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nursing diagnosis for hematochezia

nursing diagnosis for hematochezia

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School: University of Memphis
Department: Nursing and Health Science
Course: Foundations PT- Centered Care
Professor: Jacobs
Term: Fall 2016
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Cost: 50
Description: FPCC Final Exam Study Guide Acid Base Balance 2-3 questions  For each of the four types of imbalance: Primary risk factors and causes, Clinical manifestations (what does the patient look like?), Nursing care (dependent and independent interventions) o Respiratory Acidosis- pH < 7
Uploaded: 08/01/2017
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“how often do you go & what does it look like?




o Compensation- Lungs- increase respiratory rate to blow off that CO2 to get rid of hydrogen ions & correct that balance but how long can you breathe deep & fast?




 For each of the four types of imbalance: Primary risk factors and causes, Clinical manifestations (what does the patient look like?



FPCC Final Exam Study Guide Acid Base Balance 2-3 questions  For each of the four types of imbalance: Primary risk faWe also discuss several other topics like - What does POSDCORB stand for?
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Don't forget about the age old question of What is hyperosmolar hyperglycemic nonketotic syndrome (HHNKS)?
We also discuss several other topics like assessing bowel sounds with ileostomy
If you want to learn more check out the nurse is turning a client in bed. where would the nurse stand when using the friction-reducing sheet to turn the client to the opposite side of the bed?
ctors and causes, Clinical manifestations  (what does the patient look like?), Nursing care (dependent and independent interventions) o Respiratory Acidosis- pH < 7.35 & PaCO2 > 45 mm Hg o Cause: Breathing problems, not breathing enough. Hypoventilation at the alveolar level.   All three of the impaired oxygenation nursing diagnosis can lead to  hypoventilation & inadequate passing of the CO2 back into the lungs, alveoli, &  exhale. ∙ Ineffective breathing pattern, ineffective airway clearance, impaired gas  exchange  Specific examples- opioids have caused depressed breathing patterns, head  injuries, respiratory muscle paralysis, chest wall injuries, acute lung conditions  like pneumonia, pulmonary edema, atelectasis, COPD o Compensation- besides buffering, we have to count on our kidneys to come to the  rescue. It will be really slow though, so we will probably have to intervene faster than  just waiting on the kidneys to kick in. o CMs- depends on the related too, why the patient got into the problem.   Breathing pattern? If it is an opioid overdose, the breathing pattern will be slow  & shallow. If it is a problem like pnemonia then the problem is down there with  the alveolar capillary change area then the breathing pattern will be high to try  to get the gas exchange gong.  Headache  Neuro changes From restless to comatose (unresponsive) and seizures  Muscular twitching and tremors  Sometimes see vasodilation – skin may be pink & warm o Interventions   You will go back to related to & AEB. Build your intervention around correcting  what caused the problem if you can.  ∙ If the patient has an airway problem, open it. ∙ If the patient is over sedated from medications, get that reversal  medication in on it to get them waking up & breathing again. ∙ Ventilate the patient ∙ If it is gas exchange then position the head of the bed up, turn cough  deep breathe, incentive spirometer.  ∙ Suction if needed.  ∙ Adequate hydration ∙ “Breathing treatments” ∙ Antibiotics- treat the problem, if it is an infection that is causing  secretions to block the airway ∙ Supplemental oxygen ∙ With all of these we watch the patients like hawks because if they have  an acid base problem they can go downhill fast so we need to be on top  of it. o Evaluation- if pH & PaCO2 is better o Respiratory Alkalosis- pH> 7.45 & PaCO2 <35 mmHg o Cause: hyperventilation- Big, deep, rapid breathing patterns. o Compensation- kidneys will try, but are not fast enough so we will have to.  o CMs  Patient is light headed/dizzy   vision changes: tunnel vision, gray around the edges  numbness, tingling, tetany, seizures  chest pain o Interventions  Calm the hyperventilation patient down  Coach patient to slow/hold breath to decrease the loss of carbon dioxide Paper bag is causing them to retain CO2 but then they do not get the ambient  oxygen, so they lose oxygen. So don’t do this  Better to use Rebreather oxygen mask o Metabolic Acidosis- pH < 7.35 & HCO3 <22 mEq/L, monitor K & Ca o Causes:   Increased retention/production of acid  ∙ Think renal dysfunction. o If our kidneys aren’t working, they are not able to produce  ammonia as much, so more hydrogen ions will be retained in  the body. That will make the pH drop.  ∙ DM & starvation- A patient who has uncontrolled diabetes or a patient  who is in a starvation state for whatever reason may go to fat stores for  energy & with the breakdown of fat stores you start to get ketones  building up in the blood stream & that will result in rising acid levels in  the body. Ketones should be negative in urinalysis.   Loss of bicarbonate ∙ Renal dysfunction because kidneys are excreting more HCO3 than they  need to ∙ Diarrhea because we are losing the bicarb o Compensation- Lungs- increase respiratory rate to blow off that CO2 to get rid of  hydrogen ions & correct that balance but how long can you breathe deep & fast?   It will help but wont turn problem around o CMs  Headache  Dec LOC: lethargy to coma  Breathing is deep/rapid- Kussmaul’s  Anorexia, NVD, & abdominal pain o Interventions Whatever we can do to fix the Related too.   Correct blood sugar, if we have a patient who needs dialysis we can prepare  them for that & make sure they have access, & give some antidiarrheal  medicines or correct the reason they have it.   Sometimes its bad enough we give sodium bicarb through the IV, but we have to be careful because its easy to give too much.  ∙ Fluid & sodium replacement can become really important & can help cut down on some of these advanced patho things going on in the blood  stream. o Metabolic Alkalosis- pH > 7.45 & HC03 >26, monitor K o Causes:  Most common cause is acid loss from Vomiting (GI loss) or NGT suctioning.  Could happen from taking too much bicarb in, maybe patient who is just taking  lots of antacids or we could give too much bicarb when treating a patient  o Compensation- Lungs try to compensate & this time they try to retain CO2 by breathing  less fast & deep. They hypoventilate.   This is not a good long term fix.  o CMs- similar to respiratory alkalosis  Numbness/tingling  Muscle weakness/cramps/hyperactive reflexes  Tetany/seizures  Breathing: slow because lungs are trying to compensate for it. o Interventions  If you have a patient who is vomiting excessively to the point they are going to  be at an acid base imbalance, we need to go back to our interventions.   Administer the antiemetic, doing all of those basic nursing interventions about  decreasing nasty smells, move patient more slowly Assist with volume replacement, chloride messes up balance so we give  NaCl(normal saline) this will counteract with what is causing the problem  May give some potassium to these patients.   Interpretation of normal and abnormal (uncompensated) arterial blood gas results 1. pH 7.35-7.45 2. PaCO2 35-45 mm Hg 3. HCO3 (bicarb) 21-28 mEq/L 4. PaO2 (arterial) 80-100 mm Hg 5. SaO2 saturation >95% Acidosis- pH is too low Alkalosis – pH is too high  Nursing care when ABGs are obtained 6. This is done by sticking a needle into the artery. The angle is much deeper.  7. Nurses in some settings will draw blood gases. Sometimes the patient has a little line put into it that looks like an IV & its actually an arterial line.  o In most settings, a puncture like this will be done by respiratory therapist. As a bedside  nurse, need to know how to care for it before & after. 8. If you know a patient will have this drawn, the respiratory therapist will bring their  heparinized syringe/kit to do the ABG collection. They will clean the skin, do the  puncture, & it will come back into the syringe.  a. It needs to be put on ice ideally before it is run to the machine. b. Great if you have a cup of ice chips for it to be sat on after collecting.  c. Radial, brachial, & femoral arteries are most common.  d. After we have stuck this in their vessel, we are worried about breathing &  hematoma, & we need to make sure patient has good firm pressure for 5  minutes after a stick.  i. If they are on anticoagulants, then it needs to be longer than that.  e. You need to monitor the site, watch for circulation distal to where they were stuck, make sure they have good capillary refill in their fingers, there color is  pink, & still have sensation. 9. Evaluate results – results come back quickly a. Check the pH. Is it high or low. Is it too high(alkalosis) or too low (acidosis) b. PaCO2 level- Respiratory c. Then look at bicarb/HCO3 -MetabolicBowel Elimination 4-5 questions  Assessment (Client history, physical exam findings, and diagnostic testing) o Bowel movement patterns, stool appearance, abdominal exam, personal habits o Client History  o Frequency & appearance  Ask client what is normal for them. “how often do you go & what does it look  like? When was your last bowel movement? What did it look like, was it normal  for you? was it more frequent, different in color or consistency?” ∙ Normal varies between patient to patient. ∙ 2-3 times a day to 2-3 times a week can be normal depending on the  client.  ∙ Normal color for most people is brown from bile salts that we are  getting rid of.  ∙ Normal consistency is soft & semi-poor  o Personal habits  “Do you have a private place to go to the restroom? Are you able to go when  you need to go? Is it normal for you to go in the morning after coffee &  breakfast, or do you go after you exercise, after lunch?”  if patient does not feel comfortable going to the bathroom & they wont, & the  longer we don’t go, the more water that is absorbed from the feces back into  the body, then the stool becomes harder & harder. o Heath history  Surgeries ∙ especially bowel surgeries are going to cause the colon/GI tract to slow  down (peristalsis).  o This happens because the medications that we give to some  extent, the anesthetics, & then the pain meds on the opioids  can cause peristalsis to slow so patient can not get bowels to  move.  o When we have cessation (stopping of peristalsis) after surgery  we call that a paralytic ileus.  o The symptoms/Clinical manifestations of paralytic ileus   bowel sounds are very diminished or maybe even  absent,   patient will feel bloated & gassy & uncomfortable,  they aren’t moving things along in there & it feels  uncomfortable. Emotion stress- assessed related to normal bowel function. Stress can cause  either constipation or diarrhea. It will either increase or decrease the motility/  motion of the peristalsis of the GI tract.  ∙ Depression usually slows things down so those clients are at higher risk  for decreased peristalsis & constipation that results from that. o Pain- should not hurt to poop.  o Continence- “do you have problems controlling your bowels? Are you able to remain  continent of stool or are you incontinent?”  Expect to see continence at ages 2-3, then through adulthood, then older adults  sometimes have loss of sphincter control. They are at higher risk for  incontinence. ∙ Do not ever say it is normal to have a bowel accident because you are  older, because it’s not. Bowel control is not equated with aging & is  not inevitably going to happen.  o Meds-  How often do they take laxatives or something to help with stool?  ∙ If using every day & become dependent, muscles will lose their tone &  they wont go poop without it.  ∙ Basically become physically addicted to laxatives.   Opioid analgesics result in constipation.   Antibiotics cause diarrhea, & you look for C. Diff.   iron causes constipation, It makes stool look black & sticky & it can also cause  cramping, nausea.  ∙ Think about anemic patients & pregnant patients who need iron  supplements.   Calcium supplements cause constipation, Magnesium causes diarrhea & is found in a lot of laxatives. o Diet- “do you eat on a regular schedule?”  when a client eats regularly, they are less likely to have bowel problems like  constipation or diarrhea.  Also ask about fiber intake. need to take 25 grams for females & 38 grams for  males a day.  ∙ Hard to measure, so ask instead “lets go to 5 servings of high fiber food  a day” like vegetables with skin & are fresh, beans, whole grain bread,  nuts, & corn.  ∙ Fiber helps us to have soft stool, decreases risk of cancer, & is important  to keeping the stool soft enough to not get constipated. Fluid intake is  also important. o Activity Level- activity increases peristalsis.   The more we get our patients moving, the more promotion of normal bowel  function we have.  o Changes - Really important when patient says their bowel movements have changed.   Red flag area that we need to dig deeper & ask questions. “what has changed?  The frequency? The color? Consistency? Shape?” & find out & report that to the  provider.  o Normal rules you can use for everyone-   can get to the toilet without rushing to have a bowel movement  don’t have a lot of straining when you get there  do not have blood loss when you poop   can accomplish all of this without using laxatives o Physical Assessment  o Abdomen  Normal appearing abdomen should be flat or slightly rounded. When palpating  you would expect it to be soft & non-tender.   Not normal- If abdomen is distended, firm, bowel sounds are hyperactive or  absent o Stool  if stool is discolored, think gallbladder disease. ∙ Could be the patient may have blocking the bile duct  Iron makes it look black & sticky & so does blood & bleeding.   Melena- If there is blood going up higher somewhere like not close to the rectal  area, sigmoid, but way on up, & it is coming down through the colon, it will  often make stool look sticky & like tar, except it may have a reddish/black tent to it. Before assuming a patient has blood in their GI tract, ask if they have taken  iron.   Sometimes you will see brown stool & it looks like mucous-y strings are on it, it  might even have blood streaking on it, so maybe there is an infection of some  sort going on.   Hematochezia- Poop is coming out bright red, blood looking. Blood is low  enough down that it is not getting broken down like it is in the tar-y stool.   Can get ideas of where the client is bleeding based on the stool.  ∙ Consistency- is it hard, soft, or is it liquid. o Testing ∙ FOBT (Fecal occult blood test) or Occult Blood Guiac  Use this when we do not see the tar or bright red stool, but can check for the  chemicals/chemistry of the blood in the stool.   So a patient with abdominal pain, a female patient with pelvic pain, you want to  see what's going on so the provider/NP/Physcian may do a rectal exam (so have  gloves & lubricant) & you will get a card & developer.  ∙ Assist patient to the side, & after doing the rectal exam with the finger  the provider will have you open the card so they can wipe the stool on  the card. Then the card will be closed on one side, flipped to the other,  & we will put the drops of the hemo-occult developer on the other side.  ∙ If it turns blue, we see there is blood in the stool that we could not see  with our eyes.  ∙ After you hit 50, it is done every year. ∙ Cultures/ O&P  Patients can collect stool as a routine screening for colon cancer at different  ages.  ∙ Patient may be sent home with the card & told to collect the stool &  return it for testing ∙ If they are sent home do to this, teach patient to reduce protein intake  & be careful with raw green leafy vegetables for 3-7 days if possible  because they may cause false results. ∙ Vitamin C is another to caution to avoid because it could cause a false  negative.  Stool cultures- if you see mucousy crud looking sticky stuff on stool or diarrhea  you may need a stool culture.  ∙ may also collect for O&P- ova & parasites. Checking for bugs that may be causing the diarrhea or abdominal pain or whatever it happens to be.  ∙ Stool specimens need to be fresh. Need to collect & get to lab ASAP.  ∙ Do not collect stool specimens that are mixed with the water in the  toilet or with urine.  o If it is formed stool, you need an inch. If it is liquid, 15-30 mLs.  o If you are testing for O&P poop needs to be warm & fresh to see the living organisms in the stool.  ∙ Direct and indirect visualization tests d. Diagnostic tests- nurses assist, prepare patients, teach the patients to be  prepared for the exam.  e. Direct Visualization- primarily done for cancer screening, FOBT,  sigmoidoscopy, colonoscopy.   Oscopy- taking a tube with camera on it, & the doctor will go in & actually look  in the area needed with the scope.  ∙ Looking through the scope with light to see if there are tissues, polyps,  ulcers, tumors.  ∙ Sometimes you can remove polyps & get them sent to be biopsied to  see if they are cancerous & it may be used to do procedures to stop  bleeding.  ∙ Do need to have a separate consent for these studies.  ∙ Ideally the patient needs drink clear liquids 24 hours prior to procedure,  then needs to be NPO after midnight, preferably 12 hours prior to the  procedure.  ∙ After the procedure the client will start back out with clear liquids, then  advance as tolerated. ∙ Often will complain of feeling gassy because often gas is injected in  there to help dilate & see better. Patient will be bloated &  uncomfortable.   With any of these test, it is possible for the tube to perforate, poke a hole  through the area. ∙ Want to be aware of things like EGB, sudden shortness of breath, change in lung sounds. Abdominal pain, bleeding.   The tube that goes down back of the throat can leave you feeling sore, so maybe suggest hard candies, throat lossages, or warm salt water gargles to ease it.   If it is done outpatient, client will not be able to drive home because they had  been sedated.  ∙ So before it starts make sure there is someone there to drive patient  home. Withhold sedation medication until you physically see them.  The 3 test:  Sigmoidoscopy- Looks at the sigmoid colon. The S part. Does not go far up into  the colon.  ∙ Patient will receive bowl prep by using laxatives & have them keep going into the bathroom until you can not poop anymore. ∙ Take a laxative by mouth, maybe something to drink (magnesium citrate) ∙ Nurse may perform an enema to help clean out the other end.  ∙ If you work in ICU, usually clients will go to a special procedure room to  have this done.  ∙ Will receive sedation to help them forget the procedure.  ∙ Never give patient anything to eat or drink until gag reflex is returned, as you will with any sedation.  ∙ Not done as often, but guideline is to get it done every 5 years after  turning 50.  Colonoscopy- look at the whole bowel even into the proximal part of the small  bowel. Much more extensive.  ∙ After turning 50, do this every 5 years.   Upper Endoscopy (EGD)- looks over the GI tract. If patient is vomiting blood,  having trouble swallowing, they will take a scope & go through the mouth to  look through the esophophagus & into the stomach.  o Non-directly looking through the scope  KUB- flat plate- KUB, urinary bladder, very basic simple x-ray. X-rat plate is placed behind the undressed client & a picture is taken with the x-ray machine.  Barium- Swallow & enema- shows up on x-ray to see where the barium is  filling/shape it is taking.  ∙ If there is a tumor in there, we will not see the barium fil that space. ∙ If the patient has a barium enema or swallow they HAVE to drink lots  of fluids due to it being very constipating.o Stool will look gray, white until they have completely gotten it  out of their system.  Ultrasound- done with tons of different problems the patient may have.  Abdominal pains of all sorts.  ∙ Sound waves show whether it is a solid or liquid.   Computed tomography (CT) – done a lot.  ∙ When talking about the GI system, you will have clients who are given  contrast to drink sometimes because we want to see all the structures  as it goes through.  ∙ But you may also see contrast through the vein, so ask patient if they  have allergies to shellfish or iodine. ∙ Two lab values you check before you let patient roll down the hall to  have test done are BUN & Creatinine. ∙ Because the dye will stress the kidneys & we need to make sure kidneys  are healthy enough to handle that.  ∙ Lots of fluids after, NPO before if possible.   Magnetic resonance imaging (MRI)- done a lot.  ∙ sensitive for tumors, blood flow, bleeding.  ∙ Dye can be given with an MRI but it is not iodine based dye, so do have  to worry about that with this. ∙ Do need to make sure patient has no metal/ jewelry on.  ∙ Patient has to lie really still in a really noisy & loud tube. May need to  give patient something for claustrophobia.  ∙ Patient prep and teaching for testing  Primary risk factors/causes for and complications (dangers) resulting from:  Constipation- Most important is to prevent constipation from happening.  o Increase fiber diet, exercise, fluid. Go when you need to go.  o Promote normal bowel movements.   If patient has a routine, help patient to maintain that routine. If they do not have a  routine, help them to establish one.   Give them privacy.   The normal position for all of us is sitting.   Eating often will trigger peristalsis, so that means we may be able to have a bowel  movement.  ∙ Ask the patient if they need to go within an hour or so after eating.  ∙ Reassure patient to call you when they feel like they need to go to avoid  constipation & you having to do enemas.  o If these fail, you may need to give medicine. Think of it as most normal to least normal. o Bulk stool medications like Metamucil's is most common, is just a bulk of fiber you are  adding to their diet.   They will take a tsp or tbs or an ounce or whatever in a certain amount of liquid &  this will increase the fiber which causes bowel distension & stimulates the patient to need to be able to go.   Least irritating & safest.   Precautions- if not give with enough fluid, it will cause blockage. Give it with plenty  of fluid.  o Stool softeners- allow water to get into stool & make it softer. Docusate sodium is most  common, colace is a brand name. mineral oils, lubricant, lactulose is an osmotic diuretic o Stimulants/laxatives- harder on bowel, patient, just harsher. Do this last. Irritate wall of colon to stimulate peristalsis. Dulcolax is most common. Ducolax suppositories usually but also  comes in pills.  o Understand that is patient is completely & totally plugged up, yes we will go to the big  guns, but if you have someone you can work with then ideally start with bulk, then stool,  then laxatives if patients situation allows us to.   Fecal impaction- If you have a client who has been constipated for some time & it has become rock  hard & dried out that they cannot move or pass it, & it is painful & terrible & impacted. Feels like  pebbles, rock hard. o CM  prolonged constipation that has turned into impaction/ blockage. Patient can not  pass stool  Oozing of loose stool. Loose stool from up above it is sometimes able to seep around it & they ooze & leak stool. This isnt normal, it is loose stool able to get around  blockage.  Anorexia- appetite will be bad, Nausea, cramping, abdominal distention.  Rectal pain because you have pebbles up in there.  o Dangers  If patient is impacted, they are at risk for a true bowel obstruction. Can kill the  patient.  Vagal stimulation- in the process of trying to pass it & you are straining so hard  trying to get it to move, you get into vagal stimulation which causes patients to get  bradycardic, drops cardiac output, & maybe even have them pass out or have a  stroke.  o Treatment- remove it.   DRE- digital rectal exam. As nurse you get gloves & KY(lubricant) & insert finger into  the patients butthole to see if you can feel that hard stool just sitting there.   Then you notify the provider & get an order for digital disimpassion.   Never dis-impact patient without an order.   Digital disimpaction- Once you have an order, you use your finger to break it up in  there & get it into small enough pieces that you can scoop a little out or the patient  is able to start passing it out.  ∙ Careful monitoring of the patient. If they look pale, & feel light headed, you  will immediately take your finger out of their butthole & stop what you are  doing, recheck block pressure & vital signs   Diarrhea- Increase in number of stools, passing liquid unformed stool. o Problem that it is passing through gut so fast we can not get water & nutrients out that the  body needs. o Causes-viral, bacterial, over use of laxatives, IBS, food poisoning, food intolerances,  antibiotics by any route alters normal flora.  o Dangers  When you are rapidly losing stool, you are rapidly losing bicarbonates from the body. If you lose this, your body will have too much acid by comparison. Patient is at risk  for metabolic acidosis.  Losing lots of fluid  Contamination- whatever is going on in there & you share it with someone else.  Whether it is C. Diff or whatever it happens to be  Skin breakdown o Treatment- replace fluid as quickly as possible.   Give pedialyte by mouth.  Clear liquids. Really slow things down in there.   Avoid caffeine.   Lots of skin care, may need a rectal tube if it is really bad.  o Why would we not stop diarrhea sometimes?   Because body is trying to get rid of something for a reason. Maybe an infection. We  want to be cautious. Don’t want to get into an acid base imbalance, fluid volume  deficit. o If you have diarrhea for multiple days, you should get a stool culture done & look at reason  for it.  Hemorrhoids o pressure sensors that are inside the rectum. They let you know whether it is okay  o to pass gas or if you pass gas you will poop your pants.  o Inflamed hemorrhoids are the reason hemorrhoids have a bad name. prevent by restricting  straining. Use cooling bags (cause vasoconstriction that will help shrink the swollen vessels  back down) or use sitz bath which cleans the feces off with water, instead of wiping &  irritating it.   Bowel diversions o Ileostomy  Removing the ilium causing an opening of the surface on the abdomen.   Done surgically.  it is usually loose, liquidy, & hard to control. Patient will need a bag.   Purpose of a wafer is to protect the skin from the stool. Patient will empty bag &  care for it.   Treatments to give the patient continence- ∙ Kock pouch- bring a loop of it through the skin & inside & there is a pouch &  it holds the stool as a reservoir  o they can not constantly have to be draining the bag. This is a  continent stoma that is drained intermittently by the patient or us. ∙ Illoanal reservoir- part of ileum Is taken down & connected to the rectal  area. o If patient has good sphincter control, then they can pass their  bowels reasonably normally.o Continent because stool is evacuated through the anus.  o Colostomy- When the ostomy is formed in the colon.   liquid drainage from colostomy will be more formed & depend on where in the  colon is formed.   These are reversible/temporary.   Loop Colostomy ∙ In some cases there will be a little opening on the abdominal wall, they will  bring a little loop of the bowel out & the side of the bowel that is toward the belly will have a little opening in it.  ∙ The surgeon will slide something under it to keep it from falling back into  the abdomen. This is temporary, so maybe trauma patients.   Double Barrel ∙ Sometimes we need to do treatment or healing & repair & we know we will  need to take it out, so they will take part of the colon, remove the middle  section, bring both sections out to the service of the abdomen.  ∙ The side coming up will be draining stool, the side that is the dead end side  will still bring stuff out, it will just be mucous-y looking stuff.  ∙ Whenever the situation is resolved, they will take those two ends &  reanastomos them (hook them back together) ∙ Astomoses means to attach together.  Both temporary & reversible of colostomy’s.   End colostomy- Permanent or end stoma- patient had to have whole body revised. ∙ the sigmoid colon is removed.  ∙ Stool should be formed, more easily able to handle/ manage. But still is not  considered continent.  ∙ Biggest reason it is done is for cancer. o Ostonomy care  Normal stoma is moist, shiny, pink (brick red)∙ If it is dry there is danger of skin break down. If it is changing colors to blue,  brown, or black, then there is probably lost circulation.   Assess output, how loose, formed, how much. Skin around stoma is at high risk for  break down, so assess the peri-stomal skin is intact & not developing any irritation.   Nutrition- after stoma is formed, a lot of the time the patient will do a low fiber diet,  & once it is well established the client can eat whatever they want to eat.  ∙ They may find if they form a lot of gas they want to avoid those kinds of  foods because the gas will fill their bag & embarrass them.  ∙ There really are not a whole lot of restrictions for stoma once it has adapted  well.   Never underestimate the psychosocial aspect. There are a lot of different clothing's  that can be worn to hide the stoma which allows them to have intimate  relationships, go to the beach, & feel comfortable doing a lot of things like that.  You can irrigate a colostomy, so if it is continent ostomy that needs to be emptied,  the patient can tell you how to do it. It can be done but not often at all.  ∙ Never use an enema bag to do it. Use a special irrigation set to do it.  Pouching an ostomy purpose is to protect the skin, contain fecal material, control  odor to help patient feel more comfortable & allows it to be inconspicuous.   Enema types, administration, indications, and precautions- see non-directly looking through the  scope Nursing care of nasogastric tube for decompression o 4 reasons we will take a tube, put it in patients nose, & into stomach. Enteral feedings,  lavage, compression, & decompression. o Lavage- to wash. Irrigation. Patient has something in stomach, blood, pills, something we  want to get out of there.  o we may insert a tube down their nose into their stomach & use the same process of  measuring & securing & all of that, but this time irrigate it like crazy with lots of  water or saline. o Compression- wont see much anymore at all. Saline pump you have put down the patient  has balloons on it.  o Surgeon will insert it & they will inflate balloon & they will use it for pressure to stop  bleeding.   Maybe there is a vessel in the esophagus that is swollen & bleeding  profusely, life threatening. If they can put pressure on it & get it to stop  bleeding long enough to get into the OR, it’s a good stop measure. o Decompression- use all the time.  o The patient needs to not use their stomach. It needs to rest. o We need to keep fluids from building up & prevent nausea.  o Put tube down, hook it up to wall suction. Suck out all the secretions stomach puts  out & monitor what is going on. Might be emptying blood, green yellow bile stuff  out, mucous-y stuff, whatever is in there we are getting out.  o Reason to do it: resting after surgery, protractive nausea patient (patient cannot stop throwing up), pancreatitis patients, post op  o for decompression, use  clean technique  Maintaining patency by irrigating it as needed, flush with saline & then pull  back out or let it be pulled back to the wall suction.   Blue pig tail is used is an air vent. Allows air to come in to replace space you  are pulling out through the other end of the tube.  ∙ Never block, irrigate, never put anything down the blue pig tail area. ∙ If it does get backed up, take the anti-reflux valve, take the blue end  & put it in the blue pig tail. It does not block air, but it blocks  secretions from coming out & making a mess.   Complications- pressure ulcers where it is attached, becoming displaced,  acid base & electrolyte imbalances   Comfort- these patients are NPO, so oral hygiene.  o Reposition tube, to maybe a little different tape of the nose  as irritation increases.  o throat losages/ice chips if the back of their throat is  bothering them. Delegation 1-2  The “Five Rights” of delegation  Right task- delegate task that are appropriate. YOU cannot delegate administration of drugs. Tasks  must be stable & predictable & does not require a lot of modification or judgement   Right circumstance- For example, a paramedic may be able to put a breathing tube in a patient in the field, however, in the hospital that wouldn’t be appropriate. Or if the patient is unstable, you cannot  delegate hygiene to that.  Right person- Has this LPN ever done this wound care before? Have they been approved & checked  off to do this?  Right communication- need to tell exactly how to do it, when you want it done, & how often I want a report back on it.  Right supervision- coming back to monitor everything delegated is getting done. Was client turned?  Was client clean after delegating hygiene?  Examples of proper delegation (Each skill guideline has info on appropriate delegation.)- This is  throughout the study guide.  **Was discussed during nursing process** Documentation 2-3  Purpose and contents of health record Purpose o Communication “continuity of care”- We want the care to stay the same level of good quality  among everyone. So, if you took care of a patient yesterday and you do not work the following day, you want to make sure the new nurse coming on will know everything they need to know to appropriately take care of the patient.  o Think “if I am not here tomorrow, does this next person know what he/she needs to  know?” Use clear descriptions that communicate well & are in the best interest.  o Jacobs thinks this step is most important because she says communication is huge. o Legally- legal documentation is admissible in court. So, if something happens & there is either a  bad outcome or a question, this is how you protect yourself.  o Technically, “if you did not document it, you did not do it” legally. Even though it is not  100% true because there are ways to show that you did provide the care even when it is  not on the legal record, but it will ease your mind to be very careful & complete with  your documentation.  o Documentation will be the very first thing they look for & track down when there is a  problem. This is why you want to have it complete so you will have a strong  foundation/story about what you did, what happened with the client, and the care you  provided. o Financially- If insurance does not want to pay for something because it is not charted, then the  hospital may not get reimbursed.  o They might say “this hospital charged us for a wound vac & there is no evidence that the  client even had one.” Or “They were using a ton of gauze sponges they are charging us  for but the client never had a wound.” Because it was not properly documented the  patient had a wound.  o Education & quality improvement- When we see a trend on a unit that maybe the clients are  developing UTI’s or an infection at a central line site of a vein, that may be an area that we may  need education, the nurses on that floor may not know how to do something or take care of a  certain problem. o If we do this, we can then track it by continuing the documentation after we do some  education to see if it has gotten better, if there has actually been some improvement in  the quality of the care.  o Research- this is important for a client to have signed up to be in a research study. That there is  an accurate documentation we need to know if the drug/procedure is working for that client or  if they are having adverse/side effects/problems with it. o Accreditation standards- any place you work for will want to show they are accredited. That’s  how we as a community know it is safe to go there. When someone like the joint  commission(TJC) comes to do the inspection to see if they are going to give you accreditation  they look hard at documentation. Did you document that you taught the patient about smoking  sensations? Did you document that you did medication reconciliation when there was a change  in the level of care or provider?  Contents o Only write the facts. o Subjective- Patient tells you “I am really hurting right now” put in the documentation  that patient states that he/she is hurting right now or use a direct quote.   Important that if patient says something crazy like “I am so angry I am going to  kill someone” or something like that to use their direct words if possible. o Objective- only say exactly what you see/hear/smell/touch.   Do not say “client is agitated” because that’s subjective on the nurse’s part.  Instead, say “client is pacing back & fourth in the room yelling loudly.” Now you  have a picture & you are not interpreting.  Never interpret in your documentation, just state what you see/smell/read. o Complete, but concise o “Patient voided quantity sufficient” This won’t work because it is not complete without  how much the patient voided. Instead, say “Patient voided 240 mLs of dark yellow,  cloudy urine at 2 o’clock by urinal.” o “Patient’s blood pressure is low” This won’t work because you need to be more specific.  “Patient’s blood pressure is 130/80, diaphoretic, heart rate is 102 & regular.” o Do not document anything twice/that has been documented somewhere else. o Keep it current. Always document in a timely manner. o If you give meds, document immediately. Important because we do not want someone  to come behind us and try to help us out by giving our meds, but the patient already  received them, we just did not document. So they received them twice.  o Never document something before it happened- If the client is about to go to the OR,  they call & say they are coming to get the client, it is tempting to go ahead & chart  “10:28, client to OR via stretcher” then you turn around & they aren’t breathing. They  aren’t going to the OR but you just documented that they went. So, you don’t want to  document ahead of time. o If late, make a late entry. It will say on the chart you are making a late entry & you will fill it out there.  o Each entry will start with a date & time. If it is on paper, you write it. If it is electronic, the  computer will date & time it for you.  o Keep it organized. You need to develop a technique so you do not forget to document anything,  this will help you stay organized.  o Start from head to toe o Start from neurological systems o Start with what comments your patient has made & work your way down, center, then  out.  o Start with systems, start with everything about the cardiovascular system, then  respiratory, then the skin. o Whichever you choose to stay organized, use this consistently. This way you will sub  consciously be aware that you need to remember it/ go back to it.  o Use the technique of saying what you did, what was the result of doing that, & what was the clients response to it. o Always end with a signature & title. (Hannah Caldwell, SN).  o Make sure your writing is legible & in permanent/nonerasable ink.  o Never leave spaces. If you have an error, mark though it, put error with initials beside it. Then go  to the next legible area to write.  o Chart for yourself only. Never chart for anyone else, or let anyone else chart for you. o Only exception is when you chart what someone has done for you in an emergency  situation. Like a code or when someone isn't breathing or doesn't have a heartbeat.  Someone is going to be doing stuff & telling you & you will be putting it all on a  chart/document.  Maintaining confidentiality o Asking does who I am telling need to know? o Paying attention to where you are giving the hand off o Do not give the report in the hallway outside of the patient’s room, because inevitably  someone will hear. o If you need to give information during walking rounds that you cannot do at the bedside, go  back to somewhere like the nurse’s station, behind a closed door, where it is very private &  confidential. o If I am giving my report during walking rounds & the patient has company, can the company  know the information? o If the client has people in the room, say “Hey Mr. Jones I’m going home, this will be your  nurse now. We are going to talk about your care for today. You have lots of company; would  you like me to ask them to step out?” then depending on what the patient says you will have permission to let the company stay or ask them to leave.  o However, you still should use your judgement but do not be rude about it. You do need to be careful about maintaining confidentiality at the bedside.  Reporting o Handoffs o There are three ways to give an oral report.  o Face to face- this is ideal & most common. You get together & talk face to face. Try to keep is  organized by using SBAR.  o Walking rounds- This is where you walk into the client’s room, meet the client, check the IV site/look at the wound together. This is the standard that the hand off should be given at  the bedside on walking rounds. There has been a push back from it, but this is the  standard. You are providing a report face to face in the patient’” s room, which includes the patient in the conversation. It is very patient centered.  o Taped- sometimes you will record your handoff. The advantage is that you can tape your report  then go take care of a client still while the next nurse can listen to it somewhere. This helps  because you are never both occupied at the same time & someone can take care of the patient  at all times.  You must include o Significant information- name, age, diagnosis admitted with. o Changes in the treatment plan that happened today, like dressing treatment changed, IV fluid  changed & why, or their plan of being discharged.  Do not include o Routine care- the new nurse really doesn’t need to know you gave the patient a bath o Gossip/Personal opinions- Do not want to prejudice them to the new nurse. Don’t say things like  “oh you poor thing you have that client? All he does is whine.” o This is hard to do because in the real world you want to give a heads up to prepare the  nurse, but you do not want to prejudice them.  o Try to stick with facts & stay professional as much as possible. o By telephone  o If you receive an order, be sure to you carefully identified the client.  o Then immediately & as quickly as you can, get the order recorded. Write it as few times as  possible. o Always repeat the order back & document that too. “I understand you want me to give  Lasics 20 mL once now, is that correct?” doctor will say “yes that’s correct.”  o Document that you did that/read the order back. o Question if needed. o Document TO for telephone order, VO for verbal order. o If uncomfortable/in a high-risk situation, ask them to repeat order to another nurse.o The order has to be signed by the person who gave it to you within 24 hours, electronically  or on paper chart or however it happens to be. o Promote safety by rarely accepting a verbal/telephone order.   You really want it to be written down or entered through the chart so there are no  questions about it. It is not something routinely done.  o Order must then be prescribed within 24 hours.  Sentinel event- an event in which someone died, the wrong body part was cut off, they lost a  hand due to meds being given wrong or communication was not clear. 60% of these events are  related to communication problems during phone calls. Incident reports o if an event that happens that isn’t consistent with routine care (A never event, like patient  developing a pressure ulcer, falling, receiving the wrong medication), you fill out an Incident  report.  o First you will assess the patient & the patient’s response (vital signs, comments, complaints of  pain, discomfort.  o Then you will call the provider & let them know what happened. o It is very tempting to not do this because it is very time consuming, but you need to. o Give objective descriptions & include subjective comments any time you can. Put them in  quotes. Put what you saw happened & what the patient says. o Don’t include in the chart that you filed an incident report. You will say in the patient’s chart  what happened, what the patient says, objective & subjective information, but don’t say incident report completed. o Incident reports go to facility where they look for trends, things to help avoid this from  happening again. o If it was a near miss, fill it out to help incidents from happening. Fluid/electrolyte balance 4-5  Fluid intake o 2700-3700 mL  Fluid output o Fluid output is usually 2200-2900 ml/day. 2700-3700 is average intake. 2700- female 3700- male o Gastrointestinal- feces 100-200 mL/day o This is not including diarrhea; this is just normal loss. o Kidneys- urine 1500 mL/day o Sensible- skin, 200-600 mL/day o Insensible- Lungs- 300 mL/day  Fluid distribution  Intracellular- inside the cell. 2/3 of body fluids  Extracellular- out side of the cell/ 1/3 of body fluids o Interstitial- around the cells o Intravascular- in the arteries, capillaries, & veins.  Concentration- where the fluid is concentrating depends on how many colloids (our big particles  such as proteins), crystalloids (smaller things like electrolytes and what the concentration of them is  in each fluid compartment happens to be) Constant flux back & forth between the different areas.   When we have our cell, that is perfectly balanced, there is as much in all the different compartments  in & around it. If we put it into an:  o isotonic fluid- the balance will not change. If it was fine before it will stay fine. Equal balance. o If we put it into a very concentrated place, maybe a solution with tons of salt/sugar- fluid  leaves the intracellular space to the extracellular space- it will shrink, hypertonic makes it  shrink. o If we put it in a diluted concentration with very few particles- the cell will become more  concentrated & fluid will go into it causing hypotension.  this is where us as nurses will start seeing things like infusion, seizures, and changes  neurologically that boil down to what is happening at the cellular level  Fluid volume deficit  o Causes  Deficient fluid volume related to insufficient intake ∙ Maybe client can’t drink because of age, maybe doesn’t respond to thirst  mechanism, maybe they are NPO for a test, maybe they have immobility  issues.  Excessive loss ∙ Blood loss- hypovolemia ∙ Water loss- vomiting, diarrhea, excessive/copious sweating  ∙ Just does not stay in right place  Fluid shifts ∙ Illness- such as liver disease, start having fluids collect into the peritoneal  cavity. Fluid hasn’t left the body, but its not in the intravascular/intracellular  space so it is not in a place we can use it. ∙ Burns- fluids shift from normal spaces to other areas. Intravascularly to the  skin with burns. So we have fluid loss with burns, because it may not be in  the intravascular area where we could actually use it.  o Risk factors/ who is at risk  Babies- proportionately, they are higher percentage of their total body weight being  fluid. So, if they lose a lot of fluid, they are going to lose a bigger percentage of their  total body  Elderly- lower amount of fluid reserved. If they lose fluid they develop an imbalance.  Obese people- have a lower fluid reserve so they cannot cope as well with fluid loss  Occupation & environment- an AC heating person who works in an attic in the  summer, they are at high risk for fluid loss because of heat & sweating. vigorous  exercise in a hot environment, people who cannot afford air conditioning.  o Clinical manifestations  Heart rate increased, but thready.   Thirst is an early symptom, but is not reliable for fluid volume replacement.   Dry mucous membranes make it hard to swallow  Decreased weight ∙ something you can check daily. A trend you can watch for several days. ∙ A 5% drop in weight is seen as needing sufficient clinical attention.  ∙ Weight is considered one of the best indicators for fluid balance.   Decreased Skin turgor- fluid has left the cells, it is trying to keep intervascular  volume built up. ∙ Skin will be dry if you pinch it. It will not bounce back, it will remain tented. ∙ Not accurate assessment in older adults who have lost some of that skin  resilience anyway   Decreased BP   Decreased Pulse Strength  Decreased Urine Output- may only be 20 mLs out per hour the past 2 hours. Need to call someone if so.  Labs change ∙ BUN >20 mg/dl  o BUN is dilutional. It will be more concentrated on the lab work if  patient is deficient, & will be higher. ∙ Urine specific gravity >1.030 o This will be more concentrated because body will try to retain that  fluid and not put out as much urine.  ∙ Hct> 3X Hgb, but both may decrease  o “in general, if you look at any of us here, if you compare the  hematocrit to the hemoglobin, the hematocrit will be about 3x the  hemoglobin level. But when you look at a client who has lost fluid,  the 3 time will be out of whack & the Hemocratic will be higher  compared to the hemoglobin. Lets say hemoglobin is 10 (which is  low), instead of hematocrit being 30, it may be 35 or 40. it will be  more than 3x because hematocrit is an estimate of the  concentration of the cells in the blood. But keep in mind they both  may be trending down if your deficient fluid volume is related to  bleeding/ hemorrhage. Loss of blood.” o Nursing interventions   Monitor  ∙ Weights & I&O ∙ Vital signs ∙ Labs ∙ Urine output ∙ IV o When you have a client with deficient fluid volume, your iv access  can become your life line. You will watch/ monitor that iv. Make sure its securely taped and protected.   Stop the loss ∙ if bleeding, put pressure on it, send them to surgery if it is something that  needs to be stopped by a surgical procedure.  ∙ if it is from NVD- give meds for nausea, give something to slow down the  diarrhea, if someone is sweating, get them out of the heat. Stop the cause of it.   Replace the loss∙ give oral fluids (if we can as quickly as we can, with some electrolytes in  them), give iv & iv fluids of an appropriate type.  ∙ If hemorrhaging or losing blood, maybe give them blood or blood products. Decide whether to stop or replace based on which is the higher priority based on which  you can impact the fastest/ which will kill the patient first.   Comfort & safety measures ∙ Oral care- mouth will feel nasty ∙ Skin care- boney prominences, hydration in skin can cause better or worse  skin break down.  ∙ Positioning- have client change positions slowly and carefully. If they are  lying down in bed, you don’t want them to go from that to upright running  to the bathroom because they will end up in the floor. Want to bring from  lying to sitting to see how they feel. Might even check their heart rate & BP  to see if BP dropped & HR went up. If they are okay, dangle the feet at the  side of the bed, then we will stand & see how we are doing, then you will  take off & go somewhere. Change positions slowly & carefully.  How sick is the patient? ∙ Administer supplemental oxygen o Maybe client has lost a lot of blood, needs O2 ∙ Position HOB flat with legs elevated o Position patient to get blood flow to where it needs to go  Fluid volume excess o Causes  Too much fluid in ∙ Sometimes we put too much fluid in via IV.  ∙ Hard for patients to drink too much, but some psych patients might drink  water compulsively. Taking in too much hypotonic fluid will end up messing  with their sodium.   Too little fluid out ∙ Most of the time this is the case.  ∙ Ask yourself, are the kidneys working? Kidneys are how we get rid of the  fluid. ∙ Is the heart working properly/ healthy? Maybe your heart is having to pump  harder to distribute the fluids throughout the body  Eyes on/ Risk factors ∙ Iv infusions ∙ Psych problems ∙ Postop patients o These patients have had stress (surgery=stress on the body) so it will kick in ADH & aldosterone to retain water because it has sodium &  water will follow sodium. ADH (antidiuretic hormone) keeps the  fluid retained, reabsorbing more fluid instead of getting it out of the  kidneys. ∙ Renal problems o Cant put out urine.  o High risk client∙ Cardiac disease o High risk client o Clinical manifestations  High pulse rate- a bounding pulse  High pulse volume  High BP  High RR because you are fighting to get oxygen delivery going  High edema because the pressure/ volume inside the intravascular space is so high,  it is pushing it out into the interstitial tissue.  High weight  High Crackles, dyspnea, orthopnea ∙ Dyspnea- subjective, shortness of breath ∙ Orthopnea- patient cannot breathe lying down ∙ Accessory muscle use- struggling hard to breathe so you may see muscles in  the neck, maybe intercostal muscles are starting to be used, & maybe even  retractions, like the sternum is going in with breath instead of going out.  High confusion, hyperactive reflexes, seizures ∙ cant think straight, don’t know where they are, or what is going on.  ∙ Cannot follow commands.  ∙ Reflexes if checked can become hyperactive, may even progress to having  seizures.   Decreased Hct and BUN because you are looking at more fluids, so they are diluted. o Nursing Interventions- RESTRICT  R- Reduce fluid and sodium intake ∙ Remember water follows sodium, so also monitor sodium intake.  E- Evaluate breath sounds, dyspnea or orthopnea, O2 levels  S- Semi-Fowler’s position/Seizure precautions ∙ Semi fowlers helps us to breathe better, if the client can tolerate that.  ∙ Remember we said they may have seizures with neurologic changes because there is no room for the excess fluid so it goes into the cell, so now the cells  are swelling & you are going to get some neurologic changes, especially with brain cells, even seizures.   T- Treat with diuretics and oxygen as ordered ∙ We need to increase what’s going out, we may be able to do that with  diuretics.  ∙ If the kidneys are working, we will give some diuretics & try to pull some  fluid off.  ∙ Give O2 if they need it, which is a dependent intervention  R- Re-evaluate mental status  I- I & O and daily weights ∙ Really careful, maybe strict I&O.  ∙ Measure every little mL that we possibly can and record it.  ∙ Daily weights!!! – most sensitive indicator of our fluid balance.   C- Circulation – B/P, pulse rate and quality, presence of edema ∙ is BP going up?  ∙ Pulse rate & the bounding quality going up? ∙ Is there a presence of edema?  T- Turn and position at least Q 2 hrs. Consider elevating edematous arms and  legs. ∙ Skin care. Now we have fragile skin because of all the fluids & all the  distention that the skin is suffering.  ∙ Consider elevating edematous arms & legs to help the venous return get out of the interstitial & get back into the circulation to the heart.  Correct techniques for obtaining daily weights and I&O o Daily weights  Measure weights first thing in the morning, same time everyday.  Use same scale  Void before weighing  Client needs to be wearing the same thing each time  Can delegate this  Client can do this at home, if they are gaining more than 2.2 pounds a day, they need to call the provider & check in about what’s going on  1 pound increase is about 500mLs of fluid retention. o Measuring I & O  Needs to be accurate & carefully. Include what needs to be included & measure  carefully.   If delegating this you need to make sure they are doing a good job on it.  Do not eyeball because its inaccurate. Use your tools & get an mL measurement  Nursing care to encourage and restrict fluid intake o Encourage fluids  Encourage small amounts frequently. “all you have to do is take two sips” then come back 10 minutes later & them take two more.  Let the client choose what sounds good/ appealing to him/her. If they are allowed to have different kinds, give the liquid of choice.   Often cool fluids are more appealing & easier to go down. o Restricting fluids  Sometimes you need to help a client not take in much fluid.  Remove water out of sight, out of mind.   Put it in a small cup so a little looks like more  Encourage them to not drink fluids with meals, so they can drink in between meals.  Be careful about things that make us thirsty, like salt & spicy foods.  Gargling with refrigerated mouthwash, & using hard candy.   Potassium, sodium, magnesium, phosphate, and calcium imbalances Hypercalcemia- Serum calcium level is greater than 10.5 mg/dL.  o Risk factors/ Common causes o Too much calcium or vitamin D which causes the absorption of the calcium to be  different, thus having the calcium shift out of the cell & into the blood stream.  o Shifts  Immobility- when our client is put on bed rest & have decreased mobility for a  long time, the calcium starts coming out of the bones & into the blood stream, & we see hypercalcemia. Malignancy- bone cancer, we see the same kind of problem, their calcium levels  will go up.  Hyperparathyroidism- regulates a lot of potassium levels in the body. o Thiazide diuretics can raise calcium levels by decreasing calcium output in the urine. o Clinical manifestations o Decreased Heart Rate o EKG changes/cardiac arrest o Decreased reflexes o Lethargy & disorientation o Respiratory Weakness  o Constipation  o Nausea/Vomiting (GI is slow, which causes their gut to be full) o Measures that prevent imbalances from occurring o Appropriate treatment & nursing interventions o Treat the cause always o Monitor cardiac- Calcium is important to the heart being happy, so monitor the cardiac  function. o Decrease intake- if patient has been taking in too much calcium, stop them o Increase activity- if it is caused by immobility, get them moving. o Increase PO fluids to avoid calcium stones developing & building up in the kidneys. o Increase fiber intake because the GI has slowed down & we want to keep the patient  from getting too constipated. o Administer meds if needed- phosphorus supplements.   Phosphorus & calcium have opposite levels in the body. You may find with high  calcium levels you need to give phosphorus/phosphate binders/phosphate  supplements or other medications that will keep the calcium from being  released from the bones & into the blood stream. Hypocalcemia- Serum calcium is less than 9.0 mg/dL o Risk factors/Common causes o Inadequate intake o Vitamin D deficiency o Malabsorption  Problem for clients with GI problems like chronic diarrhea/ fat digestion o Hypoparathyroidism o Hyperphosphatemia  If we have high phosphorus levels, we expect low calcium levels o Keep an eye on patients who have renal failure  If the kidneys aren’t working, we will have an increased excretion of the calcium o Keep an eye on patients who have cardiac problems  Their heart will start getting really fussy & have abnormal things come up.  o Clinical Manifestations- TWITCH o T- Tingling and numbness  Patient might say “I feel like right around my mouth (circumoral) & around my  fingers. I don’t feel normal, kind of a numb & tingling feeling” o W- Watch for dysrhythmias   Cardiac dysrhythmiaso I- increase in bowel sounds  GI tract is bumped up so we have an increase in bowel sounds  o T- Trousseau, spasms, increased reflexes o C- Chevostek’s sign o H- Hypotension & low heart rate o Measures that prevent imbalances from occurring o Appropriate treatment & nursing interventions- SAFE o S- Seizure precautions, safety in moving  These client’s bones can break very easily so be careful o A- Administer calcium supplements  Give supplements either by mouth, or IV  If calcium is low, they probably need vitamin D, & maybe a phosphate binder so  that we are reducing phosphate & allowing calcium to build back up  o F- Foods high in calcium  Dairy, canned fish, dark green vegetables.  o E- Emergency equipment on standby  Always have emergency equipment on standby, if your heart becomes too  unhappy, you may need emergency drugs.  Hyperkalemia- serum potassium is greater than 5.0 mEg/L. o Risk factors/Common causes o Increased potassium intake, either by mouth or through IV o Potassium moves out of cells & into blood stream.   Vigorous exercise, inadequate insulin, crush injuries/burns will cause potassium  to be released from the cells. o Kidneys aren’t working. This is the biggest.  o Patients with renal failure & who have experienced trauma are at high risk for  hyperkalemia.  o Clinical Manifestations o Decreased heart rate- it becomes slow & irregular.  o Decreased blood pressure o EKG changes that can be really life threatening & are really serious o Gastrointestinal changes  o Neuromuscular  Abdominal cramping/ twitching/ Tingling you may see early on, but as this  progresses you will see a client who really doesn’t have much muscle tension.  Muscle weakness (late)- you may see muscle weakness in the legs, then it will  progress all the way up to maybe even the diaphragm so they may not be able  to breathe because they have severe muscle weakness from the hyperkalemia.  o Measures that prevent imbalances from occurring o Appropriate treatment & nursing interventions- STOP o S- stop the intake o T-treat as ordered  give diuretics if the kidneys are working.   Administer Kayexlate- gets rid of potassium, can be given by mouth or rectally by an enema. Helps to bind/pull off/causes diarrhea to pull off potassium.  Dextrose with regular Insulin IV Give calcium to bring heart rate back to normal/stable it back out.   Dialysis- if kidneys are not working, client needs to go to dialysis & have the  machine do the work that the kidneys can’t do right now.  o O- observe cardiac monitoring o P- provide fluids  If they kidneys are working, we really want to push fluids to get the client peeing off the potassium. Hypokalemia- Serum is less than 3.5 mEq/L.  o Risk factors/Common causes o Not taking enough in, very likely. o Shift into the cells  Diabetics who have their insulin messed up & this causes the potassium to shift  from the blood stream into the cells.  Potassium didn’t leave the body, it just is not in the blood stream anymore. o Increased output  Our loop diuretics get rid of potassium o Keep an eye on patients with Heart failure o Keep an eye on diabetic patients o Clinical Manifestations- CRRAMMP o C- Constipation  Decreased bowel sounds because bowel slows down & you get some  constipation. o R- Reflexes decrease/slow o R- Respiratory weakness o A- Arrhythmias  Cardiac rhythm is very abnormal o M- Muscle cramps and weakness  o M- Mental status: irritable/ anxious  o P- Pulse  Irregular  Weak o Long term effects- culturally, we do not take in enough potassium. This causes bone  problems, kidney stone problems, and an increased risk for hypertension & strokes.   So, insufficient intake is very real & we need to monitor that closely.  o Measures that prevent imbalances from occurring o Appropriate treatment & nursing interventions o Eat more potatoes, avocados, fresh fruits, bananas, instant coffee o Give potassium supplements  If you are giving a diuretic, especially a loop diuretic, be sure to always pair with  a potassium supplement.  o Treat the underlying cause o Arrhythmias. Serious ones!! So you need to watch that on the monitor o Support their breathing o “speak to me”  look at their neurological status o Give the patient IV potassium supplement NEVER IV PUSH. YOU WILL KILL THE PATIENT IF YOU DO THAT  MUST BE DILUTED, GIVEN SLOWLY & WITH A CARDIAC MONITOR. o Is the urine output high? This may be where you are losing your potassium o Watch muscle cramping & weakness  Hypermagnesemia- Serum magnesium is greater than 2.1 mEq/L o Risk factors/Common causes o Increased magnesium intake or absorption o Decreased magnesium output o Patients who are using laxatives whether it be to lose weight or they are elderly o Patients who are experiencing renal failure because then you are not getting rid of the  magnesium. o Clinical Manifestations o Decreased HR & BP o Decreased RR & depth o Decreased reflexes o Nausea & vomiting o Decreased level of consciousness o Patient will be flushed & warm o Experience Respiratory muscle weakness o EKG changes o Cardiac arrest o Measures that prevent imbalances from occurring o Appropriate treatment & nursing interventions o Eliminate or treat the cause  Get the patient to stop using milkamag, get them to go poop everyday o Diuretics- these will increase the renal excretion of magnesium. o Calcium gluconate could get rid of magnesium o Monitor closely because when magnesium levels are high, we can see the heart getting  irritable & unhappy, the client may not even be able to support/ keep their own  breathing going on.  Level of consciousness  Vital signs  Airway  Reflexes o You really just slow everything down when the patient has hypermagnesemia, so we  may need to do a lot of support & care for this client. Hypomagnesemia- Serum magnesium is less than 1.3 o Risk factors/Common causes o Increased output  Gastric suction/vomiting ∙ Clients may have GI secretions coming out because they are vomiting or  they have diarrhea coming out.   Chronic diarrhea  Diuretics  EtOH ∙ Alcohol increases secretions of magnesiumo Inadequate intake/absorption  Malnutrition   Chronic alcoholism  Laxative misuse o Clinical Manifestations o Low calcium levels o Cardiac irritability o Tachycardia o Hypertension o Mood changes & disorientation o Muscle spasms/cramps/tetany- even going all the way to seizures.   Chevostek’s & Trousseau’s  Hyperactive reflexes o Seizures o Measures that prevent imbalances from occurring o Appropriate treatment & nursing interventions o Discontinue magnesium- losing medications & alcohol use  Stop meds causing magnesium to be pulled off & alcohol use, maybe do some  alcohol counseling.  o Increase dietary intake  Whole grains  Dark green vegetables—spinach  Magnesium containing laxatives & antacids  o Administer Magnesium Sulfate- NEVER ABBREVIATE MS  PO or IV, not IM o Correct hypocalcemia  If we correct our calcium, then we will be helping to move forward to our  magnesium o Seizure precautions Hypernatremia- serum sodium is greater than 145 mEq/L o Risk factors/Common causes o Excessive sodium intake/not getting rid of enough o Retention- don’t get rid of enough maybe because of kidneys, endocrine disorders  (hyperaldosteronism), renal diseases o Water deprived clients  maybe they are about to have surgery & they are NPO  Immobile & can’t get to something to drink. o Fluid loss-   sweating (hypotonic generally)   N/V/D  Fever  Burns o Clinical Manifestations o Looking at a dehydrated picture o Client will be thirsty o Heart rate will riseo Blood pressure will drop o Mucous membranes will be dry o Poor skin turgor o Decreased urine output   because kidneys know they need to try to get fluid back in balance. o Neuro changes- biggest thing to think about  A client who is no longer thinking clearly. When we have shifts in sodium we  have shifts in the intracellular hydration, which causes us to have neurological  changes. Hallucinations, irritability, & gradually leading to lethargy & even  seizures.  o Serum osmolality is greater than 300 mEq/L o UA specific gravity is higher than 1.030 because we don’t have enough fluids to get the  sodium level back down to normal o Measures that prevent imbalances from occurring o Appropriate treatment & nursing interventions- SODIUMS o S- Sodium intake decreased  drop this if we possibly can.   If it is 2300 mg a day for healthy adults, try to drop that to 1500 mg a day for  someone who has chronic heart problems or something like that. o O- oral hygiene  Causes nasty dry sticky mucous membranes , so as a comfort measure we need  to keep things moist & clean up there.  o D- Diuretics that promote sodium loss o I- increase hypotonic fluid intake slowly  Drink more water if that is the problem to help balance it all out.   If you need to replace the water balance the sodium back out, give isotonic or  maybe even hypotonic slowly because cells have been dehydrated & if you put  water in too quickly, swelling will occur, which will trigger neurological problems. o U- urine output and I&O o M- monitor for UOP & LOC  urine output & intake, while keeping a real close eye on the level of  consciousness.  o S- safety & seizure precautions  May need to think about preparing for seizures.  Monitor the patient to not be steady being able to get up & walk around the  room.   orthostatic hypertension Hyponatremia – Serum sodium is less than 136 mEq/L o Risk factors/Common causes o Inadequate intake- not very likely.  o Sodium loss  Retention- we have wither retained too much fluid in relation to sodium, or we  have a loss of all the fluid in the sodium with shifts going on.  Renal/ adrenal ∙ Diuretics could be pulling off more sodium then in relation to fluids. We  may have diseases that don’t produce enough aldosterone, so we aren’t retaining the sodium, or maybe the kidneys just can’t respond to it  appropriately. ∙ Diseases o Gastrointestinal  N/V, maybe someone who has a tube down & we are suctioning a lot of GI  secretions out, loosing fluid but more sodium in relation to the fluid. o Too much water intake dilutes the sodium  Polydipsia- consistent/ constant intake of tap water.  ∙ Tap water= hypotonic. So, we are dumping hypotonic fluids in my mouth & diluting the sodium.  ∙ Take one little snap shot/ blood draw & you will see that low sodium  level  Hypotonic IVFs- giving too high of hypotonic IV fluid ∙ Maybe give a sugar/ D5W because it does not have any sodium, just  water & sugar.  Hypotonic irrigation- maybe bladder irrigations or wound irrigations.   Tap water enemas o SIADH (syndrome of inappropriate ADH (antidiuretic hormone)  Neuro thing  Example of body putting out more ADH, so its retaining the fluid & it is just a  matter of the available sodium being diluted. o Clinical Manifestations o “Patient decided to eat whole salt shaker, sodium in blood stream has gone up. This  client was good on fluids. So the water will go where the sodium is in the blood stream,  so now its diluted that back out. In fact, it may over compensate to the point that now  when we recheck it, we have a hyponatremia. Constant change in our bodies.” –jacobs  got this out of patho book o Confusion, headaches, and lethargy, seizures  Focus on neuro with sodium.  Confusion & head aches are common.  No energy will progress to seizure, especially when you get down to the low  117-120.  Or if it is a sudden change, patients will flat out have a seizure. o N/V & abdominal cramps o Muscle twitching o Decreased reflexes and respiratory effort (late)  You will see everything slowing down & becoming depressed, depressed reflexes & respiratory effort. o Measures that prevent imbalances from occurring o Appropriate treatment & nursing interventions o Increase sodium intake, which is not hard to do. Seizure precautions  Increase by taking in more sodium by fluid or by mouth o Of the problem is we have diluted the sodium too much, then maybe we do need to do a water restriction & cut down, maybe give a diuretic. o Daily weights o I&O- intake & outputo Use isotonic fluids to restore- hypertonic if severe  0.9% sodium chloride is isotonic  hypertonic- if it is really low, or client is really symptomatic, client is really  confused or maybe ready to have a seizure, we may give hypertonic fluids. ∙ 3% sodium chloride.  o Monitor for   Postural hypotension- changing positions slowly, orthostatic hypotension.  Neuro changes Hyperphosphatemia- Serum phosphate is greater that 4.5 mg/dL.  o Risk factors/Common causes o Renal failure o Chemotherapy o Hypoparathyroidism  The parathyroid increases absorption, but also increases excretion so we are  losing our phosphorus.  o Laxative use  These have phosphate components in it.  If you have an older patient with constipation or a younger person, females in  particular, who are wanting to drop some pounds, keep an eye out for people  using & abusing laxatives o Calcium deficiency because phosphate will be high, so calcium will be low o Clinical Manifestations o Decreased calcium levels o Heart rate & blood pressure drop o Muscle weakness that affects breathing o Trousseau & Chevostek signs will appear o Hyperactive reflexes o Twitches, tingling, cramps, & seizures o Diarrhea & hyper active bowel sounds. o Measures that prevent imbalances from occurring o Appropriate treatment & nursing interventions o Decrease intake of phosphate o Treat hypocalcemia. Replace the calcium then we will cause the phosphate levels to drop o Give Aluminum hydroxide (a phosphate binder) with meals  Lowers phosphate, then you will also see the calcium go back up with that. Hypophosphatemia- Serum phosphate is less than 2.5 mg/dL o Risk factors/Common causes o High calcium levels o Hyperparathyroidism o Antacid use   Client keeps popping tums for indigestion or something calcium goes up &  phosphate may be dropping o Renal disease o Chronic EtOH  People who have alcohol abuse problems will have low phosphate levels. Alcohol causes kidney to excrete more phosphorus & also has to do with  malnutrition.  o Clinical Manifestations o High calcium levels o Impaired clotting o Muscle weakness  Cardiac & respiratory o HR slows o Decreased reflexes o Irritable to confused to seizures. o Measures that prevent imbalances from occurring o Appropriate treatment & nursing interventions o Increase intake o Give supplements by mouth with vitamin D or IV if critical  Be careful when giving IV fluids that contain glucose when patient’s phosphorus  level is low. We give the glucose & it will go intracellularly along with the  carbohydrates that we are putting back into their system, and may end up  making the problem worse.  Infection Control 5-6  Nursing interventions to break steps in the chain of infection o Normal defense mechanisms- skin, mouth, eye, respiratory tract, urinary tract, GI tract,  vagina. o Nursing interventions- prevention by using standard precautions and PPE, hand hygiene,  cough etiquette (cover, mask, hand hygiene, 3 feet), prevention by sharp disposal.  Personal exposure treatments & follow up. Immunizations.  Support of primary defense mechanisms o Nurse supports by watching for impaired skin integrity, hygiene of the patient. Making  sure patient is breathing properly, eyes are protected, mouth is clean, there are no  GI/GU & bowl problems  Factors that increase risk of infection- Suseptible host o A previous injury/surgery, smoking, substance abuse, having multiple sex partners,  environmental conditions, chronic diseases, medications (might alter normal flora)  invasive procedures (catheter) o a person who is at risk for infection because of inadequate defenses against the invading pathogens. Factors: age, compromised immune system, & immune deficiency  conditions.  - HAIs- Healthcare-associated infections- Not present on admission, gained while  in hospital   Standard precautions- your PPE, scrubs, gown, mask, goggles  Isolation o Contact- patient needs a private room or cohort Patient. Wear gloves & gown.- C. diif, MRSA,  VCEs o Droplet- private or cohort room. Surgical mask needs to be worn when within three feet of  patient. patient wears a mask when transporting him/her.o Airborne- needs a private room with negative airflow. Door needs to stay closed. The air needs  to be filtered with ultraviolet radiation or an air filter. Nurse needs to wear a mask, (N95 if  patient has TB)  Surgical asepsis vs. medical asepsis o Medical asepsis- reducing and preventing the transfer of organisms. Clean technique. Hand  hygiene. Barrier techniques. Clean environment o Surgical asepsis- eliminating microorganisms. Sterile technique, equipment & supplies,  environment. OR.  Maintaining sterile field, surface, etc. o A sterile object remains sterile only when touched by another sterile object  o Only sterile objects may be placed on a sterile field o A sterile object or field out of the range of vision or an object held below a person’s waist is  contaminated. o Sterile object or field becomes contaminated by prolonged exposure to air.  o When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or  field is contaminated o The edges of a sterile field or container are considered to be contaminated (1-inch border)  Clinical manifestations of local vs. systemic infection o Local- one spot in the body, wound, infection isolated to one area. o Systemic- all over body. Heart rate, fever, respiratory rate, malaise  Care of febrile patient- hyperthermia o Give them antipyretics (acetaminophen/ Tylenol) to lower the temp. o Give them antibiotics to kill infection causing fever o Cover patient as lightly as possible to reduce fever. Cooling cloth/blanket you don’t use as often.  o Fan in room helps to dissipate the high temp & move it away. o Keep patient hydrated with proper nutrition o Practice oral care with patient to help with their appetite o Provide comfort- when fever breaks they will be soaked in sweat so get them clean & dry linens. o Identify trends- if patients fever goes up & down at certain times, make note of that. o Evaluate effectiveness- check temperature again to see if it has gone down  Needlestick prevention- never recap needle, always activate safety feature Personal exposure care to blood and body fluids o Wash needle sticks and cuts with soap & water o Allow bleeding unless its life threatening o Flush splashes to the nose, mouth, or skin with water.  o Irrigate eyes with clean water, saline, or sterile irrigants o Immediately tell supervisor.  o Follow up with source patient testing (HIV/AIDS), Prophylaxis, monitoring IV Therapy 3-4  Purposes of IV therapy  Purpose o IV therapy- taking a tube & inserting it into a vein in order to administer fluids, medication,  electrolytes, blood, nutrition, whatever it may be. o Small tube inserted into a vein.  o Most common is fluid &/or electrolyte replacement.  o To administer medications o To give blood & blood components- patients with hemophilia diseases o Parenteral nutrition- patient cannot eat/drink & their GI is not functioning so you must give  the patient nutrition directly into their vein.   Benefits of central vs. peripheral IV placement o Peripheral- easy to do. Short term use.  o Central- Can accommodate highly irritating and hyperosmolar solutions  Central veins are accessible even if the patient is experiencing severe fluid depletion  Can also be used to monitor central venous pressure  Can be left in ranging from a week to long term depending on the type used.  Nutrition can be given parenterally  Phlebitis, extravasation, & infiltration are less likely to occur with central lines  Central lines with extra ports allow you to withdraw blood from a port to use for lab  test  Orders for IV therapy vs. nursing responsibility in initiation o Order o IV therapy is a dependent nursing intervention.  o When you get the order you will have an IV fluid ordered like normal saline, ringers lactate,  D5W, 3 % sodium chloride. o Then it will either tell you to run it at a rate (mL/hour) or it may give you a volume to infuse  over a certain time period (1 L/12 hours, so you have to figure out how many mL per hour) o it may say saline lock (SL) so you take a little plastic tube, preform a venipuncture but do not  hook up fluid at all. It is just there in case you need it, or maybe patient needs medication  every few hours.  o Nursing responsibilities: pick needle, site, infusion rate  IV fluids o Isotonic- Just replacing fluid volume loss.  Expands ECV (vascular and interstitial); does not enter cells  0.9% Sodium Chloride (NS) Lactated Ringer's (LR) o Hypotonic- not as concentrated as blood stream.   Expands Extra Cellular Volume and rehydrates cells. Will go into extracellular/more  concentrated area to rehydrate the cells.  0.45 % Sodium Chloride (1/2 NS)  0.225% Sodium Chloride (1/4 NS)- use in kids a lot. o Hypertonic  Sodium replacement  Draws water from cells, from interstitial spaces into extracellular volume into the  blood stream.   3% or 5% Sodium Chloride  Types of infusion: primary, IVPB, bolus o Primary IV infusions  Continuous rate/steady drip/hour after hour  Also called maintenance IV fluids  Regulate this very carefully  o Bolus- patient needs medicine or fluid very quickly. When you give something fast you call it  a bolus. Usually a larger amount given very quickly.   Not usually on an IV pump, usually will be hung & ran in. Make sure patient tolerates well. Maybe a dehydrated patient, trauma patient who has lost a lot of blood.  Quick fluid replacement o Medications through the IV  sometimes the medication will be added to primary IV/maintenance bag.  Continuously given.  Intermittent∙ IVPB- IV piggy bag- small bag (50 mL, 100mL) you will have a time (every 4  hours, 12 hours, once a day) that you will go in & hang the small bag which  is called a “piggy back” because it hangs behind the primary/maintenance &  you will program the rate & run it in over a short period of time.  o Not constant. Will run in, finish, then it’s done.   IV “Push” – you will give some medications directly by injecting them into the iv  tubing very close to the IV site. Really high risk, want to know what you’re doing &  how fast to push  Choice of peripheral locations and catheter gauge o Location o Base on   age- adults use hand. Infants use veins in foot  type of solution- hypertonic solutions, viscous solutions, irritating medications, use a large vein to cause the least amount of trauma.   Speed- the faster the infusion rate is, the larger the IV catheter you will need.   Duration of infusion therapy  Presence of disease or previous surgery- avoid areas with scarring or impaired  circulation. o Common sites: dorsum of hand, forearm (best area), antecubital, sometimes upper arm, &  sometimes just where you can find a place to put it.   Foot & lower leg is undesirable for adults because you can not walk with it  (decreases mobility). Triggering reasons for DVT. Not convenient & not safe.   Avoid areas of flexion, antecubital & wrist are two areas you want to avoid.   When considering where to put an IV, start in the most distal location first.   Do not always want to use back of hand, but that would be most distal part to start  at, then work proximally up.  o If you have to restart an IV, move proximally or to other side. o Contraindications- a patient who has dialysis access in their arm, you don’t use that arm. Do  not want to hurt that access for them. Avoid putting IV on same side that a  mastectomy(breast removal) has been done, especially if they removed lymph nodes & things. If there is previous infection/ infiltration/thrombosis in an arm or at an IV site, you  want to avoid that site. o Gauge o Choose IV catheter size/type- choose based on why they are getting it. Size gets bigger while  the number gets smaller. 18 gauge catheter is bigger than 22 or 24 gauge.  18 gauge will be great for an adult getting blood transfusion.  Can give blood through a 20 gauge, but it is not as preferred, it will damage the  blood cells a little  20-24 is the standard IV size for adult.  Routine care and maintenance/nursing responsibilities o Change:  IV fluid containers- when the bag runs out, we are responsible for using correct  technique when hanging the bag.   IV Tubing- changing the tubing on a regular basis. Usually changed ever 96 hours/4  days. At least every 7 days.  ∙ When you put tubing up, Date & time it so which ever nurse is working a  week later can know they are due for a tube change that day.  ∙ Piggy backs need to be thrown away & changed every day/24 hours.   Dressings- we are responsible for maintaining an intact dressing over the site that  will protect it from being exposed to infection.  ∙ Usually will be transparent dressing, that is preferred. It helps us to see the  site, see if there is bleeding/signs of infection, stabilizes the site along with  statlock.  ∙ You will change transparent dressing any time you do a tubing change or  anytime the dressing becomes loose, soiled, or damp.  ∙ It is no longer doing its job. If you can’t use transparent dressing for some  reason, you can use sterile gauze over the site is a second choice. This needs  to be changed every 48 hours.  o Flush locks- if there is not fluid going into it (maybe a saline lock) we need to flush it  according to facilities policies with normal saline.  Also flush before & after medications o Monitor for & catching all complications of IV therapy   IV sites are not changed often, unless you just have to so a complication happens &  we have to remove it. General rule is same as tubing.   Change 4-7 days for both peripheral IV site & tubing.   Complications: definition, prevention, clinical manifestations, and nursing actions  o Infiltration  Tube has gone into vein & we are running fluid through the tube & it comes out of  the end of the tube & through the vein. This is what we want to happen.   When tube pierces the vein & goes into the surrounding tissue that is infiltration.   First thing you see when an IV is about to infiltrate is the rate will slow down, the  dripping will slow. Once it infiltrates you will start to see swelling/edema at the site.  The skin will become tight & shiny. Pallor. “cool, pale, swollen”  First thing you will do: stop the infusion. Turn it off.  ∙ Then take a syringe & try to aspirate or pull back from the site to see if you  are able to get anything out of it. Then you will remove the catheter.  ∙ Elevate the extremity to promote fluids getting out of it, apply compresses  (warm or cool depending on what was going into the site at the time) if you  have to restart iv, remember to go proximally or to the other arm.  o Extravasation  When the iv infiltrated & there was a drug in it & that drug killed the patient’s  tissues because it has gone out of the vein & into the patients tissues.   People have lost their hands due to some medication (like phenegran) infiltrated  with the medicine going into the surrounding tissues.   If you have this, handle this the same way as infiltration, except when you take the  IV out, you check to see if there is an antidote that needs to be given through a  catheter that will help counteract the action in the tissues around it.  ∙ For example Dopamine is a BP med & if this extravasterates then you will  give a medicine to vasoconstrict o Phlebitis Same CMs as DVTs. We have irritation, pain, hardness along the vessel, patient may  complain that it hurts, & sometimes you see a red line going up the patients arm.  Develops at the site. o Thrombophlebitis  when we actually have a clot. Biggest thing to prevent this is secure IV catheter.  Discontinue infusion, remove the catheter, elevate the extremity. Biggest thing  though is prevention. Do not allow IV to stop running & make sure to secure them. o Monitor for complications-   Infection control- local & systemic. Pain, heat, swelling, redness, drainage, purulent  drainage coming from IV site. If you see this & when you discontinue the IV, very  carefully take catheter & drop it into a sterile urine cup & save it because you will  probably send it to the lab & have it cultured.  Bleeding can occur if anything comes loose. So obviously apply pressure at the site & stop the bleeding. Make sure everything is securely connected with your tubing,  tape is there with your securement device, so nothing comes loose.  Say you pull out your IV & when you pull it out instead of it being an inch long it is a  half an inch long. The other part of the catheter is still in the patient. It has broken  off & is traveling through the patient’s blood stream & could kill them.  ∙ Apply a tourniquet above that site so we can slow down the traveling, then  they will have to go to radiology or surgery to have that embolus removed.  ∙ Air can also get into iv systems & cause an air embolus which can also kill a  patient.  Circulatory fluid overload/ fluid volume excess.   Immediate absorption leaves no time to correct errors o Embolus o Infection o Bleeding Loss, Death, & Grief  Loss  Actual losses- losses that we can no longer see something or someone. No longer can hear it,  touch it. o Physical- loss of body partso External- loss of possessions  Perceived losses- something you can not see the patient lost, but they feel it. Loss of a job, self respect. Defined by person experiencing the loss o Psychological- loss of trust, security.  o Internal- beliefs, sense of self, faith, hope, personality  Stages & theories- Use to think patients went through predictable steps/stages of grieving. Really no longer believe that anymore. It is not predictable.  Can be lost within self, lost within environment (like if your house burnt down), relational  (divorce, separation, death, military deployments even though temporary)  Grieving o Normal/uncomplicated grief- what we expect clients to move through once they  experience loss. Its common & universal reaction. o Anticipatory grief- when we know it is coming & can expect what it will be like once they are  gone. o Disenfranchised grief- “get over it why are you upset you have no right to be upset” maybe said  to a mom whose son was shot after robbing a bank. People don’t allow them to grieve. 1. Ambiguous grief- person we knew & loved is no longer with us mentally, but their  body is still  there. 2. Complicated grief- three categories o Chronic- when you are not able to function due to loss o Masked- “I’m so tired I can’t function, no its not grief though” so person is not addressing it,  might be bitter, numb, anxious, but not actually grieving. Masking it with other symptoms. o Delayed- keeping busy to put off grieving.  Palliative care compared to hospice care  Hospice care is not a place it is a philosophy. Can be done at home or facility.  o In order for her to get that, a provider must document that the patient is not expected  to live more that 6-12 months.   Usually 6 months is the cut off.  o Point in which we are focusing on patient & family & their wishes.  o All about quality of life rather than quantity.  o Want this to be a place that family & friends can come, where she is comfortable, & has  as much control of her care as possible.  Palliative care- focuses on patients comfort, prevention, relief, reduction, & control of symptoms. o Not focused on patients who are dying.  o This is for patients with a chronic illness such as COPD where they know they are not  going to get better & have coughs, shortness of breath, & fatigue that goes along with it.  o They may be on steroids & that has caused their sugar to be off balance & poor skin  integrity.  o A lot of problems that are not going to go away, but they are not dying  In both, you only care about patients control & comfort. Priorities are completely changed from  regular nursing concerns. Really focus just on basic nursing interventions like oral care, skin care,  clean linens, positioning, social & spiritual care. Anything to provide comfort.  Advanced directives  Anytime you have a patient coming into any setting you will let them know Advanced directives  (- choices about end of life care) are available to them & they can state what they are. ”do you  have a will or advanced directive” o Include a living will- patients statement of what they want done, what they prefer to  have done if something bad happens to them.  o Can declare DPAHC- durable power of attorney for health care. Instead of saying what  you want done, its allowing someone else to do it for me. Spouse, child, friend. Anyone  you designate to do that. They are authorized to make end of life decisions for the  patient.   DNR- do not resuscitate. Written by provider, says what will be done at the end of patients life.  o May be DNAR- do not attempt resuscitation. What we are headed for is allow normal  death. This is an order sheet given to you from a provider that tells you exactly what to  do if something happens. (patient stops breathing, heart stops) o Always should be based on patients instructions & preferences & if that is not available  then the families. Hopefully from the DPAHC. If patient does not have a DNR, attempt  resuscitation.   End-of-life  CMs  One to three months before death- 90% of changes you see here. o Person will withdraw from world & people. o Sleep increases o Body cannot easily digest food, especially meats. Appetite & food intake decreases. o Anorexia & the resulting ketosis may be protective, as they can diminish pain & increase  the person’s sense of well-being.  One to Two weeks before deatho Cardiovascular deterioration brings reduced BP, pulse, & skin color. o Extreme pallor of the extremities. o Temperature fluctuates and perspiration increases o May experience brief periods of apnea o Congestion may cause rattling sound or nonproductive cough.  Days to hours before death. o Increased periods of sleeping/unresponsiveness o Coolness & clamminess and color changes in extremities, nose, fingers o Bowel or bladder incontinence o Decreased urine output; dark-colored urine o Restlessness or disorientation o Decreased intake of food or fluids; inability to swallow. Becomes dehydrated o Congestion/increased pulmonary secretions; noisy respiration (death rattle) o Altered breathing patterns, breathing is noisy. Apnea, Labored or irregular breathing.   Cheyne-Stokes breathing are all normal. Educate families that these mean the  end is coming. o Decreased muscle tone, relaxed jaw muscles, sagging mouth. All normal & are a part of  the dying process.  Priorities and interventions in care of dying client and family  Priority is Comfort for Hospice patients. Prioritize by patients wishes, they are 100% control. o Pain- if pain is present that will be your first focus. Often will give morphine & may give a lot, more than you are comfortable with.   Sometimes patients want it withheld, respect their wishes.  o Fatigue- everything in the body is dying. All organs are dying, so you will be fatigued.  Turning may become to much.  Help patient to have prolonged, uninterrupted rest periods.   Group activities to minimize work.   Get hospital bed if patient is in hospice at home, bedside commode, portable  oxygen, anything that will help the patient to not have to get up & go far. o Anxiety- people may be afraid of dying, or who they are leaving behind.   A huge discomfort for the patient.   Address the underlying cause. Maybe they want to say goodbye to a family  member, do whatever you can to get the person there in person or on the  phone.   This is a time you give anti-anxiety medicine.   Even if patient gets restless NEVER restrain an end of life patient. o Skin and Eye Care- the basics. Lotion for comfort, lip balm, patients near death breathe  through mouth a lot so good oral care, numbing medication. Patients will sometimes  quit blinking, so give artificial tears to avoid irritation. o Nausea/Vomiting- if GI system stops working, that can produce nausea. if it’s a medicine  or food that’s making the patient nauseated then get rid of it. Be free with antiemetic  medications. o Elimination- does the patient want a Foley? Would they rather have incontinence pads?  Do they want to try to get up & go to the bathroom still? Will have incontinence  developing definitely in urine, sometimes in poop, always want to practice good skin  care to comfort the patient.   With bowel, constipation might develop, give them laxatives, stool softeners,  whatever we can do to make them comfortable. o Nutrition/Hydration o Dyspnea/SOB- really hard for families to see the patient becoming short of breathe. This  is care for the family.   Give morphine, even though opioids cause decreased drive to breathe, that is  not a problem of end of life care.  o Death Rattle- secretions in the airway that you hear when patient is trying to ventilate/  move gases in & out past it. Indication that death is coming within a few hours, a couple of days at most.   Reassure family that it is not distressing to patient.   Give meds that dry secretions up, put patients head of the bed up for comfort,  or put them on their side.   Avoid suctioning in end of life care. Stop oral intake, they really aren't able to  drink or eat anything else.   Nursing actions at time of death o Regulatory requirements o Dignity and Quality of Life  Psychosocial care- treat them with respect. Talk to patient even when they do  not respond. Talk to, not about or around.  ∙ Get spiritual advisor in there, turn music on if they like it.  ∙ Allow patient to talk to you about anything & listen carefully.   Basic Environmental pleasantness- remove smells, keeping linens neat, wipe off  bed side table  Abandonment and Isolation- important to educate family, encourage family &  friends to come & visit. Have them sit at the bedside, they don’t have to talk or  do anything, just be there. o Communication  Remain open- hear what ever the patient has to say to you.   Avoid false reassurance- ”it is going to be okay” does not mean patient will get  better, it just means we are going to stay with you, keep you comfortable, help  you have a good end of life experience.   Don’t avoid sensitive topics- Don’t shut patient down ever. Let them say & talk  about anything they want to. o Don’t “fix” it – patient is dying it cant be fixed. No longer saving patient, just helping  them have a good experience.  o Care of the body o Privacy- minimize what is being seen & said, provide privacy for the family.   Let them come in & stay with body as long as they need to.  Families can participate in post mortem care if they want to.   Sometimes delegate care of the body to nursing tech o Belongings- whether it is something valuable (rings, jewelry, purse, wallet) or maybe the  clothes they came in even if it was a trauma patient & the clothes are torn & bloody,  everything needs to go home with the family or at least given the option.   If there is no family to send it to, you get security to come up there, get a bag,  label in detail everything in there, lock it up, & hope that there will be someone  like a family member to come get it o Clean and position- remove every tube that is in the patient & put a dry clean gauze over the exit site.   Exception: if patient needs an autopsy then clamp off tubes & do not remove.  That is part of the evaluation.   Patient will often be incontinent of urine & stool due to the whole body relaxing.  Clean the patients body’s, preform hygiene care, change the linens.   Place patient supine with pillow under head a little up to prevent a little  discoloration.   Dentures go back in patients mouth ASAP to help maintain facial structure, close eyes & mouth, use a tie to keep jaw from sagging.   Secure arms wrist together to protect the joints & extremities & then place body tags on.  ∙ Tag will be a stamp with all the patient identifiers will go on the body,  often on the toe, will get help to place the patients body into the  morgue bag. We will zip the bag then place another tag on the bag.  Patient will go to hospital ward or funeral home. o Dim lights Care of survivors and caregivers o Care of the survivors- never make assumptions.  o Focus on how the person is reacting, not on how you think the patient should react. o Assess o Meaning of Loss- if you lose the main wage earner, who is going to pay the bills. o Circumstances of Loss- most of the time an anticipated loss Is easier to handle & grieve  over other than something that happened suddenly. Don’t anticipate children to die  before parents. o Support systems and Coping Strategies- do they have good spiritual support/coping  strategies in place so they can exercise & eat well to deal? o Developmental Stage- little ones wont really understand what happened to their mom  or where she went. There will need to be help with that. Different developmental stages  deal with death differently. o Physical Sensations and Behaviors- not unusual for family to say “I still hear her voice, I  can still feel their presence” they are not hallucinating or crazy that’s a normal kind of  thing for patients to go through  o Self-Care- is the family able to dress themselves are they eating turning to alcohol  abusing substances sleeping working too much o Facilitate mourning- acknowledging the way the patient grieves. allow family to help at time of  death if they choose to, allowing them opportunities to talk about loved one. Being frank about  what happened. Say “I’m so sorry, she has died”  o NOT using euphemisms like “she has passed on, she is in a better place” o Some cultures people wait & cry loudly. Some cultures are very quiet & self contained.  Recognize those differences, do not judge them, be considerate Medication Administration 4-6  Nursing responsibilities vs. prescriber vs. pharmacist Nurse  Know the laws & policies of the institution you are working at & the state.  Check in patient’s chart that is it the exact same in MAR. Right drug, time, dose?  Know if the medications are safe, no one will get into them, take them, mix them up, Store them  correctly.  Know medication & how to administer correctly, or use the drug reference book that company  provides for us- best way to get information, so use the pharmacist. Evaluate the medication  before you give medication to see if you should give it  Evaluate- is it doing what it is intended to do?  Know when to say no- if its hand written & you can’t read it, then you call & re-document. Is the  dose in normal range? Is the route appropriate? Always double check the allergies. Is the time  appropriate?  Prescriber- provides the order o All orders must have: o Patients name o Order dateo Medication name o Dosage o Route o Frequency o Prescribers signature Pharmacist- They will prepare it then have some means for getting it to you on the unit, it may be hand  delivered. Get it from nursing unit. There is a small number of unit supply/ stock supply.   Three checks/Six rights Three checks for right medications: 1. You check when you gather it. You check that the MAR matches the order & that the  medicine you get from the drawer matches it as well. 2. Check again when you are preparing the medicine.  3. Do final check right before administering the medicine to the patient.  Six rights of medication o Right Dose o Right Medication o Right Route o Right time o Right patient o Right documentation  Actions of medications: therapeutic, adverse, synergistic, etc. o Antagonist drugs do not work together. If OD-ing on morphine, the antagonist drug you would  give is Narcan.  o Synergistic- when taking two medications together & it increases or diminishes the way the pill  works. Might give a diuretic with a blood pressure pill & they work together to bring blood  pressure down. o Primary- The medicine does what the medicine is supposed to do o Side effects- happens as an effect of the antibiotics on the body. Doesn’t mean we made an  error, it just happens. Not intended, but predictable.  o Adverse effects- not intended effects. Cannot predict that patient will have an adverse effect.  Not an error we made, client may just be overly sensitive to the drug. Often drug will be  discontinued if adverse effects happen. Adverse effects need to be reported to government.  o Toxic- when medication goes past the therapeutic range & gets too high. Can be very serious.  Can kill kidneys, liver, can cause brain damage, & hearing loss. o Anaphylactic- allergic reaction- causes rashes, tons of swelling, blood pressure drops, throat may  close. o Idiosyncratic- an unexpected effect. Something that was not intended. Not necessarily bad or  harmful, but is unique to the client. o Therapeutic Range-range of therapeutic concentration Level-concentration of a drug in the blood serum that produces the desired effect  without toxicity  Components of medication orders o Patients name o Order date o Medication name o Dosageo Route o Frequency o Prescribers signature  Techniques for maintaining medication administration safety   Assess site before administering- BLSSTR- look for Bruising or skin Lesions, Skin integrity,  Scarring, Tattoos, & did you Rotate the site?  After administering- Assess the patient  Report immediately if there are problems with patient or medication  Monitor patient- therapeutic levels, pain rating  Near miss- an event that might have resulted in harm but the problem did not reach the patient  because of timely intervention by a healthcare provider or the patient or the family, due to good  fortune.   Peak and trough levels  Peak occurs when drug is at the highest concentration (when the rate of absorption is equal to  the rate of elimination)  Trough occurs when the drug is at its lowest concentration  Onset- When you give the medication  Peak- The high point of the medications actions  Duration of action- how long the medicine remains in the therapeutic range  Therapeutic level- When the medicine is working  Peak level- highest point in which the medicine will reach. Draw 30 minutes to an hour after  medicine is completely infused.   Trough level- The lowest amount there will be when given a medication. Draw within 30 minutes before giving next dose.  Biological half-life- amount of time for half of the drug to leave the body.  Types of medication orders –frequency, route  Paper- order sheets  Computerize Physician Order Entry- most common.   Telephone/verbal- must be repeated back & student nurses can’t take. o Must document that it was TO/VO o Must come back & sign it either electronically or physically.  Standard medication- “take Tylenol every 6 hours as needed” given until order is changed or  discontinued. Usually on a schedule.  Scheduled- given at a specific time. 8 & 8, before meals & at bed time.  Single- give it one time  Now- as soon as you have it delivered to you, you need to give it to the patient.   STAT- do not wait, stop what you are doing & give it to them right then. This becomes your top  priority.  PRN- give as needed.   Standing order- This is in the gray area. This is where medication is applied to any client in a  situation. This is not specifically ordered for that client, but are ordered because of the  condition/ diagnosis the client has. For example, client is admitted for chest pain. They may have orders on that unit that says “if client is administered with chest pain, give them morphine”   Take o Daily- once a day. o BID- twice a dayo TID- three times a day o QID- 4 times a day o Every 4 hours- usually midnight, 4, 8, noon o AC-before meals o HS- bed time, insulin orders usually o D/C discontinued  Do Not Use Abbreviations  Benefits and nursing concerns/actions for route of administration  o Intravenous o Good for emergency situations o Patient only needs one needle stick. o Limited to highly soluble medications o Poses risk for sepsis because pathogens may be introduced directly into the blood  stream.  o Patient must have usable veins o Inhalation o Quick & efficient local & systemic route through the lungs o May be given to unconscious patients o Allows for continuous dosing, and dosage can be easily modified o Requires special equipment o May irritate lung mucosa o Useful only for drugs that are gases at room temperature o May have unexpected systemic effect when only local effect is desired.  o Eye, ear, nose o Eye- used to treat eye irritants, infections, glaucoma, or to lubricate the eye o For liquid ear medication, make sure to get the liquid to body temperature.  o Nasal decongestants shrink swollen mucous membranes and allow for better airflow &  drainage of mucous. o Vaginal and rectal o Keep patient from ambulating until medication is absorbed.  o Oral/Enteral- can be tablets, capsules, or liquid forms. Advantages- easy & convenient. Non invasive.  o Contradictions- need fast (if Patient has a 10/10 pain an oral pill will not work because  you need it faster than that. If you are NV, you won’t be able to keep medicine down. If  you have an injury or disease in the GI tract, you won’t give this. Make sure patient can  swallow without choking. When giving oral meds, you want head of bed up to 90  degrees. o Sublingual- under the tongue. Cannot eat or drink until after medicine dissolved/ has been  absorbed by all mucous membranes. Can be absorbed quickly. Nitroglycerin is commonly used. o Buccal/transmucousal- can be given if client is NPO, quick delivery. o Topical/Transdermal- Always wear gloves so our skin wont absorb the medicine. Never cut a  patch because it has been made so it will absorb at a certain rate through the skin. Rotate sites  to avoid skin irritation. Placement needs to be clean, hairless, & dry with intact skin. Never heat  because that will cause vasodilation & will increase the absorption. When taking the patch off,  you peel it off (while wearing gloves), take glove off while holding it so it goes inside the glove  you took off & is isolated.o Parenteral Routes-meds that completely bypass the GI tract o Intradermal- under skin. TB test, allergy testing. Goes in at 15 degrees o Subcutaneous intramuscular- under the skin, but not in muscle. 45-90 degree angle. o Intramuscular- 90 degrees into the muscle.  Nursing documentation- document date, time, route, medication given, amount of medication given,  site, & your signature.  Nursing response to med error- fill out an incident report Mobility/immobility 5-6  Assessment of mobility o Body alignment & posture- assess the patients to see if they are symmetric bilaterally  (equal).   Do this vertically & horizontally to see if they are evenly aligned. One of our nursing  goals is the position the client where you will find that balance & protect their body  alignment o If everything is aligned, then you will assess the center of gravity.   Center of gravity means the heaviest part, it should be between the shoulders &  bottom hips.   The center of gravity is going tend fastest to fall/hit the ground. Want to see where  the patients center of gravity is landing.   Wide base support- You want a wide base of support with legs apart & balance, so  when you start to lean it will keep you from falling from side to side. Want center of  gravity it to be as low to the ground as possible.  o Coordination- getting all the pieces & parts working together. This is coming back to your  nervous system & brain being able to perceive the message, send it out to your limbs to tell  the muscles what to do.   Proprioception- sense of self in space. when you hold your (for example) arm up,  close your eyes, & still know where your arm is. You have a sense of proprioception. ∙ If this is lost, you lose coordination & become high fall risk. o ROM- range of motion- Ability of joints to move. o FROM-full range of motion.   Can measure with a goniometer & it will see the angle the range of motions can  bend. it measures if the patient has full or limited range of motion.  Diseases, disorders, & injuries that are effecting their health. o Musculoskeletal- scoliosis & kyphosis- stooped posture, seen often in older woman due to  osteoporosis. whether it is the lateral curvature or curvature of the upper thorax, it will  throw off their balance.   Osteogenesis imperfecta- congenital disease, extremely brittle bones. Causes the  patient to not be able to move.  o Assess your patient for their level of pain & where it is to see if that is keeping them from  moving when they need to be able to move.   Diseases like arthritis that effect the joints, cause them to be less mobile because it  hurts to move.  o Activity intolerance- look at patient & see what they can do without getting too short of  breath, having chest pain, some other problem besides fatigue that keeps them from being  able to move.   See activity intolerance in cardiac patients, COPD, bad asthma, heart failure.  o Injuries- traumatic injuries like bone fractures which causes you to looe the function of that  bone because it is unstable & no longer holding things in place like it was.   Sprains & strains o CNS- strokes, head injuries, Parkinson's, Multiple sclerosis, neurological problems.   In a stroke, some patients lose their ability to move certain extremities, turn  themselves. It could be generalized weakness that is causing the inability.  Effect of exercise/immobility on body systems  Exercise-   Cardiovascular- cardiac output increases with exercise.  o This helps the heart to become stronger. Stronger= greater contractility o Increased contractility means increase output. Allows your heart to beat less frequently, but  stroke volume will stay the same.  o Maintaining Venous return -when you are walking the muscle in your legs will help pump the blood back up (assuming that we have competent valves) o Low to moderate exercise will be very effective in lowering BP in patients with hypertension  Pulmonary- when you exercise, RR goes up. If you do this often, it comes back to a resting rate very  quickly.  o Improved alveolar ventilation- you are getting air down to the alveoli better. This will  promote diaphragmatic excursion. If the diaphragm is out more, then the breathing is  increased. This increases negative intrathoracic pressure which allows you to able to take a  deep breath better. Metabolic- when you exercise you use the glucose in the fatty acids more effectively. Inactivity is a  risk for type two diabetes. o Caution- diabetic patients would change their activity level & stay on the same amount of  insulin or other antihypergylcemic drugs, & you would see their blood sugar drop.   You will see a boost in insulin production because you have a boost in the glucose  metabolism.   Need to be careful that these patients don’t become hypoglycemic when they  change their exercise routines.   Musculoskeletal- if we are going & doing weight lifting, we will increase muscle tone, increase joint  mobility, maintaining flexibility, building tolerance (activity tolerance), so the more you do the more  you will be able to do.  o When we are walking & doing weight bearing exercise, we are reducing bone loss.   Psychosocial- exercise reduces endorphins. Tolerate stress better, & have an increased mood.  Immobility, Nursing assessment/clinical manifestations for each complication of immobility &  Nursing interventions to prevent and/or treat each complication of immobility  Respiratory o Atelectasis- alveoli cannot maintain inflammation which causes them to collapse, then they  are not able to get the oxygen into them to be able to cross the alveolar capillary membrane.  Maybe because the patient is hypo ventilating, lots of pain medications that reduce  the RR, secretions.  Clinical manifestations- decreased lung sounds, diminished or absent. Decreased  pulse ox. Increased respiratory & heart rate. SOB (objective), Low grade fever  developing,   if you identify it early, then you intervene, then you may be able to stop & turn it  around before it becomes a full fever.   Patient will be pale, restless, anxious. Diaphoretic (sweaty). Increase use of  accessory muscles to help, sternal retraction.  o Hypostatic pnemonia- If we have a patient lying flat in the bed with hypounderstatic moving  (not moving well) & that can get them in a pneumonia situation because of the fluids  following gravity & landing where the gravity will land on the patient.   If patient is lying flat, it will be on the back of their thorax.  Productive cough, high fever, crackles, wheezing, low pulse ox, decreased RR, heart  rate, dyspnea, anxiety, restlessness. BUT with the pnemonia, you might see fever,  WBC elevation, & Purulent looking blood tinged cough.  o NI- help patient turn, cough, & deep breathe. Turn at least every 2 hours, encourage to  cough (tell them to take a big deep breath in, hold it, then forcefully cough it out 10 times an hour).   Incentive spirometer.   May need chest physiotherapy to mobilize secretions so they can go into the central  airway so they can cough it out. Hydration (answer that’s almost never wrong) 30- 35 ml/kg/day. 2700-3700 ml/day fluid intake.   Cardiovascular o Increased cardiac workload- If you have a patient on bed rest or immobile, or have a chronic  health problem, their cardio workload is going up, it has to work harder.   This is because they lack the venous return flow from the skeletal muscles. The heart is doing all the work of moving everything through the body.   CM-heart rate goes up, edema, patient may have chest pain & heart failure.   NI-  ∙ we will make sure they know they are not going to take a big deep breath &  bear down. Make sure you tell them to continue to breath when they are  pooping or turning over.  ∙ Valsalva- decreased venous return that is released, then the heart rate  drops, then the patients have cardiac arrest o VTE- venous thromboembolism- clots in legs mostly develop in  lower extremities (DVTs) then thrombus becomes an embolus.   Causes 10-25 hospital deaths. Nurses responsibility to  prevent as much as possible. 90% of pulmonary emboli start in lower extremities ∙ Mobilize & anti-embolic exercises- want to get patient moving as much as  possible. Foot exercises (dorsiflex, planter flex, dorsiflex, etc. ) 10 times an  hour while awake. Ankle circles for an entre commercial. If they are able, do  knee flexion. Keep blood from pooling.∙ Increase venous return when patient cant get up & walk by using most of  the time SCD- sequential compression devices.  o A sleeve. It is under the patients leg, then wraps the leg, up & over.  The tubing connects to a machine that will compress the legs from  the ankle up. Causes venous return.  o SCD- request on if there is not one ordered.  o Tedhose- white hose that you pull up smoothly to cause  compression to increase venous return. Not used. Both need to be  removed every 8 hours to do a thorough skin assessment & make  sure the patient isn’t developing pressure ulcers & that the skin is  intact underneath.  ∙ Also assess for the 5 p’s of ischemia: pain, penial pulse, pallor,  paresthesia(decrease sensation), paralysis  o If you notice the circumference of one calf is much larger than the  other, you will measure 10 centimeters down, get tape measurer &  do circumference around the calf, look for your warmth, pain, & do  not continue the SCD. ∙ Positioning- we do not ever put something behind the popliteal space. If you need to elevate the feet to promote venous return, you will not put a pillow  under there to do that. it cuts off blood flow. Don’t let patient cross legs, do  not massage. ∙ Anticoagulation- have an order for an anticoagulant to decrease the risk for  DVT. when you brush teeth, look for bleeding from the gums, stool, urine,  “coffee ground” NG tube output means blood is in there.  o Moniter incisions & wounds for bleeding. ∙ Orthostatic hypotension- change positions slowly, assess patient carefully  when you move them from lying to sitting, check vital signs, ask if they feel  light headed or dizzy  Thrombus o When blood sits, it starts to clot. It is stasis (not moving) because your body is not moving.  Then, It has the opportunity to clot.   Lying flat on a mattress, if you haven't turned well you have compression on your  legs, which narrows the vessels & causes them to slow downo Thrombi/clots develop on the wall of the vein. If they want to travel, then they become an  embolus.  o Thrombus is a clot then you can get can inflammation/irritation of a vessel & that will be  anytime you see –itis.   Thrombophlebitis- vessels are irritated, swollen.   CM- pain, achy, tender to touch. Warmth. Depending on where the blockage is, you  may have pallor, but generally you will have an increased redness that may be  generalized or over that one area. Swelling.   Use a tape measurer to measure the Circumference of the calf on each side by going 10 centimeters down from knee.  ∙ If you see an unequal circumference, then you will need to let someone  know because you could have a thrombus that developed in the deep vein  of the lower legs.   Homeostein test- do not do anymore, developed in 1941. used to see if there is a  thrombosis by having patient dorsiflex their foot, & if it hurts that means they have a clot. Poor predictor  Orthostatic hypotension o When patient goes from a supine to a sitting to a standing position & the BP drops. The 10  mm drop or more in the systolic blood pressure when patient comes to an upright positon.   Systematic components, so the patient will have dizziness, light headed, feel like  they will pass out.   When you are lying flat in the bed, you have venous pulling so the heart doesn’t  have a lot to work with when we change potions, but the baroreceptors/pressure  receptors in the body forget how to work. The brain & other receptors throughout  the body forget how to tell us to increase vasoconstriction. ∙ May see reverse Trendelenburg a few times a day until they can tolerate  being upright again. o When you have orthostatic blood pressure to treat, check HR & BP with the Patient lying flat, then have them sit & dangle & check it again, then have them stand up right & check it  another time. Then you will compare the BP to see how they are doing with it. If they stand  up & feel like they will pass out, have them sit back down & document they failed their  orthostatic. Patient safety first.  Musculoskeletalo Problems in the muscles   Muscles atrophy.-Disuse causes the muscle to get smaller, lose tone, get flabbier.  Joint contractures ∙ foot drop- if you take your calf muscle & tighten it, your foot will go down. If  these muscles start flexing & contracting in the back of the calf & they start  to pull down then you are planter flexing long enough it will freeze there.  ∙ Then when you are healthy & out of bed, you will not be able to planter flex  or bend foot back up & you will only walk on toes. o Skeletal  Specific to the bones, disuse of the bone will cause it to thin due to losing calcium.  ∙ Calcium could go into the blood stream, then you may see hypercalcemia in  the blood stream.  ∙ If the kidneys are working it will regulate that but you will end up with an  overall loss of calcium & weakening of the bones.  ∙ This results in a pathological fracture.  Pathological fracture- happens because the patient has such weak, thin bones they  are breaking at the drop of the hat for no good traumatic reason.   Urinary elimination o Patient is lying supine, gravity will cause urine to be pulled at the back/back of bladder. If we  don’t constantly move & get some upright, we will have trouble voiding.   Where we have pulled urine, we have a risk for infection, or a UTI.  ∙ CM for UTI- dysuria (painful urination), burning, urgency, frequency,  urinalysis may have some WBC, RBCs, Bacteria.  o Because of that pulling of the urine & we have dumped a bunch of calcium from the bones  into the system. We may have a patient that developed renal calculi or kidney stones.   Nightmarishly painful. This patient will have flank pain, usually very acute, sharp,  nauseating, make you pass out pain.   These look like little pieces or barbwire & they move through your little tiny ureters. Complication of immobility, severe pain as it moves, when it is not moving it doesn’t hurt, patient may have blood in their urine, then really severe pain. Sometimes urine output will drop if its blocking off the ureter & you can get kidney damage.  GI Elimination o Constipations- when you don’t move you get decreased peristalsis & you get constipated.  o Another reason immobility causes constipation- hypercalcemia which decreases peristalsis.  o Paralytic ileus- peristalsis is not happening, so you the GI is not working properly.   CM- decreases bowel movement, no bowel sounds/ hypoactive bowel sounds,  beginning to get bloated, gassy feeling, nausea, anorexia. If the patient is anorexic  then they are not eating well due to decreased appetite which will make it worse by  decreasing the nutrition. o Protein resources drop then the muscles cant repair then wounds cant heal, can be a big  deal. o Pseudodiarrhea- patient who is immobile is at high risk for constipation which then can turn  into a fecal impaction, & when you see a drop in the normal bowel movement you see a  little bit of oozing of the lose stool around it  not really diarrhea, it is really an impaction that is developing & can lead to  complete bowel obstruction & can be life threatening. o NI- Look for abnormal (dark orange, brown, cloudy urine), this is where we get urinary stasis.  Urine is pulling & by the time it comes out it looks crummy & like maybe it has urea  or ammonia break down.   Want to monitor color & clarity.   Increase PO intake cranberry juice because it acidifies the urine which decreases the  probability of it getting infected.   Check intake & output every few hours, goal is to have positive intake. More in than  out.  2700-3700 ml intake a day. Assist patient to void frequently, offer bed pain or  assistance to the bathroom.  Keep patient from getting constipated by giving them fibers, fluids, stool softeners  Integumentaryo When you exercise, you increase metabolic rate, appetite, so you take in more nutrients.  o When you are immobile, your body will start to have a decrease in energy reserve. Then we  also have GI stuff going, nausea, not a healthy appetite, peristalsis is slowing, our overall  intake has dropped.  o Not taking in enough protein, when our body takes in protein & the end product is nitrogen.  When your body does not have enough nitrogen it will not be able to build back up through  the amino acids through the protein & be able to heal a wound, build up the muscles.   A negative nitrogen balance can develop & our patient can have a terrible hard time  getting better.   Mobility=positive nitrogen balance.   CM of negative nitrogen balance- atrophy, muscle wasting, weight loss, decreased  activity tolerance, if they have a wound, it will not heal properly.  o High risk for pressure ulcers due to not moving. o NI- assess skin every couple of hours, once a shift you will do full assessment, hygiene, turn  them every one to two hours,   high protein, calorie, & vit B diet  Psychosocial o Sensory deprivation- we are not getting stuff coming in. no music to hear, no family visiting,  no stimuli to get us awake & interested & hopeful about life.   Maybe you cant read, cant work the remote to control the TV o Sleep alterations develop easily because your routine is getting messed up. You do not have  the waking triggers because you are up & moving & going & doing, then your sleep triggers  are the end of the day activity & you are ready to sleep.   Sleep alterations develop then you develop sleep problems.  o Depression- patient cant cope, lose normal coping mechanisms.   Be aware: you walk in say ”hey Mr. so & so how are you?” & he throws his tray &  says get out of here, I’m sick of being here, I don’t want to see your face again” ∙ It is not directed at you, it’s the psychosocial result of immobility.  ∙ he is frustrated/angry & cant run 3 miles to burn off that steam & anxiety. ∙ Maybe you will see inappropriate giddiness, laughing inappropriately, all  kinds of emotion changes, but most often it will be anger directed at us. So,  see if there are changes you can make in their environment to help them.  Usually you see this building up.   However, if they have an abrupt change, there will usually be a physiological reason  for that, look at blood jitters, oxygen levels.   NI- prevention.  ∙ Encourage family & friends to come visit. Encourage them to come at meal  time.  ∙ Put a clock in the room where the patient can see it, open shades so they  can know its day time, put a calendar on the wall.  ∙ Update white board with date & nurses name. ∙ give the patient as much control as you can with the patient’s decisions. If  they can choose food, which way they want to turn, let them.  Metabolic o make sure patient is getting a high protein high calorie diet to prevent development of a  negative nitrogen balance.   Protein 1-1.5 kilo per day, or enough to maintain a positive nitrogen balance.   Calorie intake – 35- 40 kilocalories/kg/day.   We need vit b from proteins & c from fresh fruits & vegetables.   Promoting bone health and exercise  Encourage exercise o Flexibility- maintaining ability to be able to move in as many directions as our joints will take  us. Stretching, maintaining the ROM & preventing injury in later exercise o Resistance- lifting weights, pushing foot against foot board of bed, building muscle mass,  endurance, & strength. o Aerobic conditioning- getting heart rate up, increasing the respiratory rate, & promoting the  cardiovascular & pulmonary components of health. o Encourage any amount the patient can do, a little is better than nothing. Build on that,  encourage them, & have them build up on that.   Recommendation- 150 minutes a week of moderate intensity between 3-5 days.  Encourage people to use their ADLs & IADLs to get some exercise & increase heart rate.  o Park at the back of the parking lot & use those extra steps to be able to get in a little  exercise. Take stairs instead of elevator.   Teach bone health- after age 30, we lose bone health & density. Once females hit menopause, the  bone density really drops.  o We develop osteoporosis, decrease in bone density.  o Risk factors- post menopausal, schizophrenia, genetic predisposition, nutrition, previous  fractures, small body frame, shorter people, low Vit D, inadequate calcium intake, smoking,  excessive alcohol use, not moving/being sedentary.  When you look at a patient, you can tell they have low bone health when they have  kyphosis, sometimes you see the vertebral Colum collapsing.   Encourage patients to have bone scans, DEXA scans to be able to get a reading to know if they have  adequate bone density.   Best treatment- prevention. Continue weight bearing activity, adequate calcium intake, take in 800- 1000 iu daily vit D, 1200 mg calcium per day, stop smoking, moderate to no alcohol use.   Preventing injuries when moving patients/lifting & Nursing decisions/considerations when moving  patient  o you will have designated lift teams in the places you work. So when you need help lifting  that person will know they are “on call” for it that day to help.   You may get someone who is small, big, or anywhere in between, there is different  amounts of lifting going on due to the different amounts of abilities between the  team.  o Want to assess how much the patient can help. Some can not move at all, some can at least  lift their head, or they can at least cross their arms (so we are not worried about them  grabbing a hold of something & creating more work & more risk for damage when lifting.  o Assess whether the patient will help when they get there- sometimes patients panic when  they start to move & are terrified they will fall, so they can help but they will not.  o Get plenty of help to make sure you have full patient safety.  o Use a mechanical aid to do the lifting. This is the new standard of care. Something like a  Hoyer lift, something that will mechanically do the lifting for you.   Ambulation safety – controlled fallo If patient feels dizzy & feels like he/she is about to fall, don’t ever try to catch the patient,  use a wide base of support & slowly help them slide to the ground without actually falling &  injuring the best we can.  o Best to try to prevent falls by letting patient dangle at bed side long enough & measuring  orthostatic hypertension.  Correct use of positioning aids (trochanter roll, etc.) and assistive devices o Abductor Pillow- edge shaped pillow between the patient’s legs, used to prevent internal hip  rotation and hip abduction. Used after femoral fracture, hip fracture, or surgery. o Trapeze bar- Triangular- shaped device that is attached to an overhead bed frame. The patient  can use the base of the triangle as a grip bar to move up in bed, turn, and pull up in  preparation for getting out of bed or getting on & off the bed pan. o Trochanter roll- made from tightly rolled towels, bath blankets, or foam pads. They are placed snuggly adjacent to the hips & thighs to prevent external rotation of the hips. o Canes  Single-ended cane with a half-circle handle- for a patient who needs minimal  support and is able to negotiate stairs.  Single-ended cane with a straight handle- for patients with hand weakness with  good balance.   Multipronged cane/quad cane- 4 feet to it. Patient will use cane on strong side. The  cane goes forward with the weaker side to promote a balance. It should fit at the  top of the hip with a 30-degree angle flexion o Walkers   should be at hip level, with 30 degrees of flexion.  o Make sure patient stands within the walker, not behind it.   So when the walker goes forward they are not leaning far forward & the center of  gravity isn’t shifting too far forward causing the patient to fall.   The walker should ideally be lifted & not scooted, lifted then stepped into.  Tennis balls/wheels on walkers have the advantage of decreasing friction & work but the disadvantage is an increase in fall risk. Crutches – all gaits o Two point- partial weight bearing, use both feet. This is faster, but offers less support than the  four point. The foot opposite of the crutch goes forward, so advance left foot along with right  crutch, then right foot along with left crutch simultaneously.  o Three point- non-weight bearing. Faster than a four-point gait. Can use with walker. Injured leg  must be kept off the ground. Advance crutches, then advance good leg. o Four point- Partial weight bearing, use both feet. Patient must shift weight constantly. Offers the  most support, but is also the slowest. Patient will advance the right crutch, then advance the left  foot. Then advance the left crutch, then advance the right foot. This is not done simultaneously.  Nursing Process 3-4  Purpose of the nursing processo To form a database.  o Nursing assessment- gathering information about a patients physiological, psychological,  sociological, and spiritual status.   Gathering and interpreting data o Primary- from patient. They give subjective information, which means they are telling us  their perception of things. We see objective information from what we observe about the  patient & doing a physical examination. Start with vital signs, listen to lung sounds, heart  sounds, pulse, assess skin. o Secondary- not directly on the patient. Information may come from family or friends. Also,  comes from medical records & healthcare team.  Purpose of a nursing diagnosis (vs. medical diagnosis) o Medical diagnosis- describes a disease, illness, or injury o Nursing diagnosis- identifies patient response to health problem. Involves the individual  patient.   Types of nursing diagnoses and interventions o Actual-describes human response to actual health conditions or life processes. You see it  happening. o Risk- describes human responses to actual health conditions or life processes that may develop.  something that may happen o Health promotion- identifies motivation, desire, and readiness to enhance well-being and  actualize human health. o Syndrome- a cluster of nursing diagnosis occurring together and treated using similar  interventions. Two or more nursing diagnoses are defining characteristics.   Correct statement/format o Nursing diagnosis (actual and risk) o When writing nursing diagnosis you write NANDA-I definition, state related to factor,  then AEB. o Use frameworks  Maslow- triangle with most important things at the bottom.  ABCs- airway, breathing, circulation  Safety/Risk reduction- what is going to keep patient safest & reduce their risk?  Least restrictive/least invasive  Acute/ Chronic- prioritize acute over chronic problems o Always consider what is most important to the client. o Outcomes/Goals o Goals-long term or short termed, usually a broad statement. Think opposite of the  diagnosis. “Patient will” o Then you give expected outcome. This is a measureable criteria to evaluate goal  achievement. This is patient centered. SMART= singular, Measurable, achievable,  realistic, timed.  o “Patient will state pain of 3/10 or less within one hour of pain intervention” o Implementation (interventions) o Interventions- always start with action verbs & tell us what we are going to do. Get from  ANA, QSEN, which tells us what acceptable nursing interventions are for different things. Or clinical practice guidelines which are policies put on you by the employer. Never get intervention from someone that does something just because that’s the way  they do it.  Types of interventions 1. Independent- go in room & do it myself as a practicing nurse 2. Dependent- you need a prescription for it. 3. Collaborative(interdepentent)- when you work with someone else on getting the patient better.  Usually a wound-oscopy nurse, physical therapist, or registered dietician 1. Start with nursing action, then state the frequency, quantity, and method. Check to see if it  states a feasible action, remain evidenced base, considers patient preferences. ** interventions must impact your related to’s &/or your AEBs In risk diagnosis, it just has to eliminate the risk. o Evaluation  o Evaluation happens all along the way.  o Think- did the client achieve the plan or expected outcome? You should be able to draw  an arrow back to your outcome statement & say if you did it or not. o Where the goals/ outcomes achieved? Completely or partially? o How does the client feel about it? o Then revise plan based on whether or not we are making headway.  Nutrition & Enteral Tubes  Assessment findings (physical, labs, psychosocial) and risk factors r/t nutritional intake  o Food security - all household members have access to sufficient amount (enough food),  safe (not gone bad & you can still eat it), nutritious food to maintain a healthy lifestyle &  it is available consistently, not just at the end of the month when we get to go get fresh  fruit & vegetables while we have some money.   If the client is unable to prepare their food, make sure we find out who is  preparing their meals for them. Maybe it’s a family member who isn’t willing to  accommodate nutrition problems  o Ideal body weight- how much the patient should weigh based on how old they are,  whether they are male or female, & their body frame.  o Skinfolds- measurement that helps you to measure exactly where fat distribution is.  o Circumferences- use a lot as nurses. Look at patients body outline. Where is excessive fat located  So you can look at the girth (abdominal fat)  Increased abdominal fat means that your client is at increased risk for  hypertension, diabetes, lipid problems, cardiovascular disease, we are getting in  to all kinds of metabolic disorder problems that we will fight with our clients all  the way through.   This is going to measure the waist measurement & compare it to the hip. It  makes a waist to hip ratio o BMIo Recent changes- greater than 5% in 30 days or greater than 10% in 180 indicated a  problem. o Their dentition- can they eat? Look at teeth & see if it needs work with the dentist, oral  surgeon, or check their dentures to see if they are properly fitting  o Bowel function- ask the clients about problems like constipation or diarrhea. & any  history of bowel diseases (Chron’s disease, irritable bowel syndrome, malabsorption  diseases) o Diseases & meds- if the client is on ADD meds, their appetite may be suppressed.   Some meds like contraceptives & antibiotics cause nausea  o Culture/ethical/religious influences-   Ethical- maybe your client has chosen to be vegetarian, maybe an ethical choice  or may be related to religious expression.   Religious-  ∙ Fasting during Ash Wednesday-good Friday, maybe if your patient is a  practicing catholic. ∙ Ramadhan- if the patient is celebrating this, then during the time of  Ramadhan, they cannot eat or drink from sun up-sun down for about a  month.  ∙ Buddhism can encourage vegetarianism. ∙ Muslims & some practicing Jewish clients may avoid pork in their diet.  Some clients will avoid caffeine intake ∙ Baptist/Christian background may not drink alcohol at all. o Anorexia o Bullimia o Dysphagia o Physical assessment findings:   Listless, apathetic, fatigues ∙ Doesn’t care about things, does not have energy to care about anything.  Pallor- look in the mucous membranes & see if they are pale looking.   Muscle wasting & poor tone- muscles are not there. Thin, stingy feeling, poor  tone means they are floppy, not good solid strength.   Little SQ tissue  Stringy, brittle hair  Rough/Dry skin- skin looks scaley Brittle or abnormally shaped nails  Burning or tingling- lack of B vitamins causes burning & tingling  Tachycardia o Lab values  Albumin- means it’s a chronic problem   Pre-albumin means its an acute problem  Hemoglobin- M- 14-18 g/dL F- 12-16 g/dL  Iron & TIBC- look at oxygen carrying capabilities in the actual blood stream  Glucose- 74-106 mL/dL  Hemoglobin A1C- this is a long term test to see if diabetic patients have their  sugar managed well. Long term glucose control in client  Obesity care and concerns  o balance intake. Need to have nutrient dense foods, vegetables & beverages o Limiting certain kinds of fats to less than 10%  o Limit sugar, salt, and alcohol. o Support/ encourage clients to: o Weigh regularly/weekly, not daily. Weekly is good because you will see some changes, & not try to get on the scale everyday, because that is discouraging. o Eat Healthier foods- Some cant work, so they wont join the Y or weight watchers because they don’t have money to do so. If they can get to even the library to get on the internet,  have them look at the super tracker. The super tracker is something the government has  put out there & it is free & it Is a way that will helps clients develop a diet & have them  track what they are eating with a weight loss goal in place.  o As nurses, we have to know what these ”bag of tricks are” because if the patient needs to  lose weight we cant just say “you need to lose weight why don’t you go on weight  watchers?” & they cant because they cant afford it. Need to have many resources to help  our patients.  o Exercise-even get up out of chair, turning yourself in bed, anything is better than  nothing. parking at the end of the lot to encourage walking. o Sleep- all the chemicals that start kicking out in your body we start misinterpreting that  we are hungry when we are really sleepy. As nurses working the night shift, you will see  people gain weight  o because your body is tired & needs sleep, but your body is misinterpreting that  with lectin & all of those chemicals that will come out as needing to eat instead. o Keeping a food diary can often be a good way to kind of actually realize how much you  really did eat during the day, may be more than you thought it was.  o Be there to support your client, help your client know that it is normal that they gained a  couple of pounds or that they haven’t lost weight in a couple of weeks. The setbacks &  plateaus are normal. o Don’t let that get them to give up.  Nursing actions for food/fluid intake by mouth o Promote normal nutritional intake  General environment- make the environment more pleasant. Remove the  emesis basin from the bedside. Get rid of odors, wipe things down.  Food presentation- give hot food hot, cold food cold.  Small frequent meals- eat 6 small meals instead of 3 regular meals  Decrease fluid intake with meals- if you drink when you eat you might feel fuller.  Encourage the patient to drink between meals instead of during.  Social aspect- encourage family to come during meal times, want to make eating as enjoyable as possible.   Nausea- give nausea medicine 30-45 minutes before meal time to suppress the  nausea as much as possible to increase the appetite o Assist in feeding  Positioning- 45 degrees or more, as close to 90 as you can get.  Flex- have neck down because it is easier to swallow this way  Thickeners- the thicker the liquid is, the less likely the patient will be to aspirate.  These make it easier for the patient to swallow correctly & keep it from going  into the airway.  Time- allow as much time as needed for the client to finish their food.   Suction availably- basic safety, have handy just in case patient does aspirate &  you need to suction it out.   Therapeutic diet contents (all from NPO/clear liquids to “advance diet as tolerated”) o Clear liquid diet- Anything on this is diet is anything you can hold up to the light & more  or less see through.   Tea, Broths, coffee counts, sodas count, jellos because at room temp they are  liquid & you can see through them. They have low residue, not much fiber.   Room temp, it goes back to their I&O rule, these would-be liquids at room temp.  popsicles are good too.   Hard candies may be allowed, because they aren’t taking much in they are just  sucking to keep their mouth moist.   No dairy, & no pulp juices because we want minimum residue on this diet.   Once our client can tolerate this well, they will advance to a full liquid diet. o Full liquid diet- patient can eat everything on the clear diet, plus things like some cream  soups, dairy products (milk, ice cream), nutritional supplements (protein drinks,  breakfast drinks like ensure), pureed vegetables if they are thin, but you are looking for  fluid consistency.   So if it’s a cream soup, it will be strained or pureed. It will not have chunks of  food in it, it will be liquid that you can drink.   Frozen yogurt is a good one.   Sometimes you will see cooked cereals like thin malt oatmeal or cream of wheat  types of things. Neither of these diets will supply all the nutrients the client will need, so we  want to advance the patient back toward normal eating as fast as we can. o Mechanical/Soft- client may have this ordered.   Mechanical means that they cannot mechanically chew on the food, so this will  be a client who doesn’t have a lot of teeth left or cant chew well, maybe for  neurological reasons.  Soft diet could be not liquid, but still things that will not take a lot of work for  the patient to chew. Eggs, soft cheeses, soft breads. Sometimes like your baby  food. Mashed potatoes without the skin. These are very similar & often ordered  in one phrase. o Low residue/low fiber diet- usually someone with scaring/ scar tissue/ blockage In the  intestinal tract, or diverticuli (a little pouch that sprout out from the intestine) & it is  really easy for things like popcorn, nuts, seeds, to get stuck & trapped in there, then it  gets inflamed & the person ends up with abdominal pain. These are some reasons that  the patient might be on a low fiber diet.  Examples that don’t have a lot of fiber- white bread, cooked pasta, potato's with  no skin, white rice. Avoid raw fruits, vegetables, nuts, seeds, whole grains, &  hopefully this will pass on the through the GI tract with out any trouble.  o High fiber diet- patient is probably constipated. Anytime we talk about a patient whether its electrolyte imbalance, or immobility, think about increasing fiber in the diet which  you can do independently. You may have this ordered though.   Our goal is 20-35 grams of fiber a day.   Lots of whole grains, raw fruits, dried fruits, brown rice. So if you are increasing  fiber in the diet, you want to be careful & not just dump stuff on it really quickly.  You just want to do it little by little to avoid cramping.   Give them lots of water to go with it.  o Renal- on a renal diet, based on what we know about what renal failure causes, what do  you think would be limited in the renal diet? Limit salt, potassium (really important to  limit this), phosphorus, calcium, protein because byproducts will start building up that  the kidneys cant filter for us. o Fat restricted- low fat diet. No butters, dairy products. We see clients with terrible  cholesterol who need to watch their butters & fats, need to stick with lean meats instead of full beef kind of diet. Animal products, eggs, cheese. o Carb consistent- diabetic patients. We will need to find a balance in the amount of  carbohydrates they are taking in every meal compared to whether the body is providing any insulin or if they are completely insulin dependent. Just balancing the intake for  those patients or who is glucose sensitive.  o Regular diet- if your patient has a regular diet ordered, they can eat anything they want  to eat. So if the patient wants 5 guys, that fine. There is no restriction. o An order we will see is “advance diet as tolerated” so maybe the patient has been NPO,  & we are ready to have them work to be on a regular diet. Ask patient how does your  stomach feel, are you cramping, having nausea? Do you feel full fast like you are going to throw up when you had too much food to eat?   Assess patient, first thing you usually start with is ice chips. Just start with a few  bites of ice chips, then as that is tolerated you go to clear liquids, then full, then  hopefully you can move fast to a regular diet from there. Mostly based on  nausea & vomiting & then the other signs of comfort, like being bloated or gassy. That kind of thing  Nursing care in enteral feeding Enteral- Patient is receiving their nutrition from a nasal insertion, surgical tube, or percutaneously. o Now we are looking at a client who is not able to take food in by mouth but not able to  chew, swallow & get the the food into the body, but everything in the GI tract still works. The stomach, intestines, absorption, digestion, still has to function for this to happen.  o this is a patient with severe dysphagia who cannot swallow safely so we need to bypass  the swallowing area.  o Neurological problems like Parkinson's, stokes, that type of thing.  o Maybe they had surgery, facial trauma, or had to have oral surgery of some sort, burns,  some kind of injury to the mouth or upper airway.  o Sometimes its an indication of really severe depression, so the client simply will not  accept being able to eat. o Thing that we will do at the bedside/ assist most commonly with as far as the insertion  technique is Nasal insertion  Nasal insertion will go through the nose, either into the stomach or into the  stomach then expected to flow on in just right to the very next part of the  intestine, into the J-genial area. Its either NGT-nasogastric tube or  nasointersinal.  o G tube- gastrostomy tube, or J tube which is a jejunostomy tube which is both put in by  surgical procedure.  o Third big category-the tube is place percutaneously (by skin). Several ways this is done,  client is sedated, & they will often put a scope down the mouth & into the stomach &  often illuminate it so whoever is inserting will be able to see the bright scope & right  where it is on the abdominal wall, & then they will put a hole in, the tube will be inserted, & have placement exactly situated while they are in there with the scope  looking down this way, & getting it secured on the outside.   It is done coming through the skin & it is a procedure, not a surgery technically.  o Nasal insertion of the tube- may have an order to insert/put down a small or feeding  tube (small or, just the size is tiny) or it may just say to insert a feeding tube, then you  will have leeway as to what you use.   This is done by clean technique. You will go in through the nose, into the gastric  system.   If you are inserting through the nose aiming for the stomach you are going to  measure from the tip of the nose, to the tip of the ear, then to the xyphoid  process. You can mark where that is on the patient & know that once you’ve  inserted it that far its in the right place. Important for checking placement.   This can be done by the nurse at the bedside, for a while we stopped letting  beside nurses do it as much, but you still may work at a facility where specially  trained nurses will insert tubes at the bedside.   Sometimes they will go & insert it under thoroscopy(google) to be able to see  exactly where they are going, so that would be a physician doing it in a  procedure lab somewhere in the hospital.  CHECK PLACEMENT IMMEDIATELY AFTER INSERTION BY X-RAY  Enteral feeding care o First, you will always check the placement.   Aspiration, pulling back with the syringe, & checking the pH is a good way to do  it, if there is no feeding going into it & you aspirate through the stomach, the pH  will be low because of all the hydrochloric acid. So if you aspirate & you check  the pH paper at the bed side & its less than 5, you can be pretty sure its in the  stomach. If they are over 7, you may be looking at the pH from the lungs, but  the intestinal pH can run at about 6.5 or so.  ∙ So, in addition to pH you may want to look at the color of aspiration, &  see what color you are pulling back from it.  ∙ We expect it to be mucous-y & very light white in color.   Bottom line the best thing we have to check placement at the bedside after that  initial x-ray ongoing placement is to look where it is on the nose, because it will  be marked where we inserted it & we secured it really well if it hasn’t moved &  it is right where it should be, & the patient hasn’t had any reason like maybe you were worried the tube got pulled on or maybe you were worried the patient vomited & misplaced the tube, or they are coughing really hard or have been  suctioned, those are all reasons the tube may have moved & we should be more concerned about it.  ∙ But based on the fact that the initial confirmation of the placement was  done & none of those things have changed/none of those things have  happened, then we can go forward pretty comfortably that the tube is in the right place.  o Type of feeding  Make sure the feeding has a balance of your carbohydrates, proteins & fats, &  lots of vitamins & minerals added into it.  ∙ But obviously, your clients GI tract has to be completely functional to  tolerate that. They can’t have any absorption issues or anything.  ∙ Patients who are really sick may have all the proteins & carbohydrates  broken down into the element forms/ CHO’s, the amino acids, the small  pieces of the nutrients because the clients body cant do that for them. It is easier for the small valve to absorb at that point.   Be super careful about whether it is a specialty diet or not. High protein for  burns/terrible wounds that are not healing. Renal with sodium, potassium,  nitrogen limited. Respiratory, fiber & diabetic alterations. So if you have a tube  feeding hanging, make sure you are continuing with the right one, whatever the  bottle it is that it says.  o There are three routines we use to administer the tube feedings  Continuous- it continues running hour after hour at a certain rate (35 mL/hour)  Intermittent- Let gravity do it. Hold up the end of the feeding tube, flush the  tube, pour in the feeding, & let it flow by gravity, let the feeding run through,  flush the tube again, & clamp it off until the next feeding. Might do this every 4  hours.   Cyclic- lets say at 2pm, feeding will start, run all night, then at 10 am we will  flush the tube & turn it off for several hours. This feeding is prescribed by  whoever is looking at them, the nutritionist or nurse practitioner or whoever is  checking with it.  o Check the GVR (gastric residual volume)- how much food is accumulating in the stomach  Continuous feedings you will check this periodically, maybe every 4 to 8 hours. It will be on a schedule that is prescribed to you.  Intermittent- check before each feeding.  o Why we would rather do tube feedings instead of IV  If we are putting something in the gut, we are keeping it busy & occupied & its  doing its thing. We are keeping all the structures, all the linings working &  functioning. If we stopped doing that, those start atrophy & stop doing their job.So then it is hard to get the GI system back up to working. So maintaining the GI  structure & function is a huge benefit to enteral feeding  Also when the patient stops getting food to their gut, the microbes start to get  real unhappy. They start wanting to go find somewhere else to cause trouble, so  they do. They get into the blood stream, other areas of the body, then the  patient ends up septic(wide spread systemic infection) & they can get very sick.  It is an advantage to keep food in the GI system that it helps to prevent & cut  down & reduce the risk of that infection.  o Concerns  Ileus- when the GI tract is not moving/pushing food along, then the food will  just build up & come back up.  Tolerance- if patient isn’t tolerating the food, like they are experiencing  cramping, diarrhea, nausea, gas, then they may not be able to continue the  feeding.  Fluid imbalances- Feeding bags are very hypertonic, so we will get into a lot of  fluid balance issues if we are pulling fluid into diluting the feeding/formula, we  are pulling it from somewhere else & the patient may get into some dehydration issues.  ∙ Often you will make sure the client is getting free water.  ∙ The feeding tube is going in on this side, then there is some water &  they are both infusing in a Y at the same time. ∙ If client doesn’t have that, then you may have an order to administer  free water so you will draw up some water with the syringe & you might  give them 100mLs of water every three hours.  ∙ When you have immunocompromised patients, They will need sterile  water or sterile isotonic saline.   Infection- the feeding bag is a great risk & high medium for bacteria to get in  there & start setting an infection that could move to our patient.  o Dangers- how to take care of a patient with tube feedings safely by preventing infection  in the GI tract with the tube feeding we are giving them  ALERT  A-Aseptic technique. ∙ Everything that is hanged will be dated. Continuous feedings will come  in one system, so there are no openings in it.  ∙ If it a closed sterile system, you can hang it for 24-36 hours. ∙ If it is something we are opening a bag & pouring into it, we are adding  every few hours, we don’t want that to hang for more than 4 hours. ∙ Replace all equipment every 24 hours ∙ Always keep our NG tube above stomach level  L- labeling the date & time on the enteral tube  E- elevate the head of the bed. ∙ Elevated for an hour after intermittent feedings ∙ Elevated 30 degrees at all times, but especially for continuous feedings.   R- right patient, formula, tube  T- tracing all lines in tubing. Literally trace with your hand o Aspiration prevention  Clinical manifestations of aspiration- tachypnea, RR goes up, the cough,  shortness of breath, abnormal lung sounds, wheezing  HOB up 30o -45o  Measure residuals  Confirm placement initially with x-ray, then periodically with the other  techniques talked about  Assess patient- go back & see how patient is looking, noting any abnormal  findings  Parenteral nutrition Parenteral-patients who receive their nutrition through the vein.  o So this is the patient who cannot digest/absorb at all or they may be super sick, like with  a burn, or they have a terrible infection & they are in ICU & they have a bad head injury  or whatever it happens to be. So the nutritionist decides to have it go in through the  vein. Will go into a central large vein. Will be placed in by a physician, usually  subclavian. it may go in the antecubital area & those are called peripherally  inserted central catheters so nurses, especially trained nurses can do pick line.  You might see jugular or subclavian be placed by the physician.  o Parenteral has a high percentage of concentrated dextrose. 10-70% dextrose.  o So once the iv is placed, confirmed by X-ray, we will be responsible for securing it &  keeping it dressed under absolute sterile aseptic technique.  Usually a specially trained nurse will do this because the risk of infection is so  high.  o The kind of solution it is: your parenteral nutrition is 10-70% dextrose, some amino  acids, electrolytes, potassium, vitamins & minerals, trace elements.  o The other thing that may be given through this site is a lipid infusion. Your fat emulsions  when you hold these up & look at them in the light they look like a milk shake  that melted. They are opaque & white in color.   If you hold this bag up before you are getting ready to give this patient their fat  emulsions, & you see it is separated out like an oil & vinegar dressing, you will  not give it. You will send it back to the pharmacy, because if you give it you could give the patient fat emulous through the blood stream & it could kill the patient. It goes in as a foreign clumpfat in this case, & it can go to the lungs or brain or  wherever & can kill the patient. Hold if there are Droplets, little white globs in it,  or layers that have separated out  Needs to be completely homogeneously white & opaque to be able to use it.  o This is a IV catheter that has 3 pigtails on the end, these are different ports that can be  used for different things.   One could be IV fluid, one could be antibiotics or blood, & one could be TPN.  Only ever use the dedicated cord to put the parenteral nutrition. Do not put  other things in that port, it goes only by itself.  o Before you attach anything, you are going to scrub for 15 seconds. Scrub the hub is  what this is called.  o You always run parenteral nutrition using an IV pump. It is not ever run in by gravity.  o Rate- sometimes it will be started a little slowly then increase & you are going to have to  have some orders to be able to do all of that. o But lets say maybe that your patient goes down for a test &it gets turned off  accidentally, you don’t ever go back & increase the rate to catch back up. You will just  start back to where it was.  o Lets say something happens & it suddenly gets discontinued. Maybe the bag ran out, &  you didn’t have another ordered, whatever happens. You need to be very careful about  watching your clients blood sugar. Hypoglycemia can set in really fast with the huge  amount of sugar they have been getting suddenly dropping back off.   Usually you will give 10% dextrose through a peripheral vein if something  happened to your central line in the mean time. It may be tapered off when  being discontinued, but you will have some orders for that.  o Filter- there is always a special filter used in the IV line when you are giving the  parenteral nutrition & the lipids. o Risks & complications  Huge infection risk- 1. you are going into a central large vein directly into your  central circulation. 2. you are hanging this crazy solution with tons of sugar in it,  so you need to monitor closely for signs of infection. Fever, chills, positive blood  culture, etc.  Metabolic complications- if it is discontinued for any reason abruptly, you need  to monitor the glucose often doing finger sticks. ∙ because of the high glucose concentration, you are going to check their  glucose every 6 hours anyway, & you will be giving them sliding scale  insulin based on the value you get back from the glucometer. So the  receiving insulin probably at least every 6 hours.   Electrolyte imbalances- very hypertonic so it can lead to fluid balance problems  like pulling off lots of fluid. It’s an osmotic diuretic in effect. Vitamin k is  synthesized in the gut, when the gut is working. so now the gut is not working,  make sure your patient who is getting parenteral nutrition is receiving  supplemental vitamin K if indicated. If it’s not ordered, just question why they  are not getting it.  o Goal of all of this- constantly to be focused on moving our patient back to normal  physiologic intake of food. Oxygenation 7-9  ineffective breathing patterns o Causes/Risk Factors o Neurological/CNS problems- problem has something to do with the chest & thorax.  Maybe you have a patient with a bad head injury/stroke (CVA-cerebral vascular  accident) & the breathing center in the brain has been affected. It is no longer  sending the message telling your lungs/chest too expand/inhale. o Neuromuscular problems- ludericks disease (ALS), muscular dystrophy, giambrea (virus  based illness),   The drive is there from the brain, but these cause the nerves & the muscles to not  be able to cause the thoracic changes that have to happen for us to be able to  breathe.  o Pulmonary/thoracic structures- We must have everything intact, in normal shape, &  functioning in the chest area, thoracic area, & chest wall.   When you breathe in, rib cage goes out. Reason is diaphragm, chest wall moves  outward, creating negative pressure.  In order to do that, everything must be intact. Muscles & ribs have to not have holes or fractures o Musculoskeletal abnormalities  Pectus excavatum- Chest is inward. sometimes people are born with this. Some  cases are worse than others. It creates less space in the thorax to be able to have  room to move & pull air in.   Scoliosis- S shaped lateral change the spine can have. It contorts/distorts the shape  of the thorax & the ability to expand.   Kyphosis- compression of the upper spine that causes bending over. Expansion of  the upper abdomen/upper thorax of the back. This causes patients to not be able to  stand up & get a good, normal chest expansion.  ∙ Hypocalcemia is a cause  Normal shape/ contour of the thorax has to be intact because we need to have the  ribs intact because the bones that have muscles attached to them have to be able to  move as one & expand & pull the air in. ∙ Trauma & rib fractures & that type of thing will make that difficult.  You also have to have room to move. If the diaphragm can’t drop, the chest can’t go  out, then you cannot ventilate.  ∙ Why you wouldn’t be able to move o Maybe the client is late pregnant & the baby is taking space up. The  baby can’t move out of the way, but the diaphragm needs to go  somewhere but it can’t. So, they are simply not expanding &  ventilating well. o Obesity does the same things in terms of taking up space that the  thorax needs to be able to expand in to. At the same time, it adds  weight, so if the client is lying down flat the client has to work that  much harder to lift the weight to be able to get to the expansion of  the thorax.  o Pain- if you have a rib fracture or maybe a case of bronchitis or maybe a surgery that causes  it to hurt to breathe, so you don’t want to take a deep breath in. This causes you to take  shallower breaths & an ineffective breathing pattern.  o Medications- if you are taking pain meds, these can change drive from our brain to ventilate, to take the breath in. Different medication, sedatives, medicines for surgery, anesthetics, anxiety  medications, other substances like alcohol & illicit drugs & things like that change  the drive.  o Fatigue plays a big part in our breathing pattern, you will see a patient working so long &  hard to breathe, they just cannot do it anymore.   They will either die or we will do something for them. o Malnutrition- work of breathing, because it is work at this point. If we don’t have adequate  muscle strength to be able to move all the ribs & the diaphragm in there, we will not be able  to make an effective breathing effort & that would be another reason for this diagnosis. o Clinical manifestations/Nursing assessment findings o Rate & depth of breathing  Shallow breathing  Breathing is too fast or too slow  Irregular beating client may have a bunch of breaths then a pause or it might  be some big deep breaths or a little slow. o Chest excursion- both sides should go up at the same time & same amount.   Unequal – if you see one side going up more than the other, there is a  problem  Paradoxical- when you breathe in, chest wall moves out. If you see a patient  breathe in & the chest wall goes the opposite way, that is paradoxical chest  wall movement.  Obvious trauma- maybe you see bruising or maybe you can tell there is a  fracture in one of the ribs or maybe a client who has gotten something stuck  in their chest or something like that.  o Breath sounds  Breath sounds are diminished/very quiet/maybe even absent o Orthopnea- patient cannot breathe laying down, has to sit up to breathe comfortably.  o Pallor (pale)/Cyanosis (bluish color) o Dyspnea- subjective, patient is having a hard time breathing, feels short of breath. o Low SpO2 o Anxiety/restlessness/Stupor (near unconscious) o Diaphoresis- sweaty, drenched sometimes from the effort of trying to breathe. o Nursing interventions (dependent and independent) to promote oxygenation o Treat the cause- whatever is causing it we need to turn it around. Maybe pain meds,  maybe fractured ribs, can’t move the chest wall to breathe o Positioning- if client is obese, for example, get the head of the bed up because those  clients are very likely to have orthopnea.  45 degrees semifaulers for maximum chest expansion. o Encourage deep breathing- talk to patient & get them to wake up & take deep breaths & get moving with it.  o Administer oxygen if needed- dependent intervention. Long term- for clients who may have a chronic problem, like a neurological problem, try to help them with pulmonary  rehab.  o Nutrition & exercise- maybe they need to exercise. Need to work with nutritionist so  they have enough protein coming in that they can keep the muscle buildup & be  strong enough to breathe.

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