COMPLEX II EXAM 4 REVIEW
ACID-BASE IMBALANCES
ABG ANALYSIS ASSOCIATED WITH ENDOCRINE, BURNS, AND END-OF-LIFE DECISIONS (4-5)
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DKA
o Metabolic acidosis
HHS
o No acidosis
o Metabolic alkalosis, pH > 7.4
Burns
o Slight hypoxemia
o Metabolic acidosis
End of life patients
o Respiratory acidosis
DIABETES
DIABETIC KETOACIDOSIS (5-6)
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Acute, life-threatening condition
Breakdown of body fat/muscles for energy  ketones in blood/urine
Risk factors
o Only occurs in type I diabetes
o Infection (most common)
o Undiagnosed/untreated DM I
o Missed dose of insulin
o Condition that increases carb metabolism
o Physical or emotional stress
o Illness
o Surgery
o Trauma
o Increased hormone production
Manifestations (Polly Had a Frakkin’ Sugar High  DKA)
o Polyuria/polydipsia/polyphagia
o Headache
o Fruity breath
o Sedation
o Hot, flushed skin/Hypotension
o Dehydration
 Weight loss
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o Kussmaul respirations/Ketonuria
o Abdominal pain/Apathy (weakness, lethargy)
Diagnostics
o Blood sugar > 300
o Sodium: low, normal, high
o Potassium: high (peaked T wave)
 EKG monitoring
o BUN > 30
o Crt > 1.5
o Ketones present in urine and blood
o High osmolarity (normal = 265-295)
o ABGs
 Metabolic acidosis
 pH < 7
Nursing interventions
o Priority is always ABCs
 Can patient protect his airway?
 Get ABGs
o Rapid NS fluid replacement – circulation/perfusion (priority)
 Follow with hypotonic fluid to replace continuing losses
 Add glucose to fluid when levels near 250
 Will use D5 ½ NS w/ 20 KCl
 Minimize risk of cerebral edema
 Only give K+ once kidney function returns
o Treat underlying infection
o Regular insulin 0.1 to 0.15 unit/kg IV bolus followed by continuous infusion at
0.1 unit/kg/hr (NOT SQ)
 In the ICU
 Bring glucose level down slowly
o Monitor glucose Q 1 hr
 Adjust insulin gtt per levels
o Goal is glucose level < 200
 After pt is stabilized, place on sliding scale with SQ insulin
o Monitor potassium levels for hypokalemia
 Give K+ in replacement fluid
 Cardiac monitoring
 Ensure adequate urinary output
 For kidney function
 Sodium bicarb slowly IV infusion for severe acidosis (pH < 7.0)
 Infuse potassium with it unless pt has hyperkalemia
 Continue EKG monitoring
Complications with treatment
o Hypoglycemia
o Hypokalemia
o Cerebral edema due to fluid shifts
HYPEROSMOLAR HYPERGLYCEMIC SYNDROME (5-6)
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Acute, life-threatening condition
o But has a slow onset
Risk factors
o Only occurs in Type II DM
 Sufficient insulin to prevent development of ketosis, but not to
prevent hyperglycemia
o Lack of sufficient insulin
 Undiagnosed DM II
 Nonadherence
o Infection/stress
o Inadequate fluid intake
o Poor kidney function
o Most common in older adults (50-70 y/o)
o MI, sepsis, stroke
o Medications
 Steroids
 Thiazide diuretics
 Phenytoin
 Beta blockers
 Calcium channel blockers
Manifestations
o Polyuria/polydipsia/polyphagia
o N/V, abdominal pain
o Blurred vision
o Headache
o Weakness
o Ortho hypo
o Seizures
 Myoclonic jerking
o Reversible paralysis
o More dehydration than DKA (leads to weight loss)
 More fluid replacement or  shock
o Altered LOC
Diagnostics
o Glucose > 600, up to 1000
o Sodium: low to normal
o Potassium: normal to high – dehydration
o BUN/Crt: same as DKA
o NO ketones in blood or urine
o Osmolarity > 320 (higher than in DKA)
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 Made of sodium, BUN, and glucose
 Neuro deficits with this high of osmo – seizure precautions!
o pH > 7.4
Priority nursing interventions
o ABCs (always)
 Can patient protect his airway?
 Get ABGs
o Rapid NS fluid replacement – circulation/perfusion
 Follow fluid bolus with hypotonic fluid to replace continuing losses
 Add glucose to fluid when levels near 250
 Will use D5 ½ NS w/ 20 KCl
 Minimize risk of cerebral edema
o Treat underlying infection
o Regular insulin 0.1 to 0.15 unit/kg IV bolus followed by continuous infusion at
0.1 unit/kg/hr
 May be on insulin drip, but less common than in DKA
 May just take long-acting insulin + an increase in PO meds
o Goal is glucose level < 200
 After pt is stabilized, place on sliding scale with SQ
o Monitor potassium levels for hypokalemia
 Will not be as significant as in DKA
 Give K+ in replacement fluid
 Cardiac monitoring
 Ensure adequate urinary output
Complications
o Seizures
o Hypoglycemia
Patient teaching (both DKA and HHS)
o Educate to prevent recurrence
 Nutrition
 Adherence to medication regimen
 Illness day management
 Monitor glucose Q 4 hr
 Continue to take insulin, possible increase
o Wear a med alert bracelet
o Decrease risk of dehydration
 2-3 L/day of fluids
 Artificial sweetener fluids + water
 If glucose levels are low, consume fluid with sugar
o Check urine for ketones if sugar is > 240
o Notify provider for the following:
 Illness > 24 hrs
 Glucose > 250
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Inability to tolerate food/fluids
Temp of 101.5oF for > 24 hrs
HYPOGLYCEMIA (2-3)
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Manifestations (Dad Had To Have Sugar So Robin Brought Fructose)
o Diaphoretic/Decreased LOC
o Hunger
o Tachycardia
o Headache/lightheadedness
o Shakiness/Strange feelings
o Slurred speech/Seizure  coma/Shallow respirations
o Restless, irritable
o Blurred vision
o Fatigue
o Pale, cool skin
Diagnostics
o Blood glucose < 70
Priority interventions
o 15 G of simple carbs
 4-6 oz of juice or regular soft drink
 Glucose tablets or glucose gel per package instructions
 6-10 hard candies
 1 tbsp honey
o Recheck in 15 min
 If still low, administer another 15 G carbs and check a gain in 15 min
 If normal, snack with a carb and protein if next meal is more than 1 hr
away
o Unconscious patients or those unable to swallow
 Glucagon
 Injection (SQ or IM) of immediate sugar
 Repeat in 10 min if patient is still unconscious
 Notify provider
 Place in lateral position to prevent aspiration
 In acute care, administer D50 via IV
 Consciousness should occur within 20 min
 Once conscious again, ingest oral carbs
THYROID DISORDERS
THYROTOXICOSIS (THYROID STORM) (4-5)
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Sudden surge of large amounts of thyroid hormones into the bloodstream
Causes increase in metabolism
o Medical emergency with high mortality rate
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Risk factors
o Grave’s disease (hyperthyroidism)
o Infection
o Trauma
o Emotional distress
o Dig toxicity
o DKA
Manifestations (Thyroid Diseases Are Very Concerning to Humans)
o Tachy-dysrhythmias
o Delirium/Dyspnea
o Abdominal pain
o Vomiting
o Chest pain
o Hyperthermia/HTN
Diagnostics
o Radioactive iodine uptake
 Measures uptake of radioactive iodine
 Given orally for 24 hours pre-test
 Elevated uptake is a (+) test
Priority interventions/medications
o ABCs
 Maintain patent airway
 Mechanical vent if needed
 Continuous cardiac monitoring for dysrhythmias
o Medications
 Acetaminophen to decrease temperature
 NO aspirin – increases thyroxine levels
 Administer thionamides (PTU) or methimazole (Tapazole)
 Give sodium iodide 1 hr after
 Propranolol to control symptoms only
 Glucocorticoids to reduce immune response
o Cool sponge baths or ice packs
o IV fluids
 Provide adequate hydration
 Prevent vascular collapse from fluid volume deficit
o Hourly Is and Os
o Administer O2
o Monitor patient’s:
 Increased restlessness
 Fever
 Palpitations
 Chest pain
o Surgical intervention
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Thyroidectomy
 Total or sub-total
o Subtotal typically does not need replacement hormones;
total does
 Preop teaching
o Beta blockers to control thyroid storm manifestations
 HTN
 Tachycardia
 Postop teaching/care
o Hoarseness and sore throat are normal
o Semi-Fowler’s position
 Support with pillows
 Avoid neck extension
o Support neck when coughing and deep breathing
o Oral/tracheal suctioning as needed
o Respiratory distress can occur due to:
 Compression of the trachea from hemorrhage
 Most likely to occur in first 24 hrs
 Edema
 Trach supplies available at all times
 Humidify air
 Cough and deep breathe
 Suction PRN
 Complications
o Airway obstruction
o Hemorrhage
o Tracheal collapse
o Mucous accumulation in the throat
o Laryngeal edema
o Vocal cord paralysis
 Complication of subtotal
o Hypocalcemia (due to damage of parathyroid gland)
 Manifestations
 Tingling of toes or around mouth
 Muscle twitching
 Chvostek’s and Trousseau’s
 Seizure precautions
 Calcium gluconate available immediately
 Monitor for:
o Restlessness
o Sudden stridor
 These indicate airway closure
 Have trach tray near at all times
POSTERIOR PITUITARY
SIADH (5-6)
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Symptom of inappropriate antidiuretic hormone (SIADH) or Schwartz-Bartter
syndrome
Excessive release of ADH  fluid retention
Risk factors
o Increased intrathoracic pressure
 PEEP with mechanical vent
o Head injury
o Meningitis
o Stroke
o TB
o Medications
Manifestations
o Early
 Headache
 Weakness
 Anorexia
 Muscle cramps
 Weight gain (no edema – water is retained, sodium is not)
o Late (as sodium level decreases)
 Personality changes – hostility
 Sluggish DTRs
 N/V/diarrhea
 Oliguria
 Dark yellow, concentrated
 Confusion, lethargy
 Cheyne-Stokes
 Seizure  coma  death
o Fluid volume excess
 Tachycardia
 Bounding pulse
 Possible HTN
 Crackles in lungs
 JVD
 Intake > output
o Lab findings
 Urine chemistry (think CONCENTRATED)
 Increased everything
o Specific gravity (> 1.030), osmolarity, Na+
 Serum chemistry (think DILUTE)
 Decreased everything
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o Osmolality (< 270), Na+
Priority interventions/plan of care
o Fluid restriction (priority)
 500-1000 mL/day
 Comfort measures – mouth care, ice chips, lozenges, staggered water
intake
o Flush any enteral feedings with NS, not water
 Replaces sodium, prevents further hemodilution
o Monitor Is and Os, v/s
o Lung sounds to assess for pulmonary edema
o Weight patient daily
 Report gain of 1+ kg
o Report altered LOC
o Seizure precautions
o Safe environment (confusion, seizures)
o Monitor for heart failure r/t FVE
 Use loop diuretic if needed
o Medications
 Demeclocycline (tetracycline derivative)
 Life-long
 Stimulates urine flow  correction of F/E imbalances
 Contraindicated in impaired kidney function
 Do not take with milk
 Monitor for oral candidiasis or yeast infection
 Avoid prolonged exposure to the sun
 Vasopressin antagonists (tolvaptan, conivaptan)
 Life-long
 Promote excretion of water but not Na+
 Monitor:
o Blood glucose
o Sodium
o Is and Os
 Loop diuretics
 Hypertonic saline via IV (HIGH ALERT)
 For severe hyponatremia/water intoxication
 Gets water to come back into the vascular system from the cells
 Usually 3% NS
 Give SLOWLY and a small amount, only 200-300 mL TOTAL
o < 1 mEq/hr or about 30 mL/hr
 Monitor Na+ Q 2-4 hr
 Fluid restriction
 Adverse effects
o Central pontine myelinolysis
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 This occurs if medication is given too quickly
 Destroys myelin sheaths
 Permanent
 Parkinson’s-like state
Monitor for s/s of:
o Hyponatremia
 N/V
 Decreased appetite
o Hypernatremia
 Deterioration of mental status
Patient teaching
DIABETES INSIPIDUS (5-6)
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Occurs due to a deficiency of ADH  increased water excretion and inability to
concentrate urine  excessive, diluted urine production and electrolyte imbalances
o Primary – neuro
 Defect of hypothalamus or pituitary gland
o Secondary – neuro
 Usually caused by head injury
 MONITOR HEAD INJURY PATIENTS FOR DI AND SIADH!
o Nephrogenic
 Kidneys cannot respond to the hormone
o Drug-induced
 Drugs alter kidneys response to ADH
Risk factors
o Head injuries
o Tumors
o Lesions
o Meningitis
o Medications
 Lithium or demeclocycline
Manifestations (opposite of SIADH)
o Polyuria (4-30 L/day)
o Polydipsia (consumption of 2-20 L/day)
o Nocturia
o Fatigue
o Dehydration
 Extreme thirst
 Weight loss
 Muscle weakness
 Headache
 Constipation
 Dizziness
 Physical assessment
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Sunken eyes
Tachycardia
Hypotension
Loss of skin turgor
Dry mucous membranes
Weak peripheral pulses
Decreased cognition
o Lab tests
 Electrolyte imbalances
 Urine chemistry (think DILUTE)
 Decreased everything
o Specific gravity (< 1.005), osmolality (< 200), pH, Na+, K+
 Serum chemistry (think CONCENTRATED)
 Increased everything
o Osmolality (> 300), Na+, K+
o Water deprivation test (ADH stimulation test)
 Withhold fluids
 Test is (+) if kidneys are unable to concentrate urine despite increased
plasma osmolarity
Priority actions
o Monitor specific gravity, v/s, Is and Os, central venous pressure, and labs
o Weigh patient daily
o Diet
 Restrict foods with diuretic effect (caffeine)
 Increase fiber and fruit juice if constipation occurs, can need laxative
o IV fluids
 Hydration + electrolyte replacement
o Promote safety (low BP)
 Bed rails up
 Assist with ambulation
 Will have bad ortho hypo
o Skin and mouth care
 Lubricant for cracked lips
 Soft toothbrush
 Mild mouthwash
 Alcohol free skin care products
 Emollient lotion after bathing
o Encourage patient to drink fluids in response to thirst
Medications
o Desmopressin
 Synthetic ADH hormone
 Lifelong medication
 Give cautiously in those with CAD – this is a vasoconstrictor
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o Trauma patients
 Can be treated with a vasopressin drip in the ICU
 Give cautiously due to vasoconstriction
o Anticonvulsants
 Side effect of some is SIADH  more concentrated urine
o Transient DI – treat until symptoms go away
o Chronic DI – treat for life with nasal spray, SQ injections
Goals of care
o Replace ADH
o Retain adequate fluid for hydration
o Concentrate urine
o Know how these labs/vitals/CVP indicate therapy is working
Discharge teaching
o Lifelong self-administration of medication
o Monitor weigh daily
 Notify provider for gain > 2 lbs in 24 hours
o High fiber diet
o Med alert bracelet
o Avoid alcohol
o Monitor for s/s of dehydration
TISSUE INTEGRITY
BURN TRAUMA (9-10)
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Types
o Dry heat
 Open flames
 Explosions
o Moist heat (scald)
 Hot liquid or steam
o Contact
 Hot metal, tar, or grease
o Chemical
 Exposure to caustic agent
o Electrical
 Electrical current passes through the body
 Causes severe damage
 CARDIAC – monitor CK-MB and troponin
 Answer will always be cardiac specific
 Risk for rhabdomyolysis
 This breaks down muscles  clogging the kidneys
o Tea-colored urine
o Elevated BUN/Crt
o CK, H&H labs as well
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o Thermal
 Clothes ignite from heat or flames produced by electrical sparks
o Flash (arc)
 Contact with electrical current that travels through the air from one
conductor to another
o Conductive electrical
 Person touches electrical wiring or equipment
o Radiation
 Therapeutic cancer treatment or sunburns
Assessment
o History of event
 Burn agent
 Duration of contact
 Body area of the burn
 Demographics
 Age, weight, height
o Health history (pre-existing illness?)
o Inhalation injury
 Singed nasal hair, eyebrows, eyelashes
 Soot around/in mouth and nose
 Wheezing, hoarseness
 Edema of nasal septum
 Any facial burns
 Smoky smelling breath
 Impending loss of airway:
 Hoarseness
 Brassy cough
 Drooling/difficulty swallowing
 Audible wheezing, crowing, stridor
o Carbon monoxide inhalation
 Occurs due to burns in an enclosed area
 Headache
 Weakness
 Dizziness
 Confusion
 Erythema
 Upper airway edema  sloughing of respiratory tract mucosa
 Monitor carboxyhemoglobin levels
 Need hyperoxygenation
o Hypovolemia  shock
Stages (manifestations)
o During resuscitation phase after major burn
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SNS manifestations
 Tachycardia
 Increased RR
 Decreased GI motility
 Increased glucose
o Superficial thickness (1st degree)
 Area involved
 Epidermis
 Appearance
 Pink to red
 No blisters
 Mild edema
 No eschar
 Sensation/healing
 Painful/tender
 Heat sensitive
 Heals within 3-6 days
 No scarring
o Superficial partial thickness (2nd degree)
 Area involved
 Entire epidermis + part of dermis
 Appearance
 Pink to red
 Blisters
 Mild-moderate edema
 No eschar
 Sensation/healing
 Painful
 Heals within 3 weeks
 No scarring
 Minor pigment changes possible
o Deep partial thickness (2nd degree)
 Area involved
 Entire epidermis + deep into dermis
 Appearance
 Red to white
 No blisters
 Moderate edema
 Eschar soft and dry
 Sensation/healing
 Painful and sensitive to touch
 Heals in 2-6 weeks
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 Scarring likely
 Possible grafting
o Full thickness (3rd degree)
 Area involved
 Entire epidermis + entire dermis
 Possible SQ damage
 Nerve damage
 Appearance
 Red, black, brown, yellow, or white
 No blisters
 Severe edema
 Eschar hard and inelastic
 Sensation/healing
 Minimal or absent (nerve damage)
o Painful when healing begins
 Heals within weeks to months
 Scarring present
 Grafting needed
o Deep full thickness (4th degree)
 Area involved
 All layers of the skin
 Extends to muscle, bone, and tendons
 Appearance
 Black
 No blisters
 No edema
 Eschar hard and inelastic
 Sensation/healing
 No pain
 Heals within weeks to months
 Scarring present
 Grafting needed
o Electrical injuries
 Will not have a large external burn surface area
 Find entrance and exit wound
 CARDIAC + KIDNEYS
 Rhabdo
 Tea-colored urine
 CK
 BUN/Crt
 Compartment syndrome
Priority interventions
o Circumferential burns
 Risk for compartment syndrome – will have fasciotomy
o Phases of care
 Emergent (resuscitative phase)
 Injury through 24-48 hours
 Priority
o Securing airway
o Support circulation and organ perfusion
 Fluid resuscitation – Parkland formula
o Manage pain
o Prevent infection through wound care
o Maintain body temp
o Provide emotional support
 Acute
 Begins 36-48 hrs after injury
o When fluid shift is resolved
 Ends with closure of the wound
 Priority
o Assessment and maintenance of CV, respiratory, and GI
system (including nutrition)
o Wound care
o Pain control
o Infection prevention
o Psychosocial interventions
 Rehabilitative
 Begins when most of the burn has healed
 Ends when patient achieves highest level of functioning
possible
 Priority
o Psychosocial support
o Prevention of scars and contractures
o Resumption of activities, including work, family, and
social roles
 Can last for years
o Minor burns
 Stop the burning process
 Provide analgesics
 Cleanse with mild soap and tepid water
 Avoid excess friction
 Antimicrobial ointment
 Dressing
 Nonadherent/hydrocolloid
 No greasy lotion or butter
 Tetanus immunization
o Moderate/major burns
 Respiratory (PRIORITY)
 Assess respiratory rate and depth
o Look, listen, feel
o Rise and fall, symmetry
 Crowing, stridor, or dyspnea requires nasal or oral intubation
o Upper airway edema becomes pronounced 8-12 hr after
beginning fluid resuscitation
 Humidified O2
o Often high-flow – NRB
 Mechanical ventilation + atracurium/vecuronium may be
necessary
 Suction Q hr as needed
 Cardiovascular assessment
 Edema
 Central and peripheral pulses
 Cap refill
 Pulse ox
 Monitor BP
 ECG changes
 GI system
 NG tube insertion for those at risk for aspiration
 Elevate HOB at all times
 Fluid replacement – to maintain cardiac output
 *Hypovolemic shock is common cause of death in resuscitation
phase
 IV access with large bore catheter
o Central line needed, especially > 30% TBSA
 Third spacing (capillary leak syndrome)
o Continuous leak of plasma from vasculature to
interstitial fluid
o  hypotension/electrolyte imbalances
o Will start responding poorly to fluid treatment
 Fluid resuscitation principles
o Parkland formula
 4 mL x TBSA% x kg
 Infuse ½ over first 8 hours
 From time of burn
 If patient doesn’t get to the ED until 3
hours later, infuse total ½ volume over the
remaining 5 hours
 Subtract fluid given by EMT
 Infuse remaining ½ over the next 16 hours
o
o
o
o
o Administer LR or NS – LR is preferred
o Determine TBSA via Rule of Nines or Lund and Bower
o Infuse colloids (albumin, etc.) after first 24 hrs
o Monitor for fluid overload
 Weigh patient daily
 Maintain output > 0.5 mL/kg/hr
 Monitor for shock
 Urinary system
 Indwelling catheter
 Monitor Is and Os
 Monitor – USG, BUN/Crt, Na+
 Hypothermia
 Keep room warm
 Infuse warm fluid
 Use warm inspired air
 Warming blankets
 Hyperthermia
 Due to hypermetabolic conditions
 Low-grade fever is compensatory mechanism
Pain management
 Avoid routes other than IV during resuscitation
 Use IV opioids or anesthetics (ketamine, nitrous oxide)
 PCA for some patients
 Administer medications prior to dressing changes or skin grafting
Infection prevention
 Protective environment
 No plants, flowers, or fresh fruits/veggies
 Limit visitors
 Patient-dedicated equipment
 Tetanus vaccine (if > 5 years)
 Asepsis with wound care
Nutritional support
 Patients with large burns need 5000 cal/day (due to hypermetabolic
state)
 Needs double or triple 4-12 days after the burn
 Increase protein
 Enteral or TPN
Restoring mobility
 Prevent contractures
 Maintain correct body alignment
 Splint extremities
 Position changes
 AROM and PROM TID
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 Assist with ambulation when patient is able
 Pressure dressings for up to 2 years
 Monitor for pressure ulcers
o Psychological support
 Of patient and family
Complications
o Airway injury
 May not be apparent for 24-48 hrs post injury
o F/E imbalances/shock
 Monitor fluid volume status
o Infection/sepsis
 Discoloration, edema, odor, drainage
 Fluctuations in temp and HR
 Culture and antibx
o Loss of muscle/joint mobility
 Due to scarring and contracture
GRIEF & LOSS, SPIRITUALITY, & END-OF-LIFE CARE
DEATH & DYING, MORALITY, RELIGION, & SPIRITUAL DISTRESS (3-4)

Religion and medical care
o Judaism
 Presence of rabbi during death
 Bury the dead within 24 hours
o Islam
 Cleanliness and modesty are important
 Nurse of same gender
o Catholics
 Great respect for life
 Rituals of the sacrament (Anointing of the Sick)
 Priest to administer last sacrament
o Christians
 Generally embrace Western medicine
o Hinduism
 Embrace Western medicine but also use alternative methods
 Believe in reincarnation
 Do not participate in organ donation
o Buddhism
 Prefer Eastern medicine
 Believe illness can be cured through the mind and herbs
 Use acupuncture
 View blood donation as a great gift
o Jehovah’s Witness
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 No blood transfusions
Beliefs and nutrition
o Judaism
 Kosher diet
 No pork, shellfish
 No meat and dairy on the same tray
o Islam
 Fast during Ramadan – from sunrise to sunset
 Do not eat pork
o Hinduism
 Vegetarian
 Prefer meds not derived from animals
Spiritual distress
o Characteristics
 Express lack of hope
 Express feelings of abandonment
 Refuses interaction with family and friends
 Sudden change in spiritual practices
 Requests to see religious leader
PALLIATIVE CARE (2-3)
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

Patient candidates
o Anyone who has a life-changing event
o Do not have to be dying
Plan of care
o Improve quality of life
 Prevent and relieve suffering
 Dying patient to live to the fullest
o Pain and symptom relief
o Spiritual and psychosocial support
o Regard dying as a natural process
o Affirm life
o Goal: learn to live fully with incurable condition
Feeding tubes, mechanical vent, and CPR
o Allowed in palliative care
HOSPICE CARE (2-3)
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
Patient candidates
o < 6 months to live, diagnosed by physician
o Patient/family must be comfortable with comfort care only
Plan of care
o Provide comfort/support to patient and families
 During and after death
o Cure is no longer sought
o Symptom management
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o Advanced care planning
o Spiritual care
Decision process
o Lack of information about hospice
o Culture may play a role
 Some cultures have different views on dying
 Where the patient should die
 Who should be present at time of death
 What should be done with the body
o Physician may view decline as a personal failure
 This is difficult to overcome
o Patient or family may see it as giving up
Feeding tubes, mechanical vent, and CPR
o NOT allowed in hospice
Teaching
BRAIN DEATH (1-2)
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
Manifestations
o Irreversible loss of all brain functions
 Including brainstem
o Pupils fixed/dilated
o Coma, unresponsive, absent motor movements
o Apnea
o Flat EEG
o No ocular response
o Irritation of sclera test is (-)
 Cotton ball across eye
o No cerebral blood circulation
Organ donation
o Addressed by the expert/specialist
LEGAL / ETHICAL ISSUES (1-2)
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
Decision process
Advance directives
o Living will
o Durable power of attorney
 Healthcare proxy
o Do Not Resuscitate
 Order must be written by physician and in patient’s chart
 No CPR
o Do Not Intubate
 Again, written order
 No mechanical ventilation