Nursing 118 Final Exam

Metabolism

Metabolism

Begins when the drug reaches the site of action

The chemical breakdown & inactivation of a drug

• The drug molecules are broken down to prepare for excretion

★most drugs are _____ed in the liver

• Liver = hepatic system

★ What affects it?

• Liver disease/liver failure/impaired function

• Hepatic disease - hepatotoxicity - hepatitis

• Disease - diabetes

★ Impaired _____ can result in toxic & deadly drug levels

Excretion

The removal of drugs from the body

Drug molecules are removed from site of action & eliminated from the body

Common organs where excretion occurs

• Kidneys primary site = urine

• Renal system = kidney system

- Liver/gi tract = feces/stool

- Lungs = exhalation/exhaling air

- Exocrine glands = sweat & saliva

• What affects it?

- Renal/kidney disease or failure

- Restrictive lung disease

- Bowel obstruction

Pharmacodynamics - Primary Effects of Drug

Therapeutic Effect

Predicted, Desired, Intended

Pharmacodynamics - Secondary Effects of Drug

Types include:

Side effects - UNINTENDED BUT PREDICTABLE - CAN CONTINUE DRUG

•Adverse reactions - UNINTENDED & HARMFUL - MUST STOP DRUG

▪SEVERE ADVERSE REACTIONS ARE LIFE THREATENING

•Toxic reactions - DAMAGE ORGANS & TISSUE - CAN CAUSE DEATH

•Allergic reactions - IMMUNE SYSTEM REACTION

•Idiosyncratic reactions - UNEXPECTED -ABNORMAL - PECULIAR RESPONSE

▪PARADOXICAL = OPPOSITE OF EXPECTED RESPONSE

•Cumulative effect - INCREASED RESPONSE FROM REPEATED DOSES

Types of precautions to be aware of before entering a patient’s room

Contact, Droplet & Airborne

Contact Precautions

•Used for Diseases spread by contact - Direct or Indirect

•Used along with Standard Precautions

•PPE – gloves & gown

•Patient room placement:  private room or cohort

•Limit transport​​

•MDRO’s patient= Multidrug Resistant Organisms

•methicillin resistant staphylococcus aureus (MRSA)

•vancomycin resistant enterococcus (VRE)

•extended spectrum beta-lactamase (ESBL)

•Clostridium difficile (C-Diff)

•THIS REQUIRES HAND WASHING WITH SOAP & WATER AS WELL AS DISINFECTING WITH BLEACH WIPES FOR SURFACES & EQUIPMENT (Spores)

Droplet Precautions

•Large particle diseases that travel & fall from the air

•Particles are large and heavy >5 microns

•Occurs within 3-6 feet distance

•Close respiratory or mucous membrane contact

•Coughing - sneezing - talking - suctioning

•Used along with Standard Precautions - Freq. Hand Washing

•PPE  surgical mask

•Patient room placement:  private or cohort

•Transportation:  patient must wear surgical mask

•Influenza (flu), German Measles (Rubella),  Pertussis(whooping cough)Meningitis, Mumps, Streptococcus (strep throat)

Airborne Precautions

•Small AEROSOLIZED particles - STAY SUSPENDED IN THE AIR LONGER

•Diseases that travel by air > 6 feet

•Used with Standard Precautions

•PPE: N95 Personal Respirator

Patient placement:

•Isolated in private room with negative air pressure

•6 – 12 air exchanges per hour; keep doors closed

•Patient transport – do not transport patient unless necessary, patient wears surgical mask

Memory trick: REMEMBER MTV & NOW C & SARS

•Measles (Rubeola), Tuberculosis, Varicella (chicken pox) or (open shingles = Herpes Zoster), COVID, & SARS (CORONAVIRUSES)  

Disposing of Used Isolation Supplies

Place contaminated disposable equipment and materials containing body fluids in special isolation bags. This process requires two healthcare workers.

 The worker inside the room wears protective clothing and handles only contaminated items.

• The second worker stands at the door and holds the isolation bag open.

• The first worker places items inside the bag without touching the outside of the bag.  If the bag contains linens, the isolation bag is closed and placed in a laundry hamper.

• Securely close an isolation trash bag and place it in a special isolation trash container.

• Special disposal methods are used to prevent these objects from going into a

  landfill, where they could become a reservoir of infection.

Factors Contributing to Surgical Risk

•Age  - VERY OLD - VERY YOUNG

•Type of wound - PRE-EXISTING OR POST OP

•Pre existing conditions - ACUTE OR CHRONIC 

•Mental status - CONFUSED - MENTAL ILLNESS

•Medications - PRESCRIBED - OTC - HERBAL 

•Personal habits - SMOKING - ILLEGAL DRUGS - ALCOHOL

•Allergies - ABT’S - ANALGESICS - LATEX - ANESTHESIA - SHELLFISH

•Pre existing conditions, Risk factors for Older Adults / Medications

•Delirium

•Respiratory changes

•Age related skin changes

•Decreased gastrointestinal motility

•Decreased genitourinary function

•Kidney function

•Decreased Cardiac Output

•Increased peripheral vascular resistance

—

•Anticoagulants

•Anti-hypertensives

•Aspirin

•Corticosteroids

•Opioids

Pre-Op Meds

•Opioid -

•morphine

•Anti-infective

•ampicillin

•azithromycin

•Anesthetic sedation

•midazolam – anxiolytic, benzodiazepine, amnesiac

•Propofol – used in moderate sedation

•Anticholinergic

•atropine – reduces secretions to prevent aspiration pneumonia

•Antiemetic

•Ondansetron - nausea & vomiting

These are important to know

OPIOIDS = Can cause Resp. Depression & Sedation

Pain relief & sedation can assist to induce anesthesia = MORPHINE - MEPERIDINE - FENTANYL

ANTIBIOTICS =

Reduce microbial burden during surgery when patient at their most vulnerable state for immune defence - AMPICILLIN - VANCOMYCIN - CEFAZOLIN

ANTICHOLINERGIC =

Decreases oral and pulmonary secretions, which decrease chance of aspiration pneumonia = ATROPINE

ANTIEMETIC =

Prevents vomiting that can lead to aspiration which then causes pneumonia = ONDANSETRON

  ALSO USED POST OP FOR NAUSEA & VOMITING

PACU Responsibilities & Priority Assessment

Airway

•If unconscious, turn patient on side

•Patency, artificial airway, ventilator settings

Breathing

•Respiratory rate, lung sounds, skin color

•Pulse oximetry

Circulation

•Blood pressure, pulse rate

•Drainage on dressing

Nausea, Pain

Post OP complications & Interventions

1. HEMORRHAGE

2.INFECTION

3.DVT = THROMBUS & EMBOLUS

4.ATELECTASIS & PNEUMONIA

5.ASPIRATION PNEUMONIA

6.NAUSEA / VOMITING

—

1.Monitor vital signs(TACHYCARDIA & HYPOTENSION), dressings, wound drainage

2.ASSESS FOR - REEDA & COCAF - V/S FOR FEVER - WBC - C&S

3.PREVENT DVT BY PROMOTING VENOUS RETURN

a.AMBULATE, COMPRESSION STOCKINGS, ANKLE & LEG EXERCISES, ROM, SEQUENTIAL COMPRESSION DEVICES

4.OOB, AMBULATE, DEEP BREATH & COUGH, INCENTIVE SPIROMETER, HIGH FOWLER'S

5.KEEP NPO UNTIL + GAG, + BOWEL SOUNDS, NO N/V, CAN SWALLOW

6.KEEP NPO MEDICATE

Pain & Opioids

1.ASSESS PAIN USING APPROPRIATE PAIN SCALE

2.GATHER ALL DATA ABOUT THE PAIN, LOCATION, INTENSITY, ETC

3.DETERMINE IF THERE IS AN ORDER FOR OPIOID

4.CHECK WHEN THE OPIOID WAS LAST GIVEN

5.ASSESS PT V/S & LOC BEFORE AND AFTER ADMINISTERING OPIOID

6.OPIOIDS CAUSE SEDATION AND RESPIRATORY DEPRESSION

7.NURSE CAN HOLD OPIOID IF V/S LOW OR PT IS SLEEPY ETC..

8. POST OP PATIENTS CAN NOT PARTICIPATE IN SURGICAL RECOVERY IF THEY ARE IN PAIN.

9.IF PATIENT HAS RESPIRATORY DEPRESSION WE GIVE: NARCAN TO REVERSE OPIOID EFFECTS

Types of Wound Drainage

Serous

•WATERY - SERUM - CLEAR TO STRAW COLORED = CLEAN WOUNDS

Sanguineous

•BLOOD - BRIGHT RED TO DARK RED/BROWN = FRESH BLEEDING

Serosanguineous

•COMBO OF BLOOD & SEROUS = NEW WOUNDS

Purulent

•THICK - ODOROUS - WHITE - YELLOW - GREY  = INFECTION

Purosanguinous

•RED TINGED PUS & BLOOD = INFECTION / NEW WOUND

Types of Wound Healing

Regenerative/Epithelial -

EPIDERMIS & DERMIS REGENERATION (GROWTH OF NEW CELLS)

PARTIAL THICKNESS WOUNDS

Primary Intention - RITA’S ABDOMEN

•CLEAN - APPROXIMATED = SURGICAL WOUND

Secondary Intention - RITA’S PRESSURE ULCER

•TISSUE LOSS - NOT APPROXIMATED - LONGER TO HEAL

•HEALS BY FILLING WITH GRANULATION TISSUE INSIDE OUT

Tertiary Intention

•DELAYED CLOSURE - OPEN WOUND

•FIRST ALLOW TO HEAL BY SECONDARY INTENTION

•ONCE NO S/S OF INFECTION OR INFLAMMATION IT IS SUTURED

Wound Healing Intentions

Regenerative/Epithelial - ONLY AFFECTS EPIDERMIS & DERMIS

Primary Intention - MINIMAL OR NO TISSUE LOSS- SURGICAL INCISION

Secondary Intention - EXTENSIVE TISSUE LOSS - EDGES CANT COME TOGETHER D/T TISSUE LOSS OR INFECTION

• BEEFY RED GRANULATION TISSUE & PINK/PEARL EPITHELIAL TISSUE FILL THE WOUND BED

• GREATEST RISK OF INFECTION DUE TO LONGER TIMES TO HEAL

Tertiary Intention - TWO SURFACES OF GRANULATION TISSUE SUTURED TOGETHER

• MUST HAVE NO EVIDENCE OF REEDA PRIOR TO SURFACE SUTURING

• REQUIRE STRICT ASEPTIC TECHNIQUE

Dehiscence

•Separation of one or more layers of wound;

•Causes: poor nutrition, obesity, strain on suture line, inadequate closure, infection

•Interventions:

Maintain bedrest with HOB at 20 degrees & knees flexed

Apply binder to prevent evisceration

Notify provider of occurrence

Continue to monitor/assess patient

Evisceration

•Total separation of the layers of wound with internal viscera protruding through

•Cover wound with sterile towels soaked with sterile saline

•Bedrest with knees bent to prevent strain

•HOB 20 degrees

•Notify surgeon and prep for surgery

Stage I Pressure Ulcer

SKIN IS INTACT

EPIDERMIS

NONBLANCHABLE = DOES NOT CHANGE COLOR WHEN PRESSED

Stage II Pressure Ulcer

SKIN IS OPEN - SKIN INTEGRITY IS COMPROMISED

DEPTH - PARTIAL THICKNESS

EPIDERMIS

DERMIS

Stage III Pressure Ulcer

EPIDERMIS

DERMIS

SUB Q (fat)

MAY SEE FASCIA

Stage IV Pressure Ulcer

EPIDERMIS

DERMIS

SUB Q (fat)

MUSCLE - ONCE MUSCLE DEPTH OCCURS CAN INVOLVE SUPPORTING STRUCTURES:

FASCIA

BONE

TENDONS

JOINT CAPSULES

Unstageable Pressure Ulcer

NECROTIC TISSUE FORMS

(DO NOT REMOVE STABLE ESCHAR - ACTS AS “NATURAL COVER”

Breathing Patterns

•Eupnea - NORMAL RESP RATE 12-20

•Tachypnea - FAST SHALLOW RESP RATE > 24  - PNEUMONIA - PULM. EDEMA - METABOLIC 

ACIDOSIS - SEPSIS - PAIN - FRACTURES

•Bradypnea - SLOW RESP RATE < 10 - HEAD INJURY - DRUG OD - C02 >45

•Dyspnea - DIFFICULTY BREATHING - SOB

•Orthopnea - DIFFICULTY BREATHING WHEN SUPINE

•Apnea - ABSENT - NO BREATHING - SLEEP APNEA - DEATH

•Kussmaul’s Respirations - FAST & ABNORMALLY DEEP RESP.  - METABOLIC ACIDOSIS

•Biot’s Respirations - IRREGULAR CYCLES - FAST & SHALLOW FOLLOWED WITH APNEA - BRAIN INJURY = NEURO

•Cheyne-Stokes Respirations - REGULAR CYCLES - FAST DEEP RESP. THEN DECREASE DEPTH TO APNEA - DAMAGE TO RESP. CENTER

Assessing Respiratory Effort

Nasal flaring—The visible enlargement of the nostrils with inhalation. It helps reduce resistance to airflow in the nose and keep the nasal passages open to take in more air.

Retractions—The visible “pulling in” of intercostal, supraclavicular, and subcostal tissue, caused by excessive negative pressures generated in the chest to try to increase the depth of inhalation.

Use of accessory muscles during inspiration—The patient may use the intercostals, abdominal muscles, and muscles of the neck and shoulders when there is an increased demand for oxygen or problems with ventilation.

Grunting—Noisy, difficult breathing. It is caused by forced expiration and by involuntary muscle contraction during expiration to help keep alveoli open and enhance gas exchange.

Body positioning to facilitate respirations—The patient usually finds an upright posture the most comfortable. In the upright position, gravity pulls the abdominal organs down and allows the diaphragm more room to contract. Most patients with dyspnea cannot tolerate lying down. Orthopnea is the term for describing difficulty breathing (shortness of breath) when lying down. Ask how the patient usually sleeps. Some patients may report sleeping in a recliner or chair.

Conversational dyspnea—The inability to speak complete sentences without stopping to breathe. The more frequently the patient pauses when speaking, the more severe the dyspnea.

Stridor—A high-pitched, harsh, crowing, inspiratory sound caused by partial obstruction of the larynx or trachea. You can hear it without a stethoscope.

Wheezing—A musical sound produced by air passing through partially obstructed small airways. It is often heard in patients with asthma and lung congestion.

Diminished or absent breath sounds- You must evaluate why - what circumstances

• In patients with dyspnea these are worsening symptoms

• If a patient has right lower lobe pneumonia may expect they may have decreased breath sounds in that lobe

• If patient was intubated are there diminished breath sounds on one side, is it from ET tube placement issue

• If patient elderly, is it from poor inspiratory effort d/t weakness

Auscultating Lung Sounds

•Instruct to take slow deep breaths through open mouth

•Expect:  Lung sounds clear to auscultation

Normal Lung sounds:

•Bronchial:  over trachea

•Broncho-vesicular:  over sternum in front, between clavicles posteriorly

•Vesicular:  heard over lower lung fields

—

•Patient chest should be unclothed and bare to hear lung sounds

•Stethoscope ear stems should be pointed outward and placed snug in ears

•Requires use of the diaphragm (the larger end) of the stethoscope

•Never listen over bone - listen between ribs - Intercostal spaces

•Listen for full inspiration & full expiration - OPEN MOUTH

•Technique - Follow systematic pattern

•Move from right to left or left to right - LATERAL COMPARING BOTH SIDES

•This compares each lobe, side to side

•Note the lungs sounds heard over each lobe

Abnormal Lung sounds

Abnormal lung Sounds = Adventitious Lung Sounds

Rales (crackles) - Air bubbling through moisture/fluid in ALVEOLI - OFTEN ON INSPIRATION - Remember Rales in the Tails (Alveoli are in the “tail end” of the lung)

Hear with any illness that causes fluid in alveoli

Pneumonia - asthma - CHF - ATELECTASIS - PULM. EDEMA

CANNOT BE CLEARED BY COUGHING

Fine Rales = Crackling (Hair rubbing together) - High pitched - fireplace wood burn

Rhonchi - RUMBLING SNORING SOUND - Air moving through mucous in large TUBULAR airways = BRONCHI - REMEMBER RHONCHI IN THE BRONCHI - OFTEN HEARD ON EXPIRATION - NARROW BRONCHIAL PASSAGES - PNEUMONIA - BRONCHITIS - COPD - SECRETIONS

MAY BE CLEARED BY HAVING THE PATIENT COUGH OR WITH SUCTIONING

Wheezes - Narrow/Constricted small airways from partial obstruction - USUALLY on EXPIRATION - musical - whistling sound  - ASTHMA - BRONCHOSPASMS

Stridor - EMERGENCY!!! - UPPER AIRWAY PARTIAL OBSTRUCTION -

Can lead to full Obstruction =  Maslow = Airway 1st - Usually more prominent on INSPIRATION

CAUSES = ANAPHYLAXIS - TRAUMA - CROUP - EPIGLOTTITIS - FOREIGN BODY -  PERITONSILLAR ABSCESS - TUMOR - TRACHEITIS

Pleural friction rub - Pleural layers rubbing together - LIKE LEATHER RUBBING TOGETHER OR FINGERS RUBBING TOGETHER - INFLAMMATION - LOW PLEURAL FLUID

Grunting - Trapped air that is forced out on expiration - thus a grunting noise

Peak Flow Meter

•Measures the amount of air that can be exhaled with Forcible effort

•Patients with asthma use PEFR monitoring to detect subtle  changes in their condition

•Green – all clear (80-100% of normal breathing rate)

•Yellow – caution – take bronchodilator (50-80% of normal breathing rate)

•Red – severe reduction in peak flow – go to ED ( <50% of normal breathing rate)

Incentive Spirometer

Goal of this is to:

•acilitate sustained slow deep breath

• prevent and reverse atelectasis when   

used regularly and appropriately.

• helps to liquefy, loosen and prevent   

   pneumonia.

Hypoxemia

•Low arterial blood oxygen levels

•Poor diffusion across alveolar membranes

Etiology: 

•Heart Failure - COPD

•Sleep Apnea

•Anemia - Asthma - Pneumonia - PE

S/S =

Headache - SOB - Tachycardia - Tachypnea - confusion - cyanosis of skin fingers lips

TX =

Raise O2 blood levels- Give Medications to treat underlying causes - stop smoking - deep breathing - pursed lip breathing - H2O - eat healthy - walking

Hypoxia

•Inadequate oxygenation of organs or tissues

Etiology: 

•Hypoxemia 

•circulatory/resp. disorders

• Low Hemoglobin

Hypercarbia

•Excess of CO2 dissolved in blood

Etiology: hypoventilation - COPD - Sleep Apnea

•Anesthetic effect

Sever s/s = high blood levels of carbon dioxide have an anesthetic effect on the nervous system and can lead to somnolence progressing to coma and death

Hyperventilation to try and blow off CO2 - confusion - coma - arrhythmias = loss of consciousness - seizures

DX - ABG - Xray - CBC - BMP - PFT

Treatment =

HYPERVENTILATE TO BLOW OFF CO2 - CPAP - BIPAP - VENTILATOR

ID underlying cause AND TREAT

• ABT for resp infection

• Bronchodilators to open airways

• corticosteroids to decrease inflammation

• CPAP - O2 - Ventilator

• Lifestyle changes

Hypocarbia

•Low level of CO2 in blood

Etiology: hyperventilation

•Stimulating effect

hyperventilation usually in response to high CO2 & low O2 levels, the body tries to rid itself of high CO2 and speeds up breathing to blow off CO2 but it over compensates and drops CO2

Pulmonary causes = COPD exacerbation - PE - PN - Acute Asthmaticus  -

S/S = low blood levels of carbon dioxide have a stimulating effect on the nervous system and lead to muscle twitching or spasm (especially in the hands and feet) and numbness and tingling in the face and lips.

Fast deep breathing - tingling - dizzy - muscle cramps - seizures

DX = Same for all resp. evaluations

TX = Reduce Resp. Rate - Treat underlying causes ABT - anti anxiety meds - CPAP = Ventilator

Signs of Hypoxia

 Early S/S:

•Restlessness

•Anxiety/Apprehension

•Confusion

S/S

•Tachycardia

•Tachypnea

•Shortness of breath

•Cyanosis

•Decreased LOC

•Abnormal lung sounds = (Adventitious)

(clubbing of fingers seen with chronic hypoxia)

Hypoxia Interventions

•HOB UP - HIGH FOWLER’S

•CALL FOR HELP

•COUNT RESPIRATIONS

•PULSE OXIMETRY STAT

•APPLY OXYGEN IF PULSE OXY <90%

•CHECK VITAL SIGNS

•LISTEN TO LUNG SOUNDS

COPD Chronic Bronchitis

Etiology:

Smoking (90% of cases) - Occupational exposures - Air pollution - Asthma - CF

Signs & Symptoms:

Chronic cough

Thick, tenacious sputum

Rhonchi in the Bronchi

Wheezing

Hypoxemia & Hypoxia = Dusky - Cyanosis

Tachycardia - Tachypnea

Dyspnea - SOB

Peripheral edema

Orthopnea

Diagnosis:

PFT - C-X ray - ABG

Treatment:

Bronchodilators

Corticosteroids

Expectorant

Anti Infectives if r/t infection

Controlled Oxygen delivery or BiPAP

Pulmonary rehabilitation

Stop smoking

Decrease exposures to irritants

Get Vaccinations

COPD Emphysema

Etiology:

Smoking (90% of cases) - Occupational exposures - Air pollution - Asthma - CF

Signs & Symptoms:

•Difficulty exhaling - Grunting

•Purse lipped breathing

•Barrel chest - Hyperinflation

•Weight loss - Thin

•Tripod positioning

•Clubbing - From chronic hypoxia

•Infrequent cough

•Hypoxia - Hypercarbia (Pink)

•Dyspnea - SOB 

•Orthopnea

•Accessory muscle use

Diagnosis:

PFT - C-Xray - ABG

Treatment:

Bronchodilators

Corticosteroids

Expectorant

Anti Infectives if r/t infection

Controlled Oxygen delivery or BiPAP

Pulmonary rehabilitation

Stop smoking

Decrease exposures to irritants

Get Vaccinations

Emphysema

Destruction of alveoli, narrowing of bronchioles, and air trapping of air resulting in loss of lung elasticity

CNS Stimulation to Breathe

Normal Person:

•Increased levels of CO2

COPD=chronic bronchitis, emphysema

•Decreased levels of O2

THATS WHY ITS CALLED: HYPOXIC DRIVE

Hypoxic Drive - Patients with COPD

IF WE GIVE A COPD PATIENT TOO MUCH OXYGEN WE CAN CAUSE HARM & DEATH BECAUSE IT CAN ACTUALLY CAUSE WORSENING HYPOXIA!

THIS IS WHY KNOWING THE PATIENT'S HISTORY IS CRITICAL

Refers to people with COPD, Chronic Obstructive Pulmonary Disease

Chronic Bronchitis

Emphysema

Their stimulus to breathe is low arterial O2 levels (instead of high CO2 levels)

If we give them too much O2, it cuts down their stimulus to breathe – they can become hypoxic

So there are limits to the amount of supplemental O2 we can give them

Rationale:  their body is used to high levels of CO2, so high levels do not stimulate them to breathe

Obstructive Sleep Apnea

Typically, the soft tissue of the pharynx and soft palate collapse, tongue falls into the back of the throat, and obstructs the upper airway.

• OSA is diagnosed clinically by reports of at least five witnessed breathing interruptions or awakenings due to gasping or choking events per hour.

Sleep apnea is a periodic interruption in breathing during sleep—an absence of air flow through the nose or mouth during sleep.

• Pauses that last 10 to 30 seconds. Episodes may occur several or a hundred times a night and may last up to 1 minute or longer.

• During periods of apnea, the oxygen level in the blood drops, and the carbon dioxide level rises, causing the person to wake up.

Sleep Apnea Interventions

•Assessment- recognizing symptoms

•Promoting-Teaching

•side lying positioning for sleep, to allow full relaxation and avoid blockage of airway

•weight loss of at least 10% of the patient's current body weight

•Use of oral mouth guards that push the tongue down and pull the jaw forward to open more space at the back of the throat

•Continuous positive airway pressure (CPAP) therapy.

•Careful with meds that cause respiratory depression or sedations

Suctioning

•Only done as needed - PRN

•Is an independent nursing intervention

•Upper Airway

•Secretions in mouth or back of throat that can not be expectorated

•May be heard as gurgling, moist conversations

•We can use yankauer (Think “Yanking”) to suction & clear

•Lower Airway

•Will use suction catheter

•A sterile procedure

•Pre-oxygenate with 100% O2

•Duration of each suction pass should be limited to ten seconds and only on way out

•The number of passes should be limited to three or less

Labs

•Electrolytes

•We will discuss electrolytes under chemical regulation

•Too much or too little of certain electrolytes affect cardiac function

•Potassium (K+) levels have a very strong influence on the function of the heart, both too much or too little (K+ = heart function)

•PT/PTT

•Both are used to assess the intrinsic system and the common pathway of clot formation

•We will discuss in more detail when we discuss the anticoagulant drugs on your unit 2 drug list:  warfarin, heparin, enoxaparin

EKG ECG Pulse OX

•Electrocardiogram*   ecg ekg

•Records the electrical impulses that stimulate the heart to contract

•Used to evaluate arrhythmias, conduction defects, myocardial injury and damage, left and right hypertrophy, and pericardial disease

•Echocardiogram*

•A noninvasive ultrasound procedure used to evaluate the structure and function of the heart & how they move blood through the heart

•Used to detect heart wall function, specifically left ventricle function

•Used to detect disease of heart valves

•Determines cardiac output & ejection fraction

•Pulse oximetry

•A noninvasive way to measure peripheral O2 saturation levels

Cardiovascular Disease Interventions

•Patient Teaching: *

•Diet

•Weight Loss

•Exercise

•Modifiable & Non-modifiable Risk Factors

•Quitting Smoking

•Substance Abuse

•Reduce Stress

Heart Failure

•Heart becomes inefficient pump

•Unable to circulate blood to organs & tissues

•Leads to systemic and pulmonary edema

•Results in fatigue and organ dysfunction

•Right-sided heart failure

•Right ventricle does not pump sufficient amounts of blood to lungs for oxygenation, blood backs up into the peripheral veins

•Left-sided heart failure

•Left ventricle does not pump sufficient amounts of blood to organs & tissues, blood backs up into lungs

Left Side Heart Failure (Most Common)

THINK LEFT = LUNGS S/S

•Cough, SOB

•Wheezing, Crackles

•Pink frothy sputum

•Orthopnea, Dyspnea

PLUS THESE S/S:

•Tachycardia

•Mental confusion, change in LOC

•Fatigue (any chronic heart disease)

•weakness

•Exercise intolerance

•Lack of appetite

Right Sided Heart Failure

PERIPHERAL VENOUS CONGESTION

PERIPHERAL S/S

•Peripheral Edema of lower extremities, feet

•Ascites – edema of abdomen

•Jugular vein distention (JVD)

•Weight gain from build up of fluid

•Fatigue (any chronic heart disease)

•weakness

•Exercise intolerance

•Lack of appetite

Peripheral Arterial Disease = PAD

ARTERIAL

POOR PERFUSION

•Weak or absent peripheral pulse

•Cool Legs / Feet

•Pale or bluish (cyanotic)Legs/feet

•Loss of hair in lower extremities

•Thick toenails

•Paresthesias

•Un-healing wounds on toes, feet

PAD Interventions

Interventions: keep legs down in dependent position, if legs are hanging down gravity helps blood flow to lower extremities

•If patient has intermittent claudication, have them sit and rest

Patient Teaching:

•Regular exercise

•Diet

•Weight Loss

•Exercise

•Modifiable & Non-modifiable Risk Factors

•Quitting Smoking

•Substance Abuse

•Reduce Stress

•Foot care

Peripheral Venous Disease = PVD

Involves damaged or blocked veins that carry blood from the hands and feet back to the heart.

S/S:

•Edema - Pitting or non-pitting

•Incompetent valves in veins

•Varicose veins

•Brownish red discoloration of lower extremities

•Ulcers on lower extremities

PVD Interventions

•Keep legs ELEVATED (up) to facilitate venous return back to heart

•Regular exercise is beneficial – the exercise causes contraction of the leg muscles which helps to push venous blood back to heart

•If unable to walk or exercise encourage leg exercises

Heparin

•Given subcutaneously  and  Given IV (intravenously) SHORT TERM

•Anticoagulant, antithrombotic

•Use – prophylaxis and treatment of various thromboembolic disorders: venous thromboembolism (DVT), pulmonary embolism (PE), atrial fibrillation (AF) with embolization

•Test to monitor serum levels daily is PTT or APTT

•Antidote is protamine sulfate

•Implications

•Asses for bleeding

•Bleeding precautions

Warfin

•Coumadin – given po  LONG TERM

•Classification: anticoagulant

•Use:  prophylaxis and treatment of venous thrombosis, pulmonary embolism, prophylactically to prevent clots in pt with atrial fibrillation

• test to monitor serum level is PT, INR (must keep an eye on levels)

•Antidote:  vitamin K

•Implications

•Watch for bleeding

•Bleeding precautions

•Teach pt to avoid green leafy vegetables. 

•They contain vitamin K which would counteract the medication

Bleeding Precautions

•These are things we teach any patient who is on anticoagulants. 

•We want pt to be aware of and avoid things which could cause him to bleed.

•Avoid sharp razors, may use electric razor

•Use soft toothbrush

•Do not take aspirin

•Do not strain at BM – take stool softener if necessary

•Blow nose gently

•Do not go barefoot, wear shoes or slippers to protect your feet

•Avoid any activity that may cause injury, ie contact sports, strenuous activity

Bleeding Precautions

•These are things we teach any patient who is on anticoagulants. 

•We want pt to be aware of and avoid things which could cause him to bleed.

•Avoid sharp razors, may use electric razor

•Use soft toothbrush

•Do not take aspirin

•Do not strain at BM – take stool softener if necessary

•Blow nose gently

•Do not go barefoot, wear shoes or slippers to protect your feet

•Avoid any activity that may cause injury, ie contact sports, strenuous activity

Hypovolemia

Dehydration describes a state of negative fluid balance in which there is a loss of water (hydro = water) from the intracellular, extracellular or intravascular spaces. Dehydration can be categorized by three causes:

1. Insufficient fluid intake (e.g., as may occur with depression, sedation, or alcohol abuse)

2. Excessive fluid loss (e.g., bleeding, vomiting, diarrhea)

3. Fluid shifts (e.g., intravascular fluid may leak into body tissues, burns).

When dehydration occurs from the loss of body fluids, electrolytes may also be lost.

Fluid loss can also lead to an increase is serum osmolarity.

The first symptom of dehydration is thirst.

Hypovolemia S&S

S&S

•Sensations of thirst

•Dry mucous membranes

•Weakness, dizziness

•Poor skin turgor

•^ capillary refill time - >3

•Changes in LOC/Mentation

•Acute Weight Loss

•Elevated BUN

•Na+ increased (>145)

•^ Hematocrit

•^ Urine Specific Gravity

•Oliguria <400ML/24HR

Vital signs:

Vital Signs:

• Weak, thready pulse

• Tachycardia

• Tachypnea

• Hypotension

• Elevated Temperature

Hypovolemia Interventions

•Correct fluid volume status

•IVF -  Isotonic - 0.9% Normal Saline

•Encourage Increased Intake of Oral fluids

•Identify and treat cause - ie. STOP Vomiting/diarrhea

•Monitor VS & LOC

•Daily weights

•Monitor I&O

•Monitor Lab values - Electrolytes

•Medications

Hypervolemia

•Too much fluid in intravascular spaces (The space within the blood & lymphatic vessels)

Edema – excess fluid volume in interstitial spaces (The space between blood vessels and cells

Causes:

•Excessive fluid intake

•Excessive Na+ intake

•Decreased Cardiac Output conditions - HEART FAILURE!!!!

•Renal failure -

•Liver failure - ASCITES

•Malnutrition - LOW ALBUMIN

Hypervolemia S&S

•Weight Gain

•Distended Neck Veins (JVD)

•Dependent Edema or Pitting

•Skin pale & cool

•Crackles, dyspnea, ascites

•Hemodilution:  Decrease in - BUN, HCT, Urine Specific

•Mental status changes

•LOW NA+ OR HYPOXIA

Vital signs:

• Bounding pulse

• Hypertension

• ^ RR rate

Hypervolemia Interventions

•Correct fluid volume status

•ID and treat underlying cause

•Monitor VS & I&O

•Monitor weight

•Monitor mental status

•Skin condition (positioning)

•Monitor cardiac status

•MONITOR - ELECTROLYTES

•Monitor O2 if hypoxia from rales

•Medications:  diuretics

•Electrolyte replacement

•Diet: 

•Decrease Na+

•Fluid restriction

Isotonic Fluid

•SAME OSMOLARITY & TONE OF BLOOD

•DOES NOT MOVE INTO OR PULL FLUID OUT OF THE CELLS OR BLOOD VESSELS

•EXAMPLES = 0.9% NS & LR

•WHEN GIVEN IV, THE FLUID REMAINS IN THE INTRAVASCULAR COMPARTMENT

•AS A RESULT INTRAVASCULAR FLUID VOLUME INCREASES

•PREFERRED FOR IMMEDIATE RESPONSE FOR HYPOTENSION & HYPOVOLEMIA

•MUST ASSESS FOR FLUID VOLUME OVERLOAD.

Sodium (Na+ 135 – 145 mEq/L)

•Resides in ECF

•Regulates fluid volume, blood volume

•Helps to maintain muscle contraction

•Stimulates conduction of nerve impulses

Found in:

•Table salt

•Soy sauce

•Processed foods

•Canned products

•Cheese

•Processed meats

•Foods preserved with salt

Too High or Too Low can cause:

MENTAL STATUS CHANGES

BEHAVIORAL CHANGES

IRRITABILITY

CONFUSION/DISORIENTATION

SEVERE SEIZURES

Hyponatremia

Cause

•Diuretics

•GI fluid loss

•Excessive intake of hypotonic solution: water

S&S

•Behavior changes - AMS

•Confusion - disorientation

•ANV - anorexia, nausea, vomiting

•Weakness

•Lethargy

• muscle cramps

•seizures

Treatment

•Increase oral sodium intake

•Administer IV saline infusion

•When sodium levels in the blood are too low, extra water goes into body cells causing them to swell. This swelling can be especially dangerous for brain cells, resulting in neurological symptoms such as headache, confusion, irritability, seizures or even coma.

Hypernatremia

Cause

•Excessive sodium intake

•Water deprivation

•Increase water loss through profuse sweating, heat stroke

•Administration of hypertonic tube feeding

S&S

•Thirst

•^ temperature

•Dry mouth, sticky mucus membranes

If severe:

•Lethargy

•Seizures

•Irritability - disorientation - AMS

•Hallucinations

Treatment:

•Restrict Na in diet

•Increase water intake

•Administer iv solutions that don’t contain sodium

•D5W - HYPOTONIC

Potassium (K+  3.5 – 5.0 mEq/L)

•Maintains ICF osmolality

•Muscle contraction

•Regulates conduction of cardiac rhythm*

•Assists with acid-base balance

Found in:

•Bananas

•Oranges

•Apricots

•Figs 

High & Low can cause:

CARDIAC DYSRHYTHMIAS

DYSRHYTHMIA MEANS IRREGULAR HEART RATE & RHYTHEM

Hypokalemia

Cause

•Diuretics

•GI loss through vomiting, gastric suctioning, diarrhea

•Anorexia or bulimia

S&S 

•ANV

•Muscle weakness

•Dysrhythmias*

•Paresthesias

•Flat T wave on ECG

Treatment

•Encourage foods high in potassium

•Administer K+ supplements, PO/IV

•If patient on digoxin, monitor serum levels and toxicity

THE DIURETIC FUROSEMIDE IS ONE OF THE MOST COMMON MEDICATION THAT CAUSES HYPOKALEMIA

A SERIOUS S/S OF HYPOKALEMIA IS IRREGULAR HEART RATE & RHYTHM

Hyperkalemia

Causes

•Renal failure

•Potassium sparing diuretics

•Hyperaldosteronism

•High K+ intake coupled with renal insufficiency

•Acidosis

•Hemolyzed serum sample

Signs & Symptoms

•Muscle weakness

•Dysrhythmias

•Flaccid paralysis

•Intestinal colic

•Tall T waves on ECG

•Treatment

•Monitor I&O

•Monitor K+ level

•Caution about potassium rich food intake in patients with elevated creatinine

AVOID: BANANAS - AVOCADOS - SWEET POTATOES - SPINACH - WATERMELON - COCONUT WATER - BEANS - LEGUMES - ORANGES - APRICOTS - FIGS - 

FRUIT & VEGETABLE JUICES - POTATOES

Calcium (Ca+  8.5 – 10.5 mg/dL)

•Promotes transmission of nerve impulses

•Major component of bones & teeth

•Regulates muscle contraction

•Maintains cardiac automaticity

Sources:

•Dairy

•Dark green leafy vegetables

•Salmon

•Calcium fortified foods

•Breads, cereals

Hypocalcemia

•Cause

•Hypoparathyroidism

•Malabsorption

•Pancreatitis

•Alkalosis

•Vitamin D deficiency

S&S

•Muscle cramps

•Tetany

•Convulsions/Seizure

•Cardiac irritability

•Positive Trousseau’s sign

•Positive Chvostek’s sign

•Treatment

•^ calcium intake

•Calcium supplements

•Severe: seizure precautions & parenteral calcium

COMMON WITH HYPO-THYROID ISSUES & AFTER ANY THYROID/PARATHYROID SURGERY

Hypercalcemia

•Cause

•Hyperparathyroidism

•Malignant bone disease

•Prolonged immobilization

•Excessive supplementation

•Thiazide diuretics

•S&S

•ANV

•Muscle weakness

•Bradycardia

•Constipation

•Kidney stones

•Polyuria

Treatment

•Encourage ^ fluid

•Encourage fiber

•Eliminate calcium supplements

•Avoid calcium based antacids

Magnesium (Mg2 + 1.6 – 2.1 mEq/L)

•Involved in electrical activity in nerves & muscle (cardiac)

•Helps to maintain normal levels of K+

•Necessary for protein & DNA synthesis in cell

•Found in most foods

•High levels in green vegetables, cereal grains, nuts

Hypomagnesemia

Causes

•Chronic alcoholism

•Malabsorption

•Diabetic ketoacidosis

•Prolonged gastric suctioning

S&S

•Neuromuscular irritability

•Dysrhythmias

•Disorientation

•Increased sensitivity to digoxin

Treatment

•Encourage foods high in Mg2

•Avoid alcohol intake

•If patient on digoxin, monitor pulse and serum levels

WITH HYPOMAGNESEMIA PATIENTS DEVELOPED DIGOXIN TOXICITY

Magnesium deficiency sensitizes the patient to the toxic effects of digitalis, and the patient who has received digitalis is likely to be magnesium deficient.

Hypermagnesemia

Cause

•Renal failure

•Adrenal insufficiency

•Excess replacements

S&S

•Hypoactive reflexes

•bradycardia

•Flushing & warmth of skin

•Hypotension

•Drowsiness, lethargy

Treatment

•Monitor reflexes

•Restrict food high in Mg2

•Avoid Mg2 based antacids & laxatives

Respiratory - Lungs

• CARBON DIOXIDE IS ACID

• CO2 OUT THROUGH EXHALE

• BREATH DEEP & FAST = HYPERVENTILATE

• LOSE TOO MUCH CO2 = ALKALOSIS

• BREATH SHALLOW & SLOW = HYPOVENTILATE

• HOLDS ONTO CO2 = ACIDOSIS

Respiratory Acidosis (pH < 7.35 - PaCO2 > 45 - HCO3 WNL)

Causes:

•HYPOVENTILATION

•IMPAIRED GAS EXCHANGE

•COPD

•Drug overdose

•Alcohol Intox

•Respiratory arrest/APNEA

•Airway obstruction

Treatment:

•Improve ventilation

•Improve gas exchange

•Administer O2

•Hydrate

•Mechanical ventilation

•Naloxone

HYPOVENTILATION = HOLDING ON TO CO2 = ACID

ANYTHING THAT CAUSES HYPOVENTILATION & IMPAIRED GAS EXCHANGE LIKE COPD/CHF/ASTHMA CAN LEAD TO RESPIRATORY ACIDOSIS

SIGNS & SYMPTOMS

S/S HYPOXIA = RESTLESS - CHANGE IN LOC - CONFUSION

TACHYCARDIA

TACHYPNEA

DIZZINESS

HEADACHE

Respiratory Alkalosis (pH > 7.45 - PaCo2 < 35 - HCO3 WNL)

Cause: 

Too much CO2 exhaled

•HYPERVENTILATION

•Panic

•Anxiety

•Sepsis/Fever

•Pain

•DKA

•Hypokalemia

Treatment: 

•Treat underlying cause

•Slow respirations

•Rebreath CO2 (paper bag)

•Treat pain

•Treat anxiety

S/S:

HYPERVENTILATION

FAST BREATHING

TINGLING

HEADACHE

DIFFICULTY FOCUSING

CONFUSION

SEPSIS

FEVER

HYPOTENSION

Renal - Kidney - Metabolic

KIDNEY CONTROL

HYDROGEN IONS = ACID

BICARBONATE  HC03= BASE

KIDNEY EXCRETE ACID INTO URINE OR RETAINS MORE BICARB (HC03) IN THE KIDNEY

IF YOUR BODY HAS TO MUCH ACID THE KIDNEYS WILL PEE OUT THE ACID AND HOLD ONTO BICARB TO HELP NEUTRALIZE THE ACIDOTIC STATE

Metabolic Acidosis  (pH < 7.35  HCO3 < 22   PaCO2 WNL)

Causes:

RENAL FAILURE

•Kidneys inability to secrete H+

GI Loss of HCO3 from GI tract

• Excessive diarrhea loss of HCO3

Diabetic ketoacidosis ^H+

•Uncontrolled Diabetes

Sepsis-lactic acid acidosis ^H+

S/S:

•Headache

•Confusion - drowsiness

•Weakness

•Peripheral vasodilation

•Nausea - Vomiting

•Kussmaul’s Breathing

•Hyperkalemia

•Treatment: 

•Treat cause

•Blood sugars high - hyperkalemic - dehydration

•Possible Bicarbonate order

•Treatment is symptomatic

__

THE RESPIRATORY SYSTEM WILL WORK TO REVERSE THE METABOLIC ACIDOSIS AND COMPENSATE

IF PH IS BELOW 7.35 & BICARB IS BELOW 22 THE PATIENT IS IN METABOLIC ACIDOSIS

THE KIDNEYS WILL TRY AND PEE OUT ACID & HOLD ONTO BICARB TO REVERSE

CAUSES

RENAL FAILURE

•Kidneys UNABLE to secrete & PEE OUT HYDROGEN (ACID) H+ IN URINE = ACID IS RETAINED

GI Loss of HCO3 ACID from GI tract

• Excessive diarrhea = loss of HCO3

•POOPING OUT THE BASE FROM YOUR ASSIDOSIS = ONLY ACID LEFT

Diabetic ketoacidosis ^H+ THE WORD ACID IS IN THE CONDITION

•Uncontrolled Diabetes LEADS TO RAPID KETONE BUILDUP WHICH IS ACIDIC

•KUSSMAUL RESPIRATIONS

Sepsis-lactic acid acidosis ^H+  = LACTIC LEVELS INCREASE D/T TISSUE HYPOXIA

Hyperkalemia = PREVENTS KIDNEYS

Metabolic Alkalosis (pH > 7.45  HCO3 > 26  PaCO2 WNL)

Cause:

Renal Failure to excrete HCO3

GI issues r/t loss of gastric secretions

•Vomiting

•Gastric suction

•Diuretics

•Excessive antacid intake

S/S:

•Dizziness

•Tingling of extremities

•hypoventilation

•Hypertonic muscles

•Hypokalemia

Treatment: 

• Treat underlying cause:

•K+ replacement

•Antiemetics

VOMIT ACID OUT OF THE BODY INTO THE POTTY

SUCTION PULLING OUT THE ACID

s/s =

Hypokalemia - dehydration

Dizziness

Tingling of extremities - paresthesia

Hypertonic muscles - too much tone - muscles stiff - difficult to move

Decreased respiratory rate and depth - hypoventilation

Name the expected acid base condition

1 Patient is dehydrated due to vomiting & anorexia for 3 days

2 Pt has uncontrolled diabetes and is admitted for diabetic ketoacidosis

3 Patient took too much morphine and their respiratory rate is 8-10

4 Pt admitted with exacerbation of COPD

5 Student is very anxious & hyperventilating due to upcoming test

6 Pt has elevated lactate acid in the blood levels secondary to sepsis

7 Pt rates pain as a 15 on scale of 1-10

8 Pt has NG tube, suctioning copious amounts of stomach acid

1.METABOLIC ALKALOSIS - THEY ARE LOSING STOMACH ACID - SO ALKALOSIS IS LEFT IN THE BODY & IS HIGH - NOT A BREATHING ISSUE

2.METABOLIC ACIDOSIS - KETONES (WHICH ARE ACIDIC) BUILD UP IN THE BLOOD = HIGH ACID- NOT A BREATHING ISSUE

3.RESPIRATORY ACIDOSIS - RESPIRATIONS ARE DEPRESSED & SLOW & SHALLOW - HYPOVENTILATION OCCURS - NOT EXHALING CO2 = CO2 (ACID) BUILDS UP IN THE BODY

4.RESPIRATORY ACIDOSIS - IMPAIRED BREATHING/HYPOVENTILATION - NOT EXHALING CO2 = HIGH CO2 (ACID) LEFT IN THE BODY - BREATHING ISSUE CO2

5.RESPIRATORY ALKALOSIS - RESPIRATIONS FAST - HYPERVENTILATION - TOO MUCH EXHALED CO2 = CO2 LEAVES & HIGH ALKALINE STAYS -  BREATHING ISSUE

6.METABOLIC ACIDOSIS - SEPSIS = ELEVATED LACTIC ACID LEVELS IN THE BLOOD

7.RESPIRATORY ALKALOSIS - SEVERE PAIN = HYPERVENTILATION = FAST BREATHING = CO2 LOSS

8.METABOLIC ALKALOSIS - THEY ARE LOSING STOMACH ACID - ALKALOSIS IS LEFT IN THE BODY & IS HIGH - NOT A BREATHING ISSUE

Complications of Peripheral IV Therapy

•Infiltration - STOP IV & ELEVATE ARM & RESTART NEW IV

•Phlebitis - STOP IV & COLD COMPRESS - CHECK CIRCULATION

•Thrombophlebitis - STOP IV - WARM COMPRESS

•Infection - LOCAL - STOP - STERILE DRESSING - ABT?

•Extravasation - STOP ASAP - COLD COMPRESS - ANTIDOTE?

Interventions for Complications of Peripheral IV Therapy

INFILTRATION - IV FLUID LEAKS (NON VESICANT) INTO TISSUE D/T CATHETER DISLODGE OR VEIN PENETRATION

●CAUSES SWELLING IN TISSUE FROM FLUID

●PALE SKIN @ SITE - COLD TO TOUCH - AREA HARD TO TOUCH

●TENDER/PAIN/BURNING

●IV FLUIDS ARE SLOW OR HAVE STOPPED/IV PUMP BEEPING

TREATMENT

●STOP IV

●RESTART NEW IV IN DIFFERENT VEIN HIGHER THAN INFILTRATION SITE OR OTHER ARM/HAND

●ELEVATE AFFECTED ARM

PHLEBITIS - INFLAMMATION OF THE VEIN = INFECTION/INFLAMMATION

●REDNESS - PAIN - WARMTH - EDEMA - PALPABLE VEIN CORD

●FEVER

●INABILITY TO RESTART FLOW OF IV

TREATMENT

●STOP IV -

●IMMEDIATELY APPLY COLD COMPRESS IF SITE IS WARM & TENDER

●ASSESS CIRCULATORY IMPAIRMENT D/T VEIN INFLAMMATION

THROMBOPHLEBITIS - THROMBUS (CLOT) AND INFLAMMATION D/T UNTREATED PHLEBITIS - USING FEET/LEGS - HYPERTONIC

●SLOW IV FLOW RATE

●EDEMA - REDNESS - WARMTH

●TENDER - CORD VEIN (HARD)

TREATMENT

●STOP IV & RESTART IN OPPOSITE SIDE

●ALL NEW EQUIPMENT D/T INFECTION

●WARM MOIST COMPRESSES

●CALL MD

INFECTION - LOCAL MICROBIAL CONTAMINATION D/T POOR TECHNIQUE - NOT CHANGING IV Q 72 HOURS

●REDNESS - SWELLING - EXUDATE - FEVER

TREATMENT

●REMOVE IV - STERILE DRESSING - CALL MD - GIVE ABT IF ORDERED

EXTRAVASATION - SEEPAGE OF VESICANT INTO TISSUE D/T CATH DISLODGE

●SLOW OR STOPPED IV FLUID

●PAIN - BURNING - EDEMA - BLANCHING & COOL TO TOUCH

●LATE S/S = BLISTERS OR NECROSIS OF DERMIS

TREATMENT

●STOP IV ASAP

●CALL MD

●GIVE ANTIDOTE

●ELEVATE - COLD COMPRESS

Preparation for Blood Transfusion

•Signed Consent

•Type & Cross:   needs to be done every 72 hrs

•4 blood types:  AB, A, B, O

•Rh factor:  positive or negative

•See table 38-9  pp 1047

•Vital signs - 5-15 mins prior to administration

•IV access  18 – 20 gauge angiocath 

•Pre-medications, if ordered:  acetaminophen, diphenhydramine

BEFORE PICKING UP BLOOD PRODUCT YOU MUST ENSURE THE FOLLOWING:

VERIFY ORDER

CONSENT SIGNED BY MD & PT, WITNESSED

TYPE & CROSS RESULTS ARE DONE

IV SITE IS PATENT

V/S ARE STABLE

Transfusion

•Must be initiated within ½ hour of release from blood bank

•Must be infused: in not less that 2 hours, not more than 4 hours

•Blood must be checked and signed by 2 nurses

•Stay with patient for first 15 minutes & retake the vital signs

•CAN ONLY BE HUNG WITH 0.9% NORMAL SALINE

Transfusion Reactions

Febrile - temperature elevation due to sensitivity to WBCs plasma proteins, or platelets

Fever, chills, warm, flushed skin, aches

Stop the transfusion. Replace with a saline infusion. Notify the provider. Treat symptoms.

Allergic - allergy to blood being transfused - Flushing, itching, wheezing, urticaria (hives); anaphylaxis, if severe - Stop the transfusion. Replace with a saline infusion.

Notify the provider immediately. Administer prescribed antihistamine.
Bacterial -contamination of the blood

Fever, chills, vomiting, diarrhea, hypertension

Stop the transfusion. Replace with a saline infusion. Notify the provider.

Administer antibiotics as ordered. Treat symptoms.

Hemolytic reactions - destruction of RBCs as a result of infusing incompatible blood; occurs in 1 in 600,000 transfusions

Fever, chills, dyspnea, chest pain, tachycardia, hypotension; can be fatal

Stop the transfusion immediately. Replace with a saline infusion. Notify the provider immediately. Send the remaining blood, including tubing and filter; a sample of venous blood;hemolysis must be excluded (or proved) immediately. RUPTURE OF THE BLOOD CELL AND LOSS OF CONTENTS HEMOGLOBIN THIS CAN CAUSE HEMOLYTIC ANEMIA  and the first voided urine to the lab for analysis. Treat shock.

Hemoglobinuria is a condition in which the oxygen transport protein hemoglobin is found in abnormally high concentrations in the urine. The condition is caused by excessive intravascular hemolysis, in which large numbers of red blood cells (RBCs) are destroyed, thereby releasing free hemoglobin into the plasma.
Circulatory overload - administering too great a volume or too rapidly

Persistent cough, crackles, hypertension, distended neck veins

Slow or stop the transfusion. Monitor vital signs. Place the client upright.

Notify the provider. – GIVE LASIX

Nurses Role in Cost Containment

Nurses can help contain health care costs by advocating for patients and ensuring their care is received on time, the plan of care is appropriate and individualized to them, and clear documentation has been completed. These steps reduce waste, avoid repeated tests, and ensure timely treatments that promote positive patient outcomes and reduce unnecessary spending. Nurses routinely incorporate these practices to provide cost-effective nursing care in their daily practice:

• Keeping supplies near the client’s room

• Preventing waste by only bringing needed supplies into a client’s room

• Avoiding prepackaged kits with unnecessary supplies

• Avoiding “Admission Bags” with unnecessary supplies

• Using financially-sound thinking

• Understanding health care costs and reimbursement models

• Charging out supplies and equipment according to agency policy

• Being Productive

• Organizing and prioritizing

• Using effective time management

• Grouping tasks when entering client rooms (i.e., clustering cares)

• Assigning and delegating nursing care to the nursing team according to the state Nurse Practice Act and agency policy

• Using effective team communication to avoid duplication of tasks and request assistance when needed

• Updating and individualizing clients’ nursing care plans according to their current needs

• Documenting for continuity of client care that avoids duplication and focuses on effective interventions based on identified outcomes and goals

Nursing Roles & Prioritizations

•Using proper infection control practices

•Nosocomial infections greatly add to the costs of health care and can be prevented, ie urinary catheter infections, ventilator associated infections, wound infections

•Using time efficiently by prioritization - priority needs - Maslow

•Our practice must always consider prioritization

•Who do we see first, who needs medication first

•This can also include delegation of tasks to UAP’s (unlicensed assistive personnel), allows RN’s to focus on priorities

•Makes best use of resources and personnel

__

Tools for Prioritizing

MASLOW

ABC

CURE - (CRITICAL - URGENT - ROUTINE - EXTRAS)

DATA CUES -

ACUTE OR CHRONIC

Actual Versus Potential Problems

Unexpected Versus Expected Conditions

Handoff Report/Chart Review

Diagnostic Information