Flashcards: Adv MS1 Exam 1

1. Any self-regulating process by a biological system to maintain stability.

2. Adjusting conditions that are optimal for survival.

5. 5 Functions: Temp, BGL, BP, Toxins, pH

1. Balance of fluids and electrolytes, body is making constant adjustments to maintain balance.

2. Recognize changes early. May be obvious or subtle.

3. Timely assessments important.

1. Adults approx 60% of weight is fluid

2. 2/3 = intracellular

3. 1/3 = extracellular

4. Plasma is intravascular, including lymph

5. Transcellular is any fluid in epithelial-lined spaces such as pericardial, CSF, synovial, pleural, intraocular.

1. Regulate temperature

2. Moisten tissues in eyes, nose, mouth

3. Protects body organs and tissues.

4. Carries nutrients and oxygen to cells.

5. Lubricates joints

6. Lessens burden on kidneys and liver by flushing out waste.

7. Dissolves minerals an nutrients for accessible to your body.

1. Intake: 2500mL per 24 hours

2. Output: Sensible loss: 500-1000mL per 24hr, Insensible loss: 1500mL per 24 hr

3. Sensible can be measured and tracked.

4. Insensible is unable to track/measure.

1. Kidneys: average output 1mL/kg/hr

2. Skin: sweat can be affected by fever, exercise, burns more fluid loss

3. Lungs: give off fluid in vapor, RR, dry/wet environment, exercise

4. GI tract: lose about 200 mL daily in GI tract, diarrhea or surgery

Diffusion – particles move from area of high concentration to low concentration​

Osmosis – water particles move from area of high solute concentration to low concentrations​

Filtration – response to pressure, hydrostatic pressure exerted on walls of vessels pushes fluid inside cells​

Osmotic pressure – pressure exerted by solutes, minimum pressure which needs to be applied to a solution to prevent the inward flow of its pure solvent across a semipermeable membrane, pulls fluid out of intracellular into extracellular

1. First - normal fluid distribution

2. Second - Excessive accumulation of fluid in interstitial spaces. (Edema, fluid collecting in-between cells)

3. Third - Fluid shifts from intravascular to a "third" transcellular space (serous cavity), ascites, pleural infusions, *can be dehydrated with fluid spacing

Hypothalamic Regulation: changes in blood osmolality and triggers thirst or antidiuretic hormone (ADH) release in response to imbalances.

Pituitary Regulation: pituitary gland, specifically the posterior pituitary, in releasing antidiuretic hormone (ADH) to conserve water by reducing urine output when the body's water levels are low.

Adrenal-Cortical Regulation: relates to the influence of the adrenal cortex, which secretes aldosterone to increase sodium reabsorption and water retention in the kidneys, thus helping maintain water balance.

Renal System: regulating water balance by filtering blood, reabsorbing essential water and solutes, and excreting excess water as urine, under the control of hormones like ADH and aldosterone.

Cardiovascular System: water balance regulation by ensuring adequate blood circulation to maintain blood pressure and transport hormones like ADH and aldosterone, which affect water reabsorption in the kidneys.

GI System: water balance regulation by absorbing water from ingested fluids and eliminating excess water through feces, contributing to overall fluid balance in the body.

a hormone produced by the heart in response to stretching of the heart muscle cells, especially in the ventricles. It plays a crucial role in regulating fluid balance and blood pressure. When there is an increase in blood volume or pressure in the heart, the heart releases BNP to promote natriuresis, which is the excretion of sodium and water by the kidneys. This helps to reduce blood volume and lower blood pressure.

1. Hypovolemia: fluid volume deficit, loss of ecf exceeds intake, increased osmolality, concentrated labs, dehydration

2. HYPERvolemia: fluid volume excess, abnormal retention of water and sodium led to expansion of ecf, decrease osmolality, dilute labs.

1. Hypervolemia – high intake low output, HTN, tachyC, wob inc, fluid in pleural space (crackles), High Na diet, edema/moist skin, ​HCT lower (diluted)

2. Hypovolemia – low intake, low output, hypoBP, tachyC, inc RR, confusion, Not enough fluid intake, dry poor skin turgor, thirst, thready pulse, HCT elevated

3. To start to have peripheral edema = 5 Liters gains​. Puffy edema = 10 Liters gain

1. Electrolytes dissociate or split into ions when placed into water.

2. Ions - electrically charged.

3. Cations - positively charged (Na, K, Ca, Mg)

4. Anions - negatively charged (HCO3, Cl, PO4)

5. ECF - main cation is Na and main anion is Cl-.

6. ICF - main cation is K+ and main anion is PO4-.

1. Determine those at risk / manage underlying cause.

2. Assessment: VS, HR, rhythm, LOC, i/o, muscle strength and movement, weight

3. Lab (serum and urine): electrolytes, osmolality, bun/creatine, BNP (elevation indicates need to removal excess fluid)

1. Healthy: VS wnl, AxO4, equal i/o, strength/movement wnl, stable weight

2. Abnormal: tachycardia, dysthymias, irregular rhythm, confusion/disorientation, weak, muscle twitching, seizure and unresponsiveness. Inadequate or excessive output. Weight gain or loss.

3. Confusion and weight gain first clues of abnormal electrolyte imbalance.

1. K = 3.5-5 mEq/L

2. Regulates ICF

3. Promotes nerve impulse transmission

4. Skeletal, smooth, and cardiac muscle contractions

5. Acid/base balance: hydrogen ions exchange with potassium ions in ICF.

6. Allows glycogen to be deposited in muscle and liver cells.

7. Excess K eliminated, 80% kidneys daily, 20% bowel movements and sweat.

8. Daily replacement K for those on wasting diuretics.

1. K < 3.5 mEq/L

2. Decreased intake

3. Increased renal excretion / kidney disease

4. Movement of K from ECF to ICF (glucose metabolism)

5. GI disturbances (diarrhea/vomit)

6. Meds - (insulin, diuretics, laxatives, digoxin)

7. Low Mg levels (when mg or k gets low, lower together)

1. Kalemias do the same as prefix, except HR and urine output.

2. Usually appears at < 3.0 mEq/L

3. Cardiac arrhythmias and EKG changes.

4. Decreased DTR.

5. Polyuria and nocturia

6. Priority: Lethal cardiac dysrhythmias, cardiac arrest, coma

1. Oral / diet replacement (fruits, bananas, spinach, salt substitutes are high in K)

2. Salt sub w/ K

3. Parenteral replacement: can only give 10mEq/hr , peripheral IV potassium must be diluted usually 1liter of fluid, concerns with burning swelling irritation.

1. K > 5.0 mEq/L

2. increased intake

3. impaired excretion (renal failure, dehydration)

4. Movement from ICF to ECF (cell lysis, cancer/burns)

5. Acidosis

6. Potassium sparing diuretics

7. Adrenal insufficiency (low aldosterone, which promotes the excretion of dietary potassium)

1. Kalemias do the same as the prefix except for HR and urine output.

2. EKG changes, irregular pulse, arrhythmias

3. Anxiety, irritability

4. Muscle weakness, flaccid paralysis, paresthesia

5. GI: abnormal cramping, diarrhea

6. Metabolic acidosis

7. Priority: V fib, respiratory arrest, cardiac arrest

1. Prevent by identifying those at risk / identify underlying cause

2. Decrease oral / parenternal intake

3. Meds: diuretics, kayexalate (potassium binding, works in Large intestine)

4. IV insulin with glucose forces K into cells.

5. Calcium gluconate IV to decrease cardiac excitability

6. Dialysis

1. 8.2 - 10.2 mg/dL

2. 99% located in skeletal system

3. Daily intake needed

4. Maintains bones and teeth

5. Essential component of nerve/muscle/cardiac contractions

6. Blood clotting: converts prothrombin to thrombin

1. < 8.2 mg/dL (Vit D and Ca coincide)

2. Renal failure

3. Decreased intake, malabsorption, Vit D deficit

4. Loss of Ca: alcoholism, excessive diarrhea, aggressive diuretic therapy

5. Endocrine disorders and parathyroidectomy

6. Low Mg (reduces amount of PTH released)

7. Hyperphosphatemia (inverse relationship with Ca)

8. Meds - aminoglycosides, anticonvulsants, loop diuretics, bisphosphonates (tx osteop)

1. Calcemias do the OPPOSITE as the prefix, no exceptions.

2. Below 7 is critical, tetany and stridor, 6 can cause death.

3. Convulsions: involuntary jerking/contractions/spasms- cramps and tetany.

4. VS, arrhythmias, hypotension, ECG

5. Seizures

6. Trousseau's sign - bp cuff, Chvostek's sign-face

7. Increased peristalsis and diarrhea

8. Numbness and tingling of lips and extremities

9. Osteoporosis

10. Priority: seizures, laryngospasm w/ stridor, ventricular tachycardia

1. Correct level and treat cause, recheck q4-q6.

2. Administer IV calcium gluconate.

3. Increase dietary intake of Ca and Vit D.

4. Monitor EKG

5. Validate albumin level - if low may not need calcium. (when albumin is low, skews Ca results, ionized Ca level for more accurate results)

1. Increased intake

2. Metastatic disease processes affecting bones

3. Endocrine disorders: hyperparathyroidism, adrenal insufficiency

4. Kidney disease, decreased excretion

5. Meds: Antacids, Thiazide diuretics, glucocorticoids

1. Calcemias do the OPPOSITE as the prefix, no exceptions

2. Weakness - can be profound

3. Lethargy, confusion, personality changes

4. Decreased reflexes

5. Constipation

6. N/v

7. Bone pain, fracture

8. Polyuria, polydipsia, calcium stones

9. ECG changes - arrhythmias, bradycardia, shortened QT/ST intervals

10. Priority: coma, death

1. 1.6-2.6 mEq/L

2. 1/3 bound to proteins

3. Essential for metabolism of carbs and proteins

4. Regulates neuromuscular function and electrolyte balance

5. Cardiovascular: acts peripherally to produce vasodilation and decrease peripheral resistance

6. Balances phosphorus and calcium levels.

1. < 1.6

2. Symptoms usually start at <1.3

3. Alcoholism

4. Prolonged GI issues: diarrhea, starvation, vomiting's, malabsorption

5. NG tube with prolonged suction

6. Acute pancreatitis

7. Concurrent hypokalemia not responding to replacement

8. Limited intake or increased renal loss

9. Prolonged use of PPIs lead to decreased absorption of Magnesium

1. Mag OPPOSITE of prefix without exceptions

2. Neuromuscular irritability (trousseau and chvostek)

3. Tachycardia, HTN

4. hyperactive tendon reflexes

5. Muscle cramps

6. Psychological changes

7. Priority: Seizures, dysrhythmias (torsades de pointes)

1. Administer Mag PO or IV

2. IVP during code (usually 2grams)

3. Increase dietary intake

4. Concurrently correct other electrolyte imbalances.

1. > 2.6

2. renal failure

3. increased intake to manage eclampsia during pregnancy

4. Hyperparathyroidism

5. Hypothyroidism

6. Excessive intake of antacids or laxatives (esp w/ renal insufficency)

1. Mags do OPPOSITE of prefix, no exceptions

2. Muscles too relaxed and weak

3. Vasodilation = hypotension

4. Flushed, warm skin

5. Lethargy, sedation

6. Decreased respirations

7. Decreased deep tendon reflexes

8. Priority: Paralysis, respiratory / cardiac arrest

1. Avoid / decrease Mg containing foods

2. Administer Calcium gluconate.

3. Respiratory support

4. Good renal function- promote excretion (hydration)

5. Impaired renal function = dialysis.

1. 135-145 mEq/L

2. Regulation / maintenance of fluid balance

3. Maintains body fluid osmolarity

4. Promotes neuromuscular response: transmission of nerve and muscle impulses

5. Regulates acid-base balance: combines chloride and bicarbonate to alter pH.

1. Excessive loss of Na or excessive GAIN of water

2. Excessive skin loss: sweating

3. GI: diarrhea, vomitting, NG suction

4. Meds: diuretics, meds that cause water retention

5. Trauma: blood loss, draining wounds

6. Hormonal: SIADH (fluid ret)

7. Hypotonic IV solutions (0.45% NaCl)

1. Neuro: HA, confusion, irritable, restless, seizures, coma

2. GI: diarrhea, abd cramps

3. Hypotension (hypovolemic)

4. Muscle weakness, fatigue

5. Priority: seizures, coma, neuro damage

1. Treat underlying cause

2. Sodium replacement- mild: po, ng or iv (lactated ringers or .9% NS), DO NOT increase more than 12 mEq/L in 24 hr to avoid neuro damage due to demyelination. Severe: hypertonic fluids (3% NS) - GIVE SLOW and CLOSE OBSERVAITON, considerations for elderly and cardiac pts.

3. Fluid restriction

4. Nursing: strict i/o's, daily weights, neuro assessments

1. Water deprivation or loss

2. Hyperosmolar tube feeds and lack of free water

3. Insensible water loss - burns/wounds or hyperventilation

4. Excessive sodium intake without water

5. Excessive IV intake

6. Diabetes insipidus

7. Medications: steroids, antibiotics, sodium bicarb, cough meds

1. Thirst

2. N/v, anorexia

3. Rough, dry swollen tongue

4. If dehydrated: tachycardia, orthoBP

5. Increased body temp

6. Dry skin, poor skin turgor

7. Decreased LOC, agitation, lethargy

7. FRIED: flushed skin/fever, restless, increased BP, edema, decreased urine output.

8. Priority: seizure, coma, neuro damage

1. Gradually lower Na w/ IV hypotonic solutions (0.45% NS)

2. Diuretics - induce water and Na excretion

3. Monitor I/O, daily weights, urine specific gravity

4. Neuro assessments.

1. Cardiac = potassium

2. Neuromuscular = Ca and Mg

3. Neuro = Sodium

1. Process of regulating pH, bicarbonate and carbon dioxide concentration of body fluids and gases.

2. pH indicates hydrogen ion H+ concentration.

1. 1st line: Buffer system - acts fast to adjust hydrogen concentration

2. 2nd Line: Respiratory system - acts fast minutes to hours, adjusts pH by using carbon dioxide upon expiration, slows/increases breathing.

3. 3rd Line: Renal system - acts slow, days to compensate, affect pH by absorbing/generating Hydrogen.

Normal Values:​

pH:  7.35-7.45 ​

PaO2: 80-95 mmHg on room air​

PaCO2 (carbon dioxide): 35-45​

HCO3 (bicarb): 22-26 mEq/L​

Base Excess: -2 - +2​

SaO2 – > 95%

Base excess between observed and normal buffer system, number required to return pH to normal range

Measure ABGs through ART line

pH returns to normal range​

The lungs compensate for metabolic system​

Almost immediate​

If bicarb increases  hypoventilation occurs​

If bicarb decreases  hyperventilation occurs​

The kidneys compensate for the lungs​

Kidneys slower – up to 48 hours​

If CO2 increases  kidneys conserve bicarb​

If CO2 decreased  kidneys excrete bicarb 

1. Primary factor: HYPOVENTILATION retaining CO2 from under ventilation.

2. Pulmonary diseases

3. Oversedation or drug OD

4. Obesity

1. Oversedation, hypoxia, dizzy, drowsy, confused, HA, warm flushed skin

Treat the cause:​

Intubate and ventilate to blow off CO2. ​

Narcan if over sedated​

Suction​

Wake them up, get them moving, increase respiratory rate​

Sit in semi-Fowler’s, turn-cough-deep breath​

Turn up the vent​

If Pulmonary Edema and Heart Failure – Lasix

1. Primary: HYPERVENTILATION

2. Overbreathing on a mechanical vent or secondary to anxiety/fever.

3. Response to hypoxemia in some pulmonary disorders make patient hyperventilate.

1. Tachycardia, fast breathing, dysrhythmias, lethargic, confused, HA, dizzy, n/v, epigastric pain, numbness tingling, hyperreflexias

Treat the cause: ​

DECREASE the respiratory rate, SLOW down breathing​

Adjust ventilator settings (decrease RR)​

Breathe into a paper bag, hold breath​

Treat the anxiety, provide emotional support​

Do not provide rescue breaths too fast during a code

1. Acid accumulation or bicarbonate loss

2. Lactic acidosis - occurs with shock or tramuma, sepsis

3. DKA

4. Renal failure

5. Aspirin OD (salicylates)

6. Starvation

7. Ineffective metabolism of carbs

s/s resp distress, kussmals breathing, hypotension, dysrhythmias, drowsy, confusion, HA, warm flushed skin, n/v/d, Abd pain

TREAT THE CAUSE​

NaHCO3 IV​ (sodium bicarb)

Diabetic Ketoacidosis – Insulin and hydration​

Renal Failure – dialysis, low protein/high calorie diet

1. Retention of base or removal of acid from body fluids.

2. Loss of acid: vomitting, NG suction, gastric damage

3. Eating baking soda/ infusion of excess NaHCO3

4. Hypokalemia, K+ depeleting

5. Diuretics

6. Burns

7. Antacids OD

8. Tx the cause, may need to replace K or give Diamox to help excrete bicarb

Inc wob, resp distress, tachycardia, dysrhythmias, dizzy ,drowsy , confused, HA, n/v loss of appetite, cramping muscles/tremors

TREAT THE CAUSE​

Increase excretion of HCO3 (Diamox)​

Replace K+​

Reverse overdose

1. 24 g - pediatrics, small veins

2. 22 g - pediatrics, small adults, poor veins

3. 20 g - standard adult size, best for blood admin

4. 18 g - large adult size for trauma, rapid fluid resuscitation, blood products, surgery

5. 16 g - very large adult size for trauma, fluid resuscitation.

6. 14 g - rarely used, extremely large catheter.

1. EMLA cream - topical cream left on skin for 1 to 4 hours prior to procedure. Lidocaine 2.5% and Prilocaine 2.5%, Apply cream, cover with tegaderm, wait 1-4 hours, remove cream, start procedure.

2. SQ lidocaine - 1% lidocaine is injected SQ or intradermally as a wheal. Effect in 60 seconds. Lasts 30 to 45 mins. Start IV at wheal site.

1. Site must be changed every 72 hours. (1 week,)

2. Change tubing every 96 hours, every 24 hours if TPN running.

3. Site assessment: skin intact, no drainage, no redness, flushing/blood return. Q4 checks. Flush at beginning of shift.

4. Label lines.

5. Field sticks change out 24 hrs.

1. Looks like a PICC on outside but is NOT a central line.

2. Used as a "longer" peripheral access, put in by RN or PICC nurse.

3. Use for 3-4 weeks.

1. Long term use

2. Place sterilely in large central vein

3. Inpatient: dressing changes are sterile

4. Used for medications, fluids, blood draws and blood transfusions.

5. Jugular, subclavian, femoral, superior vena cava veins

6. Tip located in the SVC *confirm placement

1. patients receiving certain meds or infusions: chemo, tpn, long term antibiotics(endocarditis, osteomyelitis), vasopressors (dopamine, levophed).

2. Pts with no other access choice

3. Pts receiving multiple infusions simultaneously (ICU)

4. Pts who need central venous pressure monitoring (CVP). monitors fluid volume levels (high = hydrated, hypervolemic) (low = dehydrated, hypovolemic)

1. Triple Lumen Central Line

2. Peripherally Inserted Central Catheter (PICC)

3. Implanted Port

1. Non tunneled enters directly into the vein

2. Tunneled, cuffs at exit, skin adheres to cuff securing it.

1. ICU pts requiring multiple infusions. Trauma pts,

2. Replaced every 7-10 days. May stay in longer if pt is fragile requiring hemodynamic monitoring. Assessed everyday if can be removed due to infection risk.

3. Central Access, blood, vasopressors, heparin drip, continuous fluids

1. Used w/ pts limited peripheral access. Long term IV med use. Continuous admin of vesicants (chemo pts)

2. 2-6 weeks, up to a year potential.

1. Efficient access for med administration. requiring long term meds. Parenteral nutrition administration.

2. Ports can stay in for years.

1. Catheter is placed into the bone with a handheld driver and delivers fluid and medication directly into the bone marrow.

2. Placed in proximal humerus, proximal tibia.

1. Dressing and evidence based practice:

2. Transparent dressings - NOT gauze

3. Change dressings Q week or per institution policy or saturated with drainage

4. Defatting the skin with alcohol prior to application. (dry skin)

5. Antimicrobial chlorhexidine "biopatch" under dressing (replaced every dressing change)

6. Stat locks SHOULD replace sutures.

7. For PICC lines use >10 mL syringe when accessing, flush with 20 mL after blood draws. (pressure concerns)

8. Rule: if the line went in under sterile conditions, change the dressing under sterile conditions.

1. hand hygiene

2. maximal barrier precautions

3. CHF skin antisepsis

4. Optimal site selection (avoid femoral in adults, yeast infections)

5. Daily review of line necessity

1. Perform freq asessments

2. Cleanse hubs prior to use 10-15 seconds

3. Sterile insertion and adhere to sterile technique for dressing changes

4. Alcohol based catheter caps and biopatches

5. Use clamps

6. Dressing changes q7 days or prn (wet, soiled, disloged)

7. Sutures

8. Mask pt and RN

9. Bathing

10. Sterile devices to access caths

11. Staff education.

1. Frequency per hospital and type of central line

2. NS .9%, 99% of the time

3. Ports: NS and Heparin (afterwards)

4. Flushing techniques

5. CAPS

6. Intermittent pressure flushes - push pause method

1. Technique of removal: physician, coagulating testing before removal (ensure clotting intact), position insertion site below the patient heart level or Trendelenburg if tolerated. Have pt bear down to prevent air embolus. Cover site with pressure dressing.

2. RNs can remove/place PICCs with special training.

3. Assessment of cath: Tip intact, length, sending tip for culture

1. Infection

2. Occlusion (thrombotic or nonthrombotic)

3. Thrombus (non compatible meds)

4. Infiltration, extravasation(med outside vein), phlebitis (irritation)

5. Chest pain / cardiac arrhythmias

6. Device malfunction

7. Air embolism

1. Bacterial skin infection

2. Redness, pain, swollen, sometimes shiny

3. Antibiotics tx

4. Line removal options - early identification can potentially save the line

1. Clot can happen within the actual catheter

2. Clot around the catheter in the vein.

3. Potential to surgically removal fibrin sheath.

1. Most common drug is Alteplase (tpa), aka Cathflo or activase, powerful antithrombolitic, dosed in 500 mcg/mL (1mL)

2. 70-80% metabolized by oxidation during single pass through lungs

3. Half life of 5-10 minutes

4. Use for indwelling or infusions.

1. Top 5 offenders: Bicarb, Lasix, Haldol, Calcium, Dilantin

2. Use micromedex to know combability.

1. IV catheter has slipped out of the vein and is infusing into the tissue.

2. Skin is cool, puffy, blanches, usually painful, swollen

3. Tx: remove catheter, assess for circulation, elevate arm, warm compress. Review any special considerations for the fluid/drug that has infiltrated.

1. Tissue irritation, ischemia, necrosis

2. Tx: aspirate med, instill antidote

3. Assess and measure daily, photographs

4. Involve dermatology and plastic surgeon

5. Treatments medication dependent.

1. Redness at cath tip and along vein from poor blood flow around the device or caustic solution infused.

2. Nursing interventions: remove the device, apply a warm pack, notify MD.

3. Restart the IV in a bigger vein or use a smaller cath to allow blood flow around IV cath.

1. Most lawsuits filed against nurses with regards to iv therapy had to do with cases of infiltration or phlebitis.

2. Good documentation is key, date time site, type of iv, routine checks, infusion types, blood return.

3. Check at beginning of each shift, check prior to each medication.

1. turn head, cough, position changes for trouble shooting lab draw, flushing.

2. Considerations: flush amount, waste amount.

3. Cathflow potentially if still wont work, check placement if still doesn't work.

4. Waste amount may need to be more if certain meds stick to inside of line.

1. RBGL

1. red - blood bank

2. blue - coagulation

3. green - electrolytes

4. Lavendar - hematology

5. Gray - glucose

1. D/c tubing, put sterile cap on it and hang on IV pole

2. Flush IV with 10 mL sterile saline

3. If there is a clamp on the IV pigtail, clamp it

4. Secure tubing on patient

5. Reconnect: scrub the hub, flush IV, reconnect.

1. Basal rate - set continuous rate

2. Bolus dose / demand dose - best pain control is the type that the patient has control over.

3. Considerations- oversedation, appropriate use, frequent assessment of pain and use.

1. For child birth, post op surgical procedures

2. pros: pain control, non-sedation, steady direct state of pain control

3. Cons: Spinal headaches if miss, doesn't affect full area, HA, hypotension

1. One of the things that separates cc nursing from m/s nursing is the ability to hemodynamically monitor pts.

2. Arterial Lines

3. Central Venous Pressure (CVP) monitoring

4. Pulmonary Artery (PA) lines

1. Hemodynamic monitoring allows the clinician to assess pressures, fluid status and cardiac function in critically ill pts.

2. RN can monitor a pts hemodynamic status continually. Invasive lines and transducer turns pressures into wave forms.

1. MAP - mean arterial pressure

2. Arterial blood gases ABGs

3. Systemic blood pressure

4. Continuous waveform

5. used in icu, shock sepsis trauma

6. common insertion sites: radial and brachial

1. You must zero all pressurized lines when initiating therapy, when the cable comes disconnected and per hospital policy (usually once per shift)

2. The transducer must be placed at a level equivalent to the right atrium for all hemodynamic measurements. This point is called the PHLEBOSTATIC AXIS and is located at the mid-chest line, fourth intercostal space. MCL-4

1. The standard of practice is to change art line dressing, tubing, and pressure bag every 72-96 hours, depending on policy.

2. Dressing change is sterile.

3. RN assesses distal pulse and color, waveform, and correlation with manual BP cuff every shift.

1. CO = HR x SV, quantity of blood pumped by each ventricle per minute

2. Normal values: CO = 4-6 L/min

Cardiac index (CI) = 2.2-4.0 L/min/m2 (CO indexed to BSA), based on patient size, lets us know if pt is pumping enough blood

3. HR = 60-100 beats per minute

4. Stroke volume (SV) amount of blood pumped by each ventricle in one cardiac cycle or each heart beat. SV = 50-110 mL ejected with each heart beat.

1. Stroke volume (SV) is amount of blood ejected with each heart beat

2. SV = CO / HR

3. ex if co = 4.0 l/min and hr = 100, SV = 4/100 = 40mL/min

1. EF is the ratio of stroke volume to end-diastolic volume

2. The amount of blood squeezed out of the LV compared to the amount of blood left in the LV

3. Measured as a percentage

4. If LV end diastolic volume is 100 mL and SV is 60 mL that means ejection fraction is 60%.

5. Need min of 10% to live, 20% suffering

1. Preload: what is the pts volume status and filling pressures? (hyper vs hypovolemic)

2. Afterload: What kind of force does the heart have to work against to get blood out (vasodilation = afterload dec, sv inc vs vasoconstriction = afterload inc, sv dec)

3. Contractility: is heart able to squeeze effectively?

1. Preload is the maximal stretch of the cardiac muscle prior to contraction

2. A filling pressure, it represents the amount of fluid that is presented to the heart.

3. Preload is measured during diastole, when the MV and TV valves are open so it is assumed that the pressure in the ventricles is equal to the pressure in the atria.

1. CVP is a measurement of fluid status, equal to the amount of blood found in the right heart at the end of diastole. It tells you one simple thing:

2. If pt is wet or dry

3. Normal healthy person CVP ranges from 2-6

4. Less than 2 = patient is dry/dehydrated

5. Greater than 6 = patient is wet/fluid overloaded

6. Numbers you need to know: 2 = dry, and 20 = fluid volume overload

1. CVP can be monitored through any thoracic central line (usually SC or IJ)

2. CVP can be monitored through a single transducer system or in conjunction with the PA monitoring

1. CHF pt has fluids running at 125 mL/hr all night. When you check the CVP, you get 18.

2. What does the number mean? fluid overload

3. What treatment? Stop fluids, diuretics.

1. Hemodynamic values obtained are used to evaluate preload, afterload, and contractility (ventricular function)

2. Indications: shock states, evaluating vasoactive drip effects, assessing cardiac function.

1. Crystalloid- isotonic or clear fluids, hypotonic/hypertonic, used for fluid replacement and maintenance. (hydrate, esp isotonic fluids)

2. Colloid - blood products, TPN, albumin (stay in blood vessels, expand volume)

1. Isoperfect - no fluid shifts with isotonic fluids. Balanced to look like blood as much as possible

2. Builds blood volume, hydrating.

3. Ex: NS 0.9%, LR (used more with burns, trauma, acute blood loss)

4. Same osmolality and water concentration as blood in body.

1. Hypotonic - draw fluid into the cells. usually low sodium concentration (0.45% NS, 2.5% Dextrose)

2. Hypertonic - fluid escapes cells (shrink by osmosis), contain higher concentration of solutes than fluid in cells (ICF), high osmolality (NS 3%)

3. Infuse slowly

1. Vesicants, irritants

2. Highly irritating infusions will cause injury to the vein endothelium.

3. Can cause chemical phlebitis, actual tissue damage, thrombosis and necrosis.

4. Should be given through a central line if possible

5. ex: chemo, dopamine, amphotercin

1. Dextrose 5-10%, amino acids, electrolytes, minerals, vitamins, fat emulsions, short term, <3 weeks of therapy.

2. Provides 1300 to 1800 cals a day

3. Can be given through peripheral IV - has most complications and is LEAST DESIRABLE form of nutrition.

1. total parenteral nutrition

2. dextrose 20-70%, amino acids, electrolytes, minerals, vitamins, fat emulsions, Long term > 3 weeks of therapy

3. 2000 to 2500 cals a day

4. Only given through central line.

1. Monitor BS q6, cover with SS insulin

2. prevent infection- aseptic technique when dealing with tubing, bag changes. Change tubing/bag q24 hrs. Assess iv insertion site for for s/sx of infection

3. Do not change prescribed rate on TPN

4. If TPN runs out, hang d10w

5. Monitor daily weights, i/o, electrolytes

6. Double check RX with another RN

7. only run on an IV pump w/ inline filter.

1. Packed RBCs - most common, used for anemia, requires type and crross, must be ABO compatible, must be in patient within 4 hours.

2. Whole blood - contains RBCs, plasma, wbcs, platelets, requires type and cross, must be ABO Identical.

1. Fresh frozen plasma - used to replace coag factors, DIC, liver disease, coumadin reversal, coagulopathies, cannot be re-frozen, must be given within 6 hrs, ABO testing to verify A or B antibodies only

2. Platelets - used to tx thrombocytopenia and bleeding. Usual dose 6-10 units. ABO compatibility is preferred, but can given mismatched platelets in emergency situations.

1. Not to be given by students

2. Procedure specific to institution standards, require TWO RN's for check.

3. Verify MD order and pt consent

4. Blood typing and crossmatching the recipient.

5. Equipment - guage needle; sset; filters; warmers.

6. Prepare pt

7. Obtain blood product from blood bank

8. d/c all blood tubing, nothing left behind.

1. Must be followed precisely

2. Double check all numbers carefully (unit#, blood bank id, MR#, pt ID)

3. Monitor pt carefully with VS during 15 minutes to one hour.

1. Biological reactions - acute hemolytic reactions, delayed hemolytic reactions (14 days after), nonhemolytic reactions, allergic reactions( inc in billirubin), acute lung injury (ARDS), graft versus host disease(bone marrow transplants)

2. Nonimmune reactions - circulatory overload, potassium toxicity, hypothermia, hypocalcemia, bacterial contamination, transmission of infectious disease.

1. Terminate the transfusion, d/c the blood and blood tubing and set aside.

2. Maintain patency of the IV cannula by hanging new tubing with NS running.

3. Notify the physician and blood bank

4. Implement interventions as indicated.

1. The recommendation is to only transfuse PRBC's if the H/H is 7/21 AND the patient is symptomatic.

1. Liver- blood filter, detoxifies, produces clotting factors, stores ADEK vitamins, creates vile, important in fat,carb,protein metabolism, largest abdominal organ,

2. Gallbladder - stores bile secreted by liver.

3. Duodenum- mixes food with enzymes in digestion process, secretes amylase/lipase/bile from other organs.

4. Pancreas Head- produces enzymes amylase/lipase. Exo/endocrine functions. Endocrine- insulin secretion and glucagon. Exocrine- secretion of amylase/lipase for digestion.

5. Right Kidney / Adrenal Glands, Transverse colon

1. Ascending colon

2. Appendix

3. Right reproductive organs

4. Major blood vessels and nerves (GI is % of bloodflow)

1. Stomach

2. Spleen - storage site for blood, part of immune system

3. Pancreas (tail)

4. Transverse and descending colon

1. sigmoid, left reproductive organs

2. major blood vessels/nerves

1. Hx of present illness

2. Dyspepsia most common symptom of any gi issue, includes pain, belching, heartburn

3. GERD- chronic gerd assess for chronic cough (sign of aspiration of stomach contents)

4. Marijuana use, n/v, weight gain or loss, dirrahea/constipation, appetite

1. allergies

2. current meds

3. alcohol/drugs/tobacco use

4. nutrition

5. Oral health - toothbrushing, dental visits, lesions, dentures

6. Access to food/ability to prepare

7. Exposure to infectious disease

8. Stress

9. pregnancy

10. family history

1. Characteristics of stool: steatorrhea (oily stool, in pancreatitis, malabsorption of fat), light gray or clay colored, stool with mucus threads (crohns, ibs, uc), small dry rockhard, loose watery stool

2. Weight, height, BMI

3. Cardiac, neurological, endocrine, and psych disorders

4. Autoimmune disorders

5. Oral cavity

6. Labs - cbc (rbc,wbc,electros,albumin-protein/nutrition, prothrombin times, LFT)

Table 38-3 pg. 1213

1. Digestion and absorption of nutrients

2. Constipation

3. Decreased new cell growth rate

4. Heartburn - weakened stomach spinchter

5. Cancer rates inc w/ age

6. Ca regulation and changes and bone loss

1. General observation - apperance and beahvior (remove dentures and inspect under)

2. inspection

3. auscultation

4. Percussion

5. Palpation

1. provide privacy

2. assist/allow pt to empty bladder

3. supine position

4. expose abdomen

5. warm hands and stethoscope

6. assess painful areas LAST

1. Overall observation

2. flat? distended? symmetrical

3. Skin color

4. Scars

5. Peristalsis

6. Do NOT press on any visible pulsations

7. Cullen's sign - intrabd bleeding, or leakage of pancreatic enzymes

8. Grey turner's sign - blueish discoloration in flank region, indicates bleeding

9. Spider angiomas- Liver issues, cirrhosis, hepatitis, autoimmune disorder causing dilated blood vessels.

1. Auscultate before you palpate

2. Use diaphragm of stethoscope

3. Hypo, Normal, hyperactive

4. Used to determine character location and freq of bowel sounds

5. Can also be used to identify vascular sounds- bruits in aortic, renal, iliac, and femoral arteries

6. Absent previously defined as no sounds in 5 minutes per quadrant, now defined as 1 minute with no sounds per quadrant.

1. Used to assess the size and density of abdominal organs

2. Can detect presence of air-filled, fluid-filled or solid massess

3. Tympany = sound of air in gut

4. Resonance = lower pitched and hallow

5. Dullness = flat sound without echoes: liver, ascites, distended bladder, spleen

1. light 1 cm, deep 5-8cm

2. Always assess tender areas last

3. Watch patient's expression

4. Tenderness and Massess are abnormal

5. Percussion can confirm palpation findings

6. Firmness or muscle rigidty may be a sign of intraabdominal bleeding or a surgical belly - STOP palpation.

1. Erythema, edema, and ulcerations of the oral mucosa.

2. Red, shiny, or swollen mouth and gums

3. Sore and painful

4. Risk factors: alcohol, tobacco, mouthwashes, drug sensitivity, vit deficiencies (folate, zinc, iron). Side effect of chemo, smoking.

5. Can occur anywhere in GI tract, horribly painful

6. can cause airway obstruction, dysphagia, painful to eat/drink

1. A portion of the stomach protrudes upward through the esophageal hiatus with widening of the hiatal tunnel allowing stomach acid and enzymes to come into contact with esophageal tissue (barrett's esophagus)

2. Risk factors: Smoking, hx of pregnancy, lack of fiber, straining during bowel movements, obesity, strenuous physical activity

3. endoscopy to confirm hernia, x ray, EGD, barium swallow

1. Patho: chronic disorder, retrograde flow of GI contents from stomach into esophagus, with or without tissue damage. One of the most common western disease with 10-20% effected.

2. Management: antacids (increase gastric pH), histamine receptor antagonists (decrease acid production), prokinetic medications (increase gastric emptying), proton pump inhibitors (decrease gastric acid production), small number of pts may require surgery.

3. Complications: barret's, malignancy, fibrosis/scarring, strictures

4. RF: pregnancy, obesity, old age, overeating, muscle atrophy, alcohol

1. patho: can occur in any part of mouth or throat (curable if discovered early)

2. RF: tobacco or nicotine use, excessive alcohol, HPV inf, and hx of previous head/neck cancer

3. CM: few or no symptoms in early stages

4. Later stages: include painless sore or lesion that bleeds easily and doesn't heal, oral tenderness, diff in chewing, swallowing, or talking, blood sputum, limited rom for jaw, weight loss, neck mass or enlarged cervical lymph nodes.

5. May present as red or white patch in mouth or throat

6. Typical lesion is painless indurated ulcer with raised edges.

1. Dx: oral and cervical lymph node assessment. PET, mri, endoscopy, laryngoscopy, biopsy, hpv status testing

2. Management: surgical resection and chemoradiation.

3. Tx choice depends on location of cancer

4. Metastasis often occurs in neck lymphatic channel and may require neck dissection with reconstructive surgery.

5. Nursing management includes nutrition interventions, assessment of verbal comms, airway management post op with possible suctioning

6. Pt may require a temporary or permanent tracheostomy post surgery.

1. devasting disease with protracted treatment that diminishes qol and is lethal in a significant number of cases

2. Almost 18.5k new cases are diagnosed a year with about 14k cases mend and 4k are women.

3. The overall 5-year survival rate is about 20%, the cancer can spread beyond the mucosal layers and erode/perforate the mediastinum and great vessels.

4. The 5-year survival rate is caught in early stages is 90%.

1. Etiology is unknown. two types

2. Squamous: lining of the esophagus / upper 2/3 of esophagus

3. Adenocarcinoma: glandular tissue distal esophagus and gastroesophageal junction / lower 1/3 of esophagus

4. RF: smoking, etoh, untreated GERD

5. Other risk factors include chronic ingestion of hot liquids or foods, nutritional deficiencies, poor oral hygiene, and some esophageal medical conditions.

1. advanced ulceration lesion of esophagus often is present prior to symptom manifestation.

2. Progressive dysphagia (most common symptom)

3. Weight loss

4. Bleeding / hemorrahge

5. Later symptoms include substernal pain, persistent hiccup, resp distress, halitosis

6. Psychosocial assessment

1. EGD w/ biopsy, PET for staging, CT of chest/abs, Endoscopic ultrasound, thoracoscopy and laparoscopy

2. Management: nonsurgical- chemo, radiation, nutrition, swallow therapy, esophageal dilation

3. Surgical management: palliative surgical interventions to restore patient's ability to swallow and maintain optimal nutrition. PEG tube placement.

1. Esophagectomy: removal of part or all of the esophagus with use of Dacron graft to replace resected part

2. Esophagogastrostomy: resection of portion of esophagus and anastomosis of remaining portion to stomach.

1. NG tube with blood drainage for 8-12 hours, gradually changes to greenish yellow

2. Do not reposition or reinsert NG tube without surgeon's approval

3. Pulmonary care that includes turning/deep breathe every 2 hours, IS, sitting in chair, possible neb tx

4. Pain control usually PCA and epidural

5. Strict i/o

6. Strict NPO, no sips or chips until pt is cleared

7. Chest tube mangement

8. Trach care

9. May have cardiac complications / require mangement

1. patho: malignant epithelial tumor that infiltrates the mucous producing cells of the stomach, more common in lower socioeconomic groups, males 2x more than women, causes unknown, does have RFs, most frequently found in distal portion

2. CM: often asymptomatic until late in course, indigestion, anorexia, weight loss, vague epigastric pain, vomiting's, abd mass

1. dx: endoscopy with biopsy, endoscopy, CT of chest/abs, cytological students of gastric secretions, labs, barium x rays of upper GI tract

2. Management: often multimodal- surgery, chemo, radiation. Surgery may include total gastrectomy with reconstruction of the GI tract, partial gastrectomy, and complication management/palliative gastric or esophageal bypass.

3. Complications: dumping syndrome, hemorrhage, bile reflux, gastric outlet obstruction.

1. any form of bleeding that starts in the GI tract from the pharynx to the anus.

2. Symptoms of a disease or condition

3. Bleeding can range from nearly undetectable to acute, massive and life-threatening bleeding.

4. Upper GI bleed(stomach, large intestine), lower gi bleed, acute (sudden massive bleed, hypovolemia) vs chronic (slow, unnoticed)

1. 400k hospitalizations in USA per year

2. Mortality rate 5-10%

3. More than 90% of UGI bleeds are caused by peptic ulcers, erosive gastritis, Mallory-Weiss tears, or esophagogastric varices.

1. Occult blood - usually 3 mL's for pos result

2. Hematemesis - blood in vomit

3. Melena - black tarry smelly stool (usually upper) 100-200mL

4. Hematochezia - bright red blood in stool or maroon stool. Most common sign of Lower GI bleed.

5. Distal to the ligament of Treitz - hematemesis and melena above, below hematochezia.

1. Hematochezia: most common presenting symptom. Overt blood or occult (hidden)

2. Causes: diverticulosis (small pouches develop in large intestine), angiodysplasias (abnormal small blood vessels causing bleeding), colon polyps, tumors, inflammatory bowel disease, hemorrhoids, anal fissures

3. Most cases resolve spontaneously, but with chance for rebleed.

1. Most common cause of upper GI bleed

2. Mucosal damage in portion of GI tract exposed to acid-pepsin secretion

3. Risk factors: H. pylori (90% of duodenal ulcers and 75% gastric ulcers) NSAIDs

4. nsaids (15-30% long term users develop ulcers)

1. pain upper abdomen (intermittent)

2. N/v

3. Anorexia weight loss

1. Pt hx

2. Endoscopy

3. Angiography

4. Serologic or breath test for h. pylori

5. Histologic analysis of endoscopic biopsies.

1. Combination of antibiotic therapy and PPIs

2. Sucralfate (carafate) to promote mucosal barrier

3. Bismuth subsalicylate

4. Antacids

1. Stress related mucosal disease - PUD protocols

2. Erosive of hemorrhagic gastritis

3. Esophageal and gastric varices

4. Mallory-weiss tears

5. Arteriovenous malformation - small mucosal and mucosal blood vessels that bleed

1. Bleeding beyond the ligament of Treitz

2. Causes: diverticulosis or arteriovenous malformations

3. Others: ischemic colitis, internal hemorrhoids, rectal ulcers, and neoplasms.

4. Usually slow and intermittent do not require hospitalization

1. Assess the severity of blood loss

2. Administer IV replacement

3. Assist in determining the cause of bleeding (increase in BUN with GI bleed, suggests fluid volume deficit)

4. Planning and implementing treatment (iron and blood products if needed)

5. Provide supportive care and education.

1. management of the hemodynamically unstable pt

2. Oxygenation

3. Lactate levels - greater inc = severity of condition

4. Volume resuscitation: 2 IVs, fluids

5. Blood products (keep Hgb >7 and hematocrit > 28%)

6. Monitor for and report: tachycardia, decreased BP, hematemesis, bloody or tarry stools.

1. Hemorrhage that is result of chronic alcohol abuse

2. Closely observe for DTs

3. Agitation

4. Uncontrolled shaking, sweating, vivid hallucinations

1. No smoking or alcohol

2. Need for long-term follow up care

3. Instruction if an acute hemorrhage occurs in future

4. Pt/family taught how to avoid future bleeding episodes

5. Made aware of consequences of noncompliance with diet and drug therapy

6. Emphasize that no drugs other than prescribed should be taken.

1. mouth: bright red = upper gi, maroon = severe lower gi, black/coffee = old slowed or stopped bleed

2. Rectum: red = lower gi, maroon = severe upper GI, black = slow/old lower GI.

1. Inflammation of the gallbladder: calculous cholecystitis: inflammation from gallstones (cholelithiasis) that obstruct the bile outflow. (over 90% of cases)

2. Acalculous cholecystitis: inflamm w/o gallstones. Occurs after major surgical procedures, orthopedic procedures, severe trauma, burns, gallbladder, infection, cystic bile duct obstruction, or multiple blood transfusions.

3. bile digests fat, mostly happens in duodenum which sends signal to gallbladder so it can digest fat.

1. Calculous cholecystitis: bile remains in the gallbladder due to gallstone blockage creating a chemical reaction.

2. Stone can be made of cholesterol, bile salts (calcium bilirubinate)

3. Autolysis and edema occur with gallbladder vessel compression compromising blood supply.

4. Secondary infection occurs in about 50% of cases

5. RFs, 4F fair skin, fat, fertile, forty

1. RUQ pain and tenderness - may occur after eating rich or fatty foods.

2. Rebound tenderness(more pain when released pressure), guarding, restlessness.

3. Fever, tachycardia, elevated WBCs, anorexia, n/v, positive murphy's sign(inhale while doc hooks fingers under liver and presses in, pain = inflam, pos = pause/stop breathin), urine and stool color changes, vitamin deficiencies.

4. EKG to rule out cardiac issue

1. Lab- bilirubin, electrolytes, CBC, lft, pancreatic enzymes (amylase/lipase)

2. imaging: ab x ray, ultrasound, oral cholecystography, radionuclide imaging.

3. Endoscopic retrograde cholangiopancreatography (ercp) - can remove gallstones and help dx, combined with upper GI endoscopy/xray, NPO midnight night before tho can take BP meds if needed with water.

4. Percutaneous transhepatic cholangiography - contrast medium injected into bile ducts to better visualize gallbladder.

1. Non-surgical: pharmacological(morphine goto, antibiotics), diet and supportive therapies (avoid fatty/dairy/meats), extracorporeal shock wave lithotripsy (ESWL), intracorporal lithotripsy (laser)

2. Surgical: laparoscopic (most common), small-incision cholecystectomy

3. with gallbladder removal bile drains directly into duodenum

1. Pain management (IV pain meds)

2. Hydration and nutrition, during episode pt NPO, let GI rest.

3. Post-op management: pain, resp(IS,TCDB,support incisions w/cough), skin integrity, drains(c-drain helps drain fluid from gallbladder, T-tube- help drain bile and inject dye into tube for imaging, has drainage bag, cap/clamp tube, drain below insertion site in semifowler's), nutrition, complications (bleeding, abd rigidity, signs of infection, gi changes, n/v, loss of appetite )

3a. replace fluids, give antiemetics, start with clear liquids and advance diet (esp low fat)

4. education - post op exp, signs to call for, n/v rigid pain, tube/drain management

1. Exocrine: cells that excrete inactive digestive enzymes into pancreatic duct. Amylase -break down carbs to glucose. Protease (trypsin) - breaks down proteins. Lipase - breaks down fats

2. Endocrine: insulin, glucagon, islets of langerhans

1. inflammation of the pancreas

2. Two types: acute / chronic

3. Reversible

4. Autodigestion