Medications
3 priority nursing implications for Lovenox injections
What is:
1. Assess for signs of bleeding and hemorrhage & notify HCP if they occur.
2. Monitor CBC, platelet count, and stools for occult blood periodically during therapy.
2. Administer deep into subcutaneous tissue. Alternate injection sites daily between the left and right anterolateral and left and right posterolateral abdominal wall
What do the plasma glucose levels indicate?
Hyperglycemia
NL-70-100
Goal of 80-120 with DM
Reason patient had ultrasound
Ultrasound is the best imaging test for finding gallstones.
Reasoning for 12-hour I/O values
If there is excess glucose in the blood (hyperglycemia), the kidneys must work harder. In order for the kidney to be able to filter out the extra sugar, fluids are taken from the body tissues and filtered by the kidneys into the urine, resulting in increased urination (polyuria). This will increase thirst (polydipsia). As she drinks more liquids, the need to urinate increases.
Explain patient's fall risk 2/2 h/o DM
Presence of peripheral neuropathy, decreased sensation, decreased muscle strength, painful leg ulcer all contributes to imbalanced gait.
c/o fatigue which is associated with hyperglycemia; plus not sleeping well due to pain
+polyuria so getting up frequently to use BSC
Signs of bleeding & hemorrhage
bleeding gums; nosebleed; unusual bruising; black, tarry stools; hematuria; fall in hematocrit or BP; guaiac-positive stools); bleeding from surgical site
Concern related to WBC results and other data supporting concern
WBC=12,000 mm3
Concerned about infection due to elevated count (Nl=5,000-10,0000) and abdominal wound dehiscence & presence of erythema wound edges.
T=101, fatigue, h/o DM which increases risk of infection
3 nursing implications for an ultrasound
For an A.M. appointment, fat-free dinner the evening before. Nothing to eat or drink from midnight until after the examination. For a P.M. appointment, clear liquid breakfast (no milk) before 9 A.M. Nothing to eat or drink after breakfast.
Certain factors or conditions may interfere with the results of the test: Severe obesity, Barium within the intestines from a recent barium procedure, & Intestinal gas
Takes approximately 30 to 60 min. Procedure causes no pain, but having to lie still for the length of the procedure may cause slight discomfort.
S/S Hyperglycemia
Early:
Late:
The link between DM and HTN
Hypertension and diabetes generally coexist because they share similar risk factors, including being overweight, following an unhealthy diet, and living an inactive lifestyle.
Diabetes does three things that may increase blood pressure:
5 priority nursing implications for Toradol IM injection
1. Drowsiness is SE & pt is fall risk; have pt call for assistance with ambulation, OOB
2. Watch for adverse GI effects since also taking ASA
3. Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome or toxic epidermal necrolysis.
4. Evaluate liver function tests, especially AST and ALT, periodically in patients receiving prolonged therapy. May cause increased levels.
5. Reassess pain 1-2 hr after administration
Concerning CMP values and why
Na=129
BUN=5
Albumin=3.0
Patient consuming increased fluids plus IVF. The patient is in overhydration so Na and BUN levels will be low. BUN fluctuates with hydration status.
Na and BUN may also be low with malnutrition.
Low albumin indicates poor nutrition. Patient has had decreased food intake due to fatigue and anorexia which may be secondary to infection. Hyperglycemia causes polydipsia-->increased fluid intake-->diminish appetite.
Open cholecystectomy explained in detail
Surgery to remove the gallbladder that is severely inflamed, infected due to gallstones, or scarred tissue from other operations. These stones can block the ducts that bile flows through. The stones can cause inflammation, pain, and other symptoms. Typically performed under general anesthesia through a right upper quadrant incision.
Reason patient developed diabetic pressure ulcer
2/2 peripheral neuropathy and decreased sensation r/t uncontrolled DM (non-compliant with lifestyle changes, medication regimen)
Link between DM and gallstones
Insulin resistance can cause gallstones.
“In the case of insulin resistance excess carbohydrates are converted into triglycerides (or fats). You can end up with more fats than your liver can process. These fats, particularly saturated fats, interfere with gallbladder function and raise the chance of developing gallstones.” (Dr. Olanasky, OnTrack Diabetes)
4 priority nursing implications for Zosyn IV
1. Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy. Diarrhea is common SE.
2. Assess for skin reactions (rash, fever, edema, mucosal erosions or ulcerations, red or inflamed eyes). Monitor the patient with mild to moderate rash for progression. If rash becomes severe or systemic symptoms occur, discontinue.
3. Assess IV site for pain and phlebitis
4. Evaluate renal and hepatic function, CBC, serum potassium, and bleeding times prior to and routinely during therapy.
Labs that indicate poor control of diabetes for the patient and why
Hgb A1c 9% - reflects your average blood sugar level for the past two to three months The higher your A1C level, the poorer your blood sugar control and the higher your risk of diabetes complications.
glucose 180=hyperglycemia; need to consider medication compliance.
Nursing care/education pre-op open cholecystectomy (11 identified)
1. Quit smoking
2. NPO 4-24 hr before surgery
3. May need enema to empty bowel
4. Abdomen and groin cleansed with antimicrobial wash (infection control)
5. Oral care-brush teeth and use mouthwash (increased risk for respiratory infections)
6. Clip hair if present abdomen (do not shave-infection)
7. Start IV for fluids and meds during surgery; may need antibiotics after surgery to reduce risk of infection
8. Insert NGT-keep stomach empty
9. Loose stools after eating may last 4 to 8 weeks post-op.
10. No strenuous exercise or heavy lifting post-op for 4 wks.
11. DO NOT soak in a bathtub, hot tub, or go swimming until wound healed.
Risk factors (2-3) for Mrs. Showers wound dehiscence
1. Infection or poor wound healing-h/o DM, post-op cholecystectomy, h/o diabetic leg ulcer
2. Poor nutrition (malnourished)-low albumin, inadequate food intake increases risk of poor wound healing
3. Wound pressure or straining
Link between DM and OP
Some of the complications of diabetes, such as nerve damage, muscle weakness, episodes of low blood sugar, and vision problems can increase the risk of falls and fractures.
Indication for April Showers taking Lovenox? Toradol? and Zosyn?
Lovenox-prevention of DVTs; post-op and limited mobility increase risk for DVT formation
Toradol-pain control; post-op cholecystectomy and has a diabetic pressure ulcer; also has anti-inflammatory properties.
Zosyn-abdominal wound infection 2/2 dehiscence; wound culture was positive for VRE
Rationale for +VRE wound culture and nursing implications
VRE may develop in wounds after surgical procedures. Increased risk with surgical procedures such as abdominal surgery. Patient had a cholecystectomy.
Nsg Implications: contact precautions; hand hygiene; PPE: gown & gloves
Nursing implications for patient post-op open cholecystectomy (10 identified)
1. Risk for bleeding and wound complications-monitor wound for increased bleeding, drainage, swelling, pain, s/s infection, dehiscence, evisceration
2. Anesthesia during surgery; may have sore throat if intubated
3. Foley catheter to empty bladder during surgery-risk for CAUTI
4. NGT to decompress the stomach as bile may be present and may experience N/V-->may require antiemetic; monitor output and wall suction settings for complications; monitor electrolytes-->risk for dehydration
5. A drain(s) is placed during surgery to let fluid flow out of the abdomen and drain bile-maintain patency; increased risk of infection.
6. Risk for blood clots and embolus-early ambulation important, leg exercises while in bed, compression devices/anti-embolism stockings
7. Risk for PNA-DBC exercises, use of ICS
8. Risk for pain-request analgesia before pain is severe
9. Risk for constipation due to pain meds, decreased oral/food intake, decreased activity
10. Risk for falls due to pain meds, orthostasis
3 Nursing implications for abdominal incision
1. Risk for dehiscence-splint with DBC exercises
2. Risk for infection-sterile irrigation and packing of wound; Zosyn IV
3. Risk for pain-Assess and administer Toradol prn; non-pharmacologic interventions
Pathophysiology of DM
Diabetes is primarily a disorder of glucose metabolism related to absent or insufficient insulin supply and/or poor utilization of the insulin that is available.
Insulin is less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver.