Exam 1, NURS 366

diagnostic related groups

medicare developed, a set amount of money that medicare will pay the hospital for a certain diagnosis
categorizes based on diagnosis, treatment, and length of hospital stay

steps for administering meds via a NG tube

turn off suction
clamp tubing
apply 60 cc syringe to NG, insert 30cc of air or aspirate gastric contents
reclamp tubing
prepare meds, flush before and after each med with 15-30cc of water
after all meds- flush with 30-66cc of water
keep suction discontinued for one hour then reconnect to suction

abnormal lab findings patient education

understanding the results of the lab tests- meaning of lab values, terminology, causes and effects of abnormal labs
interpreting MD's diagnosis- confusions about MDs suggestions/diagnosis, receiving confirmation after a diagnosis, concerns of misdiagnosis
learning about lab tests as sources of info- specific test info, lab test recommendations, test comparisons, concerns about procedures
consulting next steps- HCP consultation

red blood cells

4.7-6.1 million/microliter
produced in bone marrow in response to blood oxygen levels
A condition that limits oxygen causes an increase in red blood cells

hemoglobin

14-18gm/dl
protein in RBC that carries oxygen, test is to evaluate oxygen carrying capacity of blood
low- anemia/bleeding/surgery, overhydration, bone marrow suppression
high- dehydration, polycythemia vera, pulmonary fibrisis

hematocrit

42-52%
measures the percentage of red blood cells found in whole blood
low- overhydration, anemia, bleeding, bone marrow suppression
high- dehydration, polycythemia vera

WBC

4500-10,000 per microliter
leukopenia (small amount of WBC) and leukocytosis (large amount of WBC

basophils

0.5-1%
allergic reaction to food/drugs, parasitic infection

eosinophils

1-4%
allergies, autoimmune issue, parasitic infection

lymphocytes (T and B cells)

20-40%
inversely related to neutrophils
Increased:
leukemia and lymphoma
infection
make antibodies and are killer cells
Decreased:
HIV, congenital immunodeficiency

monocytes

2-8%
viral infections, leukemia, TB infections

neutrophils

40-60%
bacterial infections
give antibiotics

platelets

150000-450000/microliter
Help with clotting
thrombocytopenia- gram negative infection, sepsis
thrombocytosis- infection, trauma, spleen removal

mean corpuscular volume (MCV)

80-95 fl
provides info about the size of RBC to determine if the patients anemic and what kind of anemia they have
high MCV= RBC are too large and indicates macrocytic anemia
Low MCV= RBC are too small indicating microcytic anemia

prothrombin time

11-12.5 seconds to clot
coumadin and heparin therapy causes a prolonged clotting time

international normalized ratio (INR)

0.8-1.2, 2-3 on coumadin
standardize the results of PT no matter the resting method

partial thromboplastin time

60-70 s, 1.5-2.5x longer in heparin therapy
how long it takes to form fibrin using the intrinsic pathway

sodium

135-145 mEq/L
cation, chief electrolyte of the ECF
maintains water balance throughout the body, participates in the generation of and transmission of nerve impulses

hyponatremia

<135
causes- medications, inadequate sodium intake, water gain, sodium loss
s/s- abdominal cramps, headaches, nausea, seizures, muscle twitching, tremors, weakness, altered LOC, lethargy, confusion
nursing- hx of diet, meds, behavioral changes, weight, I/O, vitals, sodium levels, replace sodium with diet, restrict fluids, NS or LR

hypernatremia

>145
causes- water deficit, excessive Na intake
s/s- polyuria, anorexia, vomiting, weakness, agitation and restlessness, confusion, dry and dlushed skin, intense thirst, lethargy, tachycardia, low grade fever from dehydration
nursing- VS, sodium levels, correct underlying problem, fluid replacement, hypotonic NS (0.45%), NS or D5W, go slow

chloride

98-106 mEq/L
extracellular anion with Na
follows sodium losses and accompanies sodium excess in an attempt to maintain electrical neutrality, affects water balance, serves as a buffer to assist in acid-base balance

potassium

3.5-5 mEq/L
ICF cation
serum level depends on aldosterone, sodium reabsorption, acid-base balance
role in transmission of electrical impulses (nerve, skeletal, intestinal, lung tissue), protein and carb metabolism, cellular building

hypokalemia

<3.5
causes- ALCOHOLISM, inadequate intake, loss of K, surgery, hyperaldosteronism, liver disease, cancer, redistribution of K
s/s- muscle cramps, anorexia, abdominal distention, constipation, weakness and fatique, n/v, weak irregular pulse, abnormal EKG
nursing- replace K with diet, supplement, IV, correct cause of imbalance, cardiac monitor, K levels, Mg levels

hyperkalemia

>5
causes- acute and chronic renal failure, excessive release from cells secondary to traumatic injury, severe infection, burn, excess IV infusion or oral intake, acidosis, meds, fast growing cancers
s/s- abdominal cramps, diarrhea, hypotension, irregular HR, muscle weakness, nausea, paresthesia (numbness and tingling), convulsions, cardiac arrest
nursing- critically ill, restrict K, correct cause of imbalance, infuse insulin and glucose or Na bicarb, IV of calcium gluconate, kayexalate (diarrhea), dialysis, cardiac monitor, K levels

CO2

23-30 mEg/L
venous blood specimens are not highly accurate for measuring true CO2 content
use as a rough guide for acid-base balance
High: lung diseases, metabolic alkalosis, cushing's syndrome, kidney failure
Low: addisons disease, shock, diabetic ketoacidosis, respiratory alkalosis, metabolic acidosis

calcium

9-10.5 mg/dL
99% found in bone

hypocalcemia

common in older adults. Vit c deficiency

hypercalcemia

>11
common in metastatic malignancy, hyperparathyroidism, thiazide diuretic therapy

magnesium

1.3-2.1 mEq/L
50% in bone, 49% intracellular, 1% blood
most are bound to an ATP molecule, more than 300 biochemical reactions
absorbed in small intestine and excreted by kidney
foods- pumplin, cashews, almonds, lentils, brown rice, shitaki mushrooms, sunflower seeds

hypomagnesemia

increase in cardiac irritability, aggravate cardiac arrhythmias

hypermagnesemia

retards neuromuscular conduction, respiratory depression

phosphorus

2.4-4.1 mg/dl
ICF anion
absorption is facilitated by vitamin D, maintains the pH of body fluids, maintains cellular osmotic pressure, important component of DNA and RNA
inverse relationship with Ca
levels controlled by intake and renal function
kidney failure- hyperphosphatemia and hypocalemia
hypocalemia- bone demineralization

blood urea nitrogen

7-20 mg/dL
formed when protein breaks down, effected by certain drugs
low- liver failure, low protein diet, malnutrition, overhydration
high- CHF, excessive protein levels, GI bleed, hypovolemia, kidney disease, kidney failure, UTI, shock, elderly

creatinine

0.5-1.1 mg/dl
waste product produced in muscles from the breakdown of creatinine
used to diagnose impaired kidney function and to determine renal damage
high- diets high in meat, heavy metal chemotherapy, cephalosporins, dehydration, elderly/renal
low- older patients with decreased muscle mass, muscular dystrophy, paralysis

glucose

60-100
formed by digesting carbs, stored in the liver as glycogen
screening for diabetes mellitus, gestational diabetes, hypoglycemia

hypoglycemia

blood sugar is too low

hyperglycemia

blood sugar is too high

lactic acid

5-20 mg/dl
helpful to document and quantify the degree of tissue hypoxemia associated with shock or localized vascular occlusion; can also be a measurement of success in treatment
causes- prolonged use of a tourniquet, vigorous exercise, meds
high- shock, sepsis, tissue ischemia, carbon monoxide poisoning, severe liver disease, genetic errors of metabolism and diabetes mellitus

HgbA1C

nondiabetic 4-5.9%
diabetic- <7%

high hgba1c= high average glucose level of the last two or three months and are at risk for developing type 2 diabetes
low hghba1c= may indicate treatment for diabetes is too aggressive and that hypoglycemia is occurring way to frequently

How do you measure fluid balance and how many lbs of weight gain in a day is concerning?

I/O
daily weight- most accurate
>3 lb/day is concerning

ventilation

the process of moving gases into and out of the lungs. it requires the muscular and elastic properties of the lungs and thorax to be coordinated

perfusion

the cardiovascular system must have the ability to pump oxygenated blood to the tissues and then return it to the lungs

diffusion

the movement of respiratory gases from one area to another by concentration gradients

atelectasis

normal exchange of oxygen and carbon dioxide is altered by a collapse of alveoli; not a disease but a condition or sign that results from disease
causes- infection, blockage of airways, compression, scarring from radiation, pneumothorax, immature lungs

pneumonia

inflammation of the lung parenchyma (alveolar spaces) creating a buildup of fluid and excrement in the alveoli; decreasing gas exchange

pulmonary embolism

a blockage of one or more pulmonary arteries by fat or thrombus, amniotic fluid or tumor tissue
presents as cardiac arrest, fatalities after 1-2 hours
obstruction causes- bronchoconstriction, impaired gas exchange, loss of surfactant V/Q mismatch, RVF, pulmonary HTN, tricuspid regurgitation, compression of RCA, elevated BNP and troponins,

chronic obstructive pulmonary disease

chronic bronchitis causes hypersecretion of mucus and chronic productive cough, emphysema causes airflow limitations due to loss of elastic recoil in airways

what are ways to avoid drug-drug interactions in the elderly?

identify indication of each medication
ask if the indication is still present
any duplications in drug therapy, any meds prescribed for an adverse drug reaction
therapeutic doses
significant drug-drug or drug-food interactions
exploration of non-pharmacologic interventions
review med reconciliation form

6 rights of medication administration

patient, medication, dose, time, route and documentation

normal vital signs

96.8-100.4, avg is 98.6 or 37 c
60-100 bpm
12-20 rr
100-120/60-80 mmHg
greater than 95%

What are the different pain scales and what is the gold standard in reporting pain?

self reporting pain is the gold standard
OPQRSTU
visual analog scale (scale with words or numbers or both), word descriptor (0= no pain 1=mild pain etc.), graphic scale(images), verbal scale (on a scale of 1-10 how much pain are you feeling?), functional pain scale (0=no pain 5= intolerable and pain prevents verbal communication. scale of 1-5 with descriptors like the word descriptor scale but references pain and activity to determine pain)

how do you asses pain in a nonverbal patient patient?

consider painful conditions and procedures
observe for behaviors recognized as pain related, get info from caregivers/family members
attempt an analgesic trial
physiologic- increased HR, RR, BP, fluid overload, immune cell suppression, arrhythmias

nociceptive pain- somatic

orginates in the skin, connective tissue, joints, muscles. Usually localized at the site of injury and gets worse with movement
ie. broken bones, sprains, cuts, bruises

nociceptive pain- visceral

originates in organs
tends to not be clearly localized, could be referred pain, aching, pressure, cramping, nausea, diaphoresis
ie. labor pain, appendicitis, bowel obstruction

neuropathic pain- peripheral

pain between spinal cord and extremities. Burning, shooting, electric shock feeling. Ie. diabetic peripheral neuropathy, neuralgia (shingles) and phantom limb pain

neuropathic pain- central

Within the spinal cord and brain. Described as tingling, pins and needles. Ie. spinal cord injury, post stroke pain

what is central sensitization?

CNS becomes sensitized resulting in patient becomes more sensitive to pain so person will respond

What is hyperalgesia?

increased sensitivity to ordinarily painful stimuli

What is Allodynia?

pain when no painful stimulus

What do allodynia, hyperalgesia, and central sensitization all have in common?

less responsive to opioid analgesia and often result in escalation of opioid dosing with a higher risk of side effects
These types of pain are less responsive to opioid analgesia

acute pain

short duration from a known cause, recent onset, limited, predictable course of healing
identifiable temporal and causal relationship to an injury or disease
objective indicators- tachycardia, elevated BP, sweating/pallor, dilated pupils, anxiety, expression

chronic pain

longer than expected duration or more than 6 months
not always clearly identifiable or flare from recurrent chronic illness
adaptation- normal HR, blood pressure, pupils, no sweating/pallor, depression

acute-on-chronic pain

acute pain from trauma or exacerbation of a disease in a patient with a chronic pain condition

nonpharmacologic pain interventions

positioning, relaxation, ice/heat, distraction, talking, increase patient's knowledge about pain, increase patient's sense of control over pain, address pain-related factors (n/v, anxiety, fear, lack of sleep)

pain evaluation and documentation

frequent reassessment, monitor for side effects, monitor for pain related symptoms (anxiety, depression, withdrawing)

acetaminophen

max dose less than 4000mg in 24 hrs
avoid in patients with liver disease
beware of hybrid drugs like vicodin and percocet

NSAIDs

mediate the inflammatory response
use cautiously in patients with renal insufficiency

adjuvants and what are adjuvants

Help with pain but aren't designed for pain
antidepressants (tricyclic)
alpha adrenergic blockers (BP meds, withdrawal)
anticonvulsants
NMDA inhibitors
corticosteroids
muscle relaxants

opioid analgesics

morphine- 5-10 min, 20 min, 1.5-4.5 hours
hydromorphone (dilaudid)- 15 min, 20 min, 4-5 hours
fentanyl- immediate, 5-10 min, 30-60 min
demorol-lowers seizure threshold
oxycodone
methadone- withdrawal and pain
adverse effects- respiratory depression, constipation, n/v, pruritus (itching skin), urinary retention, sedation

fentanyl patches

for chronic pain only, change every 3 days, transdermal delivery
systemic effects so rotate shoulders

lidocaine patches

topical, place where the pain is

at risk for uncontrolled pain

elderly, pediatric, confused, non-english speaking, different ethnicity, hx of substance abuse, chronic pain with acute pain

gastrostomy types and placements and care

PEG- local anesthesia and placed with an endoscope
mic-key- long term use, more discrete
^both are passed through the abdominal wall into the stomach
g-j tube- bypasses the stomach for those with recurrent aspiration, pneumonia, severe GERD, gastric outlet obstruction, gastric emptying
Placed through existing hole (gastrostomy) into the small bowel (jejunum)
care- keep clean and dry, use soap and water, avoid dressings, avoid ointments, no pulling on tube, child can bath, law, swim one week after

what are the signs and symptoms of acute viral nasopharyngitis (common cold) in infants and children

s/s- fever, poor feeding, vomiting, diarrhea, abdominal pain, nasal blockage/discharge, cough, respiratory sounds, sore throat, headache, neck pain
care- prevention and protection, comfort, symptom management, hydration, managing secretions, family support

what are the signs of influenza?

s/s- dry throat, hoarseness, lack of energy, sudden onset of fever and cells
complications- viral pneumonia, bacterial infections

what are symptoms of croup?

dx- inflammation of larynx, trachea, bronchi
s/s- epiglottitis, laryngitis, laryngotracheobronchitis (LTB), tracheitis (severe effects on the voice and breathing)

What areas of the respiratory system are involved in upper and lower respiratory infections and what areas does coup effect?

Upper:
oronasopharynx to the trachea

Lower:
Bronchi to alveoli

coup:
larynx (voice box)
epiglottis (protects larynx and helps swallowing)

what is acute epiglottitis and signs of epiglottitis?

medical emergency
serious obstructive inflammatory process, quickly progresses to severe respiratory distress
s/s- absense of cough, drooling, agitation (anxiety increases as respiratory distress increases), dysphagia, high fever, toxic apperance

what are the signs of acute laryngotracheobronchitis (LTB)?

most common croup syndrome (6mo-3years)
cause- viruses, rarely bacterial
s/s- preceded by URI which descends to other structures, barky cough, retractions, nasal flaring, stridor

what are the symptoms of bronchitis?

inflammation of the large airways frequently associated with URI
s/s- dry hacking non-productive cough worsen at night

respiratory syncytial virus (RSV)

s/s- increased secretions, sneezing, wheezing, tachypnea, apnea, poor air exchange, coughing, pharyngitis, rhinorrhea, cyanosis

what are the symptoms of pneumonia in children?

s/s- fever, malaise, non-productive to productive cough, chest pain

respiratory infections in infants/small children

etiology and course of infection is influenced by infectious agent, age of child (children have more generalized and localized s/s, <3 react more severely to acute respiratory infections), size of child, resistance, season, living conditions, preexisting conditions

what is a home care for child with asthma and symptoms of asthma?

create a school action pain, breathing exercises, yoga, acupuncture, diet, herbal remedies
teach how to use an inhaler
avoid triggers
s/s- prolonged expiratory phase, wheezing, chest tightness, cough, tachypnea, accessory muscle use, retractions, nasal flaring, agitation, altered muscle state, hyperinflation, increased AP diameters
meds- MDI (albuterol), inhaled corticosteroids, prednisone

Outline a plan for teaching at home care with children with influenza

-helping family implement measures to relieve symptoms
-educating on the prevention of spread
-fever during early recovery (convalescence) is a sign of a secondary bacterial infection and should be reported to physician for antibiotic therapy

what are the signs of cystic fibrosis?

dysfunction of the exocrine glands that produce thick tenacious mucous
thick mucous obstructs the respiratory passages, causing trapped air and over inflation of the lungs, thick mucous obstructs the secretory ducts of the pancreas, liver, and reproductive organs

Impact of cystic fibrosis on the pulmonary system?

causes hypoxia that results in barrel chest and clubbing

Impact of cystic fibrosis on the gastrointestinal system?

decreased absorption of vitamins and enzymes, abdominal distention, decreased enzymes, rectal prolapse, fatty stinky stool (steatorrhea) meconium ileus in newborns
s/s-fatigue, chronic cough, recurrent URTs, thick mucous,

what are treatment options and diagnostic tests for cystic fibrosis?

Diagnostic tests:
elevation of sweat electrolytes (gold standard test)
sodium and chloride are affected with abnormal chloride movement
stool analysis
test for gene

treatment options:
treat respiratory infection with antibiotics
CPT (chest pulmonary therapy)
take pancreatic enzymes, fat soluable vitamins A, D, E and K with all snacks and meals before eating
High calorie and high fat diet
CFTR modulator therapies for patients with specific mutation of CFTR gene
Regulate flow of sodium and fluids to reduce sticky mucous in organs

nasal cannula low flow

1/8-6 lpm
25-45%
humidification, lubrication, extension tubing

nasal cannula high flow

5-8 lpm
25-45%
humidification, lubrication, extension tubing

simple face mask

low flow
6-12 lpm, 35-50%
co2 retention, humidification, snug fit, short term use

partial rebreather mask

low flow
10-15 lpm, 60-90%
has reservoir bag 1/3 to 1/2 full on inspiration
co2 retention

venturi mask

high flow
4-12 lpm, 24-60%
has exhalation port and flow control attached for specific rate and fio2
may depress respiratory drive

nonrebreather mask

low flow
10-15 lpm, 60-90%
has reservoir bag 1/3 to 1/2 full on inspiration
no co2 retention bc of one way valve

safety measures for o2

-suction in the room
-oxygen flow meter with age appropriate devices
-ambu bag appropriate for infant, pediatric, adult
-masks
-intubated- have intubation supplies at the bedside and know the size of ET tubes
alarm limits set of cardiac monitors
airway, breathing, circulation drugs
no smoking, can cause retina and lung damage with toxicity

what nursing responsibilities are associated with oxygenation devices?

-check for skin break down
-put oxygen in use signs up
-ensure there's humidification
-check patients vital signs and ascultate lung sounds
-check every 8hrs for nasal cannula
-monitor patients change to oxygen
-call light and reachable
-teach back "why is it important you are on oxygen?"

measuring nonverbal children pain

FLACC scale
face, legs, activity, cry, consolability
children less than 4 or developmentally delayed
observational/behavioral tool

What is used to measure pain in children under 4?

FLACC
Observational
Looks at the body language of the child to assess pain
ie. frequent constant frown, clenched jaw = 2 on the face category

physiologic and behavioral pain scales

NIPS, CRIES, NPASS, PIPP
vital signs, oxygen, color
muscle tone, facial expression, body movements, cry, changes in state
consider infants maturity, behavioral state, energy resources available to respond, risk factors for pain