pushing IV medication through the heparin lock device....

It’s your first day being on duty at the medical ward as a student nurse and you’re trying to learn everything that you could. Upon accompanying the staff nurse in her rounds, you note that she is carrying a syringe and is about to administer IV medication to a patient who has no IV. You look around the room for IV bottles, but still you can’t find any.
“Umm, excuse me ma’am. Is that for the patient?” you ask the staff nurse.

“Yes, it is,” she answers.
“But he has no IV line”
“Oh, Ms. X, this is to be given through the hep lock” she says as she motions to that tiny yellow thing sticking out from the patient’s hand.
Oh, that’s a heplock? You ask yourself since it’s your first time to see one and wonder how one gives medications through it
Steps:

1. Observe 10 Golden rules in the administration of the medication when introducing medication to the patient
2. Verify doctor’s order sheet or prescription.
3. Check medication card against the written doctor’s prescription
4. Explain procedure to the patient (name of the medicine and action) before administration.
5. Do hand hygiene before and after the procedure (use gloves especially for chemo drugs).
6. Gather equipment to include/but not limit to IV tray, Normal Saline diluents or isotonic 2.5 cc syringes (2-3 pcs) as needed.
7. Prepare medication to be administered, e.g, antibiotic, and draw it up into syringe.
8. Fill a tuberculin syringe with Heparin solution. N.B. Heparin solution is usually prepared with 0.1 cc. Heparin plus 0.99 cc Normal Saline or isotonic solution as prescribed by theDoctor.
9. Fill the 2.5cc syringe with isotonic solution or Normal Saline solution; 1cc each.
10. If using Heparin Lock Device with 3-way stop cock with luer-lock, rotate the stop cock so that the line going to the patient is closed (this will prevent backflow of blood.)
11. Remove the cover of the injection port aseptically and keep the sterility of the cover.
12. Check the patency, open the IV line and inject NSS or isotonic solution to flush the heparin solution as prescribed by the Doctor.
13. Close the IV line and remove saline syringe and insert medication syringe into the port. Give I.V. push 5-10 minutes for IV potent drug. For 2-3 I.V. Medications, give at least 30 minutes to 1 hour interval. After each drug administered via I.V. push, flush with 2-3 cc saline solution.
14. Observe patient for any adverse reactions and do nursing intervention accordingly.
15. Discard waste according to Health Care Waste Management (DOH/DENR).
16. Document in the patient’s chart.

 Some Hospital Does Not Use Heparin Anymore

Normal Saline can take the place of Heparin. Studies have shown the efficacy of NSS. Heparin solution can be used if normal saline or isotonic is not available and as prescribed by the M.D.

Sources:

• http://nurseinfos.com/2014/05/proper-way-of-administering-drugs/https://www.scribd.com/doc/6217510/IV-Push-Through-Heparin-Lock-Device

Notes

Preoperative Medications.....

Overview
One of the important events during the preoperative phase of the surgical experience is the administration of preoperative medications. Not only are anesthetics administered during this time, but so as drugs that minimizes respiratory tract secretions. Medicating the client pre-procedure to reduce anxiety and promote relaxation may also be necessary.
Medication History
Before discussing about the preoperative medications that are used the nurse should obtain a medication history. This eliminates the possible life-threatening effects of drug interactions and allergic reactions to certain medications. During a medication history the following are done:

• Document any medication the patient is using or has used in the past including over-the-counter (OTC) preparations and the frequency with which they are taken.
• The anesthesiologist evaluates the potential effects of prior medication therapy and considers the length of time the patient has used the medications, the patient himself and the nature of the proposed surgery.
  

Medications that cause particular concerns are the following:
Adrenal corticosteroids

1. DO NOT discontinue these drugs abruptly before the surgery.
2. If discontinued abruptly, the patient may suffer from cardiovascular collapse is he or she has been taking steroids for some time.
3. Before and after the surgery, a bolus of steroid may be administered intravenously immediately.

Diuretics
During anesthesia administration, thiazide diuretics may cause excessive respiratory depression from an associated electrolyte imbalance.
Phenothiazines
These medications may increase the hypotensive action of anesthetics
Antidepressants
Anesthetics have a hypotensive effect on the patient. Monoamine Oxidase inhibitors or MAOIs increase the hypotensive effects of anesthetics.
Tranquilizers
If medications such as diazepam, barbiturates and chlordiazapoxide are withdrawn suddenly anxiety, tension and even seizures may result.

Insulin
When a patient undergoing a surgery is diabetic, interaction between anesthetics and insulin must be considered.
Antibiotics
Neomycin, kanamycin and other “MYCIN” drugs may present problems when these medications are combined with a curariform muscle relaxation. Interruption of nerve transmission may occur and apnea due to respiratory paralysis may result when these drugs are combined.

Additional Source: http://emedicine.medscape.com/article/284801-overview#aw2aab6b8

Hepatic Failure News.....

Hepatic failure can result from acute liver injury, causing acute liver failure (ALF) or fulminant hepatic failure (FHF), or progressive chronic liver disease such as cirrhosis. An alteration in hepatocyte functioning affects the liver metabolism, detoxification process, protein synthesis, manufacture of clotting factors, and preservation of immunocompetence. FHF occurs when severe hepatic injury results in encephalopathy and severe coagulopathy within 28 days of the onset of symptoms in patients without a history of chronic liver disease. Liver transplant is the only viable treatment option for patient with FHF. The most commonly identified cause of FHF is drug induced, with acetaminophen the most common culprit, followed by viral hepatitis. Other causes include infection (cytomegalovirus [CMV], adenovirus), metabolic disorders and severe ischemic insult or shock.

Signs and Symptoms

• Manifestation depends on the complications associated with the liver dysfunction.
• Patient behavior may range from agitation to frank coma.
• Evidence of GI bleeding, renal failure, or respiratory distress may also be present.
• The initial manifestation in FHF is commonly bleeding from coagulopathy.

Physical Examination

Vital signs

• BP: < 90 mm Hg (with shock)
• HR: > 120 beats/min (with shock)
• Temperature may be mildly elevated
• RR: tachypnea initially progressing to respiratory depression associated with encephalopathy.

Neurologic

• Mildly confused to coma
• Personality changes
• Asterixis

Pulmonary

• Crackles
• Labored respirations

Gastrointestinal

• Hematemesis and melena
• Ascites
• Hepatomegaly may be present
• Splenomegaly may be present
• Factor hepaticus
• Diarrhea

Skin

• Jaundice
• Ecchymosis and petechiae
• Pruritus
• Edema

Acute Care Patient Management

Nursing Diagnosis: Deficient fluid volume related to ascites secondary to hypoalbumineia, bleeding secondary to decreased clotting factors or variceal hemorrhage, and diuretic therapy.
Outcome Criteria

• BP 90 TO 120 mm Hg
• Central venous pressure 2 to 6 mm Hg
• Serum albumin 3.5 to 5 mg/dl
• Platelet count >50,000/mm3
• Urine output 30 ml/hr
• Serum sodium 135 to 145 mEq/L
• Serum potassium 3.5 to 5 mEq/L
• Intake approximates output

Patient Monitoring

1. Obtain pulmonary artery pressure, central venous pressure, and blood pressure until the patient’s condition is stable, then hourly.
2. Continuously monitor ECG for lethal dysrhythmias that may result from electrolyte and acid-base imbalances.
3. Monitor fluid volume status. Measure intake and output hourly.

Patient Assessment

1. Assess hydration status. Note skin turgor on inner thigh or forehead, condition of buccal memranes, and development of edema and crackles.
2. Assess for signs and symptoms of bleeding.
3. Measure abdominal girth once each shift to determine progression of ascites.
4. Assess respiratory status.

Diagnostic Assessment

1. Review serial serum ammonia, albumin, bilirubin, platelet count, PT, PTT and ALT to evaluate hepatic function.
2. Review serial serum electrolytes.
3. Review urine electrolyte, BUN, and creatinine to evaluate renal function.

Patient Management

1. Administer intravenous crystalloids as ordered.
2. Administer potassium as ordered. Validate adequate urine output before potassium administration.
3. Sodium restriction of 0.5 g/day and fluid restriction to 1000 ml/day may be ordered.
4. Vitamin K or fresh frozen plasma (FFP) may be required to promote the clotting process.
5. Institute bleeding precautions. Avoid razor blades and use soft-bristled toothbrushes.
6. Paracentesis may be performed if abdominal distention is severe.
7. Prepare the patient and family for liver transplant, as indicated.

Code Blue: Defibrillation......

You’re getting on with your duty as usual. Everything just started out right, conscious patient, not-so busy work environment. This ought to be a stress-free duty. You’re just beginning to prepare your due medications when everything turned upside down.
—-
“Mrs. Santos? Mrs. Santos?” You check for the pulse and breathing.
“She’s not breathing. Call the code!”
                The rescue/code team has arrived as you perform continuous CPR. Ventilation and emergency medications have been given, O2 saturation and ECG tracings have been checked. The doctor orders defibrillation.
“Clear?”
“Clear!”
*Shock*
This is often the scenario we observe in movies and television shows. A busy clinical setting where doctors and nurses try to move as quickly and at the same time as accurately as possible. It’s as if everything’s a blur. The defibrillation scenario is a common act we play in demonstrations of happenings in the clinical area. We portray it so much that sometimes we think we already know and master what we are doing, but what we are yet to discover is that working in the hospital, dealing everyday with people’s lives is not always that conventional and that our job being nurses isn’t always as easy as it seems.
Overview           
Defibrillation is defined as the process wherein an electric shock is sent to the heart to stop an arrhythmia with the use of an electrical device called a defibrillator, resulting in the return of a productive heart rhythm.
Defibrillation is often used in emergency cases for the purpose of correcting life-threatening arrhythmias such as countering the onset of ventricular fibrillation or pulseless ventricular tachycardia, which is a common cause of/ and cardiac arrest.
When it comes to cardiac emergencies, the procedure must be performed immediately after identifying that the patient is experiencing an arrhythmia. You may identify this through signs like lack of pulse and unresponsiveness, you may also confirm the arrhythmia in ECG tracings. You may note randomly occurring chaotic electrical activity without discernable depolarization or repolarization waveforms for V-fib. V-tach on the other hand appears as wide complex tachycardia on the tracings.
In non-life threatening situations, atrial defibrillation may be ordered to treat atrial fibrillation or flutter.
However, this procedure is not indicated for pulseless electrical activity and asystole or flatline wherein there is complete cessation of cardiac activity since they are not responsive to defibrillation.
Also, defibrillation in the clinical setting must only be done by professionals (doctors, nurses and health professionals) who are trained in Advanced Cardiac Life Support, though outside of the hospital, AEDs or automated external defibrillators are also available in schools and other establishments. These AEDs are very user friendly, providing step by step instructions that allow bystanders to defibrillate in an emergency until trained medical personnel arrive.
How it works
Cardiac arrhythmias like ventricular tachycardia, fibrillation, and cardiac arrest prevent the heart from pumping blood to the body and can possibly cause irreversible damage to the major organs such as the brain and heart. With every minute that the heart fibrillates, about 10% of the ability to restart the heart is and death can occur within minutes if left untreated.
In ventricular arrhythmias, defibrillation works by applying a controlled electrical shock to the heart causing depolarization of the entire electrical conduction system of the heart. Then, when the heart undergoes repolarization, the normal electrical conduction may occur and the myocardium ideally returns to a normal rhythm.
However, there must be enough used energy for defibrillation, if not then the heart may not be completely depolarized which may result to non-termination of ventricular tachycardia or fibrillation. In other cases, ventricular arrhythmia may recur, such as if the heart does not get enough oxygen or if there exists the instability of the electrolytes in the cardiac cells.
In the clinical setting, nothing is predictable. Anything could happen in just a blink of an eye that is why we nurses must always be ready at all times. However, amidst all these emergencies, it is important that we still stay as calm and composed as possible. Maintain a clear head. Don’t panic. In times like these, quick actions are not the only ones needed, but also a stable mind can come in very handy.
Source:

• http://www.surgeryencyclopedia.com/Ce-Fi/Defibrillation.html
• http://www.heart.org/HEARTORG/Conditions/Arrhythmia/PreventionTreatmentofArrhythmia/Defibrillation_UCM_305002_Article.jsp
• http://www.sciencedaily.com/articles/d/defibrillation.htm

How Not to Blow a Vein.....

As an IV therapy nurse, no matter how “pro” you consider yourself to be, there are still times when you encounter problems when it comes to IV insertion, such as very fragile veins.
Here are some tips to avoid blowing veins in IV insertion.
Assess. Feel the veins.
Don’t just look at a vein, instead, try palpating the area to search for a vein. It is important to palpate using your index and third finger pad to evaluate the vein’s resilience, patency, valves, and size. Check if the vein is straight, soft and bouncy, and large enough to accommodate the catheter needed for the IV therapy. Go for the straightest vein. For geriatric patients, a deeper vein may be less prone to blowing since they are more stabilized and less movable.
Choose the right size.
This is with regards to the IV cannula to be used. If possible and if not contraindicated, try using smaller sizes. For adults, G-22 is commonly used while for pediatric patients, G-22-26 are used.
Check tourniquet application
A too tight or too loose tourniquet can cause veins not to distend and may result to you cutting off their arterial circulation. A BP cuff may be used as a tourniquet when dealing with very fragile veins of elderly and chemo patients.
Check the bevel. Make sure that it is facing upwards
This technique is done to make sure you don’t blow a vein when advancing forward. Also, you can control the angle of insertion more when the bevel is facing upward as you have easier glided point of entry as the sharp end-tip of the needle enters the skin.
Use warm/hot packs of the arm is cold
This is to dilate the blood vessels and them pop out quickly. Warm washcloths or blanket may be used if hot packs are not available.
Anchor the vein
This is to keep an unstable vein from moving sideways as you puncture it. This can be done by holding the skin and veins taut with your non-dominant hand.
Angle well and insert the catheter directly on top of the vein
Adjust your angle of approach accordingly if your target vein is too shallow or too deep. Usually, you may do it in a 15 to 30 degree angle. Then, insert the vein catheter on top of the vein to reduce the chances of going through the two vein walls. Do it slowly but steadily.
Upon hitting a vein and seeing backflow, stop advancing the catheter and drop the angle approach.
This is to avoid puncturing the vein wall again. Release the tourniquet first. Drop your angle of approach as you advance the catheter a little bit more. Then pull back the needle a little bit before advancing the whole catheter. When you have successfully inserted the catheter, pull back the needle quickly to attach the IV fluid set and start the IV infusion with the first few drops running very slowly.
Use available visualization devices
This may include transilluminator lights and pocket ultrasound machines. These devices will illuminate vein pathways so you can track the direction of where you should insert your IV catheter.
Sources:
http://www.nursebuff.com/2014/10/tips-for-nurses-on-how-to-prevent-blown-veins/
http://piccresource.com/piccnurseblog/how-to-start-ivs-8-tips-to-improve-your-iv-success/

Changing a Colostomy bag.......

Patient X is about to be discharged today per doctor’s order. In line with this, Nurse Eva is preparing her discharge teaching plan. In her attempt to promote independence, included therein is how to change a colostomy bag. Below are the steps that should be included in the discharge plan:

1. The bathroom is a good place to change the pouch. Empty the used pouch into the toilet first, if it needs emptying.
2. Gather the supplies. If you have a 2-piece pouch, be sure you have the special ring seal that sticks to your skin around the stoma.

Follow these steps to prevent infection:

• Wash your hands with soap and water. Be sure to wash between your fingers and under your fingernails. Dry with a clean towel or paper towels.
• If you have a 2-piece pouch, press gently on the skin around your stoma with 1 hand, and remove the seal with your other hand. (If it is hard to remove the seal, you can use special pads. Ask your nurse about these.)
• Remove the pouch.
• Keep the clip. Put the old ostomy pouch in a bag and then place the bag in the trash.
• Clean the skin around your stoma with warm soap and water and a clean washcloth or paper towels. Dry with a clean towel.

Check and seal your skin:

• Check your skin. A little bleeding is normal. Your skin should be pink or red. Call your doctor if it is purple, black, or blue.
• Wipe around the stoma with the special skin wipe. If your skin is a little wet, sprinkle some of the stoma powder on just the wet or open part.
• Lightly pat the special wipe on top of the powder and your skin again.
• Let the area air-dry for 1 to 2 minutes.

Measure your stoma:

• Use your measuring card to find the circle size that matches the size of your stoma. Do not touch the card to your skin.
• If you have a 2-piece system, trace the circle size onto the back of the ring seal and cut out this size. Make sure the cut edges are smooth.

Attach the pouch:

• Attach the pouch to the ring seal if you have a 2-piece ostomy system.
• Peel the paper off the ring seal.
• Squirt stoma paste around the hole in the seal, or place the special stoma ring around the opening.
• Place the seal evenly around the stoma. Hold it in place for a few minutes. Try holding a warm washcloth over the seal to help make it stick to your skin.
• If you need them, put cotton balls or special gel packs in your pouch to keep it from leaking.
• Attach the pouch clip or use Velcro to close the pouch.
• Wash your hands with warm soap and water.

ABG, Blood Gases, Alkalosis, Acidosis....

         

Question	Answer	Hint
normal pH	pH 7.35-7.45
most common buffer system	CO2 + H2O — H2CO3 — H+ + HCO3-
normal ratio of carbonic acid to bicarbonate	1:20
respiratory acidosis	Increased CO2 results in decrease in pH
respiratory alkalosis	Decreased CO2 results in increase in pH
respiratory component of acid-base balance	CO2 (carbon dioxide)
metabolic acidosis	Increased HCO3 results in increase in pH
metabolic alkalosis	Decreased HCO3 results in decrease in pH
metabolic component of acid-base balance	HCO3 (bicarbonate)
normal PaCO2	35-45 mmHg
normal PaO2	83-100 mmHg
normal HCO3	22-26 mEq/L
ABG analysis step 1	if pH is <7.35, acidosis if pH is >7.45, alkalosis
ABG analysis step 2	if CO2 is abnormal, respiratory if HCO3 is abnormal, metabolic
ABG analysis step 3	pH is normal: fully compensated pH & opposite number out of range: partially compensated pH out of normal range, opposite number in normal range: no compensation
oxyhemoglobin curve	changes in pH alter ease with hemoglobin releases O2 to plasma
values of metabolic acidosis	pH is low, HCO3 is low
values of metabolic alkalosis	pH is high, HCO3 is high
values of respiratory acidosis	pH is low, PaCO2 is high
values of respiratory alkalosis	pH is high, PaCO2 is low
causes of metabolic acidosis	diabetic ketoacidosis, starvation, lactic acidosis, excess ETOH or ASA, renal failure, diarrhea
s/s of metabolic acidosis	lethargy, confusion, stupor, coma, hyporeflexia, muscle weakness, bradycardia, thready pulses, low BP, Kussmaul resp, warm/flushed/dry skin, hyperkalemia
treatment of metabolic acidosis	treat the cause: insulin, hydration/electrolytes, antidiarrheals, sodium bicarbonate, dialysis
causes of metabolic alkalosis	antacid overuse, IV LR overuse, NaHCO3 overuse, vomiting, NG suctioning, thiazide diuretics
s/s of metabolic alkalosis	anxiety, irritability, hyperreflexia, muscle cramps/weakness, tachycardia, normal or low BP, shallow resps, hypokalemia, hypocalcemia
treatment of metabolic alkalosis	treat the cause: fluid/electrolyte replacement, NS IV, Ca++, K-sparing diuretics, antiemetics
causes of respiratory acidosis	head injury, Rx overdose, chest injury, electrolyte imbalance, severe obesity, ascites, hemothorax, COPD, aspiration, pneumonia, pulm edema, TB, PE
s/s of respiratory acidosis	skin pale to cyanotic & dry, increase PaCO2
treatment of respiratory acidosis	increase CO2 excretion: bronchodilators, steroids, Mucomyst, O2, pulmonary hygiene, PAP
causes of respiratory alkalosis	hyperventilation – anxiety, fear, mechanical ventilation; hypoxemia – asphyxiation, shock, high altitude
s/s of respiratory alkalosis	numbness & tingling around mouth, extremities, resp. effort normal or increase
treatment of respiratory alkalosis	treat underlying condition, support renal function w/ fluids, breath into bag or rebreather, sedatives

Fluid, Electrolytes, and Acid-Base Balance....

 

I. Fluid and Electrolytes

• A.    Water is the largest single component of the body
• B.     60% of the average adult’s body is fluid
• C.     Homeostasis is the ability to maintain internal balance in the presence of external stressors

II. The Purpose of Body Fluids

A.    Medium for transportation

• 1.      Nutrients to cells
• 2.      Wastes from cells
• 3.      Hormones, enzymes, blood platelets, RBCs & WBCs

B.     Cellular metabolism/chemical functioning

C.     Normal body temperature

D.    Facilitates digestion & elimination

E.     Tissue lubricant

F.      Solvent for electrolytes & nonelectrolytes

III. Body Fluids Overview

 A.    Intracellular ICF within the cells 40% body wt 

B.     Extracellular ECF  (20% body wt)

• 1.      Intravascular IVF contained within blood vessels
• a.       5% body wt
•  2.      Interstitial ISF surrounds cells, includes lymph
• a.       15% body wt

C.     Transcellular TCF includes cerebrospinal, pericardial, pleural, synovial and intraocular fluids, sweat, + digestive secretions <1% body wt

IV. Composition of Body Fluids

A.    Electrolytes

• 1.      Ions
• a.       Cations
• 1.      Positively charged: sodium, potassium, calcium
• b.      Anions
• 1.      Negatively charged: chloride, bicarbonate, sulfate

V. Variations in Fluid Content

A.    Age

• 1.      Infant 77% water
• 2.      Adult 60% water
• 3.      Elderly 45% water

B.     Gender

C.     Body Mass

VI. Movement of Body Fluids

A.    Osmosis

• 1.      movement of a pure solvent through semipermeable membrane from area of low concentration to area of greater concentration
• B.     Diffusion
• 1.      movement of a solute in solution across a semipermeable membrane from area of high concentration to area of low concentration

C.     Filtration

• 1.      Process by which water & diffusible substances move together in response to fluid pressure; movement is from higher to lower pressure

D.    Active Transport

• 1.      Requires metabolic activity & expenditure of energy to move materials across cell membranes

VII. Osmosis

A.    A shift of fluid from an area of low concentration to an area of higher concentration until the solutions are of equal concentration.

B.     Membrane is permeable to the solvent, not the solute

C.     Tonicity is the ability of solutes to cause osmotic driving forces

D.    Moses moved water

VIII. Osmotic Pressure 

A.    Tonicity is the ability of solutes to cause osmotic driving forces

B.     Exerted on permeable membranes by high molecular weight substances

C.     To pull fluid across membranes

IX. Osmotic Pressure

A.    A fluid with a high solute concentration has a high osmotic pressure

B.     Of two solutions, higher osmotic pressure will draw fluid until equilibrium is reached

C.     Osmotic pressure of a solution is called osmolarity

D.    Osmolarity is measure used to evaluate serum and urine in clinical practice

E.     Expressed in osmols, or milliosmols per kilogram (mOsm/kg)

F.      Normal serum osmolarity is 280-295 mOsm/kg

X. Types of Solutions

A.    Isotonic – .9%/Normal Saline

• 1.      Same concentration of solute as blood 
• 2.      Expands body’s fluids without causing fluid shift

B.     Hypertonic (hyperosmolar)  – D5NS, LR

• 1.      Greater concentration of solutes than blood
• 2.      Pulls fluids from cells causing them to shrink

C.     Hypotonic (hypo-osmolar) – .45% NS

• 1.      lesser concentration of solutes than blood
• 2.      Moves fluid into the cells, causing enlargement

XI. Colloidal Osmotic/Oncotic Pressure

A.    Affected by naturally produced serum proteins

B.     Albumin exerts colloid pressure to keep fluid in the intravascular compartment by pulling water from the interstitial space back into the capillaries 

 

 

XII. Diffusion 

A.    Is the natural tendency of a substance        (or gas) to move from an area of higher concentration to one of lower concentration

B.     This achieves balance

C.     The difference between the two concentrations is called the concentration gradient

XIII. Facilitated Diffusion

A.    Diffusion is facilitated by a carrier substance.

B.     Facilitated diffusion requires a concentration gradient and sufficient carriers

C.     Example: O2 & CO2 exchange

XIV. Filtration

A.    Process of water and diffusible substances move together in response to fluid pressure

• 1.      Called hydrostatic pressure
• 2.      Determines the movement of water

B.     Examples

• 1.      Increased hydrostatic pressure on the venous side (congestive heart failure) water and electrolytes from the arterial capillary bed move to the interstitial fluid
• 2.      Results in edema

XV. Active Transport

A.    Is necessary in the absence of concentration gradient or electrochemical gradient

B.     Requires metabolic activity, expenditure of energy and, carrier substances to move materials across cell membranes

C.     Allows cells to move molecules otherwise immovable – “uphill”

D.    Examples

• 1.      Na+ & K+ movement against the gradient
• 2.      Mechanism that allows cells to absorb glucose & other substances to facilitate metabolic activities

XVI. Body Fluid Regulation

A.    Homeostasis – physiological balance

B.     Allows body to respond to disturbances in fluid & electrolyte levels to prevent & repair damage

C.     Fluid intake

D.    Hormonal regulation

E.     Fluid output regulation

XVII. Cardiovascular System 

A.    Maintains:

• 1.      Blood pressure
• 2.      Cardiac output
• 3.      Hydrostatic pressure
• 4.      Adequate glomerular filtration rate

XVIII. Definitions

A.    Osmolality

• 1.      The concentration of osmotically active particles in solution expressed in terms of osmoles of solute per kilogram of solvent

B.     Osmolarity

• 1.      The concentration of osmotically active particles in solution expressed in terms of osmoles of solute per liter of solution

XIX. Fluid Intake

A.    Regulated through the thirst mechanism located in the hypothalamus

B.     Conscious desire for water

C.     One of the major factors in fluid intake

D.    Osmoreceptors monitor serum osmotic pressure; osmolality increases; hypothalamus is stimulated; thirst results

• 1.      Increased osmolality – can occur with inability to take in fluids or administration of hypertonic fluids
• 2.      Vomiting or hemorrhage: Hypovolemia; dehydration

XX. Hormonal Regulation (Endocrine) 

A.    Antidiuretic hormone (ADH)

• 1.      Stored in posterior pituitary gland
• 2.      Released in response to changes in blood osmolarity

B.     Aldosterone

• 1.      Released by adrenal cortex in response to increased plasma K+ levels or part of renin-angiotensin-aldosterone mechanism in hypovolemia

C.     Renin

• 1.      Proteolytic enzyme secreted by kidneys, responds to decreased renal perfusion 2^nd to decrease extracellular volume
• 2.      Triggers angiotensin I production converting to angiotensin II which causes massive selective vasoconstriction ultimately directing blood to perfuse kidneys

XXI. Fluid Output Regulation

A.    Occurs through four organs of water loss

• 1.      Kidneys
• a.       Major regulatory organs of fluid balance; receive 180 L of plasma to filter & produce 1200 to 1500 ml of urine/day
• 2.      Skin
• a.       Regulated by the sympathetic nervous system; activates sweat glands
• b.      Sensible – excess perspiration; can be observed
• c.       Insensible – continuous; not perceived by the person; can increase significantly with fever or burns
• 3.      Lungs
• a.       Expire about 400 ml of water daily
• 4.      Gastrointestinal tract (GI)
• a.    3 to 6 L of isotonic fluid moved into GI tract & returned to extracellular fluid daily

XXII. Regulation of Electrolytes

A.    Cations

• 1.      Sodium
• 2.      Potassium
• 3.      Calcium
• 4.      Magnesium

B.     Anions

• 1.      Chloride
• 2.      Bicarbonate
• 3.      Phosphorus-phosphate

XXIII. Fluid Shifts

A.    First Spacing

• 1.      Normal fluid compartments

B.     Second Spacing

• 1.      Interstitial

C.     Third Spacing

• 1.      When fluid is trapped in a body space as a result of injury or disease,
• 2.      Represents a fluid loss
• 3.      Includes pericardial, pleural, peritoneal, joints

XXIV. Plasma to Interstitial

A.    Pathology

• 1.      + hydrostatic pressure
• 2.      Decreased capillary osmotic pressure
• 3.      + cap permeability
• 4.      Obstructed lymph drainage

B.     Manifestation

• 1.      Edema, hypovolemia

C.     Interventions

• 1.      Fluid replacement
• 2.      Monitor for overload

XXV. Interstitial to Plasma

A.    Pathology

• 1.      Decreased capillary permeability
• 2.      Increased capillary osmotic pressure

B.     Manifestations

• 1.      Hypervolemia

C.     Interventions

• 1.      If normal, patient excretes fluid
• 2.      With disease, must diurese

XXVI. Fluid Volume Deficit (FVD) 

A.    Thirst with 2% loss

B.     Dry mucus membranes with 6% loss

C.     Leads to cellular dehydration

D.    Weight is best indicator

XXVII. FVD Causes

A.    Anything causing loss of blood volume:

• 1.      Blood loss
• 2.      Polyuria
• 3.      GI losses
• 4.      Profuse diaphoresis
• 5.      Third spacing
• 6.      Decreased intake

XXVIII. FVD Manifestations

A.    Hypotension

B.     Increased pulse, respirations

C.     Decreased urinary output, temperature

D.    Poor skin turgor

E.     Dry mucus membranes

F.      Constipation

G.    Increased hematocrit, plasma proteins, BUN, urine specific gravity

XXIX. FVD Interventions

A.    Correct the underlying cause

B.     Replace fluid depending on type lost

XXX. Fluid Volume Excess (FVE)

A.    Caused by fluid overload

B.     Renal failure

C.     CHF

D.    Cirrhosis

E.     Corticosteroids

F.      Cushing’s syndrome

XXXI. FVE Manifestations

A.    BP up, bounding pulse

B.     Distended neck veins

C.     Rapid wt gain

D.    Peripheral edema

E.     Pulmonary edema

F.      CVP elevated

G.    BUN decreased, hematocrit decreased

H.    Plasma proteins decreased

XXXII. FVE Interventions

A.    Treat the underlying cause

B.     Fluid and or sodium restriction

C.     Diuretics

D.    Dialysis, paracentesis

XXXIII. Regulation of Acid-Base Balance

A.    Metabolic processes maintain a steady balance between acids & bases

 

 

B.     Arterial pH inversely proportioned to the hydrogen ion concentration

C.     The greater the concentration, the more acidic the solution, the lower the pH & vice versa

D.    The lower the concentration, the more alkaline the solution, the higher the pH

XXXIV. Chemical Regulation 

A.    Largest chemical buffer is carbonic acid & bicarbonate buffer system

B.     Carbonic acid – carbon dioxide

C.     Bicarbonate – excretion by the kidneys

XXXV. Biological Regulation

A.    Occurs when hydrogen ions are absorbed or released by cells

B.     Occurs after chemical buffering & takes 2 to 4 hours

C.     Hydrogen must exchange with another positively charged ion

• 1.      Chloride shift
• 2.      Hemoglobin-oxyhemoglobin system

XXXVI. Physiological Regulation

A.    Act as buffers (compensation) to return the pH to normal

B.     Lungs

• 1.      When the respiratory system is the problem agent – resp. acidosis; resp. alkalosis
• 2.      Acts as the buffer when renal system is the problem

C.     Kidneys

• 1.      When the renal system is the problem agent – metabolic acidosis; metabolic alkalosis
• 2.      Acts as the buffer when respiratory system is the problem

XXXVII. Disturbances in Electrolyte, Fluid, & Acid-Base Balance 

A.    Seldom occur alone

B.     Can disrupt normal body processes

C.     Each disturbance can cascade into a disturbance of the other 

XXXVIII. Electrolyte Imbalances 

A.    Sodium

B.     Potassium

C.     Calcium

D.    Magnesium

E.     Chloride

XXXIX. Sodium

A.    Hyponatremia

1.      Net sodium loss or excess water excess
2.      Indicators & treatments depend on cause & ECF status

B.     Hypernatremia

• 1.      Excess water loss or sodium excess
• 2.      Increases aldosterone secretion, sodium is retained, potassium is excreted
• 3.      Body conserves fluid through renal reabsoption

XXL. Potassium

A.    Normal amount is very small with little tolerance for fluctuation

B.     Hypokalemia           

• 1.      One of most common electrolyte imbalances
• 2.      Inadequate amount of potassium circulates in the ECF
• 3.      Severe cases can affect cardiac conduction and function; most common cause is use of potassium-wasting diuretics

C.     Hyperkalemia

• 1.      Produces marked cardiac conduction abnormalities
• 2.      Primary cause is renal failure; also seen in crushing injuries

Calcium

A.    Hypocalcemia

• 1.      Results from severe illnesses, especially ones that directly affect thyroid & parathyroid glands; renal insufficiency (inability to excrete phosphorous, as phosphorous rises, calcium declines)
• 2.      S/S related to neuromuscular, cardiac, & renal systems

B.     Hypercalcemia

• 1.      Frequently a symptom of underlying disease resulting in excess bone reabsorption

 Magnesium

A.    Symptoms are a result of changes in neuromuscular excitability

B.     Hypomagnasemia

• 1.      Occurs with malnutrition, malabsorption disorders, & neuromuscular system disorders

C.     Hypermagnasemia

• 1.      Depresses skeletal muscles & nerve function
• 2.      Depresses acetylcholine leads to sedative effect; leading to bradycardia, ECG changes, cardiac arrhythmias, decreased respiratory rate & depth

Chloride

A.    Commonly associated with acid-base imbalance

B.     Hypocloremia

• 1.      Occurs with vomiting or prolonged NG tube or fistula drainage with loss of hydrochloric acid
• 2.      Use of loop & thiazide diuretics
• 3.      Can result in metabolic alkalosis

C.     Hypercloremia

• 1.      Occurs when serum bicarbonate falls or sodium level rises

Fluid Disturbances

A.    Isotonic

• 1.      Occur when water & electrolytes are gained or lost in equal proportions

B.     Osmolar

• 1.      Occur with losses or excesses of only water so that concentration of serum is affected

Acid-Base Balance

A.    Arterial blood gases (ABG) are the best way to evaluate

B.     Involves analysis of 6 components

• 1.      pH
• 2.      PaCO2
• 3.      PaO2
• 4.      Oxygen saturation
• 5.      Base excess
• 6.      Bicarbonate (HCO3)

C.     Deviation from a normal value indicates imbalanc 

PH

A.    Measures hydrogen ion concentration in body fluids

B.     Even slight changes can be potentially life threatening

C.     Normal ranges 7.35 to 7.45

D.    RULER OF THE BODY

PaCO2

A.    Partial pressure of carbon dioxide

B.     Reflects depth of pulmonary ventilation

C.     Normal range 35 to 45 mm Hg

D.    Indicates the concentration of CO2 in the blood

PaO2

A.    Partial pressure of oxygen

B.     No primary role in acid-base balance regulation if within normal limits

C.     Lower levels < 60mm Hg can lead to anaerobic metabolism, resulting in lactic acid production & metabolic acidosis

D.    Normal range is 80-100 mm Hg 

Oxygen Saturation

A.    Point at which hemoglobin is saturated by O2

B.     Can be affected by changes in temparture, pH, & PaCO2

C.     Normal range is 95% to 99%

Base Excess

A.    Amount of blood buffer that exists

B.     High value indicates alkalosis

• 1.      Can result from sodium bicarbonate, citrate excess with blood transfusions, IV infusions of sodium bicarbonate to correct ketoacidosis

C.     Low value indicates acidosis

• 1.      Can result from elimination of too many bicarbonate ions, i.e. diarrhea 

Bicarbonate (HCO3)

A.    Major renal component of acid-base balance

B.     Excreted & reproduced by the kidneys to maintain normal acid-base environment

C.     Normal range is 22 to 26 mEq/L (this may vary slightly from lab to lab)

D.    Indicator of metabolic cause of acidosis or alkalosis

E.     Is buffer agent in respiratory acidosis or alkalosis

Types of Acid-Base Imbalances

A.    Respiratory Acidosis

• 1.      Excessive carbonic acid & increased hydrogen ion concentration (low pH)

B.     Respiratory Alkalosis

• 1.      Decreased carbonic acid & decreased hydrogen ion concentration (high pH)

C.     Metabolic Acidosis

• 1.      High acid content in blood causing loss of HCO3
• 2.      Analysis of serum electrolytes to detect anoin gap (which reflects unmeasurable anoins)

D.    Metabolic Alkalosis

• 1.      Heavy loss of acid or increased HCO3 content in blood
• 2.      Most common cause is gastric suction

Nursing Knowledge

A.    Imbalances can occur at any age

B.     Body’s adaptive compensatory mechanisms fail to maintain balance adequately

C.     Health becomes compromised

D.    Severity & long-term effects can influence client’s ability to return to optimal health

E.     Prolonged compromise can lead to irreversible chronic health problems that affect the quality of life for client & family

Nursing Process – Assessment 

A.    Nursing history

• 1.      Client’s history determines goals
• 2.      Age of client is important factor

B.     Prior medical history

• 1.      Acute illnesses
• a.       Surgeries, burns, respiratory disorders, head injuries
• 2.      Chronic illnesses
• a.       Cancer, cardiovascular disease, renal disease, GI disturbances
• 3.      Environmental factors
• a.       Exercise, exposure to temperature extremes
• 4.      Diet
• a.       Intake of fluids, changes in appetite, metabolic interference, physical problems
• 5.      Lifestyle
• a.       Smoking, alcohol use/abuse, drugs
• 6.      Medication
• a.       Prescription or OTC meds that perpetuate fluid imbalances

Physical Assessment

A.    F&E/A-B imbalances can affect all systems

B.     Thorough exam

C.     Include client’s intake/output history, genitourinary patterns/changes

D.    Lab study results

E.     Client expectations 

Nursing Process – Nursing Diagnoses

A.    Actual

• 1.      Ineffective breathing patterns
• 2.      Decreased cardiac output
• 3.      Deficient fluid volume
• 4.      Excess fluid volume
• 5.      Impaired gas exchange
• 6.      Impaired mobility
• 7.      Impaired tissue integrity/perfusion

B.     Risks

• 1.      Imbalanced body temperature
• 2.      Deficient fluid volume
• 3.      Impaired skin integrity/perfusion

Nursing Process – Planning

A.    Goal & Outcomes

• 1.      Client free of complication
• 2.      Demonstrates fluid balance
• 3.      Labs in range

B.     Setting Priorities

• 1.      Client’s condition sets priorities of ND

C.     Continuity of Care

• y1.      Discharge planning should happen early

Nursing Process – Implementation

A.    Health promotion

• 1.      Teach client & family to recognize risk factors
• a.       Age, activities, specific chronic illness affects

B.     Acute care

• 1.      Daily weights
• 2.      Enteral replacement of fluids
• 3.      Fluid restrictions
• 4.      Parenteral fluid & electrolyte replacement
• 5.      IV therapy implications & risks

Complications of IV Fluid Administration

A.    Systemic:

• 1.      Fluid Overload
• 2.      Air Embolism
• 3.      Septicemia

B.     Local:

• 1.      Infiltration and Extravasation
• 2.      Phlebitis
• 3.      Thrombophlebitis
• 4.      Hematoma
• 5.      Clotting and obstructing 

Fluid Overload

A.    Fluid Overload: too much fluid in circulatory system: Rapid infusion, underlying cardiac, liver, or renal disease

B.     S+S: moist crackles, edema, wt gain, dyspnea, shallow rapid resp

C.     Treatment: Decrease flow rate, monitor VS + BS, position High Fowlers

D.    Prevent: IV pumps, careful assessment

E.     Complications: CHF, Pulmonary edema

Air Embolism

A.    Occurs when air enters the bloodstream.

B.     Is threatening when the air displaces blood to the cells

C.     Most often associated with central veins

D.    S+S; dyspnea, cyanosis, hypotension, weak, rapid pulse, loss of consciousness, chest shoulder, low back pain. Complication: death

E.     Treatment

• 1.      Clamp iv lines;
• 2.      L trendelenberg position;

F.      Prevention

• 1.      Careful filling of IV tubes and syringes;
• 2.      LuerLock adapters;
• 3.      Air sensing pumps

Septicemia 

A.    Infection disseminated through the blood stream

B.     Cause:

• 1.      Contaminated IV products, break in technique

C.     Risk: immunocompromised

D.    S+S:

• 1.      Elevated Temp, backache, headache, pulse and resp elev.

E.     Treatment:

• 1.      Symptomatic, local or systemic

F.      Prevention:

• 1.      Critical hygiene and technique

Infiltration

A.    Infiltration:

• 1.      Introduction of a non vesicant solution into surrounding tissues
• 2.      Extravasation: Introduction of a vesicant or irritating solution into surrounding tissues.

B.     S+S: edema, coolness, decreased flow, discomfort

C.     Tx:

• 1.      Discontinue, restart, compress with warm or cold to affected site, elevate

D.    Prevention:

• 1.      Careful securing of IV tubing, limit mobility of limb with IV, frequent observation of site

Phlebitis & Thrombophlebitis

A.    Phlebitis:

• 1.      inflammation of a vein from chemical or mechanical irritation.
• 2.      S+S: red, warm at site or along vein, pain, tenderness, swelling.
• 3.      Prevention: (frequency parallels length of insertion), use good aseptic technique, observe frequently.
• 4.      Tx: discontinue IV, warm moist compress, elevate

B.     Thrombophlebitis:

• 1.      presence of a clot in addition to phlebitis.
• 2.      S+S: same + more discomfort, elevated WBC, immobility
• 3.      Tx: same: Prevent: avoid trauma at insert.

Hematoma 

A.    Blood leaking into tissue.

B.     From perforation of vein during insertion or later.

C.     S+S: ecchymosis, swelling, leak blood

D.    Tx: remove, pressure, +/- ice, heat.

E.     Prevent: careful technique during insertion

Clotting and Obstruction

A.    Occur from kinked tubing, slow infusion rate, failure to flush line, empty IV bag

B.     S+S: decreased flow, blood backing up,

C.     Tx: if clotted, restarting at a new site is necessary

Nursing Process – Evaluation

A.    Client care

• 1.      Client teaching
• 2.      Recognition of signs/symptoms of imbalance
• 3.      Consult physician to enhance care in chronic conditions

B.     Client expectations

• 1.      Evaluate the client’s perception of care and goals
• 2.      Use client input to understand needs and expectations