Medsurg 1 Potassium

Lab values: CHEM 7 Potassium(K+): 3.5-5 (bananas) Sodium(Na+): 135-145 Chloride(Cl-): 95-105 (good pool temp) Calcium(ca): 9-11 (call 911) BUN: 7-20 (hamburger cost) Creatine(Cr): 0.6-1.2 Glucose: 60-120 Phosphorus: 3.0-4.5 CBC WBC: 5-10k high: leukocytosis / low: leukocytopenia Plt: 150k-450k high: thrombocytosis / low: thrombocytopenia Hgb: (10-16) 14 Hct: (35-45) 44 high: erythrocytosis / low: erythrocytopenia (H&H) All high: pancytosis / all low pancytopenia COAGs Pt: (10-18) 14 Ptt: (40-48) 44 INR: >1, 2-3 *Normal capillary refill is less than 2 seconds *Normal urine excretion is 30ml/hr ABC’s Airway Breathing Circulation Blood Transfusions: (+) CANNOT donate to (-) if a positive patient has HIV a negative patient would not want their blood O can donate to everyone A can donate to AB B can donate to AB Drugs to relieve pain Analgesics: including NSAIDs and Acetaminophen TylenoL - liver toxicity (hepatotoxicity) AspirinN - nephrotoxicity Opioid Analgesics: Fentanyl - Fat loving drug (lipophilic) Morphine - Water loving drug (hydrophilic) Dilaudid - BOTH Adjuvant Analgesics: Local anesthetics Muscle relaxants Anticonvulsants Antidepressants OD: Fentanyl -> Narcan Xanax -> Flumazenil Hypokalemia: Potassium level lower than 3.5 Caused by: Excessive use of diuretics, Crushing syndrome, wound drainage, GI, prolonged nasogastric suction, Vomiting, diarrhea S/S: Muscle weakness, dysrhythmias, constipation/ hypoactive bowel sounds, lethargy Hyperkalemia: Potassium level higher than 5 (5.5) Caused by: Over Ingestion of potassium containing foods/meds Ex: potassium sparing diuretics; Kidney disease (a decrease of potassium excretion), Adrenal insufficiency (Addison's disease), Tissue damage/Burns. S/S: Increased intestinal peristalsis (diarrhea) hyperactive bowel sounds; Muscle twitching & cramps (early signs); Angina, Dysrhythmias Common foods with potassium: Avocado, bananas, cantaloupe, oranges, strawberries, tomatoes, carrots, mushrooms, spinach, fish, pork, beef, veal, potatoes, raisins Hypocalcemia: Calcium level lower than 9 Caused by: Common foods with calcium: Cheese, collard greens, kale, milk and soy milk, rhubarb, sardines, tofu, yogurt. Breakthrough pain: how to manage breakthrough pain. may need to include “rescue dose” of medication, such as adding an IR (immediate release) opioid in between doses of scheduled CR (continued release or sustained release) meds. Another option is decreasing both dose & frequency of scheduled opioid (so pt. gets it more often without getting OD). -Can try alternative pain relieving techniques to prevent and manage -Chronic pt and hospice pt are given medication to use as needed to treat breakthrough pain Q: A client is 2 days post-op from a thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action? -Encourage the pt to use guided imagery and slow rhythmic breathing Hand washing/home teaching: Keep elbows up and hands down, wash entire hands, top bottom, palms, each finger, wrists, scrub fingernails. Wash hands before handling needles Restraints: check every 2 hours, Reassess if family removes them Pedal pulse: If pt had surgery on one left, compare pedal pulses from each leg. Pedal pulse is on the foot, there are two of them. S/S hyper/hyponatremia Normal (135-145) Hypo: Coma, n/v, lethargy/weakness, tachycardia (thready pulse), orthostatic hypotension, stomach cramping (hyperactive bowel sounds) Hyper: flushed skin, restless/irritable, increased bp/ fluid retention, edema, decreased urine output -Restrict sodium & fluid intake as prescribed Q: Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia? -Review food labels for sodium content Q: Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? -Sodium S/S Hyper/hypokalemia Normal (3.5-5) Hypo: weak/irregular pulse, shallow respirations, N/V, hypoactive bowel sounds (constipation), lethargy/confusion, muscle weakness, dysrhythmias Hyper: Increased intestinal peristalsis (diarrhea) hyperactive bowel sounds; Muscle twitching & cramps (early signs); Angina, Dysrhythmias Cyanosis: Bluish hue to the skin, gums, fingernails or mucous membranes caused by lack of oxygen in the blood. -Need to check respiratory rate/ O2 stat Staging pressure ulcers Stage 1: red but no skin tear Stage 2: little skin tear but not fatty tissue visible Stage 3: full thickness SKIN loss, no exposed muscle or bone Stage 4: full thickness TISSUE loss, damage to muscle and bone. Unstageable: cant stage bc of eschar and slough in the way Q: The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states “clean the wound and then apply collagenase.” collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressure ulcer? -Irrigate the wound with sterile normal saline Q: When assessing a male client, the nurse finds that he is fatigued, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which? -Hypokalemia End of life/planning: what the pt wishes are? *Key points from davis* Living will- is a document that falls into the category of advance directives. Therefore, a living will is a type of advance directive - states what the patient would or would not want if they were to die Advanced directive- is a broad category of legal instructions you may set up for your healthcare Alzheimer's- predictable - Alzheimer’s tend to develop far more and in a predictable pattern, beginning in the areas important for memory before spreading to other regions. *memory loss is likely to come first and is predictable Antihypertensive meds- are medications used to treat high blood pressure, also known as hypertension. Can cause hypotension as an adverse effect. Asthma attackQ:A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising. Which action should the nurse implement? *determine if the client is using an inhaler before exercising* Wheezing- A high pitched or coarse whistling sound that's heard in the respiratory airway when one breathes.High pitch in exhale, high pitched violins. Q:The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, which of the following findings indicates to the nurse that the patient's respiratory status is improving? * Wheezing becomes louder* Leukotrienes- any of a group of biologically active compounds, originally isolated from leukocytes. They are metabolites of arachidonic acid, containing three conjugated double bonds - inflammatory chemicals the body releases after coming in contact with an allergen or allergy trigger. ?????? Braden scale- Six categories: sensory perception, moisture, activity, mobility, nutrition, and friction or shear, which allow nurses to assess and rate the risks for pressure ulcers. 19-23 = no risk 15-18 = mild risk 13-14 = moderate risk less than 9 = severe risk In a hospital setting reassess a patient every 2-4 hours, in LTC setting assess on admission and then every week. COPDQ:You see a patient with COPD in the tripod position, what do you do next? *teach them pursed lip breathing Q:A client with a history of COPD has established a walking program. How do we know that walking is effective? *Cardiovascular improvement Cardiac cath Q:What should the nurse expect for a client who has unstable Angina who had a cardiac catheter? *thromboembolism Cast care- Protect the cast. Do not put weight on the cast. Do not bend, lean on, or hit the cast with anything.... ● Change positions often. Change your position every 2 hours to help the cast dry faster. ... ● Keep the cast dry. Tie plastic trash bags around your cast to keep it dry while you bathe. ● Wiggle fingers or toes often ● Peripheral circulation!!!!!!!!!!!!!!!!!!!!!!! Chest tube- drain placed in the pleural space allowing re expansion and preventing air and fluids from returning to the chest: ALWAYS KEEP BELOW PATIENTS CHEST - ALWAYS CHANGE DRAINAGE SYSTEM, NEVER EMPTY - EMPTYING WILL CAUSE AIR OR FLUIDS TO RETURN TO CHEST Suction control (gently bubbling) -> Water seal (tidal) -> Blood collection chamber DM 1-DKA DNR- Do Not Resuscitate - Form written by physician, signed by patient or POA stating not to do CPR on patient if their heart stops - nursing action is to allow patient to die peacefully without reviving Droplet precautions- SPIDERMAN: S: sepsis, strep P: pneumonia I: Influenza(flu) D: diphtheria(pharyngeal) E: epiglottitis R: rubella M: mumps, meningitis AN: adenovirus ------ mask, gown, and gloves ● Do not need a N95 mask for droplet Fluid volume deficit- “dehydration” can cause weakness, excessive thirst, weight loss, dark urine, reduced skin turgor - Hypotonic: fluids with osmolality less than 270 mOsm/L : lose more electrolytes than water - Hypertonic: fluids with osmolality more than 300 mOsm/L : lose more water than electrolytes - Isotonic: fluids with osmolality 270-300 mOsm/L : lose = amount of water and electrolytes GERD- teach to wear loose clothing Q: What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD) *minimize symptoms by wearing loose, comfortable clothing* HIV CD4 count- HIV-candidiasis- fungal infection of the mouth HTN headache Q:A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmhg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, Which intervention is most important for the nurse to implement? *provide a quiet environment with low lighting Handwashing- Home technique.. Scrub for 20 seconds, rise thoroughly Healthy People 2020- strives to: Identify nationwide health improvement priorities. Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress. Hearing lossDiureticQ:A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? *At what time do you take your medication? Herpes zoster vaccineQ: A male client with herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem? *pain* Q: The nurse assesses a client being treated for herpes zoster (shingles). Which assessments should the nurse include when evaluating for effectiveness of the treatment? *skin integrity, functional ability, pain scale* Hypocalcemia- low levels of calcium Q:A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? *Hypocalcemia Hypoglycemia- Blood sugar is lower than normal. Sleepiness, anxiety, confusion and difficulty talking are also signs that a person has hypoglycemia. A person who has hypoglycemia while sleeping may sweat profusely during sleep, experience nightmares or wake feeling tired and irritable. Q:The nurse is monitoring a client with hypoglycemia. Glucagon provides which function? *It prevents hypoglycemia by promoting release of glucose from liver storage sites. Q:The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia? *59 mg/dL (3.3 mmol/L). *most common symptom of hypoglycemia is nervousness 2 I&O- track regularly - A person should excrete 400-600 mL/day and 30 mL/hr Water loss also occurs insensibly through the skin, stool, lungs - a healthy person has about 500-1000 mL/day of insensible water loss - KEEP A CLOSE WATCH ON PATIENTS WITH FLUID AND ELECTROLYTE IMBALANCES Immunity- the quality or state of being immune; especially : a condition of being able to resist a particular disease especially through preventing development of a pathogenic microorganism or by counteracting the effects of its products. Active vs passive: Passive is when the person is given antibodies Active is where the body makes its own antibodies. Natural vs artificial: Natural is when the antibodies is passed naturally (breast milk) Actifical is when it is man made passed (like a shot) MI- Myocardial infarction (heart attack) Disruption in or deficiency of coronary artery blood supply, resulting in necrosis of myocardial tissue *sudden onset of pain in the lower sternal region. Q:The nurse is caring for a client who is 1 day post-acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which intervention should the nurse implement first? *increase the client's oxygen flow rate HESI HINT: Remember mona when administering meds and treatments in a pt with MI, Morphine, Oxygen, Nitroglycerin, Aspirin MS- Multiple sclerosisQ:A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? *Schedule extra rest periods. Q:What's Priority for a client with Multiple Sclerosis and has urinary retention? *Self catheterization Med admin- verify all of your rights before giving medications, check for allergies, make sure right person, right time, right medication Oral care NG tube Q: A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement? *elevate head of bed 60 to 90 degrees* PUD- Peptic ulcer disease- A stomach disorder marked by corrosion of the stomach lining due to the acid in the digestive juices. Pain symptomsQ: A client complains of pain in the right calf. What is the nurse's priority? *remain in bed Parkinson'sQ: The wife of a client with Parkinson's disease expressed concern because her husband has lost so much weight. Which teaching is best for the nurse to provide? *coach the client to make an intentional effort to swallow* Q: A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond? *Confirm that this is an effective technique to help with ambulation PneumoniaQ:During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? *May indicate pneumonia. Post Op riskQ:Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client? *Advise the pt to remain in bed with the leg elevated Q:What intervention should be done for post op cataract extraction? *implement deep breathing Preop shavePressure ulcer-