Comprehensive Nursing Notes: IV Fluids, Pharmacology, Cardiology, and Respiratory Care of the Hypoxic Patient, and Cultural Competence

Intravenous Fluids: D5LR (D5LRD_5LR)

  • Composition and Tonicity

    • In the Bag: The fluid is considered hypertonic because of the addition of dextrose.

    • In the Body: Once administered and the dextrose is metabolized by the body's cells, the remaining fluid (Lactated Ringer's) is isotonic.

    • Metabolic Effect: Dextrose makes patients hyperactive or "hyper." It is primarily used to raise blood glucose levels.

  • Indications

    • Fluid Replacement: Used for "sludge replacement," dehydration states, and trauma.

    • Prolonged NPO (Nothing by Mouth) Status: Indicated for patients who must remain NPO for more than 33 days (e.g., bowel obstruction) to provide calories and prevent blood glucose from "bottoming out."

  • Contraindications and Monitoring

    • Potassium Sensitivity: Lactated Ringer's contains potassium. A normal potassium level is between 3.53.5 and 5.0 mEq/L5.0\,mEq/L. Consequently, D5LRD_5LR is contraindicated if the patient's potassium is greater than 5.0 mEq/L5.0\,mEq/L.

    • Lactate and Sepsis: The "L" in LR stands for lactate. It is contraindicated in patients with sepsis. A high lactic acid level is defined as being over 2.02.0.

    • Metabolic Acidosis: Should likely be avoided in acidotic states because the lactate can contribute to further lactic acid buildup.

    • Glucose Monitoring: Because of the dextrose content, blood sugar checks are mandatory based on the patient's history.

  • Administration Safety

    • Bolus Restriction: Unlike straight Lactated Ringer's, D5LRD_5LR cannot be bolused because of the dextrose content.

    • Drip Rate: It must be administered as a continuous drip, typically around 100 mL/hr100\,mL/hr.

Tylenol (Acetaminophen)

  • General Information

    • Routes of Administration: Can be given orally (PO) and intravenously (IV).

    • Indications: Mild to moderate pain and fever.

  • Dosing Constraints

    • FDA Maximum: 4,000 mg4,000\,mg per day (or 4 g4\,g/day).

    • Hospitalized/Acute Care Max: Due to the variety of medications given in a hospital setting that the patient's liver may not be accustomed to, the max dose is often held at 2,400 mg2,400\,mg per day.

  • Liver Function and Monitoring

    • Metabolism: 90%90\% of medications, including Tylenol, are processed in the liver.

    • Laboratory Tests: Nurses must monitor Liver Function Tests (LFTs), specifically AST, ALT, and bilirubin.

    • Contraindications:

      • Chronic alcoholics (used with "really, really big caution").

      • Hepatitis (A, B, or C).

      • Cirrhosis (scarring of the liver).

  • Toxicity and Reversal

    • Combination Drugs: Many drugs, such as Hydrocodone, are mixed with Acetaminophen. Failure to account for the Tylenol in these combo drugs can lead to accidental overdose and liver failure.

    • Reversal Agent: Acetylcysteine (also known as Mucomist). It binds to the Tylenol and helps the body secrete it before it damages the liver.

  • Signs of Liver Failure

    • Jaundice: First visible in the sclera (eyes), then the skin.

    • Pain: Severe Right Upper Quadrant (RUQ) pain.

    • Late Signs: Swelling (edema) and ascites (fluid in the abdomen). This happens because the liver stops producing albumin, the major plasma protein responsible for maintaining oncotic pressure and holding fluid in the vessels.

    • Nausea and Vomiting: Very common.

  • Reassessment Requirements

    • As a PRN medication, it must be reassessed within 1 hour1\,hour per JCO (Joint Commission) standards. Document the reason for giving it and the patient's response.

Aspirin (Salicylates)

  • Classification

    • Aspirin is a Salicylate. It possesses analgesic, antiplatelet, and NSAID (anti-inflammatory) properties.

  • Indications and Dosing

    • Max Dose: 4,000 mg4,000\,mg or 4 g4\,g per day.

    • Coronary Artery Disease (CAD): Used at low doses (81 mg81\,mg/day) to prevent platelets from occluding vessels built up with atherosclerotic plaque.

    • Acute MI: Given at a higher dose (325 mg325\,mg) and must be chewed for rapid absorption.

    • Other Uses: VTE prophylaxis, ischemic stroke prevention, Transmit Ischemic Attacks (TIAs), and occasionally in high-risk pregnancies (preeclampsia) if the benefit outweighs the risk.

  • Contraindications

    • Active Bleeding: Specifically GI bleeds, peptic ulcers, and hemorrhagic strokes.

    • Low Platelets: Normal platelet count is 150,000150,000 to 400,000400,000. Aspirin is contraindicated if platelets are low.

    • Children: Risk of Reye's Syndrome (race syndrome) if given during a viral illness.

    • Kidney Disease: The kidneys produce erythropoietin; advanced disease or anemia may make aspirin use risky.

    • Anticoagulants: Contraindicated with Coumadin (Warfarin), Xarelto, Eliquis, and Pradaxa due to internal bleeding risk.

  • Nursing Education and Monitoring

    • GI Protection: Always take with food.

    • Bleeding Signs: Look for Melena (dark, tarry stools).

    • Safety: Use electric razors and soft-bristled toothbrushes. Apply firm pressure to any cuts for at least 5 minutes5\,minutes.

    • Pre-Op: Must be stopped at least 7 days7\,days prior to surgery. Post-op, check for internal bleeding by feeling for hematomas under the surgical site.

    • Lab work: Monitor PT, INR, and CBC (specifically Hemoglobin). A hemoglobin less than 77 is critical.

Cardiovascular Emergencies: Angina and Myocardial Infarction (MI)

  • Chest Pain Protocols

    • Any pain between the chin and the belly button is considered cardiac until proven otherwise.

    • Priority Intervention: Immediate Stat EKG to check the ST segment.

  • Chronic Stable Angina

    • Predictable pain during exertion (e.g., walking up stairs) that goes away with rest or Nitroglycerin.

    • Pathophysiology: Heart develops anastomosis (tiny vessels) to supply oxygen around slow-growing plaque.

    • EKG: Shows ST segment depression (ischemia).

  • Unstable Angina and NSTEMI

    • Unpredictable; can occur at rest. Pain does not go away with Nitro. This is considered urgent.

    • Lab: Troponin is the gold standard lab for cardiac death. Positive Troponin indicates infarction.

  • STEMI (ST-Segment Elevation Myocardial Infarction)

    • Emergent total occlusion. No flow.

    • EKG: ST elevation (tombstoning).

    • Window: 90 minutes90\,minutes from "door to floor" (cath lab) for revascularization.

  • The MONA Algorithm

    1. Oxygen: Minimum 2 L2\,L nasal cannula, regardless of O2\text{O}_2 saturation.

    2. Nitroglycerin: Potent vasodilator. Given sublingually every 5 minutes5\,minutes (up to 33 doses). Goal is chest pain 0/100/10. Monitor BP; if systolic drops below 9090, stop and consider a bolus or pressors.

    3. Aspirin: 325 mg325\,mg chewed. Prevents further platelet aggregation.

    4. Morphine: 22 to 4 mg4\,mg IV. Helps with pain and provides additional vasodilation (provider dependent).

Respiratory Assessment and Oxygen Delivery

  • Hypoxia Signs and Symptoms

    • Early Signs: Restlessness, anxiousness, agitation.

    • Progression: Tachycardia (compensating for low output), significant shortness of breath, and tachypnea.

    • Late Signs: Cyanosis. Peripheral cyanosis (fingers) occurs first, followed by central cyanosis (around the mouth).

    • Physical Findings: Nasal flaring and use of accessory muscles (retracting).

  • Diagnostics

    • ABG: Patients are often in Respiratory Acidosis.

    • Chest X-Ray: To visualize lung status.

  • Oxygen Delivery Hierarchy

    1. Nasal Cannula: Start at 1−2 L1-2\,L. Max is 6 L6\,L. Must add humidity at 4 L4\,L.

    2. Simple Face Mask (High Flow/Green Tube): Start at 6 L6\,L, range from 6−10 L6-10\,L.

    3. Non-Rebreather Mask: 10−15 L10-15\,L (crank it all the way up). The bag must be fully inflated.

    4. Next Steps: BiPAP or Intubation. Call a Rapid Response if moving to a non-rebreather.

  • Non-Pharmacological Nursing Interventions

    • Positioning: Raise the head of the bed to High-Fowler's (90∘90^{\circ}).

    • Breathing Techniques: Incentive spirometry, deep breathing, pursed-lip breathing, and diaphragmatic breathing.

Questions & Discussion

  • Q: How do you calculate the Tylenol max for combined meds?

    • A: Look at the last 24 hours24\,hours. If the patient is consistently receiving PRN Tylenol and Hydrocodone (which contains Tylenol), call the provider to request straight Hydrocodone without the Acetaminophen to stay under the limit.

  • Q: What are the beliefs of Native Americans regarding Western Medicine?

    • Traditional Healing: They prefer spiritual and traditional methods. Education is key; always explain why an intervention is happening.

    • Surgical Tissue Removal: Many believe in being buried as a whole. If an appendix or limb is removed, the patient will want that part back to move into the spiritual realm when they eventually pass.

    • Mistrust: Historical trauma (Trail of Tears) and broken promises of free healthcare have led to a preference for holistic care over the US government-funded systems.

    • Pain Perception: They are often very stoic. Pain can be seen as a sign of weakness, leading to under-reported pain. Nurses must look for non-verbal cues and educate that untreated pain leads to complications like pneumonia (due to lack of deep breathing) and blood clots.