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1. Describe what causes fluid volume deficit, and list the clinical manifestations, nursing management, treatment, and education. HYPOVOLEMIA - Shift of fluids from plasma into interstitial fluid. Fluid Volume deficit is HYPOvolemia. Causes? Fever, heatstroke, Diabetes insipidus, GI losses, hemorrhage, dehydration Clinical Manifestations: Poor skin turgor, lethargy, thirst, dry mucous membranes, decreased urine output/concentration, increased RR, orthostatic hypotension. Nursing management/assessment: VS changes = decreased BP, Increased HR, increased RR, flattened neck veins, thready pulse. Check skin turgor, skin for breakdown, daily weights, I/O’s, LOC, oxygen administration, safe administration of blood. Treatment: Increase fluids, Blood transfusion Education: Educate patient of S/S of fluid volume deficit. NANDA: Fluid imbalance, impaired cardiac output, acute confusion, potential complication: hypovolemic shock Client education- Good skin care, if orthostatic hypotension is present, teach to change positions slowly, remind patient to drink 2. Describe what causes fluid volume excess, and list the clinical manifestations, nursing management, treatment, and education. Excess intake of fluids, abnormal retention of fluids, heart failure or renal failure, or a shift of fluid from interstitial fluid into plasma fluid. Weight gain is the #1 manifestation. Fluid Volume excess is HYPERvolemia. Causes? Excessive fluid intake, abnormal retention of fluids (CHF or renal failure), SIADH, Cushing’s’. Clinical Manifestations: Increased BP, bounding pulse, edema, HA, polyuria, crackles/dyspnea, weight increase Nursing management/assessments: 24 - hour I/O’s, assess cardio changes, respiratory changes, LOC, PEERLA, daily weights, and skin turgor. Treatment: Diet, fluid/sodium restriction, fluids, diuretics Types of diuretics>> 1. Loop diuretics – Furosemide (Lasix) 2. Thiazides – Hydrochlorothiazide 3. Potassium sparing – Spiro lactone 4. Quinazoline - metolazone Educations: Loop diuretics can cause the kidneys to increase flow of urine; this helps reduce the amount of water in your body and lower your BP. Take medication in AM. Thiazides reduce the amount of sodium and water in the body; they are the only type that dilates the blood vessels, which also helps to lower BP. Potassium-sparing is used to reduce the amount of water in the body; unlike the others, these do not cause your body to lose K+. Do NOT in increase K+ intake in diet.
3. Describe the laboratory normal values, clinical manifestations, assessment priorities (i.e. neuro, cardiac, cardiovascular, etc.) & nursing collaborative management of the below electrolyte imbalances. Clinical Lab Values Clinical Manifestations Assessment priorities Nursing Management (Include diet) Nursing Education and considerations Hyponatremia < 135 mEq/L Hypernatremia
145 mEq/L *Think Confusion * Hypo- N/V, abdominal cramping, weight gain, cold/clammy skin, fatigue, dyspnea, shortness of breath, crackles, preorbital edema, (+) JVD, restlessness, muscle weakness, low urine SG, HCT is high, seizures/coma. Hyper- Dry mucous membrane, neck vein is flat, dry skin, intense thirst, oliguria, dark urine, orthostatic hypotension, tachycardia w/ thready pulse,
tachypnea, hypoxia, weight loss. Perform a neurological assessment. Severe hyponatremia causes seizures, confusion and coma (pg 278) Perform neurological assessment for hypernatremia. Hypernatremia causes dehydration which alters the mental status and also causes drowsiness, restlessness, confusion, and lethargy to seizures and coma. (pg 276) Hypo- - Replacing fluid using isotonic sodium- containing solutions. - Encouraging oral intake. - Withhold all diuretics. - Acute or more serious, small amounts of IV hypertonic saline solution (3% sodium chloride) can restore the serum sodium level. Hyper - Treat underlying cause
- Primary water deficit- replace fluid orally or IV with isotonic Monitor daily weight, I&O and VS Monitor sodium levels Hyper-increase fluids Hypo- fluid restrictions Hyperkalemia
5.0 mEq/L Hypokalemia <3.5 mEq/L *Think heart * Hypo- Fatigue, Muscle weakness, leg cramps, Soft, flabby muscles, Paresthesia, decreased reflexes, Constipation, nausea, paralytic ileus, Shallow
- Monitor acid base balance b/c too much K+ can cause blood to become acidic, Monitor EKG with VS.
- Monitor blood levels hourly. (Can cause alkalosis)
- No potassium- rich foods, No use of salt supplements.
- Increase potassium-rich foods, administer potassium Safety Alert - Always dilute IV KCl and do not give in concentrated amounts.
- Never give KCl via IV push or as a bolus. - Invert IV bags containing KCl several times to
dehydration, Nephrolithiasis, Seizures, coma, ventricular dysrhythmias Hyperphosphatemia
4.5 mg/dl Hypophosphatemia <3.0 mg/dl Hyper- asymptomatic unless calcium binds w/phosphate= signs of hypocalcemia
- Hypocalcemia, numbness & tingling in extremities & region around mouth, hyperreflexia, muscle cramps, tetany, seizures, calcium- phosphate in skin, soft tissue, cornea, viscera, blood vessels. Hypo- asymptomatic if mild-moderate. Severe- could be fatal.
- Malabsorption syndromes, chronic diarrhea, malnutrition, Vit D deficiency, parental nutrition, chronic ETOH use, phosphate-binding antacids, DKA, hyperparathyroidism, refeeding syndrome, resp alkalosis. Acute= CNS depression, muscle weakness and pain, respiratory failure, CHF Chronic- alters bone metabolism resulting in rickets and osteocalcin Assess calcium and phosphate levels Assess for ↓BP, dysrhythmias and calcium and phosphate levels.
- Neuro assessment, VS, EEG, nutrion and absorption, monitor chemical panel and CBC, and thyroid levels.
- Withhold or supplement Phosphate levels in PT. Educate on proper diet.
- Educate PT on foods to avoid.
- Instruct PT to meet with physical therapy for daily stretches & mobility exercises. Hypermagnesemia
2.5 mEq/L (^) Hypo- Confusion, Muscle cramps, Tremors,
- Tendon response, neuro assessments, VS.
- Withhold Mg containing foods, increase fluid intake.
- Educate on proper diet.
- Educate PT on foods to avoid.
Hypomagnesemia <1.5 mEq/L *Think Reflexes seizures, Vertigo, Hyperactive deep tendon reflexes, Chvostek's and Trousseau's signs, ↑ Pulse, ↑ BP, dysrhythmias Hyper- Lethargy, drowsiness, Muscle weakness, Urinary retention, Nausea, vomiting, Diminished deep tendon reflexes, Flushed, warm skin, especially facial, ↓ Pulse, ↓ BP
- Use infusion pump, since rapid admin of medication can lead to hypotension and cardiac dysrhythmias.
- Provide good dietary sources of Mg.
- Instruct PT to meet with physical therapy for daily stretches & mobility exercises.
- Instruct PT to hydrate often. 4. Explain the difference between Chvostek’s sign and Trousseau sign when assessing a client with a calcium imbalance? Chvostek's sign (twitching of facial muscles in response to tapping over the facial nerve. Trousseau's sign (carpopedal spasm induced by pressure applied to the arm by an inflated sphygmomanometer cuff. Both signs will be positive if hypocalcemia imbalance is present. 5. Identify the normal laboratory diagnostic ranges for interpreting acid-base imbalances. (Ph, HCO3, and PaCO2). Explain the common clinical manifestations and nursing management of the following acid-base imbalances: Ph normal range 7.35-7.
7. Explain how to administer IV KCL (potassium). What guidelines must the nurse follow? Always dilute IV KCl and do not give in concentrated amounts. Never give via IV push or as a bolus. Invert IV bags containing KCl several times to ensure even distribution in the bag. Do not add KCl to a hanging bag to prevent giving a bolus dose. Infusion rates should not exceed 10 mEq/hr unless PT is in critical care setting with continuous ECG monitoring and central line access for administration. 8. Complete the table for the following: Bronchoscopy, CT scan, Thoracentesis, Sputum studies (spontaneous and induced), TB Screening test Procedure & Definition Pre-Procedure Considerations Post-procedure Considerations & Complications
Bronchoscopy: Flexible fiberoptic scope used for Dx, Bx, specimen collection, or assessment of changes. Obtain signed consent. Have the patient be NPO for 6– 12 hr before the test. Give sedative as ordered. (pg 471) Keep patient NPO until gag reflex returns. Monitor for recovery from sedation. Blood- tinged mucus is not abnormal. If biopsy was done, monitor for hemorrhage and pneumothorax.(pg 471) CT scan: Diagnose suspicious lesions difficult to assess by conventional x-ray. Before contrast medium is used, evaluate renal function. Assess if patient is allergic to shellfish, since the contrast is iodine based. Patient may need to be NPO 4 hr prior to study.(pg 471) Encourage patient to drink fluids to avoid renal problems with any contrast.(pg 471) Thoracentesis: Used to obtain specimen of pleural fluid for Dx, remove pleural fluid, or instill medication. Obtain chest x-ray after procedure to check for pneumothorax. Explain procedure and obtain signed consent. (pg 471) Observe for signs of hypoxia and pneumothorax, and verify breath sounds in all fields. Encourage deep breaths to expand lungs. Send labeled specimens to laboratory promptly for analysis.(pg
TB Screening test: The test is given by injecting 0.1 mL of PPD intradermally on the ventral surface of the forearm. The test is read by inspection and palpation 48 to 72 hrs later for the presence or absence of induration. Ask if the PT has had the BCG vaccine, this may cause a false- positive result. If the initial test is positive, the person needs further evaluation for active disease. If the first test is negative, a second TST is done 1 to 3 weeks later. Sputum studies: Acid-fast bacteria smear & culture, Culture & sensitivity, cytology, & gram stain Obtain specimen in early morning after mouth care because secretions collect during night. Have patient expectorate sputum into container after coughing deeply. If unsuccessful, try Send specimen to laboratory promptly for analysis.(pg 471)
10. Discuss the rationale for tracheostomy insertion. What is the tracheostomy post op care, priority assessment, and prevention of complications? Describe tracheostomy suctioning technique and accidental dislodgement-nursing care. Rationale: A tracheostomy may be done to (1) establish a patent airway, (2) bypass an upper airway obstruction, (3) facilitate removal of secretions, (4) permit long-term mechanical ventilation, and (5) assist with weaning from mechanical ventilation. Post-op Care: Keep a replacement tube of equal or smaller size at the bedside, readily available for emergency reinsertion; do not change trach tapes for at least 24 hours after the surgical procedure; and if needed, the HCP performs the first tube change usually no sooner than 7 days after the trach. Priority Assessments: Monitor and record the PT’s HR, RR, BP, and SpO2. Prevention of Complications: Assess the site every shift. Confirm the patency of the trach tube, observe the site for any redness, inflammation, edema, ulceration, or signs of infection. Tracheostomy Suctioning: It is a sterile procedure! Provide preoxygenation, insert catheter without suction to the point at which the PT coughs or you meet resistance. Apply suctioning, as you slowly withdraw rotating the catheter, no longer for 10 to 15 seconds at a time, no more than 3 times total. Nursing care for dislodgment: Call for help immediately. Quickly assess the PT’s LOC, ability to breathe, and the presence or absence of any respiratory distress. If respiratory distress is present, use a hemostat to spread the opening where the tube was displaced. Insert the obturator in the replacement tube, lubricate with saline, and insert the tube into the stoma. Once replaced, remove obturator at once so that air can flow through the tube. 11. Explain some communication methods used for clients who have had temporary or permanent loss of speech. Provide the patient with paper and pencil, A white board or a cellular phone for texting, use eye blinking for yes and no questions. 12. Pneumonia- Explain the risk factors, common assessment findings, nursing care, including incentive spirometer use, discharge instructions and client teaching. Definition: infection of the lungs Risk Factors: Age >65 years, air pollution, immunosuppression, bed rest & prolonged immobility, debilitating diseases, smoking. Assessment: cough, fever chills, dyspnea, tachypnea, and pleuritic chest pain, fine or coarse crackles, confusion. Diagnostics: H&P, chest x-ray, thoracentesis, bronchoscopy, ABHs, CBC, sputum gram stain, culture & sensitivity, blood cultures. Nursing Care: O2, antibiotics, I.S., antipyretics, analgesics, hydration, small, frequent, high calorie, nutritious meals, monitor weight, rest. Discharge Instructions: complete antibiotics, Pneumococcal vaccine, adequate hydration, avoid alcohol/smoke, repeat chest x-ray in 6-8 weeks. 13. Define tuberculosis, the risk factors, clinical manifestations, screening, labs & diagnostic tests, medication teaching & monitoring (side effects), airborne isolation requirements and client/family education-health promotion. Definition: infectious disease caused by Mycobacterium tuberculosis Transmission: airborne droplets Transmission requires close, frequent, or prolonged
exposure. Primary infection: bacteria inhaled Latent Infection: Infected but no active disease-Noninfectious-can’t transmit-May develop active TB later. Active TB Disease: primary or reactivation. Assessment: dry cough that becomes productive, crackles, fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats. Late: dyspnea & hemoptysis. § Risk Factors for TB: ● Homeless ● Residents of inner-city neighborhoods ● Foreign-born persons ● Living or working in institutions ● IV injecting drug users ● Overcrowded living conditions ● Poverty, poor access to health care ● Immunosuppression § Test: ● Tuberculin skin test-AKA: Mantoux test (screening) ● Interferon-y release assays (screening) ● Chest x-ray (suggestive) ● TB culture-sputum (diagnostic) § Nursing Implementation TB ● Airborne isolation ● Single-occupancy room with 6 to 12 airflow exchanges/hour ● Health care workers wear high-efficiency particulate air (HEPA) masks; fit tested ● Immediate medical workup: chest x-ray, sputum smear and culture § Appropriate drug therapy
14. Lung cancer- Describe the risk factors, clinical manifestations, diagnostic testing and/or labs and priority nursing management. Assessment: chronic cough with sputum, hemoptysis, dyspnea, wheezing, chest pain, N&V, anorexia, weight loss. Tests: chest x-ray, CT scan, sputum cytology, biopsy, pleural fluid analysis, CBC, MRI, PET scan bone & CT scans brain, abdomen, & pelvis (metastasis). Treatment: surgery, radiation, chemotherapy, target therapy Nursing Care: health promotion, support, post op care, chest tubes (if applicable).
Discharge plan: To reduce the rate of hospital readmissions, the patient with asthma may be discharged with a home monitoring system. These systems provide an easy and inexpensive approach to remotely monitoring lung function. Asthma home monitoring usually consists of PEFR, pulse oximeter, vital sounds and lung sounds. As part of your discharge planning, help the patient obtain a system and review its use. Why to use peak flow meter: to check your asthma the way that blood pressure cuffs are used to check BP. A peak flow meter is a device that measures how well air moves out of your lungs. It may tell you if there is narrowing in the airway’s hours, sometimes even days before you have any asthma symptoms. How to use your peak flow meter: Move the indicator to the bottom of the numbered scale. Stand up, take a deep breath, filling your lungs completely. Place the mouthpiece in your mouth and close your lips around it. Do not put your tongue inside the hole. Blow out as hard and fast as you can in a single blow. Acute attacks: Sa02 monitoring ABG’s Inhaled Beta-2 adrenergic agonists inhaled anticholinergics Oxygen by nasal cannula or mask IV or oral corticosteroids IV fluids IV magnesium Intubation and assisted ventilation Management: Identify and avoid or eliminate triggers Patient and caregiver teaching Drug therapy (tables 28.6 and 28.9 and figs 28.4 and 28.5) Asthma action plan (Fig. 28.9) Desensitization (immunotherapy) if indicated Assess for control ex: asthma control test
17. Pulmonary Embolism- List and understand risk factors, clinical manifestations, diagnostic procedures & labs, priority nursing care, anticoagulation therapy & antidotes for each, precautions, and preventative treatment. · Risk Factors: ➢ Immobility or reduced mobility ➢ Deep vein thrombosis ➢ Surgery within 3 months (especially pelvic and lower extremity) ➢ History of VTE (Venous thromboembolism) ➢ Cancer
➢ Obesity ➢ Oral contraceptives/hormone therapy ➢ Smoking ➢ Prolonged air travel ➢ Heart failure ➢ Pregnancy ➢ Clotting disorders ➢ Clotting disorders · Manifestations: ➢ Depend on type, size, and extent of emboli ○ Dyspnea most common (85%); mild-moderate hypoxemia ○ Other: tachypnea, cough, chest pain, hemoptysis, crackles, wheezing, fever, tachycardia, syncope, pulmonic heart sound ○ Massive PE: change in mental status, hypotension, impending doom, death · Diagnostic Studies: ➢ D-Dimer ○ Elevated with any clot degradation ○ False negatives with small PE ➢ Spiral (helical) CT scan/CT angiography or CTA ○ Most common ○ Requires IV contrast media ○ 3 - D picture of pulmonary vasculature ➢ Ventilation-perfusion (V/Q) scan ○ Used if patient cannot have contrast ➢ Important but not diagnostic ○ Arterial blood gases ○ Chest x-ray ○ Electrocardiogram ○ Troponin levels ○ B-type natriuretic peptide · Interprofessional Care: ➢ Support cardiopulmonary status ○ Oxygen: intubation/mechanical ventilation ○ Pulmonary hygiene: prevent atelectasis ○ Shock: fluids, vasopressors ○ HF: diuretics ○ Pain: opioids · Drug Therapy: ➢ Anticoagulation immediate
➢ Positive pressure in pleural space causes lung to collapse partially or fully ➢ Increased air in pleural space equals reduced lung volume ● Open: opening in chest wall ➢ Penetrating trauma sucking chest wound ● Closed: no external wound ➢ Suspect pneumothorax with chest wall trauma
20. Define and understand the below types of commonly used central venous access devices and the nursing management (maintenance) for each. VADS (venous access devices) are catheters or infusion ports that are designed for repeated access to the vascular system. PICC Line: Peripherally inserted central catheter enters a peripheral arm vein and extends through the venous system to the superior vena cava, where they terminate.
- 45 - 74 cm (18-29 in) with single or multiple lumens
- Length of use is up to 12 months
- Can be inserted into the basilic or cephalic vein one finger breadths below or above the antecubital fossa.
- Indicated for administration of blood products, chemo agents, antibiotics, and TPN MAINTENANCE: confirm placement with X-ray. Clean insertion port with alcohol for 15 seconds and allow it to dry prior to access. Use transparent dressing to allow visualization. Change dressing q 7 days. Advise clients not to immerse in water. Educate clients to avoid blood-pressure on the arm with PICC lines. Flush with 5 mL heparin when the PICC line is not in use Central venous line: CVAD or CVC: Central venous catheterization can be used as temporary hemodialysis access. Typically placed in one of the 3 large central veins: the internal jugular vein, the subclavian vein, or the femoral vein. CVC can also be used to administer medications, fluids, blood products or TPN. · Usually placed near the chest area · Patient should wash daily using CHG wash to avoid contamination of the site (CLABSI risk) · Dressing should not be changed daily unless loose or soiled · Use transparent dressing for visualization · Must don a mask, sterile gloves and perform hand hygiene when changing CVC dressing. · Assess catheter insertion daily, observing sutures are secure, and noting the last dressing change date Peripheral IV: Peripheral VAD consists of a small plastic tube or catheter threaded over a sharp stylet or needle. Available in a variety of gauges. Most used gauge is 20 and 22. Once inserted, remove the stylet, leaving the catheter in place.
· Most common IV site: radial, cephalic, cubital, basilic, superficial dorsal, and dorsal venous arch veins. · Use the smallest gauge necessary · Avoid placement in areas that can be easily bumped · Keep the IV system sterile and intact · Change IV fluid containers, tubing, and contaminated dressing. · Monitor for complications · Use aseptic technique during insertion · Clean with CHG, 70% alcohol, or povidone-iodine solution and let dry thoroughly before accessing or administering medication. · Ensure catheter stabilization devices are intact to avoid accidental movement or dislodgement.
21. Describe the clinical manifestations & nursing care for IV infiltration & phlebitis. Infiltration: occurs when IV fluid enters the subcutaneous tissue around the venipuncture site. Extravasation: occurs when a vesicant (tissue damaging drug) enters tissue. Manifestations: Skin around the site will be taut, blanched, cool to touch, edematous, and painful. The infusion may slow or stop. RN INTERVENTION: · Stop the infusion · Elevate the affected extremity · Do not apply pressure · Apply warm, moist, or cold compress · **Contact HCP if solution contained KCL, a vasoconstrictor, or any potent vesicant
