med surg unit 1

what are the clinical manifestations of hypovolemia?

weight loss, decreased skin turgor, concentrated urine output, oliguria, thirst, dry mucous membranes

what are the lab values associated with hypovolemia?

changes in hemoglobin & hematocrit (high with dehydration, low with blood loss

high: serum osmolality, BUN, creatinine, urine specific gravity, urine osmolality

what are the clinical manifestations of hypervolemia?

weight gain, ascites, edema, JVD, increased urine output, cardiac & respiratory symptoms\*

\*think about fluid overload & backup into the lungs

what are the lab values associated with hypervolemia?

\*\*\*

what are the normal ranges for potassium?

3\.5-5

what does potassium affect in the body?

neuromuscular & cardiac function, acid-base balance

what are some findings for hypokalemia?

neuromuscular: weakness, lethargy, hyporeflexia

cardiac: ST depression (dysrhythmias)

nausea & vomiting, constipation, abdominal cramping

severe: cardiac or respiratory arrest

what are the medical management practices for hypokalemia?

increase dietary intake of potassium & replace KCl PO or IV (IV must be diluted; must have adequate urinary output)

monitor EKG & urine output

what are some findings for hyperkalemia?

neuromuscular: muscle cramps, paresthesia, weakness

cardiac: palpitations, EKG changes, cardiac arrest

generalized fatigue

what are the medical management practices for hyperkalemia?

eliminate intake of potassium

medications: loop diuretics, kayexalate, inhaled albuterol (which allows potassium to move into the cells), calcium gluconate (which lowers the likelihood of dysrhythmias), IV insulin or bicarb (which is used for acidosis; can be used with dextrose to keep glucose stable)

dialysis

monitor EKG

what are the normal ranges for sodium?

135-145

what does sodium affect in the body?

water distribution, electrical activity, acid-base balance

what are some findings for hyponatremia?

water distribution: cerebral edema

electrical activity: seizure

neurological symptoms: lethargy, confusion, headache, gait disorder

nausea, vomiting

what are the medical management practices for hyponatremia?

replacement of sodium (monitor levels)

fluid restriction (monitor I & O; monitor daily weights)

hypertonic saline (only if there is neurological involvement; monitor for fluid overload)

diuretics

monitor neurological changes

what are some findings for hypernatremia?

water distribution: thirst, signs of dehydration

electrical activity: neuromuscular irritability, agitation, & restlessness (which can lead to lethargy, coma, & seizure)

nonspecific neurological changes

severe: hallucinations, delusions, disorientation

what are the medical management practices for hypernatremia?

limit sodium intake (monitor levels)

replace water deficits

monitor fluid status (I & O, daily weights)

what are the normal ranges for calcium?

8\.2-10.2

what does calcium affect in the body?

bone & teeth, clotting, nerve impulse transmission, muscle contraction

what are some findings for hypocalcemia?

trousseau & chvostek signs, smooth muscle spasms, prolonged QT, decreased myocardial contractility

anxiety, confusion, irritability

what are the medical management practices for hypocalcemia?

treat underlying cause

IV calcium gluconate, calcium rich diet, calcium & vitamin D supplements

paper bag breathing

monitor & treat pain & anxiety

seizure precautions & emergency equipment

what are some findings for hypercalcemia?

bradycardia, hypertension, thirst, lethargy, muscle weakness & soreness, abdominal discomfort, constipation, decreased deep tendon reflexes, anorexia, nausea & vomiting, kidney stones

what are the medical management practices for hypercalcemia?

promote urinary excretion (loop diuretics, IV normal saline when hypovolemic)

increase weight-bearing activity

biphosphonates (best for hypercalcemia related to malignancy; cause inhibition of osteoclasts)

removal of parathyroid

what are the normal ranges for magnesium?

1\.6-2.2

what does magnesium affect in the body?

alters the effects of calcium on smooth muscles (causes relaxation)

bone & teeth health, nerve function, clotting

what are some findings for hypomagnesemia?

smooth muscles: muscle weakness & cramping, tetany, hyperactive reflexes, tremors, trousseau & chvostek signs

nerve function: disorientation, psychosis, vertigo, irritability, combativeness, seizures

clotting: HTN (caused by vasoconstriction), tachycardia

anorexia, nausea, vomiting

what are the medical management practices for hypomagnesemia?

evaluate potassium & calcium levels

dietary replacement & supplements

seizure & fall precautions

cardiac monitoring

education about alcohol abstinence

what are some findings for hypermagnesemia?

smooth muscles: muscle weakness, loss of deep tendon reflexes, paralysis, coma

nerve function: drowsiness, lethargy

clotting: hypotension, cardiac dysrhythmias, heart blocks, asystole, increased risk of bleeding

decreased respiratory rate, respiratory arrest

what are the medical management practices for hypermagnesemia?

identify & treat cause

stop magnesium supplements

loop diuretics

hydration

supportive care

hemodialysis

calcium gluconate

what are hypotonic IV solutions used for?

when there is too much fluid in the vessels & not enough in the cells

what are isotonic IV solutions used for?

to provide hydration

what are hypertonic IV solutions used for?

to treat edema

to lower the pressure in the brain

what are the normal ranges for pH?

7\.35-7.45

what lab values indicate an acidic or basic pH?

less than 7.35 = acidic (acidosis)

greater than 7.45 = basic (alkalosis)

what are the normal ranges for PaCO2?

35-45

what lab values indicate an acidic or basic PaCO2?

greater than 45 = acidic (acidosis)

less than 35 = basic (alkalosis)

what are the normal ranges for bicarbonate?

22-26

what lab values indicate an acidic or basic bicarbonate?

less than 22 = acidic (acidosis)

greater than 26 = basic (alkalosis)

how does the body compensate for respiratory acidosis?

renal absorption of bicarb

how does the body compensate for respiratory alkalosis?

renal excretion of bicarb

how does the body compensate for metabolic acidosis?

hyperventilation

how does the body compensate for metabolic alkalosis?

hypoventilation

what are some things you should assess with IV access sites?

respiratory status, vital signs, skin (color, temperature, edema, etc.)

crystallization = incompatible

how do you manage IV access sites correctly?

hand hygiene, clean injection port, flushing & locking, monitor for complications

what are the four blood transfusion reactions?

acute hemolytic, febrile nonhemolytic, allergic, circulatory overload

what are the causes of an acute hemolytic reaction?

infusion of ABO-incompatible blood

what are the clinical manifestations of an acute hemolytic reaction?

fever/chills, hypotension, flank pain, vascular collapse

how do you manage an acute hemolytic reaction?

stop the transfusion & notify the provider, maintain BP

what are the causes of a febrile nonhemolytic reaction?

antibody reaction to granulocytes or platelets in infused blood component

what are the clinical manifestations of a febrile nonhemolytic reaction?

temperature rise of 1ºC or 2ºF, chills, headache, chest pain

how do you manage a febrile nonhemolytic reaction?

stop the transfusion & notify the provider, monitor vitals, possible administration of antipyretics, restart transfusion slowly

what are the causes of an allergic transfusion reaction?

sensitivity to donor’s plasma proteins

what are the clinical manifestations of an allergic transfusion reaction?

itching/hives, facial flushing, dyspnea, anxiety

how do you manage an allergic transfusion reaction?

stop the transfusion & notify the provider, monitor vitals, possible administration of antihistamines, restart transfusion slowly

what are the causes of circulatory overload?

administration rate is higher than patient tolerance

what are the clinical manifestations of circulatory overload?

headache, dyspnea, JVD, edema, increased BP

how do you manage circulatory overload?

stop the transfusion & notify the provider, monitor vitals, elevate HOB, possible administration of diuretics & oxygen, restart transfusion slowly

when are packed red blood cell transfusions used?

symptomatic anemia, acute or chronic blood loss

when are FFP (fresh frozen plasma) transfusions used?

massive transfusion protocol, reversal of PT/INR, DIC (disseminated intravascular coagulation; ex: placental burst), deficiency of coagulation factors

when are platelet transfusions used?

bleeding due to thrombocytopenia

what are some things you should assess with TPN (total parenteral nutrition)?

crystallization, blood glucose

how do you manage TPN correctly?

change tubing every 24 hours, administer via central line, run by itself, monitor glucose (insulin may be required)

what is a normal RBC count?

women: 4.2 to 4.87

men: 4.71 to 5.14

what is a normal hematocrit?

women: 38 to 44%

men: 43 to 49%

what is a normal hemoglobin?

women: 12 to 16

men: 13 to 18

what is a normal WBC count?

4,500 to 11,000

what is a normal platelet count?

150,000 to 450,000

what is a normal PT?

10 to 13 seconds

what is a normal INR?

0\.8 to 1.1

what is a normal PTT?

25 to 35 seconds

what is some information you should get when doing a hematological assessment?

history: liver disease, gallstones, pregnancy

medications: blood thinners

physical assessment:

what are some medications that predispose patients to bleeding?

blood thinners

what are some diagnostic examinations of the hematological system?

CBC, clotting studies, bone marrow aspiration or biopsy

what are some changes of the hematological system due to age?

fewer blood cells, decreased lymphocytes, serum iron (which helps with adherence to oxygen), & vitamin B12 (which helps with energy)

what are some neutropenic precautions?

frequent hand washing, avoid crowds, avoid sick people, safe food preparation, no live plants or cut flowers, private room, monitor temperature daily

what are some thrombocytopenic precautions?

soft toothbrush, no flossing, electric razor, use shoes, avoid sexual intercourse, avoid blowing nose, stool softener, apply direct pressure to lacerations for no less than 5 minutes, minimize sticks & blood draws (ex: midline)

what are some causes of iron-deficiency anemia?

nutritional waste, acute or chronic blood loss, poor absorption

what are the clinical manifestations of iron-deficiency anemia?

pallor, fatigue, tachycardia, tachypnea, glossitis, spoon-shaped nails

how do you treat iron-deficiency anemia?

dietary intake (leafy greens, red meat, beets, beans, fortified grains), supplements, IV or IM iron

what are some causes of folic-acid deficiency?

inadequate intake, extreme diets, malabsorption, **alcohol abuse**

what are the clinical manifestations of folic-acid deficiency?

pallor, fatigue, tachycardia, neurological issues, increased risk of bleeding

how do you treat folic-acid deficiency?

dietary intake (dark green vegetables, dried beans, nuts, carbs & grains, bran)

what are some causes of vitamin b12 deficiency?

inadequate intake (vegans), malabsorption, surgical procedures on stomach

what are the clinical manifestations of vitamin b12 deficiency?

pallor, fatigue, tachycardia, tachypnea, depression, mood swings, visual disturbances

how do you treat vitamin b12 deficiency?

dietary intake (fish, milk, eggs, meat), supplements, IM b12

what are the clinical manifestations of leukemia?

symptoms of anemia, **low-grade fever**, infection

how do you treat leukemia?

chemotherapy, bone marrow transplant

what are the clinical manifestations of bleeding disorders?

ecchymosis, petechiae, nosebleeds, bleeding gums

what is a normal creatinine?

0\.5 to 1.2

what is a normal BUN?

8 to 21

what is a normal creatinine clearance?

88 to 137

what are some potential nephrotoxic medications?

antibiotics (gentamicin, tetracycline, vancomycin)

analgesics (COX-2 inhibitors, NSAIDs, salicylates)

other drugs such as contrast media

what are some changes of the renal & urinary systems due to age?

decreased kidney size, lowered GFR, increased BUN, urinary frequency, risk for dehydration, risk for incontinence, urinary hesitancy, frequency, straining, & retention, low estrogen

when thinking about renal & urinary function, what should be considered with diagnostic studies?

informed consent, check for allergies (contrast media), have emergency medications available, review creatinine, educate on expectations, patent IV, assess for reactions, increase PO intake after

what are the clinical manifestations of polycystic kidney disease?

**HTN**, **flank pain**, hematuria, lower back pain, headache, abdominal pain, UTI, renal stones, enlarged kidneys (can be palpable)

how do you manage polycystic kidney disease?

symptom management, possible renal replacement therapy or dialysis

what are the clinical manifestations of pyelonephritis?

**fever**, **back/flank pain**, **CVA tenderness**, chills, vomiting, frequent painful urination

how do you manage pyelonephritis?

antibiotics, pain medications, hydration

what are the clinical manifestations of glomerulonephritis?

edema, low urine output (less than 30 mL/hour), HTN, increased creatinine & BUN, protein & blood in urine, abdominal pain

how do you manage glomerulonephritis?

supportive treatments, antihypertensives, antibiotics, diuretics, steroids

what are the clinical manifestations of renal stones?

pain, diaphoresis, nausea/vomiting, fever/chills, hematuria, WBCs & bacteria in the urine