NURS 337 clinical

Dr. Elaine Little

IV complication: infiltration

when the IV fluid leaks from the vein into the surrounding tissue.

• s&s: site discomfort, burning, blanching, cool skin temp, tightness, absent backflow of blood, decreased rate of flow

• Tx: remove device, apply warm soak to aid absorption, elevate limb, assess circulation, restart infusion, notify doc if severe

calcium carbonate vs sodium bicarbonate vs magnesium oxide

calcium carbonate = tums

sodium bicarbonate = alka seltzer

• both antacids for pyrosis (heartburn)

• only temporary relief

Barrett’s Esophagitis

a complication of long-term GERD

• normal squamous esophageal cells become abnormal columnar - precancerous

• tx- PPIs

• LES pressure decreased by fatty foods, caffeine, chocolate, peppermint, alcohol; increased (good) by nonfatty foods

• elevate HOB 30 degrees

• hiatal hernia- anatomical abnormality where the stomach protrudes upwards, causing GERD

chemo side effects

• n/v: administer odansetron, metoclopramide, etc (anti-emetics)

• immunosuppression: WBCs affected first, then platelets, then RBCs: WBC growth factors (-stims)

• “chemo brain”

• anemia - stims, -poetins

• diarrhea - low-fiber diet (no roughagey greens, spicy/acidic food, alc, etc)

• radiation damages skin

metoclopramide

*a METRO moves things fast - speeds things thru the stomach faster, reducing n/v, but if it moves things too quickly the muscles have jerky, repetitive movements (tardive dyskinesia)

• GERD, antiemetic, gastroparesis

• take food 30mins prior

• side effect- tardive dyskinesia (lip smacking & facial twitching)

• also sedation, diarrhea, hallucinations

pantoprazole

a proton pump inhibitor (PPI) (all end in -prazole) → PEPCID

• first-line Tx for reducing stomach acid production

• indications: GERD, PUD, healing ulcers

• common side effects- nausea, diarrhea, abd pain

• caution use with chronic renal / liver disease

• Dilute with 10ml NS over 15mins

lipid profile: normal levels

• HDL (men) > 40; women >50

• LDL: < 100

• triglycerides: <150

• total cholesterol <200

scopolamine, tolterodine, solifenacin, oxybutynin, can have CNS effects!

scopolamine - stop all that

anticholinergics

• used to decrease n/v; urinary incontinence

• can’t see, can’t pee, can’t poop, can’t spit

• caution use with BPH, renal failure, cardiac disease

levothyroxine

for Low Thyroid levels (decreased T3 & T4, increased TSH) → Myxedema coma

• gastric system slows down, so this must be given IV

• sx of myxedema coma- altered mental status, everything SLOWED

• if this med is working, it should increase T3 & T4

• take in AM before food, not near calcium supplements!

tetany

muscle cramps & spasms caused by HYPOCALCEMIA

• positive Chvostek sign (cheek twitch) & positive Trousseau’s sign (wrist/hand twitch)

• administer IV Calcium Gluconate

most important concepts for TPN

Total Parenteral Nutrition (calories administered intravenously)

• give to someone who cannot digest food in the GI tract

• TPN is HYPERTONIC → it will clog peripheral veins; give thru a central line only!

• don’t give to a pt with soybean, safflower, or egg allergy (lipid solution made from this)

• administer using an 0.22 micron filter and infusion pump!

• change TPN bag & lines q 24 hrs

• keep TPN refrigerated until 30 mins before use

• check vitals q 4 hrs

• check blood glucose q6 hrs, administer insulin accordingly

• check weights daily, report a weight gain of >1 lb per day or > 3 lbs per week (fluid retention)

• assess fluid & electrolytes, kidney & liver

• Refeeding syndrome → when a person has been starving for a long time, then they eat too much at once & their cells uptake too much, causing low blood levels, especially hypophosphatemia

• never abruptly stop TPN; always taper off to avoid rebound hypoglycemia

signs of septicemia

• sudden vomiting

• hypotension

• increased temp

• feeling chills / shaking

• fatigue / weakness

a patient is taking 5-fluorouracil and is experiencing n/v. What should the nurse do?

it’s a chemo drug - n/v is a common side effect

• administer odansetron (antiemetic) prior to the 5-Fl

side effects of dexamethasone / methylprednisone

it’s a steroid- prescribed to decrease inflammation, helps immune response in thrombocytopenic purpura (ITP)

(side effects present the same as Cushings Disease - excessive steroid production)

• dry mouth

• easy bruising

• GI upset

• EVERYTHING INCREASED EXCEPT POTASSIUM! moon face, buffalo hump, hypertension, hypernatremia, hyperglycemia, hypokalemia

famotidine / cimetidine

H2 receptor blockers

reduce stomach acid production (Fights Acid Man)

• helps heal ulcers (in burn pts)

• relieve sx like heartburn & acid reflux (GERD)

• side effects - gynecomastia, h/a, dizziness, constipation, confusion, fatigue

neutrophil values

also called ANC (absolute neutrophil count)

• normal= > 1500

• low= <1000 (neutropenia → poor immune system)

• extremely low= <500!

a patient has hypoparathyroidism. What would the nurse expect the doc to order?

Calcium & vitamin D supplements

• Hypoparathyroidism causes decreased serum calcium

IV catheter colors & gauges

14g = orange (largest)

16g = grey

18g = green

20g = pink

22g = blue

24g = yellow

26g = violet (smallest)

What actions does the nurse take when feeding a patient with a PEG tube?

flush the tube with 30ml sterile water before & after feeding & meds; change tubing & bag q24 hrs; ensure patency of tube prior to feeding

A type 1 diabetic patient is receiving intermittent enteral feeding thru a PEG tube. 15 mins prior to the next scheduled feeding, the client vomits & coughs. The current blood glucose level is 225 mg/dl. What should the nurse do?

They are hyperglycemic → hold the feeding & administer prescribed correction insulin. Assess residual volume by aspirating gastric content. Revise plan of care to include respiratory assessment for next 3 days (bc they coughed and vomited)

• DON”T hold all feedings til a doc comes, administer antiemetic+bolus insulin& feeding

IVs vs feeding equipment- how often they need changed

tubes need changed every 72-96 hrs (~3 days)

• feeding bags & tubes need changed q24 hrs

central lines (CVCs): key concepts

The catheter tip sits in large central veins (vena cava, subclavian and jugular veins).

PICC lines -can be in place for months, are less likely to get infected

• TPN can only go here

• should always get blood return

• rapid infusion can be used

• verify placement with chest x-ray

• always flush with a 10ml syringe of NS (pulsating: push-pause technique to avoid occlusion)

• change dressing every week (sterile technique), or if dressing is damp, loose, or soiled, cleansing with chlorhexidine

• during removal- place pt in supine or Trendelenburg (head lower than feet) & have them perform Valsalva Maneuver to prevent an air embolism; hold pressure for 15 mins

mixing insulin

you will withdraw from 2 different vials: one clear Regular (R), and one cloudy NPH (N)

• remember the order Nancy Reagan, Registered Nurse (N→R→R→N)!

• 1. read eMAR to see correct ordered units of each type of insulin

• 2. N→ draw back air = the amt of ordered N insulin, & inject this air into the N vial

• 3. R→ draw back air = the amt of ordered R insulin, & inject this air into the R vial

• 4. R→ draw back ordered amt

• 5. N→ draw back ordered amt

the insulins are now properly mixed, with no contamination between vials, & since it’s in one syringe, the pt will only need one injection.

pancytopenia

when the entire CBC is decreased (RBCs, WBCs, platelets)

meds that can cause nephrotoxicity

• NSAIDs (ibuprofen, naproxen) → reduce blood flow to kidneys

• certain antibiotics → may be nephrotoxic

• diuretics → can cause -lyte imbalances

• ACEs & ARBs → hyperkalemia

a patient is ordered 1000mL of 0.45% NSS to be infused via IV over 8hrs. The tubing drop factor is 15 drops per mL. How many drops per minute will be given?

formula: (amt in mL / time in mins) x drop factor

• (1000 mL / 480 min) x 15 = 31 gtts / min

A patient on the unit is experiencing severe pain and is prescribed morphine sulfate 4 mg IV push stat. The vial’s label reads morphine sulfate 10 mg / 2 mL. How many mL will be administered?

formula: (desired / have) x supply

• (4mg / 10mg) x 2 mL = 0.8 mL

what is the RN’s priority concern after administering Midazolam?

respiratory depression

• Benzodiazepines (-lams & -pams) can have this potentially dangerous side effect

phlebitis

inflammation of a vein, commonly caused by the IV

• s/s: site pain; warmth; palpable, red cord underneath skin, sign of infection

• Tx: remove device, avoid multiple insertions, apply warm compress, monitor pt for infection

IV complication: air embolism

a rogue air bubble enters the vein, blocking bloodflow. It can be serious

• S/s: respiratory distress, unequal breath sounds, weak pulse, cyanosis, hypotension

• Tx: discontinue infusion, administer O2, lay pt on left side to allow air to enter R atrium and disperse to pulmonary artery

IV complication: hematoma

blood leaks out of a vein & pools underneath the skin.

• s/s: blood seeps into subq tissues

• t: frequently assess site, discontinue flow, apply pressure

IV complications: systemic infection

• s/s: fever, chills, malaise for “no apparent reason”

• tx: monitor pt’s vitals, notify doc, administer prescribed meds, culture site & device if ordered

IV complications: circulatory overload

• causes: roller clamp opened too loose, flow rate too rapid, miscalculation of fluid requirements

• s/s: SOB, elevated bp, rr, & pulse; JVD, edema, rhonchi

• tx: raise HOB, slow infusion rate, administer O2, notify doc, administer ordered meds

Isotonic IV solutions

remember- Iso-perfect, no fluid shift

• same osmolality as body fluids, no osmotic force so it does not enter the cells —> increase ECF

• uses: with blood products, hypo-volemia (burns, dehydration, bleeding), hyponatremia

• 0.9% normal saline; Lactated Ringers (LR), 5% dextrose in water (DWS); 5% dextrose in 0.225% NSS

hypotonic IV solutions

remember- hippo tonic: fluid swells up the cell like a big hippo

• more diluted (less solutes), lower osmolality pulls fluid into the cells —> increases ICF

• uses: maintain fluid volume, to replace water in hypovolemia, hypernatremia, DKA (diabetic ketoacidosis)

• 0.45% NS (AKA ½ NS); ¼ NS'; 1/3 NS

hypertonic IV solutions

remember- hyper person skinny cells

• more concentrated (more solutes), higher osmolality pulls fluid out of cells —> decreases ICF, increases ECF

• uses: to replace calories & electrolytes in hypovolemia, hyponatremia

• 3% NS, 5% NS, 10% Dextrose in water, 5% Dextrose in NS, 5% Dextrose in Lactated Ringers

• colloids- large particles that draw fluid into the vascular spaces, ideal for ECF hypovolemia- ascites, burns, low bp