med-surg/OB exam 2

what are common risk factors for electrolyte imbalances

elderly pts, pts on diuretic therapy, pts with kidney disease, dehydration and GI fluid losses

what are common manifestations of electrolyte imbalances

decreased respiratory muscle function (HYPOkalemia), changes in cardiac function, changes in neurologic function, changes in GI motility and decreased skeletal muscle function.

common interventions for electrolyte imbalances

address cause of imbalance, monitor level of consciousness, daily weight, testing of skin turgor, intake and output levels, monitor cardiac status, fall risk safety, monitor intestinal (GI) status, monitor LAB values, admin proper medications, and educate patient

treatment of hyponatremia

PUT PT ON SEIZURE PRECAUTIONS

increase sodium intake SLOWLY, restrict free water (if by overdilution) & only in SEVERE cases admin 3% saline.

• if caused by fluid volume excess, admin diuretics to increase water excretion while maintaining sodium.

• if caused by excess diuretics causing sodium loss → decrease diuretic dose

treatment of HYPERNATREMIA

provide IV fluids if imbalance is caused by fluid loss, limit sodium intake and/or increase fluid intake. Teach pt to read food labels carefully and use salt substitutes

pt education → HIGH sodium foods

table salt, bouillon cibes/soups, soy sauce, cheese, cattage cheese, ice cream, carrots, dried fruit, canned foods, snack foods/pretzels, pickled foods, spinach, lunch meats, bacon, salami, dried cereals, graham crackers, popcorn, potato chips, ketchup, salad dressing

treatment/plan of care for HYPOKALEMIA

ask about medications (diuretics, digoxin), PUT THEM ON CARDIAC MONITORING!!!,

• if mild - treat with oral potassium supplements (give with food or dilute with juice),

• if severe, give IV replacement at max of 20 mEq/hr → is vessicant/tissue irritant and monitor respiratory status throughout infusion.

treatment/plan of care for HYPERkalemia

avoid salt substitutes (bc they are potassium salts), eat low potassium foods, use K+ wasting diuretics (loop, thiazide), give IV insulin to bring K+ into cell (along with D5W to not cause hypoglycemia), and put on CARDIAC MONITORING

pt education for foods high in POTASSIUM

apricots, avocado, bananas, melons, kiwi, dates/figs, oranges, beans, potatoes, squash, tomatoes, sweet potato, beets, yogurt, carrot juice, milk, cantaloupe and/or orange juice

treatment/plan of care for HYPOcalcemia

drug therapy → can give IV calcium replacement (CAN BE GIVEN QUICKLY), can be given orally (not at same time as other meds or they will decrease absorption), change to HIGH Ca2+ diet.

• put pt on injury prevention if chronic hpocalcemia

• put pt on CARDIAC MONITOR

• monitor for numbness, tingling and tetany for neuromuscular changes

treatment/plan of care for HYPERcalcemia

stop meds that contain/increase calcium levels, encourage fluis for renal excretion of calcium, give pts diuretics (like furosemide excretes calcium)

• put pt on CARDIAC MONITORING

• monitor neuromuscular changes → severe weakness and DECREASED DTR’s (deep tendon reflexes)

pt education for high calcium foods

cheese, yogurt, milk, sardines, dark leafy greens, fortified orange juice, soybeans, tofu, salmon, enriched breads and grains

causes of fluid volume deficit dehydration (FVD dehydrat)

hemorrhage, vomiting, diarrhea, fluid leakage (fistula), ileostomy, burns, severe. wounds, NPO (bc decreased fluid intake), diuretic therapy, GI suction, diabetes insipidus (dry inside bc too much fluid excreted), difficulty swallowing (bc decreased intake) and fever (bc increased excretion through sweat)

causes of fluid volume excess FLUID OVERLOAD

IV fluids (given too much or too fast), blood transfusion, kidney failure causing failure to excrete fluids, heart failure, obstructed lymph system, long-term corticosteroid therapy, & syndrome of inappropriate antidiuretic hormone (SIADH) → too much fluid overload bc not diureesing

weight changes r/t fluid volume deficit

weight loss - track daily weights (can delegate to CNA)!

weight changes r/t fluid volume excess

weight gain - track daily weights (can delegate to CNA!)

cardiovacular findings r/t fluid volume deficit

tachycardia, weak pulses, hypotension (esp orthostatic) → dizziness, neck and hand veins flat (aka not full)

cardiovascular findings r/t fluid volume excess

tachycardia, bounding pulses, elevated BP, pulse pressure decreased w/ central venous pressure elevated, veins are distended and engorged.

respiratory findings r/t fluid volume deficit

increased RR bc of a need for oxygen

• bc decreased blood vol = decreased 02 carrying capacity

respiratory findings r/t fluid volume excess

increased RR with shallow breaths, SOB and crackles in lungs

• bc of pulmonary edema

skin findings r/t fluid volume deficit

poor turgor with tenting. Mucous membranes are dry and cracked

skin findings r/t fluid volume excess

pitting edema and skin that is pale and cool to touch

• bc of HF (R side)

neurological findings r/t fluid volume deficit

confusion

neurological findings r/t fluid volume excess

altered LOC, headahce, visual changes and muscle weakness

kidney findings r/t fluid volume deficit

urine specific gravity > 1.030 (DEHYDRAT) that is dark in color, output below 500 ml/day

organ changes findings r/t fluid volume excess

GI = increased motility

liver = enlarged

kidney/urine = specific gravity depends (isn’t always low/1.005) and output changes

lab values seen in fluid volume deficit —> general trend

Hgb = elevated, bc hemoconcentration (less fluid plasma)

Hct, serum osmolality, glucose, protein, BUN, electrolytes) all ELEVATED bc HEMOCONCENTRATION

lab values sseen in fluid volume excess —> general trend

hgb = decreased, bc hemodilution

hct, serum osmolality, glucose, protein, BUN and electrolytes all DECREASED bc HEMODILUTION due to excess fluid

treatment/pt goal for fluid volume deficit

prevent further fluid loss, return fluid volume to normal and prevent complications from fluid volume deficit —> PRIORITY IS PATIENT SAFETY

• fluid replacement - oral fluids q2H, IV fluid admin, do not withhold fluid bc of incontinence (pt belief)

• meds = antidiarrheals (decrease diarrhea if cause), antiemetic (decrease vomiting if the cause), antipyretics (decrease fever to decrease sweating)

• monitor VS, I&Os and daily weights

are fluid volume deficit or fluid volume excess patients at a higher fall risk

fluid volume deficit, because they are low blood pressure/dizzy

isotonic IV fluids

0.9% NS, LRs, D5W

hypotonic IV fluids

0.45% NS, 0.33% NaCl, 0.2% NaCl, 2.5% dextrose in water

Hypertonic IV fluids

3% normal saline, D10W, D5LR, D51/2NS, D5NS

goal of fluid volume excess treatment

restore normal fluid balance, prevent complications of FVE and prevent future fluid overload

critical rescue for fluid volume excess

pulmonary edema can progress very quickly and lead to death

• pts at high risk = elderly, or pts with cardiac, kidney, pulmonary or liver problems

priority of fluid volume excess treatment and what to monitor

patient safety!

• monitor I&Os, VS, lung sounds (PULM EDEMA)

• too much trtmt can cause fluid volume deficit and electrolyte imbalance → DON’T OVERCORRECT

• monitor SpO2, admin O2 if needed

• assess skin → looking for brkdwn r/t edema overstretch of skin

drug therapy for fluid volume excess

key med = loop diuretics → FUROSEMIDE !!!

• increases urine output → so monitor I&Os, potassium and sodium levels and ECG CHANGES (r/t K+ levels)

Nutrition therapy and fluid restrictions (and how to monitor it)

restrict water and sodium (to 2-4 g/day)

• monitor WEIGHT:

  • call HCP if gain more than 3 pounds/week or 2 pounds in 24 hours

how would a nurse evaluate if the patient was no longer experiencing a fluid volume deficit?

an increase in BP, stable electrolyte levels, and INCREASE in UO, better skin turgor & moist mucous membranes help show pt is hydrated

what findings would be seen if the patient experienced an adverse affect from treatment of fluid volume defecit

crackles in lungs, pitting edema = fluid volume overload

how owuld the nurse evaluate if the aptient was no longer experiencing a fluid volume excess

decreased BP, decreased weight, lung sounds clear, decreased SOB, decreased edema

short peripheral catheter for IV therapy - and how long do they last

usually inserted into superficial veins of forearm

• for SHORT TERM USE, <6 days

midline catheter for IV therapy - and how long do they last

usually inserted into median anticubital vein in upper arm, intendned for vascular access >6 days long

what catheter/device category has no limitations on pH or osmolarity of infusate

port, tunneled central catheter, IJ central line

• all types of CENTRAL VASCULAR ACCESS DEVICES (CVADs)

non-tunneled CVADs (and when are they used)

inserted by provider, usually into subclavian vein in upper chest or jugular veins in neck or femoral vein.

• IT IS USUALLY INSERTED IN EMERGENT SITUATIONS ONLY

Tunneled CVAD (and why are they used)

surgically inserted by provider, portion of catheter lies is SubQ tunnel to prevent infection.

• they are intended for frequent, long-term infusion therapy (months to years)

PICC line → peripherally inserted central catheter (indications for it and timing)

indications include lengthy course of antibiotics, chemotherapy agents, parenteral nutrition, vasopressors (BC vessicants!)

• intended for months of vascular access or when peripheral site is not possible (used for vessicants or when vasculature is poor.

Implanted Port-a-cath (PORT) → info and timing

inserted into subclavian or jugular vein with access port in subQ pocket in chest/upper extremity

• intended for vascular access > 1 year

hemodialysis catheter info

used for dialysis ONLY, since they are very large lumens to accomodate the hemodialysis

• do not use them to admin other fluids/meds (except in emergency situations with clear guidance by provider)

complications of peripheral line IV therapy

all local complications - infiltration, extravasation, phlebitis, thrombosis or thrombophlebitis (inflammation of veins with clotting), ecchymosis and hematoma, site infection, venous spasm and nerve damage

complications from both peripheral line and central lines

fluid volume overload and catheter embolisms and common

complications of IV therapy through CENTRAL LINE

CLABSIs (central line associated blood stream infections), occlusion of line, catheter dislodgment (verify with chest xray)

prevention of peripheral VAD complications

select appropriate site and catheter size, monitor site frequently and FLUSH IT, educate patients about symptoms of complications, administer meds into appropriate sites at appropriate rates, adequately secure catheter, use aseptic technique for insertion and rotate sites as needed

treatment of peripheral VAD complications

remove catheter for all complications

• redness/inflammation = apply cool compress

• swollen = elevate limb

• cool to touch = warm compress to stimulate blood flow

• extravasation = administer antidote

• bleeding = apply pressure

• infection = clean site and send catheter for culture if ordered

prevention of CLABSIs

hand hygiene, change tubing every 96 hours, daily CHG baths, sterile dressings (CHG impregnated) dressings, change dressing after first 24 hours, change dressing on scheduled basis

• always complete daily review of line necessity

• always scrub the hub!!!!!

how to prevent catheter dislodgment

secure catheter properly (adhesive - tegaderm, tape), educate patient to avoid physical exertion

treatment of CVAD catheter dislodgment

stop the infusion and alert provider for further instructions

prevention of CVAD catheter occlusion

flush before, between AND after each medication

• flush using positive pressure / push pause technique of flush

treatment of CVAD catheter occlusion

flush or can administer thrombotic enzymes - like TPA

TPN (total parenteral nutrition)

daily nutrients given in IV form if GI tract not functional

• given through CVAD

• can contain lipids, electrolytes, proteins and dextrose

what tonicity is TPN

highly HYPERTONIC

side effects and adverse events from TPN

fluid overload (bc hypertonic fluid consistently infused), electrolyte imbalence, infections, blood glucose imbalence

key concern for osteoporosis

fracture

key concerns for arthritis

pain, deformity, imparied mobility, psychosocial concerns (as it progresses)

key concerns for total joint arthroplasty

pain, venous thromboembolism (VTE), dislocation, infection

osteoporosis basics and pathophysiology

chronic disease characterized by bone loss, decreased bone density, and possible fracturing

• osteoclastic actvity > osteoblastic activity causes thin, fragile bones at risk for fracture

osteoclastic activity helps do what to bones

BREAK bones down

osteoblastic activity helps do what to bones

helps BUILD bones

osteoporosis physical assessment findings

can be asymptomatic, but commonly has back pain with lifting or bedning, commonly has fractures and kyphosis is very common (thoracic sprine hump)

risk factors for osteoporosis

older age (both genders and ALL races), parental history of osteoporosis, history of low-trauma (and low-intensity) fracture after age 50 → (like fracture after ground level fall), low body weight/thin build, chronic low Ca2+/Vit. D, estrogen/androgen deficiency, current smoking, high alcohol intake, lack of physical exercise/immobile patient

what test do you use to screen/diagnose osteoporosis

DXA scan → dual x=ray absorptiometry scan

pharmacologic treatment of osteoporosis

calcium and D3 supplements (helps promote bone health)

• Biophosphonates meds = slow bone resporption

  • ex = alendronate (Fosamaz) and ibandronate (Boniva)

osteoporosis interventions (and pt education)

fall risk in hospital and after discharge, emphasize fruits/veggies, low-fat dairy and protein sources, increased fiber and moderation in alcohol/caffeine intake.

• educate to increase daily sun exposure, ADHERENCE TO MEDICATION REGIMEN and encourage exercise.

osteoporosis pt education for PREVENTION

try to implement these chanes before age 30!!
-maintain adequate calcium and vit. D intake

• smoking cessation

• limit carbonated beverages to <40 oz/day

• practice weight bearing exercise OFTEN

definition of arthritis

rheumatic diseases that affect joints, tendons, ligaments, bones and muscles

osteoarthritis

progressive loss of bone and cartilage in one or more joints

• decreases water, chondroitin and cartilage between joints → narrowing of joint space and formation of bone spurs = JOINT PAIN

• secondary joint inflammation can occur when damage is severe

what condition is also know as degenerative joint disease (DJD)

osteoarthritis

rheumatoid arthritis info/pathophysiology

autoimmune, chronic and PROGRESSIVE SYSTEMIC inflammatory condition that primarily affects synovial joints

• autoimmune antibodies attack synovium and cartilage, fluid accumulates in joint and secondary osteoporosis occurs (after inflammation, it causes the thinning out of bone tissue

• other body systems affected

typical age of onset for osteoarthritis

above 65 years old

typical age of onset for rheumatoid arthritis

all ages, but commonly 35-45 years old

major risk factors for osteoarthritis

aging, obesity and trauma/occupation

which type of arthritis has a genetic component

both osteoporosis and rheumatoid arthritis

risk factors/causes of rheumatoid arthritis

autoimmune, emotion stressors (trigger exacerbation)

disease pattern of osteoarthritis

may affect only one joint, NOT SYSTEMIC
- affects weight bearing joints, spines and hands commonly

disease pattern for rheumatoid arthritis

bilateral, symmetric arthritis that affects upper extremities first. It destorys cartilage from inside out

physical assessment findings for osteoarthritis

crepitus with one or more joints affected

physical assessment findings for both osteoarthritis and rheumatoid arthritis

progressive join pain and stiffness and eventually joint deformity

physical assessment findings for rheumatoid arthritis

early S+S:

• non syspecif stemic symptoms like fever, fatigue, weakness

late S+S:

• fatigue, osteoporosis, kidney disease

lab findings for osteoarthritis

normal or slightly elevates ESR

rheumatoid arthritis lab findings

elevated rheumatoid factor, positive antinuclear antibody and elevated ESR

plan of care for arthritis

promote mobility, encourage self-management and address psychosocial concerns

what are interventions to promote mobility for pts with arthritis

OT & PT scheduled, use of mobility aids and encourage independence (giving time for breaks when fatigued)

what are interventions to encourage self management for pts with arthritis

participate in physical activity - don’t skip exercises on hard days, just modify them, and protect joints by adjusting habits of movements to make them easier on the body.

what are interventions to address psychosocial concerns for patients with arthritis

assess and discuss cocnerns of patient using therapeutic communication. Discuss goals for improving self esteem and emphasize the patients strengths.

• consult with mental health professionals/spiritual leaders

pharmacologic approach for pain r/t osteoarthritis

acetaminophen, topical lidocaine patches, NSAIDs only if tolderated

non-pharmacologic approach for pain r/t osteoarthritis

application of HEAT/COLD, weight loss is pt is obese, & complementary treatments

pharmacologic approach for pain r/t rheumatoid arthritis

NSAIDs (bc inflammation issue), disease modifying anti-rheumatic drugs (DMARDs) like biological response modifiers (immunosuppressants) and glucocorticoids.

non pharmacologic approach for pain r/t rheumatoid arthritis

application of COLD to red, inflamed joints —> NO RED(HOT) ON RED

application of heat to stiff joints

plasmapheresis (taking plasma, processing it to remove the bad immune antibodies that are autoimmune, and injecting back into patient

non pharmacologic basic methods for both types of arthritis

rest balanced with exercise, functional position of joints, proper posture and lifting along with physical therapy

surgical management for arthritis

total joint arthroplasty - only used when failure of conservative treatments that cause severe compromise of client’s functional ability and significant pain.