Ati Medsurg Study Guide

ATI MedSurg STUDY GUIDE (Safety) Seizure precautions Epilepsy During Protect the client’s privacy and the client from injury (move furniture away, hold head in lap if on the floor). Position the client to provide a patent airway. (Remember aspiration, turn head to side) Be prepared to suction oral secretions. Turn the client to the side to decrease the risk of aspiration. Loosen restrictive clothing. Do not attempt to restrain the client. Do not attempt to open the jaw or insert airway during seizure activity (can damage teeth, lips, and tongue). Do not use padded tongue blades. Document onset and duration of seizure and findings (level of consciousness, apnea, cyanosis, motor activity, incontinence) prior to, during, and following the seizure Post Seizure This is the postictal phase of the seizure episode. Maintain the client in a side‑lying position to prevent aspiration and to facilitate drainage of oral secretions. Check vital signs. Assess for injuries. Perform neurological checks. Allow the client to rest if necessary. Reorient and calm the client, who might be agitated or confused. Determine if client experienced an aura, which can indicate the origin of seizure in the brain. Try to determine possible trigger (e.g., fatigue). (Precautions transmission): Tuberculosis Appropriate interventions • Prevent infection transmission. • Wear a N95 HEPA filter or powered air purifying respirator when caring for clients who are hospitalized with TB. (23.2) • Place the client in a negative‑airflow room, and implement airborne precautions. • Use barrier protection when the risk of hand or clothing contamination exists. • Have the client wear a surgical mask if transportation to another department is necessary. The client should be transported using the shortest and least busy route. • Teach the client to cough and expectorate sputum into tissues that are disposed of by the client into provided plastic bags or no‑touch receptacles. • Airborne precautions are not needed in the home setting because family members have already been exposed. Exposed family members should be tested for TB. • Continue medication therapy for its full duration of 6 to 12 months, even up to 2 years for multidrug‑resistant TB. Emphasize that failure to take the medications can lead to a resistant strain of TB • Sputum early AM (AFB, wear PPE) needed every 2 to 4 weeks to monitor Tx. After 3 consecutive negative, no longer consider infected • Dispose of tissues in plastic bag, wear mask in public • The client's infection is usually no longer contagious after taking TB medications for 2 to 3 weeks. Medical Surgical Asepsis: Maintain sterile field • Avoid coughing, sneezing, and talking directly over a sterile field. • Advice clients to avoid sudden movements, refrain from touching supplies, drapes, or the nurse’s gloves and gown, and avoid coughing, sneezing, or talking over sterile field • Only sterile items may be in a sterile field. • The outer wrappings and 1‑inch edges of packaging that contains sterile items are not sterile. The inner surface of the sterile drape or kit, except for that 1‑inch border around the edges, is the sterile field to which other sterile items may be added. To position the field on the table surface, grasp the 1‑inch border before donning sterile gloves. Discard any object that comes into contact with the 1‑inch border. • Touch sterile materials only with sterile gloves. • Consider any object held below the waist or above the chest contaminated. • Sterile materials may touch other sterile surfaces or materials; however, contact with nonsterile materials at any time contaminates a sterile area, no matter how short the contact. • Open drape furthest from body, then siders, than closest to body, grasp drape with finger tips and lay on surface • Cap off first, then glove non-dominant hand Microbes can move by gravity from a nonsterile item to a sterile item. • Do not reach across or above a sterile field. • Do not turn your back on a sterile field. • Hold items to add to a sterile field at a minimum of 6 inches above the field Any sterile, non-waterproof wrapper that comes in contact with moisture becomes nonsterile by a wicking action that allows microbes to travel rapidly from a nonsterile surface to the sterile surface. • Keep all surfaces dry. • Discard any sterile packages that are torn, punctured, or wet. PROCEDURE Perform hand hygiene. STERILE FIELD SETUP • Open the covering of the package per the manufacturer’s directions, slipping the package onto the center of the workspace with the top flap of the wrapper opening away from the body. • Grasp the tip of the top flap of the package, and with arm positioned away from the sterile field, unfold the top flap away from body. • Next, open the side flaps, using the right hand for the right flap and the left hand for the left flap. • Grasp the last flap and turn it down toward the body ADDITIONAL STERILE PACKAGES • Open next to the sterile field by holding the bottom edge with one hand and pulling back on the top flap with the other hand. Place the packages that will be used last furthest from the sterile field; open these first. • Add them directly to the sterile field. Lift the package from the dry surface, holding it 15 cm (6 in) above the sterile field, pulling the two surfaces apart, and dropping it onto the sterile field. POUR STERILE SOLUTIONS • Removing the bottle cap. • Placing the bottle cap face up on a clean (nonsterile) surface. • Holding the bottle with the label in the palm of the hand so that the solution does not run down the label. • First pouring a small amount (1 to 2 mL) of the solution into an available receptacle. • Pouring the solution (without splashing) onto the dressing or site without touching the bottle to the site. STERILE GLOVES • Once the sterile field is set up, don sterile gloves. • Sterile gloving includes opening the wrapper and handling only the outside of the wrapper. Don gloves by using the following steps. • With the cuff side pointing toward the body, use the nondominant hand and pick up the dominant‑hand glove by grasping the folded bottom edge of the cuff and lifting it up and away from the wrapper. While picking up the edge of the cuff, pull the dominant glove onto the hand. • With the sterile dominant‑gloved hand, place the fingers of the dominant hand inside the cuff of the nondominant glove, lifting it off the wrapper and putting the nondominant hand into it. • When both hands are gloved, adjust the fingers. • During that time, only a sterile gloved hand may touch the other sterile gloved hand. • At the close of the sterile procedure or if the gloves tear, remove the gloves. Take them off by grasping the outer part of one glove at the cuff area, avoiding touching the wrist and pulling the glove down over the fingers and into the hand that is still gloved. Then, place the ungloved hand inside the soiled glove and pull the glove off so that it is inside out and only the clean inside part is exposed. Discard into an appropriate receptacle. (Precautions transmission) Gastrointestinal Dx: Plan of care for Gastroenteritis Contact for viral Fecal-oral (Health promo) Hypertension prevention measures • BMI 30 • Crtl DM Blood Glucose • Limit Caffeine, ETOH (limit 2 servings men, 1 women 1.5oz licor, 5oz wine, 12oz beer) • MGMT Stress • Smoke Cessation • Aerobic Exercise x 3 week • Limit Sodium (1.5-2.3g/day), Fat less 20% to 35% daily Kcal, 10% Saturated Cholesterol 300mg/day. • DASH: High fruits veggies, low fat. Rich in Ca and Mg • (High risk behaviors)Female Client teaching of genital herpes • Dx can be based on Hx and CM and confirmed with • Herpes viral culture swab: A cotton–tipped applicator is used to obtain vesicle fluid from intact lesions for culture. • PCR: ID Herpes (HSV1 or HSV2) DNA/RNA from cells from lesions, blood or body fluids • ELISA HerpeSelect, HerpeSelect Immunoblit, Western Blot to Differentiate between antibodies to HSV1 & HSV2 • Acyclovir (AE Phlebitis, Nephrotoxicity), Famciclovir , Valacycolvir Use gloves for topical admin, relief but no cure • Wash tx area 3/4x day and keep dry. No sex w/ lesions present. Use condoms (Mobility immobility)Stroke care for left sided hemiplegia CM: • The left cerebral hemisphere is responsible for language, mathematics skills, and analytic thinking. • Expressive and receptive aphasia (inability to speak and understand language) • Agnosia (unable to recognize familiar objects) • Alexia (reading difficulty) • Agraphia (writing difficulty) • Right extremity hemiplegia (paralysis) or hemiparesis (weakness) • Slow, cautious behavior • Depression, anger, and quick to become frustrated • Visual changes, such as hemianopsia (loss of visual field in one or both eyes) Right side: visual and spatial awareness proprioception • Left Hemi-paresis, hemiplegia • Left hemianopsia • Overestimation of abilities • Unilateral neglect • Loss of depth perception • Poor judgment/impulse control Care: • Vitals Q1-2H Call Doc if BP 180/110 (CM ischemic stroke) Mon Temp (↑Temp =↑ICP) • O2 if SaO2 92% or ↓LOC • ECG, auscultate for murmurs or irregularities • HOB 30° Avoid extreme flexion or extension of the neck. Keep body midline neutral • ROM PROM Q2H • Dress affected side first. Counter leaning on affected side. Support affected arm to prev shoulder subluxation (Mobility immobility)Musculoskeletal trauma: Preventing complications • Provide emergency care at time of injury. • Maintain ABCs. • Monitor vital signs and neurological status because injury to vital organs can occur due to bone fragments (fractures of pelvis, ribs). • Stabilize the injured area, including the joints above and below the fracture, by using a splint and avoiding unnecessary movement. • Maintain proper alignment of the affected extremity. • Elevate the limb above the heart and apply ice. • Assess for bleeding and apply pressure, if needed. • Cover open wounds with a sterile dressing. • Remove clothing and jewelry near the injury or on the affected extremity. • Keep the client warm. • Assess pain frequently and follow pain management protocols, both pharmacological and nonpharmacological. • Initiate and continue neurovascular checks at least every hour. Immediately report any change in status to the provider. • Prepare the client for any immobilization procedure appropriate for the fracture. • Compartment Syndrome: Assess neuro Frequent, report pain unrelieved by meds, tingle, numb or change in color in extremity • Immobilize fractures, min manipulation to prevent fat embolism Casts • Monitor neurovascular (Pain, sensation, temp, cap refill, pulse, mov) status every hour for first 24 hr and assess pain. • Handle cast with palms, don’t set on sharp edges. Elevate above heart for 1st 24-48hrs. Should be room for 1 finger. Report CM of infections “hot spots” or immobility issues like SOB, skin breakdown and constipation. Traction • Neuro checks Q1h for 24hrs then 4hrs. • Keep body aligned • Weight should hang free, no fraying/knots, loosen of cords check Q8-12h • Pins may use chlorahexadine, 1 pin = Qtip 1-2 x per day Compartment syndrome IF UnTx =Necrosis, neuromusc dmg, need fasciotomy • Pain, paralysis(L), paresthesia(E), pallor, and pulselessness(L) • Pain unrelieved by elevation or meds. Intense pain with passive mov. • Paresthesia numb tingle burn early cm • Paralysis weakness =nerve damage late cm • Pallor w cyanotic nails • Pulseless Late CM • Palpated muscles hard from edema (Mobility immobility)Preventing postop complications • ABC, resp effort, SaO2 Vitals Q15 Mins • Yankauer suction for thick oral secretions or a large French suction catheter for nasopharyngeal or nasotracheal secretions • Report increases/decrease of 25% in BP, trending decrease • Prevent hypothermia • Lateral position (RorL) if unresponsive/unconscious. If responsive to stim, gradual elevation to semifowlers. No pillows or knee gatches in bed. Specifics • Airway obstructed: choking; noisy, irregular respirations; decreased oxygen saturation values; and cyanosis. Implement headtilt/chin lift to pull tongue forward and open airway. Have Res equipment. Elevate HOB if not contra. Give humid O2 and plan for reintubation. • Hypoxia: Mon oxygenation, cough deep breath, HOB elevated, turn Q2H • Hypovolemic shock: Mon BP, cap refill, narrowing pulse pressure, ↑ HR and Resp, place supine w legs elevated, admin fluids & vasopressors • Paralytic ileus: Mon bowel sounds, ambulate, advance diet when bowel sounds and flatus present, can empty stomach content with NG tube. • Deshicence /Eviseration: Mon for risk factors (steroid uses, DM, HTN, obese, no splintting when cough ambulate, infection, hematoma, malnutrition) Call for help, stay w pt, cover wound with sterile towel/dressing soaked in sterile saline, don’t reinsert organs, low fowlers with hips and knees bent. Monitor for shock and call doc. • DVT due to dehydration, immobility, obesity, trauma, malignancy, Hx, hormones, indwell venous cath. Heparin. TED hose/SCD, ROM, early ambulate. No pressure behind the knees with pillows or blankets, no dangling for long periods, hydrate with IV/PO fluids. (Nutrition/hydration) Care for receiving radiation • May have mucositis and xerostomia, dysphagia or gastroenteritis • Provide a well‑balanced diet that does not contain red meat. Radiation can cause dysgeusia (altered taste), making foods such as red meat unpalatable. • Avoid spicy, salty, acidic foods. Hot foods might not be tolerated (Nutrition/hydration) Heart Failure / PE Sodium restriction teaching Low Sodium diet low sat fat and fluid restrictions No more than 2,300 milligrams of sodium, Less than 1,500 mg a day is ideal (Nutrition/hydration) Diet recommendation for nephrotoxic syndrome Acute kidney injury: Implement potassium, phosphate, sodium, and magnesium restrictions, if prescribed (depending on the stage of injury). Restrict fluid intake, if prescribed. High‑protein diet to replace the high rate of protein breakdown due to stress from the illness. Possible total parenteral nutrition (TPN). Chronic kidney Disease: diet that is high in carbohydrates and moderate in fat. Restrict potassium, phosphate, sodium, and magnesium. Restrict fluids based on urine output. Nephrotic syndrome (kidney failure) diet: Low fat/Sodium. Too much protein can dmg nephrons (Meds AE/SE/Contra/Interactions)Interactions of medications affecting blood pressure (Meds AE/SE/Contra/Interactions)Antibiotics Bactericidal: CM to report (Penicillins) • Allergies/anaphylaxis: report skin rash/hives hypotension, dyspnea • Renal impairment :Monitor Kidney Func and I/O • Hyperkalemia/dysrhitmias (penicillin G) • Hypernatremia (ticarcillin) • Bleeding (cegotetan/ceftriaxone) • Pseudomembranous colitis:diarrhea • GI symps Carbapenems • Suprainfection Carbapenems:Thrush, candidiasis • Otoxicity Vancomycin/azotronam/fosfomycin: tinnitus, hearin loss. • Rash/flush/tachycardia during infusion Vancomycin • Renal toxicity Vancomycin Mon I/O and kidney function (Meds AE/SE/Contra/Interactions)Rheumatoid arthritis: Labs to report • Methotrexate: CBC, Liver func, • Cyclosporine Kidney Func • Prednisone Blood Glucose, potassium (Meds AE/SE/Contra/Interactions)Non-opioid analgesics interactions • Aspirin affects coagulation (COX-2 irreversible inhibitor) • Avoid ETOH, increase risk bleed • NSAIDs (COX-2 reversible inhibitor) decrease antiplatelet effect of low dose aspirin • NSAIDs and ketorolac avoid concurrent use • Ketorolac avoid use for more than 5 days (Kidney Damage) • ETOH + Tylenol= Liver Damage • Tylenol slows metabolism of Warfarin (Blood products)Admin of packed RBCs (Blood products) Initiating a transfusion of packed RBCs (Central venous access) Accessing implanted port/ (Central venous access) Flushing implanted port • Only specifically trained personnel wearing a mask and aseptic technique should access implanted ports • Apply topical anesthetic cream to skin if indicated. Palpate skin to locate the port body septum to ensure proper insertion of the needle. • Access with a noncoring (Huber) needle. • Check for blood return prior to medication administration to confirm patency and placement. • Flush with 5 mL heparin 100 units/mL after every use and at least once per month (INS recommendation). PICC LINE Pre: • Cleanse the site with chlorhexidine. • Ensure sterility of equipment. Place a STOP sign on the door to the room to restrict entry during the procedure. Intra/post: • Confirm placement of the PICC with an x‑ray. Assess the site for redness, swelling, drainage, tenderness, and condition of the dressing. • Clean the insertion port with alcohol for 15 seconds and allowing it to dry completely prior to accessing it. • Valve disinfection caps which contain alcohol are available for single use. • Use transparent dressing to allow for visualization. Follow facility protocol for dressing changes, usually every 7 days and when indicated (wet, loose, soiled). • Advise the client not to immerse his arm in water. To shower, cover dressing site to avoid water exposure. • Educate the client not to have venipuncture or blood pressure taken in arm with PICC line. Flush PICC • Use a 10 mL syringe for flushing the PICC line. Do not apply force if resistance is met. • Flush with 10 mL 0.9% sodium chloride before, between, and after medications. • Flush with 20 mL 0.9% sodium chloride after drawing blood. • Flush with 5 mL heparin (10 units/mL) when the PICC is not actively in use. The frequency of the flush depends on the type of PICC. (Central venous access) peripherally inserted central venous cath care • Flush the line according to INS recommendations or facility policy. Do not force fluid if resistance is encountered (can dislodge thrombosis). Use a 10 mL to avoid excess pressure per square inch that could cause catheter fracture/rupture. (Expected action/outcome) Meds affecting urinary output- Expected finds for med effective High-ceiling loop diuretics, thiazide diuretics, potassium-sparing diuretics, and osmotic diuretics • Decreased BP. • Decreased edema. • Increased urine output. • Reduced intracranial pressure. • Prevention of hypokalemia in patients taking diuretics. • Treatment of hyperaldosteronism. (Expected action/outcome) Valsartan admin for heart failure Preload decrease • ARB = Vasodilation and excretion of sodium/H2O and retention of potassium • Use HTN, Heart Fail, MI, stoke prevent and delay in progress DM neuropathy. • AE: Angioedema {(Skin Wheals, tongue swollen) Tx severe cases with SubQ Epinephrine} and Fetal injury. NO COUGH or Hyperkalemia like ACE Inhibitors • Decrease in blood pressure and maintenance of normotensive blood pressure. • Improvement of heart failure such as ability to perform activities of daily living, improved breath sounds, and absence of edema. • Improvement in renal function and delay of further progression of renal disease. (Expected action/outcome) Therapeutic effects furosemide • Blocks reabsorption of sodium and chloride and to prevent reabsorption of water .Causes extensive diuresis even with severe renal impairment • Tx PE r/t Heart fai. Edema r/t liver, cardiac, kidney disease that don’t respond to other diuretics. May treat hypercalcemia r/t stone formation. • AE: Dehydration, hypokalemia, hyponatremia, hypochloremia, hypotensions, otoxicity, hyperglycemia, hyperuricemia. (Med Admin) TB med therapy teaching • RIPE(S) Rifapentine, Ionazid (bacteriostatic), Pyrazinamide, Ethambutol (Streptomycin) • Latent TB: Ionazid for 6-9mo or Ionazid+rifapentine once weekly 3 months • Active: Multiple meds for min 6 months, up to 2 years for MDR-TB • Phases: Induction: eliminate basilli- non infectuos sputum. Continuation phase: eliminate other pathogens 6-24 months • AE Peripheral neuropathy, hepatoxicity, hyperglycemia • Contra: Ionazid w/ liver disease • Interactions: Ionazid inhibits metabol of phenytoin. Rifampin and pyrazinamide and ETOH - hepatox • Take ionazid 1hr AC or 2hrs PC • Rifampin turns urine orange, hepatox. Interacts with Warfarin, contraceptives, protease inhibitors, NNRT. Ionazid+pyrazinamide and rifampin =hepatox risk increase. Avoid ETOH (Med Admin) MI/Angina Nitroglycerin teaching • centrally-acting vasodilator: Direct vasodilation of arteries and veins resulting in rapid reduction of blood pressure (decreased preload and afterload) • AE: Hypotension • Teaching: Instruct the client to stop activity and rest. • Instruct the client to place a nitroglycerin tablet under the tongue to dissolve (quick absorption). • If pain is unrelieved in 5 min, the client should call 911 or be driven to an emergency department. • The client can take up to two more doses of nitroglycerin at 5‑min intervals. • Remind the client that a headache is a common side effect of this medication. • Encourage the client to sit and lie down slowly. • No ED drugs AFILS (Med Admin) teaching food interactions of warfarin • Vitamin K is antidote found in Green leafy vegetables (Spinach, broccoli, cabbage,) eggs, liver, some oils. • Avoid fluctuations in amount/frequency of consumption (Med Admin) Meds affecting BP: Contraindications for Nadolol • BB non selective (affects heart and lungs) • Contraindications: AV block, asthma, sinus bradycardia. • Caution with DM, Myasthenia gravis, depression • Interacts with Ca Channel blockers (verapamil, dilitiazem), antiHTN (Med Admin) HTN expected prescriptions to receive • Diuretics (Thiazide, loop-furosemide, spironolactone) • Ca Channel blockers -Verapamil, amlodipine, and diltiazem • Ace Inhibitors (prils) • ARBs (Sartans) Can increase K • Aldasterone Receptor antagonists (eplerenone, Spironolactone) • Beta blockers (LOL) • Central Alpha Agonist – Clonidine • Alpha antagonists- Prazosin (Med Admin)Hematological Dx procedures: Eval PT understanding of anticoagulant therapy (Med Admin)Cancer Tx: Actions to prevent chemotherapy induced nausea and vomit • Chemo can induce vomit, cause anorexia or altered taste. • Give antiemetics before therapy and repeat based on response. • Give antiemetics for several days post treatment even if nausea seems controlled • Remove vomiting cues (odors, etc) • Can admin Magestrol to increase appetite • Mouth care AC Meds: • Seratonin blockers (Ondasetron) often admin with corticosteroids, phenothiazine (antipsyche zine) and antihistamines (most end with INE) • Neurokinin receptor antagonists (aprepitant); corticosteroids (dexamethasone, methylprednisolone); dopamine antagonists (promethazine, prochlorperazine); histamine blockers and proton pump inhibitors (omeprazole, ranitidine); prokinetic agent (metoclopramide), benzodiazepines (lorazepam); and cannabinoids (dronabinol, nabilone) are other examples of medications used for chemotherapy‑induced nausea and vomiting (CINV) Teach: • Admin antiemetic’s and schedule them AC • Small freq meal; Low‑fat dry foods (crackers, toast) and avoiding drinking liquids during meals can prevent nausea • Use cold foods that don’t require cooking, no red meats, they taste like metals • High protein/calorie/ nutrient dense foods • Use plastic utensils (metal taste bad) (Med Admin) TX for diabetes insipidus Desmopressin Synth ADH PO, Nasal (clear passage before admin), Parenteral -Water absorption from kidneys and decrease urine output. Can cause vasoconstriction. Dose adjusted on urine output. Monitor for Monitor for headache, confusion, or other indications of water intoxication. Notify provider if weight gains of 0.9 kg in 24hrs. Needs lifelong admin. Get med alert bracelet. I/O, Weight daily and eat high fiber. (TPN) Nutrition assessment/data collection: caring for client w pancreatitis (ases high) Causes • Biliary tract disease: Gallstones can cause a blockage where the common bile duct and pancreatic duct meet. • Alcohol use: The primary cause of chronic pancreatitis is alcohol use disorder. Times of increased alcohol consumption, such as vacations or holidays, are associated with acute pancreatitis. • Increased age: Pancreatitis is more common in older adults. • Endoscopic retrograde cholangiopancreatography (ERCP) (postprocedure complication) • Gastrointestinal surgery • Metabolic disturbances (hyperlipidemia, hyperparathyroidism, hypercalcemia) • Kidney failure or transplant • Genetic predisposition • Trauma • Penetrating ulcer (gastric or duodenal) • Medication toxicity • Viral infections: coxsackievirus B and human immunodeficiency virus • Cigarette smoking Labs Amylase, lipase, bilirubin, glucose, WBC, erythrocyte sed rate increased Ca Mg platelets decreased CM • Sudden onset of severe, boring pain (goes through the body) Epigastric, radiating to back, left flank, or left shoulder. Worse when lying down • Pain relieved somewhat by fetal position or sitting upright, bending forward • Nausea and vomiting Weight loss • Seepage of blood‑stained exudates into tissue as a result of pancreatic enzyme actions • Ecchymosis on the flanks: Turner’s sign (54.1) • Bluish‑gray periumbilical discoloration: Cullen’s sign (54.2) • Generalized jaundice • Absent or decreased bowel sounds (possible paralytic ileus) • Warm, moist skin; fruity breath (evidence of hyperglycemia) • Ascites • Tetany due to hypocalcemia Trousseau’s sign: hand spasm when blood pressure cuff is inflated Chvostek’s sign: facial twitching when facial nerve is tapped Care • NPO: No food until pain‑free • For severe pancreatitis: TPN or jejunal feeds (contra if paralytic ileus, less risk hyperglycemia) • Diet when resumed: Bland, high protein, low fat diet with no stimulants. Small freq meals • NG tube decompress for sev vomit or paralytic lleus. • No ETOH or Smoke • Limit stress and manage pain. • Position for comfort fetal, side lying, HOB elevated, sit up/lean fw (TPN) GI Tx: Discontinuing TPN • Don’t stop abruptly EVER. Speed up/slow down contraindicated –Can alter blood glucose- rebound hypoglycemia • Flow is adjusted gradually (no more than 10% increase/hr) • Follow sterile protocol. • Change tube n bag Q24H add filter for particles • If DC for preop, sub for and a 5% or 10% dextrose solution (TPN) GI Tx: Calculating protein requirements • Min of 0.8 g of protein per kilogram, more if athlete or illness (NIH) • The recommended dietary requirement of protein for adults is 10% of intake, or 46 g/day for women and 56 g/day for men. • TPN: Available concentrations 3-5%. Protein should provide 3.5 to 20%. Goal is normal albumin level 3.5-5 (Dx test) Antimicrobial therapy: interventions for suspected septicemia Obtain a blood culture for diagnosis. Mechanical ventilation and dialysis may be needed for treatment. Systemic antimicrobials will be prescribed accordingly. Encourage increased fluid intake, use consistent hand washing, and implement protective precaution (Dx test) ECG/Dysrhythmia: Analyzing Cardiac strip • 1mmx 1mm block = 0.04secs • 5mmx5mm block = 0.2 secs • P wave Atrial depolarization (contraction) • ▪QRS Complex -Normal 0.06-0.12 -Ventricular depolarization, atrial repolarization • ▪T wave Ventricular repolarization (resting phase) • Measure heartbeat R to R If vary 0.06 (1.5 boxes) =regular) • PR interval normal is 0.12-0.20 Rhythms A-FIB: No P Wave /R-R irregularly irregular A Flutter: Sawtooth/picket fence P:QRS ratio 2+:1 SVT: Narrow QRS = 0.12 no P wave V- Tach: Wide QRS = 0.12 teeth/shark fins V-Fib: coarse squiggly lines Block 1: PR Interval 0.20 Block 2 I: Progressive prolongation followed by P w/o QRS (dropped QRS) 3:2 4:3 5:4 ect Block 2 II: Some QRSs dropped 2:1 3:1 etc Block 3: 2 distinct heartbeats. PR interval very irregular Junctional: inverted P Waves when present (Dx test) Neuro Dx: Prep Pt for lumbar puncture • Ensure that all of the client’s jewelry is removed and that the client is wearing only a hospital gown. • Instruct the client to void prior to the procedure. • Clients should be positioned to stretch the spinal canal. This can be done by having the client assume a “cannonball” position while on one side or by having the client stretch over an overbed table if sitting is preferred. (3.1) (Labs) ABGs • Ph 7.35 -7.45 • PaO2 80-100 mmHg • PaCO2 35-45 mmHg • HCO3 21-28 mEq/L • Acidic: 7.35pH 45 PaCO2 HCO3 21 • Basic 7.45 35 PaCO2 HCO3 28 (Labs) ABG values interpretation (Labs) Electrolyte imbalances: Increased risk Digoxin toxicity • Conditions that increase the risk of developing digoxin-induced dysrhythmias include hypokalemia, increased serum digoxin levels, and heart disease. Older adult clients are particularly at risk Monitor • Digoxin : 0.5 to 2.0 ng/mL. Tox signs appear at 1.75. If heart fail nest dose is 0.5-0.8 ng/ml. Decrease dose if used with Verapamil. CM tox= fatigue, weakness, vision changes, GI effects • Potassium 3.5-5 (Potential alt of systems) Peptic ulcer disease: monitor Ng output Monitor nasogastric tube drainage. Scant blood can be seen in first 12 to 24 hr. (Potential complications Dx test) Hepatitis/cirrhosis client position following biopsy • Hep A Fecal-oral (Ig post expo for 40 or older, less 12mo, or allergic to vax • Hep B Blood (Adefovir, Dipivoxil, lamivudine, entecavir, telbudine + interferons) • Hep C Blood (Interferon and rivarin) • Hep D Coninfect with B • Hep E Fecal-oral no meds, just care • Provide a high‑carbohydrate, high‑calorie, low‑ tomoderate‑fat, and low‑ to moderate‑protein diet. AVOID ETOH Liver Biopsy • Explain, Witness consent • NPO after midnight • Supine position with upper right quadrant of ab exposed • Have pt exhale and hold for 10 secs while needle inserted. Resume breathing once withdrawn • Apply pressure to puncture Post Biopsy • Right sidelying position for several hours • Vitals, assess for ab pain, bleeding, CM pneumothorax (Dyspnea, cyanosis, restless) (Potential complications Dx test) Renal Dx: Caring for pt after kidney biopsy Clients receive sedation and ongoing monitoring. PREPROCEDURE • Review coagulation studies. • Nothing by mouth for 4 to 6 hr. POSTPROCEDURE • Monitor vital signs following sedation. • Assess dressings and urinary output (hematuria). • Review Hgb and Hct values. • Administer PRN pain medication. COMPLICATIONS • Hemorrhage • Infection • Cloudy, foul‑smelling urine • Urgency • Urine positive for leukocyte esterase and nitrites, sediment, and RBCs (Potential complications Dx test) GI Tx procedures: Caring for pT receiving enteral feeding • Overfeeding: Check residual Q4-6H. Many facilities hold for residual volumes of 100-200ml the restart at lower rate after rest period • Diarrhea: Slow rate call doc/RD, provide skin protection • Aspiration Pneumonia: Stop feed, turn client to side and suction airway. O2 as prescribed. Auscultate lung sounds for congestion/diminished sounds • Refeeding syndrome: When feeding after starvation state (catabolizes own body for protein and fat) Mon for confusion and seizures, shallow respirations and muscle weakness. Get serum electrolytes if needed (Potential complications from surg and health alt) Hemodynamic Shock: MODS • MODS can develop from severe hypotension and reperfusion of ischemic cells, causing further tissue injury. • Lungs ARDS CM: Dyspnea, Bilateral noncardiogenic pulmonary edema, Reduced lung compliance, Dense patchy bilateral pulmonary infiltrates, Severe hypoxemia despite administration of 100% O2 • Kidneys • Heart decrease coronary artery perfusion, and cardiac contractility • GI-Necrosis • Assess organ function, and provide support measures that can increase tissue perfusion and improve organ function (ventilator support, inotropic medications). • Implement measures to compensate for dysfunction (administration of clotting factors, dialysis). (Potential complications from surg and health alt) GI Tx: Ostomy Complications • Monitor the type and fit of the ostomy, fit based on type n location, visual acuity and manual dexterity of client • Stoma should be pink and moist • Apply skin barrier n adhesive creams and allow to dry • Output should be more acidic/liquid closer to small intestine. • Empty when ¼ ½ full • Assess for electrolyte imbalances with ileostomy Teaching • Odor foods increase include fish, eggs, asparagus, garlic, beans, and dark green leafy vegetables • Odor foods decrease Buttermilk, cranberry juice, parsley and yogurt • With small intestine, avoid high fiber foods for 2 months post op. Eval for block when adding fiber • Filters, deodorizers, or a breath mint can be placed in the pouch Complications • Ischemia /necrosis: pale pink or bluish purple color and dry appearance. Black or purple in color, this indicates a serious impairment of blood flow and requires immediate intervention • Intestinal obstruction. Mon/record output stoma. CM: Ab pain, hypo/absent bowel sounds, distension, nausea/vomit Expected outputs • Ileostomy Cont output 1000 mL/day bile colored liquid. Then output reduced 500-1000ml paste • Transverse colostomy: Semiliquid (may have blood) 2/3 days postop. Then semiformed, formed • Sigmoid: Small to mod mucus w/ semi formed for 4/5 days postop. Then semiformed stool (Potential complications from surg and health alt) Cushing’s: Ongoing assess to Dx abnormal finds Hypercortisolism CM: Weakness, fatigue, sleep disturbances, back and joint pain, irritability and depression, decreased libido, thin fragile skin, bruising & petechiae, hypertension, tachycardia, gastric ulcers, weight gain and increased appetite, irregular menses, dependent edema (fat distribution: moonface, truncal obesity and fat collection on the back of the neck (buffalo hump), fractures and bone pain, muscle wasting, frequent infections, slow wound healing, hirsutism (excess female hair growth), red cheeks, striae (reddened lines on the abdomen, upper arms, thighs), thinning/balding hair, hyperglycemia, decreased immune function Labs • Increased Na, Glucose, ACTH (if pituitary disorder), salivary cortisol, plasma cortisol • Decreased K and Ca (ACTH in disorders of adrenal cortex) Care • Monitor I&O and daily weight. • Assess for indications of hypervolemia (edema, distended neck veins, shortness of breath, adventitious breath sounds, hypertension, tachycardia) • Prevent infection (surgical asepsis w dressing changes), pos change q2h, monitor WBC with diff daily Meds • Ketoconazole antifungal- liver tox, N/V • Mitotane Destroys adrenocortical cells- Mon for shock, renal or liver dmg and orthohypotense. Call doc if weakness, dizziness, nausea, vomiting, or weight loss • Hydrocortisone- Mon potassium glucose daily weight. Report 2.3kg week Call doc if black tarry stools or ab/back pain. CM of infection call doc. High calcium diet and vitamin D Tx • Chemo: Mon WBC, neutrophils, platelets, HgB and Hct. Assess for bruise/ bleeding gums. Prev infection • Hypophysectomy: Mon electrolytes esp NA and K, glucose and ECG. Prevent infection. Mon for bleeding, CSF leaks. Neuro assess QH for 24hrs then Q4H. Avoid increasing ICP (headache confusion call doc). No toothbrush for 2 weeks. Take fiber/stool softener Compliations • Ulcers/perforation r/t less mucus due to increase cortisol. Mon for blood in stool, avoid ETOH caffeine and smoke • Bone Fractures from hypocalcemia • Immuno suppression • Adrenal crisis insufficiency (hypotension, hypoglycemia, hyperkalemia, abdominal pain, weakness, and weight loss) TX with glucocorticoids, insulin w dextrose(to bind to K) and sodium polyseterene sulfate(bind to K) and, glucagon and glucose bolus (Potential complications from surg and health alt) Hyperthyroid: Client care post thyroidectomy • Mon Vitals Q15mins until stable then Q30mins • Keep in semi fowlers, support neck always and esp when cough/deep breathe (Q30-60mins). • Will be some hoarseness and sore throat • Take methimazole or propylthiouracil for 4/6 weeks • Check for excessive bleed. Have tracheostomy tray rdy, suction as needed. Humid air • Ask client to speak Q2hrs to check for laryngeal nerve dmg • Hypocalcemia and tetaty from parathyroid dmg CM: Tingling, twitching numbness of mouth and extremities, positive chovstek and trousseau • Monitor for hypothyroid: hypothermia, lethargy, and weight gain • Will need lifelong thyroid replacement tx (System Specific Assessment) Renal calculi: Assess pain • Severe pain (renal colic) • Pain intensifies as the calculus moves through the ureter. • Flank pain suggests calculi are located in the kidney or ureter. • Flank pain that radiates to the abdomen, scrotum, testes, or vulva suggests calculi in the ureter or bladder. • Fever n diaphoresis • Nausea and vomit • bruising is normal at the site where waves are applied in lithotripsy (System Specific Assessment) Polycystic/acute/chronic kidney disease: expected finds Restrict intake K PO4 and MG and give high protein to replenish brokendown ones Aki Phases Onset phase ends when oliguria develops Oliguria phase 100-400ml/24hrs w/wo diuretics 1-3 weeks Diuresis when kidney recovers, lg diuresis 2-6 weeks Recovery continue until full function restored, up to 12 months Stages: Stage 1 (risk stage): Serum creatinine 1.5 times baseline and urine output less than 0.5 mL/kg/hr for 6 hr or more. Stage 2 (injury stage): Serum creatinine 2 times baseline and urine output less than 0.5 mL/kg/hr for 12 hr or more. Stage 3 (failure stage): Serum creatinine 3 times baseline and urine output less than 0.3 mL/kg/hr for 12 hr or more. Prerenal Occurs as a result of volume depletion and prolonged reduction of blood flow to the kidneys, which leads to ischemia of the nephrons Intrarenal direct dmg to kidney, acute tubular necrosis; Early intervention restoring fluid volume deficit can reverse AKI and prevent CKD PostRenal bilateral obstruction of structures leaving the kidney Aki CM r/t buildup of waste and decrease urine output • CARDIOVASCULAR: fluid overload (dependent and generalized edema), dysrhythmia (hyperkalemia) • RESPIRATORY: crackles, decreased oxygenation, shortness of breath • RENAL: scant to normal or excessive urine output, depending on the phase; possible hematuria • NEUROLOGICAL: lethargy, muscle twitching, seizures • INTEGUMENTARY: dry skin and mucous membranes • Serum Creatinine gradual increase 1-2 mg Q24/48hrs or 1 -6 per week • BUN increase prerenal / decrease intrarenal • Na increase prerenal / Na intrarenal • Hyperkalemia, hyperphosphetemia, hypocalcemia CKD • Nausea, fatigue, lethargy, involuntary movement of legs, depression, intractable hiccups • In most cases, findings of chronic kidney disease are related to fluid volume overload and include the following. • NEUROLOGIC: lethargy, decreased attention span, slurred speech, tremors or jerky movements, ataxia, seizures, coma • CARDIOVASCULAR: fluid overload (jugular distention; sacrum, ocular, or peripheral edema), hypertension, dysrhythmias, heart failure, orthostatic hypotension, peaked T wave on ECG (hyperkalemia) • RESPIRATORY: uremic halitosis with deep sighing, yawning, shortness of breath, tachypnea, hyperpnea, Kussmaul respirations, crackles, pleural friction rub, frothy pink sputum • HEMATOLOGIC: anemia (pallor, weakness, dizziness), ecchymoses, petechiae, melena • GASTROINTESTINAL: ulcers in mouth and throat, foul breath, blood in stools, vomiting • MUSCULOSKELETAL: osteodystrophy (thin fragile bones) • RENAL: urine contains protein, blood, particles; change in the amount, color, concentration • SKIN: decreased skin turgor, yellow cast to skin, dry, pruritus, urea crystal on skin (uremic frost) • REPRODUCTIVE: erectile dysfunction • Hematuria, proteinuria, decreased specific gravity • Serum Creatinine Increase exceeding 4mg/dL up to 30mg • Bun 10 x 20 x creatinine finding • Decreased NA, Ca Increased K, P, Mg • Decreased HbG and Hct CKD stages • 1 GFR 90 mL/min • 2 GFR 60-89 • 3 GFR 30-59 • 4 GFR 15-29 • 5 GFR 15 ml/min PKD • Familial history of PKD • Anxiety, guilt • Abdominal and/or flank pain • Dull pain indicates increased kidney size or possible cyst infection • Sharp pain indicates ruptured cyst or possible renal lithiasis (kidney stone) • Headaches • Hypertension caused by kidney ischemia from the enlarging cysts • Enlarged abdominal girth • Constipation • Bloody and/or cloudy urine • Renal lithiasis • Hyponatremia • Nocturia (excessive urination at night) • Progressive kidney failure • Proteinuria, hematuria, bacteria/infection • gradual increase BUN serum creatinine and creatinine clearence (System Specific Assessment) Hemo/peritoneal dialysis: Monitoring patency of arterovenous graft Check the graft for patency by checking for a thrill or bruit. Changes in the bruit or thrill at the fistula site may indicate stenosis. (System Specific Assessment) IBS: priority CM appendicitis Caused by an obstruction of the lumen or opening of the appendix Fecaliths, or hard pieces of stool, can be the initial cause of the obstruction. Classic CM -classical abdomen pain starts first right lower quadrant, them nausea and vomiting CM to report • -fever • -tachycardia • -dehydration • -nausea/vomiting • -rebound tenderness • -hiccups • -distended/board-like abdomen • Signs the appendix may have rupture (perforated) : patient’s pain is suddenly relieved which will be followed by intense abdominal pain • Signs of Peritonitis Increased HR, Increase Respiration, Increased Temperature, and status of abdominal pain (very intense) and abdominal distention/bloating (System Specific Assessment) Meningitis: Assessing Pt Finds Subjective: • Excruciating, constant headache • Nuchal rigidity (stiff neck) • Photophobia (sensitivity to light) OBJECTIVE DATA: Physical Assessment Findings • Fever and chills • Nausea and vomiting • Altered level of consciousness (confusion, disorientation, lethargy, difficulty arousing, coma) • Positive Kernig’s sign (resistance and pain with extension of the client’s leg from a flexed position) • Positive Brudzinski’s sign (flexion of the knees and hips occurring with deliberate flexion of the client’s neck) • Hyperactive deep tendon reflexes • Tachycardia • Seizures • Red macular rash (meningococcal meningitis) • Restlessness, irritability Complications • Increased ICP- decreased level of consciousness, pupillary changes, impaired extraocular movements • SIADH Monitor for manifestations (dilute blood, concentrated urine). • Septic Emboli monitor extremities and coagulation (System Specific Assessment) DM Mgmt: Recognizing hypoglycemia • Glucose 70 mg/dL • mild shakiness, mental confusion, sweating, palpitations, headache, lack of coordination, blurred vision, seizures, and coma • diaphoresis, shaking, tachycardia, and headache. (Therapeutic procedures) Preventing complications post hip arthroplasty • Blood transfusions are relatively common for Hgb levels less than 9 g/dL. • Mon neurovascular Q 2-4H • Ambulate early; Transfer out of bed to WC in unaffected side, apply ice post • Weight‑bearing status is determined by the orthopedic surgeon and by choice of cemented (usually partial/full weight‑bearing as tolerated) vs. non‑cemented prostheses (usually only partial or minimal weight‑bearing [toe touch] until after a few weeks of bone growth). • Place the client supine with the head slightly elevated and the affected leg in a neutral position. Place a pillow or abduction device between the legs when turning to the unaffected side. The client should not be turned to the operative side, which could cause hip dislocation. • Use total hip precautions to prevent dislocation of the new joint • Mon for pop, acute sudden pain, internal rotation or shortened extremity= Dislocation • Use straight chairs with arms, raised chairs and toilet seat, long shoes horns, etc • Externally rotate toes • AVOID flexion of hip90°, low chairs, crossing legs, internal toe rotation, turning on operative side • Prevent DVT- Encourage plantar flexion, dorsiflexion, and circumduction exercises to prevent clot formation. Ted Hose, SCD, etcs • DO NOT keep the client's hip internally rotated, as this can lead to hip dislocation. • Keep legs abducted (apart) (Alteration body system) Hemo/peritoneal dialysis: Intervening for decreased dialysate flow rate Disequilibrium syndrome from too rapid a decrease of BUN and circulating fluid volume. It can result in cerebral edema and increased intracranial pressure • CM: Nausea, vomit, change LOC, seizures and agitation restless • Use a slow dialysis exchange rate, especially for older adult clients and first‑time hemodialysis Poor dialysate inflow or outflow: Obstruction of tubes, constipation common cause poor in/out • Reposition pt if inflow or outflow inadequate. • Milk tube to break up fibrin clots • Check the tubing for kinks or closed clamps • Avoid constipation by using stool softeners and consuming a diet high in fiber • Lower or raise the dialysate bag to improve flow • Lie supine with head slightly elevated during CCPD and APD treatment. Weight loss, lower BP, slight temp increase normal find (Alteration body system) Postop: Priority Findings Following General Anesthesia Pg 646 (Alteration body system) Asthma: Using a Peak Flow Meter Teach the child how to use a peak flow meter. (Use at the same time each day.) • Ensure the marker is zeroed. • Have the child stand up straight. • Remove gum or food from mouth. • Close lips tightly around the mouthpiece (ensure the tongue is not occluding). • Blow out as hard and as quickly as possible. • Read the number on the meter. • Repeat three more times. (Wait at least 30 seconds between attempts.) • Record highest number. • Teach the family to keep a record of PEFR results, can provide warning of increase airway impairment (Alteration body system) Cardiovascular Diagnostic and Therapeutic Procedures: Assisting with Placement of a Central Venous Catheter Pre: Cleanse the site with chlorhexidine, sterile equipment, place a stop sign in room to restrict access during procedure Percutaneous Place the client in the Trendelenburg position with a rolled towel between the client's shoulder blades. This position facilitates the insertion of the catheter by dilating the blood vessels of the client's neck and shoulders. Post: • Confirm placement of the PICC with an x‑ray. • Assess the site for redness, swelling, drainage, tenderness, and condition of the dressing. • Clean the insertion port with alcohol for 15 seconds and allowing it to dry completely prior to accessing it. Valve disinfection caps which contain alcohol are available for single use. • Use transparent dressing to allow for visualization. • Follow facility protocol for dressing changes, usually every 7 days and when indicated (wet, loose, soiled). • Advise the client not to immerse his arm in water. To shower, cover dressing site to avoid water exposure. • Educate the client not to have venipuncture or blood pressure taken in arm with PICC line. (Alteration body system) Pancreatitis: Planning Care for Acute Pancreatitis • Rest the pancreas. • NPO: No food until pain‑free • For severe pancreatitis: Total parenteral nutrition or jejunal feedings (contraindicated if paralytic ileus develops, less risk of hyperglycemia) • When diet is resumed: Bland, high protein, low‑fat diet with no stimulants (caffeine); small, frequent meals • Administer antiemetic as needed, as prescribed • Nasogastric tube: Gastric decompression (for severe vomiting or paralytic ileus) • No alcohol consumption • No smoking • Limit stress • Pain management • Position the client for comfort (fetal, side‑lying, head of the bed elevated, sitting up or leaning forward). • Administer analgesics and other medications as prescribed. • Monitor blood glucose, and provide insulin as needed (potential for hyperglycemia). • Monitor hydration status (orthostatic blood pressure, I&O, laboratory values). • Administer IV fluids and electrolyte replacements prescribed. (Alteration body system) Respiratory Management and Mechanical Ventilation: Caring for a Client Who Is Receiving Mechanical Ventilation Mode of ventilation ASSIST‑CONTROL (AC) • Preset rate and tidal volume. Client initiates breath and • Ventilator takes over for the intubated client. • Hyperventilation can result in respiratory alkalosis. • Client can require sedation to decrease respiratory rate. SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV) • Preset rate and tidal volume for machine breaths. • Client initiates breath and tidal volume will depend upon client’s effort. • Ventilator initiated breaths are synchronized to reduce competition between ventilator and client. • Used as a regular mode of ventilation or a weaning mode (rate decreased to allow more spontaneous ventilation) for the intubated client. • Can increase work of breathing, causing respiratory muscle fatigue. INVERSE RATIO VENTILATION (IRV) • Lengthens inspiratory phase to maximize oxygenation in the intubated client. • Used for hypoxemia refractory to PEEP. • Uncomfortable for clients and requires sedation and/or neuromuscular blocking agents. • High risk of volutrauma and decreased cardiac output due to air trapping. AIRWAY PRESSURE RELEASE VENTILATION (APRV) • Allows alveolar gas to be expelled by the lungs own natural recoil • Time‑triggered and pressure‑limited • Breaths can be initiated spontaneously or by the ventilator • Causes less ventilator‑induced lung injury and fewer adverse effects on the cardiovascular system INDEPENDENT LUNG VENTILATION (ILV) • Double‑lumen ET tube allows ventilation of each lung separately. • Used for clients who have unilateral lung disease. • Requires two ventilators, sedation and/or use of neuromuscular blocking agents. HIGH‑FREQUENCY VENTILATION • Delivers small amount of gas at rates of 60 to 3,000 cycles/min. • High frequency ventilation often used in children. • Client must be sedated and/or receiving neuromuscular blocking agents. • Breath sounds difficult to assess. Care • Maintain a patent airway. • Assess the position and placement of tube. • Document tube placement in centimeters at the client’s teeth or lips. • Use two staff members for repositioning and to resecuring the tube. • Apply protective barriers (soft wrist restraints) according to hospital protocol to prevent self‑extubation. • Use caution when moving the client. • Suction oral and tracheal secretions to maintain tube patency. • Support ventilator tubing to prevent mucosal erosion and displacement. • Have a resuscitation bag with a face mask available at the bedside at all times in case of ventilator malfunction or accidental extubation. • Assess respiratory status every 1 to 2 hr: breath sounds equal bilaterally, presence of reduced or absent breath sounds, respiratory effort, or spontaneous breaths. • Suction the tracheal tube to clear secretions from the airway. • Monitor and document ventilator settings hourly. o Rate, FiO2, and tidal volume o Mode of ventilation o Use of adjuncts (PEEP, CPAP) o Plateau or peak inspiratory pressure (PIP) o Alarm settings • Monitor ventilator alarms, which signal if the client is not receiving the correct ventilation. • Never turn off ventilator alarms. • There are three types of ventilator alarms. o Volume (low pressure) alarms indicate a low exhaled volume due to a disconnection, cuff leak, and/or tube displacement. o Pressure (high pressure) alarms indicate excess secretions, client biting the tubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm, or pneumothorax. o Apnea alarms indicate that the ventilator does not detect spontaneous respiration in a preset time period. • Maintain adequate (but not excessive) volume in the cuffof the endotracheal tube. • Assess the cuff pressure at least every 8 hr. Maintain the cuff pressure below 20 mm Hg to reduce the risk of tracheal necrosis. • Assess for an air leak around the cuff (client speaking, air hissing, or decreasing SaO2). Inadequate cuff pressure can result in inadequate oxygenation and/or accidental extubation. • Administer medications as prescribed. Morphine, fentanyl, propofol, haloperidol, benzodiazepines. Neuromuscular blocking agents (onium), Ulcer meds, AB • Reposition the oral endotracheal tube every 24 hr • Assess GI func Q8Hrs • Continually monitor the client during the weaning process and watch for signs of weaning intolerance. o Respirations greater than 30/min or less than 8/min o Blood pressure or heart rate changes more than 20% of baseline o SaO2 less than 90% o Dysrhythmias, elevated ST segment o Significant decrease in tidal volume o Labored respirations, increased use of accessory muscles, and diaphoresis o Restlessness, anxiety, and decreased level of Consciousness • Have a manual resuscitation bag with a face mask and oxygen readily available at the client’s bedside. • Have reintubation equipment at bedside. • Suction the oropharynx and trachea. • Deflate the cuff on the endotracheal tube, and remove the tube during peak inspiration. • Following extubation, monitor for signs of respiratory distress or airway obstruction, such as ineffective cough, dyspnea, and stridor. • Assess SpO2 and vital signs every 5 min. • Encourage coughing, deep breathing, and use of the incentive spirometer. • Reposition the client to promote mobility of secretions. • Older adult clients have decreased respiratory muscle strength and chest wall compliance, which makes them more susceptible to aspiration, atelectasis, and pulmonary infections. Older adult clients require more frequent position changes to promote mobility of secretions. (Alteration body system) Acid-Base Imbalances: Identifying Client at Risk for Metabolic Alkalosis Base excess High pH High HCO3 Low CO2 low H+ • Oral ingestion of excess amount of bases (antacids) • Venous administration of bases (blood transfusions, total parenteral nutrition, or sodium bicarbonate) • Acid deficit • Loss of gastric secretions (through prolonged vomiting, nasogastric suction) • Potassium depletion (due to thiazide diuretics, laxative overuse, Cushing’s syndrome, hyperaldosteronism) • Increased digitalis toxicity • Cystic fibrosis • (Alteration body system) Postoperative Nursing Care: Monitoring for Wound Complications • Observe drainage tubes for patency and proper function. • Check dressings for excessive drainage and reinforce as needed. Report excess drainage to the surgeon. • Outline drainage spots with a pen, noting date and time. Report increasing drainage to the surgeon. • Monitor risk factors (obesity, coughing, moving without splinting, poor nutritional status, diabetes mellitus, infection, hematoma, steroid use) • (Alteration body system) Head Injury: Indications of Increased Intracranial Pressure • Severe headache, nausea, vomiting • Deteriorating level of consciousness, restlessness, irritability • Dilated or pinpoint nonreactive pupils • Cranial nerve dysfunction • Alteration in breathing pattern (Cheyne‑Stokes respirations, central neurogenic hyperventilation, apnea) • Deterioration in motor function, abnormal posturing (decerebrate, decorticate, flaccidity) • Cushing’s triad is a late finding characterized by severe hypertension with a widening pulse pressure (systolic – diastolic) and bradycardia. • Seizures (Alteration body system) Urinary Elimination: Indwelling Urinary Catheter Care (Alteration body system) Chronic Obstructive Pulmonary Disease: Positioning for dyspnea.- Position the client to maximize ventilation (high‑Fowler’s). (Fluid electrolyte imbalance) CM Sodium Imbalance 136-145 Hyponatremia • Clinical indicators depend on whether it is associated with a normal (euvolemic), decreased (hypovolemic), or increased (hypervolemic) ECF volume • IF client is hypervolemic with hyponatremia, palpate the bounding pulse. • Vitals vary n ECF: Hypothermia, tachycardia, rapid thready pulse, hypotension, orthostatic hypotension, diminished peripheral pulses • NEUROMUSCULOSKELETAL: Headache, confusion, lethargy, muscle weakness to the point of possible respiratory compromise, fatigue, decreased deep‑tendon reflexes (DTRs), seizures, lightheadedness, dizziness • GI Increased motility, hyperactive bowel sounds, abdominal cramping, nausea Hypernatremia • Thirst • VITAL SIGNS: Hyperthermia, tachycardia, orthostatic hypotension • NEUROMUSCULOSKELETAL: Restlessness; irritability; muscle twitching to the point of muscle weakness, including respiratory compromise; decreased or absent DTRs; seizures; coma • GASTROINTESTINAL: Thirst, dry mucous membranes, nausea, vomiting, anorexia, occasional diarrhea (Fluid electrolyte imbalance) CM Hypervolemia Labs: • Decreased Hct and Hgb • Decreased serum and urine osmolarity • Decreased urine sodium and specific gravity • Decreased BUN due to plasma dilution CM: • VITAL SIGNS: Tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure • NEUROMUSCULAR: Weakness due to excess fluid retained, which depletes energy and increases the workload for the body; headache; altered level of consciousness • GASTROINTESTINAL: Ascites • RESPIRATORY: Crackles, cough, increased respiratory rate, dyspnea caused from an excess of fluids within the body and lungs • OTHER SIGNS: Peripheral edema due to an excess of fluids within the body and lungs, resulting in weight gain, distended neck veins, and increased urine output (Fluid electrolyte imbalance) CM Hypokalemia • VITAL SIGNS: Decreased blood pressure, thready weak pulse, orthostatic hypotension • NEUROLOGIC: Altered mental status, anxiety, and lethargy that progresses to acute confusion and coma • ECG: Flattened T wave, prominent U waves, ST depression, prolonged PR interval • GASTROINTESTINAL: Hypoactive bowel sounds, nausea, vomiting, constipation, abdominal distention. Paralytic ileus can develop. • MUSCULAR: Weakness. Deep‑tendon reflexes can be reduced. • RESPIRATORY: Shallow breathing HyperKalemia • Vital signs: Slow irregular pulse, hypotension • Neuromusculoskeletal: Restlessness, irritability, weakness to the point of ascending flaccid paralysis, paresthesia • ECG: Premature ventricular contractions, ventricular fibrillation, peaked T waves, widened QRS • Gastrointestinal: Increased motility, diarrhea, hyperactive bowel sounds • Other signs: Oliguria (Hemodynamics) Pacemeaker: ID postop complications Normal: spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization. • Continually monitor heart rate and rhythm • Obtain chest x‑ray to assess lead placement and for pneumothorax, hemothorax, or pleural effusion • Monitor the incision site for bleeding, hematoma formation, or infection • Assess for hiccups, which can indicate that the generator is pacing the diaphragm • Maintain the client’s safety. Following transcutaneous pacing, inspect the skin under the electrodes for thermal burns. Clients who are older, dehydrated, or have had external pacing for an extended period of time are most at risk for thermal burns • Perm Pacemaker: Provide the client with a pacemaker identification card including the manufacturer’s name, model number, mode of function, rate parameters, and expected battery life Teach: • Carry Pacemaker ID card always! • Prevent wire dislodgement. (Wear sling when out of bed. Do not raise arm above shoulder for 1 to 2 weeks.) • Take pulse daily at the same time. Notify the provider if heart rate is less than the pacemaker rate. • Call doc if signs of dizziness, fainting, fatigue, weakness, chest pain, hiccupping, palpitations, difficulty breathing, or weight gain • Clients who have pacemaker‑defibrillators, when the device delivers a shock, anyone touching the client will feel a slight electrical impulse, but the impulse is not harmful • Activity restrictions as prescribed, including no contact sports or heavy lifting for 2 months • Never place items that generate a magnetic field directly over the pacemaker generator. These items can affect function and settings. This includes garage door openers, burglar alarms, strong magnets, generators and other power transmitters, and large stereo speakers. The use of household items is not prohibited. • Inform dentist or MRI or others of pacemaker. Diathermy can be contra • Don’t let security put wand over pacemaker. Complications • Infection look for redness, pain drainage • Pneumothorax Assess breath sounds and chest mov • Arrhythmias r/t ventricular irritation from pacemaker electrode; mon ECG BP • Pacemaker: Complications often are detectable by ECG. Monitor ECG to ensure heart rate is within programmed parameters. Pacer spikes should be adequate in number and occur directly before P or QRS complexes. Pacer spikes that occur on the T wave can cause life‑threatening arrhythmias. (Illness Mgmt) Hemo/peritoneal dialysis: CM Peritonitis Rigid, board‑like abdomen (hallmark indication). Tachycardia. Monitor for infection, such as fever, purulent drainage, redness, swelling, and cloudy or discolored drained dialysate. Include sharp, constant abdominal pain, rebound tenderness, fever, nausea, vomiting, and diminished or absent bowel sounds If outflow clear, light yellow GOOD Bloody, cloudy or frothy=sign of infection Increase protein, watch for hyperglycemia (Illness Mgmt) DM complications: Priority interventions DKA • CM: Polyuria, polydipsia, polyphagia, weight loss, nausea/vomit, ab pain, blurred vision, headache, weakness, orthohypotension, fruity breath, Kussmaul (deep rapid resp trying to excrete CO2), metabolic acidosis, mental status change, seizures, myoclonic jerking, reversible paralysis • Lab Glucose 300, Bun 30mg/dL and Creatinine 1.5 mg/dL (due to dehydration) ketones in urine, pH 7.3 (Metabolic acidosis with respiratory compensation) Care • Tx Cause (infection • Rapid isotonic fluid (0.9% sodium chloride) Mon for evidence of fluid volume excess (urine output, kidney function, pulmonary status, jugular venous distention, and body weight) due to the need for large quantities of fluid • Follow with a hypotonic fluid (0.45% sodium chloride) to continue replacing losses to total body fluid • When serum glucose levels approach 250 mg/dL, add glucose to IV fluids to minimize the risk of cerebral edema associated with drastic changes in serum osmolarity and prevent hypoglycemia • Admin regular insulin 0.1 to 0.15 unit/kg as an IV bolus dose and then follow with a continuous IV infusion of regular insulin at 0.1 unit/kg/hr • Monitor serum potassium levels. Potassium levels will initially be increased, but with insulin therapy potassium will shift into cells, and the client will need to be monitored for hypokalemia. Replace as needed by labs • ECG, Monitor urine output before potassium admin • Administer sodium bicarbonate by slow IV infusion for severe acidosis (pH less than 7.0). Infuse potassium along with bicarbonate because bicarbonate promotes hypokalemia, unless the client has hyperkalemia. (Illness Mgmt) Disorders of the eye: Indications of glaucoma PG 65 Glaucoma is a disturbance of the functional or structural integrity of the optic nerve. Decreased fluid drainage or increased fluid secr