Skills Exam 2

Phlebitis:

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