutes VS per facility protocol Complete transfusion in less than 4 hours Blood transfusion reactions STOP TRANSFUSION! Maintain IV site with NS Assess patient Notify Blood Bank and Health care provider Verify tags and numbers Send blood and tubing to lab Obtain labs and urine specimens Document  Pneumoni Signs and symptoms a Nursing interventions Fever Chest x Ray Tachypnea / Dyspena Sputum I gram stain Tachycardia Blood cultures Productive cough ABGS Chest pain Antibiotics Shaking chills Nebulizer Hypoxemia Encourage fluids and ambulation High fowlers First sign of low oxygen - altered loc, restless, agitation Asthma Physical exam for Never leave pt in distress asthma when having an attack Albuterol _ rescue Corticosteroids _ maintains Use of accessory muscles diaphoresis - sweating Signs and Cyanosis symptoms lung sounds Asthma triad Nasal polyps, asthma, sensitive Wheezing to NSAIDs Dyspena Prolonged expiration Remember Chest tightness Steroids can make blood glucose HIGH Speaking 1-2 words Corticosteroids can cause thrush - rinse mouth Tachypnea Tachycardia Anxiety Maintain airway! SLIENT CHEST  Diabete s Type 2 Type 1 Autoimmune- cancerous not making Inadequate insulin secretion Absence of endogenous insulin enough insulin and resistánce to the cellular level DKA - BG 250 - 500 fruit smelling breath, kussmal Sulfonylureas (glipizide, glyburide) - breathing, lethargic, abdominal lower blood glucose by causing pain pancreas to produce more insulin Treatment HIP Hydration ( normal saline ) Insulin (regular, short acting) Biguardes (metformin) work in the liver Potassium 10 meq/hr (electrolyte to improve how much insulin works in replacement) the body and slows the process of turning carbs into sugar HHS - BG +600 Normal ranges No abdominal pain Alc 6.5 or higher- diabetes LOC change Fasting blood glucose 126 or above - diabetes Types of Insulin Rapid acting Examples lispro (Humalog) aspart (novolog) glulisine(apidra) Onset 10- Peak 30 Duration 30- 3 3- 5 Short acting Examples regular (humlin N, novoLin N) Onset 30- 1 Peak 2- 5 Duration 5- 8  Intermediate acting Examples humlin R and NovoLin R Onset 2- 4 Peak 4- 12 Duration 12- 18 Long acting Examples glargine (lantus) detemir(levemir) degludec (tresiba) Onset O.8- 4 Peak Duration 16- 24 When to check glucose levels Dawn phenomenon before meals Abnormal Carly morning increase before bed in blood glucose - usually during In the morning 2-8am Before, during, and after exercise Or a lot of activity To help with this No carbs Adjust medication doses and times with provider Set insulin pump to administer more during early hrs  Hypertension Called the client killer because it is often asymptomatic 180 / 120 =hypertensive crisis Causes Medications for HTN Cirrhosis Arb's - Sartans Oral birth control, cortidosteriods, SNS Ace - Prils stimulants, endocrine disorders Beta blockers - LOL Neurological disorders Calcium channel blockers - pines Renal disease Sleep apena Labs to monitor HDL - +50 Management LDL - less than 100 Triglycerides - less than 150 Dash diet Total cholesterol - less than 200 Low sodium Limit alcohol Excersie - 30 min X5 days Manage weight - BMI 18 - 25 STOP smoking  Stroke Ischemic Hemorrhagic blood clot within the Brain Major Bleed Can not be seen in a CT Pt will often State "worst headache of my life" Trans ischemic attack (Tia) Mini stroke Puts you at higher risk for stroke (ischemic) Watch for sudden Act F.A.S.T Face Ataxia - loss of muscle Numbness Arms coordination Confusion Hemianopasia - blindness in Speech Trouble seeing half the vision field Time! Trouble walking Severe headaches Left side stroke Right side stroke Right side visual deficit Left visual field deficit Aphasia or dysphasia Spatial deficit Speech or language problems Impulsive Depress / anxious Rapid movements Slow and cautious Minimizes Lack of awareness Nursing interventions Management with no TPA CT scan!!! Anti platelet TPA (only if you know the last Anticoagulants know well time and it's within 3-4.5 hrs)  Ace inhibitors Nitro Cause dry cough Start with I tab if needed repeat Q5 Angioedema min with up to 3 Take I hr before meals Call 911 for help after first dose Don’t give if they take viagra MI suspected Sit down vitals Myocardial Infarction Nitro Ekg ST-elevation and Non-ST-elevation MI Result of abrupt stoppage of blood flow through a coronary artery with a thrombus caused by platelet aggregation, causing irreversible myocardial cell death (necrosis) Preexisting CAD STEMI—occlusive thrombus; ST elevation in leads facing infarction 90 min NSTEMI—non-occlusive thrombus 12-72 hrs Acute otitis media - require antibiotics Chronic stable - the same each time Unstable angina - new not predictable  Heart failure Left side think lungs Right side think rest of the body EKG’ s  Meningitis Bacterial Viral What is meningitis? Bacterial Infection What is Viral meningitis What organisms can cause Bacterial HIV Herpes Meningitis? Streptococcus Common findings What populations are at highest risk of lymphocytosis contracting meningitis? +65 Prisions Young How do we treat? People in dorms Treat symptoms Endocarditis Overview Is a disease of the endocardium (the innermost layer of the heart) and the heart valves (Fig. 40.1). IE is associated with a poor prognosis and a decreased life expectancy Subacute or Acute Subacute- affects those with preexisting valve disease over a period of months Acute- affects those with healthy valves and appears progressive illness Pathophysiology Occurs when blood flow allows organisms to contact and infect previously damage  Antibiotics - through central line for 6 weeks Broad spectrum antibiotics 3 sets of cultures from 3 different sites Blood culture Complain of cramping - slow down, nausea - stop it Do not let iv drug user go home with picc line in Narrow antibiotics Pacemaker Teachin g Follow-up appointments for pacemaker function checks Incision care Arm restrictions Avoid direct blows Avoid high-output generator No MRIs unless pacer approved Microwaves OK Avoid antitheft devices Travel not restricted Monitor pulse Pacemaker ID card Medic Alert ID Rheumatic fever is from untreated strep throat Tonsillectomy No red liquids No Suction Also known as Tube Feeding TPN Administration of nutritionally balanced Administration of nutrients directly into liquefied food or formula through tube, the bloodstream catheter, or stomach directly into GI tract: Used when GI tract cannot be used for Stomach ingestion, digestion, and absorption Duodenum Goal: Meet nutrition needs and allow growth of new body tissue Jejunum Customized to meet each patient’s needs Functioning GI tract but unable or unsafe to take any or enough oral nourishment Chest xray - most reliable way to check placement Check residuals - 500 or more for residuals is a problem- call provider Give pt back the residuals that is their food TPN - blood sugar checks every 6 hours 30 degrees or higher to run feeding - stop feeding when laying the patient down Flush ng tube and give meds then flush it again  Failure to thrive Causes Finding s Weight below the 5th percentile Can be caused by underlying physical problems Medical issues Rapid deceleration in the growth Chromosomal abnormalities curve Defects in lung or heart Labs Low levels caused by malnutrition Albumin – norm 3.5-5 g/dL Serum protein – norm 6.4-8.3 g/dL Alk phos – norm 44-147 IU/L BUN – norm 10- 20 mg/dL, blood urea nitrogen produced when protein is broken down in the body, elevated w/ dehydration Creat – norm 0.6-1.2, most accurate assessment of kidney function, waste product from normal breakdown of muscles Imaging CBC & BMP Lead levels MRI/CT of head to r/o congenital defects Upper GI series to look for structural abnormalities Swallowing studies Gastric emptying scans to see if gastric emptying is delayed Bone age survey to look at growth rate Scans to rule out abuse Genetic testing to find reason for FTT Thyroid function – hormones that regulate metabolism Stool culture – r/o infection  Vision EXTRA credit Cataracts: Nursing Management - Assessment Opacity within crystalline lens Visual acuity Leading cause of blindness Psychosocial impact of visual disability Most common surgical procedure for those aged over 65 Level of knowledge of disease Comfort and ability to comply with post op treatment Etiology and Pathophysiology Influencing factors Nursing Management - Nursing Diagnoses Age Self Care Deficits Blunt trauma Congenital factors Anxiety Radiation/UV light exposure Long-term corticosteroid use Nursing Management - Planning Ocular inflammation Preoperative goals Senile cataract Make informed decisions regarding therapeutic options. Most common type Experience minimal anxiety. Altered metabolic processes cause Postoperative goals Accumulation of water Understand and comply with postoperative therapy. Altered lens fiber structure Maintain a level of comfort. Remain free of infection and other complications. Clinical manifestations Decrease in vision Nursing Management - Implementation Abnormal color perception Glaring of vision Health promotion Wear sunglasses. Diagnostic Studies Avoid unnecessary radiation. History and physical examination Adequate antioxidant vitamins Visual acuity measurement Ensure good nutrition. Ophthalmoscopy Acute intervention Slit lamp microscope Educate about disease processes and treatment Glare testing options. Administer medication. Collaborative Care Inform those with patches that they will not have depth Nonsurgical therapy perception. No nonsurgical “cure” Ensure little to no pain. Visual aids (palliative) Changing eyewear prescription Teach signs and symptoms of infection. Reading glasses Ambulatory and home care Magnifiers Activity restrictions Increased lighting Medications Follow-up visits Surgical Therapy Signs and symptoms of possible complications Preoperative phase Ambulatory and home care History and physical assessment Educate on postoperative visual acuity. Antibiotic eye drops Instruct family to modify activities and environment. Dilating eye drops (Table 22-5 in book) Remove area rugs. Intraoperative phase Prepare frozen meals. Corneoscleral incision Provide audio books. Cataract extracted and sutured Cortex irrigated and aspirated Evaluation Corticosteroid ointment applied with protective shield Expected outcomes Postoperative phase Improved vision Outpatient procedure unless complications occur Ability to care for self Antibiotic and corticosteroid eye drops Minimal to no pain Limiting activities Optimistic expectations Follow-up visits Classifications of Visual Impairment Classification is based on the vision in the better eye with the best possible correction. 20 / 30 to 20 / 60 Mild vision loss or near-normal vision 20 / 70 to 20 / 160 Moderate visual impairment 20 / 200 or worse Severe visual impairment - legal blindness 20 / 500 to 20 / 1000 Profound visual impairment Less than 20 / 1000 Near-total visual impairment No light perception Total visual impairment or total blindness