Quiz 2 Adult health I Pain assessment Pain assessment (priorities): Patient's self -report is "gold standards" for pain existence and intensity assessment . Nurse's role: - accept patient's self-report - serve as an advocate l - act promptly to relieve pain - respect values and preferences of the patient - be aware of facial expressions (nonverbal communication) Patient-controlled analgesia pump (PCA pump) ~ interactive method of pain management that allow the patient to treat their pain by self-administering doses of analgesic agents ~ used to manage all types of pain by multiple routes of administration (oral, IV, subcutaneous, epidural, perineural) *PCA pump can be controlled only by the patient* Nursing actions: - teach the patient to use the PCA pump - teach the patient to press the button (administer analgesics) only if pain is present Morphine adverse effects Nervous system: - depress CNS (everything is going to be low) Respiratory system: - respiratory depression Gastrointestinal system: - hypoactive bowel sounds - constipation - paralytic ileus Circulatory system: - decreased cardiac output (risk for cardiac arrest) - decreased blood pressure (risk for orthostatic hypotension) Renal system: - decreased urinary output Other adverse effects of morphine: -drowsiness -stomach pain and cramps -dry mouth -headache -nervousness -mood changes -small pupils -difficulty urinating -nausea -vomiting Adverse effects of opioids -constipation -nausea -vomits -urinary retention -pruritus -sedation -respiratory depression (less common, most feared) -orthostatic hypotension Acid base imbalance Values: -pH: 7.35-7.45 -PaCO2: 45-35 (respiratory) -HCO3: 22-26 (metabolic) Tic tac toe method: -fully compensated : when pH is normal -partially compensated: all three values are abnormal -uncompensated: if PaCo2 or HCO3 is normal, and the other is abnormal Respiratory acidosis- hyperventilation Manifestations: RR - respiratory depression from opioids, Sleep Apnea anesthesia, poison Post Op - neurologic issues Head trauma - inadequate chest expansion (muscle weakness, CNS Drugs apnea, tremors, deformities) Alcohol - airway obstruction pneumonia / COPD -pulmonary issues (edema, tumor, thrombus, drawing) Results: - increased CO2 - increased or normal H concentration Signs and symptoms: - increased heart rate - tachypnea - increased blood pressure - ventricular fibrillation - anxiety, irritability, confusion, comma - respiration: shallow, ineffective, rapid Interventions: - O2 therapy - positioning - breath techniques - bronchodilators Low & Slow . Into✗Eat ^ - ^ - - ' Respiratory alkalosis- hyperventilation Findings: - fear - trauma - intracerebral trauma - salicylate toxicity - excessive mechanical ventilation - asthma - pneumonia - high altitudes Results: - decreased O2 - decreased H2 concentration Signs and symptoms:: - tachypnea - inability to concentrate - numbness - tingling - tinnitus - tachycardia -ventricular and atrial dysrhythmias Interventions: - O2 therapy - anxiety reduction - intervention and rebreathing techniques Metabolic acidosis- excess production of Metabolic alkalosis- base excess hydrogen ions * vomiting (due to loss of acid) * diarrhea (due to the loss of bicarbonate) Findings: Findings: - excessive ingestion of antacids - diabetes ketoacidosis - venous administration of bases (blood - starvation transfusion, TPN, or sodium bicarbonate) -excessive intake aspirin, methyl and ethyl - vomiting or NG tube suction alcohol - K depletion due to diuretics, thiazides, - excessive exercise laxatives overuse - hypoxia - Cushing's syndrome - seizures - increase digitalis toxicity (nausea and - kidney failure vomiting) - pancreatitis Results: - severe lung problems - increased HCO3 - liver failure - decreased H concentration -diarrhea Signs and symptoms Results: - increased heart rate - decreased HCO3 - decreased or normal blood pressure - increased H concentration - atrial and ventricular tachycardia Signs and symptoms: - numbness - bradycardia - tingling - weak peripheral pulses - confusion - tachypnea - convulsion - decreased blood pressure - ineffective breathing - confusion, headache, drowsiness Interventions: - administer antiemetic - Kussmaul respirations (rapid/deep) - fluid and electrolyte replacement -warm, dry, pink (skin) - if related to K depletion discontinue Interventions: causative agent - if diabetic ketoacidosis: administer insulin - if GI looses: antidiarrheal and rehydration Ph < 7.35 - if HCO3 low: administer sodium HC 03726 bicarbonate 1 mEq/Kg Acute gastroenteritis inflammation of the lining of the stomach Causes: - food poisoning - viral causes - bacterial causes Signs and symptoms: - vomiting - diarrhea * if patient is able to tolerate PO= administer fluids by mouth * if patient is unable to tolerate PO= administer fluids by IV (applies to anybody-children, newborns, older adults…) * Acute gastroenteritis provoque nausea and vomiting so the patient is at risk for electrolyte imbalance and dehydration* Hypokalemia is associated with eating disorders (diarrhea and vomiting) Dehydration Risk factors: - hyperventilation or excessive perspiration without water treatment - excessive vomiting or diarrhea - NG tube suctioning - excessive sweating (diaphoresis) - prolonged fever - polyuria - burns -hemorrhage or plasma loss - NPO - anorexia - nausea - dysphagia - confusion - diabetes ketoacidosis/insipidus - excessive intake of salt, slat tablets, or hypertonic IV fluids - insufficient water intake (enteral feeding without water administration, decreased thirst sensation, aphasia) Expected findings: - hyperthermia (dehydration) - hypothermia (fluid volume deficit) - tachycardia - thready pulse - hypotension - orthostatic hypotension - decreased central venous pressure - tachyonea - hypoxia Neuromusculoskeletal: dizziness, confusion, weakness, fatigue, seizure (rapid/severe dehydration) GI: thirst, dry mucous membranes, nausea, vomiting, anorexia, acute weight loss Renal: oliguria (decreased production of urine) Others: - decreased capillary refill - cool clammy skin - flattened neck. veins - decreased skin turgor - sunken eyeballs - absence of tears Labs: (everything more concentrated/ increased) - increase Hematocrit, blood osmolarity, urine specific gravity, and sodium When you are dehydrated you are at risk for hyponatremia or hypernatremia, it depends on how you are losing fluids - sweating: risk for dehydration and hypernatremia (because your body is not losing too much sodium) - polyuria: risk for dehydration and hyponatremia ( because your body is losing too much sodium) In conclusion, when you sweat you loose less sodium than when you urinate. When you do not replace fluids you can lose or keep too much sodium in your body, it depends on how you lose fluids. - Electrolytes values: Hypocalcemia and - sodium: 136-145 hypomagnesemia cause - potassium: 3.5-5.0 muscle twitching - chloride: 9.0-10.5 positive Chvostek's and - magnesium: 1.3-2.1 Trousseau's sign -phosphorous: 3.5-4.5 Hypernatremia (sodium greater than 145) Hyponatremia (sodium less than 136) Risk factors: Causes: - water deprivation - kidney disease(imbalance of water) - diabetes insipidus - looses: vomiting, diarrhea, sweating, NG - watery stools tube suctioning, wound drainage - excessive sodium intake - adrenal insufficiency - thirsty (most important finding) - medications: diuretics, mental medications - heat stroke (SSRI's) - hyperventilation - NPO - increased production of ADH - excessive fluid ingestion - delusions - decreased ADH - burns - heart failure nephrotic syndrome - excessive sweating - low sodium diet - medications: glucocorticosteroids Signs and symptoms: Signs and symptoms: Vital signs: - thirst - hypothermia Vital signs; - tachycardia - hyperthermia - rapid thready pulse - tachycardia - hypotension - orthostatic hypotension - weak peripheral pulses Neuromusculoskeletal: Neuromusculoskeletal: - headache, confusion, lethargy, muscle - restlessness, irritability, muscle twitching/ weakness, fatigue, decreased deep tendon weakness, respiratory compromised, reflex, lightheaded, dizziness decreased or absent DTRs, seizures, comma GI: GI: - increased motility - thirst - hyperactive bowel sounds - dry mucous membranes - abdominal cramping - nausea - nausea - vomiting Severe causes: seizure, coma, respiratory - anorexia arrest - occasional diarrhea Labs: Labs: - decreased osmolarity - increased osmolarity - decreased urine specific gravity - increased urine specific gravity Nursing actions: *maximum sodium replacement in 24hrs is - monitor vital signs and ensure safety 12mEq* - auscultate lung sounds Nursing actions: - provide oral hygiene and other comfort - encourage intake of sodium measures to decrease thirst - administer IV fluids (lactated Ringer's, 0.9% - monitor I and O isotonic saline) -administer dextrose 5% and 0.45% sodium - monito I and O chloride - daily weight - put patient in diuretics and low sodium - monitor vital signs and levels of diet consciousness - daily weight - Hypokalemia (potassium less than 3.5) Causes: Drugs over use (laxatives, diuretics, corticosteroids) Inadequate intake (low-potassium diet, anorexia, vomiting) Too much water (dilute K) Cushing syndrome ( increased aldosterone) Heavy loss of fluids ( diarrhea, sweating, gastric content) Signs and symptoms: EKG: - prominent U wave - ST depression - inverted/flat T - prolonged PR - dyrsryhytmias Vital signs: - weak pulse - decreased blood pressure/ orthostatic hypotension - decreased HR Neurologic: - altered mental status, anxiety, lethargy that progress to acute confusion and coma GI: - hypoactive bowel sounds - nausea - vomiting - constipation - abdominal distention - paralytic ileus can develop Muscular: - weakness, deep-tendon reflexes can be reduced, paresthesias Respiratory: - shallow respirations Nursing actions: -Potassium replacement: Increased dietary potassium or IV for severe deficitconcentrate potassium to be diluted and added to IV solutions only by a pharmacist. -Potassium is a severe tissue irritant, not to give IM or SQ. IV potassium irritant for veins, can cause phlebitis. NEVER IV PUSH- can cause cardiac arrest, only IV diluted solution drip- maximum infusion rate: 10 mEq/hr -Monitor ECG for changes -Monitor ABGs -Monitor patients receiving digitalis for toxicity. Hypokalemia increases cardiac muscle sensitivity to digoxin which may result in digoxin toxicity (cardia arrhythmia, anorexia, nausea, vomiting, disturbed color vision-yellow vision spots, headache, malaise, PR prolongation) even within therapeutic levels -Monitor for early signs and symptoms -Administer IV potassium only after adequate urine output has been established -Recommended potassium supplement intake- pills, foods- meat, dairy products, fruitsbananas, kiwi, avocados, potatoes, oranges, cantaloupe, and dried fruit- raisins have high concentrations of potassium _ Hyperkalemia (potassium greater than 5.0) Causes: Cellular movement from intracellular to extracellular Adrenla gland insufficiency (Addison's Disease Renal failure Excessive potassium intake Drugs (potassium sparing diuretics-spironolactone- and ACE inhibitors) Signs and symptoms: Muscle weakness Urine production (low or absent) Respiratory failure Decreased cardiac motility Early signs muscle twitching Rhythm EKG (prominent T wave, widened QRS, ST depression, and dysrhythmias) Nursing actions: -Monitor ECG, assess labs, monitor I and O, obtain apical pulse -Dietary teaching and imitation of dietary potassium -Administration of cation exchange resins- Sodium polystyrene sulfonate (Kayexalate) -Emergent care: IV calcium gluconate, IV sodium bicarbonate, IV regular insulin and IV hypertonic dextrose, beta-2 agonists, hemodialysis. Patiromer (chronic hyperkalemia) -Administer IV slowly and with an infusion pump Reminder: - sodium: + nervous - potassium: + cardiac - potassium and magnesium son novios (lo que hace uno el otro lo hace tambien) - sodium es la novia toxica de water, lo persigue siempre To check for hyperkalemia or hypokalemia: - 1rst action: check EKG for prolonged T or U wave Example: a patient is taking a medication to decrease the levels of potassium. What is the priority to see if the medication is effective or not? - check ECK to see if the T wave is prolonged or not Hypovolemic shock Expected findings: - increased HR - increased RR - oliguria Indications: when a patient is at risk (not in the initial state yet) - agitation - hyperventilation: your body asks for more oxygen (risk for respiratory alkalosis) *your body knows that something is wrong* When a patient is in the initial state - increase HR - increase RR - oliguria ( decreased urine output) - anxiety and agitation - confusion example: A patient in a car accident is having a hypovolemic shock: Priority: administer a blood transfusion yo replace the hemoglobin/hematocrit that the patient lost *hypovolemic shock is not only fluid volume deficit, it is low blood volume as well Stages of shock INITIAL: - cell level change from aerobic to anaerobic - MAP decreased by 10 mm Hg. - decreased BP - increased HR and RR Reversible COMPENSATORY: - increased BP - increased cardiac output - increased RR reversible if not goes into the next stage PROGRESSIVE: - compensatory mechanism start to fail - MAP decreased (10-15 mmHg) REFRACTORY: - irreversible and complete failure - MAP decreased (2-40 mmHg) Your body always pass for each stage in the same order Irreversible Priority in anaphylactic shock OPEN AIRWAYS (1 priority) - remove causative agent - epinephrine (IM) - diphenhydramine (Benadryl) IV - nebulizer medications: albuterol - endotracheal intubation Cancer treatment Nursing action (immunocompromised patients): Decrease risk for contamination - isolate the patient - do not share: bathroom, utensils, BP cuff… (any equipment) - limit the amount of visitor and coworkers inside the room and the amount of time - give food at room temperature (hot food can cause nausea and vomiting) Skin care for patients in radiation: Skin tend to be dry - use water-based lotion (no chemical or perfumes) Levels of prevention (cancer) Primary: reducing the risk of disease through health promotion and risk reduction strategies - lifestyle modifications: quit smoking, exercise, healthy food - use sunblock if sun exposure - wear mask if chemicals exposure - wash vegetable and fruits before eating - supplements (omega 3) - immunization Secondary: Screening and early detection activities that seek to identify precancerous lesions and early stage cancer in individuals who lack signs and symptoms of cancer - mammography - colonoscopy - prostate screening - fecal occult blood test - rectal exam Tertiary: Efforts focus in monitoring for and preventing recurrence of the primary cancer as well as screening for development of secondary malignancies in cancer survivors - be compliant with treatment - follow up treatment to prevent complications in cancer survivors Findings in fluid overload Expected findings Vital signs: - tachycardia - bounding pulse - hypertension - tachypnea - increased central venous pressure Neuromusculoskeletal: - weakness - visual changes - paresthesias - altered level of conciseness - seizures (if severe) GI: - ascites - increased motility - liver enlargement Respiratory: - crackles - cough - dyspnea Other signs: - peripheral edema - weight gain - distended neck veins - increased urine output - skin cool to touch with pallor Proxy and advance directives Advance directives: Written documents that allow competent people to document their preferences regarding: - use or abatement of medical treatment at the end of life - specify their preferred setting for care - communicate other valuable insights into their values and beliefs Proxy - appointment and authorization of another person to make medical decision on behalf of the person who created the advance directive when she/he can no longer speak for herself/himself *can be anyone Hospice and palliative care Hospice - less than 6 months of life - prepare patient and family for eminent death - caregivers and volunteers - palliative care can be provided in hospice - do not prolong life -people with serious illnessess - aim to relieve pain - provide comfort - improve quality of life for patients and families * Similarities Palliative care - life expectancy is more than 6 months - people at any stage of a serious illness but can still do normal life activities - attempt optimize and prolong life
