med_surg_final.docx.pdf

Med-Surg I Review Guide Valve disorders The four cardiac valves—aortic, mitral, tricuspid, and pulmonic— promote the forward circulation of blood to sustain adequate cardiac output Rib fracture management Fractured Ribs Fractured ribs are a common injury and may result from a hard fall or a blow t...

Med-Surg I Review Guide Valve disorders The four cardiac valves—aortic, mitral, tricuspid, and pulmonic— promote the forward circulation of blood to sustain adequate cardiac output Rib fracture management Fractured Ribs Fractured ribs are a common injury and may result from a hard fall or a blow to the chest. Fractured ribs usually are not considered serious unless accompanied by other injuries. Flail chest occurs when two or more adjacent ribs fracture in multiple places (two or more) and the fragments are free floating. A paradoxical movement develops: with inspiration, the chest expands, but the free-floating segments move inward instead of outward. Medical Management Supporting the chest with an elastic bandage or a rib belt assists in immobilizing the rib fractures. Management of flail chest includes supporting ventilation, clearing lung secretions, and managing pain. Other treatment depends on the severity of the flail chest. If a pulmonary contusion (crushing bruise of the lung) also exists, fluids are restricted because of the damage to the pulmonary capillary bed. Antibiotics are given to prevent infection, which is common after this type of injury. Endotracheal intubation and mechanical ventilation may be necessary if a client’s respiratory status is greatly compromised. Nursing Management Nurses plan and implement care of clients with more severe injuries based on respiratory needs. The nurse assesses and monitors the client for signs of respiratory distress, infection, and increased pain. Acute bronchitis symptoms Signs and symptoms initially include fever; chills; malaise; headache; and a dry, irritating, and nonproductive cough. Later, the cough produces mucopurulent sputum, which may be blood streaked if the airway mucosa becomes irritated with severe tracheobronchitis and coughing. Clients experience paroxysmal attacks of coughing and may report wheezing. Laryngitis and sinusitis complicate the symptoms. Moist, inspiratory crackles may be heard on chest auscultation. Emphysema & nutritional considerations Emphysema Emphysema is a chronic disease characterized by abnormal distention of the alveoli. The alveolar walls and capillary beds also show marked destruction. This process of destruction occurs over a long period. By the time of diagnosis, damage to the lungs usually is permanent. Emphysema is a common cause of disability and the most common obstructive lung disorder. In emphysema, the alveoli lose elasticity, trapping air that the client normally would expire. Cause : smoking environmental factors Signs and Symptoms Shortness of breath with minimal activity is called exertional dyspnea and often is the first symptom of emphysema. As the disease progresses, breathlessness occurs even at rest. A chronic cough invariably is present and productive of mucopurulent sputum. Inspiration is difficult because of the rigid chest cage, and the chest is characteristically barrel-shaped The client uses the accessory muscles of respiration (muscles in the jaw and neck and intercostal muscles) to maintain normal ventilation. Expiration is prolonged, difficult, and often accompanied by wheezing. In advanced emphysema, respiratory function is markedly impaired. Clients with advanced emphysema characteristically appear drawn, anxious, and pale. They speak in short, jerky sentences. When sitting up, they often lean slightly forward and are markedly short of breath. The neck veins may distend during expiration. In advanced emphysema, memory loss, drowsiness, confusion, and loss of judgment may result from the markedly reduced oxygen that reaches the brain and the increased CO 2 in the blood. If the disorder goes untreated, the CO 2 content in the blood may reach toxic levels, resulting in lethargy, stupor, and, eventually, coma. This condition is called carbon dioxide narcosis. Diagnostic Findings Chest radiography, fluoroscopy, and CT scanning demonstrate hyperinflated lung fields. Medical Management The goals of medical management include improving the client’s quality of life, slowing the disease progression, and treating the obstructed airways. Treatment includes the following measures:  Bronchodilators to dilate airways by decreasing edema and spasms and improving gas exchange  Aerosol therapy with nebulized aerosols for deep inhalation of bronchodilators and mucolytics in the tracheobronchial tree  Inhaled corticosteroid drugs and oral corticosteroids on a limited basis to assist with bronchodilation and removal of secretions  Supplemental oxygen may be prescribed  Antibiotics  Physical therapy to increase ventilation—deep breathing, coughing, chest percussion, vibration, and postural drainage Nursing Management Clients with emphysema may require supplemental oxygen. It is important to monitor oxygen levels as well as partial pressure of carbon dioxide (PaCO2) levels because some clients with emphysema tend to have chronic hypercapnia (elevated PaCO 2). The safest method of oxygen administration is by nasal catheter or cannula, with the oxygen flow rate set at no more than 2 to 3 L/minute. If the client’s color improves but his or her level of consciousness decreases, the nurse discontinues oxygen administration and notifies the physician; the client may be approaching a state of respiratory arrest. Nutrition Notes 21-1 Client With Emphysema  Malnutrition among clients with emphysema is multifactorial.  Shortness of breath and difficulty breathing impair the ability to chew and swallow.  Inadequate oxygenation of gastrointestinal (GI) cells causes anorexia and gastric ulceration.   Slowed peristalsis and digestion contribute to loss of appetite.  Labored breathing increases calorie requirements.  Eating is not a priority among clients who are anxious about breathing.  To correct malnutrition, a high-protein, high-calorie diet is indicated, but an excessive calorie intake is avoided because it increases respiratory stress by increasing carbon dioxide output.  Small, frequent feedings of nutrient-dense foods help maximize intake and lessen fatigue; concentrated liquid supplements are beneficial.  Encourage ample fluid intake. Fluids consumed between meals instead of with meals are less likely to interfere with food intake.  Obese clients with emphysema are encouraged to lose weight to improve breathing. Incentive spirometer teaching Nursing Management Nursing care focuses on preventing atelectasis , especially when the client is at risk because of failure to aerate the lungs properly. Postoperative deep breathing and coughing can prevent atelectasis. If atelectasis occurs, the nurse encourages the client to take deep breaths and cough at frequent intervals and instructs the client in the use of an incentive spirometer (Client and Family Teaching 21-1). Client and Family Teaching 21-1 Using an Incentive Spirometer The nurse instructs the client as follows: 1. Sit upright unless contraindicated. 2. Mark the goal for inhalation. 3. Exhale normally. 4. Place mouthpiece in mouth, sealing lips around it. 5. Inhale slowly until predetermined volume has been reached. 6. Hold breath for 2–6 seconds. 7. Exhale normally. 8. Repeat the exercise 10–20 times per hour while awake or as ordered. 9. Do not rush during the procedure. Slow down if dizziness is experienced. Symptoms of aortic aneurysm Signs and Symptoms Many aneurysms go unnoticed until found during physical examination or the client has a massive hemorrhage. Some cause pain, discomfort, and symptoms related to pressure on nearby structures. For example, a thoracic aortic aneurysm can cause bronchial obstruction, dysphagia (difficulty swallowing), and dyspnea. An abdominal aortic aneurysm can produce nausea and vomiting from pressure exerted on the intestines, or it may cause severe back pain from pressure on the vertebrae or spinal nerves. Most clients are hypertensive. A pulsating mass may be felt or even seen around the umbilicus or to the left of midline over the abdomen. A bruit (purring or blowing sound) can be auscultated over the mass. Circulation to tissue may be impaired. Raynaud's disease symptoms & treatment Raynaud’s Disease Raynaud’s disease is characterized by periodic constriction of the arteries that supply the extremities. The disorder is most common in young women. Signs and Symptoms Attacks are intermittent and of varying frequency but are especially common after exposure to cold. When the condition occurs in the hands, they become cold, blanched, and wet with perspiration. Numbness and tingling also may occur. The client may note awkwardness and fumbling, especially when attempting fine movements. After the initial pallor, the hands, especially the fingers, become deeply cyanotic and begin to ache. The hallmark symptoms of arterial insufficiency include ischemia, pain, and paresthesia. Painful ulcers and superficial gangrene may appear at the fingertips. The fingers are especially vulnerable to infection. Healing of even minor lesions often is slow and uncertain. Medical and Surgical Management Treatment involves avoiding factors that precipitate attacks. Smoking is contraindicated because it causes vasoconstriction. Drug therapy with peripheral vasodilators, such as isoxsuprine (Vasodilan), may be attempted, but results usually are less favorable than desired. Other drugs, such as nifedipine (Procardia), are being used investigationally. An IV infusion of prostaglandin E may provide temporary relief. Sympathectomy (cutting peripheral sympathetic nerves) may be performed; however, because of disappointing results, the procedure is performed less frequently than in the past. Gangrenous areas are amputated. The nurse instructs clients to avoid situations that contribute to ischemic episodes, explaining that injuries may heal slowly. If clients smoke, they must stop because nicotine causes vasoconstriction and increases the frequency of episodes. The nurse advises clients to wear wool socks and mittens during cold weather. Clients should avoid over-the-counter decongestants, cold remedies, and drugs for symptomatic relief of hay fever because of their vasoconstrictive qualities. Electrolyte imbalances such as hypocalcemia & hypercalcemia Hypocalcemia Causes of hypocalcemia include vitamin D deficiency, hypoparathyroidism, severe burns, acute pancreatitis, certain drugs such as corticosteroids, rapid administration of multiple units of blood that contain an anti-calcium additive, intestinal malabsorption disorders, and accidental surgical removal of the parathyroid glands. Hypocalcemia is evidenced by tingling in the extremities and the area around the mouth (circumoral paresthesia), muscle and abdominal cramps, positive Chvostek sign (spasms of the facial muscles when the facial nerve is tapped, carpopedal spasms referred to as Trousseau sign , mental changes, laryngeal spasms with airway obstruction, tetany (muscle twitching), seizures, bleeding, and cardiac arrhythmias. The client has hypocalcemia if the total serum calcium level is below 8.8 mg/dL (normal range: 9 to 11 mg/dL) Treatment includes administration of oral calcium and vitamin D for mild deficits and IV administration of a calcium salt, such as calcium gluconate, for severe hypocalcemia. Hypercalcemia Hypercalcemia is associated with parathyroid gland tumors, multiple fractures, Paget disease, hyperparathyroidism, excessive doses of vitamin D, prolonged immobilization, some chemotherapeutic agents, and certain malignant diseases (multiple myeloma, acute leukemia, lymphomas). Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes such as decreased memory and attention span. Chronic hypercalcemia can promote the formation of kidney stones. Treatment includes determining and correcting the cause when possible. Mild hypercalcemia is treated by increasing oral fluid intake and limiting calcium consumption until laboratory findings are normal.  Acute hypercalcemia is treated by administering one or more of the following: IV sodium chloride solution (0.45% or 0.9%) and a diuretic such as furosemide (Lasix) to increase calcium excretion in the urine; oral phosphates; or calcitonin (Miacalcin), a synthetic hormone for regulating calcium levels. Hypercalcemia associated with cancer or chemotherapy is treated on an individual basis. > Infective endocarditis symptoms and management Infective Endocarditis Infective endocarditis (formerly called bacterial endocarditis) is inflammation of the inner layer of heart tissue as a result of an infectious microorganism The microorganisms that cause infective endocarditis include bacteria and fungi. Streptococci and staphylococci are the bacteria most frequently responsible for this disorder. They are found abundantly on the skin and mucous membranes of the mouth, nose, throat, and other cavities. Signs and Symptoms Infective endocarditis can have an acute onset (less than 1 week) from a previously healthy state. The client presents with fever, chills, muscle aches in the lower back and thighs, and joint pain. Subacute infections progress more insidiously over weeks to months with more vague manifestations, such as headache, malaise, fatigue, and sleep disturbances. As the condition advances, purplish, painful nodules called Osler nodes may appear on the pads of the fingers and toes. Black longitudinal lines called splinter hemorrhages can be seen in the nails. There may be small, painless, red-blue macular lesions known as Janeway lesions on the palms of the hands and soles of the feet (Vyas, 2014).  Roth’s spots, white areas in the retina surrounded by areas of hemorrhage, may be detected. A heart murmur may be present from malfunctioning valves. Petechiae, tiny, reddish hemorrhagic spots on the skin and mucous membranes, are signs of embolization. Pronounced weakness, anorexia, and weight loss are common. Medical and Surgical Management High doses of an IV antibiotic to which the organism is susceptible are prescribed initially. Antibiotic therapy extends at least 2 to 6 weeks. It is resumed if the infection recurs after discontinuation of the drug. Bed rest is ordered initially. If a heart valve has been severely damaged and drug therapy does not adequately support the heart in failure, valve replacement may be necessary Nursing Management Many clients cannot appreciate the danger of the disease without seeing external signs of the damage. The nurse gently but firmly reminds the client to limit activity. The nurse continually assesses for changes in weight, pulse rate, and rhythm, noting and reporting new symptoms. He or she informs clients that periodic antibiotic therapy is a lifelong necessity because they will be vulnerable to the disease for the rest of their lives. Asthma symptoms and management Asthma is a chronic but usually reversible obstructive disease of the lower airway. Signs and Symptoms Asthma is typified by paroxysms of shortness of breath, wheezing, and coughing and the production of thick, tenacious sputum. Medical Management Symptomatic treatment is given at the time of the attack. Long- term care involves measures to treat as well as to prevent further attacks. If the history and diagnostic tests indicate allergy as a causative factor, treatment includes avoidance of the allergen, desensitization, or antihistamine therapy. Oxygen usually is not necessary during an acute attack because most clients are actively hyperventilating. Nursing Management During asthma attacks, clients are extremely anxious. The nurse provides reassurance that someone will remain with the client during the acute phase. Rest and adequate fluid intake are important. Increasing fluid intake makes secretions less tenacious and replaces the fluids lost through perspiration. Signs and Symptoms Asthma is typified by paroxysms of shortness of breath, wheezing, and coughing and the production of thick, tenacious sputum. TPN-nursing interventions Total Parenteral Nutrition The physician may order total parenteral nutrition (TPN) for a client who is severely malnourished or cannot consume food or liquids for a long time. TPN uses a solution of nutrients to meet the client’s caloric and nutritional needs. The composition of a TPN solution is individualized according to the client’s nutritional requirements and medical condition. Because concentrations of protein, carbohydrate, and fat are standard in standard volumes, however, individualization is somewhat limited. Trained nurses administer TPN using filtered tubing and an electronic infusion pump. For clients receiving TPN at home or as a supplement to an inadequate oral diet, cyclical TPN is most often used. Cyclical TPN is infused in cycles over 10 to 16 hours, followed by 8 to 14 hours of rest Cyclical TPN offers the client more mobility, especially if infused during the night, and has the advantage of allowing enzyme and hormone levels to drop to normal during the rest periods. To give the body time to adjust to the decreasing glucose load (and prevent rebound hypoglycemia), the infusion should be tapered near the end of each cycle. The nurse should monitor the client’s blood glucose level because the glucose levels in TPN can cause hyperglycemia. Central venous catheters are inserted when providing TPN, monitoring central venous pressure, or administering concentrated or irritating IV solutions; when peripheral veins have collapsed; or when long-term IV therapy or thrombophlebitis (inflammation of a vein) and infiltration have reduced the availability of peripheral veins. Administering Total Parenteral Nutrition  Weigh client daily.  Use tubing that contains a filter; however, bypass the filter when administering lipid emulsions to prevent large fat molecules from obstructing the filter.  Label the tubing used for TPN to ensure that it is used exclusively for TPN and not IV medications or blood products.  Change TPN tubings daily.  Tape all connections in the tubing to prevent accidental separation and the potential for an air embolism.  Clamp the central catheter whenever separating the tubing from its catheter connection.  Use an electronic infusion device to administer TPN.  Infuse initial TPN solutions gradually (e.g., 25 to 50 mL/hour); increase rate according to the agency’s standard of care or the physician’s medical orders.  Monitor blood glucose levels regularly to assess the client’s ability to metabolize the concentrated glucose.  Administer insulin on a sliding scale according to blood glucose levels.  Wean client from TPN gradually to avoid a sudden drop in blood glucose level.  Infuse IV lipids three times a week.  Monitor the following laboratory test results to evaluate the nutritional status of the client receiving TPN and lipids: serum transferrin, serum osmolality, cholesterol, triglycerides, electrolytes, blood urea nitrogen (BUN), and urine creatinine.  Initiate nutrition consult as per institutional protocol. > Pleurisy symptoms Respirations become shallow secondary to excruciating pain. Pleural fluid accumulates as the inflammatory process worsens. The pain decreases as the fluid increases because the fluid separates the pleurae. The client develops a dry cough, fatigues easily, and experiences dyspnea. A friction rub (coarse sounds heard during inspiration and early expiration) is heard during auscultation early in the disease process. As fluid accumulates, the pleural friction rub disappears. Decreased ventilation may result in atelectasis, hypoxemia, and hypercapnia. > Flu prevention 3 Prevention Strategies for Seasonal Influenza in Healthcare Settings To prevent outbreaks of influenza, healthcare settings take the following precautions in addition to standard precautions:  Promote and administer seasonal influenza vaccine  Take steps to minimize potential exposures:  Before clients enter the healthcare setting ask if they have any respiratory symptoms, such as cough, runny nose, fever  Minimize elective visits by clients who are symptomatic  Assure that all persons with respiratory symptoms adhere to respiratory hygiene, cough etiquette, and hand hygiene  Monitor and manage ill healthcare providers  Adhere to standard precautions  Adhere to droplet precautions  Use caution when performing aerosol-generating procedures, such as bronchoscopy or sputum induction  Manage visitor access and movement within the facility  Monitor influenza activity  Implement environmental infection control  Implement engineering controls, such as installing partitions in triage areas  Train and educate healthcare providers  Administer antiviral treatment and prophylaxis of clients and healthcare providers when appropriate MDI use Metered-dose inhalers (MDIs) are pressurized devices that contain an aerosolized powder of specific medications. When the client pushes on the pressurized canister, an exact amount of medication is delivered via inhalation. Client and Family Teaching 21-2 Using a Metered-Dose Inhaler (MDI) The nurse provides the following instructions: 1. Attach the stem of the canister into the hole of the mouthpiece so that the inhaler looks like an “L.” If a spacer is used, attach the spacer to the mouthpiece on one end and to the MDI on the other end. 2. Shake the canister to distribute the drug in its pressurized chamber. 3. Exhale slowly through pursed lips. 4. Seal lips around the mouthpiece or hold inhaler a few inches from mouth. 5. Compress the canister between thumb and fingers and slowly inhale; if not using a spacer, you must compress the canister and inhale at the same time. 6. Release the pressure on the canister but continue inhaling as much as possible. Inhalation should be for 5–bacillus Calmette- Guérin (BCG) 7 seconds in order to breathe in completely. 7. Withdraw the mouthpiece. 8. Hold breath for 10 seconds (count to 10 slowly) to allow the medication to reach the airways of the lungs. 9. Exhale slowly through pursed lips. 10. If second dose is required, wait for a few seconds before repeating procedure. Benefit of purse-lip breathing in COPD Pursed-lip breathing (i.e., breathing with the lips pursed or puckered on expiration) helps to control the respiratory rate and depth and slows expiration. This maneuver may decrease dyspnea and, in turn, reduce the anxiety that often is associated with breathing difficulties. > CAD symptoms Signs and Symptoms In mild CAD, clients are asymptomatic or complain of fatigue. The classical symptom is chest pain (angina pectoris) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). The pain may radiate to the shoulders and arms, especially on the left side, or to the jaw, neck, or teeth. Some clients, especially women, experience more atypical symptoms such as nausea, fatigue, and dizziness, which are often overlooked as significant for heart disease and consequently go misdiagnosed. Some describe discomfort other than pain, such as indigestion or a burning, squeezing, or crushing tightness in the upper chest or throat. highlights various types of angina. The American Heart Association now suggests the term acute coronary syndrome to describe any group of clinical symptoms compatible with acute myocardial ischemia (impaired oxygenation). > Chest tube management After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. A catheter placed in the pleural space provides a drainage route through a closed or underwater-seal drainage system. Sometimes two chest catheters are placed—one anteriorly and one posteriorly. The anterior catheter (usually the upper one) removes air; the posterior catheter removes fluid. Chest tubes are securely connected to an underwater-seal drainage system. The tube coming from the client always must be under water. A break in the system (e.g., loose or disconnected fittings) allows air to first enter the tubing and then the pleural space, further collapsing the lung. When chest tubes are inserted at the end of the surgical procedure, they are connected to an underwater-seal drainage system. All connections are taped carefully to minimize the possibility of air entering the closed system. When caring for a client with chest tubes, the nurse should be aware of the following:  Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease when the lung  expands. The time for lung reexpansion varies. Fluctuations also may cease if  The chest tube is clogged.  The wall suction unit malfunctions.  A kink or dependent loop develops in the tubing.  Bubbling in the water-seal chamber occurs in the early postoperative period.  If bubbling is excessive, the nurse checks the system for leaks.  If leaks are not apparent, the nurse notifies the physician.  Bloody drainage is normal, but drainage should not be bright red or copious.  The drainage tube(s) must remain patent to allow fluids to escape from the pleural space.  Clogging of the catheter with clots or kinking causes drainage to stop. The lung cannot expand, and the heart and great vessels may shift (mediastinal shift) to the opposite side.  The nurse must be alert to the proper functioning of the drainage system. Malfunctions need immediate correction.  If a break or major leak occurs in the system, the nurse clamps the chest tube immediately with hemostats kept at the bedside. He or she notifies the physician if this occurs. It is also essential that the nurse check the underwater-seal drainage system, noting the amount and color of drainage and any bubbling or fluctuation. The nurse assesses dressings for drainage and firm adherence to the skin, inspecting the skin around the dressings for signs of subcutaneous emphysema. The nurse assesses the client’s color, neurologic status, and heart rate and rhythm; monitors respiratory rate, depth, and rhythm; and auscultates the chest for normal and abnormal breath sounds. He or she also assesses levels of pain and anxiety. Never leave the drainage chamber above chest level Always check out put, document the color, chest dressing EKG findings with potassium imbalances FIGURE 16-9 Effects of potassium on electrocardiogram (ECG). (A) Normal tracing. (B) Serum potassium level below normal (hypokalemia) results in ST-segment depression, flattened T wave, and a U wave. (C) High potassium level (hyperkalemia) produces prolonged PR interval; widened QRS; ST-segment depression; and a tall, peaked T wave. > Review categories of IVF's intravenous (IV) therapy is the parenteral administration of fluids and additives into a vein. IV therapy is used to maintain or restore fluid balance when oral replacement is inadequate or impossible, to maintain or replace electrolytes, to administer water-soluble vitamins, to administer drugs, to provide a source of calories and nutrients, and to replace blood and blood products. IV therapy may be used to administer medications, because drugs given by the IV route have a more rapid effect than other routes of administration. Only drugs labeled for IV use are given by this route. Administering a drug intravenously may be indicated in the following circumstances:  A rapid drug effect is required.  Oral intake is restricted.  A client cannot swallow.  Gastrointestinal absorption is impaired.  A continuous therapeutic blood level is desired. total parenteral nutrition (TPN): IV therapy designed to meet nearly all the caloric and nutritional needs of a client. Clients who are severely malnourished or cannot consume food or liquids for a long time may require TPN. Crystalloid solutions consist of water and uniformly dissolved crystals such as salt (sodium chloride) or sugar (glucose, dextrose) Colloid solutions consist of water and molecules of suspended (undissolved) substances such as blood cells and blood products Crystalloid solutions are divided into isotonic, hypotonic, and hypertonic solutions. These terms refer to the concentration of dissolved substances in relation to the plasma into which they are instilled. isotonic solution contains the same concentration of dissolved substances as is normally found in plasma. Isotonic solutions are administered to maintain fluid balance when clients temporarily cannot eat or drink. hypotonic solution contains fewer dissolved substances compared with plasma. Hypotonic solutions effectively rehydrate clients experiencing fluid deficits; therefore, they are administered to clients experiencing fluid losses in excess of fluid intake, such as those who have diarrhea or are vomiting. hypertonic solution is more concentrated (contains more dissolved substances) than body fluid. Consequently, it draws fluid into the intravascular compartment from the more dilute areas in the cells and interstitial spaces. Hypertonic solutions are used infrequently except when it is necessary to reduce cerebral (brain) edema, expand circulatory volume rapidly, administer nutrition parenterally, or treat severe hyponatremia (low serum sodium). Colloid solutions are used to replace circulating blood volume because the suspended molecules in the solutions pull fluid from other fluid compartments in the body. Examples include blood (whole blood and packed cells), blood products such as albumin, and solutions known as plasma expanders. Whole blood and packed cells probably are the most commonly administered colloid solutions. One unit of whole blood contains approximately 475 mL of blood cells and plasma, with 60 to 70 mL of preservative and anticoagulant added. Whole blood is administered when clients need fluid restoration as well as blood cells. Packed cells have most of the plasma (fluid) removed, resulting in an average volume of 285 to 300 mL. Packed cells are preferred for clients who need cellular replacements but do not need and may be harmed by the administration of additional fluid. Such clients include those who have an adequate oral intake of fluid and clients at risk for heart failure blood products, components extracted from blood, such as fresh frozen plasma (FFP), albumin, platelets, granulocytes, and cryoprecipitate. Blood products are administered to clients who need specific blood substances but not all the fluid and cellular components in whole blood. Plasma is the liquid noncellular component of blood. It contains nutrients; hormones; enzymes; plasma proteins such as albumin, globulin, and fibrinogen; and especially, all known coagulation factors.  Plasma is separated from blood cells within 8 hours after collection and subsequently frozen. coagulopathies, clotting disorders of various types, and control or eliminate hemorrhage caused by an overdose of anticoagulants. Albumin is a large plasma protein that does not normally move across semipermeable membranes like those in capillaries.it plays a major role in maintaining blood volume. In other words, its presence attracts fluid to the intravascular space, a function described as providing colloidal osmotic pressure. When a person experiences hypoalbuminemia, colloidal osmotic pressure decreases, which results in movement of intravascular fluid into extravascular areas, evidenced by peripheral edema in the limbs, organ edema, or cavity effusion such as ascites Platelets, also known as thrombocytes, are cell-like structures within blood that aggregate (clump together) and release chemicals that produce fibrin at the site of an injury Granulocytes are white blood cells (WBCs) also known as polymorphonuclear leukocytes, specifically neutrophils, eosinophils, and basophils. Neutrophils are the major type of blood cells that defend against infection. a person with a low granulocyte or neutrophil count is highly susceptible to succumbing to a life-threatening infection. Cryoprecipitate, also known as cryoprecipitated antihemophilic factor, is an acellular blood component that contains fibrinogen and multiple clotting factors. Cryoprecipitate is given for actual or potential bleeding disorders  (1) when the specific clotting factor, for example, factor VIII, is unavailable. (2) following cardiac surgery to clients experiencing hemodilution, hypothermia, or acidosis. (3) to clients who require massive blood transfusions. blood substitute is an experimental fluid emulsion, a mixture of two liquids, one of which is insoluble but remains dispersed in the other. When transfused, a blood substitute carries and distributes oxygen to cells, tissues, and organs. Many practitioners feel that blood substitutes should be more accurately called oxygen therapeutics because they do not replace all the functions of human blood. Currently, oxygen therapeutics fall into two categories: perfluorocarbons (PFCs) and hemoglobin-based oxygen carriers (HBOCs). PFCs are solutions containing fluorine and carbon that have the potential to carry 50 times more oxygen than plasma. HBOCs are derived from three sources: (1) hemoglobin harvested from outdated human blood; (2) hemoglobin from bovine (cattle) blood; (3) cultured bacteria in which the gene for human hemoglobin is inserted (recombinant technology), much like the production of human insulin. Plasma expanders are nonblood, polysaccharide colloid solutions derived from beet sugar or corn starch. Examples include dextran 70, 6% (Macrodex); dextran 40, 10% (Rheomacrodex); and hetastarch 6% (Hespan). Plasma expanders pull fluid into the vascular space twice as effectively as hypertonic crystalloid solutions. They are used as an economical and virus-free substitute for blood and blood products when treating clients with hypovolemic shock. they can affect coagulation and cause renal toxicity, intravascular fluid overload, and allergic reactions. TABLE 13-1 Types of Crystalloid Solutions SOLUTION COMPONENTS SPECIAL COMMENTS Isotonic Solutions 0.9% 0.9 g Sodium Contains sodium Saline, chloride/100 mL and chloride in also water amounts called physiologically normal equal to those saline in plasma (NS) 5% 5 g Dextrose Isotonic when Dextrose (glucose/sugar)/100 infused, but the in water, mL water glucose is also metabolized called quickly, leaving D5W a solution of dilute water Ringer’s Water and a mixture Replaces solution of sodium, chloride, electrolytes in or calcium, potassium, amounts lactated bicarbonate, and, in similarly found Ringer’s some cases, lactate in plasma; lactate, when present, helps maintain acid– base balance Hypotonic Solutions 0.45% 0.45 g Sodium Contains a Sodium chloride/100 mL smaller TABLE 13-1 Types of Crystalloid Solutions SOLUTION COMPONENTS SPECIAL COMMENTS chloride, water proportion of also sodium and called chloride than half- found in strength plasma, causing saline it to be less concentrated in comparison 5% 5 g Dextrose and 0.45 The sugar Dextrose g sodium provides a quick in 0.45% chloride/100 mL source of saline water energy, leaving a hypotonic salt solution Hypertonic Solutions 10% 10 g Dextrose/100 mL Contains twice the Dextrose water concentration of in water, glucose found also in plasma called D10W 3% Saline 3 g Sodium The high chloride/100 mL concentration of water salt in the plasma dehydrates cells and tissue 20% 20 g Dextrose/100 mL Rapidly increases Dextrose water the in water concentration of sugar in the blood, causing a fluid shift to the intravascular TABLE 13-1 Types of Crystalloid Solutions SOLUTION COMPONENTS SPECIAL COMMENTS compartment BLOOD DESCRIPTION PURPOSE FOR PRODUCT ADMINISTRATION Platelets Disk-shaped Restores or improves cellular the ability to control fragments bleeding that promote coagulation of blood Granulocytes Types of WBCs Improves the ability to overcome infection Plasma Serum without Replaces clotting blood cells factors or increases intravascular fluid volume by increasing colloidal osmotic pressure Albumin Plasma protein Pulls third-spaced fluid by increasing colloidal osmotic pressure Cryoprecipita Mixture of Treats blood-clotting te clotting disorders such as factors hemophilia > Symptoms of IV infiltration and phlebitis and management COMPLICAT SIGNS CAUSE(S) ACTION ION AND SYMPTOM S Infection Swelling, Growth of Change discomfo microorgani site rt, sms Apply redness antisepti at site, c and drainage dressing from site to previous site Circulatory Elevated Rapid infusion Slow the IV overload BP, Reduced infusion shortnes kidney rate s of function Contact breath, Impaired the boundin heart physicia g pulse, contraction n anxiety Elevate the client’s head Give oxygen Infiltration Swelling at Displacement Restart the (extravasa the site, of the IV tion) discomfo venipunctur Elevate rt, e device the arm decrease in infusion rate, cool skin tempera ture at the site Phlebitis Redness, Administratio Restart the COMPLICAT SIGNS CAUSE(S) ACTION ION AND SYMPTOM S warmth, n of IV and irritating Report the discomfo fluid findings rt along Prolonged use Apply the vein of the same warm vein compres ses > Circulatory overload Last, circulatory overload can develop if the volume of infusing solution exceeds the heart’s ability to circulate it effectively. ABG interpretation ABG Interpretation Key 1. Metabolic Alkalosis with partial compensation pH 7.58 PaCO2 48 HCO3 44 2. Respiratory Alkalosis with full compensation pH 7.44 PaCO2 26 HCO3 17 3. Metabolic Alkalosis no compensation pH 7.5 PaCO2 40 HCO3 28 4. Respiratory Acidosis no compensation pH 7.3 PaCo2 55 HCO3 22 5. Respiratory Alkalosis no compensation pH 7.5 PaCO2 30 HCO3 25 6. Metabolic Alkalosis with full compensation pH 7.45 PaCO2 50 HCO3 35 7. Metabolic Acidosis with partial compensation pH 7.33 PaCO2 25 HCO3 12 8. Respiratory Alkalosis no compensation pH 7.48 PaCO2 28 HCO3 22 9. Metabolic Acidosis with partial compensation pH 7.25 PaCO2 28 HCO3 15 10. Respiratory Acidosis no compensation pH 7.25 PaCO2 55 HCO3 25 TABLE 19-7 Normal Values for Arterial Blood Gases PARAMETERS NORMAL NORMAL VALUES VALUES ARTERIAL MIXED BLOOD VENOUS BLOOD pH, hydrogen ion 7.35–7.45 7.32–7.42 concentration, acidity or alkalinity of the blood PaO2*, partial pressure of 80–100 mm 38–52 mm oxygen in arterial Hg Hg blood PaCO2, partial pressure 35–45 mm 24–48 mm of carbon dioxide in Hg Hg arterial blood HCO3−, bicarbonate ion 22–26 mEq/L 19–25 mEq/L concentration in the blood SaO2%, arterial oxygen >94% 65%–75% saturation or percentage of the TABLE 19-7 Normal Values for Arterial Blood Gases PARAMETERS NORMAL NORMAL VALUES VALUES ARTERIAL MIXED BLOOD VENOUS BLOOD oxygen-carrying capacity of the blood Bronchoscopy instructions Bronchoscopy Bronchoscopy is used to diagnose, treat, or evaluate lung disease; obtain a biopsy of a lesion or tumor; obtain a sputum specimen; perform aggressive pulmonary cleansing; or remove a foreign body. Bronchoscopy allows for direct visualization of the larynx, trachea, and bronchi Bronchoscopy is very frightening to clients, who require thorough explanations throughout the procedure. For at least 6 hours before the bronchoscopy, the client must abstain from food or drink to decrease the risk of aspiration. Risk is increased because the client receives local anesthesia, which suppresses the swallow, cough, and gag reflexes. The client receives medications before the procedure—usually atropine to dry secretions and a sedative or narcotic to depress the vagus nerve. This consideration is important because if the vagus nerve is stimulated during the bronchoscopy, hypotension, bradycardia, or arrhythmias may occur. Other potential complications include bronchospasm or laryngospasm secondary to edema, hypoxemia, bleeding, perforation, aspiration, cardiac arrhythmias. > Stages of shock and symptoms compensation stage is the first stage of shock, during which several physiologic mechanisms attempt to stabilize the spiraling consequences. If these mechanisms are successful, homeostatic stability may be achieved. Compensatory mechanisms include the release of catecholamines, activation of the renin–angiotensin–aldosterone system, and production of antidiuretic and corticosteroid hormones Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system To compensate in shock, the sympathetic nervous system releases endogenous catecholamines, epinephrine and norepinephrine, into the circulation. Epinephrine and norepinephrine increase heart rate and myocardial contractility, which may be counterproductive in cardiogenic shock because it increases a demand for oxygen by an already compromised heart. The renin–angiotensin–aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished In response to low renal (kidney) blood perfusion, the juxtaglomerular cells release renin, an enzymatic hormone in the nephrons of the kidneys. Low blood volume also stimulates the pituitary to secrete antidiuretic hormone (ADH), also known as vasopressin, and adrenocorticotropic hormone (ACTH). ADH promotes reabsorption of water that the kidneys would ordinarily excrete. ACTH stimulates the adrenal glands to secrete corticosteroid hormones, which include glucocorticoids and mineralocorticoids. Glucocorticoids help the body respond to stress. Mineralocorticoids, such as aldosterone, conserve sodium and promote potassium excretion. Thus, they play an active role in controlling sodium and water balance. Both ADH and corticosteroid hormones promote fluid reabsorption and retention. The decompensation stage occurs as compensatory mechanisms fail. The client’s condition spirals into cellular hypoxia, coagulation defects, and cardiovascular changes. Hypoxia refers to decreased oxygen reaching the cells. Hypoxic cells are forced to switch from aerobic metabolism to anaerobic metabolism, a less efficient mechanism for meeting energy requirements. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis. adenosine triphosphate (ATP), the energy source for operating the sodium and potassium pumps, sodium and water enter the cell and potassium exits into the extracellular fluid Coagulation Defects As cells become damaged, an inflammatory response ensues. Platelets become sticky and accumulate in the blood vessels of the volume-depleted client, predisposing him or her to the formation of microemboli. Clots further compromise the ability of the red blood cells (RBCs) to deliver oxygen throughout the body. Cell and organ death are potentiated Cardiovascular Changes Impaired myocardial cells cannot maintain sufficient heart rate and force of contraction to circulate blood efficiently. Subsequently, brain cells in the medulla can no longer sustain the stimulus for vasoconstriction. The blood vessels dilate, blood pools in the periphery or leaks into the interstitium, cardiac output decreases, and BP falls. Clinical signs are more obvious and include bradycardia; hypotension; confusion; lethargy; decreased urine production; cold, pale skin; and reduced peristalsis. Aggressive interventions are necessary to prevent the irreversible stage of shock and ensure the client’s survival. The irreversible stage occurs when significant cells and organs become damaged. - The client’s condition reaches a “point of no return” despite treatment efforts. The client no longer responds to medical interventions. -Multiple systems begin to fail. -When the kidneys, heart, lungs, liver, and brain cease to function, death is imminent Signs and Symptoms The nurse monitors the client for evidence that blood volume or circulation is becoming compromised. Although shock can develop quickly, early signs and symptoms are evident during the decompensation stage. Critical assessments include vital signs, changes in mentation, skin, and urine output. Arterial Blood Pressure In shock, both systolic and diastolic arterial BPs fall because cardiac output decreases or the vascular bed increases due to vasodilation. Hypotension may be rapid and sudden or slow and insidious. A systolic BP of 90 to 100 mm Hg indicates impending shock, whereas 80 mm Hg or below indicates shock To determine the presence of shock, the client’s previous BP must be known. Regardless of the numeric figure, a significant and progressive fall in BP from baseline is serious. For example, a BP of 120/82 mm Hg usually is considered normal; however, if an individual with an original BP of 190/112 mm Hg has a BP of 120/82 mm Hg, shock is developing. The nurse must make the physician aware of any trends such as a significant fall below the client’s usual systolic BP or any trend in progressively decreasing BP Pulse pressure is the numeric difference between systolic and diastolic BP. If a client has a BP of 120/80 mm Hg, the pulse pressure is 40 mm Hg. A pulse pressure between 30- and 50-mm Hg is considered normal, with 40 mm Hg being a healthy average. In shock, the pulse pressure tends to narrow (decrease) as the falling systolic pressure nears the diastolic pressure. Respirations In shock, tissues receive less oxygen. In response, the body tries to obtain more oxygen by breathing faster. Rapid respirations help move blood in the large veins toward the heart. Respirations are shallow, and the client may be heard grunting. In early stages, the client is hungry for air, but in profound shock as death nears, the respiratory rate decreases. Temperature Heat-regulating mechanisms are depressed in shock, and added diaphoresis increases heat loss. With the possible exception of septic shock, subnormal body temperature is characteristic. Mentation Altered cerebral function often is the first sign of inadequate oxygen delivery to the tissues. Mild anxiety, increasing restlessness, agitation, and confusion can accompany shock. As the condition deteriorates, the client becomes listless and stuporous, ultimately losing consciousness. Skin In all but the early stages of septic and neurogenic shock, the skin is cold and clammy. As peripheral blood vessels constrict to direct blood from the skin to more vital organs (heart, kidneys, brain), the skin becomes pale. Eventually, the skin may appear mottled (i.e., a mix of pale and cyanotic areas lacking any uniform color). Capillary filling longer than 3 seconds and cyanosis, especially of the nail beds, lips, and earlobes, indicate oxygen deficiency. In clients with highly pigmented skin (such as African Americans), cyanosis is more accurately detected by inspecting the conjunctiva and oral mucous membranes. Urine Output Reduced cardiac output decreases renal blood flow, which leads to decreased urine output. Vasoconstriction, the physiologic response to shock, also contributes to markedly reduced renal blood flow. In many instances, the rate of urine formation is an important indicator of the status of a client in shock. When shock is quickly reversed, urine output usually returns to normal. Continued oliguria (decreased urine formation) indicates renal damage caused by reduced blood flow to the kidneys. Arterial Blood Gas Measurements Arterial blood gas (ABG) specimens are drawn from a direct arterial puncture or an indwelling arterial cathete. In shock, the partial pressure of oxygen in arterial blood (PaO2; normally 80 to 100 mm Hg) falls below 60 mm Hg. The partial pressure of CO2 in arterial blood (PaCO2) may be normal, decreased with hyperventilation, or increased with hypoventilation. A pulse oximeter, sometimes used to monitor oxygenation continuously, measures the amount of oxygen bound to hemoglobin, or the saturated oxygen (SpO 2) level, which normally is 95% to 100%. If the SpO2 level is above 90%, it can be assumed that the PaO2 is 60 mm Hg or above. Central Venous Pressure Central venous pressure (CVP) is the pressure of the blood in the right atrium or venae cavae. It distinguishes relationships among hemodynamic variables in shock: venous return, quality of right ventricular function, and vascular tone. CVP measurements, especially trends in readings, are useful in the management of a client in shock. Normal CVP is 2 to 7 mm Hg or 4 to 10 cm H2O, depending on how it is measured. In hypovolemic shock, the CVP is lower than normal owing to a low blood volume; in cardiogenic shock, it usually is above normal because there is venous congestion due to low cardiac output. The trend in CVP measurements is more helpful than isolated readings. Pulmonary Artery Pressure Although CVP measurements can indicate the status of right ventricular function, they do not provide information about left ventricular function. Because left ventricular function is more pertinent to circulation than right, knowing fluid pressures on the left side of the heart is more meaningful Drugs with beta-adrenergic activity that increase heart rate and improve the force of heart contraction are: positive inotropic agents (inotropic means affecting the force of muscular contraction). Digoxin (Lanoxin), isoproterenol (Isuprel), dobutamine (Dobutrex), milrinone (Primacor), and amrinone (Inocor) are examples.