NR226 Exam 2 Review 2, Study notes of Nursing

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NR226 Exam 2 Review 2

Values of ABG’s

**- Signs and symptoms of each

• How to interrupt these ABGS
• What causes each one
• What are we looking out for each one
• What causes each (metabolic acidosis, etc- all 4)**

- When ordering electrolyte, look at last lab value in case there was an **error somewhere

• Dehydration o vital signs:** hypo/hyperthermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea, hypoxia o neuromusculoskeletal: dizziness, syncope, confusion, weakness, fatigue, seizures o GI: Thirst, dry mucous membranes, dry furrowed tongue , nausea, vomiting anorexia, acute weight loss o Renal: oliguria o diminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, absence of tears, decreased skin turgor ▪ skin turgor test on older adults might not be reliable bc of natural loss of skin elasticity
• Increase pulse rate- low BP (hypotension)
• Decrease urine output
• Dry mucous membrane – furrow tongue
• Decrease urination
• Fatigue, dizziness, light-headness
• Pale skin
• Sunken eye
• Decreased skin turgor
• Dry lips
• Thirsty
• Dark color urine
• Increase HCT/HBG
• Monitoring fluid status o The most RELIABLE is daily weight o Calculate I & O o Measuring fluid retention- measure input and output o Most reliable measure in measuring fluid ▪ *****DAILY WEIGHT provides the most reliable measure of fluid retention** ▪ When weighing a patient daily… parameters that must be taken ▪ Measure patient at the same time, same scale, and same amount of clothes ▪ Why same time? ▪ In case of habit, weigh one day before breakfast and tomorrow after lunch, the weight will be different and inaccurate
• Same scale ▪ Different scales will be calibrated differently
• Same amount of clothes ▪ Heavy clothes = weigh more - Calculating input and output not so reliable but must be done as nurses
• Try to be as accurate as possible - Intake and output are subject to inaccuracy … why? - reason why daily weight is the most accurate measurement for fluid
• Because we cannot measure insensible losses
• Patient sneaking in drinks without telling the nurse

• Bad communication with nursing assistance personnel - Nursing assistant personnel can calculate input and output to a certain degree
• They **cannot calculate input when patients are taking fluid intravenously
• Insensible vs sensible losses o Sensible:** measurable ▪ ex: urine, stool, NG tube ▪ Fluid losses that are measurable ▪ Stool- defecation ▪ Urine ▪ Vomit ▪ Wound/gastric drainage ▪ Bleeding - Insensible: fluid loss that is not measurable o ex: from lungs, skin o Fluid losses that is non-measurable accurately o Sweat – perspiration o Breathing – respiration - Heart failure: o Patients who have chronic heart failure have diminished cardiac output, which reduces kidney perfusion and activates the RAAS. The action of aldosterone on the kidneys causes ECV excess and risk of hypokalemia o *****CHF = fluid overload with symptoms of crackles, JVD ▪ What should nurse do? Plan? ▪ Give patient diuretics, however, keep in mind they may be at risk for hypokalemia ▪ Doctors may also order water restrictions (usually 1L fluid restrictions) due to excessive water, salt restrictions also because sodium hold water in the extracellular compartments Making fluid overload worse ▪ Restriction of both fluid and salt is prescribed to decrease the workload of the heart by reducing excessive fluid volume
• Daily weight is important to see if they are gaining too much fluids or losing any fluids
• Strict I and O measurement however, **daily weight is the most reliable indicator to measure fluid retention
• Oliguria:** o occurs when the kidneys have a reduced capacity to make urine. o urine between 100-400 mL in 24 hrs OR less than 30mL/hr
• Anuria - no urine or urine less than 100 mL in 24 hours
• Someone with oliguria and renal disease, nurses are concerned with: o Oliguric renal disease prevents normal excretion of fluid, electrolytes, and metabolic acids, resulting in ECV excess, hyperkalemia, hypermagnesemia, hyperphosphatemia, and metabolic acidosis o Some conditions, such as acute nephritis, cause a sudden onset of oliguria, whereas other problems, such as chronic kidney disease, lead to chronic oliguria.
• Oliguric renal disease :

increased hr, difficulty walking, abnormal labs

- IV Complications o Infiltration ▪ occurs when an IV catheter becomes dislodged or a vein ruptures and IV fluids inadvertently enter subcutaneous tissue around the venipuncture site ▪ S/S ▪ Swelling and edema in the area ▪ Coolness ▪ Pallor ▪ Blanching and sloughing may occur at insertion site ▪ Infiltration of IV fluid that contains strong additives that damage tissue, extravasation occurs ▪ Example: vasopressor medication (increase BP) – are strong and detrimental to the skin, damage skin tissue. But if in vein it will not cause damage. But if it becomes dislodge, extravasation occurs, and sloughing coughs. - Treatment with an infiltration to an IV site includes: stop infusion, remove peripheral catheter, apply cold compress, and elevate the extremity. The nurse needs to also address the hydration issue with this client, diagnosed with hypovolemia. The nurse needs to insert a new peripheral catheter in the opposite extremity or in an appropriate extremity with good blood supply above the site of the infiltration. - Infection: - Local infection at IV site S/S - Redness - Puss or purulent drainage - Warmth - Caused by - Unsterile techniques - Improper handling - Cause central line-associated bloodstream infection (CLABSI) - ALL AT THE INSERTION SITE - Phlebitis: - Inflammation of a vein - The VEIN is inflamed - S/S - Heat, erythema(redness), tenderness all the course of the vein - Going up the arm, the vein will be hard and cordlike, tender , and red - Following the course of the site, NOT at the insertion site - Concerning - Risk for thrombophlebitis - Can cause permanent damage to the vein - Bleeding : - Bleeding: hitting a nerve

• Bleeding can occur around the venipuncture site during the infusion or through the catheter or tubing if these become disconnected inadvertently
• at the site can occur
• Due to bleeding disorder
• Anticoagulant medications - Discontinue IV access after infusion of the prescribed amount of fluid; when infiltration, phlebitis, or local infection occurs; or if the IV catheter develops a thrombus at its tip.
• STOP the IV INFUSION as soon as you notice any of the complication (CLAMP TUBING AND PRESS STOP IV PUMP), THEN discontinue the IV (TAKE IV OUT), and LASTLY contact the healthcare provider
• Then depending on the severity of the patient, arm may need to be elevated on a pillow or use cold/warm compress
• IV site - can cause nerve damage
• Blood transfusions: o Blood transfusion, or blood component therapy, is the IV administration of whole blood or a blood component such as packed red blood cells (RBCs), platelets, or plasma. o Objectives for administering blood transfusions include (1) increasing circulating blood volume after surgery, trauma, or hemorrhage; (2) increasing the number of RBCs and maintaining hemoglobin levels in patients with severe anemia; and (3) providing selected cellular components as replacement therapy (e.g., clotting factors, platelets, albumin). o ****People with type O blood are considered universal blood donors because they can donate packed RBCs and platelets to people with any ABO blood type. o ****People with type AB blood are called universal blood recipients because they can receive packed RBCs and platelets of any ABO type. o ***Always check agency policy and procedures before initiating any blood therapy. For patient safety, always verify three things: that blood components delivered are the ones that were ordered; that blood delivered to the patient is compatible with the blood type listed in the medical record; and that the right patient receives the blood. ▪ 2 RNs MUST check the blood and 2 RN must check the label of the blood against the medical record, patient ID number, blood group, name ▪ If there is any discrepancy, one letter in last name off, notify the blood bank immediately- DO NOT GIVE the blood to the patient ▪ MUST BE A NURSE and NO ONE ELSE
• NON RN personnel can pick up the blood from the blood bank but cannot check the blood
• 18 or 20 gauge IV needle is needed for blood transfusion because blood is more vicious than crystalloid or IV fluid
• Blood must be given with 0.9 sodium chloride , normal saline CANNOT BE WITH ANY OTHER FLUIDS because normal saline prevents hemolysis. ▪ Must use a “Y” connector, one with blood and one with saline
• Blood infusion tubing is given from the blood bank, has specific filter in there, needs the filter because blood is so viscous and thick - Always take patients vitals before blood transfusion (need baseline) and always stay with the patient for the first 15 minutes to observe the patient. Then check vitals after 15 minutes to compare with the baseline ▪ Takes 15 minutes for a reaction to occur if any!!!!

▪ Make sure it is not too tight around the stoma, because you do not want to constrict any blood flow. ▪ So cut the bag specific to the patients stoma size

• Stoma- we want it to be beefy, red and moist. Worry about cyanosis (blue/gray)- not enough perfusion. Tell MD immediately
• **Performing ostomy care
• Putting our patients on bedpan** o Patients restricted to bed use bedpans for defecation. Two types of bedpans are available. The regular bedpan, made of plastic, has a curved smooth upper end and a sharper-edged lower end and is about 5 cm (2 inches) deep. The smaller fracture pan, designed for patients with lower-extremity fractures, has a shallow upper end about 2. cm (1 inch) deep. ▪ Always provide patient with privacy anytime patients are making a BM
• The proper position for the patient on a bedpan is with the head of the bed elevated 30 to 45 degrees. When patients are immobile or it is unsafe to allow them to raise their hips, it is safest for the caregiver and the patient to roll them onto the bedpan. ******** trying to make patient as realistic as possible mimicking sitting in a toilet
• Try to get patient in the most optimal position
• Patient may be supine- have patient turn to the side slightly- place bed pan under patient then have patient turn supine sitting on bed pan – then elevate bed to 30- degrees
• Or have patient bridge up and place bed pan underneath. – then elevate bed
• Either way, elevate HOB unless contraindicated.
• Always wear gloves when handling a bedpan****
• Always provide privacy
• Raise side rails
• Lock bed
• Bed lowest position
• Give call bell
• Do not leave patient on bedpan
• Risk for pressure ulcer**
• Fall risk **- Fecal specimens o Stool occult blood guaiac or stool guaiac
• Infection, parasites** o DO NOT give Imodium - let the person run the diarrhea course because you want to eliminate the parasite out of the body. - Constipation:
• ****for someone to be Constipated = less than 3 BM per week o Tar, Dry stool that is difficult to pass o Distended abdomen o Straining o Hypoactive bowel sounds – slowing of the peristalsis - Common constipation causes**** o Medication –opioids ▪ Chronic long-term use of laxative can cause constipation ▪ Causing large intestines to lose muscle tone causing the body to become less responsive to the stimulation by laxatives, which eventually make a person constipation

• If you use laxative once in a while it will help with constipation, but constant long-term use will do the opposite effect
• Therefore, use laxative as the last resort AND Digital removal should be the last resort in the management
• Decrease fluid intake
• Surgery
• Diet lack in fiber
• Immobility (physical inactivity)
• Lifestyle
• Ignoring urge to defecation
• Aging – risk for constipation **- s/s
• causes of constipation -** immobility, not enough fiber or fluid in diet, age
• elderly have slower peristalsis, opioid use **- How do we prevent constipation from occurring - encourage fluids, increase fiber diet, increase activity
• Diarrhea:** diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. o Excess loss of colonic fluid can result in dehydration with fluid and electrolyte or acid–base imbalances if the fluid is not replaced. o **Priority for diarrhea: dehydration and loss of fluid and electrolytes ▪ Need to replenish the fluid and electrolytes
• S/S of dehydration** ▪ Increase pulse rate- low BP (hypotension) ▪ Decrease urine output ▪ Dry mucous membrane ▪ Furrow dry tongue ▪ Decrease urination ▪ Fatigue, dizziness, light-headness ▪ Pale skin ▪ Sunken eye ▪ Decreased skin turgor ▪ Dry lips ▪ Thirsty ▪ Dark color urine - With diarrhea always important to know the cause because you want to treat the cause ▪ C-diff – antibiotic to treat the cause ▪ Travelers diarrhea – have a parasite in their body- do not give Imodium (helps stop diarrhea)- because u want patient to eliminate the parasite, therefore do not give Imodium ▪ Have patient to keep going to bathroom to get it out of the system
• Food intolerance and diagnostic testing cause bowel elimination problems
• Flatulence – passing gas
• Impaction- occurs for unrelieved constipation
• Fecal incontinence is the inability to control passage of feces and gas from the anus

• A number of conditions such as hemorrhoids, rectal surgery, anal fissures (which are painful linear splits in the perianal area), and abdominal surgery result in discomfort. - the patient often suppresses the urge to defecate to avoid pain, contributing to the development of constipation. - ****a person is considered constipated if they go less than 3 times a week****
• As pregnancy advances , the size of the fetus increases, and pressure is exerted on the rectum - A pregnant woman’s frequent straining during defecation or delivery may result in formation of hemorrhoids. - Pregnancy can cause constipation as well as hemorrhoids
• General anesthetic agents used during surgery cause temporary cessation of peristalsis. The patient who receives a local or regional anesthetic is less at risk for elimination alterations because this type of anesthesia generally affects bowel activity minimally or not at all. Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. If the patient remains inactive or is unable to eat after surgery, return of normal bowel elimination is further delayed.****** ▪ General anesthesia can cause temporary cessation of peristalsis ▪ Paralytic ileus causes no movement in the ileus result from the use of general anesthesia or surgery ▪ Therefore, it is important that once they are cleared after surgery, they must encourage clients to eat, drink fluids, get out of bed, walk patient … just to get patient to promote the movement of peristalsis. ***** - Many medications prescribed for acute and chronic conditions have secondary effects on the patient’s bowel elimination patterns. - Alcohol, caffeine, smoking – speeds up motility **- Common med that causes constipations- opioids (narcotics) ****** - Diagnostic examinations involving visualization of GI structures often require a prescribed bowel preparation (e.g., laxatives, and/or enemas) to ensure that the bowel is empty. Usually, the patient cannot eat or drink several hours before examinations such as an endoscopy, colonoscopy, or other testing that requires visualization of the GI tract. Following the diagnostic procedure, changes in elimination such as increased gas or loose stools often occur until the patient resumes a normal eating pattern. **- ADPIE- assessment, diagnosis, planning, intervention, evaluation diff stages
• Subjective/objective data- subjective is anything verbalized by the client, objective is anything we observe
• Prioritizing patients- ABC’s - airway, breathing, circulation** o Which patient to see first? o See serious ill patient first o When do we assess patient? = when we first see them at the beginning of our shift - Ethics: o Justice o Fidelity o autonomy
• Delegation o What can we delegate vs not!! o We never delegate instruction, teaching or education!!

• Legal implications: o Negligence o Battery o Slander o Libel - Sleep: o Sleep apnea - obstructive airways during sleep o Narcolepsy - excessive daytime drowsiness, sudden sleep attacks o interventions for patients- avoid caffeine soda sugar o What to avoid before bed? ▪ Activity/exercise ▪ Caffeine ▪ alcohol ▪ Anything with caffeine, chocolate, soda, tea, ice tea, cola
  • How are we going to minimize environmental stimuli - try to do whatever skills possible when the client is awake, do not disturb the client when asleep - Older adults o Expected physiological changes o Elderly are at risk for skin breakdown o RN’s are worried about: ▪ Safety ▪ Falls ▪ Temperature of water: we worry about burns ▪ Dysphagia
  • How are we going to prevent: ▪ Falls ▪ What do we do with throw rugs and electrical cords - Restraints are a last resort o All four side rails up are considered restraints - Pain o PQRST o Asking patient pain on pain scale o Location of pain o We do PQRST about before performing intervention o Won’t perform intervention until we assess first - Know math: o Conversions: ▪ Ounces to mL = 1oz = 30 mL ▪ Cups to mL = ▪ 1 cup = 8 oz → ▪ 1 cup/8oz times 1oz/30mL ▪ cancel every time that matches and multiply 8 times 30 ▪ 1 cup = 240 mL
    • TABLE SPOON (T b sp) to mL = 1 Tbsp = 15mL
    • TEASPOON (tsp) to mL 1 tsp = 5mL - How are we calculating I&Os o Fluid based