Chapter 5.10-5.13 Overview

• Content covered:
  • Venous insufficiency, deep vein thrombosis (DVT), aneurysm, endocarditis - Cardiac concepts summary
  • Fluid compartments, fluid balance, IV therapy concepts
  • Review of electrolytes: Sodium (Na), Potassium (K), Calcium (Ca), Magnesium (Mg)
  • Acid-base balance and ABG (Arterial Blood Gas) interpretation
  • Shock
• Educational Objectives:
  • Objective #1: Cardiovascular (Venous Health)
  • Objective #3: Fluid, electrolyte, and acid-base alterations
  • Objective #4: Basic shock scenarios

5.10 Venous Insufficiency - Overview

• Definition:
  • A condition where veins struggle to return blood to the heart, leading to blood pooling due to weak or damaged valves.
• Risk Factors:
  • History of deep vein thrombosis (DVT)
  • Presence of varicose veins
  • Advanced age, obesity, pregnancy
  • Prolonged periods of sitting or standing

Assessment Findings

• Key Symptoms:
  • Progressive swelling in the ankle and lower legs.
  • Aching, throbbing, or cramping pain
  • Sensations of heaviness and fatigue in legs
  • Dark discoloration and dry/scaly skin
  • Enlarged and tortuous veins
  • Possible venous ulcers in more advanced disease stages

Diagnostic Testing

• Common tests include:
  • Doppler ultrasound: detects blood flow within veins
  • Venous flow studies: assess the efficiency of venous return
  • Venography with contrast dye: advanced imaging for venous pathology

Medical Interventions

• Standard treatments include:
  • Compression stockings to promote venous return
  • Elevating legs to ease swelling
  • Calf muscle pump exercises
  • Weight management for overall health
  • Sclerotherapy for smaller varicose veins
  • Surgical interventions for severe cases (e.g., vein stripping)

Nursing Diagnoses & Expected Outcomes

• Nursing Diagnoses:
  • Impaired Skin Integrity
  • Chronic Pain
  • Activity Intolerance
• Expected Patient Outcomes:
  • Skin remains intact with no new ulcers within 2 weeks
  • Pain is rated at 2–3 or below within 3 days
  • Patient able to walk 300 feet without undue fatigue within 1 week

Nursing Interventions

• Key Nursing Actions:
  • Educate patient on proper use of compression stockings
  • Encourage elevation of legs above the heart
  • Promote regular walking
  • Avoid prolonged sitting or standing
  • Daily skin inspections for integrity
  • Proper fitting and removal of compression stockings
  • Dietary modifications: low sodium intake and high fiber diet

Outcome-focused Nursing Priorities

• Main Goals:
  • Prevent skin breakdown
  • Maintain functional mobility
  • Control pain to facilitate activity
  • Reduce infection risk

5.11 Deep Vein Thrombosis (DVT)

• Definition:
  • Formation of a blood clot within a deep vein, most commonly the legs, thighs, or pelvis.
• Causes (Virchow's Triad):
  • Venous stasis
  • Hypercoagulability
  • Endothelial injury
• Risk Factors:
  • Prolonged immobility, recent surgery, estrogen use, pregnancy, smoking, obesity, active cancer
• Assessment Findings:
  • Unilateral swelling, redness, warmth in affected leg
  • Often accompanied by tenderness of the calf or thigh
  • Comparison of legs is important to note deviations in size and morphology
  • Monitor for symptoms of progression to pulmonary embolism (PE)

Pulmonary Embolism Warning Signs

• Symptoms to watch for include:
  • Sudden onset shortness of breath (SOB)
  • Chest pain that intensifies upon inhalation
  • Tachycardia or irregular heart rhythms
  • Hemoptysis (coughing up blood)
  • Syncope or hypotension
  • Sudden feelings of anxiety or a sense of impending doom
  • Note: PE is a medical emergency!

Diagnostic Testing for DVT

• Essential tests include:
  • D-dimer test: elevated levels suggest a possible clot; negative indicates low probability
  • Duplex ultrasound: considered the gold standard for DVT detection
  • CT pulmonary angiography (CTPA): if PE is suspected

Medical Interventions

• Treatment protocols:
  • Anticoagulants:
  • Heparin (IV), Low Molecular Weight Heparin (LMWH) subcutaneously, and fondaparinux
  • Long-term options: Warfarin, apixaban, rivaroxaban, dabigatran, edoxaban
  • Thrombolytics: tPA for life-threatening conditions
  • Procedural Interventions:
  • Inferior vena cava (IVC) filter if anticoagulation is contraindicated
  • Thrombectomy or embolectomy for critical cases

Nursing Interventions

• Strategies for DVT prevention:
  • Early ambulation post-surgery
  • Encourage leg exercises, especially in bed-bound patients
  • Promote adequate hydration
  • Use Sequential Compression Devices (SCDs)
• If DVT is already present:
  • Administer prescribed anticoagulants
  • Monitor for signs of bleeding and patient discomfort
  • Provide analgesics as necessary
  • Monitor closely for symptoms of PE

Nursing Diagnoses & Expected Outcomes

• Main Nursing Concerns:
  • Pain related to inflammation
  • Impaired venous perfusion
  • Bleeding risk due to anticoagulation treatment
  • Knowledge deficit regarding treatment & prevention of DVT
• Expected Patient Outcomes:
  • No occurrence of PE during hospitalization
  • Maintenance of adequate tissue perfusion
  • Pain control at functional levels
  • Therapeutic and safe anticoagulation management

Health Teaching for DVT

• Recommendations include:
  • Regular movement to avoid long periods of sitting or standing
  • When traveling more than 4 hours, take breaks to walk every 1-2 hours
  • Engage in leg exercises while seated
  • Wear loose-fitting clothing
  • Advise on smoking cessation and maintaining a healthy weight
  • Emphasize the importance of medication adherence and awareness of bleeding risks

5.12 Aneurysm

• Definition:
  • An aneurysm is a localized dilation of an artery, often due to weak vessel walls.
• Greatest Risks:
  • Potential for rupture or dissection, which can lead to massive and life-threatening hemorrhage.
• Common Locations:
  • Aorta (abdominal more common than thoracic)
  • Cerebral arteries
• Primary Causes:
  • Atherosclerosis, chronic hypertension, trauma, infections
• Key Risk Factors:
  • Older age, smoking habits, hypertension, atherosclerosis

Clinical Manifestations

• Symptoms based on location and size:
  • Often asymptomatic until the aneurysm is large
  • General Observations:
  • Pulsatile abdominal mass may be palpable
  • Bruits may be heard
  • Hypotension and syncope in late stages
  • Abdominal Aortic Aneurysm (AAA) Symptoms:
  • Deep, constant abdominal or back pain
  • Flank pain
  • Abdominal bruit and pulsatile abdominal mass
  • Thoracic Aneurysm Symptoms:
  • Chest pain or back pain
  • Dyspnea and cough
  • Hoarseness and difficulty swallowing (dysphagia)
  • Cerebral Aneurysm Symptoms:
  • Sudden severe headache (“worst headache of life”), neurological deficits, vision changes

Diagnostic Testing

• Recommended Tests:
  • Ultrasound for initial screening and size monitoring
  • CT Angiography (CTA): gold standard for evaluation of rupture or dissection
  • Magnetic Resonance Angiography (MRA): provides detailed vascular imaging
  • Angiography: assess the extent of vascular compromise

Medical Interventions for Aneurysm

• Treatment options include:
  • Watchful waiting for small, stable aneurysms with serial imaging
  • Blood Pressure control
  • Smoking cessation
  • Medication therapies:
  • Beta-blockers and ACE inhibitors reduce shear stress on the arterial wall
  • Surgical Options:
  • Endovascular Aneurysm Repair (EVAR)
  • Open surgical repair
  • Coiling and clipping for cerebral aneurysms

Nursing Priorities in Aneurysm Management

• Individualized Patient Care Goals:
  • Preventing aneurysm rupture: critical task
  • Blood pressure management: avoid straining and Valsalva maneuvers
  • Recognizing signs and symptoms of rupture:
  • Sudden and severe pain, hypotension, diaphoresis
  • Regular assessments of pulses, perfusion, and signs of bleeding
  • Patient education: cessation of smoking, blood pressure management, reporting new or worsening pain

Red Flags for Aneurysm

• Dangerous symptoms to be aware of include:
  • Sudden and severe abdominal or back pain indicating potential rupture
  • Hypotension combined with a pulsatile mass constitutes a medical emergency
  • In cerebral aneurysms, any new neurological changes should be treated as emergencies
  • Note: Do not palpate a pulsatile abdominal mass, as it risks rupture.

5.13 Infective Endocarditis - Overview

• Definition:
  • Infection of the inner lining of the heart and its valves, primarily caused by bacteria or fungi that create vegetations.
  • Vegetations can damage heart valves and impair overall cardiac output.
• Major Risk Factors for Infective Endocarditis:
  • Presence of prosthetic heart valves
  • Congenital heart disease
  • Intravenous (IV) drug use history
  • Recent dental procedures

Pathophysiology

• Explaining the disease process:
  • Vegetations consist of clumps of bacteria, white blood cells (WBCs), and fibrin
  • Potential for clumps to break off and form emboli leading to stroke and pulmonary embolism
  • Valve destruction can lead to heart failure, new heart murmurs, and regurgitation
  • Systemic infection manifests as fever and inflammation

Valvular Heart Disorders

• Common Causes:
  • Rheumatic fever leading to chronic valve scarring
  • Infective endocarditis leading to vegetation formation that damages valves
• Left-Sided Valve Effects:
  • Impaired blood flow leading to decreased cardiac output
  • Blood backflow into the lungs resulting in pulmonary congestion
• Key Clinical Clues:
  • Fatigue linked to reduced cardiac output
  • Orthopnea and dyspnea manifesting due to pulmonary congestion
  • New or changing murmurs result from valve damage
• Notable Indicators:
  • Patients with rheumatic fever and orthopnea may indicate mitral stenosis.

Assessment Findings in Infective Endocarditis

• Cardiac:
  • New or changing heart murmurs, tachycardia, arrhythmias
  • Signs indicating heart failure
• Neurological:
  • Weakness, numbness, altered mental status, slurred speech
• Dermatological:
  • Petechiae, splinter hemorrhages, Osler nodes (painful), Janeway lesions (painless), Roth spots in the retina
• General Systemic:
  • Fever, chills, fatigue, night sweats, joint pains

Diagnostic Testing for Infective Endocarditis

• Important tests:
  • Blood cultures × 3 to identify the causative organism
  • Echocardiogram (transthoracic or transesophageal) to detect vegetations
  • Complete blood count (CBC) and C-reactive protein (CRP) to assess infection and inflammation levels.

Medical Interventions

• Treatment includes:
  • Medication Therapy:
  • IV antibiotics for several weeks
  • Antifungals if it is fungal endocarditis (rare)
  • Surgical Management:
  • Valve repair or replacement as needed
  • Debridement of infected cardiac tissues

TAVR and Endocarditis - Nursing Clinical Connection

• TAVR (Transcatheter Aortic Valve Replacement): minimally invasive procedure for replacing a stenotic aortic valve specifically in high surgical risk patients.
• TAVR addresses severe aortic stenosis by placing a prosthetic valve
• Any prosthetic valve increases the risk of endocarditis, requiring vigilant monitoring post procedure:
  • Monitor for infection signs (fever, chills, new murmurs)
  • Educate patients on preventive measures
  • Reinforce the importance of recognizing and promptly seeking care for new symptoms
  • Note: TAVR does not treat active endocarditis; infection must clear before any valve replacement procedure can occur.

Cardiac Pattern Recognition - Nursing Considerations

• Clinical Indicators:
  • Neurological changes may suggest embolic events
  • The combination of fever and a new murmur can point towards infective endocarditis
  • Symptoms like dyspnea, edema, and crackles may indicate worsening valve functionality
  • History of IV drug use heightens the risk for right-sided endocarditis
  • Dental issues may become a source of bacterial infection
  • Many cardiac changes have systemic implications—consider the relevance of emboli, valve health, and possible infections.

Pericarditis

• Definition:
  • Inflammation of the pericardial sac surrounding the heart.
• Classic Symptoms:
  • Sharp chest pain that worsens when lying flat
  • Relief occurs upon sitting up or leaning forward
• Key Assessment Finding:
  • Pericardial friction rub on auscultation
• Common Causes:
  • Viral infections, post-myocardial infarction (post-MI), autoimmune disorders, uremia
• Major Complication:
  • Risk of pericardial effusion leading to cardiac tamponade

Cardiac Wrap Up - Nursing Priorities

Nursing Priority #1: Recognize Emergencies & Escalate

• Post-Operative Vascular Red Flags:
  • Indicators of potential vascular emergencies:
  • Cool extremity with weak or absent Doppler pulse
  • Capillary refill time > 4 seconds
  • Severe pain unrelieved by opioids
  • These signs indicate acute arterial insufficiency due to ischemia
• Possible Causes Include:
  • Graft occlusion and compartment syndrome
  • Priority Action: Notify the vascular surgeon immediately

Nursing Priority #2: Differentiate Between Peripheral Arterial Disease (PAD) vs. Venous Disease

• Key Assessment Differences:
  • Peripheral Arterial Disease (PAD):
  • Cool, pale, extremity
  • Diminished or absent pulses
  • Pain aggravated by elevation relief when dependent
  • Shiny skin with hair loss
  • Ulcers typically on toes or pressure points
  • Delayed capillary refill
  • Chronic Venous Disease:
  • Warm, edematous extremity
  • Pulses are present
  • Pain improves with elevation
  • Brownish discoloration (hemosiderin staining)
  • Ulcers located at the medial ankle
  • Thickened skin

Nursing Priority #3: Recognize When Team Care is Required

• Discharge Planning & Interdisciplinary Collaboration:
  • Identifying cues for potential complications:
  • Discharge planning needs
  • Limited mobility concerns
  • Difficulty managing medications
  • Readmission risks
• Importance of Collaborative Care:
  • Teaching alone may not suffice; referrals to specialists may be necessary
  • Home health nursing involvement
  • Cardiac rehabilitation services
  • Regular diet reviews and daily weights associated with effective nursing education

Nursing Priority #4: Refer to the Correct Expert

• Evidence-Based Lifestyle & Nutrition Care:
  • If patients express difficulty obtaining accurate nutritional information, consider referral:
  • Patients with hypertension and hyperlipidemia require tailored medical nutrition therapy
  • Engage registered dietitians as evidence-based nutrition experts
  • Stress management does not equate to nutrition treatment and should be clearly understood

Fluid and Electrolytes: Balance and Disturbance

Why It Matters:

• Homeostasis Maintenance:
  • Water makes up approximately 60% of total body weight
  • Variation based on age, body fat percentage, and gender
• Nursing Role:
  • Recognize and respond to imbalances
  • Monitor Input & Output (I&O), weight, and symptoms
  • Prevent complications through early detection

Fluid Compartments

• Distribution of Body Fluids:
  • Intracellular Fluid (ICF): fluid contained within cells (~2/3 of total body fluid)
  • Extracellular Fluid (ECF): fluid located outside of cells

Fluid Volume Deficit (FVD)

• Definition:
  • Loss of both water and electrolytes, distinct from dehydration (which involves only water loss)
• Common Causes:
  • Gastrointestinal losses: + vomiting, diarrhea, gastrointestinal suctioning
  • Poor oral intake or bleeding
• Key Assessment Findings:
  • Weight loss
  • Orthostatic hypotension
  • Low urine output
  • Weak pulses (late sign)
• Laboratory Indicators:
  • Elevated BUN/Creatinine ratio
  • Increased hematocrit
  • Best Indicator: Daily weight monitoring

FVD - Nursing Priorities

• Primary Goals:
  • Prevent further fluid losses and complications
  • Administer IV fluids per physician orders
  • Encourage oral fluids if feasible
  • Monitor I&O, weight, vital signs, and mental status

Fluid Volume Excess (FVE)

• Definition:
  • Retention of sodium and water resulting in increased extracellular fluid volume.
• Common Causes:
  • Heart failure, renal injury, liver cirrhosis, excessive sodium intake or medication administration
• Manifestations:
  • Signs of edema, crackles in lungs, bounding pulses
  • Weight gain, distended neck veins
  • Increased urine output if kidneys are functioning properly

FVE - Nursing Priorities

• Nursing Actions:
  • Monitor daily weights, lung sounds, and signs of edema
  • Administer diuretics as prescribed
  • Educate patients on the importance of a low-sodium diet and fluid restrictions
  • Promote rest and elevate to semi-Fowler’s position for comfort in breathing
  • Skin care routines and frequent repositioning to prevent skin breakdown

Older Adults & Fluid Balance

• Unique Considerations:
  • Reduced thirst mechanisms and decreased kidney reserve can lead to quick decompensation in older adults
  • Skin turgor is considered unreliable for assessing hydration; instead:
  • Focus on daily weights, orthostatic vital signs, and urine output
• Mental Status Monitoring:
  • Confusion or delirium may present as the first sign of fluid imbalance
• Monitoring Requirements:
  • Close tracking of I&O and encouragement of oral fluids unless otherwise contraindicated (such as in heart failure or renal failure)

Hormones & Fluid Balance

• Hormonal Influences:
  • Antidiuretic Hormone (ADH): promotes water retention
  • Aldosterone (Renin-Angiotensin-Aldosterone System [RAAS]): promotes sodium retention, leading to increased water retention
  • Atrial Natriuretic Peptide (ANP): promotes sodium and water excretion

Electrolyte Imbalances

Electrolytes to Watch

• Key Electrolytes:
  • Sodium (Na)
  • Potassium (K)
  • Magnesium (Mg)
  • Calcium (Ca)
• Nursing Focus:
  • Monitor laboratory values closely, assess for symptoms affecting cardiac, neurological, and muscular systems
  • Understand the implications for organs and know when to contact a physician

Hyponatremia - (Na+ < 135 MEQ/L)

• Common Causes:
  • Vomiting, diarrhea, use of diuretics, Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH), fluid overload
• Symptoms:
  • Confusion, headache, nausea, cramping, low blood pressure
• Nursing Actions:
  • Restrict water intake, replace sodium with 0.9% saline (oral or IV)
  • Monitor neurology status and track Input & Output

Hypernatremia - (Na+ > 145 MEQ/L)

• Common Causes:
  • Dehydration, heat stroke, diabetes insipidus (DI), excessive sodium intake
• Symptoms:
  • Extreme thirst, dry tongue, restlessness, muscle twitching, seizures
• Nursing Actions:
  • Gradual hydration using D5W or 0.45% saline, monitor mental status, and perform laboratory checks

Hypokalemia - (K+ < 3.5 MEQ/L)

• Common Causes:
  • Gastrointestinal loss, diuretic use, inadequate potassium intake, and conditions resulting in alkalosis
• Symptoms:
  • Muscle weakness, fatigue, premature ventricular contractions (PVCs), ileus, flat T-waves on ECG
• Nursing Actions:
  • Administer potassium orally or intravenously (never push rapidly to prevent cardiac arrest!), monitor ECG, and ensure adequate urine output

Hyperkalemia - (K+ > 5.0 MEQ/L)

• Common Causes:
  • Renal failure, trauma, acidosis, excess potassium supplements
• Symptoms:
  • Muscle weakness, paresthesia, bradycardia, elevated T-waves on ECG, risk of cardiac arrest
• Nursing Actions:
  • Administer insulin + D50 for rapid reduction of potassium levels, calcium gluconate for cardiac protection, and consider dialysis in severe cases; conduct ECG monitoring

Hypomagnesemia - (Mg²⁺ < 1.8 MG/DL)

• Common Causes:
  • Alcoholism, gastrointestinal loss, diabetic ketoacidosis (DKA), malnutrition, diuretics
• Symptoms:
  • Chvostek's and Trousseau's signs, tremors, psychosis, hyperreflexia, dysrhythmias
• Nursing Focus:
  • Administer IV magnesium sulfate (infuse only via pump, closely monitor)
  • Be cautious of dysphagia—check swallowing ability prior to medication administration
  • Implement seizure precautions and encourage high-magnesium diet (leafy greens, legumes, peanut butter)

Hypermagnesemia - (Mg²⁺ > 3.0 MG/DL)

• Common Causes:
  • Renal failure or excessive magnesium intake (such as anti-acids or laxatives)
• Symptoms:
  • Decreased deep tendon reflexes (DTRs), muscle weakness, respiratory depression, changes in ECG
• Nursing Focus:
  • Discontinue magnesium-containing medications, administer IV calcium gluconate, monitor level of consciousness, reflexes, and cardiac rhythm, and prepare for potential dialysis in severe situations

Hypocalcemia - (Ca²⁺ < 8.5 MG/DL)

• Symptoms:
  • Neuromuscular excitability, noted as: numbness and tingling, muscle cramps or tetany, Trousseau's and Chvostek's signs, seizure activity, laryngospasm
• Nursing Priorities:
  • Apprise that IV calcium gluconate may be required for severe cases
  • Safeguard the airway due to laryngospasm risk
  • Enforce seizure precautions and check serum albumin levels alongside calcium

Hypercalcemia - (Ca²⁺ > 10.4 MG/DL)

• Common Causes:
  • Cancer, hyperparathyroidism, immobilization, thiazide diuretics
• Symptoms:
  • Generalized weakness, constipation, nausea and vomiting, bone pain, excessive thirst, confusion, disturbances in ECG
• Nursing Focus:
  • Promote adequate hydration and physical activity, administer furosemide, calcitonin, or bisphosphonates as indicated, monitor neuro status for fall risk, and increase dietary fiber to mitigate constipation issues

Hypophosphatemia - (PO₄³⁻ < 2.5 MG/DL)

• Common Causes:
  • Alcoholism, DKA, refeeding syndrome, low vitamin D levels, excess diarrhea
• Symptoms:
  • Weakness, confusion, bone pain, increased risk for infection
• Nursing Focus:
  • Provide oral phosphate supplements, encourage a diet high in phosphorus (dairy, meat, legumes)
  • Regularly monitor calcium levels due to the inverse relationship
  • Initiate feeding protocols slowly with malnourished patients to prevent refeeding syndrome

Hyperphosphatemia - (PO₄³⁻ > 4.5 MG/DL)

• Common Causes:
  • Renal failure, excessive vitamin D levels, hypoparathyroidism
• Symptoms:
  • Often asymptomatic but may present with hypocalcemia signs (tingling, spasms)
• Nursing Focus:
• Administer phosphate binders (such as calcium-based antacids), implement a low-phosphorus diet (avoiding dairy, soda, and processed foods), monitor calcium and parathyroid hormone (PTH) levels, and anticipate potential dialysis if severe.

What About Chloride?

• Chloride (Cl) often follows sodium, serving to balance fluids and acid-base levels.
• Treatment for chloride disturbances is not typically done in isolation; its levels are frequently assessed in conjunction with sodium levels.
• In exams, focus study efforts primarily on sodium, potassium, calcium, and magnesium—as they are the key electrolytes relevant in clinical practice.

Acid-Base Balance

• Definition:
  • Maintaining a blood pH between 7.35 and 7.45 is vital.
• Imbalances:
  • pH < 7.35 indicates acidosis
  • pH > 7.45 indicates alkalosis
• Physiological Control:
  • Lungs manage CO₂ (acid levels)
  • Kidneys regulate HCO₃ (base levels)
• Nursing Focus:
  • Identify situations of imbalance and apply appropriate responses.

Metabolic Acidosis

• Laboratory Values:
  • pH < 7.35, HCO₃ < 22 MEq/L
  • May demonstrate high anion gap
• Common Causes:
  • Diabetic ketoacidosis (DKA), renal failure, starvation, salicylate overdose
• Symptoms:
  • Confusion, headache, deep breathing (Kussmaul respiration), decreased BP, dysrhythmias
• Nursing Actions:
  • Treat the underlying cause (e.g., administering insulin for DKA)
  • Monitor potassium levels, which may be elevated
  • Dialysis may be necessary in severe cases
  • IV bicarbonate may be provided as a treatment option

Metabolic Alkalosis

• Laboratory Values:
  • pH > 7.45, HCO₃ > 26 MEq/L
• Common Causes:
  • Vomiting, NG suction, use of diuretics, Cushing’s syndrome, low potassium levels
• Symptoms:
  • Tetany, tingling sensation, dizziness, muscle twitching, slowed gastrointestinal motility
• Nursing Actions:
  • Restore bodily fluids with normal saline (NS)
  • Cessation of suction or diuretic therapy
  • Monitor ECGs, neurological status, and potassium and calcium levels closely

Respiratory Acidosis

• Laboratory Values:
  • pH < 7.35, PaCO₂ > 45 mm Hg
• Common Causes:
  • COPD, respiratory depression (overdose), pneumonia, obesity, neuromuscular disorders
• Symptoms:
  • Drowsiness, increased respiratory rate (RR) and heart rate (HR), confusion, head fullness
• Nursing Actions:
  • Facilitate improved ventilation with oxygen therapy and bronchodilators, and suction as needed; may require intubation or CPAP support
  • Monitor Arterial Blood Gases (ABGs), Input & Output (I&O), and level of consciousness

Respiratory Alkalosis

• Laboratory Values:
  • pH > 7.45, PaCO₂ < 35 mm Hg
• Common Causes:
  • Anxiety, hyperventilation, salicylate overdose, sepsis
• Symptoms:
  • Lightheadedness, numbness in hands/feet, tachycardia, palpitations
• Nursing Actions:
  • Encourage slow breathing, consider using a paper bag technique for anxiety, and support with calming strategies
  • Address underlying causes, potentially utilizing antianxiety medications if appropriate

Anion Gap

• Normal Range:
  • 8-12 MEq/L
• Utility:
  • Assists in identifying the cause of metabolic acidosis
• Interpretation:
  • High anion gap indicates excess acid (conditions such as DKA or renal failure)
  • Low anion gap is rare but may signal protein loss or medication influences

Meet ROME (ABG Interpretation Mnemonic)

• ROME = Respiratory Opposite, Metabolic Equal
  • Respiratory conditions cause pH and carbon dioxide (CO₂) to move in opposite directions
  • Metabolic conditions cause pH and bicarbonate (HCO₃) to move together

ABG Interpretation Steps

• Step-by-step analysis:
  • Check pH for acidosis or alkalosis
  • Evaluate CO₂: Is respiratory cause indicated?
  • Evaluate HCO₃: Is metabolic disturbance indicated?
  • Align the direction of changes with the pH deviation
  • Check for compensation (is the alternate system attempting correction?)
  • TIP: If both CO₂ and HCO₃ are abnormal with a normal pH, it indicates full compensation

Causes and Clues Table

• Imbalance Summary
  • Common causes and key signs:
    | Imbalance | Common Causes | Key Signs |
    |------------------------|-----------------------------------------------------|-----------------------------------|----------------|
    | Respiratory Acidosis | COPD, hypoventilation | Confusion, increased CO₂ |
    | Respiratory Alkalosis | Anxiety, hyperventilation | Lightheadedness, numb fingers |
    | Metabolic Acidosis | DKA, diarrhea, renal failure | Deep Breathing (Kussmaul), decreased BP |
    | Metabolic Alkalosis | Vomiting, NG suction, diuretics | Muscle cramps, slow respirations |

Normal ABG Values Cheat Sheet

• Standard values:
  

• Understanding Compensation:
  • The body's response to restore pH towards normal
  • Compensating systems work in the opposite direction to the pH alteration
  • Evaluation:
  • If both PaCO₂ and HCO₃ are abnormal and pH remains abnormal, this shows partial compensation
  • If pH returns to normal but both PaCO₂ and HCO₃ remain abnormal, this indicates full compensation
  • If the non-primary compensatory system makes pH worse, it indicates a mixed disorder

Parenteral (IV) Fluid Therapy

IV Fluids Provided:

• IV fluids deliver:
  • Water, electrolytes, medications, and nutritional support
• Types of IV Fluids:
  • Isotonic (Normal Saline [NS], Lactated Ringer's [LR]): expands intravascular volume without shifting fluid
  • Hypotonic (0.45% NS): facilitates hydration of cells
  • Hypertonic (D5NS, D10): pulls fluid from cells

IV Complications

• Common issues:
  • Infiltration: non-painful peripheral swelling/coolness
  • Extravasation: infiltration of irritant or harmful drug
  • Phlebitis: redness, warmth, and tenderness around the vein
  • Fluid overload: crackles in the lungs, edema, increased blood pressure
  • Air embolism: causes shortness of breath and chest pain—trend patients to the left side
  • Septicemia: fever and chills indicate site infection
• Nursing Role:
  • Monitor IV sites and patient responses every shift, ensure proper labeling of IV fluids, and keep track of Input & Output (I&O) to know when to notify providers

Conclusion

• This guide encompasses a comprehensive understanding of vascular and fluid management concepts in clinical practice. The focus on assessment findings, diagnostic evaluations, medical interventions, and nursing priorities will enhance effective nursing care in patients experiencing fluid and electrolyte imbalances, DVT, aneurysms, and endocarditis.