EXAM 3 Flashcards
FLUID, ELECTROLYTE, ACID/BASE, ABG, MEDICATION ADMINISTRATION, ELIMINATION, SPECIMEN COLLECTION WEEKS 7-9
HYPERNATREMIA
WATER DEFICIT
HYPONATREMIA
WATER EXCESS
S/S OF FLUID VOLUME EXCESS
WET SOUNDING
CONFUSION
DECREASED LOC
EDEMA
HYPOKALEMIA
DIARRHEA
REPEATED VOMITTING
USE OF POTASSIUM WASTING DIURETICS
HYPERKALEMIA
DECREASED URINE OUTPUT
HYPOCALCEMIA
ACUTE PANCREATITIS
NEUROMUSCULAR EXCITABILITY
HYPERCALCEMIA
CANCER PATIENTS
HYPOMAGNESEMIA
INCREASED NEUROMUSCULAR EXCITABILITY
HYPERMAGNESEMIA
NEUROMUSCULAR EXCITABILITY
LETHARGY
DECREASED DEEP TENDON REFLEXES
WHAT IONS DO ACIDS RELEASAE
HYDROGEN
H+
DEGREE OF ACIDITY IS REPORTED AS
PH
1.0 IS VERY ACIDIC
14.0 IS VERY BASE
NORMAL PH VALUE
7.0 IS NEUTRAL
NORMAL ARTERIAL BLOOD IS 7.35-7.45
WHAT ORGANS WORK TOGETHER TO KEEP THE ACID-BASE BALANCE
KIDNEYS AND LUNGS
CELLULAR METABOLISM PRODUCES WHAT?
CARBONIC ACID THAT GOES TO THE LUNGS AND METABOLIC ACIDS THAT GO TO THE KIDNEYS
RESPIRATORY ACIDOSIS
- LUNGS UNABLE TO EXCRETE ENOUGH CO2
- EXCESS CARBONIC ACID IN THE BLOOD DECREASES PH
RESPIRATORY ALKALOSIS
- LUNGS EXCRETE TOO MUCH CO2
- DEFICIT OF CARBONIC ACID IN THE BLOOD INCREASES THE PH
METABOLIC ACIDOSIS
KIDNEYS UNABLE TO EXCRETE ENOUGH METABOLIC ACIDS WHICH ACCUMULATE IN THE BLOOD
METABOLIC ALKALOSIS
KIDNEYS EXCRETES TOO MUCH METABOLIC ACIDS WHICH RESULTS IN DECREASED BLOOD BICARBONATE
CAUSES OF METABOLIC ALKALOSIS
HIGH PH AND HIGH BICARB
OVERUSE OF ANTACIDS
POTASSIUM WASTING DIURETICS
LOSS OF GASTRIC JUICES
CAUSES OF RESPIRATORY ALKALOSIS
HIGH PH AND LOW CO2
HYPERVENTILATION
ANXIETY
HIGH ALTITUDES
PREGNANCY
FEVER
HYPOXIA
PULMONARY DISEASE
VENTILATOR SETTINGS THAT ARE TOO HIGH OR TOO FAST
CAUSES OF RESPIRATORY ACIDOSIS
LOW PH AND HIGH CO2
HYPOVENTILATION
AIRWAY OBSTRUCTION
COPD
CHEST TRAUMA
DRUG OVERDOSE
PULMONARY EDEMA
NEUROMUSCULAR DISEASE
CAUSES OF METABOLIC ACIDOSIS
LOW PH AND LOW BICARB
DIABETIC KETOACIDOSIS
SALICYLATE OD
SHOCK
SEPSIS
SEVERE DIARRHEA
RENAL FAILURE
TACHYPNEA
DEEP AND RAPID RESPIRATIONS
NURSING Hx FOR ACIDOSIS/ALKALOSIS
AGE: VERY YOUNG OR VERY OLD
ENVIRONMENT: EXCESSIVELY HOT?
DIETARY INTAKE: FLUIDS, Na, K, Ca, Mg
LIFESTYLE: ETOH
MEDS: OTC AND HERBAL AND Rx
MEDICAL Hx FOR ACIDOSIS/ALKALOSIS
RECENT SURGERY (PHYSIOLOGICAL STRESS)
GI OUTPUT
ACUTE ILLNESS/TRAUMA- RESPIRATORY DISORDERS, BURNS, TRAUMA
CHRONIC ILLNESS- CANCER, HF, OLIGURIC RD
DAILY WEIGHT ASSESSMENT FOR ACIDOSIS/ALKALOSIS
INDICATOR OF FLUID STATUS
MAKE SURE TO USE SAME CONDITIONS
DO YOU COUNT IRRIGATION INI&O
ACIDOSIS/ALKALOSIS
NO, SUBTRACT IT
ISOTONIC IV SOLUTION
SAME EFFECTIVE OSMOLALITY AS BODY FLUIDS
HYPOTONIC IV SOLUTIONS
EFFECTIVE OSMOLALITY LESS THAN BODY FLUIDS THUS DECREASING OSMOLALITY BY DILUTING BODY FLUIDS AND MOVING H2O INTO CELLS
HYPERTONIC IV SOLUTIONS
HAVE AN EFFECTIVE OSMOLALITY GREATER THAN BODY FLUIDS AND DRIVES H2O OUT OF CELLS
WHAT SHOULD YOU BE CAUTIOUS OF WITH IV THERAPY
TOO RAPID OR EXCESSIVE INFUSION OF ANY IV FLUID HAS THE POTENTIAL TO CAUSE SERIOUS PROBLEMS
COULD CAUSE FLUID OVERLOAD OR MYOCARDIAL INFARCTION
SIGNS THAT IV ACCESS HAS GONE WRONG
BRUISING
INFECTION
EXTRAVASATION
INFILTRATION
PHLEBITIS
BLOOD COMPONENT THERAPY
IV ADMIN OF WHOLE BLOOD OR BLOOD COMPONENT
*TAKES 2 NURSES TO VERIFY
*STAY FIRST 15 MINUTES
TRANSFUSING BLOOD
CHECK,CHECK, CHECK
MONITOR
2 PEOPLE MIN
TRANSFUSION REACTIONS AND ADVERSE EFFECTS
IMMEDIATE = FEVER, CHILLS, NAUSEA, DYSPNEA, TACHYCARDIA, HYPOTENSION
DISCONTINUING PERIPHERAL IV ACCESS
IV THERAPY
IF IT LOOKS BAD… TAKE IT OUT
INFECTION, BRUISING, EXTRAVASION, INFILTRATION, PHLEBITIS… TAKE IT OUT
TIC TAC TOE METHOD
VIDEO 1
https://www.youtube.com/watch?v=URCS4t9aM5o (solving some problems)
TIC TAC TOE METHOD
VIDEO 2
https://www.youtube.com/watch?v=3neNB0w1P9M (partially compensated vs fully)
TIC TAC TOE METHOD
VIDEO 3
https://www.youtube.com/watch?v=URCS4t9aM5o (interpreting problems)
WHY DATE AN IV
USUALLY ONLY GOOD FOR 3 DAYS SO YOU NEED TO KNOW WHEN TO TAKE IT OUT– SAME FOR TUBING
SYMPTOMS OF METABOLIC ALKALOSIS
Level of consciousness/confusion, generalized weakness, decreased BP, skin turgor. Youshould assess for dehydration
WHY DOES ADVANCED AGE PUT A PATIENT AT RISK FOR FLUID AND ELECTROLYTE IMBALANCES
Dehydration: due to not feeling thirsty.
Na RANGE
Sodium (Na*): 136 to 145 mEq/ L
K+ RANGE
Potassium (K*): 3.5 to 5 mEq/L
Ca TOTAL RANGE
Calcium total (Ca*·): 9.0 to 10.5 mg/dL
Mg RANGE
Magnesium(Mg-): 1.3 to 2.1 mEq/ L
PO RANGE
Phosphorus (PO ):3.0 to 4.5 mg/dL
CI RANGE
Chloride (CI):98 to 106 mEq/ L
ABGs
PH
PACO2
PAO2
HCO3
pH RANGE
pH : 7.35 to 7.45
PaCO2 RANGE
PaC02 : 35 to 45 mm Hg
PaO2 RANGE
Pa02 : 8O to 100 mm Hg
HCO3 RANGE
HC03 (bicarbonate):21 to 28 mEq/L
HYPOCALCEMIA VIDEO
https://www.youtube.com/watch?v=Ry5Rh3wO8Sw
ABG CHARACTERISTICS OF RESPIRATORY ACIDOSIS
LOW PH
HIGH pCO2
RETENTION OF CO2 BY LUNGS
METABOLIC ALKALOSIS ABG CHARACTERISTICS
INCREASE IN BASE OR DECREASE IN ACID
INCREASE PH
INCREASE HCO3
S/S OF METABOLIC ACIDOSIS
HEADACHE
LETHARGY
ANOREXIA
DEEP, RAPID RESPIRATIONS (KUSSMAUL)
N&V
DIARRHEA
ABDOMINAL DISCOMFORT
COMA
DANGEROUS DYSRHYTHMIAS
S/S OF METABOLIC ALKALOSIS
CARDIAC DYSRHYTHMIAS AS A RESULT OF DECREASED K+
PHYSICAL WEAKNESS
MUSCLE CRAMPING
HYPERACTIVE REFLEXES
CONFUSION
CONVULSIONS
TETANY
HOMEOSTASIS
The body must maintain a delicate balance of acids and bases
.* Metabolic and respiratory processes must work together to keep hydrogen ion (H+) levels normal and stable.
WHAT DOES THE PH OF BLOOD INDICATE
CONCENTRATION OF H+
To diagnose an acid-base imbalance, you need to ask yourself three questions
1) Does the pH indicate acidosis or alkalosis?
2) Is the cause of the pH imbalance respiratory or metabolic?
3) Is there compensation for the acid-base imbalance?
if compensation has been complete what would the ph result be
within normal range
If pH is within the normal range but the other parameters are not, you’re looking at
a case of complete compensation
.* You will need to do one extra step to diagnose the origin of the imbalance.
* You will be noting two pH values on the grid
how to notate 2 pH values on the grid
Record the one in the normal range as “pH(1)”
* Recalculate pH using the exact midpoint of the normal range, or 7.40, for your reference point.
– Thus, a pH of less than 7.40 would indicate acidosis, and one greater than 7.40 would be alkalosis
* Note this adjusted pH in the appropriate box as “pH(a)”
Treatment of any of these imbalances should be directed at
correcting the underlying cause with immediate care focused on correcting the pH level.
ISMP
(http://www.ismp.org/Tools/confuseddrugnames.pdf)
A DRUG IS
Any substance that alters physiologic function, with the potential of affecting health
A MEDICATION IS
a substance used in the diagnosis,
treatment, cure, relief, or prevention of health alteration. Regulated by the FDA.
A DRUG CAN BE ADMINISTERED FOR DIAGNOSTIC PURPOSES
e.g. assessment of liver function or diagnosis of myasthenia gravis
A DRUG CAN BE ADMINISTERED FOR PROPHYLAXIS
e.g. heparin to prevent thrombosis or antibiotics to prevent infection
A DRUG CAN BE ADMINISTERED FOR THERAPEUTIC PURPOSES
e.g. replacement of fluids or vitamins, supportive purposes (to enable other treatments, such as anesthesia), palliation of pain and cure (as in the case of antibiotics).
GENERIC NAMES
manufacturer who develops, help to recognize class (will see on NCLEX
DRUG CLASSIFICATION IS BASED ON
its desired effect on body system
MEDICATION FORMS
solid, liquid, topical, parenteral, sterile for body cavity instillation
THERAPEUTIC EFFECT
expected /predicted response on body system
ADVERSE EFFECTS AKA SIDE EFFECTS
are unintended and nontherapeutic effects, which can range from tolerable to harmful and sometimes to irreversible damage or death. Ex- GI bleeding from ASA (aspirin)
IDIOSYNCRATIC REACTIONS
opposite or different response than expected such as hyperactivity w Benadryl
SYNERGISTIC EFFECT
2 drugs cause greater body response when given together (positive or negative)
ALLERGIC REACTIONS TO MEDICATIONS
SESNSITIZED IMMUNE RESPONSE, UNPREDICTED, SIMPLE (ITCHING, HIVES, RASH, RHINITIS), OR ANAPHYLACTIC (EMERGENCY ABC PROBLEM, TX FOR BRONCHOSPASMS, WHEEZING, AND EDEMA)
PRURITUS
ALLERGIC RXNS
itching of the skin with or without rash.
ANGIOEDEMA
ALLERGIC RXNS
edema due to increased the permeability of the blood capillaries.
RHINITIS
ALLERGIC RXNS
Inflammation of mucous membranes lining nose; causes swelling and clear, watery discharge.
Pharmacokinetics
how meds enter & exit the body, are absorbed & distributed, reach their site of action, alter body processes, & are metabolized
Medication absorption
Passage of medication molecules into the blood from the site of administration
distribution of medication
After absorption, distribution occurs within the body to tissues, organs, and specific sites of action.
distribution of medication depends on
Physical and chemical properties of the medication
Physiology of the person taking it:
Circulation
Membrane permeability
Protein binding
medication metabolism
Medications are metabolized into a less-potent or an inactive form.
Kidneys, blood, intestines, and lungs play a role.
biotransformation
medication metabolism
Biotransformation occurs under the influence of enzymes that detoxify, break down, and remove active chemicals.
medication excretion
Medications exit the body through the:
Kidney- urine
Liver- bile
Bowel- stool
Lungs- gases
Exocrine glands- lipid-soluble meds
Chemical makeup of medication determines the organ of excretion.
toxic concentration
adverse or prolonged effect
therapeutic range
mec- wants a constant blood level
below the minimum effective concentration
concentration is too low to cause therapeutic effect
Therapeutic range-
constant blood level between mec & toxicity
peak
Peak is considered the maximal therapeutic level, max serum dose, time varies.
trough/level
A trough is the lowest therapeutic level.
onset
body response time
biological half life
is the time it takes for excretion to lower the blood concentration of a drug to decrease by 50%. Determines how often med is given.
plateau
occurs when a medication blood serum concentration reaches therapeutic effect and remains there
Time-critical medications-
30 minutes before or after scheduled time; non-time critical- within 1 hour of time due
Vancomycin 1 gm is due at 0800. When should the nurse draw the trough level?
a. 0600 b. 0730 c. 0900 d. 1000
b
A postoperative patient is receiving morphine sulfate via patient-controlled analgesia (PCA). The nurse assesses that the patient’s respirations are depressed. The effects of the morphine sulfate can be classified as:
a. therapeutic b. synergistic c. allergic d. adverse
d
Medication Rights
Right patient
Right medication
Right dose
Right time
Right route
Right documentation
Other rights (assessment, evaluation, refusal, education)
Standing or routine:
types of orders in acute care agencies
Administered until the dosage is changed or another medication is prescribed
single (one time)
types of orders in acute care agencies
Given one time only for a specific reason
now
types of orders in acute care agencies
When a medication is needed right away, but not STAT
prn
types of orders in acute care agencies
Given when the patient requires it
stat
types of orders in acute care agencies
Given immediately in an emergency
prescriptions
types of orders in acute care agencies
Medication to be taken outside of the hospital
According to The Joint Commission the goal of medication reconciliation is
to develop, update, coordinate, and communicate accurate client medication information during transitions of care.
Polypharmacy-
increase risk of adverse reactions, interactions
5 or more meds on a nonhospitalized client
May be meds with same actions or chemical class or to treat same illness
Risk of drug-drug or drug-food interactions
Taking herbal or nutritional supplements
OTC meds
Multiple pharmacies, providers
Topical administration:
Medications applied to the skin and mucous membranes generally have local effects.
Applied to skin
Rectal
Vaginal
Otic
Optic
Nasal
Oral Administration
Easiest and most desirable route
Food may decrease therapeutic effect. Empty stomach- 1 hr before or 2 hrs after meals.
aspiration precautions with oral medications
With tube feeding, if medication is to be given on an empty stomach, allow at least 30 minutes before or after feeding.
Risk of drug-drug interactions is higher.
enternal or small bore feedings
oral administration
Verify that the tube location is compatible with medication absorption.
Dissolve or pierce simple gelatin capsules.
Do NOT crush sustained release or enteric coated & double-check capsule before opening b/c interferes with design of med and/or increases potency.
Follow American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines.
Sublingual Administration
Administer to patient sitting
Dissolves under tongue
Don’t swallow drug, eat, drink, or smoke until after absorbed
patient teaching of administering meds via inhalation
Exhale 1st and then Inhale slowly, hold for 5-10 sec. to disperse med to get full effect. 30 sec. between puffs. Teach to rinse & spit after using inhaled steroids to decrease risk of developing thrush. Teach to monitor usage to know when to reorder.
Topical Medications- Skin
Transdermal patches:
Remove old patch before applying new.
Document the location, time & date of application of the new patch.
Document removal of the old patch as well.
Ask about patches during the medication history.
Apply a label to the patch if it is difficult to see.
Nasal Instillation (Topical)
Nasal drops are effective in treating sinus infections.
saline safer than decongestant spray which vasoconstricts and can increase BP
rebound effect- worsens nasal congestion.
Eye instillation
Artificial tears, vasoconstrictors.
Avoid touching the cornea- very sensitive, pain fibers.
Avoid the eyelids with droppers or tubes to decrease the risk of infection.
Pull down conjunctival sac and press lacrimal duct.
Never allow a patient to use another patient’s eye medication.
topical medications- ear
Structures are very sensitive to temperature. Room temp to prevent vertigo, dizziness, nausea.
Young child <3yrs- pull outer ear down & back, Older children & adults- pull ear up and back
ear instillation
Use sterile solutions in case ear drum is ruptured.
Drainage may indicate eardrum rupture.
Never occlude the ear canal.
Do not force medication into an occluded ear canal.
Topical Medications: Vaginal Instillation
Perineal care, assess for drainage.
Gloves, aseptic technique.
Supp- foil wrappers, refrigerate to prevent melting, avoid handling.
Topical Medications: Rectal Instillation
Rectal suppositories are thinner and more bullet-shaped than vaginal suppositories.
The rounded end prevents anal trauma during insertion.
Keep in fridge and avoid handling- may melt.
Identify the route of administration for ear drops.
A. Sublingual B. Parenteral C. Topical D. Intravenous
c
Suppositories should be stored in a
A. Locked box B. Pxyis drawer C. Dark area D. Refrigerator
d
Which medication could be administered via a nasogastric or PEG tube?
A. Extended release B. Sustained release C. Gelatin capsule D. Enteric coated
c
parts of the syringe and needle
bevel
shaft
barrel
tip
plunger
gauge number
hub
know where to measure
know where to avoid touching
needle description for id
1/4-3/4 inches long
27-25 gauge
needle description of im
25-18 gauge
1-1.5 inches long
needle description for subcu
3/8-5/8 inches long
27-25 gauge
Preparing an injection from an ampule
Snap off ampule neck
Aspirate medication into syringe using filter needle to prevent small glass fragments from entering syringe
Preparing an injection from a vial
If dry, use solvent or diluent as needed. Some meds unstable in solution so left as powder until reconstituted/dissolved w sterile water or normal saline for use.
Inject air into vial to create positive pressure to make med removal easier.
Insulin Administration –Patient Teaching
part 1
It is administered by subcutaneous injection and occasionally IV because the GI tract breaks down and destroys an oral form of insulin.
Rapid, short, intermediate, and long-acting (basal- lasts 24 hrs)
Insulin Administration –Patient Teaching
part 2
Timing of insulin attempts to mimic normal pattern of release of insulin from pancreas- before meals (ac) and at bedtime (hs).
Rotate vial to resuspend soln rather than shake- creates air bubbles
Rotate injection sites to avoid lipodystrophy- loss of fat cells, can be a lump or small dent in skin from repeated injections, interferes with insulin absorption.
mixing insulins video
https://www.youtube.com/watch?v=EW55TFDFrZ0
high risk of insulin
insulin
Verify insulin doses with another nurse while preparing the injection.
don’ts for mixing insulin
Do not mix insulin with any other medications or diluents unless approved by the health care provider
Never mix basal insulins- insulin glargine (Lantus) or insulin detemir (Levemir) with other types of insulin.
Regular Insulin Correctional Scale-AC & HS for high BG
blood glucose (mg/dL) = insulin (units)
61-150 = 0
151-200 = 3
201-250 = 5
251-300 = 8
301-350 = 10
351-400 = 12
greater than 400 = 15 and contact dr
Before injecting, know:
The volume of medication to administer
The characteristics and viscosity of the medication
The location of anatomical structures underlying the injection site
The subcutaneous route
injection site
under loose connective tissue, with minimal vascular supply and some pain receptor presence.
The injection site chosen needs to be free of skin lesions, bony prominences, and large underlying muscles or nerves.
preferred subcutaneous injection sites include
the outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs.
The site most frequently recommended for heparin injection is
the abdomen.
angle for subcutaneous injections
Pinch an inch, give at 45 degree angle; Pinch 2 inches, give at 90 degrees.
Enoxaparin (Lovenox)
prevents DVTs! Subcutaneous route. ALWAYS 90 degrees in Abdomen; hold 10 seconds after injecting.
Administration of low-molecular-weight heparin (LMWH) requires special considerations. When injecting the medication,
use the right or left side of the abdomen at least 2 inches from the umbilicus
Administer LMWH lovenox (enoxaparin) in its prefilled syringe slowly with the attached needle at 90 degree angle
do not expel the air bubble in the syringe before giving the medication
leave in place 10 seconds after administering.
Do not rub skin.
Hold pressure at site.
im sites
ventrogluteal
vastus lateralis
deltoid
deltoid for im
Palpate the lower edge of the acromion process, which forms the base of a triangle in line with the midpoint of the lateral aspect of the upper arm. The injection site is in the center of the triangle, about 3 to 5 cm (1 to 2 inches) below the acromion process. Locate the site by placing four fingers across the deltoid muscle, with the top finger along the acromion process. The injection site is then three finger widths below the acromion process.
vastus lateralis for im
Position in a supine or lateral position with knee and hip flexed to relax muscle. Place palm of hand over greater trochanter of patient’s hip with the wrist perpendicular to femur. Use right hand for left hip, and use left hand for right hip. Point the thumb toward the patient’s groin and the index finger toward the anterior superior iliac spine; extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle; the injection site is the center of the triangle.
ventrogluteal for im
Anterior lateral aspect of thigh, and extends in an adult from a handbreadth above knee to a handbreadth below greater trochanter of femur.
Use middle third of muscle for injection. The width of muscle usually extends from the midline of thigh to midline of outer side of thigh. Lying flat with knee slightly flexed or in sitting position relaxes muscle.
why im
Muscle is less sensitive to irritating and viscous medications.
max capacity of im for adults
Adults: 2 to 5 mL can be absorbed, 3 or less mL per injection is preferred.
assessing and prepping im sites
Assess site, find landmarks away from nerves. Aspirate 5-10 seconds to assess for blood vessel before injection of the medication. Use 90 degree angle for insertion
when to use ventrogluteal for im
involves the gluteus medius; it is situated deep and away from major nerves and blood vessels. **preferred and safest site for all adults, children & older infants. Recommended for vol > 2mL & for viscous, irritating meds.
when to use vastus lateralis for im
often used for infants less than 7 months and for very thin patients or patients who do not walk secondary to paralysis, etc.
when to use deltoid for im
Use this site for small medication volumes (Less than 2mL).
z-track video
https://www.bing.com/videos/search?q=video+on+z+track&view=detail&mid=CF857160FA29E8B35631CF857160FA29E8B35631&FORM=VIRE
Z-Track Method in IM Injections
Pull on the overlying skin during intramuscular injection to move tissue laterally to prevent later tracking (return of the medication to the skin surface). One hand holds skin 1 to 1.5 inches laterally or downward; other hand injects at rate of 10 seconds per mL. Then, keep needle inserted for 10 seconds to allow med to evenly disperse, rather than channel back. Release skin after withdrawing needle. Creates zig-zag path.
For needle gauges, the larger the number, the larger the size.
True or False?
false
Injections: Intradermal
Used for skin testing (TB, allergies)
Slow absorption from dermis to avoid anaphylaxis
Skin testing requires the nurse to be able to clearly see the injection site for changes
Injections: Intradermal
needle and angle
Use a tuberculin or small hypodermic syringe for skin testing. 27 or 25 gauge
Angle of insertion is 5 to 15 degrees with bevel up.
Injections: Intradermal
sites and expectations
A small bleb will form as you inject; if it does not form, it is likely the medication is in subcutaneous tissue, and the results will be invalid. Sites are hairless, light pigmentation, free of lesions. Ex- inner forearm, upper back.
subcutaneous medication capacity
no more than 1.5 ml
im medication capacity
ventrogluteal- 3 ml
deltoid- 2 ml
vastus lateralis- 1-3 ml
id medication capacity
ventral aspect of the forearm- 0.1 ml
Large-Volume Infusions
Safest and easiest method of IV administration
Large volumes (500 or 1000 mL) are used. Common- NS, D5W, lactated Ringer’s. Vitamins or Potassium Chloride can be added.
If infused too rapidly, patient is at risk for overdose and/or fluid overload.
Intermittent Intravenous Injections
Intermittent venous access (saline lock)
intermittent iv injections
flushing
Flush often, before and after use if not continuous fluids.
Cover saline lock with an antimicrobial cap
Infiltration or Extravasation
is when IVF is infusing into tissues outside of the vein.
phlebitis
is inflammation in the walls of a vein. Thrombophlebitis is blood clot formation at the site of the inflammation.
cellulitis
is usually a bacterial infection at the site and has similar S&S of phlebitis and tx but is more severe. Tx is similar but includes antibiotics, antipyretics, analgesics if needed.
Why are needle gauges sizes backwards?
The basic answer is that for wire and needles, you are counting how many of those things in that size will add up to one inch when lined up next to each other on a ruler. So more needles in an inch means the needles are thinner.
urethra length in women
4-6.5 cm
1.5-2.5 inches
urethra length in men
20 cm
8 in
The glomeruli filtrate and return
99% of plasma components back into the vasculature. One percent of plasma filtered is seen as urine.
ENDOCRINE FUNCTION OF KIDNEY
erythropoietin
stimulates RBC production & maturation in bone marrow
endocrine function of the kidney
synthesis of vitamin d
Synthesis of VITAMIN D as stimulated by parathyroid hormone. PTH also helps regulate CALCIUM & PHOSPHATE levels within kidneys
Chronic kidney disease can cause
anemia, hypertension, & electrolyte imbalances.
bladder contraction and relaxation
Bladder contracts during urination and urinary sphincters relax during urination.
Bladder contraction closes off ureter openings and opens urethral sphincters.
bladder capacity
holds 600-1000 ml urine
urge to void
Urge to void for Adults (250-450 mL in bladder) Children (50-200 mL) (q 2-4h)
patterns of voiding
Vary by individual
Usually after waking up, around meals, before bed, 5–6 times/day
growth and development
factors influencing urination
Children- control at 18-24 mos.- nerves innervated, pregnancy, normal aging process)
surgical procedures
factors influencing urination
NPO, anesthetics decrease bladder contractility, sensation= retention
medications
FACTORS INFLUENCING URINATION-
diuretics, anticholinergics- increase retention, sedatives- reduce cognition, meds can change the color of urine
diagnostic exams
factors influencing urination
such as cystoscopy which causes trauma to urethra and hematuria
muscle tone
factors influencing urination
weakened pelvic or abdominal muscles, muscle atrophy or trauma. Women usually sit, squat while men stand
Conditions of the lower urinary tract –
urethral narrowing, altered innervation of bladder, weakened pelvic or perineal muscles (females- pregnancy related)
benign prostatic hyperplasia
enlarged prostate (obstruction) can cause urinary retention, incontinence
COMMON URINARY ELIMINATION PROBLEMS
Catheter-associated UTIs- CAUTIs- one of most common HAI
Urinary Incontinence
Urinary Diversions (see slide)
urinary retention
unable to fully empty bladder (often from BPH)
Post-void residual (PVR)- bladder scan to measure urine left in bladder after voiding
urinary tract infections
Infections- (often E.coli from colon) Females- at risk
Upper (kidneys) or Lower (bladder, urethra)
Pyelonephritis, bacteriuria, bacteremia (urosepsis)
Symptoms are dysuria, hematuria, cystitis (bladder)- urgency, frequency, incontinence, foul urine odor, fever, chills, flank pain
Delirium in older adults
Stress incontinence-
coughing, sneezing, laughing, or physical activity causes urine leakage
Urge incontinence-
a strong need or urge to urinate c leakage
Reflex incontinence-
urine leakage due to nerve damage
Overflow incontinence-
incomplete bladder emptying- bladder overfills- when full, leads to leakage
Functional incontinence-
physical inability to reach the toilet in time
Urinary frequency- >
4-6 times/day
Nocturia –
voiding at night
Urgency –
sudden strong desire to void
Dysuria –
painful or difficult voiding
Urinary hesitancy –
delay in initiating voiding
Neurogenic bladder –
nerve pathway not intact, doesn’t sense fullness, or control sphincters
Dribbling-
leaking small amounts
Hematuria-
blood in the urine
Polyuria (diuresis)
Production of abnormally large amounts of urine
Polydipsia
Extreme thirst; associated with polyuria
Anuria
Absence of urine production
Oliguria
Decreased urine output
May signal impending renal failure
Less than 30 mL/h for more than 2 h is a cause for concern.
ASSESSMENT OF THE URINARY SYSTEM
part 2
Urine typically sterile
Average Output is 1-2L/day
NURSE observes for MINIMUM of 30 ml/ h
If urine output is < 30 mL/ h for more than 2 hours, assess for blood loss & call Health Care Provider.
Skin and mucus membranes-
pink, warm, dry, smooth, intact, look for breakdown suggesting incontinence or poor hygiene, overall good turgor (no tenting)
Kidneys-
place hand on posterior flank & other hand on abdomen & gently squeeze
Bladder-
if full, felt above symphysis pubis (Bladder scan- ultrasound)
Urethral meatus-
pink, small slit like opening – observe discharge, redness, lesions
urinalysis (ua)
Specific gravity- 1.005-1.030—Concentration of urine (Lower SG- diluted, Higher SG- dehydrated
No Glucose, Ketones, RBCs, minimal WBCs
Ultrasound-
need full bladder, scan also after voiding to check for residual urine before catheterization
Xray-
(KUB) kidney, ureter, bladder- no special prep
X-Ray- Intravenous pyelogram
(use contrast dye- assess for all allergies including to shellfish/iodine or previous rxn to contrast dye, Usually NPO & requires bowel prep to clean out & be able to see urinary tract),X-rays as dye travels through urinary tract, abnormalities, calculi, tumors, cysts. Encourage fluids after. Delayed reaction possible. Facial flushing is normal with dye
Computerized tomography of abdomen & pelvis (CT)-
cross-sectional images to assess for tumors or obstruction.
If using contrast dye- assess for allergies to shellfish/iodine, NPO X 4h.
cystoscopy
invasive
endoscopy of bladder with lighted tube- biopsy, contrast dye in bladder.
May be NPO.
Blood in urine (pink-tinged) after test for 1-2 days.
peritoneal dialysis
esrd
Surgically inserted abdominal catheter into peritoneal cavity
OSMOSIS, DIFFUSION & ULTRAFILTRATION,
around 4 exchanges per day or overnight cycling. Sterile Procedure–Risk for infection.
hemodialysis
esrd
artificial kidney circulates blood as electrolyte fluid bathes it & removes wastes & excess fluid
OSMOSIS, DIFFUSION, & ULTRAFILTRATION. Usually 3Xwk, 4 h treatments.
Risk for infection, fluid overload– may need fluid restriction, electrolyte imbalances.
TYPES OF URINARY DIVERSIONS
A- Continent urinary reservoir,
B- Urostomy, ileal conduit
URINARY DIVERSIONS
One or both ureters is connected to abdominal wall opening (stoma) or tube into renal pelvis.
Diversions can be via Nephrostomy tube into kidney or ureters
Ureterostomy.
Can be continent or incontinent-
urine stored in pouch or body-catheterize pouch.
Skin care/ pouching. Body image issues, sexuality.
suprapubic catheter
is a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow.
routine catheter changes
is Foley catheter with fluid in balloon to hold catheter in bladder. Infection prevention through hygiene, PO fluids, emptying drainage bag when ½ full.
PLANNING, GOALS, AND OUTCOMES
urinary elimination
Drink 2-3L daily
Limit caffeine, alcohol, acidic drinks, artificial sweeteners
Limit fluids 2h before bedtime
Regulate bowels
Full urinary continence with 8 weeks of starting a pelvic exercise program (Kegel).
Stop smoking
Good voiding habits
uti prevention
wear cotton panties, cleanse front to back,
no bubble baths or feminine hygiene sprays or douches, tight clothing,
void after sexual intercourse,
drink at least 2-3L of water daily,
no excessive dairy products, and have a glass of cranberry juice each morning
IMPLEMENTATION: RESTORATIVE CARE
Strengthening pelvic floor muscles- Kegel Exercises
Bladder retraining- reduce frequency, less dribbling
Habit training- improve voluntary control- functional incontinence
Self-catheterization- aseptic technique-chronic disorders such as spinal cord injury
Maintenance of skin integrity- cleansing, barrier cream
Promotion of comfort- clean & dry, reduced symptoms
IMPLEMENTATION
urinary elimination
Toileting schedule- q 2-3 h, before/after meals, tried in initial incontinence r/t cognitive/ mobility impairment, consistency, individualized
Pelvic exercises for sphincter control (Kegel Exercises)
Prevent urinary tract infections
Catheterization- Intermittent (Straight, In & Out) or Indwelling (Foley)
Preventing Cath-Associated UTI (CAUTI)
part 1
closed drainage systems- free drainage by gravity. Urine should flow unobstructed.
Securement device- females to inner thigh.
Preventing Cath-Associated UTI (CAUTI)
part 2
Maintain daily fluid intake of at least 2-3L if not contraindicated.
Catheter irrigation and instillations- Continuous bladder irrigation
Intermittent/ Straight cath or indwelling (5 French for infant, 16 fr for adult)
Removal of indwelling catheter- Smoothly & slowly, Withdraw plunger slightly & allow to drain by gravity. Make sure catheter is intact after removal.
Preventing CAUTI
part 3
Male Incontinence Device/Condom catheters. Change condom cath Q 24h. PrimoFit
Monitor urine for amount, color, clarity, and odor.
Patient education very important regarding catheter and decreasing CAUTI
Smallest catheter size possible. Discontinue as soon as possible.
Keep bag below bladder for drainage. Never let bag touch the floor.
Empty bag Q 4-8 h or when ½ full
SAFETY GUIDELINES
urine elimination
Follow principles of surgical and medical asepsis
Identify patients at risk for latex allergy (i.e., patients with history of hay fever; asthma; and allergies to certain foods such as bananas, grapes, apricots, kiwi fruit, and hazelnuts).
Identify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.
Peristalsis
moves food, cardiac sphincter at end of esophagus & stomach entrance- stops stomach reflux
stomach-
storage, mix with digestive juices (HCl, mucus, pepsin, intrinsic factor) into chyme. Mucus protects stomach from acid
Anus –
Internal & external sphincters- involuntary & voluntary control, sensory nerves
age- infancy
bowel elimination
Infancy- small stomach, rapid peristalsis,
diet
bowel elimination
Fiber- bulk-forming foods such as whole grains, fruits, veggies- help remove fats & waste products more efficiently & decrease risk of colon cancer, may also produce gas- esp onions, broccoli, cauliflower, beans. Gas stretches abd walls, increases colon motility- may be painful post-op. Spicy foods can increase peristalsis, cause indigestion, or loose stools. Food intolerances- GI distress, diarrhea, gas, cramps
fluid intake
bowel elimination
DAILY GOAL- Men- 3.7 L, Women- 2.7 L
Enough for soft stools, fruit juices soften stools & increase peristalsis, prune juice- high fiber, warmed fluids- stimulate peristalsis
physical activity
bowel elimination
promotes peristalsis, immobility slows it down.
Early & frequent ambulation after surgery, illness. Weakened abdominal & pelvic floor muscle tone- can’t bear down or control sphincter well, increased risk for CONSTIPATION.
Long-term illness, spinal cord injury, neurological diseases
Psychological factors-
bowel elimination
Depression-slow GI activity- constipation. Anxiety/ emotional stress increase digestion & peristalsis leading to gas distention, diarrhea.
Stress worsens GI diseases such as IBS, ulcers, Crohn’s disease, ulcerative colitis
Position during defecation-
bowel elimination
squatting, sitting to lean forward, exert abdominal pressure, contract gluteal muscles. 30-45 degrees for bed pan use, BSC if possible, ambulating to bathroom
Pain-
bowel elimination
hemorrhoids, rectal surgery, anal fissures (split in tissue), abdominal surgery
Pregnancy-
bowel elimination
etus pressure on rectum, decr peristalsis- constipation, straining- hemorrhoids
Surgery & Anesthesia-
bowel elimination
general anesthetic agents stop or slow peristalsis- block parasympathetic nerve impulses. Any surgery that directly manipulates intestines STOPS peristalsis temporarily & causes ILEUS- for 24-48 hrs. Ambulation, activity, eating helps return to normal function.
Medications-
bowel elimination
opioids - pain control- slow peristalsis- constipation.
Antibiotics kill normal flora- diarrhea.
Laxatives or Cathartics soften stool, increase peristalsis. Laxatives- 1st fiber, 2nd osmotic.
*Avoid stimulant laxatives long-term bc of intestine dependency due to decreased reflex to defecate.
Diagnostic tests-
bowel elimination
clear view of gastric mucosa- NPO, clear liquids, laxatives or enemas to cleanse stool
constipation
Constipation SYMPTOM- of low-fiber diet, poor liquid intake, decreased activity, medications
SIGNS- infrequent BM (<3/wk), hard & dry stools that are difficult to pass. Decreased peristalsis- fecal mass exposed longer to intestinal walls- more water loss
impaction
Impaction- unrelieved constipation & unable to expel the hardened feces in rectum. (Debilitated, confused, unconscious- dehydrated, weak or unaware of defecation need, stool dry & difficult to pass)
signs of impaction
Sign- inability to pass stool for several days in spite of urge to defecate
Oozing of liquid stools, feces leaks from above impaction. Anorexia, N&V, abd distention & cramping, rectal pain
Incontinence-
bowel elimination
inability to control passage of feces and gas from anus. Risk for Skin breakdown
Flatulence-
gas accumulation within intestinal lumen. Mouth- belching or Anus- flatus. Abd fullness, pain, cramping, esp if slower peristalsis. Ambulation helps.
Diarrhea-
faster peristalsis, increase in stool #, liquid, unformed stool.
causes of diarrhea
infectious agent such as bacteria, viruses, parasites; emotional distress, tube feedings;
GI disorders. Infectious agents must shed through diarrhea but also lose bicarbonate,
Antibiotics destroy normal GI flora & allow
C.difficile to overgrow. SOAP & H2O handwashing essential to remove spores. Bleach 10% solution to clean surfaces
Hemoccult stool-
small sample (FOBT- fecal occult blood test) Guaiac- 3 samples
No NSAIDS within 7 days of testing
Avoid Vitamin C, fruits, fruit juices for 3 days
Don’t eat red meats within 3 days of testing
Positive results require flexible sigmoidoscopy or colonoscopy
Endoscopy –
Lighted FiberopticTube to visualize esophagus, stomach, and small intestine (Upper GI tract). Can remove polyps for biopsy. Anesthetic to throat, some clear liquids ok, NPO before & until gag reflex returns
Colonoscopy-
NPO, bowel prep- Tube in to visualize LI/ colon, remove polyps for biopsy or find source of bleeding
Upper GI series (barium swallow) X-ray-
NPO, drinks barium-opaque contrast solution, clear liquids and laxative day before; shows pharynx, esophagus, stomach.
Lower GI series X-ray-
barium enema- NPO, barium into anal opening, shows large intestine.
Amylase & Lipase –
serum blood tests for hepatitis, pancreatitis (most accurate results after fasting – NPO)
Abdominal x-ray-
obstruction or abnormality, no prep
Colorectal transit study-
how food moves through colon, swallows capsule with radiopaque markers, X-ray on 5th day
Computerized tomography- CT scan-
cross-section views, Oral and/or IV sedation-contrast dye- assess for any/all allergies for IV (older idea was for shellfish allergies) NPO 4-6 h before- depends on if oral contrast is used
MRI-
magnet and radio waves to see inside body, NPO 4-6 h before, NO METAL objects on/in pt
ati review
elimination
comfort
teaching and learning/ patient ed
fluid and electrolyte balance
tissue integrity
mobility
Implementation in acute care settings
bowel elimination
Routine time for defecation (Urge most likely one hour PC- GASTROCOLIC REFLEX mass peristalsis, Offer bedpan, BSC, BRP after each meal)
Safety & comfort
Privacy & modesty
Abdominal tightening exercises 4X day
Ambulation, activity (Best way to stimulate peristalsis)
Low-residue foods for diarrhea- white rice, potatoes, bread, bananas, cooked cereals (BRAT diet)
Skin integrity – no-rinse spray, barrier cream, assess skin around wafers of ostomies
medications
Implementation in acute care settings- bowel
Laxatives- bulk forming, stool softeners, osmotic- saline-based laxative, stimulant cathartics. Suppositories- may act more quickly than oral meds. (Goal- soft, formed brown stool w/o pain or difficulty) Chronic use- weakens bowel’s response to distention from feces-promotes dependency on laxatives.
Antidiarrheal agents- slow motility, reabsorb fluid
Antiflatulent agents- merge gas bubbles & help to pass
ng tube
Implementation in acute care settings- bowel
(Decompression, compression, enteral feeding, lavage) Clean- NOT sterile technique, Placement check= pH < 5 or less for stomach, X-ray- gold standard to verify placement, NG tube measured before placement from tip of nose to ear lobe to xyphoid process, water-soluble lubricant used for insertion(less toxic than oil if aspirated), Document length of tube extending from nares to help with placement check.
bowel training
Implementation in acute care settings
Bowel training, Chronic constipation, fecal incontinence 2nd to cognitive impairmt- timed toileting, hot drinks such as tea or juices (prune), privacy, nonhurried, exercise as able
*make sure to take them when they have the urge
Ostomies- Ostomy-
temporary or permanent opening (stoma) surgically created in abdominal wall to allow passage of fecal matter
Stoma should be
pink or beefy red- NEVER purple or black or pale—— Call HCP immediately if so! Skin care- priority & body image. Skin wafer around stoma, bag to collect stool.
Colostomy-
piece of large intestine; more formed stool from colon
ileostomy-
piece of small intestine (More liquid, diarrhea like stool from small intestine) so increase fluids (drink 8oz for each emptying of bag). Avoid indigestible fiber- popcorn, corn, pineapple, Chinese cabbage, raw mushrooms, fresh pineapple. These foods may be eaten in small amounts, chewed well, and when drinking fluids with the foods.
enema implementation
Position client in left Sims
Insert tube 3-4 inches for adult, 2-3 in for child.
Hold tube 12-18 inches above anus as fluid instills. Clean not sterile technique. If c/o cramping, lower container & briefly pause solution. Ask to retain for as long as possible.
Tap water or hypotonic-
enema
Stimulates BM- Risk of water toxicity
Soapsuds-
enema
Irritant promotes bowel peristalsis
Normal Saline-
enema
safest due to equal osmotic pressure, Volume stimulates peristalsis
Low-volume hypertonic-
enema
commercially prepared, used for clients who can’t tolerate high-volume enemas
Oil-retention-
enema
lubricates rectum & colon for easier stool passage
Medicated enema-
such as w/antibiotics to dwell for 1-3 h
IV ONSET
iv = 3-5 minutes
IM ONSET
im = 3-20 minutes
SC ONSET
= 3-20 minutes
PO ONSET
po = 30-45 minutes
WHERE DOES MOST BIOTRANSFORMATION OCCUR
IN THE LIVER
WHEN DO YOU MEASURE TROUGH
by lab draw just prior to the next scheduled dose (approximately 30 min before next dose).
what subq injection site offers the fastest absorbption
abdomen
max capacity for im in Children, older adults, thin patients: up to 2 mL
Small children and older infants: up to 1 mL
Smaller infants: up to 0.5 mL
up to 2 mL
max capacity for im in Small children and older infants:
up to 1 mL
max capacity for im in Smaller infants:
up to 0.5 mL
when do you NOT aspirate an im injection
- except don’t aspirate prior to giving immunizations (CDC, 2021)
injection: iv
piggyback
By “piggyback” infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line
factors affecting urination
older adults
Older adults- Decreased thirst, ability to delay voiding, & bladder capacity. Increased urgency, incidence of overactive bladder & contractions, loss of bladder contractility (strength). Incontinence due to chronic illness, medications, mobility issues, cognition, nocturia.
crede method
manual compression of bladder to help with emptying
info for inserting catheterizing males
insert catheter at 90 degree angle to straighten urethra & ease insertion,
insert until bifurcation to ensure balloon not inflating in prostatic urethra,
secure to upper thigh or lower abdomen.
cath care
coude catheter
curvature at end to maneuver through enlarged prostate (Requires special training for insertion).
PureWick catheter for women-
gauze w/ suction tube connected to suction, canister- Change Q 8-12h
age-elderly
bowel elimination
Elderly- decreased chewing ability, Arteriosclerosis decreases GI blood flow, Innervation decreases esophageal emptying & peristalsis, Decreased perineal & sphincter muscle tone, taste bud atrophy, decreased gastric acid.
when should the nurse take the client to the bathroom while bowel training
planned times
after a meal
when they have the urge
what does a bowel training program focus on
identifying times in the client’s pattern to promote self control of defacation
if a client with a ng tube is reporting anxiety, discomfort, and feeling bloated, what should you do
- check to see if suction equipment is working
- later it might be necessary to get order for anxiety meds, irrigation, or removing and reinserting, but not at first
what should nurse teach about sl nitroglycerin tablets for angina pectoris
- should be taken prn
- if first dose doesn’t relieve pain, seek emergency care and possibly 2 more tabs at 5 minute intervals
- take 1 taab at first indication of pain
- do not drink/eat until dissolved and observed
what kind of drainage tube makes a pt more prone to hypokalemia
ng tube to suction
diet considerations for a client with chronic kidney disease and a new Rx for epoetin alfa
- increased iron
- decreased protein
- decreased potassium
- decreased salt
what are the procedures for administering a unit of packed rbc
- 2 RNs, 1 RN and 1 PN, cannot use an AP (assistive personell)
- might premedicate with antipyretic but not an antiemetic
- infuse over 4 hr to prevent bacteria growth
- remain with pt for first 15-30 minutes
what should the nurse do if the client reports that the doctor didn’t tell them they were supposed to receive xyz?
check the client’s medical record for the prescription/order
why should you not crush an enteric-coated aspirin
you might get a stomach ache or indigestion
the coating prevents breakdown in the stomach and decrease the possibility of gi distress
if a client states they are having abdominal cramps during a tap water enema, what should you do to relieve discomfort
lower the height of the solution container to slow the flow momentarily. this allows the intestinal spasms to pass and then continue at a slower rate
causes of constipation
- excessive laxative use
- ignoring the urge to defecate
- inadequate fluid intake
if urine is dark amber, cloudy, and has an unpleasant order, what might you suspect is wrong
uti
there is presence of wbcs, rbcs, and bacteria
what time/place should you complete your final medication check
at the bedside before administration
you are giving an enema. client reports mild cramping and asks you to stop so he can go to the bathroom. what should you do
slow the flow of solution briefly to prevent cramping
what is the first action you should take when preparing to discontinue an indwelling urinary catheter
position client in supine position
if client has impaired renal function, when should you notify the provider
urine output of 175 mL over 8 hrs. this is less than the norm of 30 ml/hr. it indicated fluid imbalance, decreased fluid volume, possibly inadequate renal perfusion
procedures for administering a z track injection
- pull skin 1-1.4 inches down or to the side
- insert needle quickly and smoothly
- 90 degree angle
- aspirate for 5-10 seconds
exam 3. med admin, elimination, electrolyte MATH REVIEW ATI
instructions for regular and nph insulin
- keep the open vial at room temp to reduce tissue injury and lipodystrophy
- inject into subq tissue
- not necessary to aspirate
- mix compatable solutions to reduce qty of injections
rules for auscultating client bowels
- clamp ng tube during auscultation
- perform auscultation between meals
- auscultate for 3.- minutes
- auscultate prior to palpating to prevent alterations
heparin
- effects begin within minutes
- does not dissolve clots
- stops new clots from forming
warfarin
usually started after heparin
po
does not dissolve clots
when should you auscultate bowel sounds
after inspection
before percussion
teaching for client with asthma that has just been prescribed inhaled beclomethasone
- does not cause cardiac side effects
- is an inhaled glucocorticoid
- not administered with food
- rinse after administration to reduce fungal growth
- caffeine does not interact with this
labs reflecting acute pancreatitis
calcium- decreased
rbc- decreased
wbc- increased
magnesium- decreased
amylase- increased
amylase
enzyme that changes complex sugars to simple sugars for body use
produced by pancrease and salivary glands
released into mouth, stomach, and intestines to aid in digestion
with pancreatitis- elevates 12-24 hr and remains elevated 2-3 days
how do you open a glass ampule
tap the top
place a sterile gauze around the neck
break off the top by bending it toward your body
if you notice a crushed bupropion xl was administered crushed in applesauce, what should you do
initiate an incident report
insulin glargine is a long duration insulin meaning it has a duration of
18-24 hours and is administered once a day
order of conducting an assessment
- ask Hx
- inspect
- auscultate
- palpate
- percuss
administering heparin
- use 25-26 gauge needle
- 3/8 inch or shorter needle
- inject into abdomen above the level of the iliac crest
- do not massage for 1-2 minutes
what should a nurse ask before an intravenous pyelogram for kidney stones
if pt is allergic to shellfish because the dye may cause reaction
standards for administering medication
- verify med against Rx and med label
- scan bar code on med and arm band
- check orders and confirm dosage in pdr
- document after administering
standards of administering enemas
- don clean gloves
- assist to left sims position
- hang container no more than 18 inches above
- only insert up to 4 inches
if an iv site becomes red, swollen, and painful, what is the first action you should take
discontinue the iv line
standards for transdermal nitroglycerin to treat angina pectoris
- apply new patch each day
- apply patch in the morning and leave for 12-14 hrs before removing in the evening
- rotate sites to reduce local skin irritation
- has delayed onset so good for prophylaxis but not for immediate relief
where do you administer a sublingual medication if patient has an ng tube
still under the tongue
when placing an ng tube, what should you expect the ph to be
4.0
a stool test for guaiac is to check for what substance
blood
how do you test stool for steatorrhea
send total qty of stool at one time to lab
how do you test for bacteria in stool
collect in a culture tube with sterile and aseptic technique
how do you test stool for parasites
warm stool samples over a period of days for evaluation
technique for instilling eardrops in a 5 year old
pull auricle up and out
technique for instilling eardrops in a child under 4
pull auricle down and back
standards for inserting indwelling urinary cath into female
- use non dominant hand to separate labia
- dominant hand handles cath during insertion
- coat tip with water soluble lubricant for comfort and tissue protection
standards for plan of care for dehydrated pt receiving continuous iv
- monitor vs q2h
- over 240 mL or 8 oz oral fluids every 4 hours
- check iv site and monitor infusion q1h
teaching for client prepping for cystoscopy
- increase fluids post procedure
- you may have pink tinged urine post procedure
- dark red urine should be reported because indication of bleeding
what actions should a nurse take when caring for pt 1 day postop of a transurethral resection of prostate TURP and has continuous bladder irrigation in place
- do not add amount of bladder irrigation to output
- use sterile technique when preparing irrigation solution- many pt are older with other chronic diseases making more susceptible
- ensure drainage tubing is patent and without obstruction or kinks is correct
- if pt reports continual need to void, you will not need to contact dr because they already have an indwelling catheter that is giving this sensation
- you may have a few small clots or pink tinged drainage but should contact dr if urine is bright red, ketchup like, large clots
teaching about urge incontinence
- dr may prescribe anticholinergic to suppress contractions and increase bladder capacity
- limit fluids in the evening to prevent overload while sleeping
- restrict caffein because it is an irritant
- you won’t need catheterization or vaginal repair as these are used in other types of incontinence
urinary catheterization is used in
reflex incontinence
anterior vaginal repair is used to treat…
stress incontinence
indications that a dehydrated patient is responding to Tx
- decreased Na
- decreased K+
- urine specific gravity 1.005-1.030
- decreased hct to normal range
what s/s would you find in an infant with severe dehydration from acute gastroenteritis
- sunken anterior fontanel
- hyperpnea
- 13 % weight loss
- capillary refill greater than 4 seconds
blood tinged urine in a catheter bag can indicate
bladder infection
prostate enlargement is an indication of
urinary hesitancy of difficulty initiating stream of urine
dehydration is a manifestation of
oliguria or a diminished urinary output
pernicious anemia is caused by
lack of intrinsic factor which is needed to absorb vit b12 from the gi tract. b12 is also needed to form rbc.
hematuria
blood in urine
uti symptom specific to the elderly
confusion
uti symptoms of all ages
- urinary retention
- low back pain
- inconfinence
what output indicates oliguria
less than 400 mL in 24 hr or less than 30 mL/hr
indications of fluid overload
- 5 lb weight gain in 24 hours (acceptable is 2 lb or less per day)
- distended neck veins
- o2 level less than 92
- adventitious lung sounds indicating pe
- edema
what findings are associated with urinary retention when pt is experiencing prostatic hypertrophy
- feeling pressure
- tenderness over symphysis pubis
- distended bladder
- voiding 30 mL frequently
a client with a new ileal conduit is at risk for what
- anxiety
- disturbed body image
- impaired skin integrity
- infection
collecting a stool sample
- use non sterile object like a tongue blade unless culture where you would need sterile swab
- sterile container is not necessary but should collect in dry container free of urine
- place in clean biohazard bag that is labeled and prevents contamination and spillage during transport
- send immediately to lab
sudden onset of urinary incontinence in the elderly is often caused by
- cystitis
nephrosclerosis
degenerative kidney disorder than can cause kidney ischemia and fibrosis
uremia can cause
n&v
fatigue
diverticulitis can cause
abdominal pain
nausea
leads to perionitis
a client should contract pelvic muscles to
improve strength and manage urinary incontinence
kegels
you should sip water to assist in inserting what type of catheter
ng tube
when should you ask pt to exhale slowly
when auscultating lung sounds
what should you have a pt do when inserting an indwelling catheter
bear down
what findings indicate need for catheterization of a paraplegic
- dribbling urine
- overflow incontinence
- indication of bladder distention
is urge incontinence an indicator of bladder distention
no
can a paraplegic pt feel urgency or dysuria
unlikely
when should intermittent catheterization be performed
prescribed schedule
bladder distention
dribbling present
why should a nurse perform intermittent catheterization
prevent bladder trauma or infection
appropriate schedule for intermittent catheterization
regular schedule to drain flacid bladder with no longer than 8 hr between catheterizations
what can ivp provide info about
cause of hematuria so rbc in a ua is not a contraindication
high frequency sound waves are used during
a renal ultrasound
what kind of diet would a pt have post ivp
clear liquids
what will a pt be encouraged to do post ivp
intake fluides to promote elimination of the dye
expectations after removing an indwelling catheter in the elderly
- temporary urinary retention
- if client does not urinate for 6-8 hrs after removal, reinsertion may be necessary
- urinary frequency might be temporary but a couple of days indicates possible uti
- there should be no blood in the urine nor should it be highly concentrated
what lab results indicate a therapeutic effect of epoetin alfa for chronic renal disease
hematocrit
hct
the therapeutic effect of this med is enhanced rbc production which is reflected in an increased rbc, hgb, and hct
what kind of medication is epoetin alfa
antianemic
indicated in those with anemia due to reduced production of endogenous erythropoietin which may occur with end stage renal disease or myelosuppression from chemotherapy
manifestations of urinary retention
voiding a small amount of urine (less than 100 ml) frequently (2-3 qh) and dribbling of urine
elevated bun is a manifestation of
kidney disease
painful urination is a manifestation of
uti
positive glucose in the urine is a manifestation of
diabetes mellitus
during the oliguric phase of acute kidney injury, the nurse should expect
- increased serum concentration of creatine
- increased serum concentration of K+.
- hyperkalemia- could rise quickly and become life threatening
- increased serum concentration of Mg
foods eliminated from a diet for pt with ulcerative colitis
dried apricots
high fiber foods
encourage cooked cabbage, bananas and other low fiber foods
diet for a pt with pre dialysis end stage kidney disease
limit phosphorous to 700 mg/day
limit protein to 0.55-0.6 g/kg/day
reduce foods high in K+
reduce foods high in Na
indications of fluid volume excess
bounding pulse
crackle of lungs
pitting edema
urine specific gravity greater than 1.030
teaching for adolescent with spina bifida
- cath q4hr
- infrequent cath can result in stasis and uti
- maintain increased fluid intake
- suppository to stimulate bowel mvmt ever 1-2 days as appropriate
expectations of a client that has had vomitting and diarrhea for 3 days
poor skin turgor
tachycardia
hypotension
dark urine
flat neck veins
teaching in regards to colostomy
- ileostomy adaptation can occur over time
- frequent draining
- stoma should be pink to chery red but never pale, bluish, or dark
- the skin around the stoma should be normal and not red
ileostomy adaptation
small intestine begins to perform some of the absorption function previously completed by the colon. causes a stool volume decrease. stool becomes thicker and paste like and turns yellow/gree/brown. reduces frequency of drainage
if a pt receives hemodialysis
Tx, what lab results would a nurse expect
rbc unaffected
protein unaffected
Ca increased
decreased K+
expected lab values for a pt with acute kidney injury
increased K+ (hyperkalemia)
decreased ph
metabolic acidosis
hypocalcemia
high Ca
high PO
elevated bun
if a pt receives peritoneal dialysis, what should the nurse monitor in regards to periotonitis
diminished/absent bowel sounds
N&V
abdominal tenderness
anorexia
restlessness
confusion
tachycardia
oliguria
peritonitus
inflammation of the peritoneum
complication of peritoneal dialysis
teaching for urinary catheterization with new nurse
relieves urinary retention
never for nurse/staff convenience
good for measuring residual urine after urination
no for routine urine specimen
good in case of open perineal wound
steps for preparing sterile field
hand hygiene
package to work surface
open away
open sides
open closest to you
use inner surface as sterile field
when do you empty an ileal conduit
2/3 full to prevent leakage, skin irritation and infection
