NSG 212 Exam 5

the nurse role in pre-test labs

-assess for test indications/contraindications

-provide pt and family education

the nurse role in intra-test labs

-use the correct equipment

-collect and label specimen and send to lab

-provide pt and family support

RBC normal value for men and women

men = 4.5 - 5.3 million

women = 4.1 - 5.1 million (slightly lower bc menopause)

increased RBC (polycythemia/erythrocytosis) causes

-at places of higher altitude

-after increased physical activity

-with COPD or congenital heart disease (treated by fixing the cause)

-polycythemia vera (treated by phlebotomy)

nursing interventions for polycythemia

increase hydration, encourage physical activity to prevent venous stasis

decreased RBC (anemia) causes

-loss of erythrocytes

-destruction of erythrocytes

-lack of needed elements for erythrocyte production

-bone marrow suppression

decreased RBC (anemia) treatment

treat the source of the problem

-stop the bleeding

-administer procrit as ordered (especially in chemo pts)

-transfuse RBC as ordered if hemoglobin and hematocrit are also low

nursing interventions for anemia (low RBC)

prevent further blood loss, transfuse as ordered

Hematocrit normal range for men and women

men = 37-49%

women = 36-46%

increased hematocrit causes

-decrease in plasma volume (burn pts lose a lot of plasma, so it falsely elevates hematocrit)

-if hydration status is normal, an elevated hematocrit is indicative of hypoxic state, increase muscle oxygen requirements, overactive bone marrow

nursing interventions for elevated hematocrit

prevent fluid loss, rehydrate

decreased hematocrit causes

-overhydration of the pt (increases plasma volume)

-a true decrease results from bone marrow dysfunction, blood loss, and lack of erythropoietin

nursing interventions for decreased hematocrit

-fluid restrictions

-if due to a true decrease, treat based on the source of the problem = stop the bleeding, administer procrit as ordered, transfuse RBC as ordered

hemoglobin normal range for men and women

men = 13-18

women = 12-16

increased hemoglobin cause

must be evaluated in relation to the number and size of RBC

decreased hemoglobin cause

all the conditions that cause decreased RBC and decreased HCT are likely to also cause decreased HGB

-blood loss, hemolysis, bone marrow suppression

decreased hemoglobin conditions

thalassemia major (anemia) = abnormalities in the synthesis of normal HGB

sickle cell anemia = abnormally shaped HGB which makes it less efficient at carrying O2

nursing interventions for decreased hemoglobin

-hydrate

-avoid high altitudes

-administer pain medications as ordered

-provide comfort measures

-if due to a true decrease, treat based on the source of the problem = stop the bleeding, administer procrit as ordered, transfuse RBC as ordered

normal WBC (leukocytes) range

4500-10500 (4.5-10.5)

leukopenia range

less than 2000 (critical)

-less than 500 may be fatal

leukocytosis range

greater than 30,000 (critical)

segmented/poly neutrophils differential %

50-62%

bands/stabs (young neutrophils) differential %

3-6%

eosinophils differential %

0-3%

basophils differential %

0-1%

lymphocytes differential %

25-40%

monocytes differential %

3-7%

increase in neutrophils and bands (neutrophilia) causes

body’s first defense against acute bacterial infection and severe stress

-appendicitis, osteomyelitis, septicemia, endocarditis, diabetic acidosis

-other causes = inflammation, necrosis, leukemia, blood transfusions, burns, and in babies delivered via c-section

decreased neutrophil count (neutropenia) causes

seen more frequently with viral illnesses, such as hepatitis, influenza, measles

-seen in newborns with sepsis

-pts receiving chemo, radiation, antibiotics, nafcillin, penicillin, and cephalosporins

-seen with collagen disease, such as lupus

-severe neutropenia = agranulocytosis which can lead to rapid sepsis

increased eosinophils (eosinophilia) causes

associated with antigen-antibody reactions

-most common is an allergic reaction

-seen in parasitic infections (roundworm)

-seen with skin disease (eczema, psoriasis)

-seen with neoplasms/cancers (lymphoma, metastases)

decreased eosinophils causes

result from increased levels of adrenal steroids which may occur due to corticosteroid therapy or stress response

increase in basophil count causes

leukemia, ulcerative colitis, chronic hypersensitivity states

decrease in basophil count causes

corticosteroids, infections, ovulation, pregnancy, stress

lymphocytes in adults vs. children

adults = second most common type of WBC second to neutrophils

children = most common type of WBC

increased lymphocytes (lymphocytosis) causes

-viral infections, such as mumps, hepatitis, mononucleosis

-tuberculosis

-chronic bacterial infections

-lymphocytic leukemia

decreased lymphocytes (lymphopenia) causes

HIV/AIDS, steroids, autoimmune diseases (lupus), severe malnutrition, organ failure, tuberculosis

monocytes

-act as phacotyes in some chronic inflammatory diseases

-conditions that cause increased monocytes tend to be chronic

increased monocytes (monocytosis) causes

TB, malaria, rocky mountain spotted fever, leukemia, chronic ulcerative colitis, collagen disease

platelet count ranges for adults

adults = 140-400 × 10³

-less than 20 × 10³ = spontaneous bleeding

increased platelets (thrombocytosis) causes

malignancies/cancers or splenectomy

nursing interventions for thrombocytosis

hydrate, prevent venous stasis, administer aspirin as ordered (decreases platelet stickiness)

decreased platelets (thrombocytopenia) causes

-ITP (unknown bruising)

-acute occurs commonly in children and has spontaneous remission

-chronic occurs in adults and appears to be related to autoimmune diseases like lupus

-common after viral illnesses and in pts with AIDS

-anemias, chemotherapy, radiation, overactive spleen, heparin, DIC, preeclampsia

nursing interventions for thrombocytopenia

-monitor VS

-monitor for petechiae

-protect pt from bleeding and bruising

-hold all invasive procedures

-provide clothing that prevents visualization of multiple bruises if there is a body image disturbance

international normalized ratio (INR) normal range

therapeutic = 2-3 (except for pts with mechanical heart valves)

-usually INR enters this range after 3-5 days taking coumadin

international normalized ratio (INR) normal range for a pt with a mechanical heart valve

2.5-3.5

PT and coumadin

-causes decrease in production of prothrombin by interfering with the use of Vit K in the liver

-elevated PT/INR can be treated with an injection of Vit K

-if elevation in PT/INR is not greater than 6 and no signs of bleeding, treatment may consists of stopping coumadin for a few days then restarting on a lower dose

nursing interventions for increased PT/INR

-monitor VS (increase HR, followed by decreased BP = bleeding)

-monitor labs and diet

-assess for abdominal pain, as this may indicate internal bleeding

-administer correct doses of meds as ordered

-monitor for a minimize blood loss (reduce suction, urine dipstick, hemoccult stool test, use electric razors, keep mucous membranes moist, fall precautions)

decreased PT/INR causes

thrombophlebitis, malignancies/cancers

-interventions should aimed at prevention of blood clots (exercise for the legs, hydration, prevent venous constriction)

hemoglobin A1c (HgbA1c) normal range

5-7%

blood urea nitrogen (BUN) normal range adults

5-20

high BUN (azotemia) causes

dehydration, GI bleed, burns, cancer, chronic renal disease, excessive protein intake (tube feeds)

-if dehydration is the cause, CR will NOT be elevated

low BUN causes

liver failure, malnutrition, overhydration, decreased protein intake

CR normal range men and women

men = 0.9-1.3

women = 0.6-1.1

-if both BUN and CR are elevated, indicated true renal dysfunction

glomerular filtration rate (GFR) normal range

greater than 90 and no kidney damage

GFR stages of renal failure

normal = greater than 90 and no kidney damage

stage 1 = greater than 90 and kidney damage

stage 2 = 60-89

stage 3a = 45-59

stage 3b = 30-44

stage 4 = 15-29

stage 5 = less than 15

albumin normal range

3.5-5

SLOW change in protein

pre-albumin normal range

16-35

ACUTE changes in protein levels

amylase normal range

25-125

-inflammation in parotids or pancreas can cause elevation

lipase normal range

10-140

-damage to pancreas can cause elevation

both amylase and lipase elevation causes

pancreatitis, pancreatic cancer, and some rare GI diseases

cardiac troponin use and normal range

useful in early detection of cardiac damage (right away)

normal = less than 0.12

cardiac enzyme changes with MI

onset of chest pain → time

-troponin = increases a lot and then decreases over 14 days

-creatine kinase = increases a little then decreases over 6 days

-lactate dehydrogenase = increases mildly and decreases over 14 days

B-type Natriuretic Peptide (BNP) normal range

less than 100

urine specific gravity normal range

1.015 - 1.025

IV catheter selection

16 G = trauma or rapid infusion

18 G = surgical pts or rapid blood administration

22-24 G = “normal” pts

selecting a vein for IV

-distal veins

-non dominant hand first

-site that is not painful or bruised

-IV site will not inferfere with activity

-a good vein is soft and bouncy

-if hair removal is needed, can use clippers to shave the site

veins to avoid for IV

-varicose veins

-veins in the inner wrist, over flexible parts, in lower extremities

-antecubital veins (except in emergencies)

-back of the hand

-sclerosed or hard

-in extremities with paralysis or lymphedema

-NO IV in arm after mastectomy

maintaining IV patency

-during continuous infusion DO NOT STOP or allow blood to flow back up; clots can form at the end of the catheter that may block the flow of fluid

-flush per facility policy, usually q8/12

-FLUSH BEFORE AND AFTER EACH MED, ONLY FLUSH WITH NS

-keep IV bag above the pt; if going to manipulate the IV, STOP the pump or CLAMP the tubing

-assess site and infusion rate EVERY HOUR

-change bags/tubing when a small amount is left (50-100 mL)

-IV bags are to be changed every 24 hours; tubing every 48-72 hours

-label all new tubing and solutions; REMEMBER TO CLAMP tubing prior to taking it down

-change IV site dressing when damp, soilet, or every 48-72 hours

-verify new IV solutions using 6 rights and 3 checks

s/sx. of infiltration

fluid escaped into the SQ tissue

s/sx = pain, burning, swelling at the site, pallor, coldness, decreased IV flow rate, damp dressing

s/sx. of phlebitis/thrombophlebitis

inflammation of a vein; thrombophlebitis means a blood clot is lodged in the vein

s/sx = edema, throbbing pain, burning, tenderness, redness, warm, mild edema above the area of insertion site, may have red line going up the arm, IV infusion will slow down

s/sx. of hematoma in IV

caused by an accumulation of clotted blood

s/sx = will look like a bruise

s/sx. of catheter embolus

catheter tip enters circulation

s/sx = SEVERE PAIN at the site of catheter dislodgement; catheter tip may be missing when DC’ing the IV; may have s/sx of pulmonary embolism

s/sx. of cellulitis

infection of the skin

s/sx = tenderness, warmth, pain, edema, red streaks, fever, chills, malaise

s/sx. of fluid overload in IV

too large a volume of fluid infused into circulation

s/sx = distended neck veins, increased BP, tachycardia, SOB, crackles in lungs, edema, additional findings varying with the IV solution

IV insertion for older adults

-use a BP cuff instead of tourniquet

-do not slap the extremetiy to visualize veins

-avoid rigourous friction while cleaning the site

central line lumen use: distal, proximal, medial

distal = largest lume, used for high volume or THICK fluids, can be used for CVP monitoring

proximal = used for blood sampling, administration of meds, and/or blood

medial = middle lumen, used for administration of TPN or meds

central venous access device

inserted into the jugular or subclavian vein by MD

-used often in both acute and home care settings

-provide a variety of IV fluids, meds, TPN, and blood

-can be used to monitor hemodynamic status

-can be used to withdraw blood

-placed by MD, after placement MUST verify with x-ray and have an order prior to use

central line care

-CVAD dressing change using STERILE TECHNIQUE

-changed 24 hours after insertion and then every 7 days

-DO NOT FLUSH WITH LESS THAN A 10cc SYRINGE (too much pressure)

-flush using a pulsating force (push, stop, push, stop)

-all lumens should flush easily

PICC (peripherally inserted central catheter)

-used 2-6 weeks, maybe longer

-IV AB, parenteral nutrition, chemo, fluid, blood, other meds

-NEED X-RAY to confirm placement; VERIFY ORDER TO USE PRIOR TO STARTING INFUSION

-1 to 2 lumens

-NO BP IN THAT ARM

-INSERTED BY SPECIFICALLY TRAINED RN

-FLUIDS FOR CVAD AND PICC = ALWAYS ON A PUMP

what gauge catheter is essential for maintaining the rapid rate necessary to give a fluid bolus to an adult

large (18 G or larger)

TPN

-administered via central or PICC line only

-highly concentrated hypertonic solution

-provides nutrition for wound healing

-helps with nutritional needs during bowel surgery

-highly caloric, HIGH in sugar, may contain fats (individualized to EACH PT needs)

TPN nursing care

-administer via PUMP, place FILTER on the tubing

-use STRICT ASEPSIS (HIGH risk for infection due to HIGH sugar content)

-NO meds compatible with TPN

-change tubing/container every 24 hours

-DO NOT use if the solution has an oily or “cracked” look to it

what to assess for with TPN

-hyper/hypoglycemia, weight loss and gain, total weight gain should not be more than 3 pounds per week, more than 1 pound per day can indicate fluid retention

-may be put on sliding scale insulin EVEN if not diabetic

-watch for s/sx of hypoglycemia if TPN is discontinued rapidly

-if administration is disrupted, have IV dextrose until the infusion is initiated againc

complications with TPN and how to discontinue

complications = infection, hyperglycemia, hypoglycemia, electrolyte imbalance

discontinuation = monitor for rebound hypoglycemia, wean of TPN to avoid rebound hypoglycemia, should make sure pt is able to eat 60% or MORE of their caloric requirements