Comprehensive Nursing and Medical Concepts for Patient Care

Purpose of delegation

Improve efficiency and ensure safe patient care

Delegation for LPNs

Stable assessments (not initial assessment), NO IVs, hanging antibiotics, or giving blood

5 Rights of deligation

Right task, right circumstance, right person, right communication, right supervision

Manifestation of dehydration

Dry Mucus Membranes,decreased urine, tachycardia, hypotension

Leads to Hypovolima

Interpreting Lab Values- Dehydration

Urine Specific Gravity (USG): under 1.020, BUN-to-Creatinine exceeding 20:1, Hematocrit/Hemoglobin: Elevated Serum Potassium: Can be variable; often high

Hypotonic IV Solutions- Uses

Lower osmolarity than the blood

Causes water to move from the extracellular space → intracellular space

Hypotonic IV Solutions- Types

45% NS

Hypotonic IV Solutions- Risk

Cell swelling + rupture

Measuring Fluid Balances

Calculating the difference between total fluid intake and total output over 24 hours + Daily Checks

MC- IV Intake

24-hour fluid balance and maintaining proper hydration or fluid restriction. Intake includes all fluids put into the body: IV fluids, IV medications, IV flushes, and blood products.

TPN-Complications

There is a high risk of infection so strict aseptic technique should be used

Phlebitis- Signs

Inflammation of a vein

Presents as redness above IV site and flushing is painful

Infiltration- Signs

Definition:When IV fluid flows into surrounding tissues

Presents as edema in affected extremity, very painful

Stop the infusion, remove the IV, elevate the extremity

Hemolytic Transfusion Reaction- Signs & Symptoms

Lower back pain

Hypotension

Tachycardia

Tachypnea

Febrile RXN

Fever and chills

Tachycardia

Anxiety (feeling of impending doom)

Allergic RXN

SOB

Hives

Flushing

Bronchospasm

Blood Transfusion- Nursing Action

Verify patient ID

Check doctor's order,

Verify info on blood bag and verify with another nurses (2 nurses should verify)

Get baseline VS before administration

Administer with NS and microaggregate filter within 30 minutes, transfuse over 1-4 hours

Never add meds to a blood product

VS Before

Transfusion Reaction-Monitoring

RN interventions for transfusion reactions: Most reactions occur within 15 mins

Stop transfusion and notify doctor

Treat symptoms (O2, fluids, epinephrine (EPI))

VS q15min

Transfusion Reaction

Stop infusion

Infuse saline

Call provider

Severe Hyponatremia- Manifestations "SALT LOSS"

Seizures & Stupor (decrease in consciousness → confusion)

Abdominal cramping

Lethargic

Tendon reflexes diminished, trouble concentrating

Loss of urine & appetite

Orthostatic hypotension, overactive bowel sounds

Shallow respirations (happens late due to skeletal muscle weakness)

Spasms of muscles

Hyperkalemia- MURDER

Muscle weakness

Urine output little or none (renal failure)

Respiratory failure (due to muscle weakness)

Decreased cardiac contractility (weak pulse/low HR)

Early: muscle twitches/cramps

Rhythm changes: Tall peaked T waves

Hyperkalemia- Nursing Action

Administer insulin or calcium gluconate, monitor cardiac rhythm

Hypokalemia- Treatment

Administer potassium supplements, Dietary Changes: Increasing consumption of potassium-rich foods

Hypokalemia-"7 Lows"

Lethargic

Low, shallow respirations

Lethal cardiac dysrhythmias

Lots of urine (polyuria)

Leg cramps

Limp muscles

Low BP & heart rate

Hypocalcemia- "CRAMPS"

Convulsions

Reflexes hyperactive

Arrhythmias (prolonged QT interval)

Muscles spasms in calves or feet (tetany)

Positive signs

Trousseau

Chvostek's

Sensation of tingling and numbness (paresthesia)

Fingers/toes

Mechanical Restraints- Uses

Only used when someone is at risk for hurting themselves or someone else

Use the least-restrictive method first

Check the restraint on affected appendage(s) every 15 minutes

Check for adequate circulation

Make sure two fingers can fit through

Make sure it is quick release knot!

PHYSICIAN ORDER ONLY

Managing Confusion- Patient Safety

Provide reorientation, ensure safety, reduce stimuli

Delirium- Manifestations

Acute onset comes and goes (medical emergency)

Dementia-Nursing Care

Prevent falls

Provide a safe environment

Balance stimulation w/rest

Assisting with daily routine

Reducing stress

Reassuring and redirecting

Infection-Manifestiations in the older adults

Confusion, weakness, may lack fever

Delirium- Precipitating Factors (Causes)

UTI,Infection, medications, dehydration

Parkinson's Disease- Manifestations

blank face, postural hypotension, classic triad → tremor, rigidity, bradykinesia

Seizures- Nursing Action

1.Lower the client to the floor and protect the head by padding something soft 2.Remain with the client and call for help 3.Put them on side-lying position (lateral) 4.OXYGENATE and SUCTION TO PREVENT ASPIRATION 5.Clear the area 6.Loosen tight clothing 7.Document the seizure

Hemorrhagic Stroke-FAST

Face: droopy

Arms: one arm drifts downwards

Speech: slurred/strange

Time: call 911 immediately

Stroke/Dysphagia- Aspiration Precaution

Monitoring swallowing and food intake, Thicken their liquids, Have the patient in high fowlers, Advise them to tuck their chin when swallowing, Have suction equipment nearby

Stroke- Priority Intervention

ABCS, rapid neuro assessment, IV access, prepare for CT scan

Ischemic Stroke- Treatment

TPA with plavix within a certain time frame

Transient Ischemic Attack

temporary blockage of blood flow to the brain causing sudden, temporary stroke-like symptoms (weakness, confusion, vision loss) Causes: Atherosclerosis, heart attack, abnormal heart rhythms, sharp drop in blood pressure

Nutropenic Precautions

Avoid infection exposure, no fresh flowers, good hygiene

Acute Kidney Injury- Lab Values

Increased creatinine

Elevated BUN

Reduced GFR

Electrolyte imbalances for AKI:

Hyperkalemia

Hyperphosphatemia

Hypocalcemia

Often see metabolic acidosis (slide 41 for more details)

Concerning Serum Creatinine Levels

Over 1.3 mg/dL

Concerning Urine output

less than 30 ml/hr urine output REPORT

End Stage Renal Disease (ESRD)- Diet

strict management of protein, sodium, potassium, phosphorus, and fluid intake

Chronic Kidney Disease (CKD)- Arterial Blood Gas

Metabolic Acidosis Low PH + Low HCO3, Compensation: Respiratory compensation lowers 𝑝𝐶𝑂2 (typically <35mmHg).

Anemia

Related to lack of erythropoietin (EPO)

Continuous Ambulatory Peritoneal Dialysis (CAPD)- Benefits

greater independence, flexibility, and improved quality of life compared to hemodialysis.

Hemodialysis- Common Complications

low blood pressure (hypotension), muscle cramps, nausea, vomiting, itching, and fatigue

Peritonitis- Signs & Symptoms

sudden, severe abdominal pain, high fever, rigid/tender bloating, and nausea/vomiting

Urinary Tract Infection

Infection anywhere in the urinary tract, usually caused by e.coli,There can be UPPER (ex. pyelonephritis) and LOWER UTIs

UTI S/sx

Dysuria, Cloudy colored urine, Foul odor, In older pts → CONFUSION, Flank pain, Hematuria, Abdominal pain

S/S of upper UTIs

fever, chills, flank pain, systemic manifestations

S/S of lower UTI

urinary frequency, urgency, dysuria, nocturia, confusion in older patients, can lead to upper UTI,no systemic manifestations

Indwelling Urinary Catheter Care

Encourage fluids, Maintain proper hygiene, Prevent fecal contamination, Maintain sterility, clean every shift, Make sure there is no tension, obstruction, or clogs in the catheter, Keep collection container BELOW level of bladder

COPD Diet

Key strategies include eating 4-6 smaller, high-protein meals daily to prevent fatigue, prioritizing complex carbohydrates for sustained energy, and maintaining hydration to thin mucus

Respiratory -Opposite: Opposite PH and PCO2

Metabolic-Equal

Increased PH and decreased HCo3 vice versa

pH =(7.35-7.45)

PCO2

(35 - 45 mmHg )

HCO3

(22 - 26 mEq/L)

Hypoxia- Manifestations

Decreased oxygen in the tissues, Early signs: Restlessness, Irritability and anxiousness. Late signs: Change in LOC, Cyanosis

Hypoxemia

Decreased oxygenation in the blood, ABGs are used to diagnose this Early signs: Mental status changes, Restlessness, Agitation, Confusion

COPD- Manifestations

Coughing, Wheezing, SOB, Clubbing of fingers, Low o2 sat, Barrel chest, Tripod breathing

Chronic Bronchitis- Prevention

quitting smoking, avoiding lung irritants, and using medications like bronchodilators to manage symptoms

Secretion Management

involves techniques to clear excessive or thick mucus from the airways,

Respiratory Patterns

Kusmal's Breathing=deep, rapid, and labored breathing pattern

Cheyne-Stokes Breathing

a severe, abnormal breathing pattern characterized by a cyclical crescendo-decrescendo (waxing and waning) in tidal

Biot's

a dangerous, highly irregular breathing pattern characterized by groups of rapid, shallow breaths followed by irregular periods of apnea (pauses)

Stomatitis- Diet

Avoid acidic, spicy, dry or hot beverages,Bland foods

GERD- Management

Elevate head of bed, avoid trigger foods (Avoid fatty, fried, and spicy foods, citrus and caffeine) , 5 smaller meals, Avoid eating right before bedtime, Quit smoking and reduce alcohol intake

Peptic Ulcer Disease- Risk Factors

NSAIDs, H. pylori infection

Obstructive Sleep Apnea

Weight loss improves symptoms

Low-Potassium Diet

(apples, berries, white rice, green beans).

High-Potassium Foods

fruits (bananas, oranges, cantaloupe), vegetables (potatoes, spinach, tomatoes), legumes, nuts, and dairy products.

Fat Emboli Syndrome- Manifestations

Respiratory issues (dyspnea, tachypnea and hypoxemia) often first signs- Neurological changes, Petechiae (Tachycardia + Fever )

Osteomyelitis- Treatment

Long term IV antibiotics, Surgical intervention i.e. debridement,Sterile dressing changes

Neurovascular Assessment

6P's-Pain,Pallor,Pulselessness,Paralysis,Pressure,Paresthesia + poikilothermia, Mobility Assessment to detect early signs of compartment syndrome or vascular damage, Q1 after surgery.

Acute Compartment Syndrome- Manifestations

6P-Pain,Pallor,Pulselessness,Paralysis,Pressure,Paresthesia + poikilothermia

Osteoarthritis -Signs

Heberden's + Burchards nodes, Joint Pain

Fracture- Warning Signs (Patient Education)

severe pain that worsens with movement or pressure, immediate swelling, bruising, and tenderness around the injury

Hypoglycemia- Signs

Loss of Loc~Coma,Cold, clammy, pallor, Diaphoresis, Irritability, Confusion, Shakiness, Blurred vision

Diabetes Ketoacidosis (DKA)- Patient Teaching

Autoimmune disease 3 PS,Polydipsia: thirsty, Polyphagia: hungry, Polyuria: lots of urine output, Fatigue, Weight loss, DKA

Type 1 Diabetes- Manifestations

Hyperglycemia

Polydipsia

Polyuria

Polyphagia

Weight loss

Fatigue

DKA

Diabetes- Preventing Complications

Keep glucose levels within range

Diabetic Foot Care

Inspect Feet, Warm water, Lotion, Noting in between toes, buy shoes later in the day

Heart Failure- Manifestations

shortness of breath (especially with activity or lying down), fatigue, rapid/irregular heartbeat, and swelling (edema) in the legs, ankles, or abdomen

Left Sided Heart Failure: More pulmonary symptoms

Fatigue, Confusion, Dizziness, Sob, Oliguria, Crackles, Pulmonary congestion, Pink frothy sputum

Right Sided Heart Failure

More fluid overload symptoms , Jugular venous distention (JVD), Hepatomegaly, Ascites, Edema , Weight gain, Polyuria

Troponin

found in myocardium, gold standard, Protein released into the bloodstream when the heart muscle is damaged, Trustworthy for detecting an MI and can stay elevated for 2 weeks, can be detected within hours

MCAS-mcg->mg

divide by 1000

Myocardial Infarction- Intervention

MONA (morphine, o2, nitrates and aspirin), Clopidogrel, Thrombolytics, Antihypertensive agents, Statins

Myocardial Infarction- Manifestations

-SOB

Tightness in chest

Diaphoresis

Dizziness

N/V

Fatigue

Pain radiating from jaw, shoulder, and back

Normal Sinus Rhythm

What we want normal heart beat

P wave

Atrial Depolarization/ Contraction

T wave

Ventricular Repolarization/ Relaxing

Neutropenic Precaution

Indication: ANC < 1,000

Precautions: hand hygiene, private room (limit visitors), no fresh flowers or plants, daily hygiene and oral care, no raw/undercooked foods, patient wears a mask outside of room

Report S/S of infection → this patient is severely immunocompromised

Cancer-CBC (Bone Marrow Suppression)

see this effect on a CBC 7 - 10 days after treatment

Cancer-CBC (RBC)

overall production is decreased causing anemia (usually 3 to 4 months after therapy starts) → monitor HCT and HGB → EPO may be prescribed, patient will be fatigued

Cancer-CBC (WBC)

decreased, specifically neutrophils causing neutropenia → ANC < 1,000, severe is <500

Cancer-CBC (Platelets)

less than 20,000 (normal is 150,000 - 450,000) is very severe, risk for bleeding due to thrombocytopenia

→ Expected due to bone marrow suppression

Chemotherapy- Adverse Effects

Myelosuppression (bone marrow suppression)

Gastrointestinal effects

Nausea, vomiting

Mouth sores

Diarrhea or constipation, ↓ appetite

Alopecia & skin changes

Hair loss, dry skin, nail changes

Infection risk

Fever ≥100.4°F is an emergency

Fatigue

Very common, often related to anemia

Organ toxicities (drug-specific)

Neurologic effects

Peripheral neuropathy (tingling, numbness)

Brain fog/ "chemo brain"

Reproductive effects

Infertility, menstrual changes

Palliative Care-Purpose

relieving symptoms of a disease with treatments not intended to cure the disease itself

-intended to make the patient feel better

-Purpose: relief and increase quality of life

NOT to cure

3Ps

,Polydipsia: thirsty, Polyphagia: hungry, Polyuria: lots of urine output