1
Q
Normal Ranges for RBC, Platelet, WBCs
A
RBC: 4.7-6.1 (males); 4.2-5.4 (females)
Platelet: 150000-400000
WBC: 5000- 10000
2
Q
Hematocrit and Hemoglobin normal range
A
Hematocrit (% of RBC in blood)-36-48
Hemoglobin (amount of protein in RBC)—12-16
3
Q
Hematocrit to Hemoglobin ratios
A
Normal 3:1
Dehydration/Hypovolemia: >3:1
Fluid Overload: <3:1
4
Q
3 blood products used for excessive blood loss
A
Packed RBCs (also for anemia)
Platelets (also for coagulation so give before PRBCs)
Albumin
5
Q
3 blood product used for coagulation problems
A
Fresh Frozen Plasma
Platelets
Clotting Factors (Factor VIII)
6
Q
3 kinds of blood donations
A
Autologous (own blood collectedprior to procedure; eliminates compatibility problems)
Donor Blood
Intraoperrative blood salvage (blood recycled and retransfused)
7
Q
How does compatibility testing look for the following blood products?
- Packed RBCs
- Platelets
- Plasma
- cryoprecipitate
- albumin
A
- Packed RBCs (ABO and Rh)
- Platelets (ABO and Rh but ABO does not have to match)
- Plasma (ABO)
- cryoprecipitate (neither)
- albumin (neither)
8
Q
Nursing Care: Pre- blood transfusion (7 general)
A
- ensure consent given
- prime setup w/ NS
- use 18 gauge or larger needle
- use special tubing and separate line for Blood transfusion (usually has filter to retain clots)
- get labs and vitals
- get hx of reactions
- Verify donor’s/recipient’s blood for compatibility with ABO and Rh compatibility, andexpiration w/ TWO nurses
9
Q
What are two pre-transfusion medications?
A
diphenhydramine
Acetaminophen
10
Q
Nursing Care: During blood transfusion (3 general)
A
- Document Vitals and monitor for complications (allergic, hemolytic, febrile, overload)
- Begin transfusion slowly, and stay with patient first 15 to 30 minutes
- Blood products should be infused within 4 hours or you need new blood
11
Q
Blood Transfusion Complications: Hemolytic
Signs and symptoms (6)
A
- Tachypnea
- Chills
- Fever
- Sudden Back Pain
- Nausea
- Anxiety
12
Q
Blood Transfusion Complication: Hemolytic
Nursing Care (4)
A
- Stop Transfusion Immediately!!!
- Saline infusion in separate line from blood
- Save blood bag
- Notify blood bank and HCP
13
Q
Blood Transfusion Complication: Febrile
Signs and Symptoms (5)
A
- Chills
- Tachycardia
- Fever ( increased temp of 1 degree (F) or 0.5 (C))
- Hypotension
- Tachypnea
14
Q
Blood Transfusion Complication: Febrile
Nursing Care (3)
A
- Stop Transfusion Immediately!!!
- Saline infusion in separate line from blood
- Administer antipyretics
15
Q
Blood Transfusion Complication: Allergic
Signs and Symptoms (5)
A
Itching
Urticaria
Dyspnea
Wheezing
Chest tightness
16
Q
Blood Transfusion Complication: Allergic reaction
Nursing Care (3)
A
- Stop Transfusion Immediately!!!
- Saline infusion in separate line from blood
- give diphenhydramine
17
Q
Blood Transfusion Complication: Fluid Overload
Signs and Symptoms (7)
A
Dyspnea
Chest tightness
Tachycardia
Tachypnea
Sudden crackles
Bounding Pulses
Anxiety
18
Q
Blood Transfusion Complication: Fluid Overload
Nursing Care (4)
A
- Monitor VS
- Slow infusion rate,
- Administer diuretics
- may give fluid volume expander (Hespan) prior to treatment
19
Q
4 drug Treatments for Anemia
A
- Iron Ferrous sulfate (take with meals w/ vitamin C)
- Epoetin alfa (Erythropoietin)
- vitamin B12
- Folic acid
20
Q
How do Cancer cells grow compared to benign?
A
Cancer cells grow by invasion with loose adherence and no contact inhibition while benign cells grow by expansion
21
Q
Initiation Stage of Cancer Developments
What is it?
What is the result? (2)
A
- it is a change in gene expression caused by carcinogens (anything that damages cellular DNA causing loss of cellular regulation )
- results in loss of suppressor gene function OR proto-oncogene activation to oncogene status
22
Q
Promotion Stage of Cancer Development
What is it? (3)
A
- Enhanced growth of an initiated cell by promoters(body proteins or hormones)
- consists of latency period b/w initiation and development of overt tumor
- stage where people recognize issue
23
Q
Progression Stage of Cancer Development
2 steps for tumor to become health problem
A
- vascularization
- genetic mutations (driver mutations (selection advantages) AND passenger mutations (helpful to identify cancer in targeted therapy))
24
Q
Metastasis stage of Cancer development
Difference b/w primary tumor and secondary tumors
A
- Primary tumor: original group of cancer cells and defines the type of cancer individual has even if metastasis occurs
- Secondary/metastatic tumors ( Blood borne or Lymphatic spread)
25
What is TNM System?
staging system for cancer
T: primary tumor, # denotes size or local extent(0-4)
N: Regional lymph nodes involvement (0-3)
M: Distant metastasis (0 or 1)
26
Grading of Cancer Cells
What is it? Difference b/w high and low rating?
- Compares appearance and activity of cancer cell with normal parent tissue to determine aggressiveness and sensitivity to treatment
o Grade 1 =resemble normal cells (well differentiated)
o Grade 4= poorly differentiated (aggressive)
27
Ploidy of Cancer Cells
What is it? How does it relate to malignancy?
- classifies # and appearance of tumor chromosomes as normal or abnormal
- Degree of aneuploidy increases with malignancy
28
Cancer Staging
What is it?
Difference b/w Clinical, Surgical, and pathologic staging
determines exact location of cancer and whether metastasis has occurred
Clinical staging: assess patient’s symptoms, tumor size and tumor spread
Surgical staging: assess tumor size, #, sites and spread via inspection at surgery
Pathologic staging: determines tumor size, number, sites, and spread via pathologic exam of tissues from surgery (most definitive staging)
29
CAUTION (Seven Warning Signs of Cancer
Changes in bowel or bladder habits
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump in the breast or elsewhere
Indigestion or difficulty swallowing
Obvious change in a wart or mole
Nagging cough or hoarseness
30
Primary prevention of Cancer (5)
Use sunscreen (skin)
Avoid tobacco and asbestos (lung)
Limit alcohol to < 1 ounce a day
Limit sexual partners and use safe sex
Remove "at-risk" tissue (moles, breast or colon polyps)
31
Chemopreventions for cancer
2 for colon
2 for breast
1 for prostate
1 for cervical
▪ Aspirin and celecoxib (colon cancer)
▪ Vitamin D and tamoxifen (breast cancer)
▪ Lycopene (prostate cancer)
▪ HPV vaccine (cervical)
32
5 secondary prevention for Cancer ( and ages)
o Annual mammography for women 40-54 yrs
o Annual clinical breast exam for women over 40 yrs (every 3 years for women 20-39)
o Annual fecal occult blood test for all adults
o Digital rectal exam for men over 50 yrs
* PSA test
33
Radiation Therapy: External Beam
3 things to note
- Patient is not radioactive or a hazard to others once treatment is complete
- small tattoos of ink mark the tumor location
- Radiation delivered from source outside patient
34
Radiation Therapy: Brachytherapy
3 things to note
- Patient is radioactive and emits radiation for a period of time
- Patient potential hazard to others until source of radiation is removed
- Radiation source is in direct, continous contact with tumor
35
Radiation Therapy side effects
5 localized
3 systemic
localized at site of radiation
- hair loss
- dermatitis (redness, rash, skin desquamation)
- inflammatory response
- tissue fibrosis or scarring
- DNA mutation
Systemic
- fatigue
- Severe NVD
- hematuria
36
Radiation Therapy
6 patient education
* Avoid skin irritation and friction from cloths
* Avoid deodorant and lotions on days of treatments
* Avoid sun exposure to irradiated area
* Wash irradiated area with mild soap and water but avoid skin scrubbing
* Fatigue can be reduced with exercise and sleep
* Regular dental visits, saliva substitutes, lozenges, mouth rinses are helpful for radiation to head or neck
37
Radiation Therapy
10 nursing Care
* Assign the patient to a private room with a private bath.
* Place a “Caution: Radioactive Material”
* Wear a dosimeter film badge to measure radiation exposure
* Wear a lead apron while providing care. Always keep the front of the apron facing the source of radiation (do not turn your back toward the patient).
* Do not perform patient care if pregnant
* Limit each visitor to 1 half-hour per day.
- Be sure visitors stay at least 6 feet from the source.
- no children under 16 can visit
* Never touch the radioactive source with bare hands. In the rare instance that it is dislodged, use long-handled forceps to retrieve it
* keep all linen and dressing in room until all radioactive source removed
38
Chemotherapy-Induced Neutropenia
3 preventions/treatments for neutropenia
o Drugs with similar nadirs (time when bone marrow activity and WBC counts are at their lowest) avoided in combo therapy
o Dose-dense chemotherapy: giving chemotherapy rounds closer together, supplemented with bone marrow growth factors
o Growth factors to stimulate bone marrow production of granulocytes
39
5 Signs and Symptoms of neutropenia’s
cough
dysuria
pain or drainage around IV site
Fever
Fatigue (may be only symptom)
40
7 Nursing Care for Neutropenia
* Place the patient in a private room whenever possible.
* Ensure that the patient’s room and bathroom are cleaned at least once each day.
* Use strict aseptic technique for all invasive procedures (avoid if possible)
* Keep frequently used equipment in the room for use with this patient only (e.g., blood pressure cuff, stethoscope, thermometer).
* Visitors with signs or symptoms of illness should be restricted.
* Monitor the WBC count daily.
* Restrict fresh flowers and potted plants in the patient’s room.
41
6 Nursing Care for Thrombocytopenia
* use a lift sheet when moving and positioning the patient in bed.
* Avoid IM injections and venipunctures or use smallest gauge. If platelets are <50,000, invasive procedures may be postponed.
* apply pressure to areas of bleedning
* Apply ice to areas of trauma.
* Avoid trauma to rectal tissues (no enemas; lubricate for suppositories)
* For mouth care, use soft-bristled toothbrush or tooth sponges; Do not use water-pressure gum cleaners; make sure dentures fit and do not irritate the gums.
42
10 Patient Education for Thrombocytopenia
* Use an electric shaver.
* Use a soft-bristled toothbrush.
* No aspirin or salycilate
* Avoid hard or hot foods that would scrape or burn the inside of your mouth.
* Check your skin and mouth daily for bruises; swelling; or areas with small, reddish-purple marks (petechiae)
* Avoid rectal pain (anal, use stool softeners)
* Do not wear clothing or shoes that are tight or that rub.
* Avoid blowing your nose or placing objects in your nose. If you must blow your nose, do so gently without blocking either nasal passage.
* Avoid activities that increase the pressure in your brain.
* wear shoes with firm soles whenever ambulating.
43
Chemotherapy-induced Nausea and Vomiting
prevention/treatment
antiemetic therapy i.e. 5-HT3 antagonists given prior to nausea or vomiting beginning and continued even when appears controlled
44
Chemotherapy-induced Mucositis
5 Prevention/treatment
* Oral cryotherapy with ice water or ice chips can prevent (patient should suck ice chips before, during, and after rapid infusions)
* Frequent mouth assessment
* Salt and baking soda rinse
* Non-alcohol-based mouth rinse throughout day and night
* Soft-bristled toothbrush or disposable mouth sponges
45
Chemotherapy-Induced Alopecia
4 prevention/treatment
* Scalp cooling during chemo
* Avoid direct sunlight on scalp with hat or head covering
* Use sunscreen due to increased sun sensitivity
* Pick wig prior to treatment beginning to cope with body image issues
46
5 Patient Education for at-home oral chemotherapy
o Use small paper cup and use mouth to get pill from cup (do not touch drug)
o Store drug separate from other drugs
o Do not take missed doses once remembered
o Do no flush oral drugs in toilet
o Dispose of oral drugs by returning to dispensing pharmacy
47
How is Cancer pain treated? (3)
- multimodal analgesia (NSAIDs, opioids, antidepressants)
- PCA pump
- Around the clock dosing
48
6 P's of arterial insufficiency
Pain
Pallor
Pulselessness
Poikilothermic (cold)
Paralysis
Parathesis
49
Stable vs unstable Angina
What is angina?
What is stable angina?
What is unstable angina?
Angina is when oxygen supply < myocardial demand
Stable angina is relieved by rest, sublingual nitrogen or aspirin
Unstable angina is chest pain with extra symptoms, not relieved by nitroglycerin
50
8 Signs and symptoms of unstable angina/ MI
- wheezing or SOB
- weight gain of 3 pounds a week (1-2 pounds overnight)
- dizziness or faintness
- cool, diaphoretic skin
- Nausea and vomiting
- S3 gallop
- increased temperature
- palpitations
51
STEMI vs NSTEMI MI
Differences on ECG
Recommended treatment
STEMI: ST elevation due to rupture of fibrous atherosclerotic plaque
NSTEMI: ST depression and T wave inversion due to myocardial ischemia
PCI is recommended within 90 minutes of arrival to hospital for STEMI to due revascularization
52
How are the following affected by MI?
- Lipids
- C-reactive protein
- B-type natriuretic peptide
- Troponin I and T
- Creatine kinase-MB
- Lipids (total and LDL increased, HDL decreased)
- C-reactive protein - increased
- B-type natriuretic peptide -increased
- Troponin I and T AND Creatine kinase-MB -- increased and specific cardiac markers of MI
53
5 Nursing Care for Report of Chest Discomfort in ER
* Do pain analysis and get vitals every 5 minutes after medication administration
* Obtain a 12-lead ECG within 10 minutes of report of chest pain.
* Give aspirin
* Administer supplemental oxygen therapy to maintain an oxygen saturation greater than 90%.
* Stay with the patient if possible.
54
What is Percutaneous Coronary Intervention?
3 parts
3 parts: clot retrieval, coronary angioplasty ( inflated balloon catheter to push artery plaque against vessel wall), and stent placement ( prevent reocclusion)
55
7 nursing care for PCI
- check if allergic to contrast dye (iodine) or shellfish
- keep leg straight
- keep HOb less than 30 degrees
- watch for bleeding and hypokalemia (back pain = retroperitoneal bleeding)
- have patient avoid coughing and sneezing
- give anticoagulants during procedure and antiplatelets after procedure
- maintain hydration (b-c dye can damage kidney so give adequate fluids)
56
Nitroglycerin (vasodilator)
Indication (2)
Action
Side effects (3)
Nursing Care (5)
Indication: angina, heart failure
Action: reduces preload and afterload
Side effects: headaches, hypotension, reflex tachycardia
Nursing Care
- do not give with PDE5 inhibitors
- remove patch for 12-14 hrs a day and rotate sites
- apply patch to clean hairless area
- give one tablet every 5 minutes until 3 tablets
- give w/ CCB or betablocker to prevent reflex tachycardia
57
Aspirin and Clopidogrel (Antiplatelet)
Side effects (2)
Nursing Care
Side effects: tinnitus (aspirin), bleeding risk
Nursing Care
- take w/ food
58
Warfarin (anticoagulant)
Labs
Antidote
Nursing Care (5)
Labs: INR
Antidote: vitamin K
Side effects: bleeding
Nursing Care
- discontinue heparin 3-4 days after starting
- limit vitamin K (green leafy vegtables, liver, soybeans)
- avoid NSAIDs, antidepressants, corticosteroids,
- taper drug before discontinuing
- bleeding percautions
59
Heparin or enoxaparin (Anticoagulant)
Lab
Antidote
Side effect
Nursing Care (2)
Lab: monitor aPTT or anti-Xa
Antidote: protamine sulfate
Side effects: thrombocytopenia
Nursing Care
- bleeding precautions (electric razor, soft toothbrush)
- taper drug
60
Digoxin (cardiac glycoside)
Indication (3)
Action
Lab changes (3)
Side effects (5)
Antidote
Nursing Care (2)
Indication: heart failure, a-fib, PAC
Action: increase contractility (inotropic), reduce heart rate (chronotropic), reduce AV node conduction (dromotropic)
Lab changes: hypokalemia, hypomagnesium, hypercalcemia,
Side effects/toxicity : dysrhythmias, Anorexia, muscle weakness, vertigo/confusion (elderly), halos and vision changes
Antidote: antigen binding fragments
Nursing Care
- take apical HR prior to administration (do not give if HR < 60)
- take with potassium supplements or food
61
tPA (thrombolytic/fibrinolytic )
Indication
Action
Side effects
Nursing Care
Indication: MI
Action: dissolves thrombi to restore myocardial blood flow
Side effects: bleeding
Nursing Care:
- give within 30 minutes of hospital arrival for STEMI
62
Carvedilol, metoprolol, atenolol (beta blockers)
Indications (4)
Action
Side effects (3)
Nursing Care (3)
Indication: hypertension, heart failure, dysrhythmias, angina
Action: negative chronotropic, dromotropic, inotropic
Side effects: bradycardia, heart failure, hypoglycemia (and masks hypoglycemia)
Nursing Care
- assess HR and BP (hold if HR < 50 or BP <90)
- avoid sudden withdrawal
- Avoid antacids
63
Amiodarone (Potassium Channel Blocker)
Indication
Action
Side effects (5)
Nursing Care (3)
Indication:dysrhythmias (a-fib, v-fib)
Action: slows ventricular conduction to convert A-fib to NSR
Side effects: ARDS, blue-gray skin discoloration, hypotension, bradycardia, corneal microdeposits
Nursing Care
- test pulmonary function prior to treatment
- give with food
- avoid grapefruit juice and St. John's wort
64
Verapamil (Calcium Channel Blocker)
Indication (3)
Action: (3)
Side effects (4)
Nursing Care (2)
Indication: dysrhythmias (a-fib, SVT), angina, hypertension (useful in CKD to improve kidney perfusion)
Action: peripheral vasodilation AND negative dromotropic and chronotropic
Side effects: gingival hyperplasia, prolonged PR (AV block), facial flushing/ increased heat perception, reflex tachycardia
Nursing Care
- prevent reflex tachycardia by giving w/ beta blocker
- avoid grapefruit juice and St. John's wort
65
Furosemide, hydrochlorothiazide (diuretics)
Indication (3)
Action
Side effects (5)
Indication: heart failure, hypertension, chronic kidney disease
Action: increase sodium and water excretion
Side effects: hypokalemia, hypotension, hyperglycemia, hyperuricemia, ototoxic (furosemide)
66
Furosemide, hydrochlorothiazide (diuretics)
Nursing Care (4)
Nursing Care
- Monitor for hypokalemia (dysrhythmias, muscle twitching, thready pulse, polyuria, hypoactive bowels)
- Give with potassium-rich food (citrus fruits, potatoes, bananas) (not in chronic kidney disease)
- Give in morning (no doses after 3pm)
- not useful in end-stage kidney disease
67
Atorvastatin, Simvastatin (HMG-CoA reductase inhibitors)
Indication (3)
Side effects (3)
Nursing Care (2)
Indication: heart failure, hypercholesterolemia, peripheral artery disease
Side effects: hepatotoxic, rhabdomyolysis, cataracts
Nursing Care
- avoid grapefruit juice
- increases bleeding risk when combined with warfarin
68
Captopril (ACE inhibitors)
Indication (2)
Side effects (5)
Nursing Care (2)
Indication: heart failure (drug of choice), kidney disease with hypertension
Side effects: angioedema, cough, hyperkalemia, hypotension, metallic taste
Nursing Care
- take on empty stomach
- avoid NSAIDs and potassium supplements
69
Phosphate binders (Ex. Calcium acetate, calcium carbonate, lanthanum carbonate, sevelamer)
Indication
Action
Side effects (3)
Nursing Care (2)
Indication: chronic kidney disease for hyperphosphatemia
Action: form insoluble calcium-phosphate complex to prevent hyperphosphatemia
Side effects: constipation, hypophosphatemia (weakness, slow or irregular pulse, confusion), hypercalcemia
Nursing Care
- do not take within 2 hrs of other drugs
- take with meals
70
Erythropoietin-Stimulating Agents (Ex. Epoetin alfa)
Indication
Signs of Toxicity (4)
Nursing Care
Indication: prevent or correct anemia via stimulation of RBC
Side of toxicity: chest pain, seizures, rapid weight gain, skin rash or hives
Nursing Care
- check Hgb regularly b-c may overproduce RBCs leading to MI risk
71
Losartan (ARBs)
Indication
Side effects (3)
Indication: heart failure (drug of choice)
Side effects: angioedema, insomnia, hypotension
72
6 Signs and Symptoms of Left-sided Heart Failure
- Weakness/ Fatigue
- Dizziness
- Confusion
- Pulmonary Edema (frothy, pink sputum, dyspnea, crackles)
- S3 gallop (due to early diastolic filling)
- Oliguria (nocturia at night)
73
5 Signs and Symptoms of Right-sided Heart failure (cor pulmonale)
- Distended neck veins
- Increased abdominal girth (ascites)
- Hepatomegaly (liver engorgement)
- Weight—the most reliable indicator of fluid gain or loss
- Peripheral pitting or dependent edema
74
Systolic vs Diastolic heart failure
Systolic: reduced ejection fraction (< 40%) which increases preload and afterload
Diastolic: stiffened ventricles prevents sufficient blood flow and leads to inadequate cardiac output
75
Best diagnostic for Heart Failure
Echocardiography to detect decreased ejection fraction
76
MAWDS for Heart Failure Education
Medications:
* Take medications as prescribed and do not run out.
* Know the purpose and side effects of each drug.
* Avoid NSAIDs to prevent sodium and fluid retention.
Activity: Stay as active as possible but don’t overdo it.
Weight: Weigh each day at the same time on the same scale to monitor for fluid retention (3 lb in a week or 1 to 2 lb overnight)
Diet:
*Limit daily sodium intake to 2 to 3 g as prescribed.
* Limit daily fluid intake to 2 L.
Symptoms:
* Note any new or worsening symptoms and notify the HCP immediately
77
Labs Changes Heart Failure
- BNP
- Urinalysis
- HgB/Hct
- BNP increases
- Urinalysis shows microalbuminuria and high specific gravity
- low Hct from hemodilution of fluid excess
78
EKG normal ranges
PR interval
QRS complex
QT interval
PR Interval = 0.12-0.20 seconds (start of P to start of Q)
QRS complex = 0.04-0.10 seconds (start of Q to end of S; w shaped)
QT interval = less than 0.44 seconds (start of Q to end of T)-- naturally longer in women
79
EKG Wave (what do they represent)
P wave
QRS Complex
T wave
U wave
P Wave- atrial contraction (depolarization); deformity = problem with atrium i.e a-fib does not have p waves
QRS Complex- ventricular contraction (depolarization); deformity = problem with ventricles
T Wave- ventricular repolarization
U wave: late ventricular repolarization
80
EKG Normal Rates
-SA node
-AV node
- Purkinje fibers
EKG Normal Rates
- SA node (60-100 bpm)
- AV node (40-60 bpm)
- Purkinje fibers (20-40 bpm)
81
5 Steps to read 6-second EKG
1. Heart rate (count Ps for atrial rate, count R waves for ventricular rate, count QRS complexes for general rate)
2. Heart rhythm (measure from R-R; regular if intervals different by less than 3 small boxes)
3. P wave analysis (should be present, regular, 1-1 P wave: QRS ratio, round and upright)
4. PR interval analysis (0.12-0.20) -- increases with AV blocks
5. QRS analysis (0.04-0.10)-- dysrhythmias if missing complexes or irregular pattern
82
Sinus arrhythmia
What is it?
EKG Change
- variant of NSR due to intrathoracic pressure during breathing OR due to digoxin or morphine
- Shortest PP or RR intervals vary at least 0.12 seconds from longest PP or RR interval
83
Causes of ST segment changes
Elevation (3)
Depression (3)
ST elevation due to MI, pericarditis, hyperkalemia
ST depression due to hypokalemia, MI, ventricular hypertrophy
84
6 Signs and Symptoms of Supraventricular Tachycardia (SVT)
- Rapid pulse (>150 bpm) and palpitations
- dizziness
- anxiety
- chest pain
- dyspnea
- p wave buried in EKG
85
5 treatments for SVT
- Valsalva maneuver (cough or bear down)
- Adenosine
- Beta Blockers
- Calcium Channel Blockers (verapamil or diltiazem)
- cardioversion
86
Atrial Fibrillation EKG Change
- No clear P waves b-c rapid impulses from atrial tissues
87
Signs and symptoms of Atrial Fibrillation (3 non EKG signs)
- thrombus formation (stroke risk if failure to rescue)-- speech alterations
- irregular apical pulse
- poor perfusion
88
Treatment for A-fib (2 groups)
- Antiarrhythmics (Diltiazem, Amiodarone, metoprolol, lanoxin)
- Anticoagulants (Heparin, enoxaparin, Warfarin)
89
4 Nursing Care for A-fib
- Apply oxygen
- Keep the head of the bed elevated unless patient is very hypotensive
- Notifying the HCP or Rapid Response Team
- get 12 lead EKG
90
7 signs of poor perfusion
- Fatigue/ Weakness
- Shortness of breath
- Dizziness/syncope
- Anxiety
- Palpitations
- Chest discomfort or pain
- Hypotension
91
Serum Creatinine (range: 0.6-1.2)
When is it increased? (2)
When is it decreased? (2)
Increased w/ kidney impairment (due to reduced GFR) and increased muscle mass
Decreased w/ old age and decreased muscle mass
92
BUN (range: 10-20)
When is it increased? (7)
When is it decreased? (2)
Increased
- kidney or liver disease
- dehydration or poor kidney perfusion
- infection/ stress
- high protein
- steroids
- GI or other bleeds
- old age
Decreased
- malnutrition
- liver AND kidney dysfunction
93
BUN/creatinine ratio (range: 6-25, prefer 15.5)
What does it determine?
When is it increased? (5)
When is it decreased? (1)
- determines if non-kidney factors responsible for high BUN
- increased w/ fluid volume deficit, high protein, obstructive uropathy, catabolic state, kidney disease
-decreased w/ fluid volume excess
94
Cystatin-C
What is it?
When is it increased?
-measures GFR; not influenced by BUN and creatinine factors
- increased in CKD
95
Blood osmolarity (range: 280-300 mmol/kg)
What is it?
How is it maintained?
When is it increased?
- overall concentration of particles in blood indicating hydration status
- maintained by ADH/ vasopressin release
- increased in older adults
96
Urinalysis: Specific gravity (range: 1.005-1.030; usually 1.010-1.025)
When is it increased? (4)
Increased: dehydration, poor kidney perfusion, excess vasopressin/ADH (SIADH, stress, surgery), heart failure.
97
Urinalysis: Specific gravity (range: 1.005-1.030; usually 1.010-1.025)
When is it decreased? (6)
Decreased: old age, chronic kidney disease, diabetes insipidus, malignant hypertension, diuretics, lithium toxicity
98
Protein in Urinalysis (Range 0- 8)
When is it increased? (4)
stress, infection (will be negative after infection resolved), recent strenuous exercise, Chronic kidney disease (albuminuria)
99
Urinalysis: Red Blood Cells (RBCs) (range 0-2 per high-power field)
When is it increased? (4)
Increased: menses, trauma (catheterization,tumor, stones), glomerular or bleeding disorders, cystitis
100
Urinalysis: White blood cells (WBCs) (range 0-4 per low-power field)
When is it increased? (3)
Increased: infection or inflammation in the kidney and urinary tract, kidney transplant rejection, or exercise.
101
Uremia symptoms of Chronic Kidney Disease (9)
* Azotemia (buildup of nitrogen-based wastes in blood)
* metallic taste in mouth
* anorexia
* muscle cramps
* Uremic lung (thick sputum, less coughing, tachypnea, fever, pleural friction rub)
* hiccups/ yawning/ deep sigh
* paresthesia
* uremic frost on skin (evaporated crystals cause severe itching)
* noticeable jaundice
102
Kidney Changes in Chronic Kidney Disease (2)
- hypertrophy of nephrons (to maintain homeostasis)
- fixed osmolarity of urine (dilute) followed by oliguria (due to inability to dilute urine
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Electrolyte changes in Kidney disease (4)
- hypernatremia (due to fluid retention)
- hyperkalemia (when urine output falls under 500 mL/24 hr)
- hyperphosphatemia and hypocalcemia
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Metabolic acidosis and Chronic Kidney Disease
What is the cause?
What is the compensation?
Cause: reduced bicarbonate reabsorption and excess H+
Compensation: Kussmaul breathing (tachypnea and hyperpnea)
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3 effects of phosphorus and calcium imbalance in Chronic Kidney Disease
* Renal osteodystrophy: bone mineral loss (S/s: bone pain, spinal sclerosis, fractures, bone density loss, osteomalcia, decreased height (due to compacted vertebrae))
* Metastatic calcification: crystals from calcium-phosphorus deposit in kidneys, heart , lungs, blood vessels (atherosclerotic plaques), joints, eyes (conjunctivitis, brain))
* Itching
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Cardiac changes in Chronic Kidney Disease (4)
- Hypertension ( dysfunction of RAAS = cycle of vasoconstriction)
- hyperlipidemia
- heart failure (heart must work harder)
- Uremic cardiomyopathy and pericarditis (uremic toxic to heart)-- may have narrow pulse pressure, friction rub
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GI Changes in Chronic Kidney Disease (3)
* Uremic fetor -> halitosis or stomatitis
* Peptic ulcer disease w/ ulcers cause erosion of blood vessels -> hemorrhagic shock
* Uremic colitis w/ watery diarrhea or constipation
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Neurological Changes in Chronic Kidney Disease (2)
* Uremic encephalopathy: Lethargy, seizures, coma; weakness in upper and lower extremities
* Peripheral neuropathy: sensory changes in a glove-and-stocking pattern over hands and feet
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Hematologic/immunity changes in Chronic Kidney Disease (3)
* Anemia (due to decreased erythropoietin production -- S/s: fatigue, pallor, lethargy, weakness, SOB, dizziness
* Impaired platelet function due to increased bleeding or bruising (S.s: petechiae, purpura, nose or gum bleeds, melena (black tarry stools i.e. intestinal bleeding))
* Disrupted WBC production and function from uremia
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Patient Education for Chronic Kidney Disease (urination) -2
- Drink 1 to 2 L of water a day to flush out wastes
- Avoid sugary, high-calorie drinks (prevent sugar-induced urination and weight gain)
111
Skin changes in Chronic Kidney Disease (6)
* Yellowish or darkening to brown or bronze due to pigment deposition
* Sallowness (faded suntan) due to anemia
* Decreased turgor and skin oils
* Severe pruritus
* Uremic frost (layers of urea crystals from evaporated sweat)
* ecchymosis or purpura (purple patches and rashes)
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How are the following labs/imaging tests used in Chronic Kidney disease
- BUN and serum creatinine
- Albumin-to creatinine ratio
- Kidney ultrasound
* BUN and serum creatinine = presence and degree of uremia in late stages
* Albumin-to-creatinine ratio = function and damage determination
* Kidney ultrasound or CT scan = rule out obstruction and show kidney size (shrinks from atrophy and fibrosis in end-stage kidney disease)
113
Nursing Care for Managing Fluid Volume (5)
- daily weights (same scale, clothes, time and after voiding)
- strict I & O monitoring
- use graph for trends ( 1 L water = 1 Kg)
- Distribute fluids throughout day if restricted
- Monitor for S/s of fluid overload q4h ( including narrow pulse pressure, change in LOC, headache, pulmonary edema)
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Nursing Care for Pulmonary Edema (5)
* High-fowler position with oxygen
* IV furosemide for diuresis
* IV morphine and nitroglycerin to reduce pulmonary pressure and myocardial oxygen demand via vasodilation
* Measure urine output hourly
* Monitor vital every two hours (every hour w/ nitroglycerin and morphine due to hypotension risk)
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Preventing Injury in Chronic Kidney Disease (2)
* Keep an eye out for drug complications (due to reduced excretion)- need less Magnesium (no antacids w/ magnesium), insulin ( excreted slower so higher risk of hypoglycemia), anticoagulants
* Lift with lift sheet vs pulling due to fracture risk
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Nutrition in Chronic Kidney Disease
What needs to be restricted? (4)
What needs supplementation? Why?
Limit protein, potassium, sodium, phosphorus
Supplement vitamins and minerals esp iron (due to anemia) and dialysis may remove water-soluble vitamins
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Benign Prostate Hyperplasia
Main Complications (Acute(1) vs Chronic (3))
Acute urinary retention: bladder outlet obstruction due to large prostate so unable to void
Chronic urinary retention: leads to reflux and hydroureter and hydronephrosis
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Benign Prostate Hyperplasia
Signs and Symptoms (6)
* Urinary frequency or urgency
* Distended bladder (Sensation of incomplete bladder emptying)
* Nocturia
* Overflow incontinence (Postvoid (after voiding) dribbling or leaking;
* Hematuria
* urinary stasis and hesitancy (straining to start stream) leads to UTIs and bladder calculi
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Purpose of the following Lab/diagnostics in BPH
* Prostate-specific antigen (PSA) test
* Serum acid phosphatase level
* Biopsy
* Transrectal ultrasound (TRUS)
* Prostate-specific antigen (PSA) test: screening purposes; rule out prostate cancer
* Serum acid phosphatase level: elevated in patients who have metastasized prostate cancer
* Biopsy: performed if life expectancy > 5 to 10 years, and if needed to confirm a histologic diagnosis
* Transrectal ultrasound (TRUS) (more common in the United States) -- done before biopsy
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Purpose of the following Lab/diagnostics in BPH
* Cystoscopy
* Urodynamic pressure
* Bladder scan
* Cystoscopy: used to view the interior of the bladder, the bladder neck, and the urethra; used to study the presence and effect of bladder neck obstruction
* Urodynamic pressure-flow studies: helpful in determining if there is urine blockage or weakness of the detrusor muscle
* Bladder scan: measures residual urine
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Behavioral Modification for Benign Prostate Hyperplasia (3)
* Avoid drinking large amounts of fluids in short period of time or right before bed
* Limit caffeine and alcohol due to diuretic effects
* Avoid drugs that cause urinary retention i.e. anticholinergics, antihistamines, antipsychotics, muscle relaxants
122
Finasteride or dutasteride (5-alpha reductase inhibitor)
Indication
Action
Side effects (3)
Patient Education (2)
Action: reduce prostate size
Side effects: ED, decreased libidio, orthostatic hypotension
Nursing Care
- may take 6 months for an effect
- teratogenic so no pregnant partners
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Alpha blockers (doxazosin or tamsulosin)
Indication
Action
Side effects (3)
Patient education (1)
Indication: BPH
Action: relax smooth muscle in bladder neck
Side effects: orthostatic hypotension, reflex tachycardia, syncope
Patient Education
- take at nighttime
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Patient Education after TURP (6)
- do not swim or bath with catheter
- do not try to void around catheter (urge to void will be present)
- increase fluid intake (2-2.5 L) to prevent dysuria
- temporary incontinence post-op will resolve
- sex is okay (may have retrograde ejaculation)
- do kegels to regain voluntary elimination
125
Post-Op Nursing Care for TURP (7)
- Keep leg straight if catheter is taped to thigh or abdomen
- Help patient ambulate early
- Monitor and document the color, consistency, and amount of urine output PRN or q2h
- For output, subtract amount of irrigating solution from urinary drainage bag
- Check the drainage tubing frequently for external obstructions (e.g., kinks) and internal obstructions (e.g., blood clots, decreased output)
- Assess the patient for reports of severe bladder spasms with decreased urinary output, which may indicate obstruction.
- Use continuous irrigation with NS
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3 Complications of TURP
What to do about them?
* TURP syndrome --Due to irrigation fluid being over absorbed ( S/s: headache, SOB, hypertension, bradycardia, ST elevation, wide QRS, inverted T wave)
* Arterial bleeding = bright red or ketchup like clots---Need to notify surgeon immediately and irrigate catheter w/ normal saline
* Venous bleeding = burgundy -- need to Inform surgeon and monitor hemoglobin and hematocrit
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Preoperative care for TURP (3)
* Assess patient anxiety
* Correct any misconceptions about surgery
* Remind patient to discontinue anticoagulants several days prior to surgery
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When is surgery indicated for BPH? (5)
* Acute urinary retention (AUR) due to obstruction
* Chronic UTIs secondary to residual urine in the bladder
* Hematuria
* Hydronephrosis
* Persistent pain with decrease in urine flow
129
Transurethral resection of the prostate (TURP):
What is it?
What is the disadvantage?
TURP is the gold standard of prostate surgery; enlarged prostate is removed through endoscopic instrument
Disadvantage is that only small pieces are removed
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Preventing Complications in Vascular Catheter (Hemodialysis) - 4 tips
- Assess the access site regularly with vital signs
- Use aseptic technique to dress site and access catheter
- Do not use catheters for blood sampling, IV fluids, or drug administration
- Place heparin or heparin/saline dwell solution after hemodialysis treatment
131
Preventing Complications in AV graft or fistula (Hemodialysis) - 8 tips
- Prepare skin w/ 2% chlorhexidine
- B/w hemodialysis sessions, patient should wash area w/ antibacterial soap and rinse with water
- Avoid constrictive devices such as BP cuffs, tourniquets, venipuncture in same extremity
- Rotate needle insertion sites w/ each hemodialysis treatment
- Palpate for thrills and auscultate for bruits over the vascular access site q4h while patient awake
- Encourage routine range-of-motion exercises and elevate extremity
- Do not carry heavy objects with extremity with access device
- Do not to sleep on Vascular access device or put body weight on it
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Contraindications for Hemodialysis (3)
any severe cardiac, vascular or bleeding diseases
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Contraindications for Peritoneal Dialysis (4)
- Extensive peritoneal adhesions or fibrosis
- active inflammatory GI disease (diverticulitis, IBS)
- Ascites or massive central obesity
- Recent abdominal surgery
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Procedure for Peritoneal Dialysis vs hemodialysis
In peritoneal, dialysate does fill-dwell-drain cycle in peritoneum of abdominal cavity
In hemodialysis, dialysate is filtered through AV graft, fistula, or vascular catheter through osmosis and diffusion across semipermeable membrane
135
Complications of Hemodialysis (6)
- Disequilibrium syndrome
- Muscle cramps and back pain
- Headache
- Itching
- Hemodynamic and cardiac effects (hypotension, cell lysis contributing to anemia, cardiac dysrhythmias, intracranial hemorrage)
- Anemia
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Disequilibrium Syndrome
Cause
Signs and symptoms (6)
Prevention
Cause: Due to rapid reduction in electrolytes and other particles after hemodialysis (rare)
S/s: mental status changes, seizures, fatigue, headaches, nausea and vomiting, coma
Prevention: reduced blood flow at onset of symptoms
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2 main Complications of Peritoneal Dialysis
Signs of each
Prevention for each
Peritonitis (main complication of PD)
S/s: cloudy dialysate, fever, abdominal tenderness general malaise
Prevention: sterile technique b/c due to connection site contaminations
Bowel perforation or inflammatory bowel disease
* Signs: brown effluent
* Prevent with high-fiber diet, stool softeners, enemas
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Complications of Peritoneal Dialysis (6)
Pain
Leakage of Dialysate fluid
blood clot
Protein loss
peritonitis
bowel perforation or inflammatory bowel disease
139
Nursing Care for Hemodialysis (8)
* Weigh the patient before and after dialysis.
* Hold certain drugs prior to dialysis and give after dialysis
* Be aware of reactions that occurred during previous dialysis treatments.
* Monitor vitals and neurologic status throughout treatment
* Assess serum laboratory tests to evaluate effectiveness of treatment in removing wastes and achieving desired outcomes (e.g., fluid and electrolyte balance, reduction of uremia).
* Warm Dialysate (not in microwave)-- also do this for peritoneal dialysis to decrease discomfort
* Give anticoagulation therapy to prevent clotting
* keep patient supine in low fowler (esp in peritoneal dialysis to prevent leakage at site)
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5 Reasons for Dialysis
ESKD
Pulmonary edema
Severe uncontrollable hypertension
Symptomatic hyperkalemia with ECG changes
Drug Overdoses
Concepts 2
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