Nursing Sciences Tim Duncan; RN, CCRN, CEN, EMTP KISSPharm L.L.C

Transcription

1 + Nursing Sciences Tim Duncan; RN, CCRN, CEN, EMTP 2015 KISSPharm L.L.C

2 + Fluid and Electrolyte Balance Body fluid compartments Homeostasis occurs when the number of cations and anions are the same Compartments are divided by Intracellular Fluid (2/3) Extracellular Fluid (2/3)

3 + Fluid and Electrolyte Balance Body fluid compartments Two main compartments Intracellular (ICF) : fluid inside the cell (2/3 of the cell) Extracellular (ECF) : fluid outside the cell (1/3 of the cell) Includes interstitial fluid, blood, connective tissue, water, and transcellular fluid

4 + Fluid and Electrolyte Balance Edema Excess collection of fluid in the interstitial space Localized edema Trauma from accidents or surgery Local inflammatory processes Burns Generalized edema Can occur due to cardiac, renal, or liver failure Infants and older adults are more susceptible to fluid-related problems.

5 + Body fluid transport Diffusion Process where a solute from a higher concentration may spread through a solution to area of lower concentration Membranes Permeable Selectively permeable Osmosis Force that pulls the solvent from a less concentrated solute to a more concentrated solute

6 + Body fluid transport Filtration Hydrostatic pressure Transfer of solutes and solvents from higher pressure to area of lower pressure The hydrostatic pressure is higher than osmotic pressure at the end of the capillary Consequently fluids move out of the capillary The osmotic pressure is higher than the hydrostatic pressure at the end Therefore the fluids move into the capillary

7 + Movement of body fluid Isotonic solutions Both sides are equal in concentration, very little osmosis occurs Isotonic solutions have the same osmolality as body fluids Hypotonic solutions When a solution has less concentration of solute or salt compared to another more concentrated solution Have lower osmolality than body fluids Hypertonic solutions When a solution has a more concentration of solutes than other less concentrated solutions

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9 + Movement of body fluid (con t) Active transport In order to have movement from a area of lower concentration to an area of higher Need Require active transport Ions Sodium Potassium Calcium Iron Hydrogen Some sugars Amino acids

10 + Movement of body fluid (con t) Body fluid Diarrhea can result in the loss of a lot of water and electrolytes Most water is reabsorbed in the large colon Kidneys regulate fluid and electrolyte balance Adrenal glands Regulate sodium reabsorption via secreting ADH also helps to regulate water balance

11 + Fluid Volume Deficit Isotonic dehydration Water and electrolytes are lost equally Most common type of dehydration as known as hypovolemia Results in decreased blood volume and therefore insufficient tissue perfusion

12 + Fluid Volume Deficit dehydration Causes Improper intake of fluids and solutes Fluid shifts Dramatic loss of isotonic body fluids Intracellular Fluid (2/3) Extracellular Fluid (2/3)

13 + Fluid Volume Deficit dehydration Water loss is greater than electrolyte loss Cell shrinks Causes Extreme perspiration Hyperventilation Ketoacidosis Prolonged fevers Diarrhea Early-stage renal failure Diabetes insipidus Intracellular Fluid (2/3) Extracellular Fluid (2/3)

14 + Fluid Volume Deficit dehydration Electrolyte loss is greater than water loss Cells swell Causes Chronic illness Extreme fluid replacement (hypotonic) Renal failure Chronic malnutrition Intracellular Fluid (2/3) Extracellular Fluid (2/3)

15 + Fluid Volume Deficient Findings Cardiovascular Increased pulse Decreased blood pressure and orthostatic hypotension Flat neck and hand veins Diminished peripheral pulses Decreased CVP Dysrhythmias

16 + Fluid Volume Deficient Findings Respiratory Increased rate and depth of respirations Dyspnea Neuromuscular Decreased CNS activity Fever Skeletal muscle weakness Renal Decreased urine output

17 + Fluid Volume Deficit Findings Integumentary Dry skin Poor turgor Dry mouth Gastrointestinal Decreased motility and bowel sounds Constipation Thirst Decreased body weight

18 + Fluid Volume Deficit Findings Laboratory findings Increased serum osmolality Increased hematocrit Increased BUN level Increased serum sodium level Increased urinary specific gravity

19 + Fluid Volume Excess overhydration (aka hypervolemia) The extracellular compartment is expanded Edema Complications Cardiac dysfunction CHF Pulmonary edema Causes Improper IV therapy Renal failure Chronic corticosteroid therapy Intracellular Fluid (2/3) Extracellular Fluid (2/3)

20 + Fluid Volume Excess overhydration The fluid goes from the intracellular compartment to ECF Causes Increased sodium ingestion Rapid infusion Extreme sodium bicarbonate therapy Intracellular Fluid (2/3) Extracellular Fluid (2/3)

21 + Fluid Volume Excess overhydration (aka water intoxication) All body fluid compartments are expanded Electrolyte imbalance Causes Early renal failure CHF SIADH Improper IV therapy Intracellular Fluid (2/3) Extracellular Fluid (2/3) Replacement of isotonic fluid loss with hypotonic fluids

22 + Fluid Volume Excess Findings Cardiovascular Increased pulse Increased blood pressure Distended neck and hand veins Elevated CVP Dysrhythmias Respiratory Increased respiratory rate (shallow breathing) Dyspnea Moist Crackles

23 + Fluid Volume Excess Findings Neuromuscular Altered consciousness Headache Visual disturbances Skeletal muscle weakness Paresthesias Renal Increased urine output if kidneys are working Decreased urine output if kidneys are damaged

24 + Fluid Volume Excess Findings Integumentary Pitting edema Pale, cool skin Gastrointestinal Increased motility Diarrhea Increased body weight Enlarged liver Ascites

25 + Fluid Volume Excess Findings Laboratory findings Decreased serum osmolality Decreased hematocrit Decreased BUN Deceased serum sodium Decreased urine specific gravity

26 + Normal Electrolyte values Sodium: meq/l Potassium: meq/l Chloride: meq/l Bicarbonate (venous): meq/l

27 + Hyponatremia Serum Na+ level less than meq/l Food sources Bacon Canned food Ketchup Milk Processed food Snack food Soy sauce Bread Na+ imbalance are typically related to fluid imbalances

28 + Hyponatremia Causes Increased sodium excretion Loss of Fluid Sweating Vomiting Diarrhea Renal disease Dilution of serum sodium Gain of Fluid SIADH CHF Psychogenic polydipsia DM

29 + Hyponatremia Findings Cardiovascular Normovolemic Rapid pulse NL BP Hypovolemic Weak rapid pulse Low BP Flat neck veins NL or low CVP Hypervolemic Rapid bounding pulse BP NL or elevated NL or elevated CVP

30 + Hyponatremia Findings Respiratory Shallow breathing due to skeletal muscle weakness Neuromuscular Skeletal muscle weakness (worse in extremities) Reduced deep tendon reflexes Renal Increased urinary output

31 + Hyponatremia Findings CNS Headache Personality changes Confusion Seizures Coma Gastrointestinal Increased motility Hyperactive bowel sounds Nausea Diarrhea Cramping

32 + Hyponatremia Treatment If there is a fluid volume deficit Give IV sodium chloride If due to fluid volume excess Give osmotic diuretics If due to SIADH Give ADH antagonists Increase sodium intake Monitor patients taking lithium Hyponatremia can hinder lithium excretion leading to

33 + Hypernatremia Serum Na+ levels exceed 145 meq/l Causes Decreased Na+ excretion Corticosteroids Cushing's syndrome Renal failure Hyperaldosteronism Increased Na+ intake Decreased water intake

34 + Hypernatremia Causes Increased water loss Increased metabolism Fever Hyperventilation Infection Extreme diaphoresis Watery diarrhea Diabetes insipidus

35 + Hypernatremia Treatment IV therapy If due to fluid loss Diuretics If unable to excrete Na+

36 + Hypernatremia findings Cardiovascular Heart rate and BP depend on vascular volume Respiratory Pulmonary edema (hypervolemia) Neuromuscular Early manifestation Spontaneous muscle twitches Irregular muscle contractions Late manifestation Skeletal muscle weakness deep tendon reflexes are absent

37 + Hypernatremia findings CNS Most common manifestation Altered cerebral function Normo-volemia or hypovolemia Agitation Confusion Seizures Hypervolemia Lethargy Stupor Coma

38 + Hypernatremia findings Gastrointestinal Very thirsty Renal urinary output

39 + Hypokalemia Serum K+ level lower than 3.5 meq/l Food sources Bananas Avocado Cantaloupe Carrots Meats Mushrooms Spinach Life threatening because it can cause cardiac arrhythmias!

40 + Hypokalemia Causes Total body K+ loss Overuse of diuretics or corticosteroids Increased secretion of aldosterone (Cushing s syndrome) Fluid Loss of any kind Prolonged nasogastric suction Excessive diaphoresis Renal disease Low K+ intake

41 + Hypokalemia Pathophysiology Shift of K+ from ECF to ICF Alkalosis K+ dilution Water intoxication

42 + Hypokalemia Findings Cardiovascular Weak irregular pulse Weak peripheral pulses Orthostatic hypotension Respiratory Shallow respirations Absent breath sounds

43 + Hypokalemia Findings Neuromuscular Anxiety Fatigue Confusion Coma Skeletal muscle weakness Paresthesias and deep tendon hyporeflexia

44 + Hypokalemia Findings Gastrointestinal Decreased motility Absent bowel sounds Nausea Vomiting Constipation Paralytic ileus

45 + Hypokalemia Findings Laboratory findings ST depression Shallow, flat or inverted T wave Prominent U wave

46 + Hypokalemia Treatment Give K+ supplements Oral supplements can cause nausea and vomiting Do not give on an empty stomach Liquid potassium chloride has a So give with juice

47 + Hypokalemia Treatment K+ is never given by IV push Intramuscular Subcutaneous routes IV potassium is diluted and given using an infusion device

48 + Hypokalemia Treatment Recommended infusion rate 5 to 10 meq/hr Do not exceed 20 meq/hr If patient is getting more than 10 meq/hr place them on a cardiac monitor Check for phlebitis and infiltration Nurse should also check for renal function

49 + Hyperkalemia Potassium level greater than 5.1 meq/l Causes Excessive K+ intake Decreased K+ excretion Potassium sparing diuretics Renal failure Addison s disease Shift of K+ from ICF to ECF Tissue injury Acidosis Hyperuricemia Hypercatabolism

50 + Hyperkalemia Treatment Restrict K+ diet If kidney is functioning give K+ excreting diuretics If kidney is nonfunctional give sodium polystyrene sulfonate (Kayexalate) Helps sodium absorption K+ excretion in the gut Dialysis Hypertonic glucose with regular insulin (move K+ into the cells) Blood transfusion patient should receive fresh blood

51 + Hyperkalemia findings Cardiovascular Slow and irregular pulse Decreased BP Gastrointestinal Increased motility Hyperactive bowel sounds Diarrhea

52 + Hyperkalemia findings Respiratory Neuromuscular Acute Muscle twitches Paresthesias Chronic Skeletal muscle weakness Ascending flaccid paralysis

53 + Hyperkalemia findings Laboratory findings ECG Tall peaked T waves Flat P waves Widened QRS complex Prolonged PR intervals

54 + Hypocalcemia Serum calcium level lower than 8.6 mg/dl Food sources Cheese Collard greens Milk Sardines Spinach Tofu Yogurt

55 + Hypocalcemia Causes Decreased calcium absorption in the gut Not enough oral intake of calcium Lactose intolerance Malabsorption Low vitamin D intake End-stage renal disease

56 + Hypocalcemia Causes Increased calcium excretion Renal failure Diarrhea Steatorrhea Wound drainage

57 + Hypocalcemia Causes Decreased ionized fraction of calcium Hyperproteinemia Alkalosis Medications Acute pancreatitis Hyperphosphatemia Immobility Damaged parathyroid glands

58 + Hypocalcemia Findings Cardiovascular Decreased pulse and Decreased BP Respiratory Decreased respiratory movement

59 + Hypocalcemia Findings Gastrointestinal Increased gastric motility Hyperactive bowel sounds Cramping Diarrhea Renal Urinary output depends on the cause

60 + Hypocalcemia Findings Neuromuscular Anxiety Irritability Hyperactive deep tendon reflexes Painful muscle spasms Tetany Seizures Positive Trousseau s and Chvostek s signs

61 + Hypocalcemia Findings Laboratory findings ECG: Prolonged ST interval Prolonged QT interval

62 + Hypocalcemia Treatment Treatment Give calcium supplements Warm the injections and administer slowly Watch for ECG changes Medications that increase calcium absorption Aluminum hydroxide Vitamin D 10% Calcium gluconate

63 + Hypercalcemia Serum level than 10 mg/dl Causes Increased calcium absorption Decreased calcium excretion (renal failure, use of thiazide diuetics) Increased bone reabsorption of calcium (hyperparathyroidism, hyperthyroidism, malignancy, immobility, glucocorticoids) Hemoconcentration (dehydration, lithium, adrenal insufficiency)

64 + Hypercalcemia Treatment Discontinue calcium containing substances or drugs Give medications that get rid of calcium Phosphorus Calcitonin Bisphosphonates Prostaglandin synthesis inhibitors Aspirin Dialysis Patient with calcium imbalance is at high risk for a fracture, so move them carefully Monitor for urinary stones

65 + Hypercalcemia findings Cardiovascular Increased pulse early on, later decreased heart rate can lead to cardiac arrest Bounding Full peripheral pulses Increased BP Respiratory Unsuccessful respiratory movement Renal Urinary output depends on cause Renal calculi Flank pain

66 + Hypercalcemia findings Neuromuscular Muscle weakness Absent deep tendon reflexes Disorientation Fatigue Coma Gastrointestinal Decreased motility Hypoactive bowl sounds Anorexia Nausea Constipation Abdominal distension

67 + Hypercalcemia findings Laboratory findings ECG: Shortened ST segment Widened T wave

68 + Hypomagnesemia Serum magnesium than 1.6 mg/dl Food sources Avocado Canned white tuna Cauliflower Green leafy vegetables Spinach Milk Peanut Butter Meat Raisins

69 + Hypomagnesemia Causes Low magnesium Malnutrition Vomiting Diarrhea Malabsorption syndrome Increased magnesium secretion Medications Chronic alcoholism Intracellular movement of magnesium Hyperglycemia Insulin adminstration Sepsis

70 + Hypomagnesemia Treatment Hypocalcemia usually occurs with hypomagnesemia Fix calcium levels Magnesium sulfate IV Oral Mg May cause diarrhea Increase Mg loss

71 + Hypomagnesemia Findings Cardiovascular Increased HR and BP Respiratory Shallow respirations CNS Irritability Confusion

72 + Hypomagnesemia Findings Neuromuscular Twitches Hyperreflexia Tetany Seizures Positive Trousseau s and Chvostek s signs

73 + Hypomagnesemia Findings Laboratory findings ECG: Tall T waves Depressed ST segments

74 + Hypermagnesemia Serum magnesium level than 2.6 ml/dl Causes Increased magnesium intake Decreased excretion of magnesium Treatment Diuretics Calcium chloride IV or calcium gluconate

75 + Hypermagnesemia Findings Cardiovascular Low HR and BP Neuromuscular Absent deep tendon reflexes Skeletal muscle weakness

76 + Hypermagnesemia Findings Respiratory Respiratory depression CNS Drowsiness Fatigue Coma

77 + Hypermagnesemia Findings Laboratory findings ECG: Prolonged PR interval Widened QRS complexes

78 + Hypophosphatemia Serum phosphorus level than 2.7 mg/dl Food sources: Fish Organ meats Nuts Pork Beef Chicken Whole grain breads and cereals

79 + Hypophosphatemia Causes Not enough phosphorus intake Increased phosphorus excretion (hyperparathyroidism, malignancy, antacids) Intracellular shift (hyperglycemia, respiratory alkalosis) Treatment Discontinue drugs or sources cause hypophosphatemia Give phosphorus with a vitamin D supplement Monitor renal function and for fractures

80 + Hypophosphatemia Findings Cardiovascular Decreased contractility and cardiac output Low peripheral pulses Respiratory Shallow Neuromuscular Weakness Decreased deep tendon reflexes Decreased bone density Rhabdomyolysis

81 + Hypophosphatemia Findings CNS Irritability Confusion Seizures Hematological Decreased platelet aggregation Increased bleeding time Immunosuppression

82 + Hyperphosphatemia Serum phosphorus level greater than 4.5 mg/dl Causes Decreased renal excretion Tumor lysis syndrome Increased intake of phosphorus Hypoparathyroidism

83 + Hyperphosphatemia Treatment Same as hypocalcemia Phosphate-binding medications Diet restriction Drugs containing phosphate restriction

84 + ECG and electrolyte imbalances Hypocalcemia Prolonged ST interval Prolonged QT interval Hypercalcemia Shortened ST segment Widened T wave

85 + ECG and electrolyte imbalances Hypokalemia ST depression Shallow, flat or inverted T wave Prominent U wave Hyperkalemia Tall peaked T waves Flat P waves Widened QRS complex Prolonged PR interval

86 + ECG and electrolyte imbalances Hypomagnesemia Tall T waves Depressed ST segment Hypermagnesemia Prolonged PR interval Widened QRS complex

87 + Hydrogen ions, Acids, and Bases Hydrogen ions Stated as ph Has 2 forms in the body: Volatile hydrogen of carbonic acid Nonvolatile form of hydrogen and organic acids

88 + Hydrogen ions, Acids, and Bases Acids Contain hydrogen ions and are hydrogen ion donors Number of hydrogen ions determines the strength of the acid Bases No hydrogen ions Hydrogen ion acceptors

89 + Regulatory Systems Buffers Fastest acting regulatory system Protect against any changes in hydrogen ions in the ECF Transport mechanism for hydrogen to the lungs

90 + Regulatory Systems Primary buffer systems Hemoglobin system Chloride shift Plasma protein system Carbonic acid-bicarbonate system Phosphate buffer system

91 + Regulatory Systems Lungs Second defense of the body with the buffer system to maintain acid-base balance Acidosis: ph decreases Respiratory rate and depth increase in order to exhale acids Alkalosis: ph increases Respiratory rate and depth decrease CO2 is retained Carbonic acid increases

92 + Regulatory systems (cont d) Kidneys Fundamental correction of acid-base imbalance Compensation Acidosis: Extra hydrogen ions are secreted into the tubules Hydrogen with a buffer are excreted in the urine Alkalosis: Extra bicarbonate ions move into the tubules Bicarbonate with sodium ions are excreted in the urine Regulation of bicarbonate

93 + Regulatory systems (con t) Exchange role Acidosis: Hydrogen into the cell K+ out Alkalosis: Hydrogen out to the blood K+ in the cell

94 + Respiratory Acidosis Causes Primary defect in the function of the lungs or respiratory pattern Obstruction of airway or depression of respiratory system Asthma Atelectasis Brain trauma Bronchiectasis Bronchitis CNS depressants Emphysema Hypoventilation Pulmonary edema Pneumonia Pulmonary emboli

95 + Clinical Manifestations of Respiratory Acidosis Neurological Drowsiness Disorientation Dizziness Headache Coma

96 + Clinical Manifestations of Respiratory Acidosis Cardiovascular Decreased BP Ventricular fibrillation Peripheral vasodilation Neuromuscular Seizures Respiratory Hypoventilation with hypoxia

97 + Clinical manifestations of Metabolic Acidosis Neurological Drowsiness Confusion Headache Coma Cardiovascular Decreased BP Dysrhythmias Peripheral vasodilation

98 + Clinical manifestations of Metabolic Acidosis Gastrointestinal Nausea Vomiting Diarrhea Abdominal pain Respiratory Deep, rapid respirations

99 + Respiratory Alkalosis Causes Overstimulation of the respiratory system Fever Hyperventilation Hypoxia Hysteria Over ventilation by mechanical ventilators Pain

100 + Clinical Manifestations of Respiratory Alkalosis Neurological Fatigue Lightheadedness Confusion Cardiovascular Fast HR Dysrhythmias Gastrointestinal Nausea vomiting Epigastric pain

101 + Clinical Manifestations of Respiratory Alkalosis Neuromuscular Tetany Numbness Tingling of extremities Hyperreflexia Respiratory Hyperventilation

102 + Clinical manifestations of Metabolic Alkalosis Neurological Drowsiness Dizziness Nervousness Confusion

103 + Clinical manifestations of Metabolic Alkalosis Cardiovascular Fast HR Dysrhythmias Gastrointestinal Anorexia Nausea Vomiting

104 + Clinical manifestations of Metabolic Alkalosis Neuromuscular Tremors Hypertonic muscles Muscle cramps Tetany Tingling of extremities Seizures Respiratory Hypoventilation

105 + Clinical manifestations of Metabolic Acidosis Neurological Drowsiness Dizziness Nervousness Confusion

106 + Clinical manifestations of Metabolic Acidosis Cardiovascular Tachycardia Dysrhythmias Gastrointestinal Anorexia Vomiting

107 + Clinical manifestations of Metabolic Acidosis Neuromuscular Tremors Hypertonic muscles Muscle cramps Tetany Tingling of extremities Seizures Respiratory Hypoventilation

108 + Metabolic Alkalosis Buildup of a OR Loss of an Deficit of carbonic acid Decrease in hydrogen Causes Diuretics Excessive vomiting or GI suctioning Hyperaldosteronism Ingestion Transfusion of whole blood

109 + Acid-Base Imbalances Respiratory acidosis ph: Decreased HCO3- : Normal PaO2: Usually decreased PaCO2: Increased K+: Increased

110 + Acid-Base Imbalances Respiratory alkalosis ph: Increased HCO3-: Normal PaO2: Usually normal PaCO2: Decreased K+: Decreased

111 + Acid-Base Imbalances Metabolic acidosis ph: Decreased HCO3-: Decreased PaO2: Usually normal PaCO2: Normal K+: Increased

112 + Acid-Base Imbalances Metabolic alkalosis ph: Increased HCO3-: PaO2: Normal PaCO2: Normal K+: Decreased

113 + Acid-Base Analysis via ABG 1. Know the normal values and how the align in the acid-base scale ph (Hydrogen ion concentration) NORMAL is PCO 2 (Partial Pressure of Carbon Dioxide) NORMAL is HCO 3- (Bicarbonate concentration) NORMAL is Plug the values into a tic-tac-toe board PCO 2 is a breathing parameter so it is associated with a respiratory etiology HCO 3- is a metabolic parameter so it is associated with a metabolic etiology

114 + Acid-Base Analysis via ABG Acid Alkaline ph 7.35 Normal 7.45 PaCO 2 45 Homeostasis 35 HCO THIS IS THE CONFUSING VALUE BECAUSE IT IS THE ONLY ONE THAT A HIGHER VALUE EQUATES TO ACID INSTEAD OF A BASE OPPOSITE OF THE OTHER 2 ph NORMAL is PCO 2 NORMAL is HCO 3 - NORMAL is 22-26

115 + Acid-Base Analysis via ABG Acid Alkaline ph 7.35 Normal 7.45 PaCO 2 45 Homeostasis 35 HCO ph 25 PaCO 2 19 HCO 3

116 + Acid-Base Analysis via ABG Acid Alkaline ph 7.35 Normal 7.45 PaCO 2 45 Homeostasis 35 HCO ph 32 PaCO 2 18 HCO 3

117 + Acid-Base Analysis via ABG Acid Alkaline ph 7.35 Normal 7.45 PaCO 2 45 Homeostasis 35 HCO ph 32 PaCO 2 24 HCO 3

118 + Allen s Test Evaluation of collateral blood flow prior to arterial blood draw Nursing Intervention: Explain the procedure Apply pressure over the ulnar and radial arteries at the same time Ask patient to open and close hand continually Release ulnar artery pressure while still compressing the radial artery Observe the color of the extremity distal to the pressure point Record results Draw arterial blood sampling

119 + Obtaining a blood sample Nursing Intervention: Check physician prescription Identify foods, medications, or other factors that could affect the procedure Identify the client Explain the purpose of the test and procedure Draw the blood sample Apply pressure and a Band-Aid or gauze dressing to the venipuncture

120 + Coagulation Studies Activated partial thromboplastin time ( ) Evaluates how well the coagulation sequence is functioning by measuring the amount of time it takes in seconds for recalcified citrated plasma to clot after partial thromboplastin is added to it Test screens for deficiencies and inhibitors of all factors except VII and XIII aptt is used to monitor heparin therapy and screen for coagulation disorders Should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy, if the value is prolonged (longer than 90 seconds), the client is at risk for bleeding. If the aptt value is prolonged (>90 sec) in a client receiving IV heparin therapy, initiate bleeding precautions.

121 + Coagulation studies Prothrombin Time PT measures the amount of time (sec) for clot formation and is used to monitor response to warfarin sodium (Coumadin) therapy or to screen for dysfunction of the extrinsic clotting system resulting from liver disease, vitamin K deficiency, or DIC PT normal is within 2 seconds of the control INR is used to test to measure the effects of oral anticoagulants Values PT: 9.6 to 11.8 seconds (male adult); 9.5 to 11.3 seconds (female adult) INR: 2 to 3 for standard warfarin therapy INR: 3 to 4.5 for high dose warfarin therapy

122 + Coagulation studies Nursing Intervention: A baseline PT shown be drawn before anticoagulation therapy is initiated, note the time on the lab form Put direct pressure to the venipuncture site for 3-5 mins Concurrent warfarin therapy with heparin therapy can extend the PT to times the lab control value A PT longer than 30 seconds can result in bleeding

123 + Coagulation studies Clotting time Time required for the interaction of all factors involved in the clotting process 8-15 mins No heparin therapy for 3hrs before specimen collection Heparin therapy will affect the results Anticoagulant therapy can falsely Prolong the test result Test tube agitation-????? Exposure of the specimen to high temperatures

124 + Coagulation studies Platelet count Hemostatic plug formation Clot retraction Coagulation factor activation Produced in the bone marrow Value: 150,000 to 400,000 cells/mm3 Nurse should monitor venipuncture site for bleeding in thrombocytopenic patients Platelet count increased by: High altitudes Chronic cold weather Exercise

125 + Erythrocyte studies Erythrocute sedimentation rate Hemoglobin and hematocrit Serum iron RBC count (erythrocytes) / / rule (normal RBC/HGB/HCT)

126 + Serum enzymes and cardiac markers Creatinine kinase Nurse roles: Tell patient to avoid exercising Troponins Values usually lower than.6 ng/ml Value higher than 1.5ng/mL Could indicate myocardial infarction Myoglobin

127 + Serum enzymes and cardiac markers Natriuretic peptides ANP: 22 to 27 pg/ml BNP: Less than 100 pg/ml The higher the BNP level The more severe the CHF If the BNP is raised Dyspnea is due to CHF If BNP is normal Dyspnea is due to a pulmonary problem.

128 + Serum Gastrointestinal studies Albumin Alkaline phosphatase Ammonia Alanine aminotransferase (ALT) Aspartate aminotransferase (AST) Amylase Lipase Bilirubin Lipids Uric acid

129 + Glucose studies Fasting glucose: mg/dl Glucose monitoring (capillary blood): mg/dl Glucose tolerance test (oral): Baseline fasting: mg/dl 30-min fasting: mg/dl 60-min fasting: mg/dl 90-min fasting: mg/dl 120-min fasting: mg/dl

130 + Glucose studies Glucose tolerance test Tell patient to eat a high-carbohydrate ( g) diet for 3 days before the test Avoid 36 hours before test: Alcohol Coffee Smoking 8 hours before the test: Exercise Fast 10 to 16 hours before test

131 + Glucose studies Glucose tolerance test Patients with diabetes mellitus Do not take morning insulin or oral hypoglycemic drugs Tell patient that the test may Take Require IV or oral administration of glucose Require many blood samples

132 + Glucose studies Glycosylated hemoglobin Blood glucose bound to Hb Hb A1c tells how well blood glucose levels have been controlled for the past 3 to 4 months Hyperglycemia Cause of increase HbA1c in diabetic patients Fasting is

133 + Glucose studies Glycosylated serum albumin (fructosamine) Reproduces avg. serum glucose levels over a period of 2 to 3 weeks More sensitive to recent changes than HbA1c (hemoglobin A1c) Values Not diabetic: 2.5 to 2.7 mmol/l Diabetic: 2 to 5 mmol/l Fast for 12 hours before the test

134 + Glucose studies Diabetes mellitus autoantibody panel Assess insulin resistance Recognize type 1 diabetes and patients with allergies to insulin Value: Less than 1:4 titer with no antibody detected Avoid radioactive scans within 7 days of the test No fasting required

135 + Real function studies Serum creatinine Avoid: Exercise for 8 hours before the test Extreme red meat intake for 24 hours before the test Value: 0.6 to 1.3 mg/dl

136 + Real function studies Urea Normally freely filtered through the renal glomeruli Some amount reabsorbed in the tubules and The rest excreted in the urine High levels shows a slowing of the GFR Value: 8 to 25 mg/dl BUN/CREAT ratio 10:1

137 + Elements Calcium Functions in bone formation Nerve impulse transmission Contraction of myocardial and skeletal muscles Helps in blood clotting by converting prothrombin to thrombin Value: 8.6 to 10 mg/dl Nurse roles Tell patient to eat a diet with normal calcium levels (800 mg/day) for 3 days before the test

138 + Elements Magnesium Indicative of metabolic activity and renal function Needed for blood-clotting mechanism Regulates neuromuscular activity Acts as a cofactor

139 + Elements Phosphorus Functions in bone formation Energy storage and release Urinary acid-base buffering Carbohydrate metabolism Value: 2.7 to 4.5 mg/dl Tell patient to fast before the test

140 + Thyroid studies Values TSH: 0.2 to 5.4 microunits/ml T4: 5 to 12 mcg/dl Free T4:.8 to 2.4 ng/dl T3: 80 to 230 ng/dl Avoid radionuclide scan within 7 days before the test

141 + White Blood Cell Count Value 4,500 to 11,000 cells/mm3 Neutrophils: 1,800 7,800 cells/mm3 Bands cells/mm3 Eosinophils cells/mm3 Basophils cells/mm3 Lymphocytes cells/mm3 Monocytes cells/mm3

142 + White Blood Cell Count Nurse Roles A low total WBC count with a left shift could indicate A recovery from bone marrow depression An infection of such intensity that the demand for neutrophils in the tissue is higher than the capacity High total WBC count with a left shift could be due to Increased release of neutrophils by the BM in response to an infection or inflammation

143 + White Blood Cell Count Nurse Roles A shift to the means that An increased number of immature neutrophils A shift to the means that Cells have more than usual number of nuclear segments Found in liver disease Down syndrome Megaloblastic and pernicious anemia

144 + Hepatitis testing Radioimmunoassay ELISA Microparticle enzyme immunoassay Serological tests for specific hepatitis virus markers Help in determining what specific type of hepatitis the patient has

145 + Hepatitis testing Values Hepatitis A IgM antibody Total antibody to hepatitis A Hepatitis B HBcAg HBeAg HBsAg

146 + Hepatitis testing Values Hepatitis C Confirmed with antibodies against Hepatitis C Hepatitis D antigen (HDAg) Seen in Hepatitis A virus Hepatitis E IgM and IgG antibodies to Hepatitis E

147 + Hepatitis testing Nurse role: If the radioimmunoessay tecnique is being used Within 1 week before blood test Injection of radionuclides may result in false positive levels

148 + HIV and AIDS testing Common tests include ELISA Western blot IFA ELISA Used for screening Western blot or IFA Must be performed after as a confirmatory test Repeat test later

149 + HIV and AIDS testing CD4+ T cell count Monitor progression of HIV CD4+ count will go down as the disease gets worse Immune system remains healthy with CD4+ T-cell counts higher than 500 cells/l Problems start occurring with CD4+ count is cells/l Severe immune system problems occur with CD4+ count is lower than 200 cells/l

150 + HIV and AIDS testing CD4-CD8 ratio Monitors progression of disease Normal ratio is 2:1 Viral load testing Measures the occurrence of HIV viral genetic material (RNA) in client s blood P24 antigen assay counts the quantity of HIV viral core protein in the patient s serum

151 + Urine Tests Color: pale yellow Odor: specific aromatic odor, similar to ammonia Turbidity: clear ph: Specific gravity: to Glucose: <0.5 g/day Ketones, protein, bilirubin, casts, crystals, bacteria: none White blood cells: < 4 cells/h Chloride: meq/ 24 hr Magnesium: mg/dl Potassium meq/ 24 hr Sodium meq/ 24 hr Uric acid: mg/ 24 hr Red blood cells: <3 cells/hpf

152 + Serum medication levels Acetaminophen (Tylenol) : mcg/ml Amikacin (Amikin) : mcg/ml Amitriptyline: ng/ml Carbamazepine (Tegretol): 5-12 mcg/ml Chloramphenicol (Chloromycetin): mcg/ml Desipramine (Norpramin) : ng/ml Digoxin (Lanoxin): ng/ml Disopyramide (Norpace): 2-5 mcg/m Ethosuximide (Zarontin): mcg/ml

153 + Serum medication levels Gentamicin: 5-10 mcg/ml Imipramine (Tofranil): ng/ml Lidocaine (Xylocaine): mcg/ml Lithium (Lithobid): meq/l Magnesium sulfate: 4-7 mg/dl Phenobarbital (luminal) : mcg/ml Phenytoin (Dilantin): Propranolol (Inderal): ng/ml Salicylate: mcg/ml Theophylline: mcg/ml

154 + Nutrition Carbohydrates Sugars, starches, and cellulose provide cal/g of energy Advance normal fat metabolism Spare protein Increase lower GI function

155 + Nutrition Carbohydrates Food sources Milk Grains/ Starch Fruits/ Fructose Vegetables/ Cellulose Glucose, lactose, sucrose

156 + Nutrition Fats Cholesterol, monounsaturated fats, polyunsaturated fats, saturated fats provide cal/g of energy Protects Internal organs Maintain body temperature Part of the plasma membrane

157 + Nutrition Fats Inadequate intake Feeling cold Skin lesions Risk of infection Amenorrhea Increased intake Obesity Increase risk of cardiac diseases and some cancers

158 + Nutrition Proteins Amino acids are the building blocks of protein Provide cal/g of energy Functions Build and repair body tissues Control fluid balance Uphold acid-base balance Make antibodies Provide energy Produce enzymes and hormones

159 + Nutrition Proteins Essential amino acids must be obtained through diet Food sources: Eggs Diary products Meat Fish Poultry Insufficient protein intake can lead to malnutrition and extreme wasting of fat and muscle tissue

160 + Nutrition Vitamins Good for life and growth processes Maintain and regulate body functions Fat-soluble vitamins are A,D,E, and K They can be stored in body so have there is a risk of toxicity The B and C vitamins are water-soluble Excreted in the urine

161 + Nutrition Vitamins Vitamin K Catalyst for enabling blood-clotting factors Especially Vitamin C Helps in the production of collagen Important in wound healing Vitamin A Helps with eyesight and epithelial linings

162 + Nutrition Minerals Part of hormones, cells, tissues, and bones Catalysts for chemical reactions and enhancers of cell function Deficiency can occur in chronically ill or in the hospitalized

163 + Therapeutic diets Clear liquid diet Fluids and some electrolytes to prevent dehydration Initial feeding after complete bowel rest Use to feed a malnourished person Use for preparation of bowel surgery Postoperatively in clients with fever, vomiting or diarrhea Gastroenteritis or pancreatitis

164 + Therapeutic diets Full liquid diet Used after clear liquid diet after surgery Clients who have trouble chewing, swallowing, or solid foods.

165 + Therapeutic diets Mechanically altered diet Texture is altered to require minimal chewing For those who have dental problems, surgery of head and neck, or dysphagia Soft diet For those who have difficulty chewing or swallowing Clients with mouth sores should be served food at colder temp Sour candy can increase salivary flow for those with dry mouth

166 + Therapeutic diets Low-residue, diet Least likely to form an obstruction when intestinal tract is narrowed by inflammation or scarring or when GI motility is slow Use in inflammatory bowel disease, partial obstructions of the intestinal tract, gastroenteritis, diarrhea and other GI problems

167 + Therapeutic diets High-residue, high-fiber diet Used for constipation, irritable bowel syndrome, and asymptomatic diverticular disease Give 20 to 35 g of dietary fiber daily Fruits, vegetables, and whole grain products are high-residue foods Increase fiber slowly and give adequate fluids so to avoid abdominal discomfort

168 + Therapeutic diets Cardiac diet Atherosclerosis, DM, hyperlipidemia, hypertension, MI, nephrotic syndrome, and renal failure Restrict fat amount, cholesterol and salt

169 + Therapeutic diets Fat-restricted diet Use to reduce abdominal pain, steatorrhea, flatulence, and diarrhea Used for patients with malabsorption disorder, pancreatitis, gallbladder disease, and GI reflux High-calorie, diet Used for severe stress, burns, wound healing, cancer, HIV, AIDS, COPD, respiratory failure, or any other debilitating disease Encourage snacks between meals

170 + Therapeutic diets Carbohydrate-consistent diet Used for patients with diabetes mellitus, hypoglycemia, hyperglycemia, and obesity Sodium-restricted diet Used for hypertension, heart failure, renal disease, cardiac disease, and liver disease

171 + Therapeutic diets Protein-restricted diet Used for renal disease and liver disease Renal diet Patient with acute or chronic renal failure, hemodialysis, or peritoneal dialysis patients

172 + Therapeutic diets Potassium-modified diet Low- potassium diet Hyperkalemia Impaired renal function Hypoaldosteronism Addison s disease ACE inhibitor medications Immunosuppressive meds K+ sparing diuretics Chronic hyperkalemia

173 + Therapeutic diets Potassium-modified diet High- potassium diet Hypokalemia Renal tubular acidosis GI losses Intracellular shifts K+ wasting diuretics Antibotics Glucocorticoid excess from primary or secondary aldosteronism Cushing s syndrome or exogenous corticosteroid use

174 + Therapeutic diets High- calcium diet Needed during bone growth and in adulthood to avoid osteoporosis and to enable vascular contraction, vasodilation, muscle contraction, and nerve transmission Low-Purine diet Used for gout, kidney stones, and elevated uric acid levels Food restrictions include anchovies, herring, mackerel, sardines, scallops, and glandular meats High- Iron diet Anemia Organ meats, meat, egg yolks, whole wheat, dark green leafy vegetables, dried fruit, and legumes

175 + Therapeutic diets diets Lacto-Ovo Lacto Vegan Pesco Enternal Nutrition Liquefied foods into the GI tract via a tube Used for patients with swallowing problems, burns, major trauma, liver or other organ failure, or severe malnutrition

176 + Parenteral Nutrition (PN) Supplies nutrients thru the veins Supplies carbohydrates in form of dextrose, fats in an emulsified form, proteins in the form of amino acids, vitamins, minerals, electrolytes, and water Prevents subcutaneous fat and muscle protein from being catabolized by the body for energy PN is least desirable form of nutrition and used when there is no alternative.

177 + Administration and discontinuation Types of administration Continuously over 24 hours Most commonly used in a hospital setting Less risk of complications when administered continuously Intermittent PN Generally 12-hour infusions that are usually given at night Discontinuing PN therapy Gradually decrease the flow rate for 1 to 2 hours while increasing oral (this assists in preventing hypoglycemia)

178 + Complications Air embolism Associated with tubing changes and central line placement Pneumothorax Associated with central line placement Hyperglycemia Hypervolemia Hypoglycemia Infection

179 + Intravenous therapy Used to sustain clients who are unable to take substances orally Replaces water, electrolytes, and nutrients more rapidly than oral administration Types of solutions Isotonic Hypotonic Hypertonic Colloids

180 + Intravenous devices IV cannulas Steel needles or butterfly sets Plastic cannulas The needle is.5 to 1.5 inches in length, with needle gauge sizes from 16 to 26 IV containers

181 + Intravenous devices IV gauges For rapid emergency fluid administration, blood products, or anesthetics Large-diameter lumen needles or cannulas are used 14,16,18, or 19 gauge Peripheral fat infusions (lipids) 20 or 21 gauge lumen or cannula is used For standard IV fluid and clear liquid IV medications 22 or 24 gauge lumen or cannula If client has small veins 24 to 25 gauge lumen or cannula is used

182 + Intravenous devices IV tubing Drip chambers Macrodrip chamber Microdrip chamber Filters Needleless infusion devices Intermittent infusion devices Electronic IV infusion devices

183 + Intravenous devices Complications Air embolism Catheter embolism Circulatory overload Electrolyte overload Hematoma Infection Infiltration Phlebitis and thrombophlebitis Tissue damage

184 + Central venous catheters Used to deliver hyperosmolar solutions, measure central venous pressure, infuse parenteral nutrition, or infuse multiple IV solutions or medications Tunneled central venous catheters Vascular access ports PICC line

185 + Epidural Catheter Catheter is placed in the epidural space for the administration of analgesics, this method of administration reduces the amount needed to control pain, therefore the client experiences fewer side effects Get client s vital signs, level of consciousness, and motor and sensory function

186 + Types of blood components Packed RBC Used to treat thrombocytopenia and platelet coagulation studies and fibrinogen levels White blood cells (WBCs) Types of blood donations Autologous Blood salvage Designated donor

187 + Compatibility ABO type and Rh type An antibody screen is done to determine the presence of antibodies other than anti-a and anti-b Crossmatching Universal RBC donor is O negative, the universal recipient is AB positive

188 + Compatibility Complications Transfusion reactions Signs of an immediate transfusion reaction: Chills and diaphoresis Muscle aches Back or chest pain Allergic reactions Hives Itching Swelling Rapid, thready pulse

189 + Compatibility Complications Signs of an immediate transfusion reaction: Dyspnea Cough or wheezing Pallow and cyanosis Apprehension Tingling and numbness Headache Nausea/ Vomiting/ Diarrhea Abdominal cramping

190 + Compatibility complications Signs of a transfusion reaction in an unconscious client Weak pulse, fever, tachycardia or bradycardia, hypotension, visible hemoglobinuria, oliguria or anuria Delayed transfusion reactions Signs include fever, mild jaundice, and a decreased hematocrit level Circulatory overload Caused by the infusion of blood at a rate too rapid for the client to tolerate Assessment: cough, dyspnea, chest pain, and wheezing on auscultation of the lungs, headache, hypertension, tachycardia and a bounding pulse, distended neck veins

191 + Compatibility complications Septicemia Occurs with the transfusion of blood that is contaminated with microorganisms Rapid onset of chills, high fever, vomiting, diarrhea, hypotension, shock Iron overload After receiving multiple blood transfusions Vomiting, diarrhea, hypotension, altered hematological values Tx: (Desferal)

192 + Compatibility complications Disease transmission Hypocalcemia Hyperkalemia