CBC Practice A Focused Review: Level II

Malignant Hyperthermia - (MH) a disease that causes a fast rise in temp and severe muscle contractions when pts with MH recieves anesthesia. Electrolyte Ranges - Sodium: 135-145 (HyperNa: FRIED: fever, flushed skin; restless, really agitated; increased fluid retention; edema, extremely confused; decreased urine output, dry mouth or skin. // HypoNA: SALT LOSS: seizures, stupor; abd cramping, attitude changes; lethargic; tendon reflexes decreased; loss of urine and appetite; orthostatic hypotension, overactive bs; shallow respiration; spasms of muscles.) Potassium: 3.5-5.0 (HyperK- wide QRS complex and peaked T waves, hyperactive BS. // HypoK- inverted or flat T waves, ST-segment depression, and U waves. hypoactive BS/constipation, orthostatic hypoTN) Calcium: 8.5-10.5 (S/S are opposite of levels. hypoCa=hyper active (+chvosteks and +trousseau.) // hyperCa=hypo active) Magnesium: 1.3-2.1 (similar to Ca. Hypermag causes: laxatives and antacid use) Chloride: 95-105 Phosphorus: 3.0-4.5 Hypocalcemia (8.5 - 10.0) - 8.5 RF: antacid use, malabsorption syndromes, ESKD, thyriodectomy, inadequate intake. S/S: tetany, paresthesia fingers and lips, muscle twitching, seizure, muscle spasms, increased DTRs and BS, +chvosteks and +trousseaus. Acid Base Balance (respiratory) - PaCO2 45 = Respiratory Acidosis Cause: HYPOventilation, chest trauma, inadequate chest expansion, and alveolarcapillary block. --abd ascites Tx: O2, patent airway, bronchodilators --can display mental cloudiness or confusion due to elevated carbon dioxide (CO2) retention, pale, cyanotic, and dry skin, hyporeflexia, and hypotension that can cause weak peripheral pulses. Hypotension is due to vasodilation from CO2 retention. PaCO2 35 = Respiratory Alkalosis Cause: HYPERventilation, gram-negative bacteremia, high altitudes, shock, aspirin toxicity, and fear. S/S: numbness and tingling, or paresthesia, due to a decrease in calcium ionization. lightheadedness, tachycardia, and cardiac dysrhythmias. Tx: address anxiety, bag breathing Acid Base Balance (metabolic) - HCO3 22 = Metabolic Acidosis Causes: hyperK, DKA, ASP OD, kidney failure, diarrhea, ileostomy, methanol or ethanol intoxication, hypoxia, seizure activity, diarrhea, starvation, and pancreatitis. S/S: Abnormal EKG, kussmauls resp (rapid, deep), warm dry flushed skin ( due to vasodilation from an increased respiratory rate and the loss of CO2.), brady cardia, weak P, hypoTN, lethargy, confusion, hyporeflexia HCO3 26 = metabolic alkalosis Causes: antacids D, N/V, NG suction = loss of gastric acid, cushing's disease hypocalcemia, hypoK, Hematologic Lab Values - -RBC: 4-6 million -WBC: 5,000-10,000 -Platelets 150,000-400,000 -Hgb: 12-18 -Hct: 37-52 -PT: 11-12.5 sec -PTT: 30-40 sec (1.5-2x longer for Heparin) -INR: 1 (2-3 if on Warfarin [Coumadin]) Rapid Acting Insulin (onset, peak, duration) - Lispro, aspart - onset: 15-30 min - peak: 30 min-2.5 hrs - duration: 3-6 hrs Short Acting Insulin - REGULAR Insulin (clear. can be IV drip) - onset: 30-60 min - peak: 1-5 hrs - duration: 6-10 hrs Intermediate Acting Insulin - NPH (Humulin N, Novolin N) (cloudy. do not give IV drip) - onset: 1-2 hrs - peak: 6-14 hrs - duration: 16-24 hrs Long Acting Insulin - glargine (Lantus) detemir (Levemir) - onset: 70 min - peak: NO PEAK - duration: 24 hrs Hypoglycemia - 70 S/S: tachycardia, palpitations, diaphoresis, shakiness, HA, tremors, weakness. Tx: 15g carb snack (120 mL/4 oz OJ/fruit juice, 60 mL/2 oz grapefruit juice, 8oz milk) -A client who has a blood glucose of 20 mg/dL and is unconscious should receive 1 mg of glucagon subcutaneously Hyperglycemia - S/S: increased thirst, nausea, vomiting, increased urination, flushed dry skin, acetone breath odor, and a weak, rapid pulse. Fasting glucose ranges - 70-110 BPH tx TURP (TransUrethral Resection of the Prostate) - POSTOP: -3 way indwelling cath for continuous bladder irrigation (CBI) for patency. -The rate of the CBI is adjusted to keep the irrigation return pink or lighter (if red, increase CBI rate) -if obstructed (bladders spasms, reduced irrigation outflow): turn off and irrigate 50ml solution using large piston syringe. -pt will feel continuous urge to urinate =expected. -record the amt of irrigating solution instilled (generally very large volumes) and the amount of return. The difference equals urine output. MEDS: analgesics, antispasmodics, antibiotics, stool softeners PT EDU: -drink 12+ 8oz water daily -no strenuous activity 2-6 wks -avoid bladder stimulants (caffeine, alcohol) and NSAIDS -if blood in urine, rest and increase fluids -perform Kegel exercises to assist in regaining urinary control and eliminate dribbling or the leakage of urine. -urine might contain small blood clots and pieces of tissue for several days -dribbling small amounts of urine is an expected -might experience retrograde ejaculation following a TURP procedure, in which most of the semen flows into the bladder rather than being ejaculated. Finasteride - 5 alpha-reductase inhibitor used for: -BPH -Male pattern baldness SE: -decreased libido and ejaculation vol. -gynecomastia -may experience erectile dysfunction -orthostatic hypotension PT EDU: -do not donate blood unless med has been discontinued for at least 1 mo. -6 to 12 months before improved urinary flow occurs (reduces the size of the prostate over time). IBS - S/S: cramping, N, bloating, belching, either diarrhea/constipation. changes in bowel patterns, abd distension, presence of mucous in stool. EDU: reduce stress and irritating foods (caffiene, alcohol, gassy foods). Increase fiber (30-40 g/day) and fluids (2-3 L/day). Meds: -Alosetron (IBS with diarrhea) -lubiprostone (IBS w constipation) Small/Large Bowel Obstruction - S/S for both: abd distension, BS high pitched & hypperactive above, and hypoactive below obstruction. SBO: profuse sudden projectile vomit w fecal odor. if partial -presence of peristaltic waves in upper and middle abd. hypovolemia/dehydration with intense thirst and dry mucous membranes. LBO: D/ribbon like stool, cramping in the lower abd CT scan NPO, NG tube, (provide oral hygiene Q2h, clamp tube during ambulation). Advance to clear liq diet (clamp NG), then full liq, then soft. UTI - S/S: abd discomfort, N/V, fever, urinary freq and urgency, dysurea, cloudy/foul smelling urine. Elderly: +confusion Urinalysis: bacteria, WBC, +leukocyte esterase and nitrates. Tx: antibiotics (fluoroquinolone), bladder analgesic (phenazopyridine -discolors urine to orange), increase fluids 3L/day, empty bladder Q3-4H, cranberry juice Complications of UTI - Pyelonephritis (kidney infection) S/S: cotal vertibal tenderness (flank lower back pain),fever, tachypnea, tachycardia, HTN, N/V. Urinalysis: bacteria, WBC,// positive leukocyte esterase (WBC in the urine) and positive nitrates in urine (Nitrite is an enzyme that is present in the urine when bacteria are present). Tx: antibiotics and opioids. Monitor for septic shock, chronic kidney disease, and HTN. Extracorporeal Shock Wave Lithotripsy (ESWL) - Indication: Renal Calculi (uses sound/laser/shock waves to break calculi . requires moderate [conscious] sedation and EKG monitoring.) Interventions: assess for gross hematuria and strain urine following procedure to verify calculi passed. -Report: flank persistent bleeding, inability to void, fever & chills, or recurrent N/V. EDU: bruising around site is normal. blood-tinged urine is a common occurrence for several days and does not need to be reported to the provider. No NSAIDs 7-10 days post. Instruct the client to test urine pH up to three times daily and report abnormal levels (norm: 4.5-8.0) REPORT: hematuria postprocedure. flank or bladder pain, chills and fever, or difficulty urinating (including decreased urine output or pain with urination) =client is developing an infection or can signal reoccurrence of a stone. Herbal supplements - -The nurse should include that garlic can help improve cholesterol levels, which then helps to reduce the buildup of plaque in the arteries. For some clients, it can also help lower blood pressure. -A client who has migraine headaches can take feverfew prophylactically to reduce the frequency of the headaches. -A client who has peripheral artery disease or memory impairment can benefit from taking gingko. Gingko can help improve circulation throughout the body and the brain -A client can take valerian to help promote sleep and reduce anxiety Pernicious Anemia - *S/S: bright red tongue, pain, hypoxia with sickle cell crisis (malformed), cold sensitivity, pallor, fatigue, irritability, numb/tingling ext, dizziness/syncope, DOE, tachycardia, palpitations, nail bed deformity, pale or yellowtinged skin, glossitis, weight loss, fatigue, and problems with balance. RF: Vitamin B12 deficiency chemo therapy induced anemia - TX: Epoetin -The nurse should avoid shaking the medication vial because this can inactivate the medication. -The nurse should plan to administer epoetin to clients who have chemotherapyinduced anemia when the hemoglobin level is less than 10 g/dL. The nurse should withhold epoetin if the client's hemoglobin level is greater than 12 g/dL. -Hypertension and cardiovascular events, such as myocardial infarction and stroke, are adverse effects of epoetin. Upper Respiratory Disorder Med - Acetylcysteine (thins and enhance the flow of secretions in the respiratory passage.) Class: mucolytics Indications: Cystic fibrosis. COPD. Antidote for acetaminophen. Interventions: monitor liver fx test, PT, BUN, creatinine, glucose, electrolytes. Complications: aspiration, bronchospansms (PO), dizziness, drowsiness, hypoTN, tachycardia, hepatotoxicity. -experiences white or clear mucus Pneumonia - Infection that inflames air sacs in one or both lungs, which may fill with fluid. S/S: anxiety, fatigue, weakness, chest discomfort, fever, chills, SOB, chest pain, tachypnea, cough, difficulty breathing, crackles/wheezes, confusion (elderly) from hypoxia Lab work: blood culture, sputum and sensitivity (before antibiotic), elevated WBC, ABGs, serum electrolytes, chest x-ray. *Tx: high fowlers, cough and deep breathing, suction, breathing tx, O2, incentive spirometer Q1H while awaike, determine physical limitations, promote nutrition and fluids intake 2-3L/day. Meds: antibiotics, bronchodialators (albuterol), anti-inflammatory (glucocorticoid "...sone" [monitor gi bleeds and hyperglycemia, decreased immunity, fluid retention, weight gain, mouth sores]). Children (cognition level) - Infants/ young toddlers - separation anxiety. Hospitalization= punishment. Parallel play (next to). They are unable to understand the concept of death. However, they tend to feel a sense of loss and might become increasingly irritable or withdrawn. Preschoolers - same + magical thinking (death is reversible or they caused it by being mean). Explain simple language and give them options. Associated play. School aged - can describe pain, understand cause and effect. Give factual info, encourage expressions. Cooperative play. Adolescent - body image disturbance when hospitalized. Same as school aged. when dealing with death, have difficulty communicating their feelings and alienate themselves from their peers and families. view funeral services as unnecessary or barbaric and an unwarranted expense. Death and Dying - Anticipatory grief - when its expected Complicated grief - 1 year following loss Infants/toddlers: don't understand so mirror parents or regress in behavior. *Preschoolers: magical thinking, feels guilt or shame. View dying as temporary (sleeping). View separation as result of bad behavior. School aged: similar to adults and express fear through uncooperative. Personifies death as evil or a type of monster. have a fear of transmitting their disease to others. wonders what happens to a body following death and to be interested in postmortem services. 5 stages of grief - Denial Anger Bargaining Depression Acceptance Normal grief - Is uncomplicated. ●Emotions can include anger, resentment, withdrawal, hopelessness, and guilt but should change to acceptance with time. ●Client should achieve some acceptance by 6 months after the loss. ●Somatic manifestations can include chest pain, palpitations, headaches, nausea, changes in sleep patterns, or fatigue. ●The nurse should assess the client to identify a normal vs. maladaptive grief response Anticipatory grief - This grief implies the "letting go" of an object or person before the loss, as in the case of a terminal illness. ●Individuals have the opportunity to grieve before the actual loss. Maladaptive grief - Delayed or inhibited grief ●The client does not demonstrate the expected behaviors of the normal grief process. ●Cultural expectations can influence the development of delayed or inhibited grief. ●Clients can remain in the denial stage of grief for an extended period of time. ●Due to client's inability to progress through the stages/tasks of grief, a subsequent minor loss (even years later) can trigger the grief response. Distorted or exaggerated grief response ●The client experiences the feelings and somatic manifestations associated with normal grief but to an exaggerated level. ●The client is unable to perform activities of daily living. ●The client can remain in the anger stage of the grief process and can direct the anger towards himself or others. ●The client can develop clinical depression. Chronic or prolonged grief ●This maladaptive response is difficult to identify due to the varying lengths of time required by clients to work through the stages/tasks of grief. ●Clients can remain in the denial stage of grief and remain unable to accept the reality of the loss. ●Chronic or prolonged grief can result in the client's inability to perform activities of daily living RISK FACTORS FOR MALADAPTIVE GRIEVING ●Being dependent upon the deceased ●Unexpected death at a young age, through violence, or by a socially unacceptable manner ●Inadequate coping skills or lack of social support ●Pre-existing mental health issues, such as depression or substance use disorder NURSING CONSIDERATIONS ●Clients who are experiencing a maladaptive grief response commonly experience a loss of self-esteem and a sense of worthlessness not associated with normal grief. ●The nurse should assess the client for risk factors and identify a normal versus a maladaptive grief response. Immunity - -Nonspecific Innate: the defense system a human is born with (skin); protects against all antigens; also involves inflammatory responses. Specific Adaptive: body produces antibody in response to specific antigen through T and B lymphocytes. Takes longer but more efficient and lasts lifetime. Active Natural: body produces antibodies after exposure to live pathogen (cold virus). Infection Control - CONTACT Indications: MRSA, RSV, C-diff, herpes simplex, VRE, Impetigo, scabes, wound infections, shigella. -The client should wear an isolation gown and wash his hands before being transported from the room to prevent the spread of micro-organisms. -bathe the client using warm water and a chlorhexidine solution -use dedicated equipment -private room -gloves and gowns -disposal of infectious dressings and materials into single nonporous bag. AIRBORN Indications: Measles TB Varicella-(chicken pox. lymphadenopathy [swollen lymph nodes]) -Negative air flow room -N95 DROPLET Indications: influenza, sepsis, strep, pneumonia, pertussis, bacterial meningitis, mumps ( parotitis, or enlarged parotid glands), rubella -private room -caregivers and visitors wear mask Rifampin - -can be used to treat TB -gives skin and secretions a reddish-orange color. It can also permanently stain soft contact lenses. -diarrhea -liver damage. Alcohol intensifies this risk. is contraindicated for clients who have liver disease or consume alcohol in excess. -take rifampin on an empty stomach, either 1 hr before or 2 hr after meals. Infection Process - Incubation: pathogen enters body Prodroma: onset of GENERAL symptoms until pt exhibits specific symptoms to infection. Illness: SPECIFIC symptoms occur. decline-? Convalescence: symptoms DISAPPEAR until complete RECOVERY (several months) Cellulitis - Bacterial infection. S/S: swollen, red, painful, warm to touch skin --usually in lower extremities. Dx: culture (identify pathogen) sensitivity (determine if antibacterial is sensitive to microbe -successful tx if yes) *Med: systemic antiobiotic therapy (cephalosporins or PCNs). cefazolin intermittent IV bolus antibiotic Edu: bathe daily using antibacterial soap, apply warm compress 2x/day for comfort, do not squeeze lesion but gently remove crusted exudation before applying antibacterial ointment/lotion. Interventions: -elevate extremity 7.6 to 15.2 cm (3 to 6 in) above the heart to promote venous return and decrease edema, -apply cool MOIST packs to the affected area every 2 to 4 hr until inflammation subsides then transition to warm MOIST packs to increase comfort and decrease swelling. -The nurse should not apply topical steroids to any open skin lesions that are possibly infected. The steroids can decrease the immune response and worsen the infection. Antibacterial topical ointment can be applied if an infection is present. Dermatitis - DIAPER: (rash) wash area with warm water and mild soap, expose area to air, encourage super absorbent diapers (no cloth), frequent diaper changes, avoid buble baths. TX: zinc oxide, corn starch reduces friction (NOT talcum powder). POISON IVY: TX: alcohol followed by water with mild soap. Apply calamine lotion or "burro" solution, topical corticosteroid gel. - Contact dermatitis from poison ivy is not contagious or spread through contact with the infected child. Contact dermatitis occurs following exposure to the oil in the poison ivy plant. - tepid baths containing oatmeal or mineral oil can decrease itching and evenly disperse the antipruritic solution. The parent should not place the child in a hot bath as this can aggravate the child's condition and increase itching.