Exam 1: Tissue Integrity, Comfort, Acid-Base, Fluid & Electrolytes Flashcards
stage one pressure ulcer
- non-blanchable skin
- dark on darker skin, red on lighter skin
- transparent dressing
stage 2 pressure ulcer
- skin is broken
- extends to epidermis or dermis
- hydrocolloid/saline/semi-permeable occlusive dressing
stage three pressure ulcer
- extends to subcutaneous fat
- alginate dressing
stage four pressure ulcer
- extends to muscle, bone, tendons
- dry dressing
- maybe need debridement and gauze pack
emergent phase of burn injury
- airway assessment and maintenance
- fluid resuscitation
- lab values
why do we do fluid resuscitation for burns?
- important for tissue perfusion, prevention of hypovolemia
- lots of fluid lost through skin due to burn
How do we know if fluid resuscitation is/isn’t effective?
- Monitor urine output
- HR
- BP
- capillary refil time
- mental status
urine output should be 30 mL/hr
burn labs
- BUN > 20
- creatinine > 1.2
- potassium > 5
superficial burn
epidermis, red, dry, painful, blanch to pressure, sometimes peels
superficial partial burn
epidermis and some dermis, painful, red, weepy, blanches to pressure, blisters, might see exudate and necrotic debris
deep partial burn
deep into dermis, damage glandular tissue and hair follicles, painful to pressure but doesn’t blanch, likely to scar, blister, could need grafting
full thickness burn
subcutaneous tissue, leathery, eschar, need grafting, no pain because nerve endings dead
acute phase of a burn injury
- Pain management
- Nutrition
- Infection prevention
- Wound Care
Rehab phase of burn injury
- Goal: patient functions at highest level possible
- Preventing complications: use contracture-preventing mittens, use ROM exercises
- Psychosocial issues: self-esteem and body image, support group, let patient voice concerns and needs
ecchymosis
bruising/discoloration
epithealized
regeneration of epidermis
looks shiny
granulated
pink, red, moist
new blood vessels
indurated
hardened
eschar
black, brown necrotic tissue
tunneling
deep into body, through layers of tissue
think rabbit hole
undermining
under intact skin
under periphery of wound
dehisced
partial or total separation of wound layers
eviscerated
total separation of wound layers
protrusion of visceral organs
cellulitis
cause, characteristics, interventions
- cause: strep or staph, bacteria releases toxins
- inflammation symptoms, pain, chills, edema, sweating
- antibiotics
arterial ulcer
cause, characteristics, interventions
- cause: poor arterial blood flow, hypoxic tissues, arterial insufficiency
- deep, circumscribed, decr sensation, decr pulse, pale + cool skin, hair loss on extremity
- O2, promote blood flow, wound care
venous stasis ulcer
cause, characteristics, interventions
- cause: venous insufficiency, venous blood flow pooling
- shallow, asymmetrical, uncomfortable
- wound care, compression therapy, leg elevation, aspirin
Normal pH
7.35-7.45
Normal Paco2
35-45 mmHg
Normal Pao2
80-100 mm Hg
Normal HCO3
22-26 mEq/L
risk factors for acid-base balance
- respiratory issues
- metabolism/nutrition issues
- medications (like diuretics)
- head injuries
- kidney problems
- pain
- anxiety
buffer compensatory mech
- first to respond
- prevent major changes in ECF, keeps pH in balance
- release and accept H+
respiratory compensation mech
- fast to respond but quickly exhausted and not efficient
- alkalosis: increase pH –> decreases ventilation (hypoventilation) –> increases PCO2
- acidosis: decrease pH –> increase ventilation (hyperventilation) –> decreases PCO2
renal compensation mech
- last to respond, little slow but dependable
- acidosis: pH decreases, kidney excretes H+ and retains bicarb
- alkalosis: pH increases, kidney excretes bicarb and retains H+
metabolic acidosis assessment
- I&Os
- edema
- daily weights
- vitals (especially respiratory)
- EKGs for dysrhythmias
- LOC
- labs
metabolic acidosis manifestations
- cognitive changes: headache, lethargy, coma
- hyperventilation (Kussmauls)
- GI: nausea, diarrhea, abdominal discomfort
- dysrhythmias
metabolic acidosis causes
- diabetic ketoacidosis
- lactic acidosis
- shock
- trauma
- severe or chronic diarrhea
- starvation/malnutrition
- kidney failure
metabolic acidosis labs to check
- check potassium levels and ABG
- pH less than 7.35 ACIDIC –> acidosis
- HCO3 less than 22 ABNORMAL –> metabolic problem
- paCO2 35-45 NORMAL
- potassium greater than 5, hyperkalemia
metabolic acidosis treatment
- treat cause
- slow potassium IV piggyback (never IV push) if low potassium
- isotonic IV solutions for rehydration and antidiarrheals if diarrhea
- give sodium bicarb if SEVERE
respiratory acidosis causes
- decreased respiratory stimuli (anesthesia, drug overdose)
- respiratory conditions (COPD, penumonia, atelectasis, airway obstruction)
respiratory acidosis assessment
- respiratory rate/depth
- breath sounds
- apical pulse, heart sounds
- skin/cap refill
- LOC
respiratory acidosis manifestations
- tachycardia
- tachypnea (rapid shallow breaths)
- low BP
- dyspnea
- headache
- hyperkalemia
- dysrhythmias
respiratory acidosis labs
- check potassium levels and ABG
- pH less than 7.35 ACIDIC –> acidosis
- HCO3 22-26 NORMAL
- paCO2 greater than 45 ABNORMAL –> respiratory problem
- potassium levels greater than 5, hyperkalemia
respiratory acidosis treatment
- address underlying cause
- administer naloxone if opioid overdose
- O2 supplementation
- adequate fluids
- bronchodilators for COPD
- semi-high fowler position (open airways)
- place on cardiac monitor
metabolic alkalosis causes
- tummy acid loss: vomiting, NG suctioning
- antiacid overuse
- thiazide diuretics
- secretory adenomas of colon
- cushings syndrome
- aldosteronism
- steroid overuse
metabolic alkalosis assessment
- LOC
- vitals (especially respiratory)
- I&Os
- EKG for conduction abnormalities (AFIB)
- labs
metabolic alkalosis manifestations
- tachycardia
- dysrhythmia
- hypokalemia, hypocalcemia, H+ loss
- low BP
- hypoventilation
- respiratory failure
- dizziness, irritability, confusion
- tremors, cramps, tetany, hyperreflexia, tingling
- seizure and fall risk
metabolic alkalosis labs
- check potassium, calcium, and ABG
- pH more than 7.45 ALKALINE –> alkalosis
- HCO3 greater than 26 ABNORMAL –> metabolic problem
- paCO2 35-45 NORMAL
- potassium levels less than 3.5 hypokalemia
- calcium levels less than 8.5 hypocalcemia
metabolic alkalosis treatment
- underlying cause
- seizure and fall precautions
- fluid administration (if saline responsive)
- suction and O2 at bedside
- antiemetics for vomiting
- stop antacids, diuretics, steroids if cause
respiratory alkalosis causes
- hyperventilation (rapid deep breaths from anxiety/fear)
- mechanically ventilated
- liver disease
- pregnancy
- pulmonary embolism (blood clot in lung artery)
respiratory alkalosis assessment
- vitals
- labs
- LOC
- I&Os
respiratory alkalosis manifestations
- tachycardia
- N/V
- lethargy, confusion, lightheadedness
- hypokalemia
- seizure and fall risk
respiratory alkalosis labs
- check potassium and ABG
- pH more than 7.45 ALKALINE –> alkalosis
- HCO3 22-26 NORMAL
- paCO2 less than 35 ABNORMAL –> respiratory problem
- potassium levels less than 3.5, hypokalemia
respiratory alkalosis treatment
- underlying cause
- O2 supplementation if hypoxic
- seizure and fall precautions
- antianxiety meds aka benzos
- mechanically ventilated patients reduce tidal volume
- hyperventilation: paper bag breathing helps retain CO2
what increases fluid and electrolye imbalance risk?
- heart and vessel dysfunction
- increased age
- chronic conditions
- medications
- cognitive impairment
- immobility
hypovolemia risk factors
- very old or very young
- acute,
- acute or chronic injuries
- heat injuries (heatstroke)
- dysphagia
- malnutrition,
- meds (diuretics)
- chemo
- vigorous exercise
hypovolemia causes
- hemorrhage
- GI losses (vomiting, diarrhea, excessive tube suctioning)
- fever, heat, diaphoresis
- inadequate fluid intake
- burns (large)
- diuretics
- third space fluid shifts
hypovolemia labs
- serum osmolality greater than 293
- BUN greater than 20
- creatinine greater than 1.2
- HCT males greater than 49, females greater than 45
- urine specific gravity greater than 1.030, if DI then less than 1.010
- sodium greater than 150, hypernatremia
if both creatinine and BUN increased = kidney issues
Hypovolemia manifestations
- thirst
- dark, concentrated urine
- acute weight loss
- dry mucous membranes, tongue furrowed
- dry skin, decreased turgor, tenting
- decreased tearing, sunken eyeballs
- flat neck veins, poor peripheral vein filling
- hypotension, tachycardia, weak + thready pulse
- weakness, dizziness, lightheadedness, syncope
- mental changes: irritable, confused, lethargic, seizure, coma
hypovolemia treatment
- correct underlying cause
- replace fluid loss oral or IV (NS or LR)
- antipyretics, antiemetics, antidiarrheals, ADH
what do we need to monitor for hypovolemia fluid replacement?
- parenteral feedings need free water to prevent imbalances
- when giving IV bolus (especially with heart problem patients) watch for signs of fluid overload/hypervolemia
- monitor breath + heart sounds, decr RR, coughing, edema, incr BP, etc.
hypovolemia patient teaching
- Stop or minimize drinking caffeine and alcohol
- make sure to wear hats, stay in the shade, hydrate, and wear light clothes when participating in outdoor (high heat) activities
- identify a good fluid intake with the patient
- educate patient on daily weights (report acute weight loss)
- educate on hypervolemia/fluid overload signs
- educate on risk factors
- educate on medications (diuretics need to watch potassium levels, etc.)
hypervolemia risk factors
- older adults
- organ dysfunction
- high salt diet
- hypertension
hypervolemia causes
- heart/kidney/liver failure or dysfunction
- rapid administration of IV fluids or blood products
- incr aldosterone or corticosteroids
- SIADH
hypervolemia labs
- ABGs
- serum osmolality less than 273
- HCT less than 39 males and 35 females
- HGB less than 13.6 males and 12 females
- sodium less than 135, hyponatremia
- BUN less than 8 unless kidney damage (then more than 20)
hypervolemia manifestations
- edema
- tachypnea
- tachycardia
- incr BP
- pulmonary edema signs (crackles, decr RR, coughing, labored breathing)
- JVD
- incr weight
- decr appetite
- abdominal swelling
- decr urine output (retention)
- bounding peripheral pulses
hypervolemia treatment
- monitoring mental status, I&Os, weight, labs, vitals
- correct underlying cause (heart failure, SIADH)
- fluid removal (IV diuretic furosemide, flushes out K+ so monitor those levels)
- fluid restriction (output > intake)
- help patient not feel thirsty (avoid having too much liquids in the room, break up fluids throughout the day)
- comfort (oral hygiene)
- administering cardiac function meds
- chest x ray
hypervolemia meds
- diuretics: monitor K levels (spironolactone potassium sparing and furosemide potassium flushing)
- antihypertensives closely monitor for adverse effects, watch K levels, don’t use with spironolactone (could make situation worse because K imbalances)
hypervolemia patient teaching
- low sodium diet, how to read labels for sodium content, being aware of pre-existing conditions like liver failure, risk factor education
- teach how to monitor fluid intake, sodium intake, weight gain, manage pre-existing condition, watch for signs of hypovolemia, elevate legs if edema
- no sodium substitutes because those have a lot of potassium (especially if on ACE inhibitor antihypertensive or spironolactone diuretic)
hypernatremia risk factors
- advanced age
- cognitively impaired
- tube feedings
- intense burns
- diabetes
- high sodium diet
hypernatremia manifestations
- flushed skin and fever
- cognitive: restless, irritable, anxious, confused
- incr BP
- peripheral and pitting edema
- decreased urine output, dry mouth, thirsty
- urine specific gravity greater than 1.025
- flat neck veins
hypernatremia treatment
- diuretics to excrete fluids
- fluids to dilute
- Hypernatremia caused by diabetes insipidus: desmopressin
- free water flushes for tube feedings
- fluid resuscitation for hypovolemia
- salt and fluid restrictions for those who have hypervolemia + hypernatremia
- oral care for dry mucous membrane often
hypernatremia patient education
- label read
- rinse canned foods
- report weight changes or signs of hypovolemia/hypervolemia
- educate on community resources (food access)
- educate adequate fluid intake, how to minismize thirst
hyponatremia risk factors/causes
- fluid and salt loss: diarrhea, GI suctioning, vomiting, diaphoresis, diuretics
- inadequate intake: malnutrition, diet
- fluid excess: HF, renal failure, SIADH, excess parenteral administration of hypertonic solutions like D5W
hyponatremia manifestations
- neurological symptoms: lethargy, headache, confusion, apprehension, seizures, coma
- edema, weakness, muscle cramps, orthostatic hypotension
- anorexia, nausea, vomiting
- deep tendon reflexes diminished
- thready pulses
- bulging neck veins
- urine specific gravity less than 1.010
hyponatremia treatment
- 3% hypertonic saline: give slow
- meds that address underlying cause: antiemetics, antidiarrheals, spironolactone (SIADH)
- fluid restrictions and diuretics if hypervolemic
- restoration of sodium levels
- psychiatric treatment for polydipsia
- take away diuretics if they are causing the issue
- irrigate NGs with normal saline (NOT WATER)
hyponatremia patient education
- low sodium diet
- less water if hypervolemic
- read labels
- change positions slowly bc fall risk
- teach how to monitor BP and pulse
hypokalemia causes
- lacking potassium intake
- loss of potassium
- alcoholism
- alkalosis
- anorexia nervosa
- cushing syndrome
- diuretic agents (loop diuretic)
- hyperalimentation
- prolonged vomiting/diarrhea, NG suctioning
hypokalemia manifestations
alkalosis
shallow respirations
irritability
confusion, drowsiness
arrhythmias
muscle weakness, fatigue
lethargy
decreased intestinal motility, constipation
vomiting, nausea
thready pulse
orthostatic hypertension
potassium less than 3.5
hypokalemia treatment
- potassium administration: dilute, infuse slowly, NO IV PUSH, make sure blood return good, piggyback if burning
- hold KCl unless urine output is at least 0.5 ml/kg of body weight per hour
- replacement depends on severity, patient’s ability to swallow, and kidney function
- fall risk
hypokalemia patient education
- potassium high diet: bananas, citrus fruits (oranges), kiwi fruit, dry fruit, potatoes, nuts
- don’t crush meds
- know signs of low K: irregular pulse, muscle weakness, constipation
hyperkalemia risk factors
- poor kidney function
- heart failure
- traumatic accidents (massive tissue damage)
- significant burns
- acidosis
hyperkalemia manifestations
- muscle twitching → weakness → flaccid paralysis
- irritability and anxiety
- ECG Changes: tall peaked T waves, prolonged PR, wide QRS, flat P
- dysrhythmia – irregular rhythm, bradycardia
- abdominal cramping
- diarrhea
- numbness, tingling (paresthesia)
- hypotension
- potassium greater than 5
hyperkalemia treatment
- kayexalate (sodium polystyrene sulfonate): check bicarb
- 10 units reg insulin IV w. dextrose 50% dose: temporary fix, monitor blood sugars before and after
- if really high K then dialysis
- fall risk
- monitor cardiac status, K levels, I&O
hyperkalemia patient education
- avoid taking high potassium food
- avoid salt substitutes
- avoid ace inhibitors, antibiotics, chemo drugs, beta blockers, digoxin, heparin, NSAIDS, potassium sparing diuretics (spironolactone)
- report signs of hypokalemia
hypocalcemia causes/risk factors
- lactose intolerance
- inadequate dairy intake
- excessive citrated blood intake
- alcoholism
- increase in phosphate (they have an inverse relationship)
- something wrong with the parathyroid glands/hypoparathyroidism (cannot regulate calcium)
hypocalcemia assessments
- neuromuscular function
- ECG
- blood tests
- Chvostek and Trousseau signs
hypocalcemia manifestations
- CATS: convulsions, arrhythmias, tetany, spasms, stridor
- bleeding of gums + mucous membranes
- chvostek and trousseau’s sign
- calcium less than 8.5
hypocalcemia treatment
- calcium supplementation
- assess IV site for irritation
- safety: bones are easily broken and seizure risk
hypocalcemia patient education
- if lactose intolerant or vegan: eat oranges, fortified cereals, beans, broccoli, kale, collared greens, almond milk
- seizure and fall precautions
hypercalcemia causes/risk factors
- increased intake of calcium or vit d
- kidney failure
- diuretics
- bone cancers/breakdown
- hyperparathyroidism
- dehydration
hypercalcemia manifestations
- calcium levels greater than 10.5
- BACKME: bone pain, arrhythmias, cardiac arrest, kidney stones, muscle weakness, excessive urination
hypercalemia treatment
- prevent cardiac arrest
- cardiac monitor
- underlying cause
- increase fluids
- decrease calcium intake
- diuretics to flush extra fluids
hypercalcemia patient education
- if kidney failure don’t skip dialysis
- do not over supplement
hypomagnesemia causes/risk factors
- intestinal absorption issues: crohn’s, celiac, malnutrition
- alcoholism
- diarrhea
- laxative overuse
- citrated blood transfusions
- MI
- hypokalemia or hypocalcemia
- chemo
- immunosupression after transplant
hypomagnesemia manifestations
- magnesium levels less than 1.8
- EKG changes, arrhythmias
- hypertension
- hyperactive DTR
- seizures
- positive chvostek’s and trousseau’s
- depressed mood, agitation
- tetany
- hypoactive bowels
- nystagmus
hypomagnesemia treatment
- cardiac monitor
- severe: IV magnesium sulfate
- NO digitalis or digoxin
- calcium gluconate on hand, in case of hypermagnesemia
hypomagnesemia patient education
- high magnesium diet: nuts, whole grains, peanut butter, seafood, dark green veggies
- no oral replacements, can cause diarrhea and make it worse (milk of mag)
