Nursing Process:
A-assess- gather info about the pts condition
4Ps- pain, personal needs, position, possessions
D- diagnose (analyze)- identify pts problems, causes, symptoms
P-plan- set goals of care and desires outcomes and identify appropriate nursing actions
ABCs, safety, maslow
I- implement- perform the nursing actions identified in planning
bases on clinical judgment and knowledge
types of interventions: nurse initiated, HCP initiated, collaborative
E- evaluate- determine if goals and expected outcomes are achieved
Exogenous
Outside the body
Ex: C-Diff, UTI
Endogenous
Overgrowth of Flora
Ex) Candida (yeast), Thrush
Iatrogenic
HAI from health care staff
Procedures, breaking sterile field, poor hand hygiene
Hypertonic
-Get rid of excess volume,
Before fluids given S/S: Hyponatremia
Fluids given: 3% NS, D10 w/ NS,
After fluids given Monitor: Pulmonary Edema, elevated BP, lungs sounds (crackles), hypernatremia,
Isotonic
Replacement
Dehydration, Nausea, Vomiting
Fluids given: 0.9% NS, Lactaded ringers (ER and OR)
Hypotonic
Before fluids: Hypernatremia
Fluids given: D5 in water, 0.45% NS
Hypovolemia
Na+ and H20 loss
Causes: fever, low fluid intake, burns (intravascular to interstitial), hemorrhage
Assess: thirst, cold and clammy, decrease skin turgor, cap refill >3 sec, concentrated urine, decrease urine output, weight loss, elevated Hr & RR, elevated BUN, decreased GFR, increase sodium, weak pulse.
Hypervolemia
Na+ and H20 Gain
Causes: excess fluid intake, abnormal fluid retention (HF & Kidney disease), excess sodium, interstitial to intravascular.
Assess: Edema peripheral & pulmonary, JVD, crackles, high BP, bounding pulse, weight gain, decreased BUN, elevated BNP, excess urination, clear urine, daily weight, I/O,
Hyponatremia
<135
Assess: Neuro- headache, confusion, irritability, seizures, nausea, vomiting, weakness, abdominal cramps (Hyperactive bowls), cold and clammy, hypotension.
Implementation: 3% NS, D10 w/ NS, 0.9% NS, monitor sodium, strict I/O
Causes: Burns, Diuretics, N/V/D, low sodium intake
Hypernatremia
> 145
Assess: altered mental status, Neuro -twitching, confusion, seizures, thirst, fatigue, tired, restlessness, coma.
Implementation: 0.45% NS, D5 in H20, Monitor sodium
Causes: Hypertonic fluids, dehydration, heat stroke, burns, osmotic diuretic, fever.
Hypokalemia
<3.5
Assess: changes in cardiac (PVC), brady, irregular HR, weakness, fatigue.
Implementation: Foods high in potassium, K+ IV infusion, EKG, Vitals, urine output.
Causes: Diuretics, low K+ intake, insulin, N/V/D
Hyperkalemia
> 5.0
Assess: Cardiac arrhythmias, peaked T-waves, cardiac arrest.
Implementation: Insulin w/ D50, EKG, >7.0 start dialysis, diuretics, kayexalate- K+ exits in stool need good GI.
Causes: Renal failure, high K+ intake, Ace inhibitors -pril
Prerenal
Above Kidneys- Heart/Circulation
Causes:
- decreased cardiac output
- Severe dehydration
- HF
- deceases renovascular blood flow
- emboli, thrombosis (blood clot)
- Hemmhorage
- Hypovolemia
Intrarenal
Direct kidney injury
Causes:
- NSAIDs
- Ace Inhibitors
- acute tubular necrosis (tissue in kidney dying)
- antibiotics (aminoglycosides)
- acute pylelonephritis (bacterial)
- Epstein-Barr (viral)
- Candidiasis (fungal)
- chemical exposure
- Kidney Injury (crush injury)
- hemolytic transfusion reactions
Postrenal
-Bladder/obstruction
Causes:
- BPH
- Caliculi formation (kidney stones)
- back/pelvis trauma
- prostate cancer
Cranial Nerves
PERRLA
Swallow
PERRLA: 3, 4, 6/ III, IV, VI
Swallow: 9 &10/ IX, X
Oliguric
Assess: decreased urine output, fluid overload, JVD, crackles, high BP, bounding pulse, edema, <400mL/day, last 1-7 after injury.
Labs: hyponatremia (dilution) , high K+, elevated hydrogen, low bigarb, high Bun and Creat, low GFR.
Restrict fluids
Diuretic
Assess: Extreme urination, sudden increase in urination, true hyponatremia, and hypokalemia, dehydration, notify provider,
Recovery
Assess: GFR increases, BUN and CREAT decrease, major improvements in first few weeks, longer than 12 mos is considered early stages of chronic kidney failure
4 Reasons to start Dialysis
- BUN over 120
- K+ over 7
- cerebral changes due to hyponatremia
- severe metabolic acidosis
Pneumonia
Assess:
- cough, fever, chills
- fine or course crackles
- green/yellow/rust colored sputum
- pleuretic chest pain
- tachycardia
- SOB
- Dyspnea
- Tachypnea
- Altered mental status (eldery)
- elevated HR
Implementations
- incentive spirometry
- deep breathing
- early ambulation
- CXR
- Elevated WBC
- blood and sputum culture
- give lots a fluid to break up the sputum
- corticoid steroids
- bronchodilators
- Antibiotics (after sputum culture)
- Nasal canula 1-6
- Humidity >4
- Small frequent high protein meals
- antipyretics (tylenol)
COPD
-Air gets trapped in lungs, pursed lips to breath with air already in their lungs
Assess:
- Dyspnea
- SOB
- Chronic cough
- weight loss
- Finger clubbing
- trouble sleeping
- hx smoking
- barrel chest
- Wheezing
- NO fever/chills
- early dyspnea on exertion
- use of accessory muscles
- fatigue
Diagnostics:
- spirometry test
- fEV/FVC <70% (measure of forced volume lower the sicker)
- Chest X-Ray
- 6 min walk test
Causes of exacerbation:
- cold, flu
- pneumonia
Implementations:
- pursed lips and huff cough
- Smoking cessation
- bronchodilators
- 02 therapy
- corticosteroids
- antibiotics
- no cure for COPD just control of symptoms
- small frequent high calorie soft diet, rest 30 min before, give bronchodilator 1 hr before and after before meals
- start oxygen low and slowly titrate up
- Oxygen 88-90% (respiratory drive goes down and they become dependent)
Fine Crackles
Fluid overload Pneumonia Clear w/cough Incentive spirometer Left sided HF Pulmonary edema Hear at the end of inhalation Diuretics
