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NR 226
Sept 2013 Session
Exam 1
Chapter 16 20 Nursing Process, Chapter
41 Fluid and Electrolyte, acid base balance, IV therapy, blood administration, IV flow rate
calculation
Blue Print
Nursing Process The five steps
-Assess- Gather info about the patients condition
-Diagnose-Identify the patients problems
-Plan-Set goals of care and desired outcomes and identify appropriate nursing actions
-Implement-Perform the nursing actions identified in planning
-Evaluate-Determine if goals and expected outcomes are achieved
Repeat process if outcomes have not been met.
Nursing Process Assessment phase purpose
The nursing process is a critical thinking process that professional nurses use to apply the
best available evidence to caregiving and promoting human functions and responses to
health and illness.
The nursing process is a variation of scientific reasoning.
Practicing the five steps of the nursing process allows you to be organized and to conduct
your practice in a systematic way.
You learn to make inferences about the meaning of a patients response to a health
problem or generalize about the patients functional state of health.
Through assessment, a pattern begins to form.
Databases
The purpose of assessment is to establish a database about the patients perceived needs,
health problems, and responses to these problems.
In addition, the data reveal related goals, experiences, health practices, values, and
expectations about the health care system.
Critical thinking skills help you to synthesize relevant information and use it in a
purposeful way.
Sources of data
Patient (interview, observation, physical examination)the best source of
information
Family and significant others (obtain patients agreement first)
Health care team
Medical records
Scientific literature
Nurses experience
2. Nursing diagnosis
NANDA
3. Collaborative problem
Objective data- Conditions that you can see or feel or observe, FACT
Nursing diagnosis and components of how to correctly write a nursing diagnosis
Medical diagnoses dont have a place in nursing diagnoses
Provides a precise definition of a pts problem that gives nurses and other
members of the health care team a common language for understanding the pts
needs.
Allows nurses to communicate (written and electronic) what they do among
themselves with other health care providers and the public.
Distinguishes the nurses role from that of the physicians or other health care
provider.
Helps nurses to focus on the scope of nursing practice
Foster the development of nursing knowledge
Promotes creation of practice guidelines that reflect the essence of nursing.
Components of a nursing diagnosis PES:
Problem; NANDA-I label (Impaired physical mobility)
Etiology; etiology or related to factor (incisional pain)
Symptoms; symptom or defining characteristics (evidence by restricted turning and positioning)
Nursing diagnosis errors
Errors in Interpretation and analysis of data-Following data collection, review your database
to decide if it is accurate and complete. Review data to validate that measurable, objective
physical findings support subjective data. (when a patient describes difficulty breathing you
also want to listen to lung sounds, assess respiratory rate, and measure the patients chest
Errors in data clustering- occur when data are clustered prematurely, incorrectly, or not at all.
Premature clustering of data occurs when you make the nursing diagnosis before grouping all
data.
Errors in the diagnostic statement- Clinical reasoning leads to a higher quality of nursing
diagnosis, which eventually leads to etiology specific interventions and enhanced patient
outcomes. The more competent you become in diagnostic reasoning, the more likely it is that you
will correctly select diagnostic statements.
Nursing process phases and what is done in each phase
The five steps
-Assess- Gather info about the patients condition
-Diagnose-Identify the patients problems
-Plan-Set goals of care and desired outcomes and identify appropriate nursing actions
-Implement-Perform the nursing actions identified in planning
-Evaluate-Determine if goals and expected outcomes are achieved
Repeat process if outcomes have not been met.
(Seven) Guidelines in writing nursing care plan goals
Goals and outcomes need to meet established intellectual standards by being relevant to patient
needs, specific, singular, observable, measurable, and time limited.
Goal
A broad statement that describes the desired change in a patients condition or
behavior
An aim, intent, or end
Expected outcome
Measurable criteria to evaluate goal achievement
Sometimes several expected outcomes must be met for a single goal. Direct
nursing care. Are written sequentially, with time frames
Prostatectomy
Goal: Understanding post operative risks
Expected outcome: Patient identifies sign and symptoms of wound infection
Patient explains signs of urinary obstruction
Patient centered reflect patient behaviors and responses expected as a result of nursing
interventions
Singular goal or outcome address only one
behavior or response
1) Patient centered- Patient will ambulate to the nurses desk and back (not- turn the
patient every two hours)
2) Singular goal or outcome-Each goal and outcome should address only one behavior
or response
3) Observable- The goal or outcome should be observable (how else can you prove it)
4) Measurable-Values describing quality, quantity, frequency, length, or weight allow
you to evaluate outcomes precisely. (avoid vague terms such as: adequate, acceptable,
or stable)
5) Time-Limited- Discuss with patient and decide on a realistic time-frame
6) Mutual Factors- Make sure that the patient and nurse are in agreement on the
expected outcomes, goals, and time-frame.
7) Realistic-The time allotted for care is short. You must be able to set goals that are
realistic for you and your patient.
Priority setting
Use the ABCs to direct you to the highest priority.
1st priority chest trauma, chest pain, severe respiratory distress or cardiac arrest, limb
amputation, acute neurological deficit and chemical splashes to the eye(s) (emergent)
2nd priority simple fracture, asthma without severe respiratory distress, fever, hyper
tension, abdominal pain, renal stone (urgent)
3rd priority minor laceration, sprain, cold symptoms (non urgent)
Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or
importance to establish a preferential order for nursing actions.
Helps nurses anticipate and sequence nursing interventions
Classification of priorities: (consider Maslows hierarchy)
Prostatectomy
HighEmergent (safety, oxygenation, circulation, unique patient situation
physiological and psychological)
Acute pain
Intermediate (non emergent, non life threatening)
Deficient knowledge
Page 2 of 2
NR 226
May 2013 Session Exam 1
Chapter 16 20 Nursing Process, Chapter
41 Fluid and Electrolyte, acid base balance, IV therapy, blood administration, IV flow rate
calculation
Blue Print
Fluid and Electrolyte, Acid Base Imbalances, Blood Transfusion and IV
Fluid = Water that contains dissolved or suspended substances
such as glucose, mineral salts, and proteins.
Fluid amount = Volume.
Fluid concentration = Osmolality.
Fluid composition (electrolyte concentration)
Degree of acidity = pH
Intracellular Fluid (ICF)
= Fluids within cells
~2/3 of total body
water
Lab values: Na, K, Ca, Cl, Mg, and signs and symptoms of hyper and hypo and value of PH,
PaCO2, HCO3 (bicarbonate)
Determine Acid Base Imbalances and etiology of (what can cause) those imbalances and nursing
implications
Acid production, buffering, and excretion interplay to create balance.
Acids release hydrogen (H+) ions; bases (alkaline substances) take up H+ ions.
The more H+ ions present, the more acidic the solution
Degree of acidity is reported as pH.
pH scale: 1.0 (very acid) to 14.0 (very base)
pH of 7.0 is neutral; normal arterial blood is 7.35 to 7.45.
Maintaining pH within this normal range is very important for optimal cell function.
Measured by ABGs. Discuss how ABGs are drawn. Occlude the radial and ulnar veins
and have the patient clench fist. Release the ulnar vein only and have the patient unclench
fist. The hand should be white at first and gradually turn pink again as blood fills the
hand. If the hand remains white, the ulnar vein is damged and you will not be able to
draw ABGs through that hand because you might damage the radial vein and the patient
will then lose their hand.
Extracellular fluid volume imbalances
Extracellular fluid volume (ECV) deficit
Hypovolemia means decreased vascular volume and often is used when
discussing ECV deficit.
ECV excess too much isotonic fluid in extracellular compartments too much Na
yields swelling and fluid weight gain
Osmolality imbalances: page 888 table 41-3
Sodium (NA+) 136-145 mEq/L
Hypernatremia, water deficit; hypertonic
Hyponatremia, water excess water intoxication; hypotonic, cells swellcerebral dysfunction when brain cells swell
Clinical dehydration
= ECV deficit and hypernatremia combined
Acid excretion systems: lungs and kidneys
Lungs excrete carbonic acid.
Kidneys excrete metabolic acids.
Excretion of carbonic acid
When you exhale, you excrete carbonic acid in the form of CO2 and water.
Excretion of metabolic acids
The kidneys excrete all acids except carbonic acid.
Acid base Imbalances
Types of acidosis: respiratory and metabolic
Types of alkalosis: respiratory and metabolic
Respiratory acidosis
Arises from alveolar hypoventilation
Lungs unable to excrete enough CO2
Excess carbonic acid in the blood decreases pH.
Respiratory alkalosis
Arises from alveolar hyperventilation
Lungs excrete too much CO2
Deficit of carbonic acid in the blood increases pH.
Metabolic acidosis
Arises from increase in metabolic acid or decrease in base (bicarbonate)
Kidneys unable to excrete enough metabolic acids, which accumulate in the blood
Determine Electrolyte and Fluid Imbalances and etiology of (what can cause) those
imbalances and nursing implications
Intake and absorption
Distribution
Plasma concentrations of K+, Ca2+, Mg+, and phosphate (Pi) [2.7 4.5 mg/dl] are
very low compared with their concentrations in cells and bone.
Concentration differences are necessary for normal muscle and nerve function.
Output
Normal: Urine, feces, and sweat
Abnormal: Vomiting, drainage, drainage tubes and fistulas
Potassium (K+) 3.5 -5.0 mEq/L
Hypokalemia
Hyperkalemia
Calcium (Ca2+) 8.4 10.5 mEq/L (Ionized 4.5 - 5.3)
Hypocalcemia
Hypercalcemia
Magnesium (Mg2+) 1.5 2.5 mEq/L
Hypomagnesemia
Hypermagnesemia
additional RBC-containing components until transfusion service provides newly crossmatched units.
Febrile non hemolytic (most common)-Sudden shaking, chills (rigors) fever rise
headache, flushing, anxiety and muscle painStop transfusion. Give antipyretics as
prescribed: avoid aspirin in thrombocytopenic patients. Patient Safety! Do not restart
transfusion.
Mild allergic- Flushing, itching, hives (urticaria)Stop transfusion temporarily, give
anti-histamine as directed. If symptoms are mild and trasnsient, restart transfusion slowly
(moniter)Patient Safety! Do not restart transfusion if fever, pulmonary symptoms, or
hypotension develop.
AnaphylacticAnxiety, urticaria, dyspena, wheezing, progressing to cyanosis, severe
hypotension, circulatory shock, possible cardiac arrestStop transfusion. Have
epinephrine ready for injection (0.4 mL of
1:1000 solution subq or 0.1 mL of 1:1000 solution diluted to 10 mL with saline for IV
use). Provide blood pressure support as ordered. Initiate CPR if indicated.
Circulatory overload- Dyspnea, cough, crackles, or rales in dependent portions of lungs;
distended neck veins when upright (fluid overload).Turn down transfusion rate or stop
transfusion. Place patient upright with feet in dependent position. Administer prescribed
diuretics, oxygen, or morphine. Phlebotomy may be indicated.
Sepsis- Rapid on-set of chills, high fever, severe hypotension, and circulatory shock. May
occur: vomiting, diarrhea, sudden oliguria (acute kidney injury), DICStop transfusion.
Obtain culture of patients blood and send bag with remaining blood to transfusion
services for further study. Treatment as ordered; antibiotics, IV fluids, vasopressers,
glucocoticoids.
Infiltration, Phlebitis, local infection, extravasation
Complications page 910-911, table 41-12, 41-13, 41-14
Fluid overload; pulmonary edema fluid overload infiltration; IV fluid enters subq
tissue, IV catheter becomes dislodged (remove catheter and apply warm
compress)
Extravasation; vesicant (tissue damaging) drug enters tissues (remove catheter
and apply a warm compress) (Call pharmacy!!)
Phlebitis; inflammation of the inner layer of the vein local infection; infection at
catheter point of entry can occur during infusion or after catheter removed)
Bleeding at the infusion site; oozing or continuous seepage of blood at
venipuncture site
Nursing implications for set up and transfusion of blood
Tranfusing blood requires a healthcare providers order. Perform a thorough assessment before
administering a transfusion and monitor carefully during and after the transfusion.
Pretransfusion assessment; educate pt, has the pt ever had a transfusion or transfusion reaction
before? Explain the procedure to the pt and instruct the pt to report any s/s immediately. Obtain
baseline vitals so you can compare during transfusion.
Verify 3 things:
1) Blood components ordered are the ones delivered
2) The blood is compatible to the patients blood type listed in the medical records
3) The right pt receives the blood
Two RNs or a RN and a LPN must check the label on the blood and compare it to the medical
records (If they do not match, notify the bank immediately to prevent further errors).
When administering blood you need an 18g catheter (a 20g may be used for only two units).
Prime the tubing with saline to prevent hemolysis or RBC breakdown. Intitiate the transfusion
slowly for detection of reactions. Maintain the ordered flow rate, monitor for reactions, assess
vitals, and promptly record all findings. Stay with the pt for the first 15 minutes. Pts are at the
highest risk for a reaction within the first 15 minutes. Continue to monitor the pts vitals
periodically.
Ideally the flow rate is 1u/2hr.This may be lengthened to 4 hours if the pt is at risk of
ECV. Anything over four hours is at risk for contamination because the blood warms and is an
ideal breeding ground for bacteria.
Central venous catheters are used for severe blood loss (hemorrhaging) and a blood warmer is
used. Rapid administration of cold blood can cause cardiac dysrythmias.
Initiating IV and discontinuing IV
Fluids infuse directly into the blood stream, sterile technique is necessary
Equipment
Vascular access devices (VADs) [larger the gauge the smaller the catheter],
tourniquets, clean gloves, dressings, IV fluid containers, various types of tubing,
and electronic infusion devices (EIDs), also called infusion pumps
Initiating the intravenous line [once you have withdrawn the needle, you cannot advance
the needle back into the catheter for risk of shearing off the tip of the catheter resulting in
a pulmonary embolism and MI]
Regulating the infusion flow
Electronic infusion devices (EIDs or IV pumps)
Non-electronic volume control devices [tubing sizes micro 60, macro 10, 15 or 20 gtts]
Start most distal site. Avoid sites that are red or look infected, infiltrated or signs of thrombosis.
Try to avoid flexion areas.
a. Check IV solution
b. Verbalize appropriate labeling of IV bag
c. Prepared short extension tubing with proper
connector and IV tubing, maintaining
sterility
d. Spike the IV bag aseptically; compress drip
chamber and release, to fill one-half full with
IV solution.
e. Correctly prime tubing (free of air bubbles),
place roller clamp approximately 2-5 cm (1-2
inches) below drip chamber and move to
closed position.
f. Hang IV bag appropriately
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