Fluid Volume Excess (Hypervolemia

Final Exam Review Promoting Health & Health Restoration of Adults I NUR 4226 Fluid Volume Excess (Hypervolemia) • Causes: fluid overload or diminished homeostatic mechanisms, heart failure, kidney injury, cirrhosis of liver, consumption of excessive amounts of table salt or other sodium salts, excessive administration of sodium- containing fluids with impaired regulatory mechanisms • Clinical manifestations: acute weight gain, peripheral edema and ascites, distended jugular veins (JVD), crackles, elevated CVP, shortness of breath, ↑ BP, bounding pulse, cough, ↑ respiratory rate, ↑ urine output • Nursing management: assess lung sounds, monitor for edema, I&O, daily weights, administer diuretics, patient education regarding sodium and fluid restriction, promote rest Fluid Volume Deficit (Hypovolemia) • Occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids; therefore, the ratio of serum electrolytes to water remains the same (loss of extracellular fluid exceeds intake of water) • causes: diarrhea, vomiting, sweating, GI suctioning, decreased fluid intake, burns, ascites, osmotic diuresis, hemorrhage • Clinical manifestations: weight loss, decreased skin turgor, oliguria, concentrated urine, capillary filling time prolonged, low CVP, ↓ BP, flattened neck veins, dizziness, weakness, thirst and confusion, ↑ pulse, muscle cramps, sunken eyes, nausea, increased temperature, and cool, clammy, pale skin Hyperkalemia • Serum potassium 5.0 mEq/L • Causes: impaired renal function, rapid administration of potassium, hypoaldosteronism, medications, tissue trauma, respiratory and metabolic acidosis • Clinical Manifestations: muscle weakness, tachycardia → bradycardia, dysrhythmias, flaccid paralysis, paresthesia, intestinal colic, cramps, abdominal distention, irritability, anxiety. • ECG: tall tented T waves, prolonged PR interval and QRS duration, absent P waves, ST depression Hypokalemia • Serum potassium 3.5 mEq/L • Causes: GI losses (vomiting & diarrhea), medications (i.e. diuretics, corticosteroids, beta agonists, insulin), prolonged intestinal suctioning (nasogastric tube), recent ileostomy, tumor of the intestine, alterations of acid–base balance (respiratory or metabolic alkalosis), poor dietary intake, hyperaldosteronism (increases renal K+ loss), bulimia • Clinical Manifestations: fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria, decreased bowel motility, ventricular asystole or fibrillation, paresthesias, leg cramps, ↓ BP, ileus, abdominal distention, hypoactive reflexes • ECG: flattened T waves, prominent U waves, ST depression, prolonged PR interval Hypermagnesemia • Serum magnesium 3.0 mg/dL • Causes: kidney injury, diabetic ketoacidosis, excessive administration of magnesium, medications (i.e. magnesium-based antacids or laxatives such as milk of magnesia), extensive soft tissue injury (i.e. trauma), lithium toxicity • Clinical Manifestations: flushing, hypotension, muscle weakness, drowsiness, hypoactive reflexes, depressed respirations, cardiac arrest and coma, diaphoresis • ECG: tachycardia → bradycardia, prolonged PR interval and QRS, peaked T waves Hypomagnesemia • Serum magnesium 1.3 mg/dL • Causes: alcoholism, GI losses (especially in the small bowel - major site of magnesium absorption), enteral or parenteral feeding deficient in magnesium, medications, rapid administration of citrated blood, medications (i.e. diuretics, digoxin) • Clinical Manifestations: neuromuscular irritability, positive Trousseau sign and Chvostek signs, insomnia, mood changes, anorexia, vomiting, increased DTRs, and ↑ BP • ECG: PVCs, flat or inverted T waves, depressed ST segment, prolonged PR interval, and widened QRS • Torsades de pointes Hypercalcemia • Serum calcium 10.2 mg/dL • Causes: malignancy, hyperparathyroidism, bone loss related to immobility, thiazide diuretics, medications containing calcium (i.e. antacids) • Clinical Manifestations: muscular weakness, constipation, anorexia, nausea and vomiting, polyuria and polydipsia, dehydration, hypoactive deep tendon reflexes (DTRs), lethargy, deep bone pain, pathologic fractures, flank pain, calcium stones, hypertension • ECG: shortened ST segment and QT interval, bradycardia, heart blocks Hypocalcemia • Serum calcium 8.6 mg/dL • Causes: primary hypoparathyroidism, surgical removal of the parathyroid gland, malabsorption, osteoporosis, pancreatitis, alkalosis, transfusion of citrated blood, kidney injury, medications • Clinical Manifestations: tetany, circumoral numbness, numbness & tingling of fingers & toes, hyperactive deep tendon reflexes (DTRs), Trousseau sign, Chvostek sign, seizures, respiratory symptoms of dyspnea, bronchospasm, diarrhea, impaired clotting time, anxiety, irritability • ECG: prolonged QT interval and lengthened ST Hypophosphatemia • Serum phosphorus 2.5 mg/dL • Causes: alcoholism, refeeding of patients after starvation, pain, heat stroke, respiratory alkalosis, hyperventilation, diabetic ketoacidosis, hepatic encephalopathy, major burns, hyperparathyroidism, low magnesium, low potassium, diarrhea, vitamin D deficiency, use of diuretic and antacids • Clinical Manifestations: paresthesias, muscle weakness, bone pain and tenderness, chest pain, confusion, cardiomyopathy, respiratory failure, seizures, tissue hypoxia, and increased susceptibility to infection, nystagmus Classifications of Shock • Hypovolemic: shock state resulting from decreased intravascular volume due to fluid loss • Cardiogenic: shock state resulting from impairment or failure of myocardium • Septic: circulatory shock state resulting from acute infection causing relative hypovolemia • Neurogenic: shock state resulting from loss of sympathetic tone causing relative hypovolemia • Anaphylactic: circulatory shock state resulting from severe allergic reaction producing acute systemic vasodilation, relative hypovolemia Hypovolemic Shock • Caused by external fluid losses (trauma, surgery, vomiting, diarrhea, diuresis, diabetes insipidus), or by internal fluid shifts (hemorrhage, burns, severe dehydration, or ascites) • Medical Management: ▪ treatment of underlying cause ▪ fluid and/or blood replacement ▪ redistribution of fluid ▪ pharmacologic therapy • Nursing Management: ▪ administer blood and IV fluid safely ▪ implement other measures: oxygen and modified Trendelenburg position (passive leg raising) Cardiogenic Shock • The heart’s ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and the tissues (cardiac output is impaired). Causes can be coronary or noncoronary • Medical Management: ▪ correction of underlying causes ▪ initiation of first-line treatment ▪ oxygenation (maintain O2 sat 94%) ▪ pain control (IV morphine decreases preload) ▪ hemodynamic monitoring (arterial line, pulmonary artery catheter) ▪ laboratory marker monitoring (BNP, cardiac enzymes, lactic acid) ▪ fluid therapy ▪ vasoactive medications (inotropes such as dobutamine or milrinone, vasopressors, vasodilators) ▪ mechanical assistive devices Distributive Shock • 3 Types: • Septic Shock (most common) – widespread infection • Neurogenic Shock – a loss of balance between parasympathetic and sympathetic stimulation (predominant parasympathetic stimulation causes vasodilation lasting for an extended period, leading to a relative hypovolemic state) ▪ hypotension with bradycardia occurs rather than the tachycardia that characterizes other forms of shock • Anaphylactic Shock - when patients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen–antibody reaction (widespread vasodilation and capillary permeability) ▪ epinephrine is the first line treatment Stages of Shock • Compensatory • BP remains within normal limits • vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output (SNS - release of catecholamines) • Progressive • the mechanisms that regulate BP can no longer compensate and the MAP falls below normal limits and SBP 90 mmHg or decrease in SBP of 40 mmHg from baseline • the patient shows signs of declining mental status • Irreversible • the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive General Management of Shock States • Fluid replacement: • Crystalloid (isotonic – 0.9% normal saline and LR) and colloid (i.e. albumin) solutions • insufficient fluid replacement is associated with a higher incidence of morbidity and mortality from lack of tissue perfusion • excessive fluid administration can cause systemic and pulmonary edema that progresses to acute lung injury (ALI), abdominal compartment syndrome, & MODS • Vasoactive medication therapy: (i.e. norepinephrine, vasopressin, epinephrine) • should be administered through a central line • Nutritional support: • parenteral or enteral (preferred) nutritional support should be initiated as soon as possible in ALL shock states • Control of Hyperglycemia Multiorgan Dysfunction Syndrome (MODS) • Presence of altered function of two or more organs in an acutely ill patient such that interventions are necessary to support continued organ function • Primary or secondary • High mortality rate (20% when 1 organ fails and at least 60% when more than 4 organs fail) • Treatment ▪ controlling initiating event ▪ promoting adequate organ perfusion ▪ providing nutritional support • Promoting communication ▪ address end-of-life decisions The Respiratory System • Respiration: process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body • Compliance: elasticity and expandability of the lungs and thoracic structures • Diffusion: process by which O2 and CO2 are exchanged from areas of high concentration to areas of low concentration at the air–blood interface (O2 and CO2 travel across the alveolar–capillary) • Ventilation: the exchange of air between the lungs and the atmospheric air (involves inspiration and expiration) so that O2 can be exchanged for CO2 in the alveoli • Perfusion: blood flow through the pulmonary vasculature (blood is pumped into the lungs by the right ventricle through the pulmonary artery) Ventilation-Perfusion (V/Q ratio) • Adequate gas exchange depends upon a balanced V/Q ratio • Imbalanced V/Q ratio causes shunting of blood and results in hypoxia • High V/Q ratio (shunt occurs when ventilation exceeds perfusion) – dead space results • alveoli do not have adequate blood supply for gas exchange (pulmonary embolism, pulmonary infarction, cardiogenic shock) • Low V/Q ratio (shunt occurs when perfusion exceeds ventilation) • seen with obstruction of the distal airways (pneumonia, mucus plug, atelectasis, tumor) • See Chart 20-2 • Supplemental oxygen may eliminate hypoxia Arterial Blood Gas (ABG) • Measurement of arterial oxygenation (PaO2) and carbon dioxide (PaCO2) levels • Used to assess the adequacy of alveolar ventilation and the ability of the lungs to provide oxygen and remove carbon dioxide • Also assesses acid–base balance • See handout provided in Sim Lab for ABG analysis Oxygen Therapy • Administration of oxygen at 21% (room air) to provide adequate transport of oxygen in the blood: • decreases the work of breathing and reduces stress on the myocardium • Hypoxemia: a decrease in the arterial oxygen tension in the blood • Hypoxia: a decrease in oxygen supply to the tissues and cells that can also be caused by problems outside the respiratory system • Use the lowest concentration of oxygen possible to avoid oxygen toxicity (if fraction of inspired oxygen [FiO2] of 50% is administered for an extended period of time [24 hours], oxygen toxicity can occur) Oxygen Devices • Devices (Refer to Table 21-1) • Nasal cannula (delivers a low concentration of oxygen - up to 6 L/min) • 1-2 L/min: 24-28% FiO2 • 3-4 L/min: 32-36% FiO2 • 5-6 L/min: 40-44% FiO2 • Masks (simple, partial, non- rebreather – 80-95% FiO2) • High-flow systems • High-flow nasal cannula (up to 15 L/min) • Venturi mask (delivers precise FiO2 concentrations and is used primarily in COPD patients – avoids the risk of suppressing the hypoxic drive) • Aerosol mask • Face tent • T-piece (patient with tracheostomy) Incentive Spirometry • Method of deep breathing that provides visual feedback to encourage the patient to inhale slowly and deeply to maximize lung inflation • used to prevent, reduce, or treat atelectasis • Used for postop patients (especially after cardiothoracic and abdominal surgeries) • Nursing care: • positioning of patient, encourage use, set realistic goals, and record outcomes • 10x q1 hour while awake postoperatively • patient education: place the lips around the mouthpiece with a tight seal, inhale slowly and deeply, hold the breath for 3 seconds at the end of deep inspiration, and then exhale slowly through the mouthpiece (refer to Chart 21-3) Chest Physiotherapy (CPT) • Includes: • Postural drainage (Figure 21-3) • Chest percussion & vibration • Breathing retraining (Chart 21-4) • exercises and breathing practices that are designed to achieve more efficient and controlled ventilation and to decrease the work of breathing (indicated in patients with COPD and dyspnea) • Goals: • remove secretions • improve ventilation • increased efficiency of respiratory muscles Chest Percussion and Vibration • Chest percussion is carried out by cupping the hands and lightly striking the chest wall in a rhythmic fashion over the lung segment to be drained • Vibration is the technique of applying manual compression and tremor to the chest wall during the exhalation phase of respiration • An inflatable HFCWO vest may be used to provide chest therapy (Figure 21-5) • Flutter Valve • decreases viscosity of the mucus and facilitates mucous clearance • used in cystic fibrosis patients Chest Tube Drainage System • Chest drainage systems: Figure 21-10 • suction source (usually -20 cmH2O) • collection chamber for pleural drainage • mechanism to prevent air from reentering the chest with inhalation • some have an air leak zone • Types: • Wet suction (water seal) control • Dry suction control Management of Chest Tubes and Chest Tube Drainage Systems • Suction Control Chamber: regulates the amount of negative pressure being applied to the pleural space (when suction is applied, the water in this chamber should bubble continuously) – usually set to -20 cmH2O • Water Seal Chamber: the water level in this chamber rises with inhalation and falls with exhalation, which referred to as tidaling, and is an expected finding. Continuous bubbling is abnormal and indicates an air leak. Gentle bubbling on forceful exhalation or coughing is normal. • Collection Chamber: collects pleural fluid (nurse needs to monitor and record output) • Subcutaneous emphysema (feels like crepitus underneath the skin): an indication that air is trapped in and under the skin, which be the result of a pneumothorax and should be reported to the provider Upper Respiratory Tract Infections (URIs) • Involves the nose, paranasal sinuses, pharynx, larynx, trachea, or bronchi ▪ rhinitis, rhinosinusitis, pharyngitis, laryngitis, tonsillitis, peritonsillar abscess • Management: ▪ elevate head ▪ ice collar to reduce inflammation and bleeding ▪ hot packs to reduce congestion ▪ analgesics for pain ▪ gargles for sore throat ▪ use alternative communication ▪ encourage liquids; at least 2 to 3 L/day (unless contraindicated) ▪ soft bland diet or liquid diet ▪ rest URI Potential Complications • Airway obstruction • Hemorrhage • Sepsis • Meningitis • Brain abscess • Nuchal rigidity • Medicamentosa (rebound nasal congestion due to extended use of topical decongestants) • Acute otitis media • Trismus (inability to open the mouth) – can occur in peritonsillar abscess • Dysphagia • Aphonia (loss of voice) • Orbital Cellulitis (infection of the soft tissues within the eye socket and can lead to permanent loss of vision without treatment) – manifested as periorbital edema with pain when moving the eye (report immediately) Epistaxis • Hemorrhage from the nose caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nose • anterior septum is the most common site • serious problem, may result in airway compromise or significant blood loss • Management: • Pinch soft portion of nose for 5 to 10 minutes (do not lean head back) • Phenylephrine spray (vasoconstriction) • Cauterize with silver nitrate or electrocautery • Gauze packing • Balloon-inflated catheter inserted into nasal cavity for 3 to 4 days • Antibiotic therapy (risk of iatrogenic rhinosinusitis and sepsis) Obstructive Sleep Apnea (OSA) • Cessation of breathing (apnea) during sleep usually caused by repetitive upper airway obstruction • Risk factors: obesity (increased neck circumference), male gender, advanced age, and postmenopausal status - STOP-BANG questionnaire • Diagnosis: polysomnography (sleep study) • Treatment: CPAP & BiPAP (gold standard), also mandibular advancement devices (MAD) and surgery (uvulopalatopharyngoplasty [UPPP]) Laryngeal Cancer: Signs and Symptoms Early: • Hoarseness • Persistent cough • Sore throat or burning pain in throat • Harsh, raspy voice with lower pitch • Lump in neck Late: • Dysphagia • Dyspnea • Unilateral nasal obstruction or discharge • Persistent hoarseness • Persistent ulceration • Foul breath • Metastases: cervical lymphadenopathy, unintentional weight loss, and general debilitation Atelectasis • Collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression • microatelectasis (not detectable on chest x-ray) • macroatelectasis (loss of segment, lobe, or entire lung volume) • Symptoms: usually gradual and subtle • increasing dyspnea • cough • sputum production • Characterized by increased work of breathing and hypoxemia • Physical exam: decreased breath sounds and crackles are heard over the affected area • Prevention Nursing Interventions - Atelectasis • Frequent turning and repositioning • Early mobilization • Strategies to expand lungs and manage secretions: • incentive spirometer (10x q1 hour while awake) • enhances lung expansion, decreases the potential for airway closure, and may generate a cough • voluntary deep breathing • Secretion management • directed cough, suctioning, and aerosol nebulizer treatments followed by chest physiotherapy (postural drainage and chest percussion) • Pressurized metered-dose inhaler Pneumonia • Inflammation of the lung parenchyma caused by various microorganisms including bacteria, mycobacteria, fungi, and viruses • Classification (Charts 23-3 & 23-4): • Community acquired (CAP) •occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization • Healthcare associated (HCAP) – no longer used as a classification since 2016 per the Infectious Disease Society of America (IDSA) • Hospital acquired (HAP) •develops ≥48 hours or more after admission and does not appear to be incubating at the time of admission • Ventilator associated (VAP) •develops ≥48 after endotracheal tube intubation Clinical Manifestations of Pneumonia