loretta manning, msn, rn, gnp resulting in a crash! easy! personal balance ... nursing diagnosis /...

1 2015 Copyright , I CAN Publishing, Inc.

Fluid and Electrolytes Made INSANELY Easy! Loretta Manning, MSN, RN, GNP President, I CAN Publishing®, Inc.

Fluid and Electrolytes Made

Easy!

Loretta Manning, MSN, RN, GNP

Piedmont Technical Community College

President, I CAN Publishing®, Inc.

Without electrolytes, our bodies

would be like a ship without light,

resulting in a crash!

Without electrolytes, our bodies

would be like a ship without

light, resulting in a crash!

The most important thing

in nursing is not so much

to obtain more and

more facts, but to

TRANSFORM how we

THINK about them! — Loretta Manning, MSN, RN, GNP

What concerns me

is not the way things

are, but rather the way

people think things are.

—Epictetus, Philosopher

Trivialize

Tedious

Terrorize

THE SIX STEP APPROACH

TO SUCCESS!

M Master fluid and electrolytes

A A Positive Mental Attitude

S Study and Learning Techniques

T Thinking and Time Management

E Evaluate Testing Performance

R Reflect and Redirect Learning


Learning is Directly

Proportional to the

Amount of FUN

You have.

REMEMBER!!! It’s

not what you

KNOW, but what

you REMEMBER that counts!

CUSHY CARL

©1994 I CAN

Balancing Act for the Brain and

Kidneys:

Kidneys

©2012 I CAN Publishing®, Inc.

What is the priority plan for a client with

Cushing’s syndrome?

1. Prevent skin breakdown.

2. Treat infection.

3. Teach client about symptoms of

hypoglycemia.

4. Prevent fluid overload.

FLUID SHIFTS

“Mary had a little lamb and everywhere Mary went the

lamb was sure to go.”

©1994 I CAN


Remember… “A quart a pound

the whole world

round.”

=

If weight ↑ 1 lb.,

then client has

retained another

quart of fluid

P Positive Mental Attitude

O Operate from a

Positive Self Worth

W Worth While –

You are Important

E Empowerment –

Achieve goals

R Resourcefulness

HOW TO BE A CHARGED UP

NURSING STUDENT!

9 BRAIN RULES FOR THRIVING

VERSUS JUST SURVIVING

Exercise

Attention

Memory (repeat to remember)

Memory (remember to repeat)

Sleep

Stressed brains don’t learn the same

Sensory

Vision trumps all other senses

Wiring

KAYEXALATE


What would be the desired outcome for a pediatric client

who received Kayexalate?

1. An increase in bowel movements.

2. A sodium level of 138 mEq/L.

3. A potassium level of 4.5 mEq/L.

4. A depressed T wave on the ECG monitor.

© 2013 I CAN Publishing®, Inc. 17

TIME MANAGEMENT:

SELF MANAGEMENT

Personal Time

Productivity

Priorities

Plan

Personal Balance

Procrastination


What I hear, I forget;

What I see, I remember.

What I do, I understand.

—Confusius, 451 B.C.

R REFRAME THE

QUESTION TO

DETERMINE KEY

CONCEPTS

A ACTIVELY IDENTIFY

POSSIBLE ANSWERS

C CRITICALLY EXAMINE

CHOICES

E ELIMINATE INCORRECT OPTIONS

AND EVALUATE BEST OPTION

A client is being treated for hypovolemia.

Which observation would the nurse

identify as a desired response to fluid

placement?

1. A urine output of 160 per eight hours.

2. Hgb of 13, Hct 42%.

3. Heart rate of 72 increased to 112.

4. B/P of 98/58 to 118/78.

KEY to SUCCESS!

COMPARE

CONTRAST

TRENDS

EXPECTED OUTCOMES

Note Equally Plausible Distractors

Which action should the nurse do first for a

client who has a diagnosis of dehydration and

has a medical order for an intravenous fluid

containing potassium chloride (KCl)?

a. Evaluate weight

b. Assess lips and mucous membranes

c. Monitor skin turger

d. Assess urinary output

Global Option

A 50-year-old client is presenting with

anorexia, nausea, and some muscle

cramps. There is an order for digitalis.

What is the highest priority?

a. Assess apical heart rate prior to administration.

b. Hold the digitalis.

c. Notify the provider of care.

d. Hold the digitalis and check with provider of care regarding the appropriateness of the order.


Throw back the shoulders,

let the heart sing,

let the eyes flash,

let the mind be lifted up,

look upward and say to yourself:

“Nothing is impossible”

—Norman Vincent Peale

Copyright 2008 ICAN Publishing Inc.

S System Specific Physiology, Assessments,

Labs / Diagnostic Procedures

A Analysis of Assessments, Nursing Diagnoses/

Concepts

F First-prioritize Interventions / Pharmacology

E Expected outcomes

T To Reduce Potential “RISKS”

room assignments, recognize limitations of staff, restraints, risk for falls, infection, identification, skin breakdown, scope of practice for delegation, know Standards of Practice, safe equipment)

Y (Why?) Ask questions when you don’t know

(Accuracy / Appropriateness of orders)!

Structure for Testing and Thinking!

FLUID & ELECTROLYTE

IMBALANCE

Loss of 2% body weight, an increase

of ADH and a thirsty feeling are

regulating fluid balance!


Fluid & Electrolytes

(Sung to the tune of “Jingle Bells”

Verse 1

Sodium, sodium is found outside the cells

Low levels come from pooping, puking, peeing!!

Verse 2

Sodium, sodium is found outside the cells

High levels come from too much salt and Not drin……king!

Verse 3

Potassium, potassium is found inside the cells.

Low levels come from Lasix and laxatives.

Verse 4

Potassium, potassium is found inside the cells.

High levels come from some meds and renal fail…..ure!

Verse 5

Electrolytes, electrolytes like sodium and potassium

Don’t have to be that hard when you sing our song!


ACTIVITY

Osmosis fluid moves

lower to higher

Diffusion higher to

lower

Which of these would be an example of

osmosis?

a. Water moves from an area of lower to

higher particle concentration.

b. Water moves from an area of higher to

lower particle concentration.

c. Fluid remains within the cell.

d. Fluid moves outside the cell due to

changes in protein.

Which of these would be an example of

diffusion?

a. Water moves from an area of lower to

higher particle concentration.

b. Water moves from an area of higher to

lower particle concentration.

c. Fluid remains within the cell.

d. Fluid moves outside the cell due to

changes in protein.

SAFETY::

System Specific Physiology FLUID VOLUME DEFICIT: HYPOVOLEMIA

Big Time Deficit = Shock

Loss of fluids from anywhere: vomiting, diarrhea, hemorrhage, throracentesis, paracentesis, diabetes insipidus.

Third spacing – When fluid is in a place that does you no good.

SAFETY:

System Specific Assessment

Fluid Volume DEFICIT

Decrease in weight

Decreased skin turgor

Dry mucous membranes

Decreased urine output

Decrease in Blood Pressure

Decrease in warmth to extremities

Decrease fluid to pump so pulse is↑

SAFETY:

System Specific Assessment:

Labs & Diagnostic Procedures – FVD (hypovolemia) (increased values)

↑ Hct (more that 3x Hgb)

↑ BUN > 20

↑ Specific Gravity > 1.030

↑ Osmolality > 295mOsm/kg water

↑ Serum Na > 145 mEq/L


SAFETY:

Analysis of Assessments /

Nursing Diagnosis / Concepts

Fluid Volume Deficit

SAFETY:

FIRST - Priority Nursing

Interventions –

F Fluid ↑(po), Isotonic fluids, Blood

L Level of consciousness, look at weight

U Urine < 30 ml / hr report or trending ↓

I IV fluids as ordered, I & O

D Document vital signs and watch trends

S Shock position (back with legs ↑)

What would be the priority nursing

intervention for a client with a B/P

change from 140/88 to 86/62?

a. Put client in supine position with legs

elevated.

b. Notify provider of care.

c. Put client in Fowler’s position.

d. Evaluate characteristics of mucous

membranes.

The elderly client is admitted with a preliminary diagnosis of

urinary sepsis, with these diagnostic results:

Hgb - 11.2 g/dl

Hct - 53%

BUN - 32 mg/dl

creatinine - 1.7 mg/dl

Na - 145 mEq/L

K - 3.2 mEq/L.

Which assessment is most crucial to these results?

a. Assess vital signs.

b. Assess skin turgor.

c. Determine urine output.

d. Obtain a pulse oximetry.

A client is admitted with Zayman’s Disease. Four hours

post-op the client’s pulse is 100 bpm and weak. Blood

pressure has dropped to 102/62 and respiratory rate is 42.

What would be the priority care.

1. Position client in the Sim’s position.

2. Place client upright and inspect the wound.

3. Position client in the Semi-Fowler’s position.

4. Place client in the supine position and discuss with

provider of care the need to increase the IV flow

rate.

SAFETY

Expected Outcomes For Hypovolemia

System Specific Evaluation of FVD (hypovolemia

Outcome: Fluid Volume BALANCE

Weight within client’s norm

Blood Pressure within client’s norm

Pulse within client’s norm

Moist mucous membranes

Urine output ≥ 30 cc/hr

Extremities warm to touch


Expected Outcomes – COMPARISON of initial assessment to expected outcome

evaluation

System Specific Assessment of FVD

Decrease in weight

Decrease in BP

Decrease fluid = pulse ↑

Dry mucous membranes

Decreased urine output

Decrease in warmth to extremities

Expected Outcome

Evaluation of client’s response

Weight - client’s norm

BP- client’s norm

Pulse within client’s norm

Moist mucous membranes

Urine output ≥ 30 cc/hr

Extremities warm to touch

Which assessment best indicates

proper rehydration?

1. 400 cc of po intake.

2. Heart rate of 105 beats per min.

3. Respiratory rate of 32 per min.

4. Urine output of 100 cc per hour.

Expected Outcomes – LABS COMPARISON of initial assessment to expected outcome

evaluation

System Specific

Assessment of FVD Labs

• ↑ Hct (more that 3x Hgb)

• ↑ BUN > 20

• ↑ Specific Gravity >

1.030

• ↑ Osmolality >

295mOsm/kg water

• ↑ Serum Na > 145

mEq/L

Expected Outcome

Evaluation of client’s Labs

↓ to normal range

• Hct (3x Hgb)

• BUN 10 -20

• Specific Gravity 1.005 –

1.030

• Osmolarity 285 -

295mOsm/kg water

• Serum Na 135 – 145mEq/L

SAFETY:

(Connecting NCLEX to Concept)

To Reduce Potential Risks

R Room assignments, recognize

limitations of staff, restraint safety

I Infection, Identification, Identify TRENDS

or Changes in Clinical Condition

S Skin breakdown, Safe equipment

Scope of Practice for delegation

K Know Standards of Practice, know how to

document / report errors

Which system specific assessment

findings would the client present with who

has been vomiting for 24 hours indicating

a need for further intervention?

a. B/P increase from 110/70 to 130/80.

b. Urine output decrease from 95cc/hr to

75cc/hr.

c. BUN -15.

d. Pulse increased from 68/min to 118/min.

SAFETY:

Why? Is there anything you

want to ask?

(Accuracy / appropriateness of orders)


Which of these orders would be most important for

the nurse to question for a client who is in

hypovolemic shock?

1. Administer dopamine and digitalis.

2. Infuse 0.9 Normal Saline 500 cc bolus.

3. Administer a blood transfusion as ordered.

4. Foley catheter to a straight drain.

Brain conducting Posterior

pituitary gland

Posterior

Pituitary Gland


DIABETES INSIPIDUS

SAFETY::

System Specific Physiology

FLUID VOLUME EXCESS: HYPERVOLEMIA

Big Time Deficit = Shock

↑ ECF volume due to:

Heart or renal failure, cirrhosis

↑Na, excess IV fluids

↑ aldosterone secretion

↓albumin,

Syndrome of Inappropriate Antidiuretic

Hormone (SIADH)

SAFETY:


Fluid Volume EXCESS Signs and Symptoms of Hypervolemia: ↑ in volume


pulse

temperature

↑ blood pressure

↑ in edema

↑ in ascites

↑ in crackles in lungs

↑ swelling neck (jugular vein distention)

↑ in confusion, headache and seizures

SAFETY:


Labs & Diagnostic Procedures –

FVE (hypervolemia) (Decreased values)

↓ Hct

↓ Serum Osmolality

↓ Serum Sodium (NA)

↓ BUN


SAFETY:



Fluid Volume Excess

SAFETY:

FIRST - Priority Nursing Interventions –

R Reduce IV flow rate

E Evaluate breath sounds and ABGs

S Semi-Fowler’s position

T Treat with oxygen and diuretics as ordered

R Reduce fluid and sodium intake

I I & O and weight

C Circulation, color, and presence of edema

T Turn and position at least every 2 hrs

SAFETY

Expected Outcomes System Specific

COMPARISON of initial assessment to expected outcome

evaluation

System Specific

Assessment FVE

↑ pulse

↑ B/P

↑ weight

↑ edema

↑ ascites

↑ crackles in lungs

↑ dyspnea

↑ confusion

Expected Outcome – Fluid Balance

Pulse within client norm -

B/P within client norm

Weight within client norm

↓ edema

↓ ascites

↓ crackles in lungs

↓ dyspnea

↓ confusion

SAFETY

Expected Outcomes System Specific

COMPARISON of initial assessment to expected

outcome evaluation

System Specific

Assessment FVE Labs

↓ Hct

↓ Serum Osmolarity


↓ BUN

Expected Outcome

Fluid Balance of Labs

↑ to normal range

Hct

Serum Osmolarity

Serum Sodium (NA)

BUN

SAFETY:











Which clinical finding indicates the client is

experiencing potential fluid volume excess?

a. B/P change from 108/78 to 140/90

b. Decreased crackles in lower lung fields

c. Pulse increased from 72/min to 80/min

d. Weight from 150 lbs to 142 lbs


What is the expected outcome for the

administration of IV furosemide (Lasix) with

a client who has fluid volume excess?

a. B/P change from 108/78 to 140/90

b. Pulse change from 108/min to 72/min

c. Increased crackles in lower lung fields

d. Weight from 142 lbs to 150 lbs

A client has an order to receive 1 unit of blood

to infuse in over 4 hours. The nurse makes

rounds and determines that the complete unit

infused in over 60 minutes. What is the priority

of care?

1. Notify the physician immediately.

2. Obtain a stat chext x-ray.

3. Assess the vital signs.

4. Evaluate the client’s weight.

Which nursing action would be appropriate

for a client with orthopnea, dyspnea, and bibasilar

crackles?

1. Elevate legs to promote venous return.

2. Elevate the head of the bed, decrease the

IV fluids, and notify the provider of

care.

3. Orient the client to time, place, and

situation.

4. Prevent complications of immobility.

SAFETY:


want to ask?


Which order should be questioned for a client

presenting with with orthopnea, dyspnea, BP –

150/92 with adventitious breath sounds in

bilateral lower lung fields?

a. Administer furosemide (Lasix) as ordered.

b. Daily weight every AM.

c. Increase IV fluids for 2 hours.

d. Position client in semi-Fowler’s position.

Brain conducting Posterior

pituitary gland

Posterior

Pituitary Gland



SOGGY SID

©1994 I CAN PUBLISHING, INC.

SOGGY SID S I A D H

(sung to the tune of “Bingo”)

Verse 3

But, diabetes insipidus

the opposite you’ll see—

Pee pee, give IV’s—pee pee, give

IV’s—

pee pee, give IV’s

Vas-o-pressin they need.

Verse 1

Brain tumors, trauma, and bad bugs

A complication might be—

S I A D H, S I A D H, S I A D H

This hormone stops the pee pee.

Verse 2

Low output, sodium; gained weight

And high specific gravity

S I A D H, S I A D H, S I A D H

This hormone stops the pee pee.

Chorus

S I A D H, S I A D H, S IA D H

This hormone stops the pee

pee.

What would be the highest priority of care

for a client with syndrome of inappropriate

anti-diuretic hormone (SIADH)?

1. Instruct the UAP to encourage the client to drink fluids.

2. Advise client to report large amounts of urine output.

3. Evaluate for signs and symptoms of dehydration.

4. Instruct the LPN to report a weight gain of 2.5 pounds.

SAFETY::


Sodium Deficit (Hyponatremia)

Na < 135 mEq / L

Electrolyte imbalance that may result in

disturbances involving these systems:

Neurological

Cardiac

Endocrine

SAFETY:



Na < 135 mEq / L

↓ B/P

↓ Muscle Strength

↓ Deep Muscle Reflexes (DTR)

↑ Pulse

Confusion & lethargy


↓ Serum Osmolality

SAFETY:


Lab & Diagnostic Procedures –


Na < 135 mEq / L

Labs (Decreased values)


SAFETY:



Sodium Deficit (Hyponatremia) Na < 135 mEq / L

Electrolyte Imbalance – Sodium Deficit

SAFETY: “SODIUM”


HYPONATREMIA

(Na) < 135 mEq / L


S odium intake , Seizure precaution

O verload—restrict water intake

D aily weight

I ntake & Output

U se isotonic fluids to restore

ECF

M onitor posturial hypotension, HR,

decrease CVP, dry mucous membranes / LOC

NURSING MANAGEMENT

OF HYPONATREMIA


Hyponat remia needs t o be f ixed wit h a DIME: Diet ,

IV f luids, Medicat ions, Elect rolyt e replacement

Diet IV f luids

Elect rolyt es Medicat ions

SAFETY

Expected Outcomes –

COMPARISON of initial assessment to expected outcome evaluation

System Specific Assessment of Sodium Deficit (Hyponatremia)

• ↓ B/P

• ↓ Muscle Strength

• ↓ Deep Muscle Reflexes

(DTR)

• ↑ Pulse

Expected Outcome

Evaluation of client’s response

Within client’s norm

• B/P

• Muscle Strength normal

• Deep Muscle Reflexes

(DTR) return

• Pulse

SAFETY:











Which of these assessment findings is

most consistent with a serum sodium

level-128 mEq/L?

( Select all that apply.)

a. Hypotension

b. Constipation

c. Weight increase

d. Decreased DTRs

e. Hyperactivity


The priority nursing intervention with a

client with a serum sodium level

128mEq/L?

a. Have suction at the bedside

b. Encourage water intake to 2000cc/day

c. Question order for IV for Normal Saline

d. Restrict cheese and condiments

SAFETY:


want to ask?


A client with a sodium level of 133 mEq / L has an

order to push po fluids. What would be the priority

of care?

1. Review the plan with the UAP.

2. Develop a plan for UAP to give 60 cc / hr.

3. Notify the provider of care and verify order.

4. Review the importance of recording weight

every 48 hours.


Kidneys:

Kidneys


ANEMIC ADAM

©1994 I CAN

Why am I so

BRONZE?

SALT

SAFETY::


Sodium Excesst (Hypernatremia)

Na > 135 mEq / L

Electrolyte imbalance that may result in

disturbances involving these systems:

Neurological

Cardiac

Endocrine



HYPERNATREMIA—

“LODES” OF EXTRA SODIUM

L ow H2O int ake

O smot ic Diuret ics

D iabet es Insipidus

E xcessive H2O loss

S odium int ake t oo much

f rom meds and meals

SAFETY:


Sodium Excess (Hypernatremia)

Na > 135 mEq / L

↓ B/P

↑ Pulse

Muscle irritability & twitching

↑ Deep Muscle Reflexes (DTR)

↑ Thirst (may be depressed in elderly)

Restlessness progressing to confusion


D ecreased urine out put , DRY

mout h

R est less ( irrit able) ;

progressing t o

confusion

I ncreased f luid ret ent ion

E dema (peripheral and

pit t ing)

D eep muscle ref lexes

increased

HYPERNATREMIA—

You feel “DRIED” out from too MUCH sodium!

SAFETY:



Sodium Excess (Hypernatremia) Na > 135 mEq / L

Labs (Increased values)

↑ Serum Sodium (NA)

↑ Serum Osmolality

SAFETY:



Sodium Excess (Hypernatremia) Na > 135 mEq / L

Electrolyte Imbalance – Sodium Excess

SAFETY:


HYPERNATREMIA

(Na) > 135 mEq / L

S Sodium intake ↓

O Oral hygiene

D Diuretic (I.e., Loop Diuretics)

I Increase water intake, I&O

U Use hypotonic or isotonic fluids

M Monitor for inadequate renal output


SAFETY



System Specific Assessment of Sodium Deficit (Hypernatremia)

• ↓ B/P

• ↑ Deep Muscle Reflexes

(DTR)

• ↑ Pulse

• ↑ Thirst

• Muscle irritability & twitching

Expected Outcome Evaluation of Client’s Response


• B/P

• Deep Muscle Reflexes

(DTR)

• Pulse

• ↓ Thirst

• No Muscle irritability &

twitching

SAFETY




Sodium Excess Labs

• ↑ Serum Na > 145mEq/L

• ↑ Osmolality > 300mOsm/L

Expected Outcome

Evaluation of client’s Labs

↓ to normal range

• Serum Na (135-145mEq/L)

• Osmolality

(270-300mOsm/L)

SAFETY:











Which of these assessment findings

would be most important to report to the

provider for a client with a serum sodium

147 mEq/L?

a. Dry mucous membranes.

b. Complaints of being thirsty.

c. Urine output drop from 80 cc/hr to 45 cc/hr.

d. Skin warm to touch.

Which nursing intervention would be most

appropriate to delegate to the UAP

(unlicensed personnel or CNA) for a client

with a serum sodium of 148mEq/L?

a. Restrict PO water intake

b. Evaluate effectiveness of diuretic

c. Provide oral hygiene every 2-4 hours

d. Provide a snack of crackers and cheese

SAFETY:


want to ask?



Which of these orders should the nurse question?

1. Administer IV fluids 0.9 % Sodium Chloride as

ordered.

2. Place suction at the bedside.

3. Monitor I&O.

4. Limit water intake.


Kidneys:

Kidneys


CUSHY CARL

©1994 I CAN

SAFETY::


Potassium Deficit (Hypokalemia)

(K+) < 3.5 mEq / L

Electrolyte imbalance that may result in disturbances involving these

systems:

GI Losses: vomiting, nasal gastric suctioning, diarrhea, laxative use

Renal loses: diuretics (Lasix), use of corticoids steroids

Skin loses: diaphoresis and wounds

Insufficient potassium: dietary or prolonged non-electrolyte IV

solutions ie. D5W

Intracellular shift: Tissue repair (burns, starvation, trauma)

* Older adults ↑ risk because of laxatives & diuretics

SAFETY:



(K+) < 3.5 mEq / L

• ↓ Hypoactive reflexes

• Muscle cramping

• Weak & irregular Pulse

• EKG changes: Inverted T waves

• ↓ Bowel sounds (hypoactive), constipation


C onstipation, i bowel

sounds

R eflexes i

A rrhythmias, inverted T waves

M uscle cramps

P ulse—irregular and weak

SAFETY: “CRAMP”



(K+) < 3.5 mEq / L


SAFETY:




(K+) < 3.5 mEq / L

• ↓ Serum Potassium < 3.5mEq/L

• Arterial Blood Gases

Metabolic alkalosis: pH > 7.45

• EKG changes: Inverted T waves, V-Tach

depressed ST segment

SAFETY:




(K+) < 3.5 mEq / L

Electrolyte Imbalance: Potassium deficit

SAFETY:


HYPOKALEMIA

(K+) < 3.5 mEq / L

P Potatoes, Avocados, broccoli, etc. (↑ K+)

O Oral potassium supplements

T T waves depressed (flattened)- monitor

A Arrhythmias - monitor

S Shallow ineffective respirations - monitor

S Sounds of breathing diminished - monitor

I IV supplement is NEVER an IV push!!!

U Urine output monitor

M Muscle cramping, motility (GI) ↓

SAFETY



System Specific Assessment of Potassium Deficit (Hypokalemia)

• ↓ Hypoactive reflexes

• Muscle cramping

• Weak & irregular Pulse

• EKG changes: Inverted T

waves

• ↓ Bowel sounds (hypoactive)

Expected Outcome Evaluation of Client’s Response


• Normal Muscle Reflexes

• No muscle cramping

• Pulse within client’s norm

• No EKG changes

• Bowel sounds within client’s

normal

SAFETY:











Which documentation indicates the nurse

understands how to provide safe care for a

client with a serum potassium of 3.3

mEq/L?

a. Potassium Chloride administered IV push.

b. Oral potassium supplement held due to level.

c. Discussed eating oranges, broccoli, bananas.

d. Administered Lasix as ordered.


SAFETY:


want to ask?


A client is scheduled for a cardiac

catheterization at 0900. On admission 3 days

ago lab work was: K 3.1 mEq/L and

Na 147 mEq/L. She is currently complaining of

muscle cramps and weakness. Which nursing

intervention is a priority at this time?

a. Hold 0700 dose of spironolactone (Aldactone).

b. Call the provider to recommend a stat K level.

c. Recommend eating a banana for breakfast.

d. Observe EKG for spiked T waves.

A nurse assesss a 48-year-old male client who suffered a

myocardial infarction 5 days ago. The client's hear rate is 80

beats per minute, respirations are 20 breaths per minute, serum

potassium 3.3mEq/L, and temperature is 100. 2 degrees F.

Which nursing intervention is most important for the nurse to

implement prior to administering the digoxin (Lanoxin)?

a. Administer oxygen per face mask and observe for signs of a pulmonary embolism.

b. Administer acetaminophen (Tylenol) 650 mg. p.o.

c. Hold the client's next dose of digoxin and notify the provider of care of the client's pulse rate.

d. Notify the provider of care of the potassium level and recommend evaluating the digoxin level.

HYPERKALEMIA

(K+) > 5.0 mEq / L

S Stop infusion of IV

potassium, Salt

substitutes avoid

T Tall T waves (peaked)

O Orders: Kayexalate or dextrose with regular insulin

P Provide potassium restricted foods, Potassium-losing diuretics (Lasix)

Which of these medications should be

questioned for a client with a potassium

level 5.2mEq/L?

a. Furosemide (Lasix).

b. Hdrochlorothiazide (HCTZ).

c. Kayexalate.

d. Lisinopril (Prinivil).

HYPOCALCEMIA

CA - 8.5-11 mg/dL

Risk factors: P Parathyroid (hypo)

E End-stage renal disease

T Thyroidectomy

S Steroids


HYPOCALCEMIA: Assessments

T rousseau’s sign (hand/finger

spasms)

W atch for arrhythmias

(↓ pulse, ↑ ST - ECG

I ncrease in bowel sounds

diarrhea

T etany

C hvostek’s sign (facial twitching)

H ypotension, Hyperactive DTR

NURSING CARE

S eizure precautions

A dminister calcium supplements

F oods high in calcium,(I.e. dairy, green)

E mergency equipment on standby

The client is admitted with hypoparathyroidism.

What is mot important to have at the bedside for

this client?

a. Cardiac monitor

b. IV Pump

c. Heating Pad

d. Tracheostomy set

Which foods would the nurse encourage

the client with hypoparathyroidism to eat?

a. High calcium

b. High potassium

c. Low sodium

d. Low potassium

HYPERCALCEMIA

CA . >11 mg/dL

Risk Factors:

Immobility

Malignant tumors

Hyperparathyroidism

Thiazide diuretics

Excess calcium or vitamin D supplements

HYPERCALCEMIA:

Assessments

Constipation

Flank pain (Calcium in urine ↑)

Deep bone pain

↓ reflexes


Nursing Care:

The 4 F’s)

↑ Fluids

↑ Fiber

Fluids (IV) that are ordered

Furosemide

SAFETY

KEY TO SUCCESS

R REVIEW, REFLECT

E ENGAGE WHILE STUDYING

L LEARN TO PRIORITIZE AND THINK!

A APPLICATION

X X OUT NEGATIVE THINKING!

Fluid and Electrolytes Made

Easy! You CAN do it!!!

We wish you much SUCCESS!

“The secret of joy in

work is contained in

one word-EXCELLENCE.

To know how to do

something well is to

enjoy it.”

—Pearl Buck

1


Page 213 HYPERNATREMIA


Page 215

HYPONATREMIA


Page 217 HYPERKALEMIA


Concept developed by Dr. Melissa Geist

Page 219

HYPOKALEMIA


Concept developed by Dr. Melissa Geist

1 HYPERCALCEMIA


Page 223


HYPOCALCEMIA


Page 225 RENAL PATHOLOGY


Page 227

DRUGS THAT CAN CAUSE

NEPHROTOXICITY


Page 229 1

DIAGNOSTICS FOR THE RENAL

SYSTEM

D iagnost ic t est result s – monit or; int ervene for complicat ions.

I injury and/ or complicat ions f rom procedure should be prevent ed.

A ssist wit h invasive procedures (e.g., t horacent esis, bronchoscopy) .

G lucose monit oring, ECG, O2 sat urat ion, et c. may be performed. N ot e client ’s response t o procedures and t reat ment s.

O bt ain specimens ot her t han blood (e.g., wound, st ool, et c.) . S igns and sympt oms of t rends and/ or changes-monit or, and int ervene.

T each client and family about procedures and t reat ment s. I dent if y vit al signs and monit or for changes and int ervene.

C omplicat ions should be not ed and followed immediat ely wit h an act ion.

“Diagnostic” exams can be hazardous t o t he healt h of our

client s. It is our mission t o keep t hem safe!

The designat ed NCLEX® st andards are out lined below t o assist

you in organizing t he assessment s, nursing

int ervent ions, and evaluat ion t hat must be

incorporat ed int o our crit ical t hinking and clinical

reasoning for client s experiencing a diagnost ic

procedure, t reat ment , or laborat ory procedure.

This image is t o remind you t hat “ Sure Look” Holmes is looking int o t he hippo’s mout h t o assure he is safe! Just as “ Sure Look” Holmes, t he nurse is not responsible

for ordering t hese t est s, but t o maint ain client SAFETY prior t o, during, and af t er t hese diagnost ics have been complet ed.


LAB CHANGES WITH CHRONIC

RENAL FAILURE


Page 233

CHRONIC KIDNEY DISEASE


Page 235


DIALYSIS


Page 237

loretta manning, msn, rn, gnp resulting in a crash! easy! personal balance ... nursing diagnosis /...

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