Download NUR2392/NUR 2392 Multidimensional Care II Exam 1 Study Guide 2021. and more Exams Nursing in PDF only on Docsity! Multidimensional Care II Exam 1 Study Guide *The exam questions are not limited to only what is listed on this guide, please refer to your chapter readings and module materials Ch. 21: Principles of Cancer Development @ Benign vs. Malignant cells o. Benign: Specific Morphology- they resemble the tissue they originated from (they look like the host). Small Nuclear to Cytoplasmic Ratio- they have a similar structure inside the cell to normal cells and small nucleus. Specific Function- they contribute to the body in some way. Tight Adherence- they bind close together. No Migration- they do not move around the body or invade other tissue sites. Orderly Growth-they grow at a normal rate. Euploidy- they have a normal amount of chromosomes per cell. © Malignant (Cancer): Anaplasia- loss of appearance of the parent cell. Large Nuclear to Cytoplasmic Ratio- they have a large nucleus and occupy space. Specific Functions are Lost- they serve no purpose to the body. Loose Adherence- loose binding of the cells, causing potential spread into the blood and body. Migration/Metastasis- spreads and moves easily. Loss of cellular regulation and contact- the cells will crowd, push, and grow on top of other cells. Rapid Cell Division- the cells will be produced and grow at a faster rate m= Aneuploidy- abnormal number of chromosomes per cell. @ Seven warning signs of cancer o “CAUTION” mC: changes in bowel or bladder habits A: asore that does not heal or mouth sources (mucositis) U: unusual bleeding or discharge T: thickening of a lump in a tissue |: indigestion and dysphagia O: obvious change in a wart or mole m N: nagging cough @ Cancer development stages of malignancy © Initiation: the normal cell becomes damaged which is irreversible and can lead to cancer developing © Promotion: repeat exposures to a damaging stimuli enhances growth- mutations can cause this © Progression: because of repeat exposures, there is an increase in production of malignant cells © Metastasis: movement of the cancer cells m= Malignant transformation: some cells will divide enough to form a tumor area on top of tissue. = Tumor vascularization: cancer cells secrete tumor angiogenesis factor stimulating the blood vessels to bud and for channels to grow. m Blood Vessel Penetration: cancer cells break off from the main tumor and enzymes on the surface of the tumor cells make holes in the blood vessels, allowing the cancer cells to enter blood vessels and travel around the body. @ = Arrest and Invasion: cancer cells clump up in the blood vessel walls and invade new tissue aera to support continued growth of cancer cells and new tumors. @ Cancer classification: monitor tumor growth, aggression, progression, and to determine appropriate treatment. © Tumor grading: based on cellular aspects of cancer. m Based on the aggressiveness of the cancer cell and differentiation from the normal tissue. @ GO: the grade cannot be determined @ G1: Tumor cells are well differentiated and closely resemble the normal cells from which they arose.This grade is considered a low grade of malignant change.These tumors are malignant but are relatively slow growing. @ G2: Tumor cells are moderately differentiated; they still retain some of the characteristics of normal cells, but also have more malignant characteristics than do G1 tumor cells. @ G3: Tumor cells are poorly differentiated, but the tissue of origin can usually be established. The cells have few normal cell characteristics. = Different types will be used depending on the type of cancer. = Will often be run through a microscope to see the cells. Imaging: CT, MRI, PET scans ANC- Absolute Neutrophil Count: percentage and actual number of mature circulating neutrophils. The higher the number, the greater the risk of infection resistance. Other labs: m RBC"s: 4.7-6.1, Hemoglobin= 12-18, Hematocrit 36-50, WBC 5000-10000, Platelets 150000-450000 m Pancytopenia= low RBCs,WBCs and platelets. @ Risk factors ° 000000 ° AGE is the BIGGEST #1 RISK Oncogene activation: something mutates the cell and we do not know why. Chemicals: tobacco, hairspray, gases, pesticides, asbestos Physical: radiation, drugs, UV radiation Viruses: HPV can change pelvic structure Dietary -red meat Immune function Genetic risk- remember about genetic testing. @ Other Terms regarding Cancer care to know ° ° ° ° Pancytopenia: low numbers of RBCs,WBCs and platelets. Neutropenic precautions: we must place our patient receiving cancer treatment because their immune system is suppressed, and they are a higher chance of infection m No fresh flowers No fresh food No kids Must have caretaker wear a mask Patient must wear mask outside of room m=» Wash hands. Mucositis: inflammation of the mouth due to cancer treatment or progression Extravasation: the cancer treatment leaks out of the lV and damages the surrounding skin. Epoetin: medication that stimulates the production of rbcs Neupogen: stimulates WBC production @ Types of therapy (i.e. surgery, radiation, chemotherapy) ° ° Surgery: the provider will take out as much of the cancer as possible. Radiation: uses high levels of radiation to kill cancer cells, control the disease, or provide symptom relief. Used locally often based on exposure (amount of radiation delivered to a tissue) and radiation dose (amount of radiation absorbed by the tissue) ™ Often in divided doses in small amounts due to radiation sensitivity and location to other body tissues. = Will often not cause complete destruction of all cancer cells at once. Some can also repair themselves from the radiation. ™ Can be froma radiation emitting beam externally, or by an implanted radiation device that emits doses of radiation. Types of Radiation External beam: radiation delivered from a source outside of the patient. Because the source is external, the patient is not radioactive, and there is no hazard to others. © The exact tumor location is determined and then small markings are placed for precision, and a device may be placed ina splint or mold. Brachytherapy: internal radiotherapy. Radiation is delivered to the patient internally, making the patient a source of radiation as there is potential for one to emit radiation for a period of time and be hazardous to others. © Seeds can be placed and they are small pieces of radioactive material. Patients are still hazardous with them, even if they run out. © Chemotherapy: treatment of cancer cells with the use of chemical agents that damages cell DNA and regulation. Specific to the type of tumor and the movement. m Systemic effects, but can cause damage to normal healthy cells m Drug Types: Alkylating Agents: cross-link DNA, making the DNA strands bind tightly together. This action prevents proper DNA and ribonucleic acid (RNA) synthesis, which inhibits cell division. Antimetabolites: closely resemble normal metabolites and act as “counterfeit” metabolites that fool cancer cells into using the antimetabolites in cellular reactions. Because antimetabolites cannot function as proper metabolites, their presence impairs cell division. Antimitotic Agents: interfere with the formation and actions of microtubules so cells cannot complete mitosis during cell division. As a result the cancer cell either does not divide at all or divides only once. Anti-tumor Agents: drugs that were originally developed as antibiotics that have effects on cancer cells. These drugs damage the cell's DNA and interrupt DNA or RNA synthesis. The exact mechanism of interruption varies with each agent. Topoisomerase inhibitors: disrupt an enzyme (topoisomerase) essential for DNA synthesis and cell division. When drugs disrupt the enzyme, proper DNA maintenance is prevented, resulting in increased DNA breakage and eventual cell death. Miscellaneous Chemotherapeutic Agents: those with mechanisms of action that are either unknown or do not fit those of other drug categories. @ Done ina combination: will give more than 1 chemo drug to more effectively kill cancer cells ™ Dose dense Chemo: giving chemo rounds closer together w/ growth factors to minimize neutropenia. m™ Can give IV, but more than likely other routes such as a port, PICC, TLC to prevent complications. ™ Can have potential to cause healthcare worker toxic effects- why people who are chemo certified can only give chemo. © Immunotherapy Biological response modifiers: enhance or alter the patient's biologic responses to cancer cells. Can help the body recognize cancer cells as foreign and improve immunity and repair cells. m= Interleukins: substances the body makes to help regulate inflammation and immunity. Helps different immune cells recognize and destroy abnormal body cells. m= Interferons:cell-produced proteins that have some effect in the treatment of melanoma, hairy cell leukemia, renal cell carcinoma, AIDS-related Kaposi's sarcoma, and lymphoma. Slowing tumor cell division.Stimulating the growth and activation of NK cells. Inducing cancer cells to resume a more normal appearance and function.|Inhibiting the expression of oncogenes m Supportive therapy: helps with growth factor and induces more rapid recovery of bone marrow cells after suppression by chemotherapy. © Monoclonal Antibodies: bind to their target antigens, which are often specific cell surface membrane proteins. Binding prevents the protein from performing its functions. By binding these proteins, monoclonal antibodies change cellular regulation and prevent cancer cell division. © Tyrosine Kinase Inhibitors: Drugs with the main action of inhibiting activation of tyrosine kinases. TKI drugs are effective in disrupting the cellular regulation and growth of some cancer cell types and not others. o Epidermal Growth Factor/Receptor Inhibitors: block epidermal growth factor from binding to its cell surface receptor. When this receptor is blocked, it cannot activate tyrosine kinase. As a result, the signal transduction pathway for promotion of cell division is inhibited. o Vascular Endothelial Growth Factor/Receptor Inhibitors: It binds to vascular endothelial growth factor (VEGF) and prevents the binding of VEGF with its receptors on the surfaces of endothelial cells present in blood vessels. This inhibits formation of new blood vessels within a tumor. As a result, tumor cells are poorly nourished and growth is inhibited. © Multikinase Inhibitors: inhibit the activity of specific kinases in cancer cells and tumor blood vessels. © Proteasome Inhibitors: prevent the formation of a large complex of proteins (a proteasome) in cells. Limit the amount of proteasome present, impairing the tumor’s © Xerostomia and dental caries © Trismus © Osteoradionecrosis © Hypothyroidism @ Lung © Pulmonary Fibrosis @ Heart: © Pericarditis © Cardiomyopathy © Coronary Artery disease @ Breast/Chest Wall ° Atrophy, fibrosis of breast tissue o Lymphedema @ Abdomen and Pelvis © Small and Large bowel injury © Chemotherapy Extravasation can occur if given through IV. Must give cancer through PICC/CL/Port Vesicant: will destroy and eat away tissue Risk for infection due to bone marrow and immune suppression and neutropenia. Risk for bleeding: impaired clotting Chemo induced nausea and vomiting may occur Mucositis Alopecia Cognitive changes Peripheral neuropathy o Immunotherapy: biological response modifiers: Severe inflammatory reactions widespread edema that can affect the function of all organs Flu like symptoms Peripheral neuropathy Neurological symptoms skin dryness and reactions © Photodynamic therapy Airway issues © Hormonal Manipulation Masculine effects in women Feminizing effects in men (gynecomastia) Fluid retention Acne m Hypercalcemia @ Patient Teaching Points liver dysfunction VTE © Surgery: Must have psychosocial support since diagnosis and surgery fall within a short time frame of each other. Assess coping mechanisms based on the diagnosis and changes in body image and roles. Coordinate with the team for assistance with the patients concerns regarding feelings, ADL’s and body acceptance Refer to support groups. Rehab may be needed to improve functioning. Teach patients the importance of regular exercise. © Radiation: ® Assist with calming the patient and family with the procedure m Brachytherapy (Internal Radiation): Assign the patient to a private room with a private bath. Place a “Caution: Radioactive Material” sign on the door of the patient's room. If portable lead shields are used, place them between the patient and the door. Keep the door to the patient's room closed as much as possible. Wear a dosimeter film badge at all times while caring for patients with radioactive implants. The badge offers no protection but measures a person's exposure to radiation. Each person caring for the patient should have a separate dosimeter to calculate his or her specific 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). If you are attempting to conceive, do not perform direct patient care, regardless of whether you are male or female. @ Pregnant nurses should not care for these patients; do not allow pregnant women or children younger than 16 years to visit. @ Limit each visitor to one-half hour per day. Be sure visitors stay at least 6 feet from the source. @ Never touch the radioactive source with bare hands. In the rare instance that it is dislodged, use long-handled forceps to retrieve it. Deposit the radioactive source in the lead container kept in the patient's room. @ Save all dressings and bed linens in the patient's room until after the radioactive source is removed. After the source is removed, dispose of dressings and linens in the usual manner. Other equipment can be removed from the room at any time without special precautions and does not pose a hazard to other people. m Skin teaching: @ Wash the irradiated area gently each day with either water or a mild soap and water as prescribed by your radiation therapy team. @ Use your hand rather than a washcloth when cleansing the therapy site to be gentler. @ Rinse soap thoroughly from your skin. @ If ink or dye markings are present to identify exactly where the beam of radiation is to be focused, take care not to remove them. @ Dy the irradiated area with patting rather than rubbing motions; use a clean, soft towel or cloth. @ Use only powders, ointments, lotions, or creams that are prescribed by the radiation oncology department on your skin at the radiation site. @ Wear soft clothing over the skin at the radiation site. @ Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at the radiation site. allow them to cool before placing them in your mouth.Eat foods that are high in fiber (e.g., fruit, whole grain cereals, vegetables).Drink 2 to 3 liters of fluid (nonalcoholic) daily unless your health care provider has told you to restrict fluid intake.Use the actions for “Falls Prevention” supplied by the cancer center during all activities.Get up slowly from a lying or sitting position. If you feel dizzy, sit back down until the dizziness fades before standing; then stand in place for a few seconds before walking or using the stairs.To prevent tripping or falling, look at your feet and the floor or ground where you are walking to assess how the ground, floor, or step changes.Avoid using area rugs, especially those that slide easily.Keep floors free of clutter that could lead to a fall.Use handrails when going up or down steps o Immunotherapy: biological response modifiers: m Use moisturizers and mild soap for skin cleaning. Protect skin from sun No swimming No use of steroid creams Assess for fever and use acetaminophen to treat Use antiemetic for n/v Teach early recognition of neuro s/s © Photodynamic therapy m@ Avoid sunlight exposure for 24-48 hours. must educate the family © Hormonal Manipulation m Educate about side effects = Must understand the implications of falls and body changes @ Oncological emergency classification types (what are they, how do you assess it, how do you treat it?) ***Life- threatening emergencies affecting cancer patients. Can occur at any time from diagnosis through treatment. They may be directly related to the tumor or a result of treatment therapy. Oncological emergencies are classified as metabolic, hematologic, & structural or side effects of treatment. Early detection and treatment of these emergencies are imperative to reduce patient harm and preserve life. *** ©. Sepsis or Febrile Neutropenia (Hematologic Emergency) ® Acondition in which organisms enter the bloodstream causing an infection resulting in septic shock (septicemia). = Widespread infection triggering whole-body inflammation m= Leads to distributive shock when infectious microorganisms are present in the blood and then commonly referred to as septic shock. One of the most common side effects of chemotherapy Life-threatening condition (requires immediate medical care) Adults w/cancer w/ low WBCs (neutropenia) and impaired immunity from cancer therapy are at an increased risk for infection and sepsis. s/s associated with sepsis/ septic shock includes erythema, swelling, warmth, high fever. Other s/s associated w/ febrile neutropenia is absolute neutrophil count less than 500 per mm’3 Often a low-grade fever (100.4) is the only sign of infection initially seen in septic patients. Infection and sepsis have a high mortality rate in adults w/ neutropenia Treatment options: @ Inpatient treatment @ Antibiotic therapy @ Determine the cause of the infection @ Temperature management Nursing Care: Assess for s/s Monitor and treat temperature Collect cultures Implement isolation precautions Monitor labs Administer medications as prescribed Manage comfort Provide emotional and spiritual support © Disseminated Intravascular Coagulation (DIC) (Hematologic Emergency) Occurs when there is a problem w/ the blood clotting process Triggered by severe illness including cancer In patients w/ cancer DIC is caused by gram-negative sepsis Normal bacterial flora enter the bloodstream through any site of skin breakdown causing severe infection Extensive & abnormal clotting occurs in the small blood vessels depleting circulating clotting factors and platelets resulting in extensive bleeding for patient w/ DIC Bleeding from many sites is the most common problem and ranges from oozing to fatal hemorrhage DIC causes decreased blood flow to major body organs s/s include pain, ischemia, stroke like symptoms, dyspnea, tachycardia, reduced kidney function, and bowel necrosis DIC is life-threatening even when proper therapies are instituted Prevention of both sepsis and DIC are key Identify patients at greatest risk for sepsis and DIC Practice strict adherence to aseptic technique during invasive procedures and during contact w/ nonintact skin and mucous membranes Teach patients and families the early indicators of infection and to seek prompt assistance Focus of treatment therapies is halting the DIC process IV antibiotic therapy is initiated Anticoagulants (especially heparin) are given to limit clotting and prevent rapid consumption of circulating clotting factors during the early phase of DIC When DIC has progressed and hemorrhage is the primary problem clotting factors and blood transfusions Some of the most common clotting factors given to treat DIC patients @ Factor 1- Fibrinogen Factor 2- Prothrombin Factor 3- Thromboplastin Factor 4- Calcium Factor 5- Proaccelerin or Labile Factor Factor 6- Stable factor Factor 8- Antihemophilic factor @ Manage comfort @ Provide emotional and spiritual support to patient and family © Epidural Spinal Cord Compression (Structural Emergency) Life-threatening complication of metastatic cancer caused by tumor compression of the spinal cord. Can result in permanent neurological deficits Early recognition and treatment are imperative to improve and maintain patient function Epidural spinal cord compression is associated with breast, lung, renal, prostate cancer and myeloma S/s include new onset of back pain that worsens when lying down, late paraplegia, incontinence, constipation, and loss of sensory function Treatment options include radiation and surgical intervention Nursing Care: @ Assessment for neurological deficits (diminished DTRs, numbness or tingling in hands or feet, unsteady gait, inability to distinguish a pinprick, or determine hot or cold sensations) @ Manage pain (both pharmacological and non-pharmacological (i.e. external back or neck braces to reduce pressure on spinal cord or spinal nerves) @ Administer medications as prescribed (i.e. IV corticosteroids to reduce swelling & inflammation) Prevent skin breakdown Provide emotional and spiritual support © Hypercalcemia of Malignancy (Metabolic Emergency) Increased serum calcium level occurs in up to a third of patients w/ cancer Metabolic emergency that can lead to death Completely treatable condition Dehydration worsens hypercalcemia Associated w/ lung, breast, and kidney cancer as well as multiple-myelomas Three major triggers that result in hypercalcemia of malignancy @ Tumor secretion of parathyroid hormone-related protein @ Osteolytic metastasis w/ release of cytokines @ Tumor production of 1.25-dihydroxyvitamin D S/s include fatigue, anorexia, nausea, vomiting, constipation, mental status changes/altered sensorium, renal failure, coma, myalgia, and headache. Treatment options: Inpatient monitoring Aggressive rehydration followed by diuresis Monitor serum phosphate levels Phosphate replacement IV. bisphosphonate Hemodialysis Nursing Care: Assess for s/s Monitor I&Os Administer fluids as prescribed Monitor for side effects of medications Monitor vital signs and cardiac rhythm Prepare patient for hemodialysis Provide emotional and spiritual support © Superior Vena Cava Syndrome (Structural Emergency) Compression of the superior vena cava walls by a tumor prohibiting venous return of blood to the heart. Associated w/ lung cancer, metastatic mediastinal tumors, lymphoma, and indwelling venous catheters. s/s include swelling of the face, neck, and arms, dysphagia, and cough Late s/s include hemorrhage, cyanosis, mental status changes, decreased cardiac output, dyspnea, and hypotension Imaging w/ CT or MRI is essential for diagnosis and treatment planning Death results if compression is not relieved Treatment options include radiation and chemotherapy Nursing Care: Assessment of respiratory and cardiac systems Maintain a patent airway Monitor oxygenation Monitor labs Provide emotional and spiritual support to the patient and family © Tumor Lysis Syndrome (Metabolic Emergency) Large number of tumor cells are destroyed rapidly TLS results in a release of large amounts of intracellular products such uric acid, calcium phosphates, and potassium. These products disrupt homeostasis and destroy the nucleus of cells. Uric acid formation causes hyperuricemia and precipitate in the kidney blocking kidney tubules resulting in AKI Intracellular contents of damaged cancer cells, including potassium and purines (DNA components), are released into the bloodstream faster than the body can eliminate them. TLS differs from the other types of oncologic emergencies because it is a positive sign that cancer treatment is effective in destroying cancer cells. TLS is associated w/ hematologic malignancies, acute leukemia, and high- grade lymphoma. Severe or untreated TLS can cause tissue damage, acute kidney injury (AKI), and death. Serum potassium levels can increase to the point of hyperkalemia causing cardiac dysfunction Adults receiving radiation or chemotherapy for cancers are at risk for TLS and more likely to develop/ occur in older adults Early symptoms of TLS include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, edema, and altered mental status. Other s/s include azotemia (damaged kidneys), acidosis, hyperphosphatemia, hypocalcemia. Hydration prevents and manages TLS by diluting the serum potassium level and increasing kidney flow rates. Managing agitation and delirium ll Assess for pain, urinary retention, constipation, other reversible cause Pharmacologic agents- avoid benzodiazepines in older adults as it increases the risk of causing delirium. Music therapy; aromatherapy Managing refractory symptoms of distress proportionate palliative sedation- a care management approach involving the administration of drugs such as benzodiazepines, neuroleptics, barbiturates, or anesthetic agents for the purpose of decreasing suffering by lowering patient consciousness. The intent of proportionate palliative sedation to promote comfort. (it's different from euthanasia). Meeting psychosocial needs. Grief—Emotional feeling related to the perception of loss. Mourning—Outward social expression of the loss Interventions are based on cultural beliefs, values, and practices. Presence Therapeutic communication Life review Reminiscence Spirituality Religion e Explain the Multidisciplinary method for those with cancer/ death ©. Involves care from every discipline to provide comfort and care for the patient while maximizing life outlook. © MD,PT,OT,RT,Specialists, SLP, dietitian, psychologist, social work, chaplain. Ch. 11: Care of Patients with Problems of Fluid and Electrolyte Balance @ Lab values form for normal ranges= Hypomagnesemia and hypophosphatemia = alcoholism ELECTROLYTES REFERENCE RANGE SIGNIFICANCE OF ABNORMAL VALUES Sodium (Na+) 136 - 145 mEq/L Elevated: Hypernatremia; dehydration; kidney disease; hypercortisolism Low: Hyponatremia, fluid overload, liver disease, adrenal insufficiency Potassium (K+) 3.5 - 5.0 mEq/L Elevated: Hyperkalemia; dehydration; kidney disease; acidosis; adrenal insufficiency; crush injuries Low: Hypokalemia; fluid overload; diuretic therapy; alkalosis; insulin administration; hyperaldosteronism Calcium (Ca 2+) 9.0 - 10.5 mg/dL Elevated: Hypercalcemia; hyperthyroidism; hyperparathyroidism Low: Hypocalcemia; vitamin D deficiency; hypothyroidism; hypoparathyroidism; kidney disease; excessive intake of phosphorus- containing foods and drinks. Chloride (CI-) 98- 106 mEq/L Elevated: Hyperchloremia; metabolic acidosis; respiratory alkalosis; hypercortisolism Low: Hypochloremia; fluid overload; excessive vomiting or diarrhea; adrenal insufficiency; diuretic therapy Magnesium (Mg 2+) 1.8 - 2.6 mEq/L Elevated: Hypermagnesemia; kidney disease; hyperthyroidism; adrenal insufficiency Low: Hypomagnesemia; malnutrition; alcoholism; ketoacidosis @ Fluid balance and hormonal regulation : Three hormones support the control of fluid and electrolyte balance : Aldosterone, antidiuretic hormone (ADH), and natriuretic peptide o Aldosterone : secreted by adrenal cortex when sodium levels in the extracellular fluid (ECF) are low. It prevents water and sodium loss. When it’s secreted, it acts on the kidney nephrons enabling them to reabsorb sodium and water from the urine back into the blood. Increases blood volume. Antidiuretic hormone (ADH) [aka, vasopressin] : release from the posterior pituitary gland in response to changes in blood osmolarity. Increased osmolarity results in slight shrinkage of these cells and triggers ADH release from the posterior pituitary gland. It also acts on kidney nephrons, making them permeable to water. As a result, more water is reabsorbed by these tubules and returned to the blood, making it more dilute (decreased osmolarity). Natriuretic peptides (NPs) are secreted by special cells that line the atria ( atrial natriuretic peptide [ANP]) and ventricles (brain natriuretic peptide [BNP]) of the heart. These peptides are secreted in response to increased blood volume and blood pressure, which stretch the heart tissue. Kidney reabsorption of sodium is inhibited at the same time that urine output is increased. The outcome is decreased blood volume and blood osmolarity. @ Assessment and treatment of dehydration and fluid overload o Dehydration m Assessment: Urine is darker, dry mouth, dry eyes, muscle cramps, heart palpitations, syncope, decreased urine output, increasing heart rate. = Confirming diagnosis: physical manifestations, blood tests, and urinalysis. m Treatment: Treatment: Provide oral fluids (within dietary restrictions), offer fluids every two hours. If oral fluids are not tolerated, IV fluids should be administered. © Fluid Overload m= Assessment: Patients often have pitting edema, increased pulse rate, elevated blood pressure, decreased pulse pressure, weight gain, engorged varicose veins, increased respiratory rate, shallow respirations, shortness of breaths, moist crackles present on auscultation. Skin is pale and cool to the touch. Treatment: Skin integrity is at risk with swollen limbs, ensuring the patient is being repositioned every two hours to prevent breakdown. Diuretics are used for fluid overload if kidney function is normal (furosemide). If a patient has syndrome of inappropriate antidiuretic hormone (SIADH), conivaptan (vaprisol) or tolvaptan (samsca) may be prescribed. Monitor intake and outake. Restrictions on fluid intake and sodium intake. @ S/S of hypo/hyper______ ELECTROLYTE HYPO- HYPER- Sodium e@ Cerebral changes are the most obvious problems. e@ Behavioral changes result from cerebral edema and increased e Neuromuscular changes are seen as general muscle weakness. Deep tendons reflexes diminish, and muscle weakness is worse in the legs and arms. intracranial pressure. Nervous system changes start with altered cerebral function. Assess for patients mental status for attention span and cognitive function. Skeletal muscle changes: twitching, irregular muscle contractions. The worse it gets, the less it responds to stimulus. Cardiovascular changes include decreased contractility. High pulse rate, peripheral pulses are difficult to palpate. Neck veins are distended. BP is include reduced motility, anorexia, nausea, constipation, and abdominal distension. @ Electrolyte changes with disease processes or treatment (i.e. DKA, end-stage renal failure, vomiting) © End Stage Renal Failure: Loss of potassium (Hyperkalemia) is one of the most common and life-threatening electrolyte disorders in Chronic Kidney Disease and End Stage Renal Disease. Treatment: Patients will need dialysis such as Hemodialysis that filters waste, removes extra fluid and balances electrolytes (sodium, potassium, bicarbonate, chloride, calcium, magnesium and phosphate) © DKA: there is an increase of potassium due to the diabetes not being controlled. High serum potassium levels may occur in acidosis because of the shift of potassium from inside the cells to the blood. Treatment: low K= give supplements PO or IV pump infused K. High K= candik= calcium gluconate, albuterol, insulin, D5NS, kayexelate, HCO3 @ Electrolyte replacements (type and how is it administered?) © Potassium supplement should never be given IV push, only hung by infusion and given slowly. Can result in burns. © Normal saline (0.9% sodium chloride) or half-strength saline (0.45% sodium chloride) solution is given by IV to replace the chloride. © Low Na= use hypertonic solution and water. © Treatment of hypernatremia consists of a gradual lowering of the serum sodium level by the infusion of a hypotonic electrolyte solution (e.g., 0.3% sodium chloride) or an isotonic non saline solution (e.g., dextrose 5% in water [D;W]). D;W is indicated when water needs to be replaced without sodium. @ Types of fluids (isotonic, hypotonic, hypertonic) © ISOTONIC: Mimics the blood m Fluids given: 0.9 % saline, 5% dextrose in water (D5W), 5% dextrose in 0.225%, Lactated Ringers o HYPOTONIC: makes the fluid go into the cell, and makes the cell swell (Mr. HypOOOOOOtonic) m Fluid Types: 0.45% Saline (1/2 NS), 0.225% Saline (1/4 NS), 0.33% Saline (1/3NS) o HYPERTONIC : Makes fluid go out of the cell and shrink the cell. m Fluid Types: 3% Saline, 5% Saline, 10% Dextrose in water [can cause fluid overload in pulmonary edema], 5% Dextrose in 0.9% Saline, 5% Dextrose in 0.45% Saline, 5% Dextrose in Lactated Ringer