Nursing Notes

* Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr.

* The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.

* Signs of hypocalcemia: paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. * Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

* ECG Hypocalcemia: prolonged ST or QT interval.

ECG Hypercalcemia: shortened ST segment widened T wave.

* The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia.

ECG hypomagnesemia: tall T waves, depressed ST segment.

ECG hypermagnesemia: Prominent U waves, widenened QRS complexes

* The normal serum phosphorus level is 2.7 to 4.5 mg/dL.
Hypophosphatemia causative factors: malnutrition or starvation and the use of aluminum hydroxide–based or magnesium-based antacids. Malnutrition is associated with alcoholism. Causative factors of Hyperphosphatemia: Hypoparathyroidism, tumor lysis syndrome, and renal insufficiency.

* The normal serum amylase level is 25 to 151 units/L.
Chronic pancreatitis: the rise in serum amylase levels usually does not exceed three times the normal value. Acute pancreatitis: the value may exceed five times the normal value.

* The normal serum lipase level is 10 to 140 units/L. The client who is recovering from acute pancreatitis usually has elevated lipase levels for about 10 days after the onset of symptoms. This makes lipase a valuable test in monitoring the client’s pancreatic function because serum amylase levels usually return to normal 3 days after the onset of symptoms.

* Troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL.

* The normal serum creatinine level for adults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a slightly elevated level. A creatinine level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creatinine level of 3.5 mg/dL may be associated with acute or chronic renal failure. * The diet for a client with renal failure who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids.

* The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Hold next dose of warfarin if PT level is too high or near the critical range ex.: 35secs.

* The normal activated partial thromboplastin time (aPTT) varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal.

* The normal hemoglobin level for an adult female client is 12 to 15 g/dL. Low HgB: Iron deficiency anemia
High HgB: Dehydration may increase the HgB level by hemoconcentration, Heart failure and COPD may increase the hemoglobin level as a result of the body’s need for more oxygen-carrying capacity.

* The normal platelet(thrombocytes) count is: 150,000-450,000 per μl (microlitre). Too low: bleeding. Too high:thrombosis that blocks blood vessels and could lead to MI, stroke, pulmonary embolism and etc. Oral agents that suppresses platelets: Aspirin, Clopidogrel, Cilostazol, ticlopidine, and prasurgel. * The normal white blood cell count ranges from 4,500 to 11,000/mm3. The client who is immunosuppressed has a decrease in the number of circulating white blood cells. The nurse implements neutropenic precautions when the client’s values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy.

* Foods high in potassium are:
Bananas, Oranges, Orange Juice, Milk, Prunes, Prune Juice, Tomato Juice, Tomato Sauce, Nuts, Chocolate, Dried Peas and Beans

High sodium foods:
Salt, Bacon, Ham, Corned Beef, Pepperoni, Sausage, Pizza, Chinese Food, Fast Foods, Pickles, Cheese, Soy Sauce, Canned Soups, Potato Chips, Fritos, Cheetos

High phosphorus foods:
Milk, Beans (red, black, white), Black Eyed Peas, Lima Beans, Nuts, Chocolate, Yogurt, Cheese, Liver, Sardines, Desserts made with milk

High in Vitamin C:
Papaya, Bell Peppers, Strawberries, Brocolli, Pineapple, Brussel Sprouts, Kiwi, Oranges, Cantaloupe, Kale

* A client with an unreported history of lactose intolerance would develop symptoms such as abdominal cramping, distention, and the passage of liquid stool in response to nutritional therapy with these formulas. If the client is diagnosed as lactose intolerant, a lactose-free formula should be prescribed by the physician. This will resolve the client’s symptoms and promote adequate nutrition for the client.

* The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid.

* Parenteral Nutrition: When a client begins eating a regular diet after a period of receiving parenteral nutrition, the PN is decreased gradually. Parenteral nutrition that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. Optimal weight gain on PN is 1 to 2 lb/week.

* Parenteral nutrition is indicated in clients whose GI tracts are not functional or who cannot take in a diet enterally for extended periods. Examples: extensive burns, severe exacerbation of Crohn’s Disease, persistent N&V, those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency syndrome.

* If the pump that is infusing PN shuts off for a period of time, the nurse assesses the client for signs and symptoms of hypoglycemia. These signs include weakness, shakiness, headache, anxiety, diaphoresis, and complaints of hunger. The blood glucose level will be lower than 70 mg/dL.

* The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention that can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, and weight gain more than desired.

* Circulatory (fluid overload) is a complication of intravenous therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present, the client’s blood pressure would also increase.

* Hematoma is characterized by ecchymosis, swelling and leakage at the IV insertion site, and hard and painful lumps at the site.

* Systemic infection is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia.

* An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site.

* Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site.

* An IV allergic reaction produces a rash, redness, and itching. A major reaction, such as IV hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis.

* A solution of 5% dextrose in 0.45% sodium chloride is hypertonic. An advantage of hypertonic solutions is that they may be used to treat hypovolemia when plasma expanders are not readily available.

* BLOOD TRANSFUSION REACTION:
Septicemia - transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. Delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level. Fluid overload, the client has the presence of crackles in addition to dyspnea. Allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash.

* BLOOD TRANSFUSION:
The major blood types are A, B, AB, and O. The blood type indicates an antigen found on the surface of the red blood cell. Acute hemolytic transfusion reaction (ABO incompatibility) can occur if a client receives blood that is not compatible with his or her blood type. Acute hemolytic reaction is the most serious adverse reaction to a blood transfusion.
Albumin: plasma expander
Platelets: are necessary for proper blood clotting; given if platelet count is low. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Cryoprecipitate: useful in treating bleeding from hemophilia or disseminated intravascular coagulopathy because it is rich in clotting factors.
Packed red blood cells: replace erythrocytes and are not a plasma expander. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. Erythrocyte count and HgB and Hct levels are determined after transfusion of packed red blood cells.
An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body. The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts to evaluate the effectiveness of the therapy. * Fresh frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level.

* RESTRAINTS: The restraint straps are secured to the bed frame and never to the side rail to avoid accidental injury in the event that the side rail is released. A half-bow or safety knot should be used for applying a restraint because it does not tighten when force is applied against it and it allows quick and easy removal of the restraint in case of an emergency. The jacket restraint should be secure, and one to two fingers should slide easily between the restraint and the client’s skin.

* To perform the Heimlich maneuver on an unconscious woman in an advanced stage of pregnancy, place the woman on her back. Place a wedge, such as a pillow or rolled blanket, under the right abdominal flank and hip to displace the uterus to the left side of the abdomen

* Serous drainage is an expected finding at a surgical site. S/Sx infection: warm, red, and tender skin around the incision. Purulent material may exit from drains or from separated wound edges. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. * Which among the 4 meds. Could be given for pre-op client who must be NPO?
Prednisone(Deltasone) is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily.
These other three medications may be withheld before surgery without undue effects on the client:
Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia.
Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant.
Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. * Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported to the physician. A temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client’s preoperative or baseline blood pressure is used to make informed postoperative comparisons.