NR 226 Final Exam for Fundies 2

NR 226 Final Exam for Fundies 2 Chapter 42 Electrolytes We will be focusing on Potassium, Magnesium, and Sodium Potassium Potassium normal level is 3.5 – 5 • Potassium is cardiac sensitive Hypokalemia (less than 3.5) Risk factors/causes for low potassium Your body is trying to DITCH K+ • Drugs (diuretics, corticosteroids) • Inadequate intake of K+ • Too much water intake (dilutes the K+) • Cushing syndrome – retains Na, excretes K+ (increase in secretion of Aldosterone) • Heavy Fluid loss (K+): Vomiting, diarrhea, NG suctioning, diuretics, ileostomy drainage, sweating • Glucose in urine pulls K+ into cells – insulin • Alkalosis Expected findings (low and slow) • Cardiovascular o Thready, weak, irregular pulse o Weak peripheral pulse o Orthostatic hypotension o Dysrhythmias o ECG changes: ST depression, flat T wave, prominent U wave (this is abnormal) • Respiratory o Shallow, ineffective respirations that result from profound weakness of the skeletal muscles of respiration o Diminished breath sounds • Neuromuscular o Anxiety, lethargy, confusion, coma o Skeletal muscle weakness, leg cramps o Loss of tactile discrimination o Paresthesia o Deep tendon hyporeflexia • GI o Decreased motility, hypoactive to absent bowel sounds o Nausea, vomiting, constipation, abdominal distention o Paralytic ileus Nursing Interventions • Assess o Cardiac monitor o Intake and output o Changes in the LOC • Monitor (labs & diagnostic studies) o K+ levels o BUN o Creatinine • Administer o Potassium • Perform o Blood draw • Teach o Foods that they can eat to increase K+ o If they’re taking Lasik’s, they need a potassium supplement What foods are high in POTASSIUM? • Potatoes & Pork • Oranges • Tomatoes • Avocadoes • Strawberries • Spinach • fIsh • mUshrooms • Melons  Cantaloupes Hyperkalemia (levels more than 5.0) Risk factors/Causes of Hyperkalemia “Your body CARED too much for potassium” • Cellular movement of K+ from intracellular to extracellular, Cellular destruction – burns, traumatic injury • Adrenal insufficiency (Addison’s disease), Acidosis (metabolic and respiratory) • Renal failure • Excessive Potassium intake • Drugs (K+ sparing, ACE inhibitors, NSAIDs) Expected Findings for Hyperkalemia “MURDER” • Muscle weakness • Urine, Oliguria, Anuria • Respiratory Distress • Decreased cardiac contractility • ECG changes (Tall T wave) • Reflexes (hyperreflexia or areflexia) Nursing Interventions • Assess o VS o I & O • Monitor o K+ • Administer o Diuretic o Dextrose or Glucose • Perform o Cardiac monitor • Teach o Avoid POTASSIUM What foods are high in POTASSIUM? • Potatoes & Pork • Oranges • Tomatoes • Avocadoes • Strawberries • Spinach • fIsh • mUshrooms • Melons  Cantaloupes If the K+ is too high during an infusion, stop the infusion and call the provider. Magnesium Helps with muscle relaxation Normal levels: 1.5 – 2.5 Hypomagnesemia (less than 1.5) *Muscles are excited Risk factors/causes of Hypomagnesemia Remember “LOW MAG” • Limited intake of Mg+ (starvation) • Other electrolyte issues cause low Mg+ • Wasting Mg+ via the kidneys • Malabsorption issues • Alcohol • Glycemic issues Expected clinical manifestations Remember “TWITCHING” • Tovessau’s sign (positive) • Weak respirations • Irritability • Tardive Dyskinesia, Twitching, Tetany • Cardiac changes (Tachycardia, EKG changes: Widened QRS, prolonged PR & QT intervals, depressed ST segments, broad flattened T waves, prominent U wave) • Hypertension, Hyperreflexia (Increased DTR) • Involuntary movements • Nausea • GI issues Difficulty swallowing, Paralytic ileus, Nystagmus (eye twitching) Nursing Interventions • Assess o VS (tachycardia & tachypnea) • Monitor o Magnesium levels • Administer o Magnesium • Perform o Dd • Teach o Foods that are rich in Magnesium Always Get Plenty Of Foods Containing Large Numbers Of Magnesium Avocado Green leafy vegetables Peanut butter; pork Oatmeal Fish Cauliflower Legumes Nuts Oranges Milk Hypermagnesemia (more than 2.5) *Muscles are way too relaxed Risk factors/Causes Remember “MAG” • Magnesium containing antacids (too many laxatatives) • Addison’s Disease (adrenal insufficiency) • Glomerular Filtration insufficiency (renal failure) Clinical manifestations Remember “LETHARGIC” • Lethargy • EKG changes • Tendon reflexes are absent/diminished Paralysis • Hypotension • Arrhythmias (bradycardia) • Respiratory arrest (bradypnea) • GI issues (N/V) • Impaired breathing (due skeletal weakness) • Cardiac arrest Diaphoresis, Flushing, Decreased LOC Nursing Interventions • Assess o VS (HR and Respirations) o Neuro checks • Monitor o Magnesium • Administer o Calcium Gluconate (if it’s more than 2.5) • Perform o EKG (Place them on a cardiac monitor) Sodium (135 – 145) *Sodium is sensitive to fluid Hyponatremia (less than 135) When Na+ is low then there is an excess in fluid Risk factor/Causes Remember “No Na+” • Na+ excretion increased with renal problems, NG suction, vomiting, diuretics, sweating, diabetes insipidus • Overload of fluids (CHF, Hypotonic fluids, liver failure) • Na+ intake low • Antidiuretic hormone over secreted Clinical manifestations of hyponatremia Remember “SALT LOSS” • Seizures & Stupor • Abdominal cramping & attitude changes (confusion) • Lethargy • Tendon reflexes • Loss of urine and appetite (nausea, vomiting, anorexia) • Orthostatic hypotension • Shallow respirations • Spasms of muscles Headache Nursing Interventions • Assess o LOC o VS • Monitor o Electrolytes (Na+) • Administer o Hypertonic solution • Perform o Fall risk • Teach o Eat foods with salt Hypernatremia (more than 145) *High Na+ but low water so the patient is dehydrated Risk factors/Causes Remember “HIGH SALT” • Hypercortisolism (Cushing syndrome), Hyperventilation & Heat stroke • Increased Na+ intake (oral or IV routes) • GI feeding without adequate H20 supplement • Hypertonic solutions • Sodium excretion is decreased • Aldosterone problems • Loss of fluids (dehydration) • Thirst impairment Clinical manifestations of hypernatremia Remember no “FRIED” foods for you • Fever, flushed skin • Restless, really agitated • Increased fluid retention • Edema, extremely confused • Decreased urine output, dry mouth/skin Furrow tongue Nursing Interventions • Assess o VS • Monitor o Na+ o Chest X-Ray • Administer o Hypotonic o Diuretic • Perform o Reposition Q2 o Weigh daily • Teach o Have them eat less salt Chapter 50 Perioperative Pre-op • You need to get the consent from the client: it needs to be the patient, surgeon, and the nurse o The people involved are the surgeon, the patient and the nurse • The role of the surgeon o Explain the procedure to the client, answer any questions, risk factors, make sure that the person has a complete understanding • The patient cannot sign the paper if they are unsure of what they are getting done • The patient gives the informed consent, and the nurse witnesses the signature • If the consent isn’t signed, the patient cannot go to surgery • The patient needs to be NPO for at least 8 hours • The patient needs to have a bath, a chlorohexidine bath to make sure that the patient is clean and prevent infection of the skin • STOP ALL ANTICOAGULANTS • Very important to know what conditions the patient has before performing surgery • The labs are important as well. Know the Hgb (females 12-16, male 14-18), (pg.1334), platelets, hematocrit, RBCs, WBCs (know that it is different for male than females) Intra-op Role of the Circulating Nurse • Updates the family • Verifies consent • Counts the instrument and the gauze • Positions the patient and pads the patient to prevent nerve damage • Advocate for the patient • Asks for timeout • Makes sure that they have the right patient and is operating on the right side Role of the Scrub Nurse - Hands the instrument to the surgeon - Counts the instruments with the circulating nurse Role of the Anesthesiologist • Responsible for perfusion and oxygenation • Nurse Anesthetist General anesthesia: primary complication is aspiration (that’s why the patient needs to be NPO Local anesthesia • Epidural: primary complication is the spinal cord o Priority is to give the patient a foley o Make sure the HOB is elevated but without the pillow Conscious sedation • Aspiration is the complication During surgery the priority is ABCs make sure airway is patent Early signs: tachycardia, muscle rigidity Malignant hyperthermia The person monitoring for malignant hyperthermia is the anesthesiologist. • Early signs o Tachycardia o Tachypnea o Muscle rigidity • Late signs o High fever Post-op To prevent post-op complications in general • Get the patient up and mobile as soon as possible • Incentive Spirometer (see table for instructions) • Q2 turns Signs of a PE • Sharp pain • Sudden chest pain • Dyspnea You cannot feed a patient until the gag reflex has returned, and you start to hear active bowel sounds. You should hear the bowel sounds 6-8 hours after the surgery. How do you test for the gag reflex? For GI: start the patient on clear liquids the continue the full liquids Clear liquids • Water Full liquids • You know that you cannot move on from the clear liquids if the patient is vomiting or has distention. What ways can you give a patient to prevent constipation? • Increase fluids, high fiber, increase activity What position do you put a patient in to give an enema? • Left lateral IF the patient is bleeding externally, you will see that the gauze is soaked with blood. IF the patient is bleeding internally, you will see blood in the poop. PACU vitals • Q15 for the first hour • Q30 for the next hour • Every hour for the next 4 Priority teaching post-op • Deep breathing and coughing if no IC Which position is important for the patient in post-op? • Semi-Fowlers (at least 30 degrees) Wound Evisceration • Organs are protruding o Implementation: Sterile saline and sterile gauze, don’t push the organs in, notify the physician, STAY WITH THE PATIENT, always splint, the patient needs to be NPO because they will be going back into surgery Wound dehiscence Thromboprevention • SCDs • Ambulation After the patient has had surgery, how do you get the patient out of bed? • ! Chapter 47 Bowel Elimination Guaiac test – to test for blood in the stool Endoscopy – checks in the upper GI for ulcers Colonoscopy – checks the lower GI, they check for polyps, NPO, Golightly Colorectal cancer Risk factors • Diet that is high in red meat and processed foods • Family history • Smoking and heavy alcohol intake • Over 50 Enema • 12 inches above the entrance of the anal canal Ostomy • An opening for gastrointestinal, urinary, or respiratory tract onto the skin Ileostomy • RLQ • Feces are liquid • Patient is at risk for fluid and electrolyte imbalance • It does not smell Ascending Colostomy • You can smell the odor • Feces is liquid • RUQ • Patient is at risk for fluid and electrolyte imbalance Sigmoid Colostomy • Feces is really formed and hard • Patient sometimes need irrigation Descending Colostomy • Stool is firm • It smells Transverse • Stool will be mushy • Stool will start to smell When do you change the ostomy bag? • When the bag is 1/3 to ½ full Steps to change the ostomy bag. 1. Remove it 2. Wipe around with wipes or you can use mild warm soap and water. Rinse it well 3. Apply cream 4. Measure the wafer 5. Make sure its 1/8 or ¼ larger than the stoma (to prevent leaking or strangulation of the stoma) Gas producing foods Laxative-producing foods Constipation-producing foods Other Cabbage Onions Cauliflower Bananas Apples Bran Prunes Figs Chocolate Alcohol Cheese Pasta Eggs Lean Meat Spicy foods: Diarrhea & flatus Excessive sugar: diarrhea Color of the stoma • Should be red. • If its light pink, it is lacking perfusion • If it’s dark in color, its dead. You need to report it if there is a deviation in color! Bowel Diversions: Ileostomy Koch pouch or continent ileostomy • Creates an internal pouch, or reservoir, to collect ileal drainage. • To drain the pouch, the pt. inserts a rectal tube through the external stoma into the pouch several times during the day. This avoids continuous drainage. A total colectomy with ileoanal reservoir • Removes the colon, creates a pouch from the ileum, and connects the ileum to the rectum. • The pt. evacuates the bowel on the commode through the anus.