Midterm Flashcards
**In the state of WV, what is the order of medical power of attorney?
Why does hospital medicine exist?
The discipline of hospital medicine grew out of the increasing complexity of patients requiring hospital care and the need for dedicated clinicians to oversee their management
_____ is care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
patient centered care
In pt or out pt medicine does NOT need prior authorization from insurance?
in pt does NOT need prior auth from insurance while out pt does
What are 2 examples that use the hospital/clinician centric model? What is the highlighted difference in the patient-centric model?
VA hospital ands government owned skilled nursing facilities
SHARED DECISION MAKING
** What are the 2 components of patient centered care?
- Patient Experience
- Patient Engagement
_____ is the sum of all interactions that influence patient perceptions across a continuum of care and is measured by patient surveys. What is the most frequent method used?
patient experience
HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey
Why does the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey matter?
Value Based Purchasing…..Medicare reimbursements are tied, in part, to the patient satisfaction portion of the survey.
What are the 7 components of the HCAHPS survery?
pain management
communication with doctors
communication about medicines
communication with nurses
cleanliness and quietness of hospital environment
responsiveness of hospital staff
discharge info
______ actions taken by individuals to obtain the greatest benefit from the health care services available to them. Under what circumstances does this happen? Why does it matter?
patient engagement
Occurs when patients feel empowered to move to a state of active participation and self-efficacy in managing their health
Engaged patients have better health outcomes, incur less costs, and enjoy greatest value (quality/cost) from health care system
What are the 5 ways you can improve the patient engagement?
when customizing the patient plan consider:
Literacy Level
Readiness to Learn
Readiness to Change
Learning Style
Family Dynamics
What are the 4 primary focuses of a hospitalist?
Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine
What is the role of the consultant? Who is ultimately in charge?
The role of the consultant is to give RECOMMENDATIONS, not to become the primary provider
attending physician NOT the consultant
Consider reading how to perform effective consultation again. not going to memorize
Determine The Question
Look For Yourself
Establish Urgency
Be As Brief As Appropriate
Be Specific and Concise
Provide Contingency Plans
Honor Thy Turf
Teach With Tact
Talk Is Cheap And Effective
Follow-Up
The Co-management of patients between _____ and _____ has become a mainstay of hospital medicine. What does it lead to?
Surgeons
Hospitalists
Collaborative effort that can lead to decreased length of stay and decreased complication rates
What are the 2 models of co-management in the hospital setting? What is important to make clear?
The first model assigns the hospitalist as the patient’s primary attending, utilizing the subspecialist as a consultant.
The second model assigns the hospitalist to serve as a consultant to the patient while the subspecialist is the patient’s primary attending.
structure must be clearly defined and excellent communication must exist
What is the structure of a traditional consult?
Requesting physician in charge
Requesting physician treats primary medical problems
Specific question addressed
Consultant does NOT write orders
Limited follow-up….as needed
What is the structure in a co-management model?
Shared responsibility
Medical/Surgical consultant treats primary medical problems
Broader issues – other conditions
Consultant writes orders
Daily follow-up until discharge
_____ may be the first and most significant care transition a patient will experience in their medical care
Hospital admission
What are the goals regarding transition of information when the pt is coming from the emergency department? What are the risks?
Transfer information AND clarify who is responsible for patient care
Usually a delay between information exchange and physical relocation….creates opportunity for error and safety issues
What information should be included when the pt is being admitted from the ED?
Principal diagnosis and problem list (acute and pertinent chronic)
Medication list (home and current)
Patient cognitive status
Test results / pending results (and who is responsible for those pending)
What are 2 things to note when directly admitting someone from an outpt office?
Need to ensure admission to correct care LOCATION and ensure they are not at risk for deterioration prior to admit.
Prolonged wait at admission could lead to decompensation (aka that is why they are being directly admitted)
What are the 4 selection recommendations for direct admission?
- Admitting diagnosis is fairly certain/No additional triage is needed
- Patient is clinically stable – does not require supplemental O2, immediate IV fluids, antibiotics or urgent imaging
- Has been evaluated on the day of admission by PCP
- Arrives at hospital early in the day (before 4 pm) to facilitate communication between the admitting physician and the hospital team before shift change
Overall, _____ patients have higher levels of morbidity and mortality that cannot always be accounted for by severity of illness alone. So ______ needs to outweigh _____. But ___ and ____ both show improved outcomes overall
transferred
Benefit should outweigh risk
MI and trauma (because they need higher level of care certain outlying hospitals cannot provide)
Why are pts who are transitions from a SNF sometimes harder to treat?
usually are medically complex pts who frequently are NOT able to provide coherent medical history/medication and do NOT have anyone with them to provide an accurate history
often have non-specific complaints such as falls, dehydration, or confusion, and without accurate info, will result in more investigations, particularly head CTs
**What 3 pieces of information are vital to have when transferring a SNF pt into the hospital that approximately 40% of patients do NOT know?
baseline cognitive function
current medications
advance directive status
the transition of responsibility from ED to inpt are not clear cut. Institutions should develop a clear plan for transfer of responsibility: _____ and _____ to be initiated in the ED prior to transfer to an inpatient unit
plan for shift changes
standardized order sets
When does the transition of responsibility occur when admitting from a AMBULATORY OFFICE / OUTLYING HOSPITAL / SNF?
the admitting/transferring provider is responsible for the patient while they remain at their facility and once the patient leaves the admitting/transferring facility they become the responsibility of the accepting provider.
What are the 2 admission types? Describe what each is. Why does it matter?
inpt and outpt status is determined upon admission
Outpatient: admitting physician expects the patient to need to stay in the hospital less than 2 midnights
Inpatient: admitting physician expects the patient to stay in the hospital across 2 midnights
insurances reimburse at a higher rate for inpt stays
What are the 4 units typically available at most hospitals? Do they have to stay in their assigned unit their entire length of stay in the hospital?
Intensive Care Units
Intermediate Care / Step Down Units (not always present in smaller hospitals)
Telemetry Units
Medical / Surgical Wards
NO!! can be transferred to multiple units depending in their current condition
What should telemetry NOT replace? How often should telemetry needs be reassessed?
Telemetry should not replace frequent observation and assessment of patient
DAILY!!
What is the handoff? What can the handoff depend on?
The Handoff is a fluid, dynamic exchange regarding a patient on admission, change of service, discharge, or any other time of communication
distractions, interruptions and the incoming clinician’s confidence in the quality and completeness of the information
**What is the #1 cause of sentinel events?
communication!!!
What are the 3 different types of intrahospital handoffs? Which ones require written documentation?
shift change
service change** requires documentation
service transfer** requires documentation
_______ the transfer of content and professional responsibility from one clinician to another at the end of the shift
shift change
_______ a permanent transfer of content and professional responsibility at the end of one’s on-service time or rotation to a new physician or team of providers who will assume ongoing care of the patients
service change
_______ the change of service of a patient from care of one group of clinicians to an entirely different group of clinicians, usually from a different specialty or ward, to receive a different service that is unique to the receiver’s specialty or ward
service transfer
What are the 3 core components of a handoff?
verbal communication
written communication
transfer of professional responsibility
What are the 2 standardized handoff methods acrononyms?
IPASS and SBAR
IPASS:
intro
patient
assessment
situation
safety concerns
SBAR:
Situation
Background
Assessment
Recommendations
What are the 4 key elements of discharge care coordination? When should discharge planning begin?
- Appropriate Discharge Destination
- Proactive Scheduling of Follow-Up appointments
- Careful medication reconciliation
- Engagement of Patients and Caregivers
Discharge planning should begin at ADMISSION and continue throughout hospitalization in parallel to the medical evaluation and treatment plan
What are the 6 common discharge locations?
home with or without caregivers
home with home health services
inpatient rehabilitation facilities
skilled nursing facilities
long-term acute care hospitals
extended care facilities.
What type of facility? “Qualifying event” of 3-night inpatient stay; skilled needs >1 h per day, 5 d per week. How often do Drs come?
skilled nursing facilities
initial physician visit required within 30 d of admission to facility
What facility? 75% of patients fall into 13 diagnosis categories; require multidisciplinary therapy; >3 h of therapy per day, 5 d per week. How often do Drs come?
inpatient rehabilitation facilities (IRF)
Face to face visits by a rehabilitation physician at least 3 times per week
what facility? Average length of stay ≥25 d; highly complex medical patients (ventilator management, complex wound care). How often do Drs come?
Long term acute care hospitals (LTAC)
Daily or near-daily physician visits; consultant specialists widely available
What facility? Long term custodial care; reimbursement through Medicaid. How often do Drs come?
extended care facilities
Physician visits every 30 d
what facility? Medicare requires Face to Face Encounter form and physician certification of homebound status. How often do drs come? What are some examples of services they provide?
home health
Requires a physician (usually primary care) to oversee plan of care
wound care, IV therapy, medication and disease education
When should follow up appts be made? What is the generic PCP f/u? What is the pt is high risk?
Appointments should be made BEFORE the patient leaves the hospital to ensure access to follow-up care
standard is 1-2 weeks with PCP
high risk is 48-72 hours following discharge
Patients should be given sufficient instructions at discharge regarding _____ and who to contact with questions and concerns
“red flag” symptoms
What is medication reconciliation? **What needs to be explicitly notated?
Process by which a patient’s medication list is OBTAINED, COMPARED, and CLARIFIED across different sites of care, in order to decrease medication errors during transitions
Should include explicit notation of which medications have been ADDED, DISCONTINUED, or CHANGED during hospitalization
Who is responsible for medication reconciliation?
everyone!!
** How should you perform pt engagement and education?
Perform in small sessions throughout the hospitalization, reiterate main points, provide written handouts
What 7 things should be included in the discharge INSTRUCTIONS?
Reason for hospitalization, treatment received, names of clinicians involved in care if questions arise postdischarge
Pertinent test results as well as pending test
results
Diet and activity
Medications, including any changes in regimen and potential side effects
Follow-up appointments
Identification of the person to contact with questions or concerns
List of concerning symptoms and how to respond
Why is a good discharge summary important?
because rarely have direct communication between hospital provider and PCP
helps to decrease risk of medical error
What are the 10 components of the discharge SUMMARY?
Primary and secondary diagnoses
Important test results
Pending results and responsible party
Recommendations regarding additional work-up or treatment plan
Patient’s condition at discharge (including cognitive and functional status and abnormal exam findings)
Complete list of reconciled medications
Follow-up arrangements
Identification and contact information for the sending and receiving providers
Resuscitation status
Documentation of patient education
What are CPOE? Why was it originally developed?
Computerized provider order entry (CPOE) systems, way to electronically input order to replace the paper-based ordering system
improve the safety of medication orders
What is the purpose of clinical decision support system (CDSS)?
which can help prevent errors at the medication ordering and dispensing stages and can improve safety of other types of orders as well.
checks drug safety features, drug allergies and drug-drug interactions
CPOE systems sometime have excessive and nonspecific warnings. What can it lead to?
alert fatigue and providers may start to ignore even critical warnings because they get so many
Give one example of when CPOE fails?
order sets change in the system without notifying anyone, so could accidentally order the wrong dose of something without noticing
What are 3 things you need to check to. make sure you are NOT just coping and pasting old notes?
Make each note specific to the patient on that encounter date.
Modify information and language brought forward from any previous encounters so the current documentation demonstrates the distinct clinical service of today.
Do not include excessive data or repetitious information that is not relevant to the current service
How does the in pt hospital payment system work? What 4 things is it based on?
using CPT (Current Procedural Terminology) codes
describe all medical, surgical, and diagnostic services and procedures
How do you select the evaluation and management level?
based upon the History, PE, and Medical Decision Making
Time: but only affects the E/M level when counseling and/or coordination of care dominate more than 50% of the physician’s total visit time
What are the 4 components of the history?
chief complaint (CC)
history of present illness (HPI)
review of systems (ROS)
past, family, and social histories (PFSHs
What are the different coding options for HPI?
brief (1-3 elements)
Extended (4+ elements)
What can involving PT and OT early in the pt’s hospital course due?
reduce length of stay
minimize inpt complications
lead to a more successful discharge at a higher level of independence
How long is PT school? What do they focus on?
4 years
breathing, posture, mobility, joint ROM and strengthening of respiratory muscles
What are some additional benefits of working with PT?
prevent loss of function during long-term hospitalization and can start “moving” the patients even while they are still in bed
prevent development of joint contractures
assess fall risk and make recommendations
help prevent and treat skin injuries
What are 3 ways PT helps to prevent joint contractures?
stretching, strengthening and protective splinting
How long is OT school? What is their main focus?
4 years
assessing, preserving and restoring UE strength, function and ROM with the goal of basic self care and independent living
Who participates in identifying post-discharge needs and perform home safety evaluations?
OT
What is the role of speech and language pathology? Why is it important?
dx swallowing disorders and make tx recommendations
ability to swallow/eat affects nutritional status and should be part of the functional status on admission
speech therapists perform _______ to diagnose disorders of swallowing
bedside swallow evaluations
What are the 2 MC MSK impairments?
low back pain and knee pain
What are ways to decrease risk of developing osteoporosis in the hospital setting?
early mobilization
strength and gait training
______ is a common complication of a stroke that may be aggravated by problems with muscle control, speech and congnition
loss of bladder control
What is debility? What is it in healthy young men?
deconditioning related to bed rest or inactivity
loss of strength is about 1% per day or roughly 10% per week, this is WORSE in elderly patients
What is an strategy is combat debility?
early consultation of PT so they can maintain muscle strength by contracting the muscle about 30-50% of max tension for several seconds each day
What specialities are involved in cardiac rehab?
both PT and OT!
What is the main focus of pulmonary rehab?
exercise!!! including strength training for the UE an LE as well as respiratory muscle specific training
What are 3 common trauma complications that can be prevented or managed by rehab services?
contractures, immobility and skin breakdown
What professional roles are eligible to be on the hospital ethics committee? What is the role of the ethics committee?
Physicians
Advanced Practice Professionals
Nurses
Social Workers
Attorneys
Theologians
ADVISORY only
What is futility?
demands for medically ineffective treatment
informed consent and refusal requires what 4 things?
Ability to communicate a choice
Understand the nature and consequences of the choice
Manipulate rationally the information necessary to make the choice
Reason consistently with previously expressed values and goals
Concern about patient decision-making capacity typically occurs with____ rather than with _____ of a proposed therapy.
refusal
agreement
What should you try to do if the patient refuses the recommended treatment?
Every effort should be made to discern the patient’s rationale for refusal of recommended treatment and counter any misinformation with appropriate facts.
Ethics consultation may help resolve ethical issues when treatment refusals are made by a surrogate, on behalf of an incapacitated patient
What is truth telling?
The provider must communicate to the patient specific information necessary for making informed and deliberate choices
most providers adhere to a “reasonable person” standard by providing the amount of information that an “average” person would need to make an informed choice
In terms of truth telling _______ is the norm for most western people
full medical disclosure
What is the “therapeutic exception” or “privilege”?
On that rare occasion when the risks associated with disclosure outweigh the benefits, practitioners can deliberately withhold information counter to the patient’s self-determination and right to know.
need to document thoroughly as to why you did NOT fully disclose everything
When should advanced directives be discussed with a patient?
By taking on discussions at the ONSET of care
and discussion needs to be thoroughly documented
What are the 2 parts of an advanced directive?
medical power of attorney
and the patient’s code status
Surrogates make decisions for incapacitated patients according to three distinct decision-making standards: what are they?
patients’ expressed wishes
substituted judgments
best interests
If the patient did not designate a surrogate as part of the advanced directive, then it will be assigned by the _____
attending physician
What should you do if a conflict arises between surrogates of equal standing? If that doesnt work, then what?
ask them to set aside their own preferences and articulate what each believes is in the patient’s best interest.
hospitalists may give ethical and legal precedence to that surrogate who has been assuming more of the care responsibilities
What does it mean to withhold life-sustaining therapy?
Withholding LST means a decision not to institute an intervention that could prevent death or prolong a dying process.
What is the the prototypic example of withholding LST?
is a do-not-resuscitate (DNR) order, which, in the hospital setting, means the forgoing of cardiopulmonary resuscitation (CPR) or basic cardiac life support (BCLS) as well as advanced cardiac life support (ACLS) to patients who have sustained a cardiopulmonary arrest.
Can a DNR order be reversed at any time?
YES!!
The American College of Surgeons calls for a process of ______ of the preexisting DNR order as part of the informed consent process for surgery.
“required reconsideration” because arrest during sx could be considered reversible
aka standard protocol is to temporarily revoke DNR code during sx and reinstate it upon arrival in the recovery room or at a specified time interval after surgery
If the patient, or surrogate, wants to maintain a DNR status during the procedure, this must be documented in the ________
If the patient dies in the OR, it is considered an ______
preoperative consent
“expected death”
When the decision is made to withdraw life sustaining therapy, what does that include?
mechanical ventilation
hydration
artificial nutrition
Who gets to decide if ICD and pacemakers are turned off or kept on in a DNR status pt?
The patient—or in the setting of decision incapacity, the surrogate—retains the ability to deactivate or remove these devices under the rubric of informed refusal, as a form of withholding or withdrawing therapy.
**____ _when it is absolutely—or to a reasonable degree of medical certainty—impossible to achieve a physiologic effect such as CPR in the setting of persistent acidosis
Physiologic futility
**_____ when the patient’s physiology may improve, but there is no patient-centered benefit
Qualitative futility
aka when the family is refusing intubuation for an anoxic brain injury
**______ when the intervention has not worked in similar patients within an accepted confidence interval
Quantitative futility
aka the pt’s family wants random medication that is not indicated but the “what if” question remains
**Draw the chart of determining level of history chart
During the PE are you allowed to document generalized findings?
YES, may document specific findings (“abdomen soft”) or make a generalized comment (“HEENT normal”)
**Draw the PE level chart
*Detailed should expand on at least one or more organ systems, with more than one comment
aka comprehensive and detailed must be at least 2 comments
What are the different levels of medical decision making? What 3 things determine the level of medical decision making?
straightforward, low, moderate, or high
- the number of diagnoses
- the amount and complexity of data
- the risk to the patient.
In order for the diagnosis to count, ____ must be present
must have PLAN under the diagnosis and “per endocrinologist” does NOT count
**Draw the medical decision making number of dx chart with point values
**Draw the amount and/or complexity of data ordered/reviewed chart
What are the 4 levels of risk to the patient?
minimal, low, moderate and high
need to pick the highest one!
How do you assign medical decision making complexity?
two of the three categories must meet or exceed the requirements assigned to a specific level of complexity to select that level
**Draw the medical decision making chart
How does the CPT level assigning differ from initial patient encounter and subsequent encounters? **How do you determine the final level of service?
initial pt requires consideration of all 3 key components
subsequent requires consideration of only 2 of the key components
**The lowest component of the two or three key components required determines the visit level.
** How do you determine level of service for a subsequent hospital visit? Draw the chart
** How do you determine level of service for a initial hospital visit? Draw the chart
For inpatient services, time accrues as _____ or _____ in addition to _____ time
unit
floor time
face-to-face
When more than ____ of the total service time involves counseling and/or coordination of care, you may select a code reflecting the _____ with the patient, rather than the three key components. What must you do next?
50%
total time spent
MUST BE DOCUMENTED!!!
If billing for time spent instead of the standard 3 components, what are the guidelines?
The amount of counseling and coordinating care (CCC) time may be estimated and you are to round the total visit time to the closest “average” total visit time
What are the 7 factors that count towards the CCC time?
Tasks that count toward counseling the patient include but are not limited to discussions of the plan
evaluation
procedures
prognosis
treatment options
risk factor reduction
patient and family education.
In order to bill for CCC services, both ____ and _____ must be documented. Also should document ______
the total visit time
portion of that total visit time that was spent CCC
a brief description of what was discussed
In order to dx malnutrition, need ___ of the following 6
2 of the following 6
- Insufficient caloric (energy) intake (estimated from dietary recall)
- Weight loss (based on objective measurement of weight)
- Loss of muscle mass (temporal/interosseous muscle wasting; clavicular prominence)
- Loss of subcutaneous fat (cheeks/orbital area, or space between thumb and forefinger)
- Localized or generalized fluid accumulation, that may mask weight loss (pitting edema)
- Diminished functional status (assessed by handgrip strength with a dynamometer)
What are the 2 equations for determining nutrition requirements?
Harris Benedict Equation
Mifflin St. Jeor Equation
Generally, hospitalized patients require between ____ and ____ g/kg/d, with burn patients requiring up to ___ g/kg/d.
In critically ill obese patients, up to ___ g/kg/d (IBW) is recommended
generalized hospitalized pts: 1.2 - 1.5
burn: 2.0
critically ill obese patients : 2.5
What is the quick “rule of thumb” for most hospitalized pts for caloric and protein needs?
25 to 30 calories/kg/d
1.2 protein g/kg/d
What type of nutrition is preferred? What is a good way to add additional calories? What are the specifications?
oral nutrition
boost shakes : 10g protein and 240 calories a shake
When should EN or PN feeding be initiated? How long should it be used?
after ~7-10 days with no oral intake
and only if going to be using for at least 5-10 days
What does enteral nutrition look like?
Enteral nutrition requires tubes entering the GI system directly at the stomach or small intestine - “if the gut works, use it”
What are the 6 relative and absolute CI to enteral feeding?
- major GI hemorrhage
- peritonitis
- severe ileus
- bowel obstruction or fistulae distal to enteral access site
- intestinal ischemia
- malabsorptive disorders with high-volume diarrhea
How are enteral nutrition feeding generically started?
Feedings are typically started at a low rate, and gradually advanced to the infusion goal over a period of 24 to 48 hours
Patients who cannot tolerate ____ should be considered for _____
enteral nutrition
parenteral nutrition
What are some conditions that are more commonly seen with PN when compared to EN?
higher rates of infectious and metabolic complications such as volume overload, hyperglycemia, and electrolyte abnormalities
parenteral nutrition is STRAIGHT into vascular system
What are parenteral nutrition solutions generically composed of? What needs to get added?
PN solutions contain carbohydrate in the form of dextrose, protein as crystalline amino acids, and lipids from polyunsaturated long-chain triglycerides such as soybean oil or a safflower/soybean oil mixture
Vitamins, electrolytes, and trace elements are added to the formulation as needed.
**_____ when seen in the context of parenteral nutrition may increase infectious complications, hospital length of stay, and cost.
Hyperglycemia
What is refeeding syndrome characterized by?
by electrolyte abnormalities that occur during the reinstitution of carbohydrate calories to a starved patient.
Serum phosphate, magnesium, and potassium depletion may develop
What are the generic starting requirements for parenteral nutrition? What are the monitoring requirements?
Generally, start slow - 1 liter for 1st day, monitoring glucose every few hours and BMP every 8-12 hours
parenteral nutrition requires ______ in order to administer. Why?
Central venous access
TPN solutions are hyperosmolar
**What are the 3 harmful things that could happen if you use intravenous fluids and they are NOT neccessary?
Fluid overload
Dangerous electrolyte derangements
Line infections
What is the equation to calculate total body water (TBW)? Give both male and female
Wt (Kg) x .6 (m) .5 (f) = TBW in liters.
What is the 2/3, 1/3 rule?
Calculate the total distribution of total body water for a 70kg male? Give a value for the following:
TBW
Intracellular Volume
Extracellular Volume
- Interstitial volume
- Intravascular volume
70 kg male
TBW= 42 L
Intracellular volume = .66 x 42 = 28 L
Extracellular volume = .34 x 42 = 14 L
Interstitial volume = .75 x 14 = 10.5 L
Intravascular volume = .25 x 14 = 3.5 L
Normal adults are considered to have a minimal obligatory water intake or generation of _____. What is the breakdown of ingested water vs water in food vs water from oxidation
~ 1600 mL/day
Ingested water – 500 mL
Water in food – 800 mL
Water from oxidation – 300 mL
** How much more water per day does a patient with a fever need?
water requirements increase by 100 to 150 mL/day for each degree of body temperature elevation over 37ºC
What is the short equation for estimating daily fluid requirements?
35ml/kg/day
What is the Na electrolyte requirement? How much Na is in .45% saline in 1 liter?
Na: 1-3 meq/kg/day
77 meq NaCl per liter
What is the potassium requirement? What does adding it due to the IV fluid? ____ is the common IVF additive dose
Potassium: 1 meq/kg/day
K+ increases the osm load
20 meg
____ meg/L of potassium is a common IVF additive and will supply the basal needs of most pts who are ____
20meq/L
NPO
What should you do if your pt is significantly hypokalemic?
should order separate K+ supplementation
ORAL is preferred
potassium is osmotically as active as _____. What will adding it to .45% saline do?
sodium
Adding 40 mEq to a liter of 0.45% saline (77 mEq sodium) will create a solution similar to ¾ isotonic saline, containing less free water
What is the common infusion rate for a potassium solution? What happens if you give it faster?
Potassium most commonly infused at a rate of 10 mEq/hr
potassium burns the veins!! so need to give it slowly
A plasma K+ _____ below normal corresponds to a total body potassium deficit of approximately ______ and a drop in plasma K+ to _____ below normal requires _____ for repletion
1 mmol/L
200 to 400 mmol
2 mmol/L
400 to 800 mmol
in general, every ____ of KCl raises the serum K+ level by ____
10 mEq
~ 0.13 mEq/L
What form of potassium is preferred? What is a typical dose for a pt with normal renal function?
oral potassium if there is NO threat to life
A typical initial dose in a patient with normal renal function is 40 to 100 mmol (40-100 mEq) per day, in two to three divided doses.
** What 3 medications are used in hyperkalemia?
calcium gluconate 10mL of 10% solution infused over 2-3 minutes
10 units regular insulin IV
albuterold 10-20mg nebulized
Calcium as like a ______ in the tx of hyperkalemia. Both insulin and albuterol act like _____
cardiac membrane stabilization
redistributors by pushing K out!
What is the though process behind giving glucose in a starvation setting? What are the normal glucose requirements?
During starvation, caloric needs are supplied by body fat and protein
The protein-sparing effect is one of the goals of basic IV therapy. Giving at least 100g/d of glucose reduced the protein loss by more than half
100–200 g/d (65–75 g/d/m2)
What are the 3 different types of fluids?
colloids
crystalloids
blood products
types of fluids: _____ contain large molecules that don’t pass through the cell membranes. Where do they go?
Colloid Solutions
When infused, they remain in the intravascular compartment and expand the intravascular volume and they draw fluid from extravascular spaces via their higher oncotic pressure
types of fluids: _____ contain small molecules that flow easily across the cell membranes, allowing for transfer from the bloodstream into the cells and body tissues. What effect does it have on interstitial and intravascular spaces?
Crystalloid Solutions
This will increase fluid volume in both the interstitial and intravascular spaces
What are the 3 subtypes of crystalloid solutions?
Isotonic / Hypotonic / Hypertonic
What are the 4 types of isotonic fluids?
0.9% sodium chloride (0.9% NaCl)
Lactated Ringer’s solution
5% dextrose in water (D5W)
Ringer’s acetate solution
How much sodium and chloride are in 0.9% NaCl?
Contains 154 meq of Na and 154 meq of Cl
What are the different components of Ringers lactate? What is another name for it?
Na 130 meq, K 4 meq, Ca 3 meq, Cl 109 meq, HCO3 28 meq
Hartmann solution
______ is the most physiologically adaptable fluid because its electrolyte content is most closely related to the composition of the body’s blood serum and plasma.
Ringer’s lactate
When should you use Ringers lactate or Hartmann solution?
To replace GI tract fluid losses (Diarrhea or vomiting), Fistula drainage, Fluid losses due to burns and trauma.
Ringers lactate or Hartmann solution is also very good for patients experiencing ______ or _____ due to third-space fluid shifts.
acute blood loss
hypovolemia
Where is LR metabolized? What does it convert lactate into?
liver
lactate into bicarb
LR is often administered to patients who have ______, not patients with _____
metabolic acidosis
lactic acidosis
What 2 type of patients should you NOT give lactated ringers to? Use caution with what population?
Don’t give LR to patients with liver disease as they can’t metabolize lactate
don’t give LR to pt’s with a pH higher than 7.5
Used cautiously in patients with severe renal impairment because it contains some potassium
______ is considered a isotonic solution but when _____ is metabolized, the solution actually becomes ______ and causes fluid to shift _____
dextrose 5% in water
dextrose
hypotonic
into cells
D5W provides _____ that pass through membrane pores to both _____ and _____ spaces. Its smaller size allows the molecules to pass more freely between compartments, thus ______ both compartments simultaneously
free water
intracellular
extracellular
expanding
How many calories a liter does D5W contain?
It provides 170 calories per liter, but it doesn’t replace electrolytes
What should you do before ordering fluids?
ALWAYS look at basic chemistry prior to ordering fluids.
If your reason for giving fluids is hypovolemia which 2 fluids should you choose? why?
NS or LR
because they both put the most volume into the intravascular space
If the reason for fluids is dehydration, what is the fluid of choice? Why?
se a hypotonic fluid usually 0.45% saline or D5W.
primary goal is free water replacement
What is the fluid of choice for a post-op patient?
0.9 % saline
What is the 4,2,1 MAINTENANCE rule for fluids in pediatrics patients?
First 10 kg= 4cc/kg/hr
Second 10 kg= 2cc/kg/hr
1cc/kg/hr thereafter
**What is the IVF rate in adults?
wt (kg) + 40
70+40= 110cc/hr
What should you do to a patient’s IVF rate if they are taking some PO?
IVF rate must be decreased accordingly
What 5 things should be monitored daily in a pt receiving significant IVF?
Daily electrolytes
BUN
Cr
I/O
and if possible, weight
