NRSE 320: Final Exam

Intraoperative: Monitor for…

• **Patients with potential for Malignant Hyperthermia will be given different anesthesia products *no succinylcholine

  • Ventricular dysrhythmias –signs/symptoms of Malignant Hyperthermia

  • Inherited muscle disorder that certain anesthetics induce

  • Malignant hyperthermia rescue cart: Dantrolene

Postoperative: Complications

• Hypoxia

  • Monitor oxygen

• Hypovolemia shock

• Paralytic ileus

• Wound Dehiscence/ evisceration

• DVT

pH less than 7.35….

• Acidosis

• Too much acid

pH above 7.45…

• Alkalosis

• Too much base

pH

• Acidosis or Alkalosis

• Normal range: 7.35 – 7.45

• Acidosis: Less than 7.35

• Alkalosis: More than 7.45

PaO2: Normal Range

80 to 100

PaCO2

• Respiratory

• Normal Values: 35 – 45 mm Hg

• Alkalosis: Less than 35

• Acidosis: More than 45

HCO3: Normal Values

• Metabolic

• Normal Range: 22 – 26 mEq/L

• Acidosis: Less than 22

• Alkalosis: More than 26

Fully Compensated

• pH in the expected range (7.35 to 7.45)

• PaCO2 and HCO3 are BOTH outside of expected range

Partially Compensated

The pH, HCO3 and PaCO2 are outside of expected range

Uncompensated

• pH outside the of expected range

• EITHER HCO3 or PaCO2 is out of the expected range

Respiratory Acidosis

• Low pH

• High CO2 levels

• Typical caused by impaired lung function

• Hyperkalemia

Respiratory Alkalosis

• High pH

• Low CO2 levels

• Typically caused by hyperventilation

  • anxiety

  • pain

  • fever

Metabolic Acidosis

• Too much acid or not enough base

• Low pH

• Low HCO3-

• Typically caused by

  • Kidney failure

  • Diabetic ketoacidosis

  • Lactic Acidosis

Metabolic Alkalosis

• High pH

• High HCO3-

• Increase in Base

  • Ingestion of antacids containing bicarbonate

• Decrease in Acids

  • Excessive vomiting

  • NGT suctioning

  • Low Potassium and Calcium

• Hypokalemia

• Hypocalcemia

Metabolic Acidosis: Cardiovascular (Clinical Manifestation)

• Hypotension

• Dysrhythmias

• Peripheral vasodilation

• Warm, flushed, dry skin

Metabolic Acidosis: Respiratory (Clinical Manifestation)

• Kussmaul’s respirations

  • Deep, rapid pattern

Metabolic Acidosis: Central Nervous System (Clinical Manifestation)

• Drowsiness

• Coma

• Headache

• Confusion

• Lethargy and weakness

Metabolic Acidosis: Gastrointestinal (Clinical Manifestation)

• Nausea and vomiting

• Diarrhea

• Abdominal pain

Metabolic Acidosis: Nursing Diagnosis

• Decreased cardiac output

• Impaired memory

• Fall risk

• Dehydrated

Metabolic Acidosis: Nursing Interventions

• Monitor ABG

• Maintain patent IV access

• Monitor I & O

• Monitor loss of bicarb through GI tract

• Administer fluids

• Seizure precautions

Metabolic Alkalosis: Cardiovascular (Clinical Manifestation)

• Tachycardia

• Dysrhythmias – atrial tachycardia, PVCs

• Hypotension

Metabolic Alkalosis: Respiratory (Clinical Manifestation)

• Hypoventilation

• Respiratory failure

• Slow shallow respirations

Metabolic Alkalosis: Central Nervous System (Clinical Manifestation)

• Dizziness

• Irritability

• Nervousness

• Confusion

• Tremors

• Muscle cramps

• Tetany

• Paresthesia in fingers, toes

Metabolic Alkalosis: Gastrointestinal (Clinical Manifestation)

• Anorexia

• Nausea and vomiting

• Paralytic ileus with hypokalemia

Metabolic Alkalosis: Nursing Diagnosis

• Decreased cardiac output

• Inappropriate use of potassium-wasting diuretics and antacids

• Hypoventilation

• Excess gastrointestinal fluid loss

• Risk of injury

Metabolic Alkalosis: Nursing Intervention

• Monitor ABG

• Maintain IV access

• Monitor I & O

• Avoid alkaline substances

• Replace fluid deficits

• Administer antiemetics

Respiratory Acidosis: Cardiovascular (Clinical Manifestation)

• Hypotension

• Ventricular fibrillation

• Peripheral vasodilation with thready, weak pulse

• Tachycardia

• Warm flushed skin

Respiratory Acidosis: Respiratory (Clinical Manifestation)

• Dyspnea

• Hypoventilation with hypoxia

Respiratory Acidosis: Central Nervous System (Clinical Manifestation)

• Headache

• Seizures

• Altered mental status

• Muscle twitching

• Decreased level of consciousness

Respiratory Acidosis: Nursing Diagnosis

• Ineffective breathing pattern

• Fatigue

• Sensory-perceptual alterations

• Seizures

• Altered mental status

• Anxiety

Respiratory Acidosis: Nursing Interventions

• Monitor ABG

• Monitor for symptoms of respiratory failure

  • Low oxygenation levels

  • Increased respiratory effort

• Provide oxygen

• Monitor neuro status

• Position to facilitate maximum lung expansion

• Provide adequate fluid intake

Respiratory Alkalosis: Cardiovascular (Clinical Manifestations)

• Increased myocardial irritability, palpitations

• Increased heart rate

Respiratory Alkalosis: Respiratory (Clinical Manifestations)

• Rapid, shallow breathing

• Chest tightness and palpitations

• Nausea

• Vomiting

Respiratory Alkalosis: Central Nervous System (Clinical Manifestations)

• Dizziness

• Lightheadedness

• Tetany

• Seizures

• Confusion

  • Hyperactive reflexes

Respiratory Alkalosis: Nursing Diagnosis

• Sensory/perceptual alterations

• Altered thought processes

• Ineffective breathing pattern

• Risk for injury related to weakness/seizures/tetany ( involuntary muscle contractions)

Respiratory Alkalosis: Nursing Interventions

• Monitor ABG

• Monitor for indications for respiratory failure

• If indicated, have client use rebreather mask or paper bag to breathe into

• Provide oxygen if necessary

• Reduce oxygen consumption

Normal Serum Levels: Bicarbonate (HCO3−)

22-26 mEq/L

Normal Serum Levels: Chloride (Cl−)

96-106 mEq/L

Normal Serum Levels: Potassium (K+)

3.5-5.0 mEq/L

Hyperkalemia: Clinical Manifestation

• Cramping leg pain

• Weak or paralyzed skeletal muscles

• Abdominal cramping or diarrhea

• Cardiac dysrhythmias

Hyperkalemia: Nursing Implementation

• Eliminate oral and parenteral K+ intake

• Increase elimination of K+

  • Diuretics

  • Dialysis

  • Kayexalate

• IV fluids with regular insulin: Dextrose

• Administer sodium bicarbonate to reverse acidosis

• Antidote: Calcium gluconate IV…may require dialysis in chronic or severe cases

• Monitor cardiac rhythm:

  • Arrhythmias (PVC, V-fib, peaked T waves, widened QRS

  • Hypotension

  • Slow pulse

  • Weakness, Flaccid, Paralysis,Parasthesia

Hypokalemia: Clinical Manifestations

• Cardiac most serious

• Skeletal muscle weakness (legs)

• Weakness of respiratory muscles

• Decreased gastrointestinal motility

• Impaired regulation of arteriolar blood flow

• Hyperglycemia

Hypokalemia: Nursing Implementation

• KCl supplements orally or IV

• Always dilute IV KCL: NEVER give KCL via IV push or as a bolus

• Should not exceed 10 mEq/hr; assess IV site for phlebitis

  • To prevent hyperkalemia and cardiac arrest

Normal Serum Levels: Phosphate (PO43−)*

2.4-4.4 mg/dL

Hyperphosphatemia: Clinical Manifestation

• Neuromuscular irritability and tetany (hypocalcemia)

• Calcified deposition in soft tissue such as…

  joints

  arteries

  skin

  kidneys

  and corneas

  (can cause organ dysfunction)

Hyperphosphatemia: Management

• Identify and treat the underlying cause

• Restrict foods and fluids containing phosphorus

• Phosphate-binding agents

• .Adequate hydration and correction of hypocalcemic conditions

• Hemodialysis, IV insulin, and glucose

Hypophosphatemia: Clinical Manifestation

• CNS depression

• Confusion

• Muscle weakness and pain

• Dysrhythmias

• Cardiomyopathy

• Rhabdomylosis

Hypophosphatemia: Nursing Mangement

• Oral supplementation

• Ingestion of foods high in phosphorus

• IV administration of sodium or potassium phosphate

Normal Serum Levels: Magnesium (Mg2+)

1.5-2.5 mEq/L

Hypermagnesemia: Clinical Manifestations

• Lethargy

• Nausea and vomiting

• Impaired reflexes

• Somnolence

• Respiratory and cardiac arrest

Hypermagnesemia: Nursing Mangement

• Prevention first

• restrict magnesium,intake in high-risk patients

• Emergency treatment: IV CaCl or calcium gluconate

• Fluids and IV furosemide to promote urinary excretion

• Dialysis

Hypomagnesemia: Clinical Manifestations

• Hyperactive deep tendon reflexes

• Muscle tetany

• Positive Chvostek’s and Trousseau's signs

• Seizures

• Cardiac dysrhythmias/ PVC’s ,inverted T waves, ST depression,

• Prolonged PR interval

• Corresponding hypocalcemia and hypokalemia

Hypomagnesemia: Clinical Management

• Treat underlying cause

• Oral supplements

• Increase dietary intake

• Parenteral IV _magneisum when severe

Normal Serum Levels: Sodium (Na+)

135-145 mEq/L

Hypernatremia: Nursing Implementation

• treat underlying cause

• Primary water deficit

  • replace fluid orally or IV with isotonic or hypotonic fluids

• Excess sodium

  • dilute with sodium-free IV fluids and promote excretion with diuretics

• Monitor…

  • LOC

  • Vital signs

  • Heart rhythm

  • Lung sounds

  • I”s & O”s

Hypernatremia: Manifestation

• Thirst

• Lethargy

• Agitation

• Seizures

• Coma

• Impaired LOC

• Symptoms of fluid volume deficit

Hyponatremia: Nuirsing Implications

• Monitor…

  • I&O

  • Daily weight

  • vital sign

  • Vasopressin (ADH)

Hyponatremia: Manifestation

• Headache

• Confusion

  Muscle weakness to the point of respiratory compromise

  Lethargy

  Dizziness

  Seizures

Hyponatremia: Treatment

• Fluid replaced with sodium-containing solution: 0.9%

• Give small amount of IV hypertonic saline solution (3% NaCl)

Normal Serum Levels: Calcium (Ca2+) (total)

8.6-10.2 mg/dL

Normal Serum Levels: Calcium (ionized)

4.6-5.3 mg/dL

Hypercalcemia: Clinical Manifestation

• Lethargy, weakness, stupor, coma

• Depressed reflexes

• Decreased memory

• Confusion

• Personality changes

• Psychosis

• Anorexia, nausea, vomiting

• Polyuria

• Dehydration

Hypercalcemia: Nursing Implementation

• Low calcium diet

• Hydration with isotonic saline infusion

• Excertion of calcemia with loop diuretic

• Montior…

  • I’s & O’s

  • Cardiac ryhtms

Hypocalcemia: Clinical Manifestation

• Tetany/ muscle twitching

• Positive Trousseau’s

  • Hand spasms from inflating a blood pressure cuff

• Chvostek’s sign

  • Tapping on facial nerve which triggers twitching

• Cardiac dysrhythmias

  • prolonged QT interval decreased heart rate and hypotension

• Confusion

• Depression

• Seizures

Hypocalcemia: Nursing Implementation

• Oral or IV ________ supplements

  • Not IM to avoid local reactions

  • Seizure precautions/ keep the room quiet to avoid overstimulation

• Encourage foods high in calcium

  Dairy

  Salmon

  Dark leafy greens

Hemodialysis (HD)

• Acute Kidney Injury

  • Short-term HD for days to weeks until the kidney works again

• Chronic Kidney Disease & End-Stage Kidney Disease

  • Long term or forever

  • 3 times a week

Hemodialysis (HD): Goals

• Extract toxic nitrogenous substances from the blood and to remove excess fluid via a dialyzer

• Toxins are filtered from the blood and the cleansed blood is returned to the patient

Hemodialysis: Requires…

• It requires vascular access to immediately access the patient’s circulation at a rapid rate of 300-500 mL/min.

  • Central Venous Catheter

  • AV Fistula

  • AV Graft

• NOTHING MEDICAL CAN BE DONE WITH THAT ARM

Hemodialysis: Nursing Management

• Monitor for Disequilibrium Syndrome

  • Nausea

  • Headache

  • Changes in LOC

  • ( increased intracranial pressure from increased urea levels)

• Monitor for clotting & diet

Peritoneal Dialysis (PD)

through the peritoneal catheter into the abdomen with subsequent dwell times.

Peritoneal Dialysis (PD): Goals

• Remove toxic substance

• Metabolic wastes

• ________________ may be the treatment choice for patients who are unable or unwilling to undergo HD or kidney transplant

  can be done at home

Peritoneal Dialysis (PD): Nursing Consideration

• Dry weight

• Vital signs, electrolytes, creatinine, BUN, blood glucose

• Determine the client’s ability to preform the procedure

• Keep the outflow bag lower than the client’s abdomen

• Outflow should equal to or be greater than the inflow of dialysate

Peritoneal Dialysis (PD): Complications

• Peritonitis

  • The first sign is cloudy dialysate effluent

• Abdominal pain

• Rebound tenderness

• Hypotension

• Signs of shock

Lower UTI’s: Signs & Symptoms

• Burning on urination

• Urinary frequency

• Urgency

• Nocturia

• Incontinence

• Suprapubic or pelvic pain

Lower UTI’s: Assessments, Nursing Interventions & Treatment

• Assessments

  • Collect urinalysis with urine culture!

  • Positive leukocytes indicate UTI

• Nursing intervention

  • Perineal care

  • Assess for fall risk

• Treatment

  • Antibotics

  • Pain mangement

Upper UTI: Clinical Manifestations

• Acute pyelonephritis:

  • Fever/chills

  • Leukocytosis

  • Bacteriuria

  • Pyuria

  • Low back pain

  • Flank pain

  • Nausea/vomiting

  • Headache/Malaise

  • Pain and tenderness around costovertebral angle upon physical exam

• MONTIOR FOR SIGNS OF SHOCK!

Upper UTI: Assessment and Treatment

• Acute pyelonephritis and chronic pyelonephritis are the most likely type

• Pyelonephritis

  • Bacterial infection of the renal pelvis, tubules and interstitial tissue of one or both kidneys.

• Assessment

  • CT

  • ultrasound

  • urine culture

• Treatment:

  • treated outpatient unless severe symptoms

  • Antibiotics

  • Increasing hydration

Chronic Kidney Disease: Nursing Assessment

• Normal Glomerular filtration rate (GFR) is 125 mL/min

• Risk

  • Edema

  • Heart failure

  • Hypertension

  • Metabolic acidosis

  • Anemia

• Maintain kidney function and homeostasis for as long as possible

• Calcium and phosphorus binders

• Manage BP

  • Antihypertensive

  • Cardiovascular agents

• Erythropoietin therapy

• Nutritional therapy

• Dialysis

Chronic Kidney Disease: Stage 1

• GFR: Greater than 90 mL/min

• Kidney damage with normal or increased GFR

Chronic Kidney Disease: Stage 2

• GFR: 60 to 89 mL/min

• Mild decrease in GFR

Chronic Kidney Disease: Stage 3

• GFR: 30 TO 59 mL

• Moderate decrease in GFR

Chronic Kidney Disease: Stage 4

• Severe decrease in GFR

• 15 TO 29mL

Chonic Kidney Disease: Stage 5

GFR less than 15mL

Hypertension: Clinical Manifestations

• Known as the “Silent Killer”

• Patients are often asymptomatic until the target organ disease occurs

• Symptoms are often secondary to target organ disease and can include:

• Fatigue, reduced activity tolerance

• Dizziness

• Palpitations

• Angina

• Dyspnea

Hypertension

• Persistent elevation of…

  • Systolic blood pressure of 130 mm Hg or higher

  • Diastolic blood pressure 80 mm Hg or higher

• The heart is working harder than normal, putting both the heart and blood vessels under strain

• Increased risk for…

  • Heart attack

  • Stroke

  • Renal disease

Hypertension: Nursing Intervention

• Weight loss

• Sodium restriction

• DASH Diet

  • Fish, low-fat milk, grains, fruits/veggies

• Decreased Alcohol Consumption:

  • Men: no more than 2 drinks/day

  • Women: no more than 1 drink/day

• Increase physical activity

• No smoking

• Stress mangement

Hypertensive Crisis: Hypertensive Emergency

• Sudden severe BP elevation

• Systolic greater than 180 mmHg or Diastolic greater than 120 mm Hg with new or worsening target organ damage:

  • Hypertensive encephalopathy, cerebral hemorrhage

  • Acute renal failure

  • Myocardial infarction

  • Heart failure with pulmonary edema

• If untreated, can lead to MI or stroke

• Goal= lower the MAP by no more than 20-25% within the first 1-2 hours

Hypertensive Crisis: Hypertensive Urgency

• Severe BP elevation

• Systolic is greater than 180 mm Hg or Diastolic greater than 120 mm Hg in STABLE patients without target organ damage

• Most common reason: noncompliance with medication

Hypertensive Crisis: Nursing Mangement

• Hospitalization

• IV drug therapy: Titrated to mean arterial pressure

• Monitor cardiac and renal function

• Neurologic checks

• Determine cause

• Education to avoid future crises

Anemia

• Fewer than normal red blood cells in the bloodstream

• Less oxygen reaches the tissues

• Complications: Tissue Hypoxia

  • Damage heart and CNS (brain damage)

Anemia: Clinical Manifestations

• Dyspnea

• Irritability

• Cool skin/cold tolerance

• Headache

• SOB

• Dizziness

• Difficulty concentrating

• Insomnia

• Pallor

• Fatigue

• Tachycardia

Type of Anemia: Iron Deficiency Anemia

• Most common

• Low red blood cells

• Low Iron

• Can be caused by…

  • Blood loss

  • GI Bleed due to OTC pain medication

  • Lack of Iron in diet

  • Pregnancy

  • Blood transfusion

  • Iron transfusions & supplements & iron rich food

Type of Anemia: Aplastic Anemia

• Most dangerous and chronic

• Bone marrow makes fewer RBCs, WBCs and platelets (pancytopenia)

• Body stops producing new blood cells

• Can be a result of bone marrow damage:

• Present at…

  • birth

  • after an infection

  • radiation/chemo exposure

  • some drugs

• Diagnostic tests to confirm

• Interventions:

  • Bone marrow transplant

  • blood transfusions

  • immunosuppressive therapy

  • `monitor for infection

Type of Anemia: Hemolytic Anemia

• Red blood cells are destroyed faster than they are being made

• Can be caused by…

  • Inherited diseases (sickle cells & thalassemia)

  • Autoimmune conditions

• Diagnostic tests to confirm

  • blood test

  • bone marrow biopsy

  • genetic testing

• Interventions

  • Blood transfusions

  • steroids (to decrease the immune system attack on RBCs

Nursing Management: Anemia

• Encourage increased dietary intake of deficient nutrients

• Monitor O2 saturation

• Lab testing: Monitor hemoglobin and hematocrit

• Blood transfusion

Blood Admission

• During the first 15 minutes or first 50mL of blood, the nurse should remain with the patient

  • Blood transfusion reactions usually occur during this time

• After the first 15 minutes…

  • Retake vitals

• Rate of infusion is determined by produced infused and condition of the patient

Blood Transfusion Reaction: Allergic

• Facial flushing

• Hives

• Rash

Blood Transfusion Reaction: Febrile

• Headache

• Fever

• Chill

• Anxiety

• Tachycardia

• Tachypnea

Blood Transfusion Reaction: Hemolytic

• Decrease in blood pressure

• Increase in respiratory rate

• Headache

• Chest pain

• Lower back pain

• chills

• Fever

• Tachycardia