Electrolyte Imbalances
Patient is presenting with confusion and high fluid levels, what is imbalance is the patient experiencing and what treatment should the patient receive?
Hyponatremia, give sodium and set fluid restrictions.
ABC's
Airway obstruction → First priority (e.g., choking, anaphylaxis, or severe trauma).
Breathing issues → Second priority (e.g., asthma attack, respiratory distress).
Circulation problems → Third priority (e.g., severe bleeding, hypotension, cardiac arrest).
Reaction Occurs
Stop the transfusion immediately.
Disconnect the blood tubing from the patient.
Stay with the patient and monitor their status every 5 minutes.
Notify the doctor and blood bank.
Prepare for further instructions from the doctor.
Document all actions taken and the patient’s response
If a patient with a PCA is asking a family member to press the button for more medication; how should the nurse respond?
The patient is the only one allowed to touch the button. If the patient is struggling to press the button themselves then a PCA is not appropriate.
What is the purpose of SCIP?
preventing infection, cardiac events and thromboembolism
Patient has CHF and is given LASIX and receiving intermittent nasogastric suctioning. Recent cardiac changes such as Flattened T waves and U waves on ECG. Recent lab results revealed low magnesium. Which imbalance could the patient be experiencing and what treatment can we expect them to receive?
Hypokalemia. Potassium (IV or PO) and educate to eat foods rich in potassium
Triage Principles (Emergency Settings)
Emergent (Life-threatening, immediate care needed) – Severe trauma, stroke, heart attack.
Urgent (Serious, but not immediately life-threatening) – High fever, severe pain, dehydration.
Non-urgent (Minor conditions, can wait) – Small lacerations, mild cold symptoms.
Fever.
Skin rash (can be widespread).
Jaundice (yellowing of skin/eyes).
Abdominal pain or diarrhea.
GVHD (Graft vs. Host Disease)
What are some safety measures that should be considered when a patient is receiving opioids?
Access for respiratory depression
Risk for fall
Monitor for constipation
Use Narcan for reversal
The nurse should always access for new ___, ___, and ____ in post op for skin integrity and output; DOCUMENT FINDINGS.
DRAINS, TUBES, DRESSINGS
Patient is presenting with CKD with Peaked T waves on ECG, Diarrhea, and bradycardia. Which imbalance is the patient experiencing and what treatments can we expect can be ordered?
Hyperkalemia. Possible treatments are Kayexalate (MONITOR FOR BM); glucose and insulin to bring potassium into cells; calcium gluconate to decrease arrhythmia problems; dialysis
A nurse is caring for the following patients. Which patient should the nurse assess first?
A. A 28-year-old patient with acute appendicitis who is experiencing mild abdominal pain and has a fever of 100.2°F (37.8°C).
B. A 75-year-old patient with chronic obstructive pulmonary disease (COPD) who is dyspneic and has a new productive cough with green sputum.
C. A 40-year-old patient who just had laparoscopic cholecystectomy and is complaining of increased abdominal distention and nausea after eating.
D. A 50-year-old patient with hypertension who is reporting a headache and has a blood pressure of 200/110 mmHg.
Correct Answer: D – The hypertensive patient (Option D) with a blood pressure of 200/110 mmHg should be assessed first due to the risk of hypertensive crisis (which can lead to stroke or organ damage). This needs immediate intervention to prevent life-threatening complications.
Sudden onset of shortness of breath (dyspnea).
Hypoxia (low oxygen levels).
Bilateral lung infiltrates (visible on chest X-ray).
Severe hypotension.
TRALI (Transfusion-Related Acute Lung Injury)
What are the physical consequences of unrelieved pain?
Decreased immune response
Developing Chronic pain
Slower healing times
Increased Immobility
Causes: vomiting, diarrhea, ileostomy, burns, severe wounds
S/S: Low BP; high HR; flat veins; dry mucus membranes; decreased skin turgor; decreased urine output;
3 D’s: decreased- turgor, urine, mucus
Which nursing diagnosis and treatment fits these descriptions?
Fluid Volume Deficit.
Treatment:
Oral (PO) or intravenous (IV) fluid replacement.
Rehydrate with isotonic sodium chloride solution. (0.9% NS)
Patient is presenting with low urine output, hypotension, confusion, and lethargic. Which imbalance is the patient experiencing and what treatment should they receive?
Hypernatremia.
if the patient’s dehydration is causing a higher loss of water than sodium, then hypernatremia might be present.
Hypotonic fluids are typically used, such as:
D5W (5% dextrose in water), which is essentially free water.
0.45% NaCl (half-normal saline): This is another option as it provides free water along with some sodium to avoid overly diluting the body’s sodium balance.
A nurse is assigned to care for four patients. Which patient should the nurse prioritize?
A. A 25-year-old patient with type 1 diabetes who is alert, complaining of thirst, and has a blood glucose level of 350 mg/dL.
B. A 68-year-old patient with myocardial infarction who is stable, receiving medications (aspirin, morphine, and nitroglycerin), and reports mild chest pain.
C. A 42-year-old patient with sepsis who has fever, tachycardia, and low blood pressure (90/60 mmHg) despite receiving IV fluids.
D. A 55-year-old patient with severe asthma who is using a nebulizer for dyspnea and wheezing but is becoming less responsive to treatments.
Correct Answer: C – The septic patient (Option C) with fever, tachycardia, and hypotension despite IV fluids needs immediate attention because sepsis can rapidly lead to septic shock and organ failure.
Fever (≥1°C or 1.8°F above baseline).
Chills.
Headache.
Nausea or vomiting.
Febrile Reaction
Explain gate control theory and ways to relieve pain beside drug therapy.
Gate control theory is the idea that our spinal cord acts like a "gate" that controls how pain signals are sent to the brain. If the gate is open, pain signals pass through and we feel pain. If the gate is closed, those signals are blocked or reduced, which can lessen the pain we feel.
Endorphins, imagery, or distraction can help to close the “gate”. Other sensations, like touch, can also help "close" the gate and reduce pain.
Preop laboratory assessment should include?
What teaching is important?
Urinalysis (UA)
Blood type and cross-match
Complete blood count (CBC) or hemoglobin level and hematocrit
Clotting studies
Electrolyte levels- POTASSIUM!!!
Serum creatinine level
Pregnancy test- **young females
Patient should have been educated about their surgery by the doctor and provided INFORMED CONSENT.
Patient should be NPO 6-8 hours before surgery.
Patient is recently diagnosed with hypoparathyroidism, high phosphorus and low magnesium levels, and twitching around the eyes or face when touched. What imbalance is the patient experiencing and what treatment could we expect?
what if the patient had hyperparathyroidism and low phosphorus and high magnesium levels, or long term immobility?
Hypocalcemia. Vitamin D; calcium; phosphorus reducing medication, seizure precautions
Hypercalcemia. Get patient up (ambulation is KEY); give phosphorous (hyperparathyroidism) to help reduce calcium levels; calcitonin to move calcium into bones ** with vit D; cardiac monitoring
A nurse is assigned to care for four patients. Which patient should the nurse see first?
A. A 67-year-old patient with pneumonia who has a temperature of 101.3°F (38.5°C) and is requesting pain medication.
B. A 72-year-old patient with congestive heart failure (CHF) who has bilateral lower extremity edema and reports mild shortness of breath.
C. A 45-year-old patient who had an open cholecystectomy 4 hours ago and reports increasing restlessness and pain despite IV pain medication.
D. A 56-year-old patient with chronic kidney disease (CKD) who has a potassium level of 5.6 mEq/L and is scheduled for hemodialysis in 2 hours.
Correct Answer: C – The postoperative patient (Option C) showing increasing restlessness and pain despite medication requires immediate assessment. Increasing restlessness may indicate hypoxia, hemorrhage, or impending shock, which are life-threatening complications.
Rash or hives.
Itching (pruritus).
Swelling (angioedema).
Difficulty breathing (wheezing or bronchospasm)
Allergic Reaction
What is the 4 step to pain pathway (nociception)?
*Transduction: Noxious stimuli initiate a pain signal.
*Transmission: Pain impulse travels PN fibers to the spinal cord
*Perception: Pain becomes a conscious experience.
*Modulation: Neurons in the thalamus & brain stem send signals to the dorsal horn of the spinal cord.
Causes: Cardiovascular or renal dysfunction; Sodium issues; Increased aldosterone; Rapid infusion of IV fluids; Increased ADH;
S/S: distended or bounding neck veins; possible edema; possible wet lung sounds; increased HR; increased BP
Fluid Volume Excess= water retention
Treatment:
Reduce sodium levels.
Use diuretics to increase fluid excretion.
Address the underlying cause of the fluid excess.