Skills Exam 2

Phlebitis:

- inflammation of a vein

- Inspect for localized redness, tenderness, and swelling over vein sites.

How to assess for phlebitis:

- Stop infusion and discontinue intravenous therapy; Restart new intravenous line if continued therapy is necessary
- Place moist, warm compress over area

How to treat phlebitis:

- blood clots/emboli (thrombophlebitis)

What can phlebitis cause?

Infiltration:

- occurs when IV catheter becomes dislodged and vein ruptures so IV fluids inadvertently enter subcutaneous tissue around the IV site
- potentially dangerous

Fluid overload:

- hypervolemia
- too rapid administration
- excessive amount of fluids (edema)
- can lead to vascular congestion impairing body’s ability to deliver oxygen to tissues
- swelling, bloating, headache
- treat with diuretic

Diuretics:

- given PO, IV, IM
- decreases BP, Na, Cl, K, weight, I&O, dehydration, hyperglycemia
- furosemide, aldactone, kayexalate

Aldactone:

- saves the potassium
- gets rid of water and sodium
- blocks aldosterone in kidneys
- watch for headache, diarrhea, hyperkalemia, electrolyte imbalance, fatigue, and GI disturbance
- can cause weakness in heart muscles

kayexalate:

- PO or enema
- need to get rid of potassium or it can kill you
- watch for constipation, gastric irritation, diarrhea, sodium retention, and hypokalemia
- watch heart rate and sodium levels

furosemide:

- PO or IV
- potassium wasting
- loop diuretic
- used for edema, hypertension, and ascites
- side effects: decreased BP, photosensitivity, hyperglycemia, decreased potassium

- through lab work

Best way to assess fluid and electrolyte imbalances:

hyperkalemia:

- potassium level 5.1 or higher
- need kayexalate
- look for peaked T waves and dysrhythmias
- abdominal dissension
- muscle weakness, cramps, irritability anxiety, low BP, pins and needles sensation

hypokalemia:

- potassium level 3.5 or below
- administer potassium rich diet
- arrhythmia (thready pulse), tachycardia
- weakness, fatigue, intestinal mobility decreases, drowsiness
- metabolic alkalosis

potassium deficiency symptoms:

- alkalosis
- shallow respirations
- irritability
- confusion
- weakness
- arrhythmias
- lethargy
- thready pulse

hypernatremia:

- sodium level above 145 in blood
- rehydrate

hyponatremia:

- sodium level below 135 in blood
- fluid restriction
- water intoxication

hypercalcemia:

- loop diuretics
- increase hydration
- synthetic calcitonin
- monitor I&O, vitals, and HR
- administer diuretics (kayexalate)
- constipation

hypocalcemia:

- give foods high in calcium with vitamin D supplements
- watch for bleeding gums and mucus membranes
- chvostek's sign
- trousseau's sign

factors contributing to fluid loss:

- vomiting
- diarrhea
- bleeding
- sweating

alkalosis:

- pH above 7.45
- kicking up the pH

acidosis:

- pH below 7.35
- sliding the pH down

R.O.M.E. acronym

- Respiratory Opposite:
---------high pH=low CO2, low pH=high CO2
- Metabolic Equal:
---------high pH=high HCO3, low pH=low HCO3

respiratory acidosis:

- low pH, high CO2
- hypoventilation, hyperkalemia, shallow respirations, nausea and vomiting, numbness and tingling
- use ventilator
- causes: COPD, pneumonia, atelectasis

respiratory alkalosis:

- high pH, low CO2
- hyperventilation, hypokalemia, deep respirations, muscle weakness, cyanotic pale skin
- causes: hyperventilation (stress), mechanical ventilation

metabolic acidosis:

- low pH, low HCO3
- hyperventilation, hyperkalemia, muscle twitching, increased body temp.
- check renal labs
- causes: DKA, severe diarrhea, renal failure, shock

metabolic alkalosis:

- high pH, high HCO3
- hypoventilation, hypokalemia, tremors/cramps/tingling, nausea
- causes: severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3

BUN (Blood Urea Nitrogen)

- indicates renal function and hydration status

10-20 mg/dL

Normal range of BUN (Blood Urea Nitrogen):

above 100

Critical range of BUN (Blood Urea Nitrogen):

symptoms of increased BUN:

- dehydration
- impaired renal function
- excessive protein intake

symptoms of decreased BUN:

- malnutrition
- overhydration
- liver damage

when to take a patients weight:

- at the same time every day with the same circumstances
- indicates fluid status
- its a gold standard

- Normal saline IV solution

What type of solution is hung with blood?

- 30 minutes from the blood bank
- 2-4hr infusion rate

How long do you have to hang a bag of blood for a blood transfusion?

- "Y" tubing
- for the blood and saline
- change after 4 hours

What tubing is used for blood transfusions?

- based on hospital policy
- when any change occurs
- stay with patient for the first 15 minutes

when to take vitals during blood transfusions?

Febrile reaction to blood transfusion:

- chills, fever, headache, flushing, tachycardia, increased anxiety

allergic reaction to blood transfusion:

- mild: hives, pruritis, facial flushing
- severe: shortness of breath, bronchospasm, anxiety

Hemolytic transfusion reaction:

- Low back pain, hypotension, tachycardia, fever and chills, chest pain, tachypnea, hemoglobinuria, may have immediate onset

- stop transfusion immediately and notify the prescriber
- change the IV tubing
- treat symptoms if present (O2, fluids, epi)

what to do when complications arise during a blood transfusion?

5 mL

1 tsp = ___ mL

ways to transfer a patient:

- gait belt
- pivot
- cane
- crutches
- if patient is obese, utilize equipment!!!

sequential compression devices

SCDs

- promote venous return as a prevention of DVT

What do SCDs do?

how to open an ampule:

- break away from body with gauze
- use filter needle to extract meds

antidiuretic hormone (ADH)

- promotes retention of water by kidneys
- when we are low on volume
- released from pituitary gland
- helps control blood pressure
- KEEP 1

renin-angiotensin-aldosterone system (RAAS)

- a hormone cascade pathway that helps regulate blood pressure and blood volume
- watches fluid levels and helps protect volume through the kidneys
- sodium reabsorption and potassium secretion

Atrial natriuretic peptide (ANP)

- causes sodium loss and inhibits the thirst mechanism
- influences sodium and water release
- hormone secreted in response to atrial stretching and an increase in circulating blood volume
- RELEASE 2

what do you do if a patient is trying to get out of bed, but the doctor will not order restraints?

- try to distract with videos, puzzles, toys, etc.
- bed alarm
- move close to nursing station

how to start an IV:

- Inform client about procedure and indication
- Gather supplies
- Wash hands and Wear gloves
- Apply tourniquet
- Locate vein
- Clean area with alcohol
- Position and insert needle-looking for a flash of blood
- Advance catheter
- Release the tourniquet
- Remove the needle
- Secure the catheter and start IV fluid if ordered
- Document

- only LICENSED personnel
- not us

who can start and IV?

hypertonic solutions:

- sodium and volume replacement
- used for hypernatremia (water insufficiency)
- go slow
- cells shrink

hypertonic IV solution examples:

- D5 ½ NS
- D5 NS

hypotonic solutions:

- isotonic until INSIDE the body
- used for hyponatremia (water excess) and hypoglycemia
- don't give to infants or head injury patients (cerebral edema may occur)
- cells swell

hypotonic IV solution example:

- D5W

isotonic solutions:

- fluid resuscitation
- expands the volume, dilutes medications, and keeps veins open
- same osmolarity as body fluid

isotonic IV solution examples:

- lactated ringers
- NS 0.9% NaCl

Subcutaneous injection sites:

- upper arms, back, abdomen, top of legs.
- insulin and heparin
- 45 degree angle

Intramuscular injection sites:

- deltoid, ventrogluteal, vastus lateralis
- vaccines
- 90 degree angle
- aspirate except for deltoid

Heparin needle size and length:

- 27G x 1/2"
- 1mL syringe

Insulin needle size and length:

- 31G
- 1mL syringe

IM needle size and length:

- 23G x 1"
- 3mL syringe

anions:

- negatively charged ions
- bicarbonate and phosphate

cations:

- positively charged ions
- magnesium, sodium, and potassium

Nasogastric tube:

- tube inserted through the nose into the stomach
- short term use only

- to prevent gastric dilation, vomiting and paralytic ileus (intestinal muscle paralysis)

why is a NG tube inserted?

- drink water

What should you instruct a patient to do when inserting a NG tube?

urinary incontinence

- inability to control urination
- pregnancy and old age
- functional, overflow, reflex, stress, urge

colostomy:

- creation of an artificial opening into the colon
- opening is called a stoma which is at the end of the colon protruding through the skin
- ileocecal valve allows food to pass from small intestine to large

UTI:

- E. coli
- common in females due to shorter urethra

micturition:

- urination

PACO2

- 35-45mmHg
- how well lungs excrete CO2

HCO3

- 21-28meq/L
- how kidneys excrete metabolic acid
- increased means not enough metabolic acid

PAO2

- 80-100
- how well gas exchange occurs in alveoli

ABG’s

- ph 7.35-7.45
- measures blood acidity
- PACO2, HCO3, PAO2

Aldosterone

- keeps sodium, releases potassium
- KEEP 1 RELEASE 1

Fluid overload values:

- hemoglobin
- blood glucose
- hematocrit
- BUN

Fluid overload

- give sodium
- give diuretic
- edema and crackles

Abnormal fluid output:

- wound drainage
- vomiting
- hemmorage
- diarrhea

Carbonic acids:

- Respiratory

Cardiac rhythms

Dehydration

- sodium, specific gravity, hemaocrit go up

Overhydration

- sodium, specific gravity, and hematocrit go down

Angiotensin II

- vasoconstriction (increases BP)
- kidneys retain sodium and water
- stimulates aldosterone from adrenal cortex
- KEEP 2

Functional Incontinence

- inability of urethral sphincter to function properly

overflow incontinence

- bladder holds so much
- only 1000mL

Reflex incontinence

- hands in water and feeling the need to urinate

Stress incontinence

- increased urination pattern

Urge incontinence

- disease process
- neuromuscular and obesity