Nur 202 Exam 3

Meds, Fluids, Skin Integrity, Grief, Sleep, Nutrition

Conversions

1 Tbsp = 3 tsp = 15mL

1 tsp = 5mL

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1 oz = 30mL

1 cup = 8oz = 240mL

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2.2lb = 1kg

1in = 2.54cm

Intake & Output

Intake = oral, IV, NG Tube, G/J Tube

Output = urine, stool, vomit, NG Tube

…

…

Drug Classifications

Therapeutic = what being treated by the drug

—antidepressants, anticoagulants, antihypertensives

Pharmacologic = how drug acts

—diuretic, calcium channel blocker, vasodilator

Controlled Substances

Schedule 1 = not approved, high abuse potential

Schedule 2 = used medically, high abuse potential

Schedule 3 = still potential for psych/phys abuse

Schedule 4 = some potential abuse

Schedule 5 = contain small amount of controlled substance

Pharmacokinetics

What happens to drug in body?

-Absorption, Distribution, Metabolism, Excretion

—time until onset/peak, therapeutic range, biological half-life, concentration of active drug

…

Factors Affecting

-age, body mass, gender, pregnancy, environment

-route, timing, fluids

-pathological states, genetic factors, psychological factors

Pharmacodynamics

How does the drug affect the body?

…

Primary Effects = therapeutic

—predicted, intended, desired, why prescribed

Secondary Effects = nontherapeutic

—unintended, can be predictable/harmless/harmful

—Side effects, adverse reactions, toxic reactions, allergic reactions, idiosyncratic reactions, cumulative effect

Drug Interactions

Antagonistic, Synergistic, Incompatibilities

Food interactions

Drug Abuse/Misuse

Tolerance, Dependence, Misuse, Abuse, Illicit drugs

Admin Scheduling Terms

Before meals = AC, After meals = PC

Every 2hr = q2h

4 times/day = QID, 3 times/day = TID

2 times/day = BID

Immediately = STAT

As needed = PRN

Technology to Prevent Errors

Computerized Prescriber Order Entry CPOE

Barcode medication administration

Smart pumps

Automated dispensing cabinets

What to do after committing a medication error

Immediately assess vital signs & physical status

Report findings to provider

Notify nurse manager, report events surrounding error

—Incident reporting

Med Admin Rights & Checks

Rights

-Drug, dose, time, route, patient

-Documentation, assessment, education, evaluation, to refuse

…

Checks

-Checking MAR, after preparing, at beside before giving

Routes of Administration

Oral = most commonly used route

-Not when patient has difficulty swallowing, unconscious, NPO, vomiting/nausea

-less expensive, fewer side effects, widely available

-simplest, easiest route

…

Topical = local effects

Transdermal = patch on clean, dry skin

Ophthalmic = lower conjunctival sac of eye

OTIC = warm in hand, on side, in ear

Nasal = spray into nose to treat congestion & dryness

Vaginal = remain on back for 10 min

Rectal = suppositories, enemas

Enteral = NG Tubes

Respiratory inhalers

Parenteral = intradermal, subcutaneous, IM, IV

-Absorbed quickest, increased infection rate

Parenteral Injections

Intradermal

-5-15deg, 1mL syringe, 26-28 gauge

…

Subcutaneous

-45deg-90deg, 3/8-5/8in, 25-27 gauge

-abdomen, anterior thighs, posterior upper arm

-rotate sites, choose sites carefully

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Intramuscular IM

-90deg, 3-5mL, 5/8-1.5in, 20-25 gauge Z-track

—deltoid = 0.5-1mL, vastus lateralis 1-3mL, ventrogluteal 1-3mL

-absorbed faster than subcutaneous

Insulin Mixing

Inject air into cloudy insulin vial —NPH

Inject air into clear insulin vial—regular

Withdraw dose from clear vial

Withdraw dose from cloudy vial

Patient Safety with Med Admin

Hand hygiene, medical asepsis, 3 checks, 10 rights

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Children

-Under 5yo = liquid form

—Dropper/syringe between gum & cheek

-Crush tablets, mix well with food

-Praise, not bribery

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Older Adults

-Decreased saliva production

-Decreased stomach peristalsis, gastric acidity, & colon motility

-Assess for swallowing problems

-Make sure tablets/caplets are swallowed

—No pocketing

…

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Macronutrients

Supply body with energy/kilocalories kcal

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Carbohydrates

-fiber, starches, sugars

-complex carbs = less likely to cause blood sugar spikes, simple carbs = more likely to cause blood sugar spikes

…

Lipids

-saturated, trans

-monosaturated = mainly plant-based foods

—avocadoes, nuts, olives, oils from these foods

-polyunsaturated = omega-3, omega-6

…

Proteins

-11/20 amino acids produced by body, 9 from food

-complete protein = contains all 9 AA

—fish, poultry, eggs, dairy, whole soy

-incomplete protein = more vegetarian/vegan

—legumes, nuts, whole grains, vegetables

Micronutrients

Help manufacture, repair, & maintain cells

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Vitamins

-Fat soluble = KADE

-Water soluble = thiamin B1, riboflavin B2, niacin B3, pyridoxine B6, pantothenic acid B5, folate B9, cyanocobalamin B12, Vitamin C

…..

Minerals

-Macro/Major = need the mineral in 100mg/day or more

—calcium, magnesium, phosphorus, potassium sodium

-Trace = essential but in lower concentration

—copper, fluoride, iodine, iron, zinc

Energy Balance

For stable weight: #consumed = #used

—too few = lose weight, too many = gain weight

…

Basal Metabolic Rate BMR = measure energy used while at rest in neutral temperature

-energy required for vital organs and brain function

-affected by body composition, growth periods, body temperature, environmental temperature, disease processes, prolonged physical exertion

…

Total Energy Needs = # needed to replace those used for BMR + physical activities

-considers age, weight, & physical activities

Factors Affecting Nutrition

Age/Developmental Stage, Lifestyle Choices, Vegetarian/Veganism, Ethnic/Cultural practices, Medications

…

Disease Processes/Functional Limitations

-Chronic Disease, Illness/infection, Traumatic Injury, Long-term insufficient caloric intake, Alcoholism, Cognitive function

-Ability to obtain/prepare food, chewing/swallowing, stomach function, peristalsis issues, issues of intestinal surface area, enzyme secretion issues, medications

…

Bariatric Surgery

-Restrictive = limit capacity to hold food

—gastric sleeve, gastric banding

-Malabsorption = impair uptake of food, nutrients, & fats

—intestinal bypass

Diets

Vegetarian = exclude red meat & poultry

—Lacto-ovo = no meat, fish, poultry

—Lacto = only dairy & plant-based

Pescatarian = fish okay

Vegans = plant only

Fruitarian = fruit, nuts, honey, & vegetable oils

..

DASH Diet = hypertension diet

Fad Diet = promises quick, dramatic weight loss

—limited food range, can rely on supplement use

..

Mediterranean

-Rich in olive oil, fish, fruits, vegetables, nuts

-Low in dairy, processed, saturated fats, red meat

Asian = plant based, low in dietary fat

Indian = rich in spices, low in processed foods

Hispanic = heavy on grains, legumes, & corn-based products, low in fresh vegetables

Regular = house diet, balanced meal 2000kcal/day

..

NPO = no food or fluid

Modified Diet Consistency

Clear Liquid

-Prevents dehydration, not enough nutrition

-More than 3 days, need commercial liquid supplement

—oral hygiene, ice chips, don’t eat around them

..

Full Liquid

-all liquids at room temperature

-usually short term

..

Mechanical Soft

-for chewing difficulties

-lot of nutrients but low fiber

..

Pureed

-blended/smoothie diet, baby food

Nutritional Problem Screening

Subjective Global Assessment

-used overall medical history & physical exam

—weight history, diet history, GI symptoms, energy level, existing disease, physical exam date

…

Nutrition Screening Initiative

-older adults

…

Mini Nutritional Assessment

-all ages

-screen nutritional risk, then complete rest if there’s an increased risk

Body Composition

Anthropometric Measurements

—height, weight, head circumference

—circumferences = mid upper arm, abdominal, waist to hip ratio

Skin Fold Measurements

Body Mass Index

Underwater Weighing

Nutrition Labs

Albumin = 70-100 mg/dL

Prealbumin = 3.4-4.8 g/dL

Transferrin = 204-360 mg/dL

Urea BUN = 5-20 mg/dL

Creatinine = 0.5-1.2 mg/dL

…

Hemoglobin

-13.2-17.3 g/dL

-11.7-15.5 g/dL

..

Hemoglobin A1C

4-5.6% = normal

5.7-6.4% = pre-diabetes

greater than 6.5% = diabetes

Nausea Interventions

Cool compresses, loose clothing, open window/fan, calm environment, distraction

Decrease scent, frequent oral hygiene

Upright 30-45min after eating, small meals

Fresh squeeze lemon to cool water, bland/cold foods, cool soda, suck on ice, chamomille tea

Overweight/Obesity

Body Measurements: 20% greater than ideal for height/frame

Percentage of Body Fat

-21-25% overweight for men, over 25% obese

-31-33% overweight for women, over 33% obese

…..

BMI

Normal = 18.5-25

Overweight = 25-30

Class 1 Obesity = 30-35

Class 2 Obesity = 35-40

Class 3 Obesity = 40+

Undernourished/Malnourished

BMI less than 18.5

-Under 16 = severely underweight

-16-16.99 = moderately underweight

….

Interventions to Stimulate Appetite

-High protein supplements between meals

-Frequent, smaller, nutrient-dense meals

-Restrict liquids with meals

-Don’t smoke 1hr before meals

-Control pain, oral hygiene, clean/neat environment, comfortably positioned

Impaired Swallowing Aspiration Precautions

Monitor: level of consciousness, gag, cough, swallowing ability

Position upright at 90deg, keep elevated for 30-45min after meal

Keep suction at bedside

Feed in small amounts, cut food into small pieces

Inspect oral cavity for retained products

Impaired Digestive Function

Dry Mouth

-avoid caffeine, alcohol, tobacco, dry/bulky/spicy/salty/acidic food

-sugarless hard candy, frequent water sips, lip moisturizer

…

Decreased Gastric Secretions

-regularly scheduled meals, chew thoroughly

-take prescribed meds, adequate calcium/vitamin D

…

Glucose Intolerance

-avoid concentrated/refined sugars

-complex carbs are better, small/frequent meals

Enteral Nutrition

Used for: feeds, lavage, collect specimen, decompression

Risks: aspiration, bacterial growth, diarrhea, N/V, nasopharyngeal trauma, alterations in drug absorption, metabolic disturbances

……..

Long Term Feedings = G, PEG, J/PEJ, G Buttons

-placed laparoscopically

…

NG/NJ tubes places without direct visualization

-must check location once per shift

-Before starting feeds, need radiographic verification & provider order

-Need to continuously assess since tube can migrate

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Aspirate pH

-5.5 or under = stomach

-6 = intestine

-7 = respiratory secretions

Enteral Feeding Solutions

Basic = no nutrient deficiency, can’t eat/drink, usually lactose-free

High protein = burn wounds, malnutrition

Elemental = no complex proteins, severe small bowel dysfunction

Diabetic = diabetics, carbohydrate control

Renal = limit potassium sodium, nitrogen

Pulmonary = 55% calories as fat, less carbon dioxide produced

Fiber containing = long-term use

Enteral Feeding Schedules

Continuous Feeds

-pump decreased reflux

-gravity is not precise, risks GERD/diarrhea/aspiration

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Cyclic

-nocturnal or 20hr schedule

-helpful when transitioning

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Intermittent

-supplements oral intake

-several times a day over 30-60 min

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Periodic = based on oral intake

-eats 90% or more of diet

Bolus = 300mL-400mL formula over 5-10min

-easiest to teach family, increased aspiration/distention risk

Med Admin through Enteral Feeding

Cannot be extended release ER or slow released SR

After med admin, flush 30-60mL of water

Parenteral Nutrition

IV through large, central vein

—subclavian site, PICC lines

-only when patients cannot be nourished through GI tract

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Liquid emulsions: essential fatty acids, trigs, supplemental kcals to prevent deficiency

-safflower or soybean oil based

………….

Complications

-infection/septic shock, blood clots, liver dysfunction with long term use, gallbladder disease/cholecystitis

…

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Sleep Terms

Rest = body is inactive or engaging in mild activity

—after which you feel refreshed, things you find calming & relaxing

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Sleep = cyclically occurring state of decreased motor activity & perception

—not disturbed by exterior stimuli, altered consciousness

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Circadian Rhythm = biorhythm based on day/night pattern in 24hr cycle

—regulated by hypothalamus & responds to light changes

—sleep is best when it aligns with circadian. why there’s issues with night shift, hospitalizations, & time zones differences

Extremes of Sleep

Too Little:

—cardiac disease, stroke, reduced energy expenditure, obesity, type 2 diabetes

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Too Much:

—depression, anxiety, sedentary lifestyle, habitual late sleeping, poor dietary habits

Sleep Needs

Newborn

—15-18hr, 2-4hr at a time, not related to circadian

Infants

—12-16hr, day/night confusion ends

Toddlers

—11-14hr, naps

Preschoolers

—10-13hr, shorter naps

Middle/Late Childhood

—9-12hr, insufficient sleep can lead to behavior/school/health problems

Adolescents

—8-12hr, screen time interferes

Adults

—7-8hr, hormone changes in menopause can affect

Older Adults

—7-9hr, fragmented sleep, harder time staying asleep, frequent night wakening

Stages of Sleep

Non-Rapid Eye Movement NREM

-restful phase when physiological function slows

-cortisol is at lowest, sleep muscles relax

-body temperature lowers, HR & RR decreases

-important for memory consolidation

—long-term memory

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Rapid Eye Movement REM

-brain is highly active, waves resemble being awake

—can see rapid eye movements

-more spontaneous awakenings, dreams

-essential for restoration

—loss impairs memory & learning

—Can rebound: not enough 1 night, more the next

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Cycling between: 4-6 times a night, 90-100min a cycle

Factors Affecting Sleep

Age

Illness

Noise & Light

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Physical Activity

—need at least 2hr

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Diet

—high saturated fats near bedtime interferes with sleep

—tryptophan & adenosine from milk/cheese/animal products induce sleep by converting into serotonin

—satiation induces sleep

—carbs promote relaxation

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Nicotine

—more difficulty falling asleep, more easily aroused

—disturbances during withdrawal period

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Caffeine

—blocks adenosine, inhibits sleep

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Alcohol

—disrupts REM sleep, can lead to vivid dreams & awakenings

—diuretic causing nocturia

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Medications

—Induce: benzos, ambien, melatonin, barbiturates, antidepressants

—Non-prescription Induce: antihistamines, chamomile, valerian root, hops, passionflower, kava, magnolia bark, CBD oil

Sleep Hygiene

Set of practices & routines that help you get better sleep

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Bed only for sleep

Same time every night

Dark, cool, quiet room

Get up and do something non-stimulating if not asleep in 30min

No screen time

Progressive relaxation

Exercise no less than 3hr before bedtime

Short naps under 20min are ideal

Warm bath before bed

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Avoid: catching up on sleep, screentime, sleep aid/med dependence, tobacco/caffeine/alcohol/heavy meals/carbs right before bed, going to bed angry

Sleep Disorders

Dyssomnias = characterized by insomnia or excessive sleepiness

—insomnia, circadian disorders, sleep apnea, restless leg, narcolepsy

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Parasomnias = patterns of waking behavior that appear during sleep

—sleepwalking

…………………………………………………………………………………………………………………………..

Insomnia = inability to fall asleep, remain asleep, or go back to sleep

—at least 3 nights a week for 3months or longer

—most common sleep disorder, especially women, older adults, & those with chronic illness

—Manifestations: excessive daytime sleepiness, poor concentration, fatigue, lethargy, irritability

—Increased risk for anxiety, depression, and cardiovascular disease

—Combo of behavioral & pharmacological therapy, short term/aggressive used to prevent chronic issue

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Restless Leg Syndrome RLS = CNS disorder characterized by strong, overwhelming urge to move legs while resting or before sleep

—Risk Factors: family history, women, low iron, antidepressants

—Mild-Moderate Disease = Lifestyle Changes: decrease alcohol/tobacco, no stimulants, regular sleep pattern, exercise, massage/stretching, foot wrap

—Moderate-Severe Disease = Meds & Dietary Iron

………..

Narcolepsy = Inability to regulate sleep/wake cycle

—Sudden uncontrollable urge to sleep, lasting seconds to minutes, cannot avoid but easily awakened

—Manifestations: sleepiness, slurred speech, slackening of facial muscles, feeling of impending knee weakness, paralysis, hallucinations

………..

Night Terrors = Sudden arousals in which a person is physically active & expresses strong emotions such as terror

—Manifestations: cry, scream, cannot be consoled, appear to be awake but aren’t, difficult to wake

—Can last 10-30min, person has no recollection

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Sleepwalking

—Usually occurs 1-2hr after falling asleep

—May perform what appears to be conscious motor activities, but don’t wake up

…………………………………………………………….

Cataplexy = sudden loss of muscle tone, usually triggered by an emotional event

Bruxism = grinding/clenching teeth

Nocturnal Enuresis = bed wetting

………………………………………………………………………………………………………………………….

Hypersomnia = Excessive sleeping, especially in daytime

—Fall asleep when need to be awake/alert

—Most commonly caused by sleep apnea OSA and narcolepsy, can also be due to depression

………………………………………………………………………………………………………………………..

Sleep Deprivation = not getting enough sleep or sleep is of poor quality

—NOT technically a sleep disorder

—Manifestations: drowsy during day/malaise, difficulty performing daily tasks, impaired cognitive processing, tremors, diminished immunity

—Common in healthcare workers with long/late hours, increases risk of occupation injury & patient injury

Sleep Provoked Disorders

When signs & symptoms of disease appear/become worse during sleep

—Coronary artery disease, asthma, diabetes, gastric/intestinal ulcers, epilepsy

Secondary Sleep Disorders

Disease causes alteration in sleep stages or in sleep quantity/quality

—-Depression, pain, hyperthyroidism, hypothyroidism

Sleep Apnea

Periodic interruption in breathing during sleep

—Can last 10-30sec, hundreds of times a night

—OSA, Central, or Mixed

………….

Central Sleep Apnea = Brain doesn’t send proper signals

—Risk Factors: prematurity, meds, head trauma, brainstem issues

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OSA = soft tissue of the pharynx & soft palate collapse, tongue falls into back of throat, obstructing airway

—at least 5 witness breathing interruptions/awakenings due to gasping/choking events per hour

—Risk Factors: over 40, men, black/latino, overweight, large neck, nasal obstruction, family history, alcohol, sleep meds, smoking

……………………………………………………………..

Clinical Manifestations

-Snoring, snorting, gasping

-Restlessness during sleep, especially when on back

-Unrefreshed sleep, tired during day, easily falling asleep during sedentary activities

-Morning headache, waking up with dry/sore throat, mood changes, forgetfulness

……………………………………………………………

Complications

-Cardiac dysrhythmias, heart attack, stroke, hypertension

-job-related injuries, motor vehicle accidents

-depression, worsening ADHD, headaches, accelerated aging

……………………………………………………………

Treatments

-oral appliances to adjust lower jaw/tongue & prevent obstruction

-CPAP = forced air to keep airways open, same pressure when breathing in & out

-BiPAP = two different pressure levels: 1 for inspiration, 1 for expiration

—higher for inhalation, lower for exhalation

-nose tape

-saline spray

-surgery = remove obstruction, implantable device

…

…

Body Fluid Functions

Maintain Blood Volume, Transport Materials

Medium for Cellular Metabolism & Excreting Water

Assist with Digestion of Food

Regulate Body Temperature

Body Fluid Compartments

Intracellular

Extracellular

—Includes interstitial, intravascular, transcellular

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Third Spacing

-Abnormal accumulation of fluid in areas where it doesn’t normally collect

—blisters, ascites, pericardial effusion

Passive Transport

Sodium = greatest impact on serum osmolality

—outside cells

Potassium = greatest impact on intracellular osmolality

—inside cells

…………………………

Filtration

-movement of water/molecules through membrane

-pressure forces from high to low

Diffusion

-water/solutes moving high to low concentration

—Osmosis = water diffusion, moving to higher electrolyte concentration

Active Transport

Goes against concentration or natural flow

Energy via ATP

—need to pump sodium out of cells & potassium in

Fluid Input & Output

Input

-If concentration is too high = not enough water = thirst to bring down concentration

-If concentration is too low = too much water = not thirsty

………….

Output

-sensible/insensible fluid loss

-Urine = report under 30mL/hr

-feces, skin, lungs

Hormonal Regulation

ADH

-pituitary

-fluid low = more ADH released

-fluid high = less ADH released

………..

RAS & Aldosterone

-intravascular volume is low, kidney responds, releasing renin

-renin, angiotensin 1, angiotensin 2

—angiotensin 2 tells adrenal glands to release aldosterone

-Aldosterone = tells kidney to hold sodium, triggers thirst

—water follows sodium hold onto water, increase BV & BP

…………

Thyroid Hormone

-thyroid

-high = high metabolism = heart working harder = more fluid loss in sweat & urine

-low = low metabolism = fluid retention & hyponatremia

………….

Brain Natriuretic Peptide BNP

-released by heart when too stretched from too much fluid or high BP

-helps get rid of extra fluid/sodium to release strain

-high = a lot of fluid

Fluid & Electrolyte Lab

Creatinine

—0.5-1.2 mg/dL

BUN

—10-31 mg/dL

………………………..

Sodium

—135-145 mEq/L

Potassium

—3.5-5 mEq/L

Calcium

—8.5-10.5 g/dL

Magnesium

—1.6-2.6 mEq/L

Phosphorus

—2.5-4.5 mEq/L

Chloride

—95-105 mEq/L

Bicarbonate

—22-26 mEq/L

……………………………..

Urine Specific Gravity

—1.001-1.029

Serum Osmolality

—275-295

Urine pH

—5-9

Hydration

Hgb, Hct, and Specific Gravity increased when hydration decreases

Basic Metabolic Panel BMP

Glucose, BUN, Creatinine

Sodium, Potassium, Bicarbonate/Carbon dioxide, Chloride, Calcium

Comprehensive Metabolic Panel CMP

Glucose, BUN, Creatinine

Sodium, Potassium Bicarbonate/Carbon Dioxide, Chloride, Calcium

…

Alanine transaminase ALT, alkaline phosphatase ALP, aspartate aminotransferase AST

albumin, bilirubin

IV Fluids

Isotonic = same concentration as blood

-used for hypotension or hypovolemia

-0.9% NS, lactated ringers LR, D5W

……………….

Hypotonic = less concentrated than blood

-used for hyperglycemic episodes

-0.45%, 0.33%, 0.2% NaCl

-0.45%, 0.33%, 0.225% NS

………………

Hypertonic = more concentrated than blood

-used for BP stabilization, increasing urine output, volume expanders

-D5NS, D5 1/2NS, D5 LR

-3% NS, 5% NS, D5W/NS

Sodium

Regulates fluid, interacts with calcium to maintain muscle contraction, stimulate nerve impulse conduction

..

Salt, processed foods, canned foods

—No more than 2300mg/day, 1500mg/day if hypertension

..

Normal Range = 135-145 mEq/L

Low = Hyponatremia = Under 135

High = Hypernatremia = Over 145

…………………………………………………………….

Hyponatremia

-diuretics, GI fluid loss, excessive water

-weakness, lethargy, confusion, seizures, N/V

—SALT LOSS = Stupor/coma, Anorexia/nausea/vomiting, Lethargy, Tendon reflex decrease, Orthostatic hypotension, Seizure/headache, Stomach cramping

-administer IV saline, seizure precautions

………………

Hypernatremia

-excessive sodium intake, water deprivation, increased water loss, hypertonic tube feeding

-thirst, elevated temperature, dry mouth

—severe: hallucinations, irritability, lethargy, seizures

—FRIED SALT = Flushed skin/fever, Restless/irritable/anxious/confused, Increase BP/fluid retention, Edema-peripheral/pitting, Decreased urine output/dry mouth, Skin flushed, Agitation, Low-grade fever, Thirst

-restrict sodium, increase water, IV solutions without sodium

—beware of hidden sodium

Potassium

Nerve signaling, muscle function, BP regulation, pH balance

…

Bananas, oranges, carrots, potatoes, diary products, meats

—At least 4700 mg/day

…

Normal Range = 3.5-5 mEq/L

Low = Hypokalemia = under 3.5

High = Hyperkalemia = over 5

……………………………………………………………..

Hypokalemia

-diuretics, GI fluid loss, steroids, anorexia/bulimia

—DITCH = loop diuretics/laxatives/glucocorticoids, Inadequate intake, Too much water intake, Cushings syndrome, Heavy fluid loss

-fatigue, anorexia, N/V, decreased GI motility, dysrhythmia, paresthesia, EKG with flat T waves

—7Ls = Lethargy, Low/shallow respirations, Lethal cardiac dysrhythmias, Lots of urine, Leg cramps, Limp muscles, Low BP/Heart

-encourage potassium-rich food, supplementation

………………..

Hyperkalemia

-renal failure, K sparing diuretics, high K intake with renal insufficiency, acidosis, major trauma, hemolyzed specimen

—CARED = extracellular movement, Adrenal insufficiency/Addisons, Renal failure, Excess intake, potassium-sparing diuretics/ACE inhibitors/NSAIDS

-muscle weakness, dysrhythmias, tall/peaked T waves on EKG

—DEATH = Decreased HR, early muscle twitching/later weakening, Arrhythmias, Tummy trouble, Hypotension

-caution about potassium-rich foods with elevated creatinine/renal disease

…………………………………

EKG Changes

-Hypokalemia = T wave inversion, ST depression, prominent U waves

-Hyperkalemia = peaked T waves, P wave flattening, PR prolongation, wide QRS complex

Calcium

Bone health, neuromuscular function, cardiac function, blood clotting

…

Milk & milk products, dark green leafy vegetables, fortified foods

—1000-1200 mg/day

…

Normal Range = 8.5-10.5 mg/dL

Low = Hypocalcemia = under 8.5

High = Hypercalcemia = over 10.5

…………………………………………………………

Hypocalcemia

-hypoparathyroidism, malabsorption, pancreatitis, alkalosis, vitamin D deficiency

-diarrhea, paresthesia, muscle cramps, tetany, positive trousseau & chvostek, seizures, cardiac irritability

—CRAMPS = Convulsions, Reflexes hyperactive, Arrhythmias, Muscle spasms, Positive signs, Sensation of tingling/numbness

—SPASMODIC = Spasm, Perioral paranesthesia, Anxious/irritable, Seizures, Muscle tone increased, Orientation impaired/confusion, Dermatitis, Impetigo herpetiformis, Chvosteks sign/cardiomyopathy

-calcium supplements

—severe = monitor airway, seizure precautions, parental calcium

………………………

Hypercalcemia

-hyperparathyroidism, malignant bone disease, prolonged immobilization, excess calcium supplements, thiazide diuretics

-constipation, kidney stones, bizarre behavior, bradycardia, anorexia, N/V, muscle weakness

—Bones, Groans, Thrones, Psychiatric Overtones

-increase fluid/fiber, eliminate calcium supplements, limit calcium-rich foods, no calcium-based antacids

—severe = may need dialysis

Trousseau’s Sign

BP cuff around arm

Inflate for 1-4 min

If hands or fingers spasm in palmar flexion = Positive

Chvostek’s Sign

Tap face just below & in front of ear

If face twitches on one side of mouth/nose/cheek = Positive

Magnesium

Carb/protein metabolism, Protein/DNA synthesis, Electrical activity in nerves/muscles/brain, BP regulation

…

18-30mEq/L a day needed

…

Normal Range = 1.6-2.6 mEq/L

Low = Hypomagnesemia = under 1.6

High = Hypermagnesemia = over 2.6

……………………………………………………..

Hypomagnesemia

-Chronic alcoholism, malabsorption, diabetic ketoacidosis, prolonged gastric suctioning

-neuromuscular irritability, dysrhythmias, mood changes, disorientation

—Confusion, increased DTRs, seizures, muscle cramps, tremors, insomnia, tachycardia

-encourage high-magnesium foods, avoid alcohol, monitor for digoxin toxicity

……………………

Hypermagnesemia

-Renal failure, adrenal insufficiency, excess replacement

-flushing, hypotension, lethargy, hypoactive reflexes, depressed respiration, bradycardia

—decreased DTRs, muscle weakness

-monitor VS/airway/reflexes, avoid magnesium-based antacids/laxatives, restrict magnesium in diet

Phosphorous

Catalyst for intracellular activities, muscle/nerve action, acid-base balance

…

Meat, fish, poultry, milk

…

Normal Range: 2.5-4.5 mEq/L

Low = Hypophosphatemia = under 2.5

High = Hyperphosphatemia = over 4.5

……………………………………………………….

Hypophosphatemia

-refeeding after starvation, alcohol withdrawal, diabetic ketoacidosis, respiratory acidosis

-paresthesia, joint stiffness, seizure, cardiomyopathy, impaired tissue oxygenation

—respiratory failure, numbness, confusion, reduced oxygen transport, bone resorption, cardiomyopathy, convulsions, irritability, leukocyte/platelet dysfunction, muscle/nerve dysfunction, coma

-monitor calcium, start total parenteral nutrition TPN slowly

……………………

Hyperphosphatemia

-renal failure, hyperthyroidism, chemotherapy, excess phosphate-based laxative

-short term = tetany, long term = calcification in soft tissues

—tetany, calcification, convulsions, cardiac arrest, hyper-neuromuscular activity, prolonged QT interval

-monitor for tetany

—severe = aluminum hydroxide with meals

Oral Electrolyte Supplements

Supplements = Medications

Potassium with juice

Hydration important with calcium

Fluid Volume Imbalances

Hypovolemia = fluid volume deficit

-Begins as dehydration

—Insufficient intake, excessive loss/shift, burns

—First symptom = thirst

-Progresses to hypovolemic shock

—Rapid, weak pulse, Orthostatic hypotension, Increased temperature

-Clinical Manifestations = acute weight loss,

--decreased skin turgor, dry mucous membranes

—oliguria, orthostatic hypotension, thirst, anorexia

—muscle weakness/cramps, seizures, coma

-Correct underlying cause, replace water/electrolyte

……………………………………………………

Hypervolemia = fluid volume overload

-excessive sodium & water retention

—excessive salt intake, kidney/liver disease, poor pump of heart

-Clinical Manifestations = weight gain,

—headache, lethargy,

—edema, JVD, crackles/wheezing, dyspnea,

—increased BP, bounding pulse, polyuria

-remove fluid without changing electrolyte composition/osmolality, fluid restriction, sodium restriction

……………………………………………………..

Assessing Fluid Imbalances

-Vital Signs, BUN, Creatinine, Electrolytes, Specific Gravity

Vascular Access

Peripheral

-Butterfly needle, peripheral IV, midline peripheral catheter

..

Central

-Implanted ports, peripherally inserted central catheter PICC, tunneled central venous catheters

-Advantages:

—avoid vein irritations, access even with severe fluid depletion, longer duration than peripherals

—nutrition, blood draws

—less likely for phlebitis, extravasation, infiltration

-Disadvantages:

—specialized training, patient consent, placement confirmation, sterile technique, riskier

Central Line Care

Assess

-radiographic confirmation, dressings, tenderness, infection/bleeding/compromise

…………

Nursing Interventions

-stabilizer, semipermeable clear dressing

—dry, intact, air occlusive

-manipulate as little as possible, don’t use arm

-flush before/after any infusion, never flush against resistance

-label lumen

Intraosseous Access

Matrix of bone

—quickly absorb into central circulation

—most commonly proximal tibia

Infection Risk = osteomyelitis

For immediate/short term access

—Less than 24hr

How Often?

Change Dressings

-Short Term Central Line Transparent

—every 5-7 days

-Short Term Central Line Gauze

—every 2 days

-Tunneled/Implanted Central Line

—no more than once a week

……………………………

Administration Sets

-Continuous Infusion

—primary/secondary no earlier than 96hr, no later than 7 days

-Intermittent Infusion

—every 24hr

Parenteral Infusion

—at least every 24hr, with each new solution

Blood

—after each unit

IV Fat Emulsion

—every 12hr

Managing Multiple Lines

Label, number each site, keep untangled

Check solution compatibility

NEVER infuse anything with blood, TPN, or lipids

IV Therapy Complications

Infiltration = IV infusion enters tissues not vein

—Infusion stopped/slowed, swelling, tenderness, pallor, hardness, coolness, burning sensation

—stop infusion, restart in different vein, elevate arm, notify provider

…………………………

Extravasation = IV infusion enters tissue, not vein but substance is HARMFUL to the tissue

—IV infusion stopped/slowed, swelling, burning, swelling, blanching/coolness, blistering = late sign

—stop infusion, cold compress, elevate arm, notify provider

………………………..

Phlebitis = Inflammation of vein

—Redness, pain, warmth, local swelling, palpable cord slowed/stopped infusion

—Stop infusion, start in new location, cold compress then warm compresses, assess circulation, notify provider

—Prevention: smallest catheter that’s practical, stabilize catheter, minimize catheter movement, rotate sites

……………………….

Thrombophlebitis = thrombosis & infection

—Slow flow, edema, warmth, erythema, feeling a cord

—Stop infusion, restart in opposite arm with all new equipment, warm/moist compresses, notify provider

……………………..

Hematoma = localized collection of blood

—Ecchymosis, localized mass, discomfort

—Apply pressure when discontinuing IV, don’t fish

……………………..

Nerve Injury = Inadvertently injured or compressed

—Direct: sharp pain at site, paresthesia, electric shock sensation, all persisting after needle is removed

—Compression: paresthesia 24-96hr after venipuncture

—No more than 2 attempts, stop if complaining of symptoms, apply pressure to prevent hematoma, notify provider, don’t use the arm

Systemic IV Complications

Fluid Volume Excess

—What to do: slow infusion rate, high fowler’s monitor vital signs, oxygen as needed, notify provider

………………………..

Sepsis = bacteria in bloodstream

—Signs: fever, tachycardia, altered mental status, high WBC

-What to do: stop IV infusion, notify provider

………………………

Air Embolus = air gets into bloodstream

—Causes: loose connection, not clearing line of air, adding bag to a line that ran dry without priming

-What to do: EMERGENCY, turn on left side/trendelenberg

……………………..

Catheter Embolus = piece of catheter breaks off

—Causes: reinserting a catheter after an unsuccessful insertion, removing & reinserting stylet

—What to do: apply tourniquet above site, notify provider

…

…

Skin Terms

Maceration = softening due to soaking/steeping

Excoriation = superficial skin loss due to scratching

………………………..

Amputation, Puncture, Crush, Laceration

Avulsion = skin flap

Steven Johnson’s Syndrome SJS

Serious skin peeling condition caused by severe allergic reaction to medication or illness

-Rashes, blisters, peeling

-Mucus membranes: eyes, genitalia, mouth

—eyes can seal shut, painful urination, drooling, can’t eat

Most commonly under 30yo

…..

Causes

-Children: infections

-Adults: medications

—anti-epileptic, allopurinol, NSAIDS, antibiotics

Wound Culture

Organism identified

Colony count

Antibiotic sensitivity testing

…………………………………………………………

Over 100k organisms/gram tissue = infected

-need higher count to overwhelm immune system

-Unless beta-hemolytic streptococci

—causes RBC breakdown

—strong ability to cause infection

—any found in wound = infected

Wound Depth

Superficial = outer layer of skin

—redness, swelling

—heals well with appropriate first aid

………………………

Partial thickness = epidermis

—raw area with blistering

—medical treatment needed after first aid

………………………

Full thickness = all layers

—nerve & tissue damage

—urgent medical attention need

Leg Ulcers

Arterial = insufficient blood supply to area

-Risk Factors: vascular insufficiency, uncontrolled blood sugar, limited joint mobility, improper footwear

-Characteristics: punched out, smooth wound edges, pain at night, relieved by elevating leg, lower extremities cool to touch, pale/shiny/thin skin, minimal/no hair growth, minimal wound drainage, usually lateral foot

…………………………….

Venous = blood pooling due to increased venous pressure

-Risk Factors: varicose veins, deep vein thrombosis, incompetent valves, muscle weakness in legs, immobility, pregnancy

-Characteristics: shallow and superficial, irregular shape, painful from edema/phlebitis/infection, usually in lower legs/ankles

…………………………………………………………

Diabetic

-Typically painless due to altered sensation

-Highly susceptible to infection

-Usually on plantar surfaces/toes

Wound Healing

Types

-Regenerative/Epithelial = only involves epidermis & dermis

—no scar, can’t tell was there

…

-Primary = edges are clean, brought together with closure

—small scar, surgical incision, stitched hand laceration

…

-Secondary = edge not close together, tissue loss

—shouldn’t be closed, leave to heal on own

—heals from inside, bigger scar, heals slower, more prone to infection

—gaping, irregular wound

…

Tertiary/Delayed = left open, then closed later

—not closed either due to infection risk/swelling

—less scaring than secondary, more than primary

—prone to infection, increased granulation

………………………………………………………..

Phases of Wound Healing

-Inflammatory

—1-5days, hemostasis & inflammation

-Proliferative/Granulation

—5-21days, cells fill in wound & resurface skin, granulation tissue is fragile & bleeds/damages easily

-Maturation/Epithelialization

—2-3weeks until healed, remodeling, forms scar tissue

Types of Wound Closures

Adhesive strips/steri strips

—low tension wounds, additional closure to an already closed wound

—don’t pick off, fall off on own

………………

Sutures/stitches

—absorbable doesn’t need to be removed

……………….

Staples

—lower risk of infection & tissue reaction than sutures

—have to be removed

……………….

Surgical glue

—good for low tension wounds, don’t pick at, no ointments

Types of Wound Drainage

Serious = clear, yellow

Sanguineous = bright red

Serosanguineous = light pink, pale red

Purulent = thick, milky

……………………………..

Penrose, Hemovac, Jackson Pratt, Negative Pressure Wound VAC

..

What to know = label & assess drains, don’t dislodge, monitor amount of drainage, make sure no kinks in tubing, report any significant change to provider

Wound Complications

Hemorrhage

-profuse, rapid blood loss

-greatest risk 24-48hr after surgery/injury

-internal or external

…………………………..

Infection

-Traumatic wound usually 2-3 days

-Clean surgical wound usually 4-5 days

………………………….

Dehiscence

-separation of 1+ layers of wound

-Causes = poor nutrition, inadequate closure, wound infection, increased tension, obesity

-What to do: bedrest, heat of bed 20deg, knees flexed, apply binder, notify provider

…………………………..

Evisceration

-organ is protruding through wound

-EMERGENCY

—what to do: cover with sterile dressing soaked in saline, don’t put organs back, bedrest with knees bent, NO BINDER, notify provider

………………………….

Fistula

-abnormal passage connecting 2 body cavities or body cavity/skin

-Causes: infection, debris in wound

-Commonly between GI & urinary tracts

Pressure Injuries

Localized injury to skin & underlying tissue over bony prominence

-When ischemia first occurs, skin is pale & cool

—When pressure is relieved, hyperemia

—If redness doesn’t disappear quickly, then damage has occurred

……………………

Risk Factors: impaired circulation, reduced oxygen, immobility, reduced sensation

…………………….

Stages

-Stage 1 = non blanchable redness

-Stage 2 = open but swallow wound, red/pink wound bed, no slough, may be a blister/ulcer

-Stage 3 = deep crater, full-thickness skin loss, damage/necrosis of subcutaneous tissue, may go down but not through underlying fascia, undermining, can’t see or palpate bone/tendon

-Stage 4 = extensive tissue destruction, necrosis, damage to muscle/bone/support structures, can see/palpate tendon/bone

—Unstageable = slough, eschar

—Deep Tissue = intact but persistently discolored, purple/deep red

…………………….

Scales/Tools

-Braden, Norton

—lower score, higher risk

-PUSH tool

—progression of pressure injury

—as injury heals, score falls

……………………

Assess skin daily

-For at risk patients: at least every 8-12hr

Wound Labs

Serum Protein

—6.0-8.0 g/dL

Serum Albumin

—3.4-4.8 g/dL

Serum Prealbumin

—12-42 mg/dL

…………………………….

Partial Thromboplastin Time aPTT

-Normal = 25-35 sec

-Critical value = greater than 75sec

………...

Prothrombin Time PT

-Normal = 10-13 sec

-Critical value = greater than 40ec

………..

International normalized ratio INR

-Uncoagulated = 0.9-1.1

-Coagulated = 2-3

-Critical value = Greater than 5

Cleansing & Irrigation

Cleanse

-remove exudate, slough, foreign materials, microorganisms

-always clean initially & with each dressing change

-gently pat surface with saline-soaked gauze or wound cleanser

-try not to disrupt granulation tissue

……………………………

Irrigation

-Sterile saline warmed to room temperature

-Improve wound healing, reduce inflammation, remove debris, hydrate site, cleanse wounds

—less than 15 psi to avoid tissue damage

—Total Volume = 50-100 cc per cm laceration length

Debridement

Sharp = scissors, scalpel

Mechanical = lavage, wet to dry dressing, hydrotherapy

Enzymatic = cream, only apply to devitalized tissue

Autolytic = occlusive moisture retaining dressing and body’s own enzymes

Biotherapy = medical-grade maggots

Types of Wound Dressing

Primary = applied directly to wound

Secondary = covers/holds primary

………………….

Absorbent

-wounds with moderate/large dressings

-not used for packing, only if wounds are draining

…

Alginate

-derived from seaweed/kelp, assess for allergies

-promotes moist, facilitates autolytic debridement

-good for wound tunneling/undermining

-will adhere if wound is dry

…

Antimicrobial

-silver, iodine, assess for allergies

…

Collagens

-bovine or porcine, check with religion

-absorbs exudate, moistens wound bed

-doesn’t stick to wound bed

…

Foams

-heavy drainage, protects friable skin, doesn’t stick

-don’t use on tunneling, dry, or dehisced wounds

-can macerate, can’t see wound bed

-high change of bacterial invasion

…

Gaze

-cleansing, protection, packing

-can stick to wound bed

…

Hydrocolloid

-absorb, protect, promote autolytic debridement

-good for minimal exudate

-not good if surrounding skin is delicate/friable, can be odorous, opaque

…

Hydrogels

-rehydrates wound bed, promotes autolytic debridement, softens eschar/slough

-not absorbent, can macerate the peri wound area

…

Skin Sealants & Moisture Barriers

-zinc, dimethicone, petrolatum

-used every dressing change, can impair adhesions of wound to dressing/tapes

…

Transparent Film

-promote autolysis, prevent external bacterial contamination

-clear = can leave in place for assessment

-don’t use on friable skin, can macerate draining skin wounds

…

…

Types of Loss

Actual, Perceived

Physical, Psychological

External, Aspects of self, Environmental, Significant relationships

Grief

5 Stages

—Denial, Anger, Bargaining, Depression, Acceptance

………………………

Types

—Uncomplicated, Dysfunctional, Disenfranchised, Anticipatory