2050 Exam 4

pH

reflects acid-base balance

measure of dissolved H+ in blood

acidosis

greater concentration of H+

lower pH

alkalosis

lower concentration of H+

higher pH

pH norms

7.35-7.45

PaCO2 norms

35-45

PaO2 norms

80-100

HCO3 norms

22-26

risk for alkalosis

PaCO2 <35

HCO3 > 26

risk for acidosis

PaCO2 >45

HCO3 <22

respiratory opposite

pH high, PCO2 low = alkalosis

pH low, PCO2 high = acidosis

metabolic equal

pH high, HCO3 high = alkalosis

pH low, HCO3 low = alkalosis

causes of resp acidosis

CNS depress, spinal cord injury, pulmonary disorders, functional disorders limiting rrs

s/s of resp acidosis

anxiety, confusion, lethargy, SOB, hypoventilation

tx for resp acidosis

O2, bronchodilators, corticosteroids

narcan if its an OD

causes of resp alkalosis

fear/anxiety, severe stress, pain, trauma/head injury, hypothyroidism

lungs excreting too much CO2

s/s of resp alkalosis

hyperventilation, lightheadedness, dizziness, confusion, tingling, tachycardia, dysrhythmias, decreased LOC

tx for resp alkalosis

anxiety reduction

breathing exercises

O2 therapy

focused on breathing regulation

causes of metabolic acidosis

DKA, diarrhea, sepsis, kidney failure

s/s of metabolic acidosis

kussmaul breathing, confusion, lethargy, HA, N/V

tx for metabolic acidosis

goal is to decrease excess acid

IV fluids, insulin (DKA), antidiarrheals, NaHCO3 (if bicarb low), dialysis for ESRF

causes of metabolic alkalosis

prolonged V, gastric sxn, K+ depletion (diuretics), excess use of antacids

too much expelling of acid

s/s of metabolic alkalosis

muscle spasms, lethargy, numbness, tachycardia

tx for metabolic alkaosis

reverse underlying cause

GI: antiemetics, IV fluids, electrolyte replacement

discontinue K+ wasting med

resp acidosis compensation

kidneys increase HCO3 slow

resp alkalosis compensation

kindeys lower HCO3 slow

metabolic acidosis compensation

lungs decrease CO2 fast

metabolic alkalosis compensation

lungs increase CO2 fast

uncompensated

pH is off plus one other valve is off

partially compensated

pH is off plus both CO2 and HCO3

fully compensated

pH is normal, both CO2 and HCO3 are off

factors affecting bowel elimination

age, diet, fluid intake, physical activity, psychological factors, personal habits, position, pain, pregnancy, surgery, anesthesia, meds, diagnostic tests

s/s constipation

less than 3 bowel movts a week, hard/lumpy stool, difficult to pass

causes of constipation

age, pregnancy, lack of fiber, med, GI disorders

when to seek med attention for constipation

fever, GI bleed, abd pain, vomiting, low back pain, wt loss

tx for consitpation

push fluids, enema, laxatives, increase fiber, bowel training, don’t ignore urge to defecate

impaction

can be due to impaction

oozing liquid stool with hx of constipation and complaints of abd fullness

obstruction

can occur in severe cases, may require surgery

s/s of impaction

unable to pass stool even with urge to defecate

nursing role in impaction

watch for bradycardia when performing disimpaction

tx for impaction

mineral oil, disimpaction

s/s of diarrhea

frequent, loose, watery stool throughout the day, dehydration and malabsorption

acute: 1-2 days

persistent: 2-4 weeks

contributing factors to diarrhea

prolonged emotional distress, hx of ibs, consuming large amounts of dairy, axb

med follow up for diarrhea

fever

BRAT diet

bananas, rice, apples, toast

urge defecation incontinence

need to defecate, but unable to reach the toilet in time

passive defecation incontinence

most common, need to defecate but unable to reach the toilet in time

causes of defecation incontinence

nerve damage, weak pelvic floor muscle, decreased physical mobility, lack of privacy, meds

complications of defecation incontinence

skin irritation, poor self esteem

c. diff

antibiotics or exposure to health care workers not washing their hands

melena

black tarry stool

FOBT

no red meat 3 days prior = false positive

no NSAIDS 7 days prior = false positive

no vitamin C and citrus fruits 3 days prior = false negative

stool culture

don’t mix with urine or water

looking for bact, viruses, parasites, hidden blood inflammation, digestive issues

sigmoidoscopy

persistent stomach pain

bleeding from rectum

changes in stool habits

first sign of colon cancer

weight loss that isn’t intended

polyps

sigmoidoscopy, even if they are benign, they are pre-cancerous

advantages to sigmoidoscopy

shorter prep time, easier and faster, doesn’t require anesthesia, lower risk of damage to rectum or colon

colonoscopy

scope that allows them to see entire colon

diagnose: IBS, polyps, tumors, diverticulitis, bleeds

3 days prior prep for colonoscopy

no high fiber food and fiber supplements

can leave residue and prohibit visualization of bowel

1 day prior prep for colonoscopy

clear liquid diet

no red or purple liquids

no dairy or OJ = leaves residue

no alcohol = impacts anesthesia

bowel prep for colonoscopy

follow guidelines depending on type or prep prescribed

avoid NSAIDs or supplements

side effects of GoLytely Fluid

refrigerate, suck on ice or lemon, chew gum, drink through straw

tap water enemas

hypotonic, osmotic pressure lower than interstitial fluid

worry about water toxicity and circulation overload

normal saline enema

isotonic

volume helps it work

sodium phosphate enema

hypertonic, low volume

contraindication: dehydration or young infants

soap suds

add to tap water

irritant which causes peristalsis

use in caution with pregnant women and older adults cause of electrolyte imbalances and damage to mucosal lining

high, hot, and a heck of a lot

high large volume

height and pressure

pt turn left, dorsal, right

fluid to large intestine

oil retention

lubricates feces; retain several hours

carminative enema

small volume

used if pt is complaining of gas

meds for enemas

kayexalate and neomycin

ostomy

empty when 1/3 to ½ full

change pouching system every 3-7 days

assess stoma

diet for ostomy

fiber and fluid, small meals when starting out

drink 8 oz of water every time you empty ostomy

ileostomy

temporary

created at end of small intestine

allows colon to heal

stool is thin or pasty

always assess for herniation

colostomy

temporary or permanent

stool is soft

taking colon and pulling it through opening

ascending colostomy

stool is watery

very rare

transverse colostomy

loop, single barrel, double barrel

stool is soft, not as watery

across top of colon

loop colostomy

two openings in one stoma

one opening excretes stool, the other excretes mucus

colon stays connected to rectum, pt may still pass gas

single barrel colostomy

colon below ostomy is removed

permanent

double barrel

divides colon into two ends with two separate stomas

stool exits from one, mucus exits from other

descending colostomy

stool is very formed

J pouch

a pouch is formed within ileum

reservoir is connected to anus after removal of colon and rectum

stool passes like a normal bowel movement

kock pouch

formed using ileum, emptied with catheter

pt chooses when to empty

bowel training: cognitive decline

dementia or alzheimer’s

high fiber diet

increase fluids

follow routine timing of toileting

positioning

privacy and enough time

hot beverage or prune juice

bowel training: neurogenic bowel

stimulant then digital stimulation at same time every other day

relax anal sphincter

use suppository or mini enema 20 min after eating

move to toilet 15-20 after suppository/enema

digital stimulation

digital stimulation

10-20 sec, 5-10 min apart = BM

preoperative

start: decision to have surgery

end: transfer to OR

education occurs

intraoperative

start: arrival to OR

end: transfer to PACU/recovery room

DNRs suspended during surgery

postoperative

start: admit to PACU

end: at follow-up appointment

inpatient procedure

expect to stay

hospital setting

urgent and emergent

stable or unstable

outpatient w/in hospital when pt has risks

cost is higher because all the supplies are readily available

outpatient procedures

expect uncomplicated - quick discharge

occurs surgical and freestanding centers

stable

cost is cheaper

not attached to hospital

plastic surgery, colostomy, etc

elective surgeries

pt chooses to have procedure, not needed

joint, cosmetic surgery

urgent surgery

pt needs surgery but can be delayed

delaying too long can have consequences

tumor, gallbladder, kidney stone, unruptured appendix

emergent surgery

pt needs surgery right now and will die if delayed

trauma, fast-growing cancer (glioblastoma), heart w/ severe vessel blockage

skin assessment for surgery

pre-existing: open areas, PI

hydration: skin turgor, mucous membranes, edema

cardiac and pulmonary assessment for surgery

baseline: EKG, VS, lung + heart sounds

pacemaker, ICD, JVD

edema, SOB, crackles, wheezes, stridor

abdominal assessment for surgery

distention, last bowel mov’t

neuro assessment for surgery

LOC, baseline neuro check, pulses, push/pull

greatest age risk for surgery

<5, >65

hand off

any time the pt is being handed to a different area/team

health hx

allergies, current meds, smoking, alcohol, drug use, medical hx, surgical hx, emotions, culture and religion, nutrition

smoking hx and surgery

decrease perfusion/diffusion/ventilation

harder to intubate/extubate

blood clot/mi

alcohol hx and surgery

increase bleeding

anesthesia interaction

withdrawal