exam 2

Nutrition: body's intake & use of adequate amounts of necessary nutrients nutrients necessary substances Obtained from ingested food that supply the body with energy, build and maintain bones, muscles, and skin, and aid in normal growth 3 function of each body system.

• Nutritional balance has an impact on normal growth, development, function, and maintenance of the body.

• enhances Wellness, promotes healthy lifestyle choices, reverses effects

• healthy eating can reduce risk for chronic diseases

malnutrition: imbalance in the amount of nutrient intake & body needs

Healthy people 2030

• promotes healthy lifestyles & v health

Normal structure and function 

• health is dependent on a combo of appropriate nutritional intake, rest, exercise, and Weight management

• Poor nutrition, lack of exercise, obesity, and stress contribute to health issues

  • heart disease, cancer, Stroke, hypertension, diabetes, Kidney disease

  • STRONG relationship between infection & malnutrition

Metabolism: process of chemically changing nutrients into end products that care used to meet energy needs of the body

• basal metabolic rate (BMR): Minimum amount Of energy required to maintain body functions In a resting, awake state.

• anabolism: simple to complex use energy

• Catabolism. Complex to Simple release energy

macronutrients: needed in large amounts

• major nutrients

• carbohydrates: provide energy for cells, tissues, urgans

• sugars, gratarus tiber, starches

• Fats: major sorce ot energy & promote absorption of Vitamins

• proteins: build, maintain, repair muscies & tissue

• Water assists body with Metabolic processes 

micronutients: nutrients needed by the body in limited amounts

• Minerals: needel for enerqy, muscle building, nerve conduction, blood clotting, immunety to disease

• Vitamins: Urganic compounds responsible for regulation of body processes, reproduction, growth

Failure of the body to properly use nutrients can result in conditions & diseases

• heart & Kidney disease, renal disorders, diabetes, malnutrition Obesity

Carbohydrates: chemical substances composed of Carbon, hydrogen, oxygen molecules

• 4 Kilocalories per gram

• kilocarores amount of heat energy it takes to raise the temp. of 1000g of water to I degree Celsius

• Carbs are major suppliers of energy

  • Sugar, starch, fiber

• Kuep body from using protens as energy

• Prevents detosis body burns fat in absence of adequate Carb intake

• Simple carbs: broken down & absorbed quickly providing a quick sovace of ptergy

  • sugars: fructose (fruit), table sugar (sucrose) lactose (mik), glucose | blood sugar)

• complex carbs: take longer to break down & aised by cals

  • Starches, aucogen, tiber

    • giyeogen needed for proper function of brain and other tissues

      • musces store qucoge

      • If glycogen becomes deplated, extreme fatique

• vitamins & minerals

  • Bread, rice, pasta, legumes, starchy Veggies

• fiber: soluble or insoluble

  • Solubility: disposition of the fiber when nixed with anoter substance

  • soluble fiber: mixes with water, slower digestion

  • insolublefiberi does not retain water, slow Starch absorbtion

  • high fiber diets promote cardiovascular health

    • low Choisterol & BP, Weight control, improve glycemic Control

  • Lack of fiber

    • constipation, hemorrhoids, aiterticula

  • 20-35g of fiber a day

  • Whole grains cereals, fruit, vegetables, legumes 

Fats: Composed ot carbon, hydrogen

• 9 Kilocalories per gram

• lipids: any fat within the body

• elevated monounSaturated fats, lower polyunsaturated & saturated

  • Santurated: many hydrogen atens as carbon atonns

    • No double bonds

    • Margarines, vegetable shortening, pastries, crackers, cheese, fried foods, ice cream

  • Monosaturated: one double bond between carbon bonds

    • Canola, olive and peanut oil, almonds, sesame seeds, avocados, cashews

  • Polyunsaturated: muttiple double bonds

    • corn, Sesame, Soybean, fish, sunflower oil

• fats are needed for energy & sellular growth

• Take longer to digest & reguires carbs

  • Triggerides most abundant kpid

• Benifits: energy, insulation, energy storage, iubercation, Vitamin absorbtion, transport of tat soluble vitamins ADEK

• Trans fat: Partially hydrogenated fatty acids

• Trans & saturated fat increase choresterol

• OMega 3 & omega 6: unsaturated "essential" fatty acias

  • Body can not produce them

  • Benefit: Blood clotting, brain and nervous System function

  • omega 3

    • fish, nuts, seeds, Oils (flaxseed dil highest)

Protein: Participants in development, maintenance, repair of body tissues, organs, cells

• Hemoglobin: part of erythrocytes

  • transports oxygen through body

• Prothrombin needed for blood clotting

• Production of hair 3 nails, muscle movement, nerve conduction, digestion

• amino acids: building blocks for proteins

  • must be consumed in food every day

• complete proteins: all essential amino acids

  • Animal-based foods

  • Cannot be made by the body

  • Only plant protein is soy beans

• Incomplete protein: lack one or more amino acids

  • Beans, peas, nuts, seeds, fruits, vegetables, bread

Water

• Controls body temp, regulates fluids and electrolytes, transports nutrient and waste from kidneys

• Water loss decreased equals blood volume decreased

  • Oxygen and nutrients cannot be furnished to cells

  • CO2 cannot be effectively removed

• Dehydration

  • Loss of concentration, headache

• Excess

  • Dilute the amount of sodium, hyponatremia

  • Congestive heart failure, renal disease

    • Fluid Limited

Vitamins

• Fat soluble (ADEK)

  • Stored in the liver and fat tissue

  • Not excreted by kidneys

  • Excessive amount equals toxicity (especially a & D vitamins)

  • vitamin A

    • Increases resistance to infection, promotes night vision, AIDS and development of bones and teeth

    • Deficiencies equals night blindness, poor appetite, low immunity, impaired growth

    • Carrots, green, leafy vegetables

  • Vitamin D

    • Synthesized when skin is exposed to light

    • Bone and tissue formation, development of collagen

    • Calcium loves vitamin vitamin D

  • Vitamin E

    • Antioxidant that protects cells from free radicals: byproducts from when body transforms food into energy

    • Maintain a healthy immune system system

  • Vitamin K

    • Synthesized in the body by bacteria

    • Promotes clotting

      • Prothrombin (protein) is dependent on vitamin K for this process

    • Deficiency equals bruising and bleeding

• Water soluble: dissolve in body and excreted through urine

  • Vitamin C

    • Wound healing, repair and maintenance of Cartlidge, bone, teeth, and development of a strong immune system

    • Citrus, fruits, broccoli, brussels sprouts, tomatoes

  • Vitamin B complex

    • Helps form red blood cells

    • Facilitates energy production

    • Vitamin B1: metabolism of protein, fat, carbs to produce energy

    • Vitamin B2: metabolism of protein

    • Vitamin B3: coin enzyme for energy production, formation of fatty acids

    • Biotin: used to produce energy, forms purines

    • Vitamin B5: metabolism of carbs, fats, protein, synthesis of acetylcholine

    • Vitamin B6: assist as a co-enzyme in the synthesis and cannibalism of amino acids

    • Vitamin B12: production of red blood cells (RBC), facilitates entrance of folate into cells, necessary to make DNA

    • Vitamin B9 (folic acid): water, soluble, not produced in the body, synthesis of DNA, used for red blood cell formation, rapid cell growth

      • Absorption may be affected by oral contraceptives and antibiotics

Minerals

• Micro nutrients

• Potassium, sodium, chloride

  • Maintain fluid balance in the body

  • Nerve conduction, and muscle contraction

• Calcium, phosphorus, magnesium

  • Production and maintenance of bone tissue

  • Magnesium and calcium together, regulate blood pressure and regular heartbeat

  • Zinc may lower magnesium level levels

Antioxidants

• Protects body from free radicals

  • free radicals are produced when the body breaks down food

• Slow or preventing oxidation process

• Vitamins ACE

Digestion: breakdown of food into smaller nutrients

• Iingestion: consumption of food

• Enzymes: chemically breakdown food by substance

• Absorption: movement through walls to the blood

• First stage is by the Salvatore glands

  • Chewing takes place

• Glucose is then carried through the bloodstream to the liver where it is either stored or used

• Food is physically or chemically absorbed in the membranes of intestines and enters the bloodstream - catabolism

• Body has to have adequate carbs to utilize fat

• Intestinal mucosa facilitates absorption

Dietary guidelines

• Fruit, fruits, vegetables, whole grains, fat-free milk

• Limit: Low saturated fats, trans, fats, sodium, added sugar

• Fruits and vegetables are half of the plate

Diversity considerations

• The longer woman breast-feeds lowers her risk for diseases and lowers the child’s risk for infection, obesity, diabetes

• Adolescent boys need increased iron for lean body mass

• Adolescent girls need increased iron for menstrual periods

• Pregnant women and child bearing age are high risk for iron deficiency anemia

• Excess protein increases calcium loss

Musculoskeletal 

• Poor nutrition, places person at risk for bone defects (A and D)

Neurological

• Increased sodium equals, hypertension, increased risk for stroke

Cardio pulmonary

• Arthrosclerosis: blood flow to part of the heart is occluded

Digestive system

• Absorption causes rickets (vitamin D deficiency), and scurvy (vitamin C deficiency)

  • Vitamin C may result in gingivitis and stiff joints

• Marasmus: protein, and calorie deficiency

• Kwashiorkor: lack of protein with fluid retention

Diabetes mellitus

• Insulin dependent is type 1

• Non-insulin dependent is type 2

  • oral antiglycemic, diet, exercise

• High risk for developing blindness

Allergies and intolerances

• allergies: anti antibodies created to fight it

  • Life-threatening

• Intolerance: upsets digestive tract

  • Discomfort

Obesity

• ObeseBMI is 30 or above

• Morbidly obese BMI equals 40 or above

• High BMI equals blood pressure and cholesterol, and low ADL and good cholesterol

• Hyperlipidemia: elevation of plasma, cholesterol, triglycerides, or both

Malnutrition

• Just the lack of one vitamin

• Anorexia: lack of appetite

• Anorexia nervosa: fear of gaining weight

  • Use of laxatives, diuretics, exercise, limits calories, vomiting

• Bulimia nervosa: binging and purging

Nutrition history

• Dietary intake, changes and weight or appetite

• Dietitian makes an individual program for exercise, diet, behavior

• Food journal

  • 3 to 5 days including the weekend

Screening for malnutrition and older adults

• Close attention to mouth, teeth, gums

• DETERMINE self assessment

  • Disease, eating poorly, tooth loss/mouth, pain, economic hardship, reduce social contact, multiple medication’s, involuntary weight gain/loss, need assistance in self-care, elderly years above 80

Waste circumference and risk of cardiovascular disease

• Pear shape: inflammation, insulin resistance, metabolic syndrome

• Apple shape: type two diabetes, coronary heart, disease, hypertension

Physical assessment

• Height, weight, BMI, lab values

• MORPHOLOGY

  • BMI helps establish obesity, malnutrition, CACHEXIA: physical wasting

• Anthropometric measurements

  • Anthropometry: study of measurements of the human body

  • Children: Height, weight, length, head circumference

  • Adult: height, weight, BMI, waist to hip ratio

  • Waste circumference can be used as a diagnostic criterion for metabolic syndrome

    • Metabolic syndrome is characterized by obesity, insulin resistance, abdominal fat, high blood glucose, hypertension, elevated cholesterol and triglycerides

  • Skinfold measurements can determine a person‘s body, composition and fat percentage

    • Measured by skinfold thickness use of calipers, at a specific location

For obese patients

• Check A1c, lipid panel, blood pressure, CBC, CMP

• Teach diet control, exercise, rest, appropriate nutritional intake

Skin and hair

• Thinning hair: dry, stiff, lack of shine, appear pale

• Lip: deep red, lesions, or cracks, oral, mucosa, more red, oral lesions

• Pernicious anemia: beefy, red tongue

• Skin: dry, rough, pallor, petechiae 

Dentition

• Edentulous: toothless

Swallow studies

• Should be monitored for coughing, wheezing, dyspnea, apnea, bradycardia, hypotension

• Speech therapist conduct swallow studies

Laboratory studies

• Protein and pre-albumin are affected by fluid balance, liver and renal function, acute stress, colloid administration

• Prealbumin: measures the amount of protein in internal organs

  • Proteins, synthesized and liver, broken down by the kidneys

  • Determine nutritional status

    • Low 11mg/dl = malnutrition

  • Decreased levels may be caused by stress, inflammation, surgery, renal failure

  • Half life two days

• Albumin: prolonged nutritional status

  • Determines liver function

  • Half-life 21 days

  • Determines the presence of ample supply of protein

• Transferrin

  • Transports iron in the body

  • Levels elevated equals iron levels lower

• Hemoglobin and hematocrit

  • Provide oxygen to the cells

  • Iron is essential in hemoglobin

    • Iron depleted a equals fatigue, pallor, shortness of breath, rapid respiration

  • Hematocrit indicates the number and size of red blood cells in whole blood

    • Low hematocrit equals anemia

• Blood urea nitrogen and creatine

  • Part of the comprehensive metabolic profile

  • Evaluates kidney function

Aspiration precautions

• Symptoms: coughing, wheezing, dysphasia, apnea, bradycardia, hypotension

• patient at risk: endoscopy procedures

• Procedural concerns

  • Elevate head of bed to 45° or higher during eating and 45 minutes after eating

  • Keep head of bed at 30° at all other times

  • Avoid eating or drinking 2 to 3 hours before bed

  • Maintain NPO until gag reflex has been verified

Elimination patterns

• Constipation: fiber, fluid, get them moving

• Diarrhea: increase soluble fibers

Comprehensive nutritional care

• Dietitian provide provides education and services that may address the psychosocial and economic factors that affect patient care

• Care managers are responsible for coordinating, timely, costly, effective inpatient, and outpatient services

• Speech therapist = impaired swallowing

Dietary preferences

• Vegans do not eat animal products

  • At risk for pernicious anemia

    • Supplement vitamin B12 to decrease risk

• Vegetarians do not eat meat

• Lacto-ovo consume milk and eggs

Food patterns based on religious and culture

• Kosher diet: no pork, shellfish, rare meats, no blood

  • No combining milk or dairy with meat

• Catholic: holy days with fasting; lent

• Islamic: no alcohol, pork, caffeine

  • Halal

• Ramadan: no eating or drinking from sun up to sundown

• Mormon: no alcohol, caffeine, tobacco

• Seven day activist: vegetarian diet, no alcohol

• Buddhist: no meat or meat by products

• Hindus: no beef consumed, but can eat byproducts

• Ask patient about diet restrictions of alcohol based on medications such as antitussives

  • Cough medicine

Special diets

• Clear: short period, see-through, no pulp

• Full liquid: liquid at room temperature

• Purée: blended, cannot safely swallow/chew food

• Thickened liquid: for people who have difficulty swallowing/risk for aspiration

• Regular: no restrictions

• Diabetic: control carbs

  • High fiber complex carbs (fruits, and vegetables) are preferred to simple carbs, sugars, starchy foods

• Cardiac: low sodium, low cholesterol

  • Minimize animal, products, soups, processed foods

• Renal: restrict, potassium, sodium, protein, phosphorus

  • No bananas, but eat other fruits and vegetables

Assistance with feeding

• Elevate head of bed, 30 to 45°

• Observe swallowing

  • Dysphasia sign: coughing, and complete lip closure, poor tongue, control, excessive, chewing, gagging before swallowing, failure to swallow, pocketing, refusal to eat

• Follow dietary and nutritional orders

• Provide oral care before and after feeding

• Elevate bed, 30 to 45°

• One sided muscle weakness = has patient turned head to the affected side

  • Chin tucking helps prevent aspiration

• Allow 30 minutes for each meal and wait 10 seconds per bite

• Alternate food with liquids

• Log roll patient if semi Fowlers is contradicting to side laying

  • Have suction at the bedside

NPO orders

• Used before and after surgery

• Oral care is important

  • Padded tongue blade holds mouth open to allow toothbrush to reach inside cheeks and lips

Eternal feeding tube

• Short term use

• Radiographic confirmation

• G.I. tract is functional, but cannot swallow, refuses to eat, or needs additional nutrients

• Nurses can insert NG tube, but a peg tube is surgically placed

• Nasal gastric (NG)

  • Nares to stomach

  • Short term

• Percutaneous endoscopic gastronomy (PEG)

  • Surgically placed through an incision in the upper left quadrant of the abdomen

  • Long-term

  • Can give meds through tube, but never give meds with food

  • Good for patient who has had esophageal cancer, or an injury to mouth, nose, throat

  • Peg tube care

    • Surgical sepsis if tube is newly placed

    • If tube becomes occluded, flush with a small amount of air, then use warm water

    • Complications: pneumonia, bleeding, bowel, perforation, infection

    • If a patient experiences bleeding, pain before or after feedings or medication administration or leakage around the site, the feeding or medication should be stopped immediately

• Make sure tube feedings are connected to internal tubes only

Medical medication administration via enteral tube

• Cannot crush enteric coated pill (ER, XL, SR, extended release) 

• Medication’s are never directly given through a a tube feeding

  • Mixed with liquid or powder form

    • 15 to 30 mL sterile water

    • Flushed with at least 15 mL of sterile water after each medication

    • After medication’s, flush, and then you can resume feedings

• Can use gravity or push medication’s

Total parenteral nutrition TPN

• TPN: may be given through a picc line or CVC by means of infusion pump

• Maybe used for a patient with a non-functioning G.I. tract, a patient who is unable to ingest, digest or absorb essential nutrients

  • Conditions: Crohn’s disease, G.I. obstruction, diarrhea, burns

• TPN is individualized

• Should include weight, CBC, electrolytes, BUN,I&O

  • Plasma, glucose and electrolytes help determine tolerance of solution

  • Glucose should be checked every six hours

• Tubing is changed every 24 hours

• A septic technique

• Dressing changed every 48 hours

  Chapter 39: fluid and electrolytes 

  Composition of body fluids

  • Water

    • Regulates temperature, lubricate joints, shock, absorber, transports nutrients, and waste products throughout body

    • Total body water equals 60%

  • Intracellular fluid is in the cell

  • Extracellular fluid is out of the cell

    • Interstitial: fluid between the cells (edema)

    • Intravascular: blood plasma (mostly albumin protein)

    • Transcellular: cerebrospinal, synovial, peritoneal, pleural, pericardial fluids

  • Solutes: substances that dissolve in a liquid

    • Crystalloids: dissolve easily

    • Colloids: do not dissolve easily

    • Electrolytes: charged, conduct electrical impulse across the cell (extracellular has no protein)

      • Cations: positive

      • Anions: negative

      • Cations and anion should be equivalent

        • Milliequivalent: ability of cations to bond with anions to form molecules

    • Non-electrolytes: oxygen, carbon dioxide, glucose

  Movement of body fluids

  • Osmosis: movement of water across cell membrane

  • Osmotic pressure: force created when two solutions of different concentrations are separated by a selectively permeable membrane: cell membrane allows water to move across, but not solutes

    • Water moves by osmosis from low concentration to high concentration to attempt to equalize the concentration across the membrane

      • The higher the difference in concentration, the greater of osmotic pressure

  • Osmolality: number of osmoles, per kilogram of solvent

  • Osmolarity: number of Osmoles per liter of solvent 

  • Tonicity: level of osmotic pressure of a solution

  • Isotonic solution: solution that has the same osmolarity as blood plasma

    • Normal saline, 0.9% sodium chloride

  • Hypertonic solution: pulls water from the cell to extracellular

    • Shrinks the cell

    • Higher osmolarity than body fluids

  • Hypotonic solution: excess water moves into the cell

    • Swelling of cell

    • Lower osmolarity than body fluids

  • Give patient the opposite solution to what they are experiencing

    • Hypotonic patient = hypertonic solution

    • Hypertonic patient = hypotonic solution

  • Fluid volume deficit

    • Isotonic: losing salt and water at the same time

    • Hyper: volume is high water is low

  • Fluid volume excess

    • Isotonic: gaining sodium and water at the same time

    • Hypotonic: too much water, not enough salt

    • Edema: water moves into the tissue faster than the body can absorb it

  • Simultaneous fluid volume excess and deficient

    • Cirrhosis of the liver: causes low albumin, blood is leaving the vessel, blood pressure will be low because loss of volume

      • Albumin: helps pull fluid back into the vessel

  • Filtration: processed by which fluid and so move together from an area of higher pressure to lower pressure

  • Hydrostatic pressure: force of the fluid pressing against the blood vessel

    • Controlled

  • Fluid balance is influenced by the opposing forces of hydrostatic and oncotic pressure

  • Filtration across a selectively permeable membrane occurs when the hydrostatic pressure is greater than the oncotic pressure

  Regulation of body fluids

  • water is lost from the body primarily through kidneys and urine

    • Small amount of water is lost through respiration, perspiration, and a very small amount through feces

  • Homeostasis: maintenance of fluid balance, monitored by the kidneys through changes in blood pressure

  • Renin- angiotensin system: regulates blood pressure and fluid balance through vasoconstriction and excretion or absorption of sodium

  • Antidiuretic hormone (ADH): maintain serum osmolarity by controlling the amount of water excreted in the urine

    • Excluded by the pituitary gland

  • Hypovolemia: decreased in fluid volume

    • Decrease fluid volume and decrease in blood pressure stimulate the enzyme renin by the kidneys

  • Angiotensin II causes:

    • Vasoconstriction: narrowing of blood vessels

    • Stimulates adrenal cortex releases

    • Aldosterone: and increases the amount of water and sodium rib, absorbed back into the bloodstream

    • ADH is secreted

    • Thirst is elevated

  • Osmo receptors: monitor osmolarity of blood plasma

    • Osmolarity increases receptors stimulates secretion of ADH

      • ADH works on collecting ducks of the kidneys to Reeve absorbed more water less urine produced

  • Aldosterone: stimulate absorption of water and sodium

    • Increase volume and does not affect osmolarity

  • ADH absorbs water only

    • Increased fluid volume and decreased plasma osmolarity

  • Atrial netriuretic peptide (ANP): secreted by the cells in response to increased pressure due to increase blood volume

    • ATM causes an increase in the glomerular filtration rate (GFR), which increase increases excretion of water and urine

    • Inhibit secretion of renin and ADH and reabsorption of sodium chloride and water into the bloodstream

  Movement of electrolytes

  • Electrolytes move in and out of the cellular space

    • Diffusion, filtration, active transport

    • Diffusion: movement across selectively permeable membrane from high concentration to low concentration until equilibrium is reached

      • Rate of diffusion is influenced by: 

        • Temperature: increased temperature, faster it diffuses

        • Molecular weight: lighter molecules, diffuse, fast faster

        • Steepness: the more uneven, the surface, the faster

        • Membrane permeability: condition that causes the membrane to become more permeable to larger molecules, otherwise would not be able to cross the membrane

    • Facilitated diffusion occurs when a solute is unable to pass through a membrane and requires a carrier

    • Active transport: transport of a solute from low concentration to high concentration

      • Requires energy

  Regulation of electrolytes

  • Potassium and phosphate are found inside the cell

  • Sodium and chloride are found in the intravascular fluid

  • Electrolyte function

    • Sodium (Na+): 135-145 mEq/L

      • Moves out of the cell by NAK pump

      • Regulated by secretion of aldosterone and ATP

      • Foods: bread, cereals, chips, cheese, processed food, table salt

      • Hyponatremia: < 135 

        • Low concentration and extra cellular

        • Water moves into cell, which makes the cell swell

        • causes: G.I. fluid loss, sweating, diuretics

        • Manifestations: lethargy, seizures, anorexia, confusion, muscle cramping

        • Interventions: foods, high and sodium, restrict water, monitor sodium levels ( too much sodium too fast can cause brain damage)

      • Hypernatremia: >145

        • Greater decrease of water compared to sodium

        • Sodium levels high

        • Intravascular water follows

        • Cause: excess water, loss, hypertonic IV solutions

        • Manifestations: thirst, weakness, high temperature, hypertension, confusion, low level of consciousness, seizures, sweating, vomiting

        • Interventions: monitor vital signs, level of consciousness, I&O’s, and increased water intake

    • Potassium (K+): 3.5-5

      • Moves into the cell by NAK pump

      • Regulated by kidneys through reabsorption or excretion

      • Foods: fish (no shellfish), whole grains, nuts, broccoli, cabbage, cucumbers, citrus fruit

      • Hypokalemia: <3.5

        • Causes: vomiting, gastric suction, enemas, laxatives, potassium wasting diuretic

        • Manifestations: weak, irregular, pulse, anorexia, cardiac dysrhythmia, decreased peristalsis, hypo active bowel sounds

        • Interventions: monitor heart rate and rhythm, give potassium supplements

        • NEVER ADIMINISTER POTASSIUM AS AN IV BOLUS OR IV PUSH

      • Hyperkalemia: >5.0

        • Four source:

          • Increase intake of potassium

          • Transfusions and medications

          • Impaired renal excretion

          • Cellular movement

        • Causes: Randall failure, dialysis, trauma, diabetic ketoacidosis, potassium sparing diuretics

        • Manifestations: dysrhythmia (bradycardia), abdominal cramping, low blood pressure

          • Too much potassium, it’s coming out your assium

        • Interventions: no orange juice, ECG, monitor heart rate and rhythm, administer glucose and insulin

    • Calcium (Ca+): 9-10.5 mg/dL

      • Primary component of bones and teeth

      • Roll in blood clotting, nerve and pulse transmission, muscle contraction

      • If calcium levels drop, parathyroid hormone pulls calcium from the bones

      • Calcitonin moves excess calcium into the bones

      • Foods: cheese, ice cream, milk, yogurt, rhubarb, spinach, tofu

      • Hypocalcemia: <9

        • Happens when calcium cannot be absorbed from the small intestine

        • Low protein equals high calcium, making it more prone to be excreted

        • Causes: pancreatitis, vitamin D, deficiency, hyperphosphatemia

        • Manifestation: confusion, anxiety, numbness, tingling, cramps, technique, seizures, hyperactive, refluxes, cardiac, dysrhythmia, positive chvostek and trousseau signs

          • Chvostek signs: tap on face, face will scrunch (calcium cheek chvostek)

          • Trousseau signs: take blood pressure, cuff and fleet cuff above systolic for 3 to 5 minutes. The thumb will abduct and the wrist will flex

            • Looks like a gang sign

        • Interventions: monitor cardiac rhythm with ECG, fall and seizure precautions

      • Hypercalcemia: > 10.5

        • Elevated secretion of parathyroid hormone

        • Increased calcium released in bones

        • Cause: prolonged bedrest, osteoporosis

        • Manifestations: lethargy Stupor, coma, anorexia, constipation, fractures, dysrhythmias, renal calculi

        • Interventions: monitor heart rate and rhythm, increased fluid intake, activity, and range of motion

    • Magnesium (Mg+): 1.5-2.5 

      • Key role and production of ATP

      • Helps maintain calcium levels

      • Cashews, halibut, Swiss chard, green, leafy vegetables, tofu

      • Hypomagnesia: <1.5

        • Decreased levels result from decreased intake, decreased absorption, decreased loss through kidneys

        • Causes: TPN without magnesium, nasal gastric, suctioning, diarrhea, malabsorption syndrome, ulcerative colitis, Crohn’s disease, loop diuretics

        • Manifestations: hyperactive deep tendon reflexes Tay arrhythmias altered level of consciousness, delusions dysphasia

        • Interventions: monitor heart rate and rhythm, assessment status monitor, potassium and calcium, seizure precautions, assess swallowing

      • Hypermagnesia: > 2.5

        • Excessive intake of an acids or TPN

        • Causes: and acids, renal failure, dehydration, leukemia

        • Manifestations: worm, flush appearance, weakness, hypotension, dysrhythmia, bradycardia, slow shallow respirations, respiratory arrest

        • Interventions: modern heart rate and rhythm, level of consciousness, increased fluids, loop diuretics, respiratory support

    • Chloride (cl-): 98-106 

      • Required for formation of stomach acid

      • Where sodium goes chloride also goes

      • Food: seaweed, rye, tomatoes, lettuce, celery, olives, table salt

      • Hypochloremia: <98

        • Occurs with simultaneous shifts of water, sodium and bicarbonate

        • Cause: overhydration, vomiting, gastric, suctioning, heart failure, loop and thiazide diuretics

        • Manifestations: irritable, nerves, and muscles, technique, hypotension, shallow breathing

        • Interventions: monitor vital signs and eyes and I&O, and laboratory results, restrict water, intake, hypertonic IV solutions

      • Hyperchloremia: >106

        • Affected by dehydration and certain medication’s

        • Causes: dehydration, anemia, excessive normal saline, infusion, kidney disease

        • Manifestations: weakness, lethargy, deep breathing

        • Interventions: monitor vital signs and I&O, and laboratory results and level of consciousness, limit salt, increased water, hypotonic solutions

    • Phosphate (PO-): 2-4.5

      • Helps maintain bone and teeth structure

      • Roll in cellular metabolism and ATP production

      • Essential for carbohydrate metabolism

      • Inverse relationship with calcium

      • Milk, meats, nuts, legumes, grains

      • Hypophosphatemia: <2

        • Decrease absorption from intestines or increases excretion by kidneys

        • Hyperventilation facilitates phosphate into the cell

        • Cause: hyper ventilation, hyperglycemia, starvation, absorption syndrome, decreased vitamin D, hypocalcemia

        • Manifestations: weak pulse, shallow, respirations, hypotension, decreased cardiac output, bleeding, increased bruising, increased risk for infection

        • Interventions: monitor, respirations, oxygen saturation, blood pressure, assess for heart failure

      • Hyperphosphatemia: >4.5

        • Causes: impaired, renal function, cell injury, hypo parathyroidism

        • Manifestations: hypocalcemia, technique, muscle, spasm, tachycardia, nausea, diarrhea

        • Interventions: monitor, phosphorus, and calcium and BUN and creatinine and I&O, assess signs of hypocalcemia

  Fluid imbalance

  • Excessive fluid loss can lead to decrease circulating volume which directly affects cardiac output

    • Leads to increasing workload of the heart

  • Disorders

    • Isotonic fluid volume deficit (hypovolemia)

      • Cause: hemorrhage, burns, vomiting, fever

      • Manifestations: confusion, thirst, orthostatic, hypotension, tachycardia, a weak pulse

      • Laboratory findings (increased): specific gravity >0.030, BUN >20

      • Interventions: monitor in taking output, laboratory, results hematocrit, BUN, specific gravity

    • Hypertonic fluid volume deficit (dehydration) 

      • Cause: diabetic ketoacidosis, hypertonic, feedings or IVs, vomiting, diarrhea

      • Manifestations: confusion, thirst, seizures, coma, flushed, dry skin, elevated temperature

      • Laboratory findings (elevated): specific gravity >1.030, BUN >20, sodium >145

      • Interventions: fluids, neurological checks, monitor intake output, laboratory results, BUN and specific gravity and sodium

    • Isotonic fluid volume excess

      • Cause: heart failure, renal failure, cirrhosis of the liver

      • Manifestations: weight gain, edema, bounding, balls, hypertension, dysphasia, cough, jugular vein distention

      • Laboratory findings (decreased): specific gravity <1.005, BUN <7

      • Interventions: monitor intake and output, laboratory results, edema

    • Hypotonic fluid volume excess

      • Causes: increased water intake, long use of hypotonic IV solutions

      • Manifestations: weight gain, edema, bounding, poles, hypertension, dysphasia, cough, jugular vein, distention, neurological changes that indicate cerebral edema ( decreased level of consciousness, coma, seizures)

      • Laboratory values (decreased): specific gravity <1.005, BUN <7 , sodium <135

      • Intervention: monitor intake and output and lab results and check for neurological changes

  Fluid volume deficit

  • Fluid volume deficit: occurs with excessive loss or inadequate intake of fluid

  • Isotonic fluid deficit (hypovolemia) occurs when water and sodium are lost at the same rate

    • Circulating volume decreases, but osmolarity remains unchanged

  • Hypertonic fluid volume deficit (dehydration)

    • Fluid loss continues the circulating fluid volume decreases, and osmolarity increases

  • Age related changes

    • Decreased thirst

    • Kidneys are less able to concentrate urine

    • Medication side effects

    • Swallowing problems

    • And ability to drink or hold a cup

    • Confusion or delirium

  • Severity of dehydration

  • 2% is mild

  • 5% is moderate

  • 8% is severe

  • 15% is life-threatening

  Fluid volume excess

  • Fluid volume excess: fluid intake exceeds

  • Severity of volume excess

    • 2% is mild

    • 5% is moderate

    • 8% of severe

  • Edema: abnormal accumulation of fluid in the in interstitial space

    • Mostly in extremities

    • Fluid moves into a tissue at a faster rate that it can be re-absorbed into the interstitial space

    • Primary cause of edema

      • Increase in hydrostatic pressure due to fluid overload

      • Decrease production of circulating plasma proteins

      • Obstruction of lymph drainage

      • Increase capillary permeability due to tissue damage

  • Isotonic fluid volume excess

    • Equal increase in fluid and sodium retention

    • Results in circulating blood volume while osmolarity remains unchanged

  • Hypotonic fluid volume excess

    • Water is ingested at a rate greater than sodium

    • Results in a increase in circulating blood volume and a decrease in osmolarity

      • Results in fluid moving into the cell

        • Cell swelling

  Simultaneously fluid volume excess and deficient

  • Cirrhosis of the liver

    • Albumin levels are very low, hydrostatic pressure is higher than the onconic pressure, fluid sees into the interstitial spaces

    • Excess patient will present with: weight gain, pulmonary congestion, edema

    • Deficits patient will present with: hypotension, weak, threading, pulses, tachycardia, poor skin turgor

    • Treatment

      • Replacement of plasma proteins

      • Allow fluids to shift back into intervascular space

      • Fluid replacement after fluid shift has occurred

  Health history

  • recent changes in fluid intake, diet, lifestyle, habits

  • Medication’s

  • Herbal medication’s can affect electrolyte and fluid balance

    • Aloe: laxative, hypokalemia, hypoglycemia, and diabetics

    • Celery and dandelion: diuretic

  Vital signs

  • Pay attention to prolonged fever, tachycardia, changes and respiration, alteration in blood pressure

    • Dehydration, body temperature increases

    • Isotonic fluid volume deficit, body temperature decreases

  • Alterations and potassium, calcium magnesium can lead to dysrhythmia

  • Orthostatic hypotension: decreased more than 20 MMHG in systolic or 10 MMHG in diastolic when moving from lying to sitting or seated to standing

  And taking output

  • When things are melted, it is approximately half the frozen amount

  • Fluid balance is positive when intake exceeds output

  Weight

  • Change in 1kg is equivalent to 1 L of fluid

  • Daily weight is the number one most reliable indicator of a patient’s hydration status

    • Same scale, clothes, time of day

  Edema

  • Significant and visible indicator of fluid volume excess

  • Bedridden patient usually have sacral edema instead of peripheral

  • Brawny edema: obvious swelling, but tissues are too firm and hard to be indented

  • Edema is a late indicator of fluid volume excess

  Mucous membranes

  • Normal mucous membranes are pink and moist

  • Fluid volume deficit mucus membranes are dry sticky have cracks in the lips and furrows on the tongue

  Assessment of hydration

  • Neurologic

    • Chvostek sign

    • Trousseau sign

    • Deep tendon reflexes

    • Tremors

    • Confusion

    • Coma

  • Cardiovascular

    • Jugular vein distinction

    • ECG waves

    • Pulse

    • Blood pressure

  • Respiratory

    • Abnormal lung sounds

    • Respiratory rate

  Diagnostic test for fluid and electrolytes

  • Electrolytes

    • Direct information on extracellular levels

    • Indirect information on interest, cellular levels

  • BUN and creatinine

    • Indicates renal function

  • Osmolarity

    • Information on hydration status

  • Red blood cells, hemoglobin, hematocrit

    • Indicates oxygen carrying capacity

    • Hematocrit can be influenced by fluid volume

  • Serum Albumin

    • Indicates colloid oncotic pressure capability

  • UrAnalysis

    • PH: information on hydrogen ion concentration

    • Specific gravity: increase with fluid volume concentrated, and is low with fluid volume excess

    • Osmolarity: increased with fluid volume deficit decreased fluid volume excess

  • Oxygen saturation is the amount of O2 bound to hemoglobin

  • PAO2 represents the free floating O2 molecules

  • Hypoxemia: decreased O2 and arterial blood

    • PAO2 also decreased

      • 60- 80 MMHG is mild hypoxemia

      • 40-60 MMHG is moderate

      • Below 40 MMHG is severe

  Factors affecting fluid and electrolyte balance

  • Age: infants and elderly are more susceptible to fluid imbalance

  • Stress: increased fluid retention and decreased renal excretion

  • Weight: total body fluid, disproportionate weight in obese people

  • Surgery: preoperative= PO, blood loss, stress, fluid drainage. postoperative = vomiting, and increased ADH

  Monitor fluid balance

  • Elevate the impact of disease and effect of treatment

  • Vital signs and intake and output

    • Daily weight gives information on fluid and electrolyte status

  • Blood test are ordered to check effectiveness of treatment

  Restricting fluid intake

  • Heart failure, and renal failure patients

  • 50% of fluid during the day when patient is most active and consumes two meals

  • Offer fluids, and small amounts

  • Use 4-6 oz cups

  • Avoid sweet and salty foods

    • Stimulate their sensation

  Restricting electrolyte intake

  • Fluid excess may need to restrict sodium

    • 3000-4000 MG a day is mild

    • 2000 MG a day is moderate

    • 500 MG a day is severe

    • Some meds contain sodium

  Electrolyte a replacement

  • Two most commonly prescribed

    • Potassium: potassium wasting diuretics, the doctor may prescribe a potassium supplement

    • Calcium: an adequate intake of milk, milk, products, vitamin vitamin D promotes the need for calcium supplements

    • Take supplements with juice to mask the taste

  IV advantages

  • Immediate access for fluid and electrolyte and maintenance or replacement

  • Faster, medication onset, and more predictable effect

  • Provides access for supplemental or TPN replacement

  • Allow transfusion of blood to increase O2 carrying capacity

  Rights to IV administration

  • Write patient, write solution, right rate, right documentation, right time, right reason, right response

  Intervenous solutions

  • Classified as crystalloids and colloids

    • Crystalloids are solutions with small molecules

      • dextrose is a common element of IV solutions and can provide additional calories for energy

        • patient should be monitored for hyperglycemia

        • Continued use of 5% dextrose in water can lead to water intoxication

          • after dexterous enters the bloodstream, it is quickly metabolized, leaving only free water, a hypotonic solution

      • Normal saline 0.9% naCl

        • Isotonic solution

        • Used for fluid replacement, sodium and chloride

        • Only solution used to finish or begin blood transfusions

        • Prolonged use results in hypernatremia and circulatory overload

      • Saline hypertonic

        • Often combined with dextrose to provide calories

      • Lactic ringers

        • Most closely resemble blood plasma

          • Often used after surgery or trauma

      • NEVER push potassium through an IV

    • Colloids

      • Contain protein or starch

  Intervenous sites

  • Peripheral site

    • Short term

    • Can be used for maintaining vascular access with the use of an intermittent infusion device

    • Children: head and feet

      • Adults cannot use feet because the chance of thrombophlebitis

    • Vein choice should be soft and full

    • No more than two attempts per person and four total attempts

    • Hypertonic solutions are less likely to cause phlebitis

  Intravenous solutions

  • hypotonic

    • 0.33% NS: allows kidneys, to select amount of electrolyte to retain or excrete

    • 0.45% NS: used for hypernatremia and or people who do not need glucose. Establishes renal function.

      • Do not give to diabetics

  • Isotonic

    • 0.9% NS: replaces losses without altering fluid concentrations

    • Lactated ringer: closest to blood plasma. Do not use in renal or liver failure patients

  • Hypertonic

    • D5 0.45% NS: treats, hypovolemia, and maintains normal fluid balance

    • D5 LR: same as isotonic lactated ringer, but with dextrose to add calories

    • 3% NS: used to treat hyponatremia

  Peripheral Intravenous catheters 

  • Smaller the diameter, the larger the gauge

    • Three basic types: 

      • Over the needle: after the needle is inserted, the catheter threaded into the vein and stylet is removed

      • Winged infusion needle: small needle wings are pinched together during insertion and then taped flat

      • Midline: longer IV use needs ultrasound. Guidance after catheter’s threaded needle is removed. It is used for less than two weeks.

        • Is longer than two weeks a pick line is needed

  Central venous catheter (CVC)

  • Assess frequently

  • Inserted into a major vein

    • X-ray is needed to check placement

  • Rapid infusion of fluid

    • Irritating medications like TPN and hypertonic solutions are diluted

  • Used for blood draws

  • Preferably inserted central catheter (PICC) 

    • Long-term to indefinitely

    • Sits in superior vena cava

    • Can simultaneously infuse medications, blood, fluid, TPN

    •  Used for blood draw

  • Non-tunnel CVC

    • Short term

    • Subclavian vein

    • Simultaneous blood, meds, fluid, TPN

  • Tunnel CVC

    • Long-term to lifelong

    • TPN, chemo, dialysis

    • Subclavian or jugular vein

  • Implanted/Mediport

    • Surgically placed

    • Long-term

    • No visible signs of device

      • Under the skin

    • Angled Huber needle needed to access port

      • Port should be access monthly and flushed

  Equipment

  • Small bags (50-250 mL) used for medicine administration

  • Larger bags for continuous IV solutions

  • Macro drip: 10,15,20

  • Micro drip: 60

    • Slow infusions

  • When I continuous infusion is no longer needed by IV access is a intermittent infusion device is attached (saline lock, or PRN adapters) 

  • Never use force when flushing a vascular access device

    • Can disc logic, clots, and cause a embolism

  • Clean IV and port for at least 30 seconds

  • Document patency of the line, date, and type and amount of flush

  • Change IV dressings every one to three days

  Flow rate

  • factors that influence the flow rate:

    • Distance, patient position, catheter size, tubing obstruction

      • The shorter the distance between the IV bag and IV catheter the slower the IV infusion flows. To increase the flow raise the bag to a higher level.

  • Volume control device

    • Prevents accidental fluid overload due to improperly regulated IV infusion

  • Electronic infusion device: allows the nurse to program the rate and volume of the fluid to be infused

  • Controllers operate by gravitational force and regulate the flow using an electronic dispenser

    • When the rate falls below the programmed rate and alarm sounds

  • Electronic infusion devices are used for patients who have additives those receiving IV medication‘s and any person for whom fluid overload is a concern

  • The IV flow rate is the amount of milliliters infused over one hour

  Complications of intravenous therapy

  • Complications associated with IV therapy 

    • Occlusions, phlebitis, infiltration, extravasation

    • Systematic complications

      • Fluid overload, speed, shock, embolism

    • Never discontinue a central venous catheter without an order

  Care of a patient with a peripheral intravenous catheter

  • IV therapy currently ordered, including the type of catheter, the date and serve of insertion, and the solution type and rate

    • Verify the correct solution is infusing at the correct rate and appropriate amount

    • Examine the drip chamber making sure it’s half full and the IV is dripping

    • Examine tubes for kinks

    • Check the date on the tubing

      • Tubing has changed every 24 to 72 hours

    • Moved down the insertion site checking for signs of complications

      • Dressing site should be clean, dry and intact

      • Peripheral IVs should be changed every 72 to 96 hours

    • The IV solution, right, tubing, insertion site should be assessed every hour

  Care of a patient with a central Venus line

  • The tubing is changed every 24 hours

  • Cause dressings are changed every 48 hours

  • Checked for blood return and flushed and locked with either 0.9 normal saline or a heparin lock solution

  • Routine site rotation is not needed for CVC or pics

  • CVC are discontinued only with a written order

  • Febrile non-hemolytic reaction reactions occur when a patient reacts to the white blood cells, platelets or plasma proteins

    • Causes a rise of 2°F in a patient’s temperature

  • Adverse reactions the nurse first action is to stop the transfusion

  Complications of intervenous therapy

  • Hematoma: swelling collection of blood within the tissues at the insertion site

    • Symptoms: discoloration from blood, swelling, and pooling

    • Consideration: fragile vans, and those taking anticoagulant are at risk. Do not go digging. If a hematoma forms immediately remove the needle and a apply drug pressure and dressing.

  • Catheter occlusion: partial or complete occlusion caused by clot formation within the catheter or a medical obstruction

    • Symptoms: IV sluggish or stopped. Attempts to flush catheter are met with resistance.

    • Considerations: attempt to flush catheter with normal saline. Do not force. Forcing the flesh can dislodge the clot which becomes an embolism. If peripheral IV continue the site and restart a new site.

  • Catheter related infection: can become systemic caused by poor aseptic technique during insertion or dressing or tubing changes can occur when peripheral site has been in use for longer than four days

    • Symptoms: local: pain, side, tenderness, redness, swelling, temperature drainage. Systemic: fever, chills, tachycardia, hypotension, headache, backache.

    • Considerations: assess site frequently discontinue if signs of infection develop

  • Phlebitis: inflammation of the van caused by poor insertion and care

    • Symptoms: tenderness, redness, swelling of the side of pain, burning, heat

    • Considerations: a septic technique discontinue catheter immediately if phlebitis is suspected apply warm compress for 20 minutes three or four times per day

  • Infiltration: infusion or IV solution and or non-vascular medications into surrounding tissues caused by protruding of the blood vessel through and prosper insertion or frequent manipulation of IV catheter

    • Symptoms: skin is cold, swelling, tenderness, and firmness blanching of the skin

    • considerations: if infiltration is suspected to stop infusion immediately remove catheter and assist for extra vastation

  • Extravasation: irritating solution, or medication into surrounding tissues

    • Symptoms: burning or discomfort blistering is a late sign

    • consideration: dopamine nor epinephrine potassium is an extra vent station is expected infusion is discontinued immediately using skin marker attract area of damage apply cold, and warm compress and elevate the extremity never apply pressure

  • Air embolism: accidentally entry of air and two bloodstream

    • Symptoms: chest pain, shoulder and lower back pain, dysphagia cyanosis, hypertension, tachycardia, decrease level of consciousness

    • Considerations: ensure the catheter and tubing are clamped closed when changing tube prime all tubing with IV solution before attaching to catheter if an air embolism is suspected place patient in trendelenburg position on LEFT side